Rural, urban: the real world for medical education

The 1992 Rural Health Incentives Program was a wide response to deterioration in rural health care and falling recruitment to rural general practice. Its Rural Undergraduate Steering Committee1 was charged with developing and implementing a program of undergraduate medical education for rural practice. Studies had suggested that graduates would be more likely to return to rural communities if they had a rural background and positive clinical attachments in rural health care. Funds were available for strategic plans for rural student recruitment, increased rural placements, rural health curricula and strengthened staffing, student support and rural clubs. Research and innovation was funded to develop new educational paradigms. An early example, the Flinders Parallel Rural Community Curriculum was the starting point of an international network.2

Continuing funding depended on results, and in time there followed larger long-term initiatives, including rural clinical schools, and endorsement by the Australian Medical Council. Bonded scholarships encouraged students to commit to rural careers.

Two current MJA articles test initial suppositions. Participation in extended rural clerkships is shown to be a stronger predictor than rural background for early career choice;3 and a literature review finds junior medical officers in rural general practice are able to match the skills requirements of the Australian Curriculum Framework for Junior Doctors (ACFJD).4 The review also recorded additional benefits of rural experience, including “treating patients in context — both rural and Indigenous; and capacity for personal and professional growth”, pointing to a wider horizon for medical education than the scope of the ACFJD.

This wider horizon has received much attention in recent years, specifically through student experience within communities.5 The Rural Undergraduate Steering Committee emphasised that rural placement should of course provide experience of health care but should also ensure engagement with the community itself, its history, its context, its economic and social character, its real world. An exemplar at the time was Hawkesbury Agricultural College, which placed its students in rural communities as both the curriculum and the classroom.

The underlying principles were not new. Edwin Chadwick’s 1842 “Report on the sanitary condition of the labouring population of Great Britain”6 focused on the remediable physical and social determinants of health and disease. The 1915 Welch–Rose Report (unpublished report on behalf of the Institute of Hygiene) on training for public health in the United States highlighted “the many points of contact between the modern social welfare movement and the public health movement” and commended the practice of having Agricultural Extension Officers live within the rural community as trusted advisers and leaders in agricultural development. As it happens, in New Mexico, US, health extension officers are now being trained on the pattern of agricultural extension officers.7

The 1999 conference “Universities and the Health of the Disadvantaged”, convened by the World Health Organization (WHO), the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the University of Arizona, recommended that universities as a whole, not just health sciences, should commit to engagement with disadvantaged communities and their health and its determinants.8 The 2008 WHO Marmot Report on Social Determinants of Health was a focus for the recent MJA pre-election article “Comprehensive primary health care and social determinants as top priorities”.9

Such educational practice is not new either. In developing countries, health professional students have for many years become involved with these issues by living and learning within communities for weeks at a time, through curriculum programs such as Community Based Education and Service in Nigeria10 and many other countries. They move beyond the medical boundary of clinic and hospital to the fields of public health and welfare. Reviews have confirmed the value of this experience for professional orientation, contextually appropriate clinical practice and a commitment to equity in health.

Australia is a prominent leader within the several global networks now exploring and researching the practical experience of the interconnecting themes of community-based education, social accountability and equity for health.11

Many developments have been led by a concern for rural health, and that is proper. But urban communities have comparable regions of difficulty and inequity. It is not easy to place a student in an urban community. How can they engage with the most disadvantaged groups? In the medical schools of Durham (United Kingdom), Newcastle (Australia) and elsewhere, students are placed in the welfare and social care sector, including non-government organisations, where they experience at first hand a world that most students hardly see and which health services reach only in part: the disabled, the dispossessed, the homeless, the mentally ill, the unemployed, the destitute, the abused, refugees, and the socially and intellectually disadvantaged. These are transforming experiences. In Durham, such placements have led graduates to commit to inner-city practice where previously few would go.

There is common ground in the challenge of socially accountable medical education for both rural and urban health care. The common ground is the real world.