Factors that sustain indigenous youth mentoring programs: a qualitative systematic review.

BACKGROUND: Indigenous youth worldwide continue to experience disproportional rates of poorer mental health and well-being compared to non-Indigenous youth. Mentoring has been known to establish favorable outcomes in many areas of health but is still in its early phases of research within Indigenous contexts. This paper explores the barriers and facilitators of Indigenous youth mentoring programs to improve mental health outcomes and provides evidence for governments' response to the United Nations Declaration on the Rights of Indigenous Peoples. METHODS: A systematic search for published studies was conducted on PubMed, Embase, Scopus, CINAHL, and grey literature through Trove, OpenGrey, Indigenous HealthInfoNet, and Informit Indigenous Collection. All papers included in the search were peer-reviewed and published from 2007 to 2021. The Joanna Briggs Institute approaches to critical appraisal, data extraction, data synthesis, and confidence of findings were used. RESULTS: A total of eight papers describing six mentoring programs were included in this review; six papers were from Canada, and two originated from Australia. Studies included mentor perspectives (n = 4) (incorporating views of parents, carers, Aboriginal assistant teachers, Indigenous program facilitators, young adult health leaders, and community Elders), mentee perspectives (n = 1), and both mentor and mentee perspectives (n = 3). Programs were conducted nationally (n = 3) or within specific local Indigenous communities (n = 3) with varying mentor styles and program focus. Five synthesized findings were identified from the data extraction process, each consisting of four categories. These synthesized findings were: establishing cultural relevancy, facilitating environments, building relationships, facilitating community engagement, and leadership responsibilities, which were discussed in the context of extant mentoring theoretical frameworks. CONCLUSION: Mentoring is an appropriate strategy for improving general well-being. However, more research is needed to explore program sustainability and maintaining outcomes in the long term.

Undergraduate rural medical training experiences and uptake of rural practice: a retrospective cohort study in South Australia.

BACKGROUND: Rural medical training experiences provided by Rural Clinical Schools (RCS) can encourage future practice in rural locations. However, the factors influencing students' career choices are not well understood. This study explores the influence of undergraduate rural training experiences on graduates' subsequent practice location. METHODS: This retrospective cohort study included all medical students who completed a full academic year at the University of Adelaide RCS training program between 2013-2018. Details of student characteristics, experiences, and preferences were extracted from the Federation of Rural Australian Medical Educators (FRAME, 2013-2018) survey and linked to graduates' recorded practice location obtained from the Australian Health Practitioner Regulation Agency (AHPRA, January 2021). The rurality of the practice location was defined based on the Modified Monash Model (MMM 3-7) or Australian Statistical Geography Standard (ASGS 2-5). Logistic regression was used to examine associations between student rural training experiences and rural practice location. RESULTS: A total of 241 medical students (60.1% females; mean age 23.2 ± 1.8 years) completed the FRAME survey (response rate 93.2%). Of these, 91.7% felt well supported, 76.3% had a rural-based clinician mentor, 90.4% reported increased interest in a rural career, and 43.6% preferred a rural practice location after graduation. Practice locations were identified for 234 alumni, and 11.5% were working rurally in 2020 (MMM 3-7; 16.7% according to ASGS 2-5). In adjusted analysis, the odds of working rurally were 3-4 times more likely among those with a rural background or lived the longest in a rural location, 4-12 times more likely among those preferring a rural practice location after graduation, and increased with the student's rural practice self-efficacy score (p-value < 0.05 in all cases). Neither the perceived support, having a rural-based mentor, or the increased interest in a rural career were associated with the practice location. CONCLUSIONS: These RCS students consistently reported positive experiences and increased interest in rural practice after their rural training. Student reported preference for a rural career and rural practice self-efficacy score were significant predictors of subsequent rural medical practice. Other RCS could use these variables as indirect indicators of the impact of RCS training on the rural health workforce.

Australian rural medical students' perceived readiness for work as a junior doctor: A cross-sectional national survey.

