Exploring interprofessional education and collaborative practice in Australian rural health services.

This article explores how work-based interprofessional education (IPE) influences collaborative practice in rural health services in Australia. Using a qualitative case study design, three rural hospitals were the focal point of the project. Marginal participant observations (98 hours) and semistructured interviews (n = 59) were undertaken. Participants were medical practitioners, nursing and midwifery professionals, physiotherapists, paramedics, social workers and administrative staff, who provided services in relation to each hospital. Data in the form of audio recordings and field notes, including researcher reflections were recorded over a three-year period. Whilst this study comprised of three phases, this article explores the extent to which collaborative practice was present or not before and after IPE. An inductive content analysis resulted in the following themes: Conceptualizing Collaborative Practice, Profession-Driven Education, and Professional Structures and Socialization. Community of practice theory is used to explore the barriers created through profession-based communities of practice.

Leasing a medical curriculum: What's it worth?

Introduction: The early part of this century saw an unprecedented growth in number and size of Australian medical schools. There was some partnering of the new schools with existing programs. Griffith, Deakin and Curtin Universities leased an established curriculum from Flinders University. Nature and rationale for curriculum leasing: The new schools had short startup times and leasing a curriculum enabled them to appoint key staff, develop facilities and meet accreditation requirements in a timely way. However, the lease arrangements were costly and the curriculum was largely determined before the Dean and key staff appointments. Outcomes of leasing: There was differential adoption of the leased curriculum. The first two years of the courses at Flinders were transferred with little change. The final two years of predominantly clinical studies were developed differently. This is explained through Michael Fullan's work on context in educational change. The context of the clinical years of the courses involved negotiations with local health services and other schools using those health services. The advantage of the leasing arrangements was that the new schools could proceed through early development and accreditation, while having time and opportunity to negotiate a clinical curriculum that engaged local health services and fulfilled the new schools' missions.

The global-local tension in medical education: turning 'think global, act local' on its head?

CONTEXT: Medical education has not been immune from forces for globalisation in the contemporary world. At the same time the social accountability of medical schools in addressing local health priorities has been emphasised. This paper explores the global-local tension in medical education through a careful selection of key overview papers. GLOBALISATION: Globalisation in medical education has taken two main forms: economic and altruistic. The former includes licensing curricula, recruiting internationally and establishing 'offshore' schools or campuses. Altruistic collaborations focus on the spread of learning and educational innovations. Both forms bring benefits but have been subject to critique for their differential impact and focus on educational inputs rather than outputs. SOCIAL ACCOUNTABILITY: Social accountability requires medical schools to direct their activities to local priorities and to serving local health systems. Adoption of the principles of social accountability compels all medical schools to ask questions of their educational programmes and graduate outcomes. However, these are globally interdependent questions and are the intent of some well-known social accountability collaborations. It is naïve to think that adoption of a social accountability agenda by all medical schools would necessarily reduce global health inequity. A recent Australian example shows that workforce maldistribution, for example, is resistant to even high-level intervention. CONCLUSIONS: It is yet too early to fully accept that 'think global, act local can be turned on its head'. There is much research to be carried out, particularly on the outcomes and impacts of medical education. Establishing cause and effect is a challenge, as is determining whether globalisation or localisation can contribute to greater global health equity. If we are ever to resolve the global-local tension in medical education, we need more evidence on the outcomes of what we do, whether globally or locally inspired.

Student academic performance in rural clinical schools: The impact of cohort size and competition.

