Design, participants and setting: A retrospective audit of medical students’ files from Northern Territory General Practice Education placements in Central Australia for the period from January 2006 to December 2007.
Results: A total of 163 placements were undertaken. Of these, 98 (60%) had adequate documentation to determine whether an incident had occurred. There were 28 cases (17%) where potentially harmful incidents were judged to have occurred. Most incidents fell under several descriptive categories, but clinical supervision, professional practice and administrative issues were most common.
Conclusions: One in six students experienced a potentially harmful incident during remote area placement in 2006–2007. While acknowledging the exploratory nature of this investigation and the major educational benefits that clearly arise from these placements, our findings indicate problems with clinical supervision and administration.
Through its Rural Undergraduate Support and Coordination Program (RUSC), Northern Territory General Practice Education (NTGPE) is responsible for 2–8-week elective placements undertaken by medical students from around Australia in remote Aboriginal communities in the Northern Territory (Box 1). Most students report high levels of satisfaction with their experience (unpublished data, NTGPE, 2006), and these placements are highly sought after.1
Although RUSC students are drawn from Australian universities and placed within Australia, there are similarities between the remote Australian context and international electives in developing countries. These include physical isolation and a challenging environment; communities with health beliefs and norms different to mainstream Australian culture; higher rates of poverty, poor housing, unemployment and violence; and health problems that are different in their presentation, prevalence and severity. Models of health care provision are also different: government and Aboriginal community-controlled primary health care clinics are the norm, staffed by remote area nurses and Aboriginal health workers. A doctor may not be on-site or available for clinical care and supervision. Services are often understaffed and underresourced, with difficult access to secondary or tertiary care.
The literature on international electives suggests they promote the uptake of general practice; encourage doctors to work in public health and with underserved populations; and provide benefits to students’ personal and professional development.2-4 However, there are also concerns about the risks, which include important ethical issues for patients as well as students.5 If students work beyond their experience and are “expected to diagnose and treat patients without direct supervision from a qualified doctor”,6,7 patients may be placed at risk. This raises difficult questions. Is some care better than no care?8 Is the student the “most qualified” health care worker present to fulfil the patient’s right to quality care? The personal safety of the student is also crucial; in remote locations, students are at greater risk of accidents, infectious diseases, personal violence and even political threats.9
We conducted a retrospective file audit of all RUSC student placements in Central Australia for a 2-year period from January 2006 to December 2007. Sources of information included the written notes in students’ files such as the application form, teleconference notes, debrief notes and any other file and action notes. Students were ideally debriefed weekly by group teleconference, and at the end of their placement by a medical educator and program administrator. However, debrief attendance was variable, and students were not specifically asked about adverse experiences. While NTGPE staff were aware of some incidents that had not been recorded in the files, anecdotal or verbal recall was not regarded as sufficient for this study.
We used an educational institution-based definition of a “critical incident”10 to develop a student placement-specific definition of an incident as: an event, or the threat of one, which may
cause, or is likely to cause, significant physical and/or emotional distress or harm to the student experiencing or witnessing the event
be regarded as outside the normal range of experience of the persons affected
threaten, disrupt or prevent the ordinary functioning of the student placement.
Clinical: events related to medical or clinical work by the student or other clinicians, or to patient morbidity and mortality (eg, accidental, avoidable or traumatic deaths or suicides; near-misses; needle-stick injuries; lack of supervision judged necessary for student competence; improper or negligent practice).
Non-clinical: events outside the direct medical, patient-related work of the student or clinic (eg, motor vehicle accidents; physical or verbal assault; bullying or harassment; extreme weather conditions; cultural transgressions; culture shock).
The principal investigator (A P) obtained all the hard-copy student files for the study period. She systematically checked all files, coded demographic data, and noted whether a potential or actual incident had occurred during the placement, and if there was sufficient information recorded to make such a judgement.
Face validation of cases was achieved by independent file review by two other staff (M V and H T N), who assessed whether the identified case met the agreed definition of an incident. Broad descriptors were developed to categorise the cases by common themes (Box 2). The three reviewers independently recorded which descriptors they thought best applied to each case. There was no discussion of which descriptors were applied by each reviewer, and each descriptor could therefore be applied multiple times to a case.
A total of 31 files with possible critical incidents were identified on initial screening. After face validation by the three investigators, six needed review; three were discarded, leaving a total of 28 identified cases (17% of all placements). There was a preponderance of female students placed, and this was proportionately represented in the incidents (Box 3).
