Time to Re-Think Rural Medical Education? Challenges and Issues Raised in Planning Umeå University's ‘Rural Stream’

Abstract

The inspiration for this editorial comes from my involvement in the design of Umeå University's ‘rural stream’ in 2017/18 [1]. The University had been delivering ‘non-metropolitan’ medical education in northern Sweden since 1959 [2]. The medical degree program was initially offered in the city of Umeå (which has grown from 40 000 to 80 000 residents since 1959), but since 2011 students could elect to do nearly half the degree in one of three other small cities in the north. Despite this long history of ‘rural’ medical education, northern Sweden continues to experience physician shortages, most acute in the smaller centres (typically 5–10 000 residents) which have only primary care services. The rural stream allows students to do clinical rotations in one of these centres while continuing classroom education in Umeå. Implementation of the rural stream has been hindered by the Covid19 pandemic, but there are early indications that students in the stream develop greater interest in both working in general practice and working in rural areas.

In developing the rural stream, we consulted rural medical education experts particularly from Australia and Canada where the longitudinal integrated clerkship (LIC) model has been a common feature since the early 2000s. The LIC model seems to produce graduates who are more likely to spend the early parts of their careers in rural general practice, although the evidence varies [3]. As I reflected on the development of the rural stream, there were aspects of the LIC and associated rural medical education models in Australia and elsewhere which I found challenging from a long term workforce development perspective. I present some of those challenges here in the hope that they will inspire some critical thinking and contribute to continuous improvement in what we are doing about the global challenge of rural physician shortages. These reflections will also be of interest to other health professions, which likewise experience spatial maldistribution and which have their own (sometimes very longstanding) rural education models. I acknowledge from the outset that I am not an educationalist, and that the Swedish experience, with its focus on a particular kind of rural setting may or may not be of interest or relevance to a wider Australian audience.

Graduates of rural medical (and other health professional) education programs gravitate towards high amenity rural areas (as do most rural migrants), and/or limit their practice to regions where they grew up or where they were trained [4, 5]. This entrenches a system of ‘have and have not’ rural communities, and leads at least to the temptation for educators to focus their efforts on the ‘haves’ where successful outcomes are more likely. The focus on ‘home-grown’ workforce [6] presents an immediate demographic problem for smaller rural communities (who experience workforce shortages across multiple health and other professions). As rural communities age, and even as populations decline or grow very slowly, the potential home-grown workforce shrinks while the demand for professional workers increases [7]. It is easy to see why the home-grown approach might be attractive to rural medical educators—rural origin students are the ‘low hanging fruit’ on the workforce tree. However, real improvement in geographic distribution can only occur through increasing attraction one should never need to ‘convert’ [8] of urban origin students to rural locations. More research is needed to understand how mechanisms to attract students from diverse geographic backgrounds might be improved [9]. In Sweden, statutory barriers to discrimination in student selection make this task particularly urgent.

Further entrenching ‘have and have nots’ is the apprenticeship approach which underpins the LIC model. Only communities with qualified and motivated physicians willing to serve as LIC supervisors participate in LIC programs, making it difficult to engage certain types of physicians, including overseas trained doctors and locums who dominate under-serviced areas. This is a problem if you are trying to ‘fill the gaps’ in geographic distribution. More thinking needs to be done (and action taken) to encourage physicians to ‘push out’ from relatively well-serviced areas to where the needs are greater.

‘Have not’ locations tend to be those that are smaller and more distant from centres with secondary and tertiary medical services, the exact type of locations we want the rural stream to impact. Recent evidence suggests that these sorts of places, at least in northern Australia, have failed to benefit from rural education models, and in fact, even having relatively close advanced teaching facilities (as in north Queensland) does not appear to have contributed to positive workforce development [10]. Rather, those proximate teaching facilities appear to simply produce replacement (no larger, but also thankfully no smaller) of the workforce which came from more distant facilities in the past. This is not a problem if the point of rural education is not to grow the health professional workforce for these smaller places, but to ensure that the workforce in these places has been educated in context. This, however, raises its own challenges (see the next section).

Providing contextual ‘rural’ education is increasingly difficult