OBJECTIVE: To report self-perceived readiness for work as a junior doctor in a national cohort of rural clinical school students. DESIGN: Cross-sectional study using a self-report questionnaire. Independent variables included 14 individual readiness items related to clinical and professional tasks, sociodemographic data and reported experience of rural clinical school (RCS) training. Participants were 668 medical students (55.3% females) completing a full academic year in rural Australia. Multivariable analysis explored factors associated with overall readiness for work as a junior doctor. FINDINGS: 86% agreed that RCS experience prepared them to undertake the roles and responsibilities of a junior doctor. Self-ratings for specific clinical and professional tasks varied from a mean score of 5.9-8.0 out of 10, and 13 of the 14 items were associated with the outcome (p-value <0.001, except for performing spirometry). Lowest readiness scores were seen for some aspects including raising concerns about a colleague (mean score 6.1) or responding to workplace bullying (mean score 6.0). Aspects of the RCS experience that were strongly associated with overall readiness included: feeling a valued team-member (OR 9.28, 95%CI 2.43-35.39), feeling well-supported academically (OR 6.64, 95%CI 3.39-13.00), having opportunity for unsupervised but supported clinical practice (OR 4.67, 95%CI 1.45-15.00), having a rural mentor (OR 3.38, 95%CI 1.89-6.06) and having a previous health professional qualification (OR 2.7, 95%CI 1.32-5.54). DISCUSSION: Most RCS students felt ready for work as a junior doctor. Important aspects of RCS experience are likely to include students feeling integrated within the clinical team and having opportunities for authentic clinical roles. There remains a significant challenge for medical school curricula to address professional areas where graduates felt less prepared.

Evaluating the impact of the Adelaide Rural Clinical School longitudinal clinical placement on the rural medical workforce: A retrospective cohort study of graduates, 2004-2019.

OBJECTIVE: To evaluate the contribution of the Adelaide Rural Clinical School (ARCS) longitudinal integrated clerkship to the rural medical workforce. METHODS: Design: Retrospective cohort study. SETTING: Practice location data were sourced from the Australian Health Practitioner Regulation Agency (AHPRA, January 2021) and matched using university records. PARTICIPANTS: University of Adelaide medical school alumni graduating between 2004 and 2019 (ARCS alumni who completed a full year of rural training [n = 423], metropolitan-trained peers [n = 1655]). MAIN OUTCOME MEASURES: The proportions of medical graduates working in a rural location (Modified Monash Model [MMM3-7] or Australian Statistical Geography Standard [ASGS-RA2-5] classifications). Logistic regression was used to examine the association between ARCS training and working rurally, and the influence of rural background and sociodemographic factors. RESULTS: Working in a rural location was almost three times more frequent among ARCS alumni than their metropolitan-trained peers, using the MMM3-7 (14.7% vs. 5.3%) classification; for ASGS-RA2-5 classification (21.3% vs. 8.9%). In adjusted analysis, working rurally (MMM3-7) was associated with having a rural/remote residence on enrolment (OR 8.29, 95% CI 4.22-16.26) and was 3.1 times more likely for ARCS alumni (OR 3.06, 95% CI 2.06-4.53) than their peers. The magnitude of the effects of ARCS training on whether they are working rurally was similar among those with metropolitan or rural background (p-value for interaction 0.873). Similar associations were observed using ASGS-RA2-5 classifications. CONCLUSIONS: Extended rural placements through the Adelaide Rural Clinical School increased the rural medical workforce, with a similar impact among those with a rural or metropolitan background.

The safety of anaesthesia delivered by rural generalist anaesthetists: a scoping review of the literature.

INTRODUCTION: Rural generalist anaesthetists (RGAs) are central to the delivery of health care in much of rural and remote Australia. This article details a systematic review of the literature specifically asking the question, 'What is the current evidence of the 'safety' of anaesthesia delivered by RGAs?' METHODS: Six databases were searched using terms including 'safety', 'rural', 'anaesthetics', 'general practitioners', and associated search terms. Relevant articles were assessed for rigour, and information was summarised using qualitative grid analysis that included information on the study setting, participants, methods, limitations and key result areas. The primary author developed key themes from the data, which were refined in discussion with other authors. RESULTS: The safety of RGAs was described using five concepts: appropriate training and leadership, rates of complications, volume or scope of practice, access to equipment, and case selection. CONCLUSION: RGAs are pivotal in the delivery of health care in rural and remote communities. The sparse literature available on RGA safety is broadly grouped into five areas. There is a need to characterise and describe the role of RGAs, review and revise training and education, recognise RGA scope of practice and understand how RGAs lead the management of safety and risk in their practice.

