Exploring recent trends (2014-21) in preferencing and accepting Queensland medical internships in rural hospitals

BACKGROUND

Medical internship is a key transition point in medical training from student to independent (junior) doctor. The national Regional Training Hubs (RTH) policy began across Australia in late 2017, which aims to build medical training pathways for junior doctors within a rural region and guide students, interns and trainees towards these. This study aims to explore preferencing and acceptance trends for rural medical internship positions in Queensland. Moreover, it focuses on internship preference and acceptance outcomes prior to and following the establishment of RTHs, and their association with key covariates such as rural training immersions offered by medical schools.

METHODS

Data from all applicants to Queensland Health intern positions between 2014-2021 were available, notably their preference order and location of accepted internship position, classified as rural or metropolitan. Matched data from Queensland's medical schools were added for rural training time and other key demographics. Analyses explored the statistical associations between these factors and preferencing or accepting rural internships, comparing pre-RTH and post-RTH cohorts.

RESULTS

Domestic Queensland-trained graduates first preferencing rural intern positions increased significantly (pre-RTH 21.1% vs post-RTH 24.0%, p = 0.017), reinforced by a non-significant increase in rural acceptances (27.3% vs 29.7%, p = 0.070). Rural interns were more likely to have previously spent ≥ 11-weeks training in rural locations within medical school, be rurally based in the year applying for internship, or enrolled in the rural generalist pathway.

CONCLUSIONS

The introduction of the RTH was associated with a moderate increase of graduates both preferencing and accepting a rural internship, though a richer understanding of the dominant reasons for and against this remain less clear. An expansion of graduates who undertook longer periods of undergraduate rural training in the same period did not diminish the proportion choosing a rural internship, suggesting there remains an appetite for these opportunities. Overall, domestic graduates are identified as a reliable source of intern recruitment and retention to rural hospitals across Queensland, with entry to the rural generalist pathway and extended rural placement experiences enhancing uptake of rural practice.

Telehealth program for symptomatic COVID-19 patients in Mindanao, Philippines: a whole-of-system, pragmatic interventional study on patient monitoring from isolation facilities to community reintegration

The COVID-19 pandemic is impacting individuals and society's physical and mental health. Despite the lack of any definite and effective therapeutic regimen, public health measures such as quarantine and isolation have been instituted to contain this pandemic. However, these mitigating measures have also raised issues regarding isolated patients' mental and psychological well-being. Several stakeholders were engaged in this approach, including the university, the local health office, the tertiary hospital, and the local communities. This intervention addresses concerns regarding the health status of isolated individuals due to COVID-19 infection, making the program available to anyone who agrees to participate. This was done through telehealth services delivered via phone calls and SMS. The university provided technical support and telehealth manpower through medical students. The local health unit manages the isolation facilities, while the referral hospital offers specialty care for isolated patients through teleconsultation. Finally, the local community is the one that reintegrates discharged patients into their communities. Three hundred forty-four (344) participants were provided seven sessions on telehealth education and tracking of their COVID-19 prescribed practices and mental health. The mean age of the patients was 37 years; half were females, and 15% had comorbidities. Regarding their mental health status, the level of depression dropped from 6% to 1% (p<0.0001), the level of anxiety dropped from 12% to 2% (p<0.0001), and the level of stress dropped from 3% to 0% (p<0.0001) from the first day of admission to 2 weeks after discharge. Moreover, a general trend of statistically significant increase in various practices was noted: wearing face masks, physical distancing, disinfecting frequently held objects, hand hygiene, and self-monitoring for COVID-19 symptoms. Those with progressing symptoms of COVID-19 were referred immediately to the referral hospital. There were also no reports of complications of co-morbidities during their stay in the isolation facilities or social isolation upon community reintegration. The study concludes that telehealth services have the potential to address many challenges in providing continuous healthcare services to isolated patients until they are reintegrated into their community. Furthermore, a whole-of-society approach is necessary to provide holistic care to patients affected by the pandemic.

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.

Haemostatic resuscitation in practice: a descriptive analysis of blood products administered during Operation HERRICK, Afghanistan

INTRODUCTION

Life-threatening haemorrhage is the leading cause of potentially survivable injury in battlefield casualties. During Operation HERRICK (Afghanistan), mortality rates improved year on year due to a number of advances in trauma care, including haemostatic resuscitation. Blood transfusion practice has not previously been reported in detail during this period.

METHODS

A retrospective analysis of blood transfusion at the UK role 3 medical treatment facility (MTF) at Camp Bastion between March 2006 and September 2014 was performed. Data were extracted from two sources: the UK Joint Theatre Trauma Registry (JTTR) and the newly established Deployed Blood Transfusion Database (DBTD).

RESULTS

3840 casualties were transfused 72 138 units of blood and blood products. 2709 adult casualties (71%) were fully linked with JTTR data and were transfused a total of 59 842 units. Casualties received between 1 unit and 264 units of blood product with a median of 13 units per patient. Casualties wounded by explosion required almost twice the volume of blood product transfusion as those wounded by small arms fire or in a motor vehicle collision (18 units, 9 units, and 10 units, respectively). More than half of blood products were transfused within the first 2 hours following arrival at the MTF. There was a trend towards balanced resuscitation with more equal ratios of blood and blood products being used over time.

CONCLUSION

This study has defined the epidemiology of blood transfusion practice during Operation HERRICK. The DBTD is the largest combined trauma database of its kind. It will ensure that lessons learnt during this period are defined and not forgotten; it should also allow further research questions to be answered in this important area of resuscitation practice.

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.

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.

"Learning by Doing": a Mixed-Methods Study to Identify Why Body Painting Can Be a Powerful Approach for Teaching Surface Anatomy to Health Science Students

Introduction

Teaching human anatomy to produce deeper understandings and knowledge retention in learners requires meaningful, engaging, and practical activities. Previous studies identify that most students who participated in body painting (BP) reported improved understanding of surface anatomy (SA). This study investigates the key factors underpinning how BP helps students learn SA.

Methods

The study involved an explanatory mixed-methods approach. Towards the end of an anatomy course, a survey was administered to three cohorts of first-year chiropractic, osteopathy, and Chinese medicine students and second-year biomedical sciences students over 3 years (n = 311; response rate = 30%). The survey assessed the effectiveness of BP as a hands-on, group-based approach for learning SA in practical class. Three student focus groups (n = 13) explored the key survey findings.

Results

Overall, 72% of student respondents reported BP activities helped them learn SA "quite a bit" or "very much". Multivariate analysis identified students found BP helped them learn SA by "remembering the position of the bones, joints, muscles, actions and insertions" (POR = 5.7; P < 0.001); "integrating textbook and other knowledge on a real live person" (POR = 2.4; P = 0.027); and "achieving a deeper understanding of SA" (POR = 5.2; P < 0.001). The qualitative findings describe specifically how BP helps students learn, understand, and remember SA.