Thematic analysis of the 28 cases found that clinical supervision, professional practice and administration were the key issues causing distress for the students (Box 4). A small sample of cases is described in Box 5.
This study suggests that, during the 2-year audit period, potentially distressing incidents occurred in at least 17% of medical student placements in remote Aboriginal communities in Central Australia. In 2006, from the 75 anonymous feedback forms completed by the cohort of 97 students, 64 (85%) rated their overall placement as above average or excellent, and 61 (81%) believed it had increased their interest in rural practice, while only four (5%) considered the placement below average or poor, and three (4%) reported less interest in rural practice as a result (unpublished data, NTGPE, 2006). Thus, there were many more students who experienced critical incidents than those who rated the placement poorly, suggesting that a “distressing” incident does not necessarily lead to an overall negative placement and may in fact be a powerful learning experience.
This retrospective audit has several limitations. The large number of files with inadequate documentation and the reliance on self-reporting by students increases potential bias. The primary feedback noted was from students and NTGPE staff, rather than supervisors, clinic staff or patients. The interviewers’ own experiences, both of the clinical context and in counselling skills, may inform how they interpret and attach significance to feedback. The number of descriptors and the brevity of their explanations may have led to a lack of clarity for the reviewers and a wider spread of descriptors. Multiple descriptors applicable to a case may also be interrelated: for example, clinical supervision is dependent on functional interpersonal relationships, appropriate professional practice, and professional attitudes.
Good supervision promotes professional development, but we found that the quality of clinical supervision appears to be a major concern. Complex patients with multiple morbidities; major traumatic events; lower health and language literacy; clinics characterised by understaffing, high staff burnout and turnover; and some recruitment practices (eg, appointment of short-term locums) all make it difficult to develop and maintain supervisory and teaching quality. Clinical workloads can be high and students seen as a valuable “pair of hands” and left to see patients on their own. The tension between service delivery demands and teaching may result in the teaching role being seen as a low priority. Clinics are staffed by interprofessional teams; non-medical staff may supervise medical students, and there may be a lack of clarity in roles, commitment or confidence in supervising across professional disciplines. Students may not value the roles of remote area nurses or be reluctant to accept their authority as supervisors, and have attitudes perpetuating the traditional hierarchical medical–nursing divide. Lack of training and skills in clinical supervision, compounded by remoteness and difficulty in attending training, may hamper the professional development of supervisors. These factors suggest that students require particularly careful clinical supervision to protect patients’ and students’ safety and promote ethical practice.
Personal qualities such as resourcefulness, self-confidence and cross-cultural skills will aid students in making the most of their elective. However, a “medical tourist” attitude may undermine the learning component and lead to mismatched expectations. Some students may be experiential learners and “keen to have a go”; they may appreciate a lack of supervision as it allows them to do more, but they may lack insight into their own capabilities and have “strategies to appear as competent as possible”.11,12 All these attitudes and perceptions can challenge the inexperienced supervisor.
A review from the United Kingdom recognised the value of more structured approaches to medical electives to maximise learning and minimise the risks.13 Strategic planning can address some of the challenges of clinical education14 in the primary care and remote Aboriginal community setting, and should be applied to student electives. Immediate strategies can include organisational systems for risk management; staff and student commitment to processes such as ethical practice; feedback and debriefs; and employing staff who are familiar with local conditions. Establishing more intimate partnerships with communities, universities and clinics with stable staffing, developing rigorous standards for selection of supervisors, and resourcing interprofessional training in clinical education are some longer-term practical strategies.
While student placements are attractive and have demonstrated positive outcomes, they demand due consideration be given to safeguarding students, supervisors and, most importantly, patients. This is timely given the increasing burden of clinical education that is being placed on community-based health services and general practice, and in rural and remote Australia.
1 Northern Territory General Practice Education (NTGPE) Rural Undergraduate Support and Coordination Program (RUSC) process
2 Descriptors for potentially harmful incidents
Related to clinical supervision of the student by a doctor, remote area nurse or an Aboriginal health worker, and to direct patient care and clinical activity, including history taking, diagnosis and management
3 Number of student placements and incidents recorded, by year and sex
4 Frequency of descriptors for 28 critical incident cases,* 2006–2007
5 Examples of potentially harmful incidents occurring during medical student placements in Central Australia*
A 22-year-old female student in her third year of a 6-year course, placed at a remote Aboriginal medical service (AMS) community clinic, reported being worried about standards of clinical care she observed; for example, no hand washing between seeing patients with infected sores (no water available); not recording vaccine details; no sharps bins for needles. She also felt the staff were not interested in teaching but used students as workforce. She had interpersonal problems with one remote area nurse in particular (eg, being expected to drive out to a house to be first on call for an after-hours case, yet not being called for interesting after-hours cases in the clinic). She thought that the staff were “burnt out” and that it was “medically boring” and “very slack compared with other placements”. She was “turned off remote health” by her placement experience. This feedback was confirmed by another student who was placed with her at the same community.