Insights into rural generalist therapeutic reasoning using a simulated multi-patient emergency scenario.

INTRODUCTION: Therapeutic reasoning focuses on the decisions related to patient disposition and management. This is in contrast to diagnostic reasoning, which is the focus of much of the current discourse in the medical literature. Few studies relate to therapeutic reasoning, and even fewer relate to the rural and remote context. This project sought to explore the therapeutic reasoning used by rural generalists working in a small rural hospital setting in Australia, caring for patients for whom it was unclear if escalation of care, including admission or interhospital transfer, was needed. METHODS: This study was conducted using an interpretivist approach. A simulation scenario was developed with rural generalists and experts in medical simulation to use as a test bed to explore the reasoning of the rural generalist participants. The simulation context was a small rural Australian hospital with resources and treatment options typical of those found in a similar real-life setting. A simulated patient and a registered nurse were embedded in the scenario. Participants needed to make decisions throughout the scenario regarding the simulated patient and two anticipated patients who were said to be coming to the department. The scenario was immediately followed by a semi-structured interview exploring participants' therapeutic reasoning when planning care for these three patients. An inductive content analysis approach was used to analyse the data, and a mental model was developed. The researchers then tested this mental model against the recordings of the participants' simulation scenarios. RESULTS: Eight rural generalists, with varying levels of experience, participated in this study. Through the semi-structured interviews, participants described five themes: assessing clinician capacity to manage patient needs; availability of local physical resources and team members; considering options for help when local management was not enough; patients' wishes and shared decision making; and anticipating future requirements. The mental model developed from these themes consisted of seven questions: 'What can I do for this patient locally and what are my limits?'; 'Who is in my team and who can I rely on?'; 'What are the advantages and disadvantages of local management vs transfer?'; 'Who else needs to be involved and what are their limits?;' 'How can we align the patient's wants with their needs?'; 'How do we adapt to the current and future situation?'; and 'How do I preserve the capacity of the health service to provide care?' CONCLUSION: This study explored the therapeutic reasoning of rural generalists using a simulated multi-patient emergency scenario. The mental model developed serves as a starting point when discussing therapeutic reasoning and is likely to be useful when providing education to medical students and junior doctors who are working in rural and remote contexts where resources and personnel may be limited.

Developing conceptually sound items for a clinical courage questionnaire.

INTRODUCTION: Clinical courage can be described as a rural doctor's adaptability and willingness to undertake clinical work at the limits of their training and experience to meet the needs of their patients. This article describes the in-house development of survey items to include in a quantitative measure of clinical courage. METHODS: The questionnaire development involved two key concepts: a second-order latent factor model structure and a nominal group technique, used to develop consensus among the research team members. RESULTS: The steps taken to develop a sound clinical courage questionnaire are described in detail. The resulting initial questionnaire is presented, ready for testing with rural clinicians and refinement. CONCLUSION: This article outlines the psychometric process of questionnaire design and presents the resultant clinical courage questionnaire.

Point-of-care ultrasound in general practice: an exploratory study in rural South Australia.

INTRODUCTION: Access to ultrasound imaging services is limited in rural areas and point-of-care ultrasound (POCUS) has the potential to address this gap. We aimed to examine how POCUS is utilised by doctors in contemporary Australian rural general practice. METHODS: A portable ultrasound machine and access to a training course were provided to four general practices in rural South Australia, and the type and frequency of POCUS scans were recorded, along with user information, between July 2020 and June 2021. Participating general practitioners (GPs) completed a survey at the commencement of the study regarding their previous experience and confidence in using POCUS for specific assessments and procedures. RESULTS: Of the 472 scans recorded, most (95%) were for clinical indications, 3% for teaching activities and 2% for self-learning. Overall, 69% were obstetric scans, followed by abdominal (12%), gynaecological procedures (10%), other procedural (7%) and thoracic exams (1.5%). Users reported higher confidence for lower complexity POCUS. CONCLUSION: Although POCUS has diverse potential applications in rural practice, GPs reported limited confidence for certain scans and used POCUS predominantly for obstetric indications. Further studies should examine the barriers to POCUS utilisation, with particular attention to training requirements, reimbursement for use and access to machines.