Conclusions

The findings show the majority of students believed BP benefitted their learning of SA through enhancing engagement in self-directed classroom and out-of-hours learning opportunities, deeper understandings of form and function, retention of knowledge, and practical physical examination experiences palpating the variations in form between individuals.

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.

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.

A Curriculum for Achieving Universal Health Care: A Case Study of Ateneo de Zamboanga University School of Medicine

Introduction: Universal Health Care requires equal distribution of a health workforce equipped with competencies appropriate for local population needs. While health inequities persist in the Philippines, the Ateneo de Zamboanga University School of Medicine (ADZU-SOM) in Zamboanga Peninsula – an impoverished and underserved region – has demonstrated significant success retaining graduates and improving local health statistics. This study describes the qualitative evidence of ADZU-SOM students and graduates having positive impacts on local health services and communities, and the contextual factors associated with the school's socially-accountable mission and curriculum that contribute to these impacts.

Methods: This qualitative study involved 41 one-on-one or group interviews conducted across seven participant groups (faculty, graduates, final-year students, health professionals, health workers, community members, community leaders). Gale et al's method for analyzing qualitative data in multi-disciplinary health research, WHO's “6 Building Blocks for quality health systems” framework and THEnet's social-accountability framework were used to organize and interpret data.

Results: Local community members, community leaders, and health staff consistently reported examples of ADZU-SOM students and graduate doctors developing health infrastructure and providing health education, health promotion, and disease prevention activities accessible to all population groups. Students and graduates suggested these impacts were due to a number of factors, including how ADZU-SOM's sandwich model of longitudinal community-engagement culminating in 10-months continuous community placement in the final year helped them develop a strong motivation for community service, the teachings and curriculum activities that focused on public health and the social determinants of health, and faculty's commitment and ability to operationalize ADZU-SOM's mission and values. Staff also reported impacts were driven by integration of regional and national health priorities as core curriculum, and involving local stakeholders in curriculum development.

Conclusions: This study provides qualitative evidence that ADZU-SOM's curriculum content and immersive community placements are training a medical workforce that is strengthening local health systems and health infrastructure across all 6 WHO “Building Blocks for quality health systems.” These findings suggest ADZU-SOM has managed to evolve a consciousness toward community service among final year students and graduates, adding evidence to the assertion it is a fully socially-accountable health professions institution.

Smoking cessation in head and neck cancer patients: Factors influencing successes and failures

INTRODUCTION

This study investigated the smoking behaviours and cessation rates of head and neck cancer (HNC) patients, and their barriers and facilitators to cessation.

METHOD

The study used a mixed methods, sequential explanatory design. The quantitative data were collected at baseline (around time of cancer diagnosis) via a survey prior to commencement of treatment. Participants identified as current smokers at baseline were then followed up to determine their smoking status after treatment and asked to participate in one-on-one, semi-structured interviews.

RESULTS

Sixty-four participants with HNC were recruited, with 29 classified as current smokers. The 7-day point prevalence cessation rate for current smokers was 72% at 1-month follow-up, and 67% at 3 months, while continuous smoking cessation was 54% at 1 month, and 42% at 3 months. Participants who continued smoking were found to consume more alcohol (P = 0.032), be in a lower stage of change (pre-contemplation or contemplation stages of the transtheoretical model) at baseline (P = 0.012) and be less confident in being able to cease smoking (P = 0.004). Qualitative analysis revealed 5 key themes associated with smoking cessation: the teachable moment of a cancer diagnosis and treatment, willpower and cessation aids, psychosocial environment, relationship with alcohol and marijuana, and health knowledge and beliefs surrounding smoking and cancer.

CONCLUSIONS

This study demonstrates that the majority of HNC patients achieve smoking cessation, but relapses are common. Cessation programmes should be developed that are comprehensive, sustained and address factors such as alcohol, marijuana and depression.

Factors impacting the solo remote placement experiences of undergraduate James Cook University medical students: A mixed-methods pilot study

OBJECTIVE

To determine the factors impacting the experiences of James Cook University medical students on solo placements in remote towns.

DESIGN

This 2018 pilot study used an exploratory sequential mixed-methods approach to explore the recent solo remote placement experiences of James Cook University medical students. Qualitative interviews were performed initially to elicit context sensitive themes for the self administered survey. The survey went on to use Likert-scale questions in addition to pre-validated survey instruments.

SETTING

Focus groups and interviews took place at James Cook University Medical School in Townsville in late 2018 after students returned from their rural rotation. Two telephone interviews were conducted for Year 6 students unable to attend the focus groups.

PARTICIPANTS

James Cook University medical students in years 2, 4 and 6 students who experienced a solo placement in a remote (MMM 6 or 7) town during 2017 or 2018 were invited to be part of the study. Only Townsville-based students were involved. A total of 14 students participated in the focus groups (n = 14) and a further 31 students completed the survey (n = 31).

MAIN OUTCOME MEASURE(S)

Interviews identified themes negatively or positively impacting solo remote placement experience, while bivariate analysis identified factors associated with having an 'excellent' overall experience.

RESULTS

Student interviews identified five main themes impacting student experience in remote communities: culture of the medical facility; quality and quantity of clinical experiences; quality of accommodation; placement length; and community infrastructure and services. Negative impacts could result in students experiencing social isolation. Students reporting an 'excellent' solo remote placement experience in the survey were more likely to have: felt very welcome in the community; felt the health staff supported them; heavily involved themselves in clinical activities; enjoyed the experiences remote communities can offer; positive rural career intentions; reported they 'bounce back during and after life's most stressful events'; and come from a rural or remote hometown.

CONCLUSIONS

Solo remote placements provide medical students with opportunities to further knowledge, clinical capabilities, social experiences and careers, but can have negative aspects. However, negative aspects are often modifiable management issues or can potentially be avoided if prospective students are better informed of the challenges associated with remote communities.

"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.

Training a Fit-For-Purpose Rural Health Workforce for Low- and Middle-Income Countries (LMICs): How Do Drivers and Enablers of Rural Practice Intention Differ Between Learners From LMICs and High Income Countries?

