Rural generalist medicine: a developing approach to health care in rural and island Japan.

INTRODUCTION: Despite universal health coverage and high life expectancy, Japan faces challenges in health care that include providing care for the world's oldest population, increasing healthcare costs, physician maldistribution and an entrenched medical workforce and training system. Primary health care has typically been practised by specialists in other fields, and general medicine has only been certified as an accredited specialty since 2018. There are continued challenges to develop an awareness and acceptance of the primary health medical workforce in Japan. The impact of these challenges is highest in rural and island areas of Japan, with nearly 50% of rural and remote populations considered 'elderly'. Concurrently, these areas are experiencing physician shortages as medical graduates gravitate to urban areas and choose medical specialties more commonly practised in cities. This study aimed to understand the views on the role of rural generalist medicine (RGM) in contributing to solutions for rural and island health care in Japan. METHODS: This was a descriptive qualitative study. Data were collected via semi-structured interviews with 16 participants, including Rural Generalist Program Japan (RGPJ) registrars and supervisors, the RGPJ director, government officials, rural health experts and academics. Interviews were of 35-50 minutes duration and conducted between May and July 2019. Some interviews were conducted in person at the WONCA Asia-Pacific Conference in Kyoto, some onsite in hospital settings and some were videoconferenced. Interviews were recorded and transcribed. All transcripts were analysed through an inductive thematic process based on the grouping of codes. RESULTS: From the interview analysis, six main themes were identified: (1) key issues facing rural and island health in Japan; (2) participant background; (3) local demography and population; (4) identity, perception and role of RGM; (5) RGPJ experience; and (6) suggested reforms and recommendations. DISCUSSION: The RGPJ was generally considered to be a positive step toward reshaping the medical workforce to address the geographic inequities in Japan. While improvements to the program were suggested by participants, it was also generally agreed that a more systematic, national approach to RGM was needed in Japan. Key findings from this study are relevant to this goal. This includes considering the drivers to participating in the RGPJ for future recruitment strategies and the need for an idiosyncratic Japanese model of RGM, with agreed advanced skills and supervision models. Also important are the issues raised by participants on the need to improve community acceptance and branding of rural generalist doctors to support primary care in rural and island areas. CONCLUSION: The RGPJ represents an effort to bolster the national rural medical workforce in Japan. Discussions from participants in this study indicate strong support to continue research, exploration and expansion of a national RGM model that is contextualised for Japanese conditions and that is branded and promoted to build community support for the role of the rural generalist.

Exploring what GP registrars consider distinctive to consultations with Aboriginal and Torres Strait Islander patients: a mixed-methods study.

BACKGROUND AND OBJECTIVE: Understanding what general practice (GP) registrars consider as distinctive in their consultations with Aboriginal and Torres Strait Islander patients may help bridge the gap between patient-determined cultural safety and current medical and behavioural practice. This project seeks to explore what GP registrars perceive as distinctive to their consultations with Aboriginal and Torres Strait Islander patients. METHODS: This mixed-methods study involved a survey considering demographic details of GP registrars, questionnaire regarding attitude and cultural capability, and semistructured interviews. RESULTS: 26 registrars completed the survey. 16 registrars completed both the survey and the interview. Despite recognising a need to close the gap on health outcomes for Aboriginal and Torres Strait Islander peoples and wanting to do things differently, most registrars adopted a generic approach to all consultations. DISCUSSION: This study suggests that overall, GP registrars want to improve the health of Aboriginal and Torres Strait Islander patients, but do not want their consultations with Aboriginal and Torres Strait Islander patients to be distinctive. Registrars appeared to approach all consultations in a similar manner using predominantly patient-centred care principles. Given the importance of a culturally safe consultation, it is important for us to consider how to increasingly transform these learners and teach cultural safety in this context.

A Post-Fellowship Support Framework for Rural Doctors: the Queensland experience.