A 24-year-old female student in her final year of a 5-year degree, placed at a remote AMS community clinic, reported at a weekly teleconference that a baby had died from a respiratory infection and that she had had a “massive day today”; “Wednesday was one of the worst days of my medical career to date”. She had quite a degree of emotional distress and shock, with concerns about clinical competence of staff and clinic systems. She received considerable support and continued at the clinic. By the end of the placement, several weeks later, she reported being very positive about her placement experience, and that it was a “fantastic placement and great learning [experience]”.
A 25-year-old female student in her final year of a 5-year course was involved in a road ambulance rollover accident while returning from transporting a patient to the local district hospital. The road was unsealed, it was dark and it had been raining. Fortunately, there were no major injuries among the four people in the car, who had all been wearing seatbelts. They were able to alert the hospital and, after some hours, an ambulance arrived to retrieve them. Contributing factors were that an unlicensed driver had been driving, and that the vehicle’s wheels were not locked to engage them in four-wheel drive mode. This incident was not advised to Northern Territory General Practice Education (NTGPE) until some time after the event; the student had participated in the clinic’s internal review and debriefs.
A 32-year-old female student in her final year of a 4-year postgraduate course reported that she was not picked up when she arrived at the community at 3 am on the bus from Alice Springs. She was fortunate that a passer-by helped her get to the nearby hospital, where she spent the night. She found the student accommodation to be dingy and dirty, and she moved herself to a share house with local police. She also mentioned other administrative issues with NTGPE, included phone calls not being returned, and that she felt unsupported by NTGPE. While on the placement, she became sick with a respiratory illness and did not seek care until quite unwell. She had some concern about supervision by locum doctors in the hospital. However, she commented that, overall, the placement “has increased [my] interest in rural/remote [general practice]” and it was a “good placement medically”.
* De-identified details of other incidents are available for teaching purposes on request from NTGPE (see http://ntgpe.org).
Provenance: Not commissioned; externally peer reviewed.
- 1. Smith JD, Wolfe C; RhED Consulting. NT review of medical education and training: final report. Darwin: NT Department of Health and Community Services, 2007. http://www.health.nt.gov.au/library/scripts/objectifyMedia.aspx?file=pdf/6/92.pdf (accessed Dec 2010).
- 2. Imperato PJ. A third world international health elective for US medical students: the 25-year experience of the State University of New York, Downstate Medical Center. J Community Health 2004; 29: 337-373.
- 3. Ramsey AH, Haq C, Gjerde CL, Rothenberg D. Career influence of an international health experience during medical school. Fam Med 2004; 36: 412-416.
- 4. Haq C, Rothenberg D, Gjerde C, et al. New world views: preparing physicians in training for global health work. Fam Med 2000; 32: 566-572.
- 5. Pinto AD, Upshur RE. Global health ethics for students. Dev World Bioeth 2009; 9: 1-10.
- 6. Radstone SJ. Practising on the poor? Healthcare workers’ beliefs about the role of medical students during their elective. J Med Ethics 2005; 31: 109-110.
- 7. Banatvala N, Doyal L. Knowing when to say “no” on the student elective [editorial]. BMJ 1998; 316: 1404-1405.
- 8. Bhat SB. Ethical coherency when medical students work abroad. Lancet 2008; 372: 1133-1134.
- 9. Tyagi S, Corbett S, Welfare M. Safety on elective: a survey on safety advice and adverse events during electives. Clin Med 2006; 6: 154-156.
- 10. Charles Sturt University critical incident management handbook. September 2006: 11. http://www.csu.edu.au/division/facilitiesm/services/docs/critical-incident-management-hbook.pdf (accessed Dec 2010).
- 11. Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Med Educ 2000; 34: 827-840.
- 12. Shah S, Wu T. The medical student global health experience: professionalism and ethical implications. J Med Ethics 2008; 34: 375-378.
- 13. Dowell J, Merrylees N. Electives: isn’t it time for a change? Med Educ 2009; 43: 121-126.
- 14. Gordon J, Hazlett C, Ten Cate O, et al. Strategic planning in medical education: enhancing the learning environment for students in clinical settings. Med Educ 2000; 34: 841-850.