Equity in health outcomes for rural and remote populations in low- and middle-income countries (LMICs) is limited by a range of socio-economic, cultural and environmental determinants of health. Health professional education that is sensitive to local population needs and that attends to all elements of the rural pathway is vital to increase the proportion of the health workforce that practices in underserved rural and remote areas. The Training for Health Equity Network (THEnet) is a community-of-practice of 13 health professional education institutions with a focus on delivering socially accountable education to produce a fit-for-purpose health workforce. The THEnet Graduate Outcome Study is an international prospective cohort study with more than 6,000 learners from nine health professional schools in seven countries (including four LMICs; the Philippines, Sudan, South Africa and Nepal). Surveys of learners are administered at entry to and exit from medical school, and at years 1, 4, 7, and 10 thereafter. The association of learners' intention to practice in rural and other underserved areas, and a range of individual and institutional level variables at two time points-entry to and exit from the medical program, are examined and compared between country income settings. These findings are then triangulated with a sociocultural exploration of the structural relationships between educational and health service delivery ministries in each setting, status of postgraduate training for primary care, and current policy settings. This analysis confirmed the association of rural background with intention to practice in rural areas at both entry and exit. Intention to work abroad was greater for learners at entry, with a significant shift to an intention to work in-country for learners with entry and exit data. Learners at exit were more likely to intend a career in generalist disciplines than those at entry however lack of health policy and unclear career pathways limits the effectiveness of educational strategies in LMICs. This multi-national study of learners from medical schools with a social accountability mandate confirms that it is possible to produce a health workforce with a strong intent to practice in rural areas through attention to all aspects of the rural pathway.

Workforce supply of pharmacists in Queensland communities from James Cook University Pharmacy Graduates

OBJECTIVE

This study investigates whether the regional pharmacy school at James Cook University in North Queensland is providing graduates geared to address the pharmaceutical needs of the state's regional, rural and remote communities.

DESIGN

A cross-sectional study of practice locations of James Cook University pharmacy graduates in 2019 compared to those from other Australian pharmacy schools.

PARTICIPANTS

Pharmacists from the James Cook University pharmacy program and those from other Australian pharmacy schools working in Queensland.

MAIN OUTCOME MEASURES

Comparison of the proportion of James Cook University pharmacy graduates practising in the seven Modified Monash Model rurality classifications in Queensland to graduates from other pharmacy schools. Comparison of Index of Relative Social Advantage and Disadvantage for local government areas in these practice locations. Association between Modified Monash Model for hometown and Australian practice locations for domestic James Cook University pharmacy graduates.

RESULTS

Of 973 James Cook University pharmacy graduates, 640 (65.8%) practised within Queensland in 2019. Compared to other Australian pharmacy graduates practising in Queensland at this time, James Cook University graduates had significantly higher odds of practising in local government areas with greater social disadvantage (lower Index of Relative Social Advantage and Disadvantage indices [<975]) and in rural and remote locations. Of 822 domestic James Cook University graduates, 84.5% were from a regional, rural or remote area, and compared to their hometown Modified Monash Model classification, two-thirds of these graduates practised in settings with the same or more rural Modified Monash Model classification.

CONCLUSIONS

This study indicates that regional pharmacy schools have potential to attract and retain graduates in regional, rural and remote areas, including disadvantaged and/or rural towns.

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.

Opinions of vascular surgeons and podiatrists in Australia and New Zealand on the use of hyperbaric oxygen therapy for lower limb ulcers

INTRODUCTION

Hyperbaric oxygen therapy (HBOT) has been suggested to improve healing of lower limb ulcers, though the quality of available evidence is weak to moderate. This study assessed the opinions and use of HBOT by specialists treating lower limb ulcers.

RESEARCH DESIGN AND METHODS

Accredited vascular surgeons and podiatrists in Australia and New Zealand were sent an online survey via their professional organizations. The survey asked about their use and opinions of HBOT in treating lower limb ischemic, neuropathic and venous ulcers. Data were summarized with descriptive statistics. Non-parametric tests were used to compare survey results obtained from vascular surgeons and podiatrists.

RESULTS

61 vascular surgeons and 40 podiatrists completed the survey. Thirty-seven specialists used HBOT for treating lower limb ulcers, with the remainder indicating they did not feel there was a role for HBOT (n=25) or did not have access to HBOT (n=39). Less than 8% of specialists indicated that HBOT frequently or always had a role in treating ischemic, neuropathic or venous ulcers. Compared with podiatrists, vascular surgeons were significantly less likely to indicate HBOT had a treatment role for any ulcer type (p<0.001, p=0.004, and p<0.001, respectively), though significantly more likely to indicate they currently used HBOT for treating lower limb ulcers (p<0.001). Most specialists (n=76) believed that a large clinical trial is needed to determine the efficacy of HBOT in treating lower limb ulcers.

CONCLUSIONS

Vascular surgeons and podiatrists do not feel HBOT has a frequent role in treating lower limb ulcers, but do feel there needs to be a large clinical trial to test its value.

Women's epidural decision-making in labour: A Townsville perspective

BACKGROUND

Despite being an efficacious means of pain relief, there is a broad range of usage rates of epidural analgesia among countries worldwide. Australia sits between common usage in North America and more conservative usage in the UK. The reason for this is unclear, raising the question of whether there is a difference between Australia and other Western countries in pregnant women's attitudes toward epidural use, or the hospital context.

AIM

To explore predictors for epidural analgesia request among pregnant women in Townsville, Australia.

MATERIALS AND METHODS

A three-phase mixed methods exploratory study design, with Phase One involving 12 one-on-one interviews with pregnant and post-partum women regarding attitudes toward labour analgesia decision-making and epidural preferences. Interview data were analysed thematically to develop a survey distributed to 265 third-trimester women in Phase Two. Phase Three involved a chart review of survey participants to record delivery mode, epidural request and indication. Bivariate and logistic regression analysis of Phases Two and Three data were used to develop predictive models for epidural decision-making.

RESULTS

Interviews revealed several themes influencing analgesia preferences in Townsville women: concerns regarding personal safety, trust in health professionals, and previous experiences with labour. The logistic regression identified epidural request in labour to be predicted by: primiparity, epidural experience, induction or augmentation of labour, and perceived sense of control associated with epidural use.

CONCLUSIONS

This study suggests that the most significant influencers on Townsville women's epidural decision-making were parity, induction or augmentation of labour, previous experience of epidurals and attitude toward epidurals.

Links between perceived general practitioner support and the wellbeing of Australian patients with persistent pain

BACKGROUND AND OBJECTIVES

Approximately one-fifth of the population have persistent pain of moderate-to-severe intensity, which affects patients physically, mentally, psychosocially and financially. The aim of this study was to investigate the association between self‑reported wellbeing of patients with persistent pain attending a pain clinic and perceptions of care from general practitioners (GPs) and other treating health professionals.

METHOD

Patients with persistent pain completed a self-administered survey.