OBJECTIVES: The Deakin University School of Medicine commenced in 2008 as a rurally focused medical school in south-eastern Australia. This research was designed to examine the effectiveness of the school's adoption of small regional clinical school settings. METHODS: A retrospective cohort study of the first two cohorts of students was employed to assess academic performance at each of five geographically dispersed clinical training sites, with varying student cohort sizes. The Dundee Ready Education Environment Measure (DREEM) questionnaire provided quantitative data regarding the students' perception of their educational environment. The data were analyzed using univariate and multivariate analyses. RESULTS: The highest examination scores, and greatest satisfaction with educational environment, were associated with the clinical school that had a small-sized group of students and was not co-located with another medical school. These differences remained after adjusting for multiple potential confounding factors. CONCLUSION: The smaller sites appear to have provided superior support for student learning in this new medical school. This advantage diminishes when smaller cohorts are co-located with students from other medical schools. Cohort size and co-location of medical school curricula may be important independent variables for researchers to consider when comparing the results of clinical education innovations in different settings.

A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME Guide No. 40.

BACKGROUND: This review, which focused on faculty development initiatives designed to improve teaching effectiveness, synthesized findings related to intervention types, study characteristics, individual and organizational outcomes, key features, and community building. METHODS: This review included 111 studies (between 2002 and 2012) that met the review criteria. FINDINGS: Overall satisfaction with faculty development programs was high. Participants reported increased confidence, enthusiasm, and awareness of effective educational practices. Gains in knowledge and skills, and self-reported changes in teaching behaviors, were frequently noted. Observed behavior changes included enhanced teaching practices, new educational initiatives, new leadership positions, and increased academic output. Organizational changes were infrequently explored. Key features included evidence-informed educational design, relevant content, experiential learning, feedback and reflection, educational projects, intentional community building, longitudinal program design, and institutional support. CONCLUSION: This review holds implications for practice and research. Moving forward, we should build on current success, broaden the focus beyond individual teaching effectiveness, develop programs that extend over time, promote workplace learning, foster community development, and secure institutional support. We should also embed studies in a theoretical framework, conduct more qualitative and mixed methods studies, assess behavioral and organizational change, evaluate transfer to practice, analyse key features, and explore the role of faculty development within the larger organizational context.

Clinical participation of medical students in three contemporary training models.

OBJECTIVES: As community settings are being used increasingly in undergraduate medical programmes, this study aimed to explore and compare the clinical experiences of students in hospital-based and community-based training programmes. It measured students' clinical participation and compared the perspectives of Year 3 medical students in three different models of clinical education: a tertiary hospital block programme; a community hybrid programme, and a rural longitudinal integrated clerkship (LIC) programme. METHODS: The study used a mixed methodology approach to examine the clinical experiences of students through the analysis of logbooks and semi-structured student interviews. This involved the quantitative analysis of 88 logbook weeks, data from which were triangulated through the analysis of 101 individual interviews using grounded theory. RESULTS: A total of 35 students across the three different clinical training models participated in the study. The results demonstrate significant differences among the three models in students' clinical participation and suggest that community settings provide more opportunities to students for meaningful engagement in patient care activities. CONCLUSIONS: Consistent wider and more direct access to patients for students, as found in the community-based model, provides a pathway for engaging students in the learning processes, and a step towards making them aware of their learning needs and knowledge. Interviews provide evidence that authentic clinical activities can be enhanced through structured systems of supervision and through the provision of authentic roles for students in clinical teams.

Medical schools as agents of change: socially accountable medical education.

Medical education reform can make an important contribution to the future health care of populations. Social accountability in medical education was defined by the World Health Organization in 1995, and an international movement for change is gathering momentum. While change can be enabled with policy levers, such as funding tied to achieving equity outcomes and systems of accreditation, medical schools and students themselves can lead the transformation agenda. An international movement for change and coalitions of medical schools with an interest in socially accountable medical education provide a "community of practice" that can drive change from within.

The context of clinical teaching and learning in Australia.

Gaining clinical experience for an extended period of time in teaching hospitals is one of the enduring strengths of medical education. Teaching hospitals have recently faced significant challenges, with increasing specialisation of services and workload pressures reducing clinical learning opportunities. New clinical teaching environments have been established in Australia, particularly in rural and regional areas; these are proving to be ideal contexts for student learning. The new clinical teaching environments have shown the importance of developing symbiotic relationships between universities and health services. Symbiotic clinical learning is built around longitudinal, patient-based learning emphasising priority health concerns. The symbiotic framework provides a basis for reconstructing clinical teaching in teaching hospitals so th@they continue to play a vital role in Australian medical education, with additional clinical experience provided by primary care and community, rural and regional hospitals.

