Innovative training forrural medical studentsMalcolm Moore, Keryn Bolte and Paul Bennett Department of Rural Health, SydneyUniversity, New South Wales, Australia

SUMMARYBackground: Traditional ap-proaches to curriculum deliveryare primarily devoted to produc-ing graduates who are proficientin their professional domain,leaving little time for interactionbetween disciplines. Rural doctorsneed to work closely with otherhealth workers in the context oflife in smaller communities.Context: The Broken Hill Univer-sity Department of Rural Health(BHUDRH) was established toimprove health care in far-westernNew South Wales (NSW). It runs aprogramme of extended clinicalplacements for 10 medical stu-dents from three universities. Italso takes many medical students

on short-term placements, as wellas nursing and allied healthworkers.Innovation: The BHUDRH hasestablished a programme ofweekly workshops that focus onrural and cultural issues in aninterprofessional learning con-text. This programme is designedto deepen the medical students’experience, and to further the goalof developing the rural and remotehealth workforce. This article de-scribes the Enhanced Rural Inter-Professional Cultural Health (EN-RICH) programme. ENRICH usescommunity resources – profes-sional, cultural and artistic – toprovide stimulating educationalopportunities. Students cover

topics ranging from hands-onresuscitation skills to life-drawingclasses with students from severalhealth disciplines. The regular,programmed nature of this schemegives rural, interprofessional andcultural aspects of learning a highprofile in the students’ experience.Implications: The ENRICH pro-gramme puts issues of life andpractice in a rural communityfirmly on the agenda of BHUDRHstudents. It gives them an expe-rience of the depth of a ruralcommunity that they mightotherwise not be aware of, andpromotes teamwork through in-terprofessional education. It isanother strategy for encouragingstudents to return to rural work.

Rural doctorsneed to workclosely withother health

workers in thecontext of life

in smallercommunities

Educationin ruralcommunities

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INTRODUCTION

Strong voices are calling fornew approaches to globalhealth care education.1

There is an identified need tobroaden the perspectives ofhealth care workers and toencourage the incorporation of aholistic view of their patients intotheir practice.2 The focus onclinical competencies withincurrent curricula is producing adeficit in the learning of practi-tioners: ‘In general, medicalschool educators focus more onthe parts, the building blocks forfuture doctors’.3 Traditional ap-proaches to curriculum deliveryare primarily devoted to produc-ing graduates who are proficientin their professional domain,which leaves little time for inter-action between disciplines. This isa problem for all doctors, and theproducts of this kind of educationare not well prepared for work inrural communities.

A DEPARTMENT OF RURALHEALTH

The Broken Hill UniversityDepartment of Rural Health(BHUDRH) is one of 11 similardepartments funded by the Com-monwealth Government of Aus-tralia. It was established toimprove health care in far-westernNew South Wales (NSW) – aremote, sparsely populated area –by providing support, educationand training to rural and remotehealth workers. It has a clear focuson encouraging students to returnto work in rural and remote areas.

The BHUDRH runs a pro-gramme of extended clinicalplacements (from 6 to 12 monthsin length) for 10 medical studentsfrom three universities. It alsotakes many medical students onshort-term placements as well asnursing and allied health workers.The medical students on extendedplacement follow curricula fromtheir home universities, coordi-nated through the UDRH.

THE ENRICH PROGRAMME

The UDRH decided to supplementthe core curricula of universitieswith a ‘home-grown’ programmeto deepen the students’ experi-ence, and to further its own goalsof developing the rural and re-mote health workforce. This arti-cle describes the Enhanced RuralInter-Professional Cultural Health(ENRICH) programme. The pro-gramme was conceived as a ‘va-lue-adding’ component thatcomplements the curricula of thethree home universities of themedical students. It has evolvedto include students from otherhealth sciences in discussing abroad range of rural and culturalhealth issues. It has been foundto be stimulating and highlyregarded by the students. But itstrue value will be shown if stu-dents are further stimulated toreturn to work in rural and remotehealth communities.

The ENRICH programme hasbecome a distinctive part of theeducation that the BHUDRH of-fers its medical students. It wasprompted by a desire to broadeneducational opportunities beyondthe concept of clinical compe-tencies. However, on a broaderlevel, it is part of the BHUDRHstrategy to encourage students toconsider joining the rural andremote health workforce. To thisend, the programme is firmlyembedded in the local commu-

nity. It seeks to use communityresources – professional, culturaland artistic – to provide stimu-lating educational opportunities.Through this the students cansee and experience some of thedepth of a rural community thatthey might otherwise not beaware of. Box 1 outlines theoriginal objectives of theprogramme.