RESULTS

Overall, only 29 (35%) patients with persistent pain were satisfied with their overall wellbeing, with a positive sense of wellbeing solely predicted by a belief that their GPs are 'treating their problem sympathetically' (P = 0.001; prevalence odds ratio = 5.4; 95% confidence interval: 1.9, 14.9). Voluntarily disclosed free-form comments from patients with persistent pain also appear to indicate that GP-managed pain clinics may be able to provide a more consistent level of support and care to patients with persistent pain than other practice settings.

DISCUSSION

These findings suggest psychological support provided by GPs is an important factor for the maintenance of a positive sense of wellbeing for patients with persistent pain.

Perceived patient benefits from using prescription opioids and other therapies to manage persistent pain

OBJECTIVE

There is current controversy surrounding the long-term prescription of opioids to persistent pain (PP) pa-tients due to potential dangers of addiction and overdose. This study is the first to explore the perspectives of PP pa-tients attending a multidisciplinary pain clinic on the benefits associated with using opioids and other self-medication strategies for pain relief.

DESIGN, PATIENTS, AND SETTING

Cross-sectional study utilizing a self-administered survey of patients attending an Austra-lian General Practice pain clinic for treatment of PP for at least 1 year (n = 93; response rate = 89 percent).

RESULTS

Of the 93 participants, 79 percent reported being on opioid medication, with 49 percent on such medication for over 1 year. One or more side-effects were experienced by 53 percent of PP patients using opioids (although all felt these side-effects were at least "somewhat" acceptable). In addition, 64 percent of PP on opioid medication felt the benefits were "sub-stantially" worth the risk of harm, and 50 percent reported their medication had led to "substantial" improvements in their qual-ity of life. Many PP patients also used nonprescription medications and other complementary therapies for pain relief; how-ever, only the illicit drug cannabis was consistently stated (by 79 percent of users) to have benefits regarding relaxation and sleeping.

CONCLUSION

Overall, PP patients felt the benefits of opioid use outweighed the risks, and using opioid medication sig-nificantly improved their quality of life. This may be partly due to the poor efficacy of other nonprescription medications and complementary therapies in managing PP beyond short-term relief.

Factors Influencing Medical Students' Experiences and Satisfaction with Blended Integrated E-Learning

OBJECTIVES

Blended learning has been presented as a promising learner-centred model that emphasises the learning outcome rather than the process of education, but it can negatively affect learners' engagement with learning.

SUBJECT AND METHODS

Using a mixed-methods approach, this study aimed to determine the significant predictors of learning satisfaction and to evaluate the experiences of medical students with the different domains of an introduced blended integrated learning approach.

RESULTS

The survey was administered to 92 respondents with a mean age of 20.5 years. Male students had significantly higher computer self-efficacy and overall learner satisfaction ratings than their female counterparts. Multiple regression analysis showed that gender (student characteristics), performance expectations (cognitive factors), and learning climate (social environment) were predictors of the perceived satisfaction of learners.

CONCLUSION

Wider integration of blended learning into pre-clinical undergraduate medical education could enhance the shift towards competency-based education and life-long learning among medical students. However, effective implementation would depend largely on student characteristics, as well as environmental and cognitive components of the delivery method.

Does a socially-accountable curriculum transform health professional students into competent, work-ready graduates? A cross-sectional study of three medical schools across three countries

Background: Socially-accountable health professional education (SAHPE) is committed to achieving health equity through training health-workers to meet local health needs and serve disadvantaged populations. This research assesses the biomedical and socially-accountable competencies and work-readiness of first year graduates from socially-accountable medical schools in Australia, the United States and Sudan.Method: A self-administered survey to hospital and community health facility staff closely associated with the training and/or supervision of first year medical graduates from three SAHPE medical schools.Main outcome measure: Likert scale ratings of key competencies of SAHPE graduates (as a group) employed as first-year doctors, compared to first year doctors from other medical schools in that country (as a group).Findings: Supervisors rated medical graduates from the 3 SAHPE schools highly for socially-accountable competencies ('communication skills', 'teamwork', 'professionalism', 'work-readiness', 'commitment to practise in rural communities', 'commitment to practise with underserved ethnic and cultural populations'), as well as 'overall performance' and 'overall clinical skills'.Interpretation: These findings suggest SAHPE medical graduates are well regarded by their immediate hospital supervisors, and SAHPE can produce a medical workforce as competent as from more traditional medical schools, but with greater commitment to health equity, working with underserved populations, and addressing local health needs.

Dysregulation of the actin scavenging system and inhibition of DNase activity following severe thermal injury

Background

Circulating cell‐free DNA (cfDNA) is not found in healthy subjects, but is readily detected after thermal injury and may contribute to the risk of multiple organ failure. The hypothesis was that a postburn reduction in DNase protein/enzyme activity could contribute to the increase in cfDNA following thermal injury.

Methods

Patients with severe burns covering at least 15 per cent of total body surface area were recruited to a prospective cohort study within 24 h of injury. Blood samples were collected from the day of injury for 12 months.

Results

Analysis of blood samples from 64 patients revealed a significant reduction in DNase activity on days 1–28 after injury, compared with healthy controls. DNase protein levels were not affected, suggesting the presence of an enzyme inhibitor. Further analysis revealed that actin (an inhibitor of DNase) was present in serum samples from patients but not those from controls, and concentrations of the actin scavenging proteins gelsolin and vitamin D‐binding protein were significantly reduced after burn injury. In a pilot study of ten military patients with polytrauma, administration of blood products resulted in an increase in DNase activity and gelsolin levels.

Conclusion

The results of this study suggest a novel biological mechanism for the accumulation of cfDNA following thermal injury by which high levels of actin released by damaged tissue cause a reduction in DNase activity. Restoration of the actin scavenging system could therefore restore DNase activity, and reduce the risk of cfDNA‐induced host tissue damage and thrombosis.

Benefits of simulated General Practice clinics in the preparation of medical students for primary healthcare

The James Cook University (JCU) medical school has a mission to produce doctors who are willing to work across northern Australia and may choose generalist rather than specialist careers. In addition to real-life placements in primary healthcare settings, the medical school has developed simulated General Practice (GP) clinics (simGPclinic) for Year 5 (Y5) students. This study compares the simGPclinic with actual GP placements for authenticity, teaching clinical skills, and preparation for real-life primary healthcare settings. Y5 students were administered a survey following their simGPclinic (n = 65; response rate = 97%). Students rated the simGPclinic's authenticity as 77 out of 100, and were more likely to rate the simGPclinic as being 'better' than their real-life GP placement in teaching them to: 'formulate a medical management plan and order correct pathology tests'; 'rule out the "red flags" for the key clinical problem'; 'undertake a patient-centred history and examination'; 'make a differential diagnosis for the key clinical problem'; and, 'develop communications skills'. The simGPclinic provided medical students with authentic and positive learning experiences in primary healthcare that were at least as beneficial as those provided in real-life settings, as well as being more reliable and better structured.