Contemporary Australian socio-cultural factors and their influence on medical student rural career intent.

OBJECTIVE: To understand how contemporary socio-cultural factors may impact medical students' rural career intent. DESIGN: Cross-sectional study using data from the national Federation of Rural Australian Medical Educators survey. PARTICIPANTS/SETTING: Medical students across 18 Australian universities who completed a full academic year of clinical training in rural areas in 2019. MAIN OUTCOME MEASURE(S): Preferred location of practice post-training reported to be either: (i) a major city; (ii) a regional area or large town; or (iii) a small rural location. RESULTS: In total, 626 students completed the survey (70.1% response rate). A small rural location was the most preferred location of practice after graduation for 28.3% of the students (95% CI 21.6-36.0). Four socio-cultural factors were positively associated with a preference for a rural career location: poor health status of rural people, motor vehicle traffic congestion in cities, rural generalist training opportunities in the state and the Royal Flying Doctor Service. Other socio-cultural factors, including specialists' under-employment, Medicare freeze effect on doctors' income, bullying/sexual harassment in hospitals, climate change/natural disasters or recognised rural health personalities did not influence the investigated outcome. CONCLUSIONS: Our findings indicate a novel association between contemporary socio-cultural factors and rural career intention in a cohort of Australian rural clinical school students. These findings advocate for further consideration of research exploring socio-cultural factors shaping rural career intent and workforce outcomes.

Pregnancy-related aeromedical retrievals in rural and remote Australia: national evidence from the Royal Flying Doctor Service.

BACKGROUND: Inequalities in the availability of maternity health services in rural Australia have been documented, but not the impact on aeromedical retrievals. This study aims to examine the prevalence of pregnancy-related aeromedical retrievals, the most common conditions (overall and in specific age groups), and their distribution according to operation area and demographic characteristics. METHODS: Cross-sectional study using administrative data from the Royal Flying Doctors Service (RFDS) including all pregnant women aged 15-49 years retrieved by the RFDS between 2015 and 2019. All pregnancy-related aeromedical retrievals were classified according to the International Classification of Diseases, Tenth Revision (ICD-10, chapter XV). The distribution of pregnancy-related conditions was presented overall and stratified by age group (i.e. < 20 years, 20-34 years and 35+ years). Retrieval and receiving sites were geographically mapped with Tableau mapping software® based on postcode numbers of origin and destination. RESULTS: A total of 4653 pregnancy-related retrievals were identified (mean age 27.8 ± 6.1 years), representing 3.1% of all RFDS transfers between 2015 and 18 and 3.5% in 2018-19 (p-value 0.01). The highest proportion of pregnancy-related retrievals (4.8%) occurred in Western operation. There was an apparent increase in pregnancy-related retrievals in South Australia and the Northern Territory (Central Operation) in 2018-19. Preterm labour/delivery was responsible for 36.4% of all retrievals (40.7% among women aged 15-19 years) and premature rupture of membranes for 14.9% (19.4% among women aged 35-49 years). Inter-hospital transfers represented 87.9% of all retrievals, with most patients relocated from rural and remote regions to urban hospitals; most retrievals occurred during the day, with a median distance of 300 km. Adolescents and Aboriginal and Torres Strait Islander were overrepresented in the sample (four and eight times higher than their metropolitan counterparts, respectively). CONCLUSIONS: The proportion of pregnancy-related aeromedical retrievals varies geographically across Australia. Overall, one-third of retrievals were related to preterm/delivery complications, especially among adolescents. Most retrievals performed by the RFDS are susceptible to public health strategies aimed at improving antenatal care and preventing unintended pregnancies among adolescents and Aboriginal and Torres Strait Islander women. Greater capacity to manage pregnancy conditions in rural hospitals could reduce the requirement for aeromedical inter-hospital transfers.

Factors associated with medical students' interest in remote and very remote practice in Australia: A national study.