It is a truism that ‘assessmentdrives learning’, and this is cer-tainly a feature of medical stu-dents’ lives. So a programme thatis not assessable and that canstray far away from clinical com-petences is liable to be seen as‘soft’ or irrelevant. The flexibilityof the programme helps to protectit from this danger. The coreprinciples are ‘rural’, ‘cultural’ and‘interprofessional’. However, indrawing on local expertise andresources, the programme stillcontains strongly clinical ele-ments. For example, doctors andnurses from the local Royal FlyingDoctor Service run training inemergency medical procedures.Despite being non-assessable, theattendance of long-stay studentsis close to 100 per cent.

The content of ENRICH ses-sions is placed in a rural contextwherever possible. This isachieved by inviting people fromthe local community to contrib-ute, and by framing clinicalproblems in a specific local

Students cansee andexperiencesome of thedepth of a ruralcommunity

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context. For example, a session oncare of the injured patient spe-cifically looks at issues relating toremoteness, lack of equipment,long response times and the needfor transport to an urban centre.In geriatric medicine the studentsvisit community services and talkwith service providers. They hearfirst-hand the strengths andweaknesses of rural care for theaged.

There are several cultural ses-sions delivered by local aboriginalpeople. These focus on indigenoushistory, culture and art, andhighlight the ways in which his-torical and cultural factors are adetermining factor in the healthof local aboriginal people. Theseare interactive and hands-on ses-sions, and enable students to getto know real people rather thanjust statistics.

The interprofessional aspect ofthe sessions is highlighted. Thecore attendance at sessions is bymedical students, but students

from other disciplines attendaccording to the topic. For exam-ple, in the session discussing thedevelopment of ‘not-for-resusci-tation’ orders, nursing and socialwork students make an importantcontribution. Sometimes theinterest across disciplines is sur-prising. Pharmacy students at-tended a clinical session onrecognising and managing sickchildren, and were stimulated bydiscussing scenarios about sickchildren collapsing in theirpharmacy.

The ENRICH sessions are runweekly, usually on an afternoon,but can involve the whole day.There are many people involved inrunning sessions, including localand visiting clinicians, alliedhealth providers, artists, aborigi-nal educators and police. A com-munity-based approach has beenadopted, with students, teachers,patients, and community mem-bers being actively involvedthroughout. The programme is runin a safe learning environment

that has been student-driventhrough regular feedback andevaluation. Box 2 presents asample of the topics covered.

The format of each session isdetermined by the topic. Theyinclude group discussions, skillslab training, site visits and evensketching with charcoal! It isrelatively easy to justify theinclusion of sessions on culturaland rural issues in a medicalcourse. This has been discussedbriefly above. But ‘Art in health’might sound a little far-fetched.In fact it has been a highly ratedand well-attended component ofthe programme. Students haveenjoyed the chance to look athuman bodies in a very ‘non-clinical’ way. They have beenencouraged to consider aspects ofpersonal development that theycan use throughout their profes-sional lives. Perhaps most impor-tantly, it has given students aglimpse of community life thatthey would not otherwise havebeen exposed to. There is life andcreativity outside of the bigcities.

THE BENEFITS OF THEPROGRAMME

Every ENRICH workshop is evalu-ated by the students. Generallybetween 10 and 20 studentsattend. They rate overallsatisfaction, achievement oflearning objectives and have the

Box 1. Original ENRICH objectives

• To explore how geographical location and demographic mixdetermines the nature of primary and secondary health serviceprovision in Far West New South Wales (FWNSW).

• To understand the collaborative aspects of the provision ofprimary and secondary health care in FWNSW, and the economicsand logistics pertaining to this service provision.

• To understand the challenges posed by remoteness and thedemographic mix of different rural communities, and how thisimpacts directly on health outcomes.

• To appreciate the positive aspects of living and practisingmedicine in rural and remote communities, and how to overcomethe potential pitfalls of professional isolation.

• To understand the history and dynamics of rural ⁄ remotecommunities in FWNSW, including cross-cultural issues.

• To explore the history and determinants of health in indigenouspopulations.

• To have an experience of working effectively as part of amultidisciplinary team when dealing with medical emergenciesthrough clinical simulation techniques.

• To experience directly and appreciate the value of learning andapplying knowledge together when working with an interpro-fessional team.