Background: International workforce shortages have prompted many initiatives to recruit, train and retain rural doctors, including Australia's emerging National Rural Generalist Pathway. This project explored an important component of retention, rural doctors' post-Fellowship support needs, to develop and validate a post-Fellowship support framework. There has been considerable international attention on social accountability in medical education and how medical schools and other institutions can address the needs of the communities they serve. The recognition that rural and remote communities globally are underserved has prompted numerous educational approaches including rurally focused recruitment, selection, and training. Less attention has been paid to the support needs of rural doctors and how they can be retained in rural practice once recruited. Methods: The project team reviewed international and Australian rural workforce and medical education literature and relevant policy documents to develop a set of guiding principles for a post-Fellowship support framework. This project utilised a mixed methods approach involving quantitative and qualitative methodologies. A range of rural doctors, administrators, and clinicians, working in primary and secondary care, across multiple rural locations in Queensland were invited to participate in interviews. Thematic analysis was undertaken. Results: The interviews validated ten interconnected guiding principles which enabled development of a grounded, contextually relevant approach to post-Fellowship support. This framework provides a blueprint for a retention strategy aiming to build a strong, skilled, and sustainable medical workforce capable of meeting community needs. Conclusions: The ten principles were designed in the real-world context of a mature Queensland Rural Generalist Pathway. Four themes emerged from the inductive thematic analysis: connecting primary and secondary care; valuing a rural career; supporting training and education; and valuing rural general practice. These themes will be used as a basis for engagement and consultation with rural stakeholders to develop appropriate retention and support strategies.

Using competition for plasma donor recruitment and retention: An Australian university case study.

BACKGROUND AND OBJECTIVES: Using evidence from one Australian university's participation in the Vampire Cup (an 8-week national inter-university blood donation competition), this study aimed to (1) understand important motivators and successful promotional strategies driving engagement in the competition, and (2) determine the impact of competition on the recruitment and retention of young adult plasma donors. MATERIALS AND METHODS: We used a sequential explanatory mixed-methods design involving a self-administered survey (Study 1, n = 64) and four focus groups (Study 2, n = 20) with plasma donors aged 18-29 years who participated in the 2021 Vampire Cup. Also, we used a 12-month prospective comparative cohort analysis (Study 3) of those who did (n = 224 'competition donors') and did not (n = 448 control group) present to donate for the Vampire Cup. RESULTS: Competition was a strong motivator, with 76% of survey participants donating to help their university win the Vampire Cup. The survey and focus groups suggested that successful engagement in the competition was due to peer-led recruitment, leveraging existing rivalries at both the inter- and intra-university level, and using prize draws to create an active online social community promoting blood donation. Competition donors donated plasma significantly more often during the competition but donated at similar rates after the competition, compared to the control group. CONCLUSION: Rivalry-based competition strategies, combined with enthusiastic team leaders and an active social media community, can help to recruit, and retain, young adult plasma donors, and motivate an intermittent boost to donation frequency over a short period each year.

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review.

OBJECTIVES: Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN: A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES: Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA: Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS: Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS: The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION: High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.

Cultural safety in telehealth consultations with Indigenous people: A scoping review of global literature.

INTRODUCTION: Telehealth has become increasingly routine within healthcare and has potential to reduce barriers to care, including for Indigenous populations. However, it is crucial for practitioners to first ensure that their telehealth practice is culturally safe. This review aims to describe the attributes of culturally safe telehealth consultations for Indigenous people as well as strategies that could promote cultural safety. METHODS: A scoping review was conducted on key features of cultural safety in telehealth for Indigenous people using the Johanna Briggs Institute (JBI) guidelines and PRISMA-ScR checklist. Five electronic databases were searched, and additional literature was identified through handsearching. RESULTS: A total of 649 articles were screened resulting in 17 articles included in the review. The central themes related to the provision of culturally safe telehealth refer to attributes of the practitioner: cultural and community knowledge, communication skills and the building and maintenance of patient-provider relationships. These practitioner attributes are modified and shaped by external environmental factors: technology, the availability of support staff and the telehealth setting. DISCUSSION: This review identified practitioner-led features which enhance cultural safety but also recognised the structural factors that can contribute, both positively and negatively, to the cultural safety of a telehealth interaction. For some individuals, telehealth is not a comfortable or acceptable form of care. However, if strategies are undertaken to make telehealth more culturally safe, it has the potential to increase opportunities for access to care and thus contribute towards reducing health inequalities faced by Indigenous peoples.