Career choices of the first seven cohorts of JCU MBBS graduates: producing generalists for regional, rural and remote northern Australia

INTRODUCTION

Generalism in the health workforce has been established as an important strategy to address health workforce maldistribution. Thus, to best serve the medical needs of northern Australia, the James Cook University (JCU) College of Medicine and Dentistry has a mission to produce graduates who both practise in the region and have a generalist orientation. This study investigated the postgraduate qualifications and key factors that shaped the current career choice of JCU medical graduates, and whether JCU graduates are more likely to choose generalist careers than other Australian medical practitioners of a similar level of experience.

METHODS

JCU medical graduate data were obtained via cross-sectional survey of 298 early career JCU medical graduates from postgraduate year (PGY) 4 to PGY 10 (the first seven cohorts) who had consented to be contacted for further studies and were still contactable (n=180, response rate=60%). Australian medical graduate data were obtained via the National Health Workforce Dataset released by the Department of Health.

RESULTS

Compared to a group of Australian medical graduates with similar years of experience, JCU medical graduates are significantly more likely to choose careers as 'generalists' (general practitioners/rural generalists (p=0.044)) or 'generalist specialists' in general surgery (p=0.008), general paediatrics (p=0.008), obstetrics and gynaecology (p=0.038) and emergency medicine (borderline significance p=0.058). However, they are less likely to be 'specialist specialists' such as pathologists/radiologists (p=0.003) or a physician subspecialty (p=0.004). Key factors identified as influencing current career choice included 'interest developed or strengthened during undergraduate training', 'interest developed from early postgraduate career experiences', 'specialty has a good work-life balance', 'specialty involves continuity of care with patients', 'interest in rural practice', 'enjoy a wide scope of practice/being a generalist' and 'mentors'.

CONCLUSIONS

The JCU medical school produces significantly more graduates with a generalist rather than specialist career focus compared to a similarly experienced group of Australian medical practitioners. Contributing factors may include the JCU selection process, and the curricular focus on providing students with a wide range of generalist experiences and exposure to rural, remote, Indigenous and tropical health. Developing approaches that facilitate local vocational training and subsequent specialist practice is also an important part of the regional, rural and remote training pathway. Lastly, the findings suggest JCU medical graduates choose a career that is not only compatible with regional, rural or remote practice, but also involves continuity of care with patients, a wide scope of practice and a good work-life balance, and that this choice has been influenced by a combination of undergraduate and early career experiences. These findings are in line with international evidence and have implications for other jurisdictions planning an educational and workforce strategy to meet the needs of their own regional, rural and remote locations.

Are all rural placements created equal? A national study of placement experiences among multidisciplinary health students

OBJECTIVE

Members of the National Rural Health Student Network have expressed concerns that the quality and accessibility of rural placements might vary between health degrees. This study compared a range of placement factors between health student disciplines.

DESIGN

Cross-sectional survey.

SETTING

An online survey tool was distributed in 2016 by the National Rural Health Student Network and its Rural Health Clubs to the National Rural Health Student Network's 10 218 members in all Australian states and territories.

PARTICIPANTS

Responses were received from 897 health students (9% response rate). Participants were from the disciplines of medicine, dentistry, nursing, midwifery or an allied health degree.

MAIN OUTCOME MEASURES

Bivariate analysis between medical and non-medical students relating to the support received for rural placements: support provided to help students coordinate their placement; assistance with financial costs; mental health support; social support; and student orientation regarding both the placement's health service and community.

RESULT

Compared with medical students, non-medical students were more likely to have coordinated the majority of their placement themselves, but were less likely to have had control over their placement location or to have received financial support, mental health support, social support, a health service orientation or a community orientation.

CONCLUSION

Among National Rural Health Student Network members, those studying health degrees other than medicine had significantly less rural placement support in all examined domains when compared with medical students.

Use of supplemental oxygen in emergency patients: a systematic review and recommendations for military clinical practice

INTRODUCTION

Supplemental oxygen is a key element of emergency treatment algorithms. However, in the operational environment, oxygen supply poses a challenge. The lack of high-quality evidence alongside emerging technologies provides the opportunity to challenge current guidelines. The aim of this review was to appraise the evidence for the administration of oxygen in emergency patients and give recommendations for its use in clinical practice.

METHODS

A critical review of the literature was undertaken to determine the evidence for emergency supplemental oxygen use.

RESULTS

Based on interpretation of the limited available evidence, five key recommendations are made: pulse oximetry should be continuous and initiated as early as possible; oxygen should be available to all trauma and medical patients in the forward operating environment; if peripheral oxygen saturations (SpO₂) are greater than or equal to 92%, supplemental oxygen is not routinely required; if SpO₂ is less than 92%, supplemental oxygen should be titrated to achieve an SpO₂ of greater than 92%; and if flow rates of greater than 5 L/min are required, then urgent evacuation and critical care support should be requested.

CONCLUSION

Oxygen is not universally required for all patients. Current guidelines aim to prevent hypoxia but with potentially conservative limits. Oxygen should be administered to maintain SpO₂ at 92% or above. New areas for research, highlighted in this review, may provide a future approach for oxygen use from point of injury to definitive care.

Aligning an undergraduate psychological medicine subject with the mental health needs of the local region

BACKGROUND

The James Cook University (JCU) medical school recently revised its Year 2 human development and behaviour module to be more relevant and practical for students, and more aligned with the mental health priorities of the local region (north Queensland). This study reports medical students' level of preparedness conferred by the re-designed 'Psychological Medicine and Human Development' (PMHD) subject for their later 4-week, rural clinical placement in Year 2.

METHODS

Non-randomized, controlled 'naturalistic' study with pre- and post-intervention surveys. The patient mental health experiences of Year 2 students who went on clinical placement after undertaking the PMHD subject were compared to those who went on placement before undertaking PMHD.

RESULTS

A total of 209 JCU Year 2 medical students completed surveys from a possible 217 (response rate = 96%). Compared to students whom had not taken PMHD before going on placement, students going on placement after undertaking PMHD were significantly more likely to report: feeling comfortable discussing mental health issues with patients (p = 0.001); being prepared for mental health discussions with patients (p < 0.001); having an actual mental health discussion with a patient (p < 0.001); and, volunteering an opinion on the appropriateness of their supervising doctor's response (p < 0.001). Students reported subject content involving information and classroom instruction on assessing and interviewing patients for mental illness to be of most use.

CONCLUSIONS

Providing medical students with psychological medicine information on locally prevalent mental health conditions plus practical classroom experiences in conducting mental state exams better prepares them for interacting with patients experiencing psychological distress. This novel methodology - aligning formal teaching in a subject with an evaluation utilizing a proximate student placement to provide useful feedback on the curriculum content and assess the relevance of the material taught - could be used to revise other content areas of a medical course to be more locally relevant and practically focused, and then to evaluate the success of this revision.

