Teaching compassion for social accountability: A parallaxic investigation.

BACKGROUND: In an arts integrated interdisciplinary study set to investigate ways to improve social accountability (SA) in medical education, our research team has established a renewed understanding of compassion in the current SA movement. AIM: This paper explores the co-evolution of compassion and SA. METHODS: The study used an arts integrated approach to investigate people's perceptions of SA in four medical schools across Australia, Canada, and the USA. Each school engaged approximately 25 participants who partook in workshops and in-depth interviews. RESULTS: We began with a study of SA and the topic of compassion emerged out of our qualitative data and biweekly meetings within the research team. Content analysis of the data and pedagogical discussion brought us to realize the importance of compassion in the practice of SA. CONCLUSIONS: The cultivation of compassion needs to play a significant role in a socially accountable medical educational system. Medical schools as educational institutions may operate themselves with compassion as a driving force in engaging partnership with students and communities. Social accountability without compassion is not SA; compassion humanizes institutional policy by engaging sympathy and care.

Social responsiveness: The key ingredient to achieve social accountability in education and health care.

While social accountability (SA) is regarded as an obligation or mandate for medical school administration, it runs the danger of becoming a bureaucratic checkbox. Compassion which leads to social responsiveness (SR), in contrast, is often recognized as an individual characteristic, detached from the public domain. The two, however, complement each other in practice. Institutions must be truly socially accountable, which is possible if there is spontaneous SR to the needs, and is fueled by compassion. Compassion in this article is defined as a "feeling for other people's sufferings, and the desire to act to relieve the suffering." Compassion has a long history, whereas SA is more recently described concept that follows the historical development of social justice. SR is the moral or ethical duty of an individual to behave in a way that benefits society. Not everyone feels the need to do something for others. Even if the need is felt, there may be a lack of will to act for the needs or to act effectively to fulfill the needs of society. The reasons are many, some visible and others not. SR provides the basis for being compassionate; hence, medical schools need to include SR as a criterion in their admissions process for student recruitment and inculcate compassion in health professions education and health care. By fostering SR and engaging compassion and self-compassion to achieve SA, we can humanize medical education systems and health care.

The Limerick Declaration on Rural Health Care 2022.

The 19th World Rural Health Conference, hosted in rural Ireland and the University of Limerick, with over 650 participants coming from 40 countries and an additional 1600 engaging online, has carefully considered how best rural communities can be empowered to improve their own health and the health of those around them. The conference also considered the role of national health systems and all stakeholders, in keeping with the commitments made through the Sustainable Development Goals and the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being. This conference declaration, the Limerick Declaration on Rural Healthcare, is designed to inform rural communities, academics and policymakers about how to achieve the goal of delivering high quality health care in rural and remote areas most effectively, with a particular focus on the Irish healthcare system. Congruent with current evidence and best international practice, the participants of the conference endorsed a series of recommendations for the creation of high quality, sustainable and cost-effective healthcare delivery for rural communities in Ireland and globally. The recommendations focused on four major themes: rural healthcare needs and delivery, rural workforce, advocacy and policy, and research for rural health care. Equal access to health care is a crucial marker of democracy. Hence, we call on all governments, policymakers, academic institutions and communities globally to commit to providing their rural dwellers with equitable access to health care that is properly resourced and fundamentally patient-centred in its design.

Integrated clinical learning: team teaching and team learning in primary care.

Developed in Northern Ontario, Canada, Integrated Clinical Learning (ICL) involves a team of clinical teachers from a range of health professions teaching a team of students and trainees together in common community and clinical settings. It is the balanced integration of educational strategies to develop healthcare providers and team-based competencies focused on improving the quality of care. Learning outcomes are developed with and in consideration of the goals of patients or the community through relational learning that mirrors patient-centred care. Implementing ICL requires a systematic approach that addresses the practical issues and enhances the quality of experience for all involved. These practicalities include academic institutions valuing ICL through the appointment and support of primary care clinicians as academic staff with protected time; the provision of physical space, as well as clinical and teaching equipment; and the appointment of local administrative coordinators. The team approach shares the teaching load with the multiple students actually teaching each other so that the load on individual clinicians is less than for one student at a time. Through ICL, students are learning from patients and developing a service-oriented professional identity. The patient and family centred nature of ICL helps bridge the primary care-secondary care divide as students follow their patients into and out of hospital services. This is positive for patients and specialists and provides authentic learning for students. ICL enhances the quality of care; the quality of learning; and the quality of professional satisfaction for primary care clinical teachers.