Do educational interventions improve prescribing skills of medical students compared to no additional learning? A systematic review.

Research suggests that medical students are not confident and may be ill-prepared to prescribe competently. Therefore, changes to standard education may be required to fortify medical student prescribing skills, confidence, and competence. However, specific education to write a safe and legal prescription is generally lacking. Furthermore, the term prescribe and the skill thereof is not clearly defined. This review compares additional education for medical students to no identified additional education or another educational modality on the skill of prescription writing. Secondary aims include review of education modalities, prescribing skill assessments, educator professional background, and timing of education within the medical curriculum. This systematic review was conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Databases searched included: CINAHL, Cochrane Library, EMBASE, Emcare (Ovid), MEDLINE (Ovid), PubMed and Scopus. Search terms included: medical education, medical undergraduate, medical student, medical school, and prescriptions. The search was conducted in February 2023, and quantitative outcomes were reported. Of the 5197 citations identified, 12 met the inclusion criteria. Eleven studies reported significant improvements in prescribing skills of medical students after additional educational intervention(s). Various educational modalities were implemented, including case-based teaching (n=3), patient-based teaching (n=1), tutorial-based teaching (n=2), didactic teaching (n=1), and mixed methods (n=6). There were no commonalities in the professional background of the educator; however, five studies used faculty members. There was no consensus on the best assessment type and time to implement prescription writing education during medical training. There are a range of interventions to educate and assess prescribing competencies of medical students. Despite heterogenous study designs, there is evidence of the superiority of additional prescription writing education versus no identified additional education to develop prescription writing skills. The introduction of formal teaching and standardised assessment of prescribing skills for medical students is recommended.

Assessing cultural safety in general practice consultations for Indigenous patients: protocol for a mixed methods sequential embedded design study.

BACKGROUND: Assessment of cultural safety in general practice consultations for Indigenous patients is a complex notion. Design and development of any assessment tool needs to be cognizant that cultural safety is determined by Indigenous peoples and incorporates defined components of cultural safety and current educational theory. Consideration of how social, historical, and political determinants of health and well-being impact upon the cultural safety of a consultation is also important. Given this complexity, we assume that no single method of assessment will be adequate to determine if general practice (GP) registrars are demonstrating or delivering culturally safe care. As such, we propose that development and assessment of cultural safety can be conceptualised using a model that considers these variables. From this, we aim to develop a tool to assess whether GP registrars are conducting a culturally safe consultation, where cultural safety is determined by Aboriginal and Torres Strait Islander peoples. METHODS: This protocol will be situated in a pragmatic philosophical position to explore cultural safety primarily from the Australian Aboriginal and Torres Strait Islander patients' perspective with triangulation and validation of findings with the GP and GP registrar perspective, the Aboriginal and Torres Strait Islander community, and the medical education community. The study will integrate both quantitative and qualitative data through three sequential phases. Data collection will be through survey, semi-structured interviews, an adapted nominal group technique, and a Delphi questionnaire. We aim to recruit approximately 40 patient and 20 GP participants for interviews, conduct one to five nominal groups (seven to 35 participants) and recruit fifteen participants for the Delphi process. Data will be analysed through a content analysis approach to identify components of an assessment of cultural safety for GP registrars. DISCUSSION: This study will be one of the first to explore how cultural safety, as determined by Indigenous peoples, can be assessed in general practice consultations. This protocol is shared to stimulate awareness and discussion around this significant issue and prompt other studies in this area.

Mid-career graduate practice outcomes of the James Cook University medical school: key insights from the first 20 years.