From the nurses' station to the health team hub: how can design promote interprofessional collaboration?

Interprofessional practice implies that health professionals are able to contribute patient care in a collaborative environment. In this paper, it is argued that in a hospital the nurses' station is a form of symbolic power. The term could be reframed as a "health team hub," which fosters a place for communication and interprofessional working. Studies have found that design of the Nurses' Station can impact on the walking distance of hospital staff, privacy for patients and staff, jeopardize patient confidentiality and access to resources. However, no studies have explored the implications of nurses' station design on interprofessional practice. A multi-site collective case study of three rural hospitals in South Australia explored the collaborative working culture of each hospital. Of the cultural concepts being studied, the physical design of nurses' stations and the general physical environment were found to have a major influence on an effective collaborative practice. Communication barriers were related to poor design, lack of space, frequent interruptions and a lack of privacy; the name "nurses' station" denotes the space as the primary domain of nurses rather than a workspace for the healthcare team. Immersive work spaces could encourage all members of the healthcare team to communicate more readily with one another to promote interprofessional collaboration.

Demonstrating the value of longitudinal integrated placements to general practice preceptors.

CONTEXT: This paper aims to consider why general practitioners (GPs) teach, in particular by defining the longitudinal supervisory relationships between rural clinician-preceptors and students. METHODS: A total of 41 individual semi-structured interviews were conducted with GPs, practice managers and students. All interviews were audiotaped, transcribed and analysed for emergent themes. RESULTS: In this study preceptors identified many ways in which precepting added value to their roles. However, themes relating to the doctor-student relationship were central to GP preceptors' experiences. These developed in chronological order and resulted in changes in the triangular relationship between doctor, patient and student in the consultation. DISCUSSION: Interpretive findings identify that the motivators for precepting represent a group of constantly changing interconnected factors that contribute to the defining of preceptors as central members of their professional community of practice. This critical finding challenges the simplistic organisational concept that universities can recruit and retain GPs by offering increased rewards. This paper introduces four clinical preceptor models, which involve the roles of, respectively: the student-observer; the teacher-healer; the doctor-orchestrator, and the doctor-advisor. Symbiosis between student learning and patient care was found to occur in the doctor-orchestrator model. CONCLUSIONS: The evolution of doctor-student relationships in long-term student placements explains how students become more useful over the academic year and sheds light on how GPs are changed through precepting as part of the complex process by which they come to recognise themselves as central members of the rural generalist community.

Assessment for selection for the health care professions and specialty training: consensus statement and recommendations from the Ottawa 2010 Conference.

Assessment for selection in medicine and the health professions should follow the same quality assurance processes as in-course assessment. The literature on selection is limited and is not strongly theoretical or conceptual. For written testing, there is evidence of the predictive validity of Medical College Admission Test (MCAT) for medical school and licensing examination performance. There is also evidence for the predictive validity of grade point average, particularly in combination with MCAT for graduate entry but little evidence about the predictive validity of school leaver scores. Interviews have not been shown to be robust selection measures. Studies of multiple mini-interviews have indicated good predictive validity and reliability. Of other measures used in selection, only the growing interest in personality testing appears to warrant future work. Widening access to medical and health professional programmes is an increasing priority and relates to the social accountability mandate of medical and health professional schools. While traditional selection measures do discriminate against various population groups, there is little evidence on the effect of non-traditional measures in widening access. Preparation and outreach programmes show most promise. In summary, the areas of consensus for assessment for selection are small in number. Recommendations for future action focus on the adoption of principles of good assessment and curriculum alignment, use of multi-method programmatic approaches, development of interdisciplinary frameworks and utilisation of sophisticated measurement models. The social accountability mandate of medical and health professional schools demands that social inclusion, workforce issues and widening of access are embedded in the principles of good assessment for selection.