Plan, recruit, retain: a framework for local healthcare organizations to achieve a stable remote rural workforce.

BACKGROUND: Recruiting and retaining a skilled health workforce is a common challenge for remote and rural communities worldwide, negatively impacting access to services, and in turn peoples' health. The research literature highlights different factors facilitating or hindering recruitment and retention of healthcare workers to remote and rural areas; however, there are few practical tools to guide local healthcare organizations in their recruitment and retention struggles. The purpose of this paper is to describe the development process, the contents, and the suggested use of The Framework for Remote Rural Workforce Stability. The Framework is a strategy designed for rural and remote healthcare organizations to ensure the recruitment and retention of vital healthcare personnel. METHOD: The Framework is the result of a 7-year, five-country (Sweden, Norway, Canada, Iceland, and Scotland) international collaboration combining literature reviews, practical experience, and national case studies in two different projects. RESULT: The Framework consists of nine key strategic elements, grouped into three main tasks (plan, recruit, retain). Plan: activities to ensure that the population's needs are periodically assessed, that the right service model is in place, and that the right recruits are targeted. Recruit: activities to ensure that the right recruits and their families have the information and support needed to relocate and integrate in the local community. Retain: activities to support team cohesion, train current and future professionals for rural and remote health careers, and assure the attractiveness of these careers. Five conditions for success are recognition of unique issues; targeted investment; a regular cycle of activities involving key agencies; monitoring, evaluating, and adjusting; and active community participation. CONCLUSION: The Framework can be implemented in any local context as a holistic, integrated set of interventions. It is also possible to implement selected components among the nine strategic elements in order to gain recruitment and/or retention improvements.

Retaining graduates of non-metropolitan medical schools for practice in the local area: the importance of locally based postgraduate training pathways in Australia and Canada.

INTRODUCTION: The objective of this study was to identify commonalities between one regionally based medical school in Australia and one in Canada regarding the association between postgraduate training location and a doctor's practice location once fully qualified in a medical specialty. METHODS: Data were obtained using a cross-sectional survey of graduates of the James Cook University (JCU) medical school, Queensland, Australia, who had completed advanced training to become a specialist (a 'Fellow') in that field (response rate = 60%, 197 of 326). Medical education, postgraduate training and practice data were obtained for 400 of 409 (98%) fully licensed doctors who completed undergraduate medical education or postgraduate training or both at the Northern Ontario School of Medicine (NOSM), Ontario, Canada. Binary logistic regression used postgraduate training location to predict practice in the school's service region (northern Australia or northern Ontario). Separate analyses were conducted for medical discipline groupings of general/family practitioner, general specialist and subspecialist (JCU only). RESULTS: For JCU graduates, significant associations were found between training in a northern Australian hospital at least once during postgraduate training and current (2018) northern Australian practice for all three discipline subgroups: family practitioner (p<0.001; prevalence odds ratio (POR)=30.0; 95% confidence interval (CI): 6.7-135.0), general specialist (p=0.002; POR=30.3; 95%CI: 3.3-273.4) and subspecialist (p=0.027; POR=6.5; 95%CI: 1.2-34.0). Overall, 38% (56/149) of JCU graduates who had completed a Fellowship were currently practising in northern Australia. For NOSM-trained doctors, a significant positive effect of training location on practice location was detected for family practice doctors but not for general specialist doctors. Family practitioners who completed their undergraduate medical education at NOSM and their postgraduate training in northern Ontario had a statistically significant (p<0.001) POR of 36.6 (95%CI: 16.9-79.2) of practising in northern Ontario (115/125) versus other regions, whereas those who completed only their postgraduate training in northern Ontario (46/85) had a statistically significant (p<0.001) POR of 3.7 (95%CI: 2.1-6.8) relative to doctors who only completed their undergraduate medical education at NOSM (28/117). Overall, 30% (22/73) of NOSM's general speciality graduates currently practise in northern Ontario. CONCLUSION: The findings support increasing medical graduate training numbers in rural underserved regions, specifically locating full specialty training programs in regional and rural centres in a 'flipped training' model, whereby specialty trainees are based in rural or regional clinical settings with some rotations to the cities. In these circumstances, the doctors would see their regional or rural centre as 'home base' with the city rotations as necessary to complete their training requirements while preparing to practise near where they train.