INTRODUCTION: Previous studies demonstrate early-career James Cook University (JCU) medical graduates are more likely to practise in regional, rural and remote areas than other Australian doctors. This study investigates whether these practice patterns continue into mid-career, identifying key demographic, selection, curriculum and postgraduate training factors associated with rural practice. METHODS: The medical school's graduate tracking database identified 2019 Australian practice location data for 931 graduates across postgraduate years (PGY) 5-14, which were categorised into Modified Monash Model (MMM) rurality classifications. Multinominal logistic regression was undertaken to identify specific demographic, selection process, undergraduate training and postgraduate career variables associated with practice in a regional city (MMM2), large to small rural town (MMM3-5) or remote community (MMM6-7). RESULTS: One-third of mid-career (PGY5-14) graduates were working in regional cities, mostly in North Queensland, with 14% in rural towns and 3% in remote communities. These first 10 cohorts were undertaking careers in general practice (n=300, 33%), as subspecialists (n=217, 24%), rural generalists (n=96, 11%), generalist specialists (n=87, 10%) or hospital non-specialists (n=200, 22%). DISCUSSION: The findings show positive outcomes from the first 10 JCU cohorts for regional Queensland cities, with a significantly higher proportion of mid-career graduates practising regionally compared with the overall Queensland population. The proportion of JCU graduates practising in smaller rural or remote towns is similar to the overall Queensland population. The establishment of the postgraduate JCUGP Training program and the Northern Queensland Regional Training Hubs for building local specialist training pathways should further strengthen medical recruitment and retention across northern Australia.

A return-on-investment analysis of impacts on James Cook University medical students and rural workforce resulting from participation in extended rural placements.

INTRODUCTION: Although all James Cook University (JCU) medical students complete multiple rural placements, some undertake extended 5-10 month rural placements in their final year. This study uses return-on-investment (ROI) methodology to quantify student and rural medical workforce benefits of these 'extended placements' from 2012 to 2018. METHODS: Forty-six medical graduates were sent a survey exploring the benefits to students and to the rural workforce from participation in extended placements, as well as estimated costs to students, deadweight (how much change would have occurred without participating), and attribution (how much change was due to other experiences). The key student and rural workforce benefits were each assigned a 'financial proxy' to allow calculation of ROI as a dollar value that could be compared with the costs to students and to the medical school. RESULTS: Of the graduates, 25/46 responded (54%), reporting the major benefit was 'greater depth and breadth of clinical skills'. The overall cost of undertaking extended placements for students was $60,264 (AUD), while the medical school costs were $32,560 (total costs: $92,824). Given the total value of benefits ($705,827) calculated for the key student benefit of increased clinical skills and confidence in the internship year ($32,197) and for the key rural workforce benefit of willingness to work rurally ($673,630), the ROI from the extended rural programs is $7.60 for every dollar spent. DISCUSSION: This study confirms significant positive impacts of extended placements on final-year medical students with longer-term benefits for rural workforce. This positive ROI is important evidence for shifting the conversation around supporting extended placements from one of cost to one of value.

Identification of barriers, enablers and interventions to inform deimplementation of low-value care in emergency medicine practice: A protocol for a mixed methods scoping review informed by the Theoretical Domains Framework.

INTRODUCTION: Low-value care can lead to patient harm, misdirected clinician time and wastage of finite healthcare resources. Despite worldwide endeavours, deimplementing low-value care has proved challenging. Multifaceted, context and barrier-specific interventions are essential for successful deimplementation. The aim of this literature review is to summarise the evidence about barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. METHODS AND ANALYSIS: A mixed methods scoping review using the Arksey and O'Malley framework will be conducted. MEDLINE, CINAHL, EMBASE, EMCare, Scopus and grey literature will be searched from inception. Primary studies will be included. Barriers, enablers and interventions will be mapped to the domains of the Theoretical Domains Framework. Study selection, data collection and quality assessment will be performed by two independent reviewers. NVivo software will be used for qualitative data analysis. Mixed Methods Appraisal Tool will be used for quality assessment. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework will be used to present results. ETHICS AND DISSEMINATION: Ethics approval is not required for this scoping review. This review will generate an evidence summary regarding barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. This review will facilitate discussions about deimplementation with relevant stakeholders including healthcare providers, consumers and managers. These discussions are expected to inform the design and conduct of planned future projects to identify context-specific barriers and enablers then codesign, implement and evaluate barrier-specific interventions.

Understanding medical students' transformative experiences of early preclinical international rural placement over a 20-year period.