Work settings of the first seven cohorts of James Cook University Bachelor of Medicine, Bachelor of Surgery graduates: Meeting a social accountability mandate through contribution to the public sector and Indigenous health services

OBJECTIVE

The James Cook University medical school's mission is to produce a workforce appropriate for the health needs of northern Australia.

DESIGN, SETTING AND PARTICIPANTS

James Cook University medical graduate data were obtained via cross-sectional survey of 180 early-career James Cook University medical graduates from 2005-2011 (response rate of 180/298 contactable graduates = 60%). Australian medical practitioner data for 2005-2009 graduates were obtained via the 2015 'Medicine in Australia: Balancing Employment and Life' wave 8 dataset.

MAIN OUTCOME MEASURE

Comparison of the range of work settings and hours worked by James Cook University medical graduates to Australian medical graduates.

RESULTS

Compared to a similar group of Australian medical graduates, James Cook University Bachelor of Medicine, Bachelor of Surgery graduates are significantly more likely to work in government-funded 'public' organisations (hospitals, community health centres, Aboriginal Community Controlled Health Services, government departments, agencies or defence forces). In particular, James Cook University medical graduates were more likely to work in Aboriginal Community Controlled Health Services and community health centres and other state-run primary health care organisations than other Australian medical graduates.

CONCLUSION

James Cook University medical graduates appear to work in a higher proportion of public settings; in particular, primary care settings, than Australian medical graduates. This is an appropriate mix for the predominantly rural and remote geography of Queensland and its associated medical workforce priorities. Reporting medical graduate outcomes by their nature of practice could be an important adjunct to other measures, such as geographic location and choice of specialty.

Inclination towards research and the pursuit of a research career among medical students: an international cohort study

BACKGROUND

Involvement of clinicians in biomedical research is imperative for the future of healthcare. Several factors influence clinicians' inclination towards research: the medical school experience, exposure to research article reading and writing, and knowledge of research. This cohort study follows up medical students at time of graduation to explore changes in their inclination towards research and pursuing a research career compared to their inclination at time of entry into medical school.

METHODS

Students from medical schools in six different countries were enrolled in their first year of school and followed-up upon graduation in their final year. Students answered the same self-administered questionnaire at both time points. Changes in inclination towards research and pursuing a research career were assessed. Factors correlated with these changes were analysed.

RESULTS

Of the 777 medical students who responded to the study questionnaire at entry into medical school, 332 (42.7%) completed the follow-up survey. Among these 332 students, there was no significant increase in inclination towards research or pursuing a research career over the course of their medical schooling. Students from a United States based school, in contrast to those from schools other countries, were more likely to report having research role models to guide them (51.5% vs. 0%-26.4%) and to have published in a peer-reviewed journal (75.7% vs. 8.9%-45%). Absence of a role model was significantly associated with a decrease in inclination towards research, while an increased desire to learn more about statistics was significantly associated with an increase in inclination towards pursuing a research career.

CONCLUSION

Most medical students did not experience changes in their inclination towards research or pursuing a research career over the course of their medical schooling. Factors that increased their inclination to undertaking research or pursuing a research career were availability of a good role model, and a good knowledge of both the research process and the analytical tools required.

Socially accountable medical education strengthens community health services

CONTEXT

Socially accountable health professional education (SAHPE) is committed to achieving health equity through training health professionals to meet local health needs and serve disadvantaged populations. This Philippines study investigates the impact of SAHPE students and graduates on child and maternal health services and outcomes.

METHODS

This is a non-randomised, controlled study involving a researcher-administered survey to 827 recent mothers (≥1 child aged 0-5 years). Five communities were serviced by SAHPE medical graduates or final-year medical students (interns) in Eastern Visayas and the Zamboanga Peninsula, and five communities in the same regions were serviced by conventionally trained (non-SAHPE) graduates.

FINDINGS

Mothers in communities serviced by SAHPE-trained medical graduates and interns were more likely than their counterpart mothers in communities serviced by non-SAPHE trained graduates to: have lower gross family income (p < 0.001); have laboratory results of blood and urine samples taken during pregnancy discussed (p < 0.001, respectively); have first pre-natal check-up before 4th month of pregnancy (p = 0.003); receive their first postnatal check-up <7 days of birth (p < 0.001); and have a youngest child with normal (>2500 g) birthweight (p = 0.003). In addition, mothers from SAHPE-serviced communities were more likely to have a youngest child that: was still breastfed at 6 months of age (p = 0.045); received a vitamin K injection soon after birth (p = 0.026); and was fully immunised against polio (p < 0.001), hepatitis B (p < 0.001), measles (p = 0.008) and diphtheria/pertussis/tetanus (p < 0.001). In communities serviced by conventional medical graduates, mothers from lower socio-economic quartiles (<20 000 Php) were less likely (p < 0.05) than higher socio-economic mothers to: report that their youngest child's delivery was assisted by a doctor; have their weight measured during pregnancy; and receive iron syrups or tablets.

CONCLUSIONS

The presence of SAHPE medical graduates or interns in Philippine communities significantly strengthens many recommended core elements of child and maternal health services irrespective of existing income constraints, and is associated with positive child health outcomes.

Positive implications from socially accountable, community-engaged medical education across two Philippines regions

INTRODUCTION

Hundreds of millions of people worldwide lack access to quality health services, largely because of geographic and socioeconomic maldistribution of qualified practitioners. This study describes differences between the practice locations of Philippines medical graduates from two 'socially accountable, community-engaged' health professional education (SAHPE) schools and the practice locations of graduates from two 'conventionally trained' medical schools located in the same respective geographic regions. Licensed medical graduates were currently practising in the Philippines and had been practising for at least 6 months. Graduates were from two Philippines SAHPE schools (Ateneo de Zamboanga University-School of Medicine (ADZU-SOM) on the Zamboanga Peninsula (n=212) and the University of the Philippines Manila-School of Health Sciences (SHS-Palo) in Eastern Visayas (n=71), and from two 'conventional' medical schools Methods: Current graduate practice locations in municipalities or cities were linked with their respective population size and socioeconomic income class, and geocoded using Geographical Information System software onto a geospatial map of the Philippines. Bivariate analysis compared the population size and socioeconomic class of communities where the SAHPE medical graduates practised to communities where 'conventional' medical school graduates practised.