Predicting medical students' intentions to take up rural practice after graduation.

OBJECTIVES: Using a novel longitudinal tracking project, this study develops and evaluates the performance of a predictive model and index of rural medical practice intention based on the characteristics of incoming medical students. METHODS: Medical school entry survey data were obtained from the Medical Schools Outcome Database (MSOD) project implemented in all Australian and New Zealand medical schools and coordinated through Medical Deans Australia and New Zealand, the representative body for the Deans of 18 Australian and two New Zealand medical schools and faculties. The medical school commencement survey collects data on students' education and family background, including rural upbringing, personal circumstances and scholarships, and on their practice intentions in terms of location and specialty. The MSOD will also allow tracking of medical graduates after graduation. Logistic regression modelling was used to develop a predictive model of rural practice intention. Split-sample validation was used to gain some insight into the stability of performance of the model. RESULTS: Response rates to the MSOD survey exceeded 90% on average. The model findings confirm and extend previous research examining the association of medical student characteristics with intention to take up rural medical practice. The statistically significant independent factors in the model included students' rural backgrounds, financial arrangements and intentions regarding specialist versus generalist practice upon graduation. Model performance was good, with an area under the receiver-operator characteristics curve of 0.86, and reproducible, with an area in a validation sample of 0.83. CONCLUSIONS: The model and related index provide important insights into individual factors associated with rural practice intention among students commencing medical studies. The model can also provide a means for optimising the use of scarce medical programme resources, thereby helping to improve the supply of rural medical practitioners. This study illustrates the power and potential of a robust, consistent, systematic longitudinal tracking project.

What do general practitioners do differently when consulting with a medical student?

OBJECTIVES: The practice of having medical students see patients in a general practice setting, in their own consulting rooms, prior to the GP preceptor joining the consultation does not increase general practitioner (GP) consultation time. How do GPs meet the needs of both patient and student without extending consultation time? This study sought to quantify and compare GP consultation activities with and without students. METHODS: This was a prospective cohort study of 523 videotaped consultations. Consultations were analysed in 15-second intervals using a modified Davis observation code to define GP activity. Estimated marginal means were calculated using mixed model analysis accounting for confounding factors. RESULTS: In comparison with consulting alone, GPs precepting a student spent 37 seconds less time examining patients (P = 0.001), 41 seconds less on patient management, and 1 minute, 31 seconds less on clerical and other activities (P < 0.001). This created time for GPs to take a history from both the student and patient (39 seconds longer; P = 0.002) and to teach students (1 minute, 10 seconds; P < 0.001). DISCUSSION: General practitioner activity in the consultation changes significantly when precepting a student; GPs spend longer exploring the history in order to unpack the student's clinical reasoning, verify the patient's story and resynthesise the information. They spend less time on examination, management and clerical activities and presumably delegate or defer these activities. Conclusions This organising of clinical activities in order to meet the needs of both patient and student is likely to require different processing skills to solo consulting.

Medical education in Australia: much has changed but what remains?

Australia is a young country in medical education terms. Traditionally courses followed a 6-year British model with a pre-clinical/clinical divide. There is no national licensing system. After graduation there are two postgraduate years followed by specialist training. From the mid-1990s there has been considerable expansion and innovation in medical education. There are now 19 medical schools with a mix of 4-, 5- and 6-year courses. The creation of rural clinical schools has fostered new clinical placements and community-based programmes. Indigenous health is a priority. There is a nationally accepted curriculum framework in Indigenous health for all medical schools. Clinical teaching remains as a significant challenge especially with the increasing number of medical schools and students. There are also important issues in aligning a teaching hospital-based system with the health services of the future. Medical education research is a developing discipline. There is an emerging national recognition of research and schemes to promote young researchers. The Medical Schools Outcomes Database project is providing an important impetus to career choice and outcomes research. While the period of expansion may have ceased, Australian medical education still faces considerable challenges posed by a new health care reform agenda.