Beyond rural clinical schools to “by rural, in rural, for rural”: immersive community engaged rural education and training pathways

Cradle‐to‐grave regional programs featuring immersive community engaged education are needed to ensure a sustainable rural medical workforce

In this issue of the MJA, Seal and colleagues1 report a multi‐university investigation that found that extended rural clinical school (RCS) placements have a positive impact on rural workforce recruitment and the retention of both rural and metropolitan origin medical graduates. The authors examined the practice locations of medical graduates, as listed in the Australian Health Practitioner Regulation Agency (AHPRA) register, five and eight years after graduation; many doctors were probably still registrars in training locations five years after graduation. The authors considered a limited range of variables in their study, and did not adjust their analyses for registrars who had received bonded or other scholarships, nor for factors such as incentives to relocate and employment opportunities for partners. Nevertheless, there is merit in their conclusion that their “findings reinforce the importance of longitudinal rural and regional training pathways, and the role of RCSs, regional training hubs, and the rural generalist training program in coordinating these initiatives.”1

The publication of this study is timely, following the endorsement of the National medical workforce strategy 2021–20312 by Australian health ministers on 24 December 2021. The strategy includes five priorities and 25 actions, all of which are important for ensuring an adequate future rural medical workforce.3 Despite the encouraging findings of Seal and colleagues, the strategy highlights many challenges to achieving success by 2031, particularly with respect to a balanced workforce supply, mix, and distribution, and building the generalist capability needed to meet the future health needs of all Australians.

Priority three focuses on reforming training pathways, with clear recognition of the challenge: “A whole‐of‐training pathway view from medical school to Fellowship is required, with information provided to trainees on how to navigate it.”2 Such a facilitated education and training pathway from medical school to unsupervised practice is necessary but not sufficient to ensure success. A cradle‐to‐grave approach is required, whereby students are recruited from under‐served and under‐represented remote, rural, and Indigenous communities into rural‐based undergraduate education programs, with a facilitated pathway of rural‐based postgraduate training and professional development to support careers in rural practice.4

Specifically, rural‐based education and training should feature socially accountable immersive community‐engaged education, in which students and graduates learn in the community and clinical settings where they are expected to pursue their careers.5 This contrasts with the conventional Flexner model, in which clinical education is largely provided in metropolitan tertiary teaching hospitals. Although rural clinical schools are based in regional centres, they often replicate the hospital‐centric education of metropolitan centres. From an educational perspective, the importance of learning in context is recognised, with a growing literature on workplace‐integrated and service learning, as well as on socially accountable education.5

The longer the period of immersive community‐engaged training, the better the results in terms of educational outcomes and the career choices of graduates. Flinders University (South Australia) was the first in Australia to introduce 12‐month longitudinal integrated clerkships (LICs) that support students while living and learning in rural communities. The students participate in comprehensive patient care, learn through educational relationships with community‐based clinicians, and concurrently acquire core clinical competencies across multiple disciplines.6 The benefits of LICs for students, communities, and clinical teachers are particularly relevant to rural communities. Students achieve higher levels of clinical knowledge and skills, together with heightened confidence and competence. They also experience authentic assessment and feedback, becoming progressively more responsible for patient care; they appreciate community support and relationships and develop their professional identity, and their interest in a general practice career is fostered. In the short term, communities gain through active participation in medical education and the expansion of their local health teams, and later through local recruitment of LIC graduates. The benefits of LICs for clinical teachers include personal and professional growth and development, recognition, and enhanced succession planning and recruitment. With few exceptions, patients are very receptive to care by medical students on LICs.7

Implementing socially accountable immersive community‐engaged education requires active community engagement8 that provides authentic interdependent partnerships between health service delivery organisations and academic institutions that respect and value the communities’ local knowledge and expertise. The benefits of community engagement may include community empowerment with respect to local health services, enhanced health service access and the promotion of locally relevant services that reflect community needs, the development and delivery of education programs that assist students and trainees to appreciate the social determinants of health at the local level, and improved local health workforce recruitment and retention.9

Graduates who have undertaken immersive community‐engaged education are more likely to choose careers in general practice or other generalist disciplines. “By rural, in rural, for rural” immersive community‐engaged education is an important aspect of implementing the “plan, recruit, retain” stability framework10 required to optimise the rural medical workforce Australia needs, and to realise the aspirations of the National medical workforce strategy 2021–2031.