Needs of the many: Northern Ontario School of Medicine students' experience of generalism and rural practice.

OBJECTIVE: To explore the Northern Ontario School of Medicine (NOSM) student and graduate experience of generalism in rural practice, in the context of a growing discourse on generalism. DESIGN: Qualitative analysis. SETTING: Northern Ontario School of Medicine in multiple sites across northern Ontario, which is the NOSM campus. PARTICIPANTS: A total of 37 graduating medical students and 9 practising NOSM graduates. METHODS: The Centre for Rural and Northern Health Research and NOSM tracking studies use mixed methods drawing on data from various sources. This paper reports on an arts-based study using semistructured interviews. MAIN FINDINGS: Key themes from student observations include an affinity for the northern Ontario environment and a recognition that rural medicine involves a broad scope of practice. Students from NOSM consider generalist care to be a comprehensive service with a strong focus on responding to the health needs of the communities they serve. Beyond primary care, a rural medicine "true generalist" is viewed as a complete package-a physician who provides care ranging from promoting prevention to performing specialist tasks. CONCLUSION: Rural practitioners, particularly in family medicine, are extended generalists with a broad scope of practice guided by the health needs of the communities they serve. The NOSM students' and graduates' experience of rural generalism is positive and highly influential in determining their career directions, including specialty, scope, and location of practice. The generalist approach of NOSM might be effective beyond rural applications and an advantageous approach for foundational medical education. Students and graduates report that NOSM's distributed community-engaged learning prepares them well for rural generalist practice.

Geographic variation in FP and GP scope of practice in Ontario: Comparative provincial study.

OBJECTIVE: To describe and compare the scope of practice (SoP) of GPs and FPs between the rural northern, rural southern, urban northern, and urban southern regions of Ontario. DESIGN: Cross-sectional retrospective analysis of the 2013 College of Physicians and Surgeons of Ontario official register and annual membership renewal survey data. SETTING: Ontario. PARTICIPANTS: All independently practising GPs and FPs with a primary practice address in Ontario. MAIN OUTCOME MEASURES: For each of the 4 regions, we determined the distribution of GPs and FPs, the mean number of hours worked per week, the mean number of clinical activities reported, the proportion of GPs and FPs reporting specific clinical activities, and the proportion of time dedicated to each activity. RESULTS: The rural north has 2.4% of the province's GPs and FPs, who on average report working more hours per week (a total of 50.82 hours a week) than practitioners in all other regions do. Rural northern and rural southern GPs and FPs report participating in more types of clinical activities than their urban counterparts do. The types of clinical activities reported vary across regions. For example, 13.3% of GPs and FPs in the urban south reported that emergency medicine was an aspect of their clinical activities, compared with 57.5% in the rural north. Urban GPs and FPs engage in fewer clinical activities and thus spend proportionately more time on each clinical activity than rural GPs and FPs do, indicating that clinical practice concentration and narrower SoP is more common in urban practices. CONCLUSION: The SoP for GPs and FPs is not uniform across Ontario. Rural physicians work more hours and engage in a broader spectrum of clinical activities. Clinical activity variation was found across all practice locations, indicating that SoP is driven by patient and community needs, which vary from region to region. Our findings are relevant for rural and northern policy and program development in medical education, continuing professional development, and physician recruitment and retention.

Rural Health Care Access and Policy in Developing Countries.