RESULTS

Thirty-one percent of ADZU-SOM medical graduates practised in communities <100 000 population versus 7% of graduates from the conventional school in the Zamboanga region (p<0.001), while 61% of SHS-Palo medical graduates practised in communities <100 000 population versus 12% of graduates from the conventional school in the Visayas region (p<0.001). Twenty-seven percent of ADZU-SOM graduates practised in lower income category communities (categories 2-6) versus 8% of graduates from the conventional school in the same region (p<0.001), while 49% of SHS-Palo graduates practised in lower income category communities (categories 2-6) versus 11% of graduates from the conventional school in the same region (p<0.001).

CONCLUSIONS

SAHPE has contributed to increased medical coverage across rural and/or economically disadvantaged areas in two Philippines regions. The extensive community-based medical student placements associated with SAHPE likely play a significant role in graduates choosing to practice in rural and/or economically disadvantaged communities. Governments experiencing medical workforce maldistributions similar to those in the Philippines should consider SAHPE as a potentially cost-effective strategy in recruiting and retaining health graduates to underserved areas.

The impact of socially-accountable, community-engaged medical education on graduates in the Central Philippines: Implications for the global rural medical workforce

INTRODUCTION

Developing and retaining a high quality medical workforce, especially within low-resource countries has been a world-wide challenge exacerbated by a lack of medical schools, the maldistribution of doctors towards urban practice, health system inequities, and training doctors in tertiary centers rather than in rural communities.

AIM

To describe the impact of socially-accountable health professional education on graduates; specifically: their motivation towards community-based service, preparation for addressing local priority health issues, career choices, and practice location.

METHODS

Cross-sectional survey of graduates from two medical schools in the Philippines: the University of Manila-School of Health Sciences (SHS-Palo) and a medical school with a more conventional curriculum.

RESULTS

SHS-Palo graduates had significantly (p < 0.05) more positive attitudes to community service. SHS-Palo graduates were also more likely to work in rural and remote areas (p < 0.001) either at district or provincial hospitals (p = 0.032) or in rural government health services (p < 0.001) as Municipal or Public Health Officers (p < 0.001). Graduates also stayed longer in both their first medical position (p = 0.028) and their current position (p < 0.001).

CONCLUSIONS

SHS-Palo medical graduates fulfilled a key aim of their socially-accountable institution to develop a health professional workforce willing and able, and have a commitment to work in underserved rural communties.

Addressing health workforce inequities in the Mindanao regions of the Philippines: Tracer study of graduates from a socially-accountable, community-engaged medical school and graduates from a conventional medical school

Developing and retaining a high-quality medical workforce in low-resource countries is a worldwide challenge. The Filipino Ateneo de Zamboanga University-School of Medicine (ADZU-SOM) has adopted a strong focus on socially accountable health professional education (SAHPE) in order to address the shortage of physicians across rural and urban communities in the Western Mindanao region. A cross-sectional survey of graduates from two Philippines medical schools: ADZU-SOM in the Mindanao region and a medical school with a more conventional curriculum, found ADZU-SOM graduates were more likely to have joined the medical profession due to a desire to help others (p = 0.002), came from lower socioeconomic strata (p = 0.001) and had significantly (p < 0.05) more positive attitudes to community service. ADZU graduates were also more likely to currently work in Government Rural Health Units (p < 0.001) or be generalist Medical Officers (p < 0.001) or Rural/Municipal Health Officers (p = 0.003). ADZU graduates were also less likely to work in private or specialist Government hospitals (p = 0.033 and p = 0.040, respectively) and be surgical or medical specialists (p = 0.010 and p < 0.001, respectively). The findings suggest ADZU-SOM's SAHPE philosophy manifests in the practice choices of its graduates and that the ADZU-SOM can meet the rural and urban health workforce needs of the Western Mindanao region.

Lessons learnt from implementing blended 'integrated' learning into an undergraduate medical curriculum

This article was migrated. The article was marked as recommended. Method:This study utilized a mixed-method design involving a cross-sectional survey (n=111, response rate=61%) to compare Year 2 medical student perceptions of content delivered by a Blended Integrated Learning (BIL) approach versus a traditional didactic teaching (TT) approach, plus 2 focus groups to explore learner perceptions of the BIL approach and brainstorm improvements. Results: Most medical students preferred the BIL approach over TT with respect to 'practically applying basic sciences to a patient case' and 'knowledge retention in the subject' (53% versus 30%, and 51% versus 35%, respectively). However, most medical students preferred TT with respect to 'level of interaction with other students and lecturers while reviewing teaching materials' (78% versus 11%), 'overall enjoyment of learning' (54% versus 32%), and 'understanding the lecture content faster' (49% versus 39%). Focus groups identified what did and did not work with the BIL approach and brain-stormed specific improvement strategies. Conclusions: Students preferred BIL over TT for knowledge retention and integrating basic sciences into common clinical cases, but found BIL less preferable for aspects related to learning engagement. However, focus groups identified a variety of strategies to promote student engagement in BIL by improving online content, delivery processes and further innovative use of technology.

Medication calculation and administration workshop and hurdle assessment increases student awareness towards the importance of safe practices to decrease medication errors in the future

BACKGROUND

Medication errors are the second most frequently reported hospital incident in Australia and are a global concern. A "Medication Calculation and Administration" workshop followed by a "hurdle" assessment (compulsory task mandating a minimum level of performance as a condition of passing the course) was introduced into Year 2 of the James Cook University medical curriculum to decrease dosage calculation and administration errors among graduates. This study evaluates the effectiveness of this educational activity as a long-term strategy to teach medical students' essential skills in calculating and administering medications.

METHODS

This longitudinal study used a pre- and post-test design to determine whether medical students retained their calculation and administration skills over a period of 4 years. The ability to apply basic mathematical skills to medication dose calculation, principles of safe administration (Part 1), and ability to access reference materials to check indications, contraindications, and writing the medication order with correct abbreviations (Part 2) were compared between Year 2 and 6 assessments.

RESULTS

Scores for Parts 1, 2 and total scores were nearly identical from Year 2 to Year 6 (P = 0.663, 0.408, and 0.472, respectively), indicating minimal loss of knowledge by students in this period. Most Year 6 students (86%) were able to recall at least 5 of the "6 Rights of Medication Administration" while 84% reported accessing reference material and 91% reported checking their medical calculations.

DISCUSSION

The "Medication Calculation and Administration" workshop with a combined formative and summative assessment - a "hurdle" - promotes long-term retention of essential clinical skills for medical students. These skills and an awareness of the problem are strategies to assist medical graduates in preventing future medication-related adverse events.

Predictors of remote practice location in the first seven cohorts of James Cook University MBBS graduates

INTRODUCTION

This article describes factors predicting James Cook University (JCU) medical graduates undertaking at least 1 year of remote practice. The cross-sectional design involved point-in-time (2015) analysis of the JCU medical school's ongoing longitudinal graduate tracking database. Participants were the first seven cohorts of graduates from the JCU medical school who had completed at least their postgraduate year (PGY) 4 in Australia (<i>n</i>=529); that is, PGY 4 to PGY 10 graduates.