OBJECTIVE: To investigate the factors that are associated with medical student interest in remote and very remote practice in Australia. DESIGN: Aggregated data of an annual cross-sectional survey from 2013 to 2017. SETTING: Australia. PARTICIPANTS: Medical students from 17 medical schools, at the point of finishing one year of clinical training in a rural or remote location in Australia. MAIN OUTCOME MEASURES: Intention for working in a remote or very remote location as a doctor. RESULTS: Responses were analysed from 3328 medical students. From this cohort, 37.6%, 54.0% and 7.0% of students reported future career intent in capital or major cities; regional Australia; and remote or very remote Australia respectively. Multivariable analysis indicated students interested in remote and very remote practice compared to those interested in regional practice were more likely to be from a rural background, have prior generalist intentions, felt as though their rural clinical school (RCS) experience increased interest in remote and very remote practice, and had higher rural practice self-efficacy. Odds ratios were larger for these factors when students interested in remote or very remote practice were compared with students interested in practicing in capital or major cities. CONCLUSIONS: Rural background, prior generalist intentions, rural practice self-efficacy and the overall influence of the RCS experience are associated with interest in remote and very remote practice.

Rural emergency departments: A systematic review to develop a resource typology relevant to developed countries.

OBJECTIVE: Despite low patient numbers, rural emergency departments have a similar diversity of case presentations as urban tertiary hospitals, with the need to manage high-acuity cases with limited resources. There are no consistent descriptions of the resources available to rural emergency departments internationally, limiting the capacity to compare clinical protocols and standards of care across similarly resourced units. This review aimed to describe the range of human, physical and specialist resources described in rural emergency departments in developed countries and propose a typology for use internationally. DESIGN AND SETTING: A systematic literature search was performed for journal articles between 2000 and 2019 describing the staffing, access to radiology and laboratory investigations, and hospital inpatient specialists. RESULTS: Considerable diversity in defining rurality and in resource access was found within and between Australia, New Zealand, Canada and USA. DISCUSSION: A typology was developed to account for (a) emergency department staff on-floor, (b) emergency department staff on-call, (c) physical resources and (d) access to a specialist surgical service. This provides a valuable tool for relevant stakeholders to effectively communicate rural emergency department resources within a country and internationally. CONCLUSION: The proposed five-tiered typology draws together international literature regarding rural emergency department services. Although further research is required to test this tool, the formation of this common language allows a base for effective communication between governments, training providers and policy-makers who are seeking to improve health systems and health outcomes.

Are Australian rural clinical school students' career choices influenced by perceived opinions of primary care? Evidence from the national Federation of Rural Australian Medical Educators survey.

OBJECTIVE: To investigate whether perceived opinions of primary care are associated with student career preferences after graduation among a rural clinical school cohort and whether the preferred location of practice moderates these relationships. DESIGN: Cross-sectional study using data from the national Federation of Rural Australian Medical Educators survey. PARTICIPANTS/SETTING: Medical students across 18 Australian universities who completed a clinical year in a rural setting in 2019. MAIN OUTCOME MEASURE(S): Career preference in primary care after graduation. RESULTS: The survey was completed by 624 students (response rate = 69.9%). A preference for primary care was reported by 35.5% (95% CI: 29.4-42.0) of students and was more likely among those age 30+ years, with a rural background, or preferring to practise rurally after graduation. Students reported that primary care was more commonly respected by medical academics (66.8%) than peers (24.0%) or junior/hospital doctors (24.0%). In adjusted analysis, none of the perceived opinions were associated with student career preferences. However, among students aiming to work in small rural locations, a career in primary care was associated with more frequent reports that peers had poor opinions of primary care (P = .004). CONCLUSION: Rural clinical school students perceive negative opinions of primary care, particularly among peers and junior/hospital doctors. Students aiming to work in small towns after graduation are more likely to report negative opinions among their peers, suggesting they may be more attuned to negative attitudes. This points to the need for a community of practice of like-minded peers and clinicians to preserve the career interest of these students.

The impact of interpersonal relationships on rural doctors' clinical courage.