Compared to their urban counterparts, rural and remote inhabitants experience lower life expectancy and poorer health status. Nowhere is the worldwide shortage of health professionals more pronounced than in rural areas of developing countries. Sub-Saharan Africa (SSA) includes a disproportionately large number of developing countries; therefore, this article explores SSA in depth as an example. Using the conceptual framework of access to primary health care, sustainable rural health service models, rural health workforce supply, and policy implications, this article presents a review of the academic and gray literature as the basis for recommendations designed to achieve greater health equity. An alternative international standard for health professional education is recommended. Decision makers should draw upon the expertise of communities to identify community-specific health priorities and should build capacity to enable the recruitment and training of local students from underserviced areas to deliver quality health care in rural community settings.

Training for impact: the socio-economic impact of a fit for purpose health workforce on communities.

Across the globe, a "fit for purpose" health professional workforce is needed to meet health needs and challenges while capitalizing on existing resources and strengths of communities. However, the socio-economic impact of educating and deploying a fit for purpose health workforce can be challenging to evaluate. In this paper, we provide a brief overview of six promising strategies and interventions that provide context-relevant health professional education within the health system. The strategies focused on in the paper are:1. Distributed community-engaged learning: Education occurs in or near underserved communities using a variety of educational modalities including distance learning. Communities served provide input into and actively participate in the education process.2. Curriculum aligned with health needs: The health and social needs of targeted communities guide education, research and service programmes.3. Fit for purpose workers: Education and career tracks are designed to meet the needs of the communities served. This includes cadres such as community health workers, accelerated medically trained clinicians and extended generalists.4. Gender and social empowerment: Ensuring a diverse workforce that includes women having equal opportunity in education and are supported in their delivery of health services.5. Interprofessional training: Teaching the knowledge, skills and attitudes for working in effective teams across professions.6. South-south and north-south partnerships: Sharing of best practices and resources within and between countries.In sum, the sharing of resources, the development of a diverse and interprofessional workforce, the advancement of primary care and a strong community focus all contribute to a world where transformational education improves community health and maximizes the social and economic return on investment.

A typology of longitudinal integrated clerkships.

CONTEXT: Longitudinal integrated clerkships (LICs) represent a model of the structural redesign of clinical education that is growing in the USA, Canada, Australia and South Africa. By contrast with time-limited traditional block rotations, medical students in LICs provide comprehensive care of patients and populations in continuing learning relationships over time and across disciplines and venues. The evidence base for LICs reveals transformational professional and workforce outcomes derived from a number of small institution-specific studies. OBJECTIVES: This study is the first from an international collaborative formed to study the processes and outcomes of LICs across multiple institutions in different countries. It aims to establish a baseline reference typology to inform further research in this field. METHODS: Data on all LIC and LIC-like programmes known to the members of the international Consortium of Longitudinal Integrated Clerkships were collected using a survey tool developed through a Delphi process and subsequently analysed. Data were collected from 54 programmes, 44 medical schools, seven countries and over 15 000 student-years of LIC-like curricula. RESULTS: Wide variation in programme length, student numbers, health care settings and principal supervision was found. Three distinct typological programme clusters were identified and named according to programme length and discipline coverage: Comprehensive LICs; Blended LICs, and LIC-like Amalgamative Clerkships. Two major approaches emerged in terms of the sizes of communities and types of clinical supervision. These referred to programmes based in smaller communities with mainly family physicians or general practitioners as clinical supervisors, and those in more urban settings in which subspecialists were more prevalent. CONCLUSIONS: Three distinct LIC clusters are classified. These provide a foundational reference point for future studies on the processes and outcomes of LICs. The study also exemplifies a collaborative approach to medical education research that focuses on typology rather than on individual programme or context.

Milestones on the social accountability journey: Family medicine practice locations of Northern Ontario School of Medicine graduates.