METHODS

Multiple logistic regression and Classification and Regression Tree (CART) analysis of medical graduate application data (age, gender, hometown, interview score, ethnicity), undergraduate data (scholarships awarded, clinical school location) and postgraduation data (internship location, specialty training) was performed. Analysis identified independent predictors of having practised for at least 1 year in a 'remote' Australian town (Australian Standard Geographic Classification Remoteness Area 4-5).

RESULTS

Forty-seven (9%) of JCU Bachelor of Medicine and Bachelor of Surgery graduates in the first seven cohorts had practised for at least 1 year in a remote location between PGY 4 and 10. Practice in a 'remote' town was predicted by undertaking rural generalist training (<i>p</i><0.001; prevalence odds ratio (POR)=17.0), being awarded an 'above average' interview score at medical school selection (<i>p</i>=0.006; POR=5.1), attending the Darwin clinical school in years 5-6 (<i>p</i>=0.005; POR=4.7), being female (<i>p</i>=0.016, POR=3.6) and undertaking an outer-regional or remotely based internship (<i>p</i>=0.006; POR=3.5). CART analysis identified Indigenous graduates as another key subgroup of remote practice graduates.

CONCLUSIONS

This study provides the first Australian evidence that likelihood of remote medical practice is enhanced by investment in a 'remote pipeline' - medical education via clinical schools and internships in rural/remote locations, with a later option of a rural generalist pathway. The proportion of medical graduates working in remote practice may also be increased by preferentially selecting Indigenous Australian applicants and applicants who score highly for communication, teamwork, self-reliance and motivation for rural and remote practice.

The impact of socially-accountable health professional education: A systematic review of the literature

This literature review describes the impact of health professional schools with a social accountability mandate by identifying characteristics of medical education found to impact positively on medical students, health workforce, and health outcomes of disadvantaged communities. A critical appraisal tool was used to identify the strengths and weaknesses of the published articles. Data are presented as a narrative synthesis due to the variety of methodologies in the studies, and characterized using a logic model. Health professional schools aiming to improve health outcomes for their disadvantaged local communities described collaborative partnerships with communities, equitable selection criteria, and community-engaged placements in underserved areas as positively impacting the learning and attitudes of students. Students of socially accountable schools were more likely to stay in rural areas and serve disadvantaged communities, and were often more skilled than students from more traditional schools to meet the needs of underserved communities. However, published literature on the impact of socially accountable health professional education on communities and health outcomes is limited, with only one study investigating health outcomes. The findings of this literature review guide schools on the inputs likely to maximize their socially accountability outputs and increase their impact on students, local health workforce and local communities.

Predictors of rural practice location for James Cook University MBBS graduates at postgraduate year 5

OBJECTIVE

To describe factors predicting James Cook University (JCU) medical graduates having a rural practice location at postgraduate year (PGY) 5.

PARTICIPANTS

JCU MBBS graduates who had completed their PGY 5 in Australia (n = 260).

DESIGN

Multiple logistic regression analysis involving graduates' application data (age, gender, location of hometown, School Leaving Score, interview score, ethnicity), undergraduate data (scholarship awarded, honours program), and postgraduation data (internship location, specialty training undertaken).

MAIN OUTCOME MEASURE

Predictors of practice in a 'rural' town (Australian Standard Geographic Classification Remoteness Area (ASGC-RA)) 3-5 at PGY 5.

RESULTS

Practice in a 'rural' town in PGY 5 was predicted by 'internship in an ASGC-RA 3-5 location' (prevalence odds ratios (POR) = 3.9, P < 0.001), 'undertaken postgraduate training as a general practitioner or rural generalist' (POR = 3.4, P < 0.001), 'hometown at application located in ASGC-RA 3-5 area' (POR = 2.9, P = 0.023), 'Aboriginal & Torres Strait Islander ancestry' (POR = 5.6, P = 0.031), and NOT undertaken postgraduate training in surgery (POR = 5.4, P = 0.055).

CONCLUSIONS

This study provides evidence that likelihood of early career rural medical practice in Australia is enhanced by education strategies, such as providing rurally located internship places, supporting rural general practice, and selecting applicants with rural origins, Aboriginal or Torres Strait Islander ancestry, and/or a genuine interest in rural, remote, Indigenous, and tropical medicine. This early evidence supports the proposition that investing in rural medical education will produce an appropriately trained medical workforce to meet the needs of rural Australia. Findings also suggest rural workforce may be further enhanced with additional specialty training opportunities in rural tertiary hospitals, in particular, surgery.

James Cook University's decentralised medical training model: an important part of the rural workforce pipeline in northern Australia

INTRODUCTION

There has been much recent investment to improve the recruitment and retention of medical graduates in rural Australia. This paper describes the different outcomes of the strategies used at the James Cook University (JCU) medical school to improve the recruitment and retention of medical graduates in northern Australian towns: the decentralised model of four rural clinical schools, selecting students with a rural home town, enrolling students under the Bonded Medical Placements (BMP) scheme, and providing rurally orientated scholarships.

METHODS

Home town at application to medical school, clinical school location, scholarship, BMP and postgraduate practice location data for JCU medical graduates were retrieved from an ongoing longitudinal cohort study. Multivariate logistic regression analysis was used to identify independent predictors of intern practice location from 2006 to 2013, and current (2014) practice location for postgraduate year 4-9 graduates for each of the four rural clinical school sites of Townsville, Cairns, Darwin and Mackay.

RESULTS

The strongest predictor of JCU Bachelor of Medicine, Bachelor of Surgery (MBBS) graduates undertaking their internship in Townsville, Cairns, Mackay or Darwin hospitals was attending the JCU clinical school in that location (p<0.001, prevalence odds ratios (POR)=7.1; p<0.001, POR=11.5; p<0.001, POR=19.4; p<0.001, POR=85.7; respectively). Attending the JCU clinical school in the main town was also a strong predictor of JCU MBBS graduates currently practising (2014) in the Townsville, Cairns and Mackay health service districts (p<0.001, POR=2.9; p<0.001, POR=3.8; p=0.033, POR=3.6; respectively).

CONCLUSIONS

While this study supports the effectiveness of improving the rural medical workforce via the targeted selection of students with a rural background, the JCU medical school's decentralised medical education program also appears to be significantly associated with rural recruitment and retention, including in districts of workforce shortage and/or geographically remote locations. These findings support other evidence that decentralised medical training can assist recruitment to underserved regions, and have implications for other jurisdictions looking to invest in a decentralised training model.