Students have aglimpse of

community lifethat they would

not otherwisehave been

exposed to

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opportunity for free comments.The results of these evaluations forsemester 1 in 2011 showed that forall sessions 90 per cent or more ofstudents felt that their learningobjectives were met, the workshopwas appropriate and enjoyable,and that they would recommendthe workshop to others.

A qualitative evaluation of theprogramme was performed at theend of semester 1. This was facil-itated by health professionals notinvolved in the programme deliv-ery, and used a draft questionguide that was discussed with thewhole group of long-stay stu-dents. The session was taped andtranscribed. The students felt that

ENRICH was a positive and dis-tinctive experience, and the in-terprofessional contact wasvalued:

‘it [was] one of the majordraw cards for coming here –none of our rural sites haveanything like it anddefinitely don’t have theinvolvement of alliedhealth’;

‘it’s a massive highlight’;

‘it’s definitely something alot of other students don’tget to have’.

They valued the small-groupopportunities, the hands-on workand the close interaction withexperienced local teachers. Thecultural sessions gave them somepositive experiences of indige-nous communities,

‘cross-cultural awarenesswas pretty good, there was alot of stuff I had no ideaabout’.

There have been difficulties. Theflexibility of the programme is apositive aspect as well as a curse. Itcan be hard to decide what is an‘ENRICH topic’ amongst the grow-ing list of possibilities. Some wantmore hands-on sessions, somewant more clinical sessions andsome want more art. There wasgeneral consensus that ‘overall itbalances out’. As exam time loomsthe programme can look lessimportant. Scheduling can be anightmare of juggling multiplestudent timetables and thecommitments of many facilitators.Yet, these are mostly adminis-trative difficulties and goodcommunication minimises theirimpact.

It is not possible, or desirable,to make all sessions attractive toall disciplines, but over a semes-ter there are many opportunitiesfor collaboration. Interprofes-sional education (IPE) has beendefined as ‘when two or moreprofessions learn with, from, andabout each other to improve col-laboration and the quality ofcare’.4 Two Australian examplesare the RIPPER project (2008) inTasmania and the Health CareTeam Challenge, University ofQueensland (2009).5,6 Our expe-rience supports the call to embedIPE within curricula rather than asseparate or ‘special’ events.1,7

In summary, ENRICH uses anintegrated approach to high-quality health education in aremote setting based on strongpartnerships between universi-ties, communities, clinicians and

Box 2. Examples of ENRICH topics

Semester 1, 2011

• Basic life support (clinical simulation)

• Advanced life support (clinical simulation)

• Envenomation and anaphylaxis (clinical simulation)

• Cardiovascular emergency management (clinical simulation)

• Not-for-resuscitation discussions with patients, families andcarers

• Head and spinal injuries, including burr hole insertion

• Primary and secondary survey

• Geriatrics and rehabilitation

• Obesity in Far West New South Wales

• Medication misuse in the community

• The coroner’s court

• Art in health 1–3 (photography, life drawing, Aboriginal art andculture)

• Crash simulation mass casualty disaster

• Aged patient simulation

• Cultural sensitivity, awareness and cultural change management

• Person-centred care

• Paediatric management

• Evidence-based medicine

• Breaking bad news

• Alcohol and drug use in the community

• Cognitive impairment in the elderly

ENRICH uses anintegratedapproach tohigh qualityhealtheducation in aremote setting

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students. The role of ENRICH isnot just to instruct competencebut to broaden the experience ofstudents by encouraging creativeand critical thinking at an under-graduate level in a safe learningenvironment. ENRICH incorpo-rates IPE and uses existing infra-structure provided by localservices and clinicians so thatstudents will develop fundamentalskills that will stay with them fortheir entire career, and may latercontribute to the rural and remoteworkforce. The long-term successof the programme will be difficultto measure against this outcome.However, it is one valuable ini-tiative amongst many.

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Corresponding author’s contact details: Keryn Bolte, Department of Rural Health, Sydney University, Broken Hill, New South Wales, Australia.E-mail: keryn.bolte@rfdsse.org.au

Funding: None.

Conflict of interest: None.

Ethical approval: This is not an interventional study involving human subjects but a descriptive paper of an approved institutional

course.

doi: 10.1111/j.1743-498X.2012.00556.x

ENRICHincorporatesIPE and uses

existing infra-structure so

that studentsdevelop

fundamentalskills

242 � Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 238–242