OBJECTIVE: To assess the effect of different levels of exposure to the Northern Ontario School of Medicine's (NOSM's) distributed medical education programs in northern Ontario on FPs' practice locations. DESIGN: Cross-sectional design using longitudinal survey and administrative data. SETTING: Canada. PARTICIPANTS: All 131 Canadian medical graduates who completed FP training in 2011 to 2013 and who completed their undergraduate (UG) medical degree or postgraduate (PG) residency training or both at NOSM. INTERVENTION: Exposure to NOSM's medical education program at the UG (n = 49) or PG (n = 31) level or both (n = 51). MAIN OUTCOME MEASURES: Primary practice location in September of 2014. RESULTS: Approximately 16% (21 of 129) of FPs were practising in rural northern Ontario, 45% (58 of 129) in urban northern Ontario, and 5% (7 of 129) in rural southern Ontario. Logistic regression found that more rural Canadian background years predicted rural practice in northern Ontario or Ontario, with odds ratios of 1.16 and 1.12, respectively. Northern Canadian background, sex, marital status, and having children did not predict practice location. Completing both UG and PG training at NOSM predicted practising in rural and northern Ontario locations with odds ratios of 4.06 to 48.62. CONCLUSION: Approximately 61% (79 of 129) of Canadian medical graduate FPs who complete at least some of their training at NOSM practise in northern Ontario. Slightly more than a quarter (21 of 79) of these FPs practise in rural northern Ontario. The FPs with more years of rural background or those with greater exposure to NOSM's medical education programs had higher odds of practising in rural northern Ontario. This study shows that NOSM is on the road to reaching one of its social accountability milestones.

Students learning medicine in general practice in Canada and Australia.

BACKGROUND: Over the past 20 years, there has been increasing focus on general practice and the role of general practitioners (GPs) in undergraduate medical education. OBJECTIVE: This article explores the experiences in Australia and Canada of students learning medicine in the general practice setting, drawing on general practice and medical education literature in both countries and beyond. DISCUSSION: In Canada and Australia, there is substantial and growing evidence that students learning medicine in general practice has positive value for all involved, including the students, patients, wider community, academic institutions and GPs. The space, time and financial aspects of GP-based medical education require further study. Nevertheless, there is considerable potential to develop and implement a national plan for GP-based medical education with targeted government investment and commitment from academic institutions.

Learning in context: education for remote rural health care.

Ensuring access to high quality health care in remote and rural settings is particularly challenging. Remote and rural communities require health service models that are designed in and for these settings, and care provided by health practitioners with the requisite knowledge and skills responsive to people's health needs. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are (1) a rural upbringing, (2) positive clinical and educational experiences in rural settings as part of undergraduate medical education and (3) targeted training for rural practice at the postgraduate level. After exploring the remote and rural context, this article presents examples from Canada and from Australia of education programs that provide the majority of clinical education in remote and rural settings, supported by electronic communications including remote clinical supervision. The success of these programs demonstrates clearly that education in remote rural communities for remote rural communities contributes to substantially improved access to and quality of remote rural health care.

A "Simple" Evidence-Based Intervention to Improve Care Transitions for Frail Patients with Complex Health Conditions: Why Didn't It Work as Expected?

The transition from hospital to home is a vulnerable period for patients with complex conditions, who are often frail, at risk for adverse events and unable to navigate a system of poorly coordinated care in the post-discharge period. Care transition interventions are seen as effective care coordinating mechanisms for reducing avoidable adverse events associated with the transition of the patient from the hospital to the home. A study was undertaken to evaluate the effectiveness of a care transition intervention involving a hand-off between a hospital-based care transitions nurse and a community-based rapid response nurse. Two focus groups were held, one involving rapid response nurses and the other involving care transition nurses. Individual interviews were conducted with the managers (n = 2) and executives (n = 2) to identify the factors that facilitated or were barriers to its implementation. Using thematic content analysis, it was found that the effectiveness of transitional coordination efforts was thwarted by ineffective communication, which affected the quality of the underlying relationships between the two teams. Other barriers to achieving the desired outcomes included the following: issues of role clarity, role awareness and acceptance, the adequacy and reinforcement of coordinating mechanisms, the effectiveness of the information exchange protocols and the absence of shared measures of accountability. Clinical integration initiatives have fewer human resource and financial implementation barriers compared with organizational integration efforts but are complex undertakings requiring clear alignment between organizations, shared accountability measures, effective communication processes and relationships of trust and respect between interprofessional teams.