INTRODUCTION: Clinical courage occurs when rural doctors push themselves to the limits of their scope of practice to provide the medical care needed by patients in their community. This mental strength to venture, persevere and act out of concern for one's patient, despite a lack of formally recognised expertise, becomes necessary for doctors who work in relative professional isolation. Previous research by the authors suggested that the clinical courage of rural doctors relies on the relationships around them. This article explores in more depth how relationships with others can impact on clinical courage. METHODS: At an international rural medicine conference in 2017, doctors who practised rural/remote medicine were invited to participate in the study. Twenty-seven semistructured interviews were conducted exploring experiences of clinical courage. Initial analysis of the material, using a hermeneutic phenomenological frame, sought to understand the meaning of clinical courage. In the original analysis, an emic question arose: 'How do interpersonal relationships impact on clinical courage'. The material was re-analysed to explore this question, using Wenger's community of practice as a theoretical framework. RESULTS: This study found that clinical courage was affected by the relationships rural doctors had with their communities and patients, with each other, with the local members of their healthcare team and with other colleagues and health leaders outside their immediate community of practice. CONCLUSION: As a collective, rural doctors can learn, use and strengthen clinical courage and support its development in new members of the discipline. Relationships with rural communities, rural patients and urban colleagues can support the clinical courage of rural doctors. When detractors challenge the value of clinical courage, it requires individual rural doctors and their community of practice to champion rural doctors' way of working.

Doctors' rural practice self-efficacy is associated with current and intended small rural locations of practice.

OBJECTIVE: Key factors which positively influence recruitment and retention of doctors to rural practice include rural background and positive rural training experience. Despite this knowledge, there is no well-established conceptual framework to explain how these factors influence intention. The aim of this study was to consider rural practice self-efficacy and its influence on rural career choice by doctors. Questions relating to self-efficacy were formulated using Bandura's four proposed sources of self-efficacy, which include mastery experiences, vicarious experience, social persuasion and emotional and physical response to experiences. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Medical school graduates from Flinders University, who completed a rural year as a part of the clinical component of the course between 1997 and 2015. MAIN OUTCOME MEASURES: Rural self-efficacy; current and intended location of practice in small rural communities (<25 000 people). RESULT: It was found that 28.5% of participants were currently working in communities of <25 000 people. Levels of intent for future small town rural practice were consistent across career stages after internship. Higher rural practice self-efficacy scores were found in doctors working in smaller towns (<25 000) and small communities (<10 000). Higher self-efficacy was also associated with rural background, more senior career status, earlier speciality decision time and smaller expectation-experience gap. CONCLUSION: An independent association exists between rural self-efficacy and intention to remain or return to small rural practice. The article offers rural clinical schools the opportunity to consider how they can influence future rural career outcomes.

Stakeholder views of rural community-based medical education: a narrative review of the international literature.

CONTEXT: Rural community-based medical education (RCBME), in which medical student learning activities take place within a rural community, requires students, clinical teachers, patients, community members and representatives of health and government sectors to actively contribute to the educational process. Therefore, academics seeking to develop RCBME need to understand the rural context, and the views and needs of local stakeholders. OBJECTIVES: The aim of this review is to examine stakeholder experiences of RCBME programmes internationally. METHODS: This narrative literature review of original research articles published after 1970 utilises Worley's symbiosis model of medical education as an analysis framework. This model proposes that students experience RCBME through their intersection with multiple clinical, social and institutional relationships. This model seeks to provide a framework for considering the intersecting relationships in which RCBME programmes are situated. RESULTS: Thirty RCBME programmes are described in 52 articles, representing a wide range of rural clinical placements. One-year longitudinal integrated clerkships for penultimate-year students in Anglosphere countries were most common. Such RCBME enables students to engage in work-integrated learning in a feasible manner that is acceptable to many rural clinicians and patients. Academic results are not compromised, and a few papers demonstrate quality improvement for rural health services engaged in RCBME. These programmes have delivered some rural medical workforce outcomes to communities and governments. Medical students also provide social capital to rural communities. However, these programmes have significant financial cost and risk student social and educational isolation. CONCLUSIONS: Rural community-based medical education programmes are seen as academically acceptable and can facilitate symbiotic relationships among students, rural clinicians, patients and community stakeholders. These relationships can influence students' clinical competency and professional identity, increase graduates' interest in rural careers, and potentially improve rural health service stability. Formal prospective stakeholder consultations should be published in the literature.

Block versus longitudinal integrated clerkships: students' views of rural clinical supervision.