INTRODUCTION: Rural placements are an important component of rural medical education programs seeking to develop rural practice pathways for medical students. These placements are usually domestic, but James Cook University in Australia developed an international rural placement program in the first half of the medical course that was funded through bursaries. This study explores how the international rural placement helped to shape the lives (personal development and learning) of the participants, using Transformational Learning Theory as a framework for identifying and describing the transformational elements, process and impact of the program. METHODS: Sixty-five students received a bursary for an international rural placement between 2001-2019. All were contacted by email and invited to participate in a short survey and a follow-up interview. Fifteen participants agreed and twelve were able to participate in individual semi-structured interviews which were recorded, transcribed and analysed using inductive thematic analysis. RESULTS: Participants reported that the bursary provided a "once in a lifetime opportunity" to "experience eye-opening and culturally rich difference". Nonetheless, some elements of the placement experience presented disorientating dilemmas that triggered deep reflections and shifts in perceptions. The bursary recipients realised that "being open-minded" allowed them "enjoy good company". They were also able to assume "outsider view which allowed reassessment of their own country" and the "isolation experiences gingered desire to right health wrongs". The triggers and mental shifts had significant impact on the bursary recipients and fostered the development of "inspirational new horizons" based on an appreciation of the "value of rural practice" and "role-modelling for life-long learning." These findings are consistent with Transformational Learning Theory. CONCLUSION: Participants in this study reported meaningful and strongly positive impacts from the experiences gained during an international rural clinical placement early in their course. They described transformative experiences which appear to contribute strongly to personal development. This finding supports maintaining opportunities for international experiences during rurally-oriented medical programs as these may impact longer term career choice.

Assessment of cultural safety in a post-Objective Structured Clinical Examination (OSCE) era.

BACKGROUND: As The Royal Australian College of General Practitioners (RACGP) introduces alternatives to the Objective Structured Clinical Examination, it is imperative that standards are continually set for a culturally safe general practice workforce. Assessments have many functions and should be continually reviewed to ensure that they require general practitioners (GPs) to demonstrate genuine cultural safety. OBJECTIVE: The aim of this article is to highlight the complexities in assessing the cultural safety of GPs when consulting with Aboriginal and Torres Strait Islander peoples. DISCUSSION: Presently there is a lack of validated approaches for assessing cultural safety of GPs. This creates challenges for the RACGP in redesigning fellowship examinations. Yet in this challenge is an opportunity to consider assessment design that is not competency based, amplifies Aboriginal and Torres Strait Islander peoples' voices and reflects the complexity of cultural safety.

Mid-career graduate practice outcomes of the James Cook University medical school: key insights from the first 20 years.