Transition processes through a longitudinal integrated clerkship: a qualitative study of medical students' experiences.

CONTEXT: This paper describes the transition processes experienced by Year 3 medical students during their longitudinal integrated clerkship (LIC). The authors conceptualise the stages that encompass the transition through a LIC. OBJECTIVES: The purpose of this study was to understand the perspectives of 12 Northern Ontario School of Medicine (NOSM) Year 3 medical students about their transition process. METHODS: Data were collected longitudinally through three conversational interviews with each of these students, occurring before, during and after the clerkship. The authors used a guided walk methodology to explore students' everyday lives and elicit insights about the transition process, prompted by the locations and clinical settings in which the clerkship occurred. RESULTS: Participants identified three interconnected stages in the transition process: (i) shifting from classroom to clinical learning; (ii) dealing with disorientation and restoring balance, and (iii) seeing oneself as a physician. Interview data provided evidence for the adaptive strategies the participants developed in response to these stages. CONCLUSIONS: Based on these findings, the transition process during a LIC can be characterised as one of entering the unfamiliar, with few forewarnings about the changes, of experiencing moments of confusion and burnout, and of eventual gains in confidence and competence in the clinical roles of a physician. Recommendations are made regarding future research opportunities to further scholarship on transitions.

Urban washout: how strong is the rural-background effect?

OBJECTIVE: To test predictors of practice location of fully qualified Monash University Bachelor of Medicine, Bachelor of Surgery (MBBS) graduates. DESIGN: Cohort survey, 2011. SETTING: Australia. PARTICIPANTS: Rural (n = 67/129) and urban (n = 86/191) background doctors starting at Monash University 1992-1999. Approximately 60% female, 77% married/partnered, 79% Australian-born, mean age 34 years, 31% general practitioners, 72% fully qualified and 80% training/practising in major cities. MAIN OUTCOME MEASURES: First and current practice location once fully qualified. Intended practice location in 5-10 years. RESULTS: Logistic regression found that rural versus urban background was a significant predictor of rural (outside major city) first practice location (odds ratio (OR) 5.0, 95% confidence interval (CI) 1.3-19.2) and rural current practice location (OR 5.6, 95% CI 1.5-21.2) for fully qualified doctors. General practitioner versus other medical specialists significantly predicted first (OR 7.2, 95% CI 2.1-25.2) or current (OR 3.6, 95% CI 1.1-11.9) rural practice location. Preference for a rural practice location in 5-10 years was predicted by rural background (OR 4.4, 95% CI 1.6-11.8) and positive intention towards rural practice upon completing MBBS (OR 4.6, 95% CI 1.7-12.6). Surveyed in 2011, 28% of those who also responded to the 2006 survey shifted their preferred future practice location from rural to urban communities versus 13% shifting from urban to rural (McNemar-Bowker test, P = 0.02). CONCLUSION: The majority of fully qualified Monash MBBS graduates practicing in rural communities have rural backgrounds. The rural-background effect diminished over time and may need continued support during training and full practice.

Rural health activism over two decades: the Wonca Working Party on Rural Practice 1992-2012.

The Wonca Working Party on Rural Practice (WWPRP) was formed in 1992 in response to the realization that rural healthcare faced many serious and similar challenges around the world. Over the years the members of the committee have come from many different countries but found inspiration and strength in developing and sharing educational and health system innovations that could be modified and applied to different rural settings. The 11 world rural health conferences organized by the WWPRP over the first two decades since it was founded brought together a range of people, from rural doctors and other front-line healthcare workers to administrators and educational leaders, who connected with and learned from each other to advance rural health care around the world. The WWPRP policy documents and conference consensus statements have been important in shaping rural health care in a number of different contexts, and have led to issues of rural health care rising to prominence on the world stage. The WWPRP has throughout been an activist lobby group with a focus on the rural communities it serves rather than its members, and enters its third decade with much left to be done.