CONTEXT: Medical students undertaking longitudinal integrated clerkships (LICs) train in multiple disciplines concurrently, compared with students in block rotations who typically address one medical discipline at a time. Current research suggests that LICs afford students increased access to patients and continuity of clinical supervision. However, these factors are less of an issue in rural placements where there are fewer learners. The aim of this study was to compare rural LIC and rural block rotation students' reported experiences of clinical supervision. METHODS: De-identified data from the 2015 version of the Australian national rural clinical schools (RCSs) exit survey was used to compare students in LICs with those in block rotations in relation to how they evaluate their clinical supervisors and how they rate their own clinical competence. RESULTS: Multivariate general linear modelling showed no association between placement type (LIC versus Block) and reported clinical supervision. The single independent predictor of positive perception of clinical supervisors was choosing an RCS as a first preference. There was also no association between placement type (LIC versus Block) and self-rated clinical competence. Instead, the clinical supervision score and male gender predicted more positive self-ratings of clinical competence. CONCLUSIONS: The quality of clinical supervision in block placements and LIC programmes in rural Australian settings was reported by students as equivalent.

Expectations of rural community-based medical education: a case study from Thailand.

INTRODUCTION: Thailand has recognised and sought to remedy rural medical workforce shortages. The Collaborative Project to Increase Production of Rural Doctors (CPIRD) has improved rural workforce recruitment through publicly funding medical school places for students with rural backgrounds. However, challenges in rural retention continue. CPIRD is seeking to develop a Thai rural community-based medical education (RCBME) program in the southern region of Thailand to improve preparation for rural practice and rural medical retention rates. Prospective stakeholder consultations will allow the understanding of expectations and concerns of stakeholders required for successful RCBME implementation. This study aims to explore stakeholders' expectations of the Southern Thai RCBME initiative. METHODS: A qualitative case study comprised a purposive sample of students, clinical educators, policymakers, rural health professionals and local community stakeholders, all likely to be involved in a new RCBME program in Songkhla Province, Thailand. Individual semi-structured interviews were audiotaped, transcribed in Thai and coded using Worley's symbiosis framework. Following this, text and quotes used in the initial analysis were translated into English, discussed and reanalysed for emergent themes across the framework. RESULTS: A total of 21 participants contributed RCBME stakeholder perspectives. They demonstrated expectations and concerns in each of the relationship axes of the symbiosis model including the clinical, institutional, social and personal axes. Three major themes emerged from the data that integrated stakeholder perspectives on the implication of RCBME in Thailand. These themes were a dramatic shift in Thai medical education paradigm, seeing rural practice as a future career, and collaboration to improve education and health in rural services. CONCLUSION: This study comprehensively describes Thai stakeholder expectations of RCBME and demonstrates that, although some principles of RCBME are universal, context does influence the expectations and capacity of stakeholders to contribute to RCBME. Prospective formal stakeholder engagement is recommended to ensure successful implementation of new educational innovations.

Early dynamic ultrasound for neonatal hip instability: implications for rural Australia.

BACKGROUND: Neonatal instability of the hip (NIH), where the femoral head can move away from the acetabulum, in the first weeks of life, is an important risk factor for developmental dysplasia of the hip (DDH). In rural areas in Australia, there is a recent trend to increased late diagnosis of DDH. Clinical screening of infant hips, a common practice in Australia, is experience dependent. Best practice early screening techniques are still debated with different techniques and timing used internationally. This systematic review examines early dynamic ultrasound (eDUS) screening for hip instability in the first 6 weeks after birth, and the early interventions informed by these findings and considers the findings for the context of rural Australia. METHODS: The Cochrane Library, Medline, CINAHL and PEDro were searched for original research or systematic reviews, and clinical studies 1998 to 2015 involving dynamic ultrasound. Critical Appraisal Skills Programme tools were used to appraise the studies. RESULT: Nineteen studies were included. Early Dynamic Ultrasound (DUS) is consistently described as a reliable assessment of NIH. Early DUS is recommended for risk factors including geographical areas of high prevalence. Approaches to early intervention of hips with excessive movement are somewhat discipline-related and include: primary prevention (advice), secondary prevention (abduction supports), and conservative management (removable splints). CONCLUSIONS: In the context of increased prevalence of DDH in rural Australia, contemporary evidence suggests that introduction of early DUS could provide rural infants with more effective screening than clinical examination alone. Targeted early advice about posturing and simple removable supports to abduct infant hips could prevent some cases of DDH in rural Australia.