INTRODUCTION: Previous studies have demonstrated early-career James Cook University (JCU) medical graduates are more likely to practise in regional, rural and remote areas than other Australian medical practitioners. This study investigates whether these non-metropolitan practice location outcomes continue into mid-career, and identifies the key underlying demographic, selection process, curriculum and postgraduate training factors associated with JCU graduates choosing to currently practise in regional, rural and remote areas of Australia. METHODS: This study used the JCU medical school's graduate tracking database to identify 2019 Australian practice location data for 931 JCU medical graduates across postgraduate years (PGY) 5-14. This data was sourced primarily from the Australian Health Practitioner Regulation Agency, and then categorised into Modified Monash Model (MMM) rurality classifications using the Department of Health's DoctorConnect website. For these mid-career (PGY5-14) cohorts, multinominal logistic regression was undertaken to identify specific demographic, selection process, undergraduate training and postgraduate career variables found to be associated with a 2019 practice location in a regional city (MMM2), large to small rural town (MMM3-5) or remote community (MMM6-7). Additional multinominal logistic regression analysis was then used to determine the key independent predictors of mid-career JCU medical graduates working in regional cities (MMM2), rural towns (MMM3-5) and remote communities (MMM6-7) in 2019. RESULTS: Around one-third of mid-career (PGY5-14) JCU medical graduates were working in regional cities during 2019, mostly in North Queensland, with a further 14% in rural towns and 3% in remote communities. These first 10 cohorts were undertaking careers in general practice (n=300, 33%), as subspecialists (n=217, 24%), rural generalists (n=96, 11%), generalist specialists (n=87, 10%) or hospital non-specialists (n=200, 22%). Key statistically significant, independent predictors of JCU MBBS graduates practising in MMM3-5 and MMM6-7 locations in 2019 were, respectively, being awarded a rurally bonded Australian Government undergraduate Medical Rural Bonded Scholarship (MRBS) (p=0.004, prevalence odds ratio (POR)=3.5; p=0.017, POR=7.3); graduation from the JCU postgraduate general practice training program, JCU General Practice Training (p=0.001, POR=3.9; p<0.001, POR=20.1) and internship training in a hospital located in a regional city (p=0.003, POR=2.4; p=0.049, POR=4.3) or in a rural or remote town (p=0.033, POR=5.0; p=0.002, POR=54.6). JCU MBBS graduates practising in MMM3-5 locations was also predicted by a rural hometown at application to the medical school (p=0.021, POR=2.5) and choosing a career in general practice (p<0.010, POR=4.4) or in rural generalism (p<0.001, POR=26.4), while JCU MBBS graduates practising in MMM6-7 locations was also predicted by undertaking an extended 20- or 35-week undergraduate rural placement during year 6 (p=0.014, POR=8.9). CONCLUSION: The findings show positive outcomes from the first 10 cohorts of JCU medical graduates for regional Queensland cities, with a significantly higher proportion of mid-career graduates practising in regional areas of Queensland than the percentage of the overall Queensland population. The proportion of JCU medical graduates practising in smaller regional and remote towns is similar to the overall Queensland population. The recent establishment of the postgraduate JCU General Practice Training program for vocational generalist medicine training and the Northern Queensland Regional Training Hubs for building local specialist training pathways should further strengthen the retention and recruitment of JCU and other medical graduates across the northern Australia region.

Medicine and dentistry: Understanding the language of dentistry.

BACKGROUND: Dental problems are common in general practice and are responsible for many avoidable hospitalisations. Medicine and dentistry are often practised in isolation, with little shared language or understanding. OBJECTIVE: The aim of this article is to help general practitioners (GPs) maximise effective dental referral strategies by briefly outlining basic dental nomenclature and describing the roles of different types of oral healthcare providers. DISCUSSION: The oral cavity contains hard and soft tissues that are all prone to oral disease, which can lead to systemic disease. It is important for GPs to have some basic familiarity with dental nomenclature, anatomy and tooth eruption times. In Australia, there are seven different oral healthcare providers and 13 dental specialities. This article will summarise their distinct roles and explain some common dental procedures used to definitively treat oral health problems. This knowledge should encourage more efficient interprofessional communication and enable general practitioners to optimise referral pathways for patients with oral health problems.

A return-on-investment analysis of impacts on James Cook University medical students and rural workforce resulting from participation in extended rural placements.

INTRODUCTION: Although all medical students at James Cook University (JCU), Queensland, Australia, undertake rural placements throughout their course, a proportion (currently about 20 per year out of 170-190 final-year students) undertake extended rural placements in rural and remote towns - 5-month Integrated Rural Placement (IRP) or 10-month Longitudinal Integrated Clerkship (LIC) programs. This study uses a return-on-investment (ROI) approach to quantify student and rural medical workforce benefits arising from these 'extended placements' between 2012 and 2018. METHODS: Seventy-two JCU MBBS graduates participated in extended rural placements between 2012 and 2018. In 2019, 46 of these graduates who had reached at least postgraduate year 2 and provided consent to be contacted for health workforce research were emailed a link to an online survey. Questions explored the key benefits to students' development of competencies and to rural medical workforce as a direct result of student participation in the IRP/LIC activities, as well as estimations of costs to students, deadweight (how much change would have occurred without participating in an extended placement), and attribution (how much change was due to other programs or experiences). The key student and rural medical workforce benefits were each assigned a 'financial proxy' to allow calculation of ROI from 2013 to 2019 as a dollar value, compared with the costs to students and to the JCU medical school from implementing the IRP/LIC programs between 2012 and 2018. RESULTS: Twenty-five of the 46 JCU medical graduates who undertook an extended placement responded (response rate 54%), reporting that the most common (96%) and most important benefit (56%) from their extended placement was 'greater depth and breadth of clinical skills'. Seventy-five percent (18/24; one missing response for this question) of the respondents also reported intending to have a full-time career in rural and remote practice. The overall cost of undertaking an IRP or LIC program for students between 2012 and 2018 was calculated to be $60,264, while the cost to the JCU medical school for sending 72 students out on extended rural placements was calculated as $32,560, giving total costs of $92,824. Given the total value of benefits ($705,827) calculated for the key student benefit of increased clinical skills and confidence in the internship year from participating in an extended placement ($32,197) and for the key rural medical workforce benefit of willingness to work in a rural or remote town ($673,630), the ROI from the extended rural programs between 2013 and 2019 (after students graduated and entered the workforce) is calculated at $7.60 for every dollar spent. CONCLUSION: This study confirms that undertaking an extended placement has significant positive impacts on final-year medical students' clinical confidence, clinical skills and communication skills into their internship year. In addition, the extended placements have longer-term impacts on the non-metropolitan health workforce by inspiring more JCU medical graduates to take up rural generalist, rural general practitioner or generalist specialist positions in rural and remote towns. This positive ROI from extended rural placements is important evidence for shifting the conversation around supporting these programs from one of cost to one of value.

Systematic review of specialist selection methods with implications for diversity in the medical workforce.

PURPOSE: There is growing concern that inequities in methods of selection into medical specialties reduce specialist cohort diversity, particularly where measures designed for another purpose are adapted for specialist selection, prioritising reliability over validity. This review examined how empirical measures affect the diversity of specialist selection. The goals were to summarise the groups for which evidence is available, evaluate evidence that measures prioritising reliability over validity contribute to under-representation, and identify novel measures or processes that address under-representation, in order to make recommendations on selection into medical specialties and research required to support diversity. METHOD: In 2020-1, the authors implemented a comprehensive search strategy across 4 electronic databases (Medline, PsychINFO, Scopus, ERIC) covering years 2000-2020, supplemented with hand-search of key journals and reference lists from identified studies. Articles were screened using explicit inclusion and exclusion criteria designed to focus on empirical measures used in medical specialty selection decisions. RESULTS: Thirty-five articles were included from 1344 retrieved from databases and hand-searches. In order of prevalence these papers addressed the under-representation of women (21/35), international medical graduates (10/35), and race/ethnicity (9/35). Apart from well-powered studies of selection into general practice training in the UK, the literature was exploratory, retrospective, and relied upon convenience samples with limited follow-up. There was preliminary evidence that bias in the measures used for selection into training might contribute to under-representation of some groups. CONCLUSIONS: The review did not find convincing evidence that measures prioritising reliability drive under-representation of some groups in medical specialties, although this may be due to limited power analyses. In addition, the review did not identify novel specialist selection methods likely to improve diversity. Nevertheless, significant and divergent efforts are being made to promote the evolution of selection processes that draw on all the diverse qualities required for specialist practice serving diverse populations. More rigorous prospective research across different national frameworks will be needed to clarify whether eliminating or reducing the weighting of reliable pre-selection academic results in selection decisions will increase or decrease diversity, and whether drawing on a broader range of assessments can achieve both reliable and socially desirable outcomes.

Leadership curricula and assessment in Australian and New Zealand medical schools.

BACKGROUND: The Australian Medical Council, which accredits Australian medical schools, recommends medical leadership graduate outcomes be taught, assessed and accredited. In Australia and New Zealand (Australasia) there is a significant research gap and no national consensus on how to educate, assess, and evaluate leadership skills in medical professional entry degree/programs. This study aims to investigate the current curricula, assessment and evaluation of medical leadership in Australasian medical degrees, with particular focus on the roles and responsibilities of medical leadership teachers, frameworks used and competencies taught, methods of delivery, and barriers to teaching leadership. METHODS: A self-administered cross-sectional survey was distributed to senior academics and/or heads or Deans of Australasian medical schools. Data for closed questions and ordinal data of each Likert scale response were described via frequency analysis. Content analysis was undertaken on free text responses and coded manually. RESULTS: Sixteen of the 22 eligible (73%) medical degrees completed the full survey and 100% of those indicate that leadership is taught in their degree. In most degrees (11, 69%) leadership is taught as a common theme integrated throughout the curricula across several subjects. There is a variety of leadership competencies taught, with strengths being communication (100%), evidence based practice (100%), critical reflective practice (94%), self-management (81%), ethical decision making (81%), critical thinking and decision making (81%). Major gaps in teaching were financial management (20%), strategic planning (31%) and workforce planning (31%). The teaching methods used to deliver medical leadership within the curricula are diverse, with many degrees providing opportunities for leadership teaching for students outside the curricula. Most degrees (10, 59%) assess the leadership education, with one-third (6, 35%) evaluating it. CONCLUSIONS: Medical leadership competencies are taught in most degrees, but key leadership competencies are not being taught and there appears to be no continuous quality improvement process for leadership education. There is much more we can do as medical educators, academics and leaders to shape professional development of academics to teach medical leadership, and to agree on required leadership skills set for our students so they can proactively shape the future of the health care system.

"We learnt it, then we lived it": Influencing medical students' intentions toward rural practice and generalist careers via a socially-accountable curriculum.

OBJECTIVE: The James Cook University (JCU) medical school has a mission to produce graduates committed to practising with underserved populations. This study explores the views of final-year students regarding the influence of the JCU medical curriculum on their self-reported commitment to socially-accountable practice, intentions for rural practice, and desired postgraduate training pathway. METHODS: Cross-sectional survey of final year JCU medical students (n = 113; response rate = 65%) to determine whether their future career directions (intentions for future practice rurality and postgraduate specialty training pathway) are driven more by altruism (commitment to socially accountable practice/community service) or by financial reward and/or prestige. RESULTS: Overall, 96% of responding students reported their JCU medical course experiences had cultivated a greater commitment towards 'socially-accountable' practice. A commitment to socially-accountable practice over financial reward and/or prestige was also significantly associated with preferring to practise Medicine in non-metropolitan areas (p = 0.036) and intending to choose a 'generalist' medical discipline (p = 0.003). CONCLUSIONS: The findings suggest the JCU medical curriculum has positively influenced the commitment of its graduating students towards more socially accountable practice. This influence is a likely result of pre-clinical teachings around health inequalities and socially-accountable medical practice in combination with real-world, immersive experiences on rural and international placements.

Examiners' decision-making processes in observation-based clinical examinations.

BACKGROUND: Objective structured clinical examinations (OSCEs) are commonly used to assess the clinical skills of health professional students. Examiner judgement is one acknowledged source of variation in candidate marks. This paper reports an exploration of examiner decision making to better characterise the cognitive processes and workload associated with making judgements of clinical performance in exit-level OSCEs. METHODS: Fifty-five examiners for exit-level OSCEs at five Australian medical schools completed a NASA Task Load Index (TLX) measure of cognitive load and participated in focus group interviews immediately after the OSCE session. Discussions focused on how decisions were made for borderline and clear pass candidates. Interviews were transcribed, coded and thematically analysed. NASA TLX results were quantitatively analysed. RESULTS: Examiners self-reported higher cognitive workload levels when assessing a borderline candidate in comparison with a clear pass candidate. Further analysis revealed five major themes considered by examiners when marking candidate performance in an OSCE: (a) use of marking criteria as a source of reassurance; (b) difficulty adhering to the marking sheet under certain conditions; (c) demeanour of candidates; (d) patient safety, and (e) calibration using a mental construct of the 'mythical [prototypical] intern'. Examiners demonstrated particularly higher mental demand when assessing borderline compared to clear pass candidates. CONCLUSIONS: Examiners demonstrate that judging candidate performance is a complex, cognitively difficult task, particularly when performance is of borderline or lower standard. At programme exit level, examiners intuitively want to rate candidates against a construct of a prototypical graduate when marking criteria appear not to describe both what and how a passing candidate should demonstrate when completing clinical tasks. This construct should be shared, agreed upon and aligned with marking criteria to best guide examiner training and calibration. Achieving this integration may improve the accuracy and consistency of examiner judgements and reduce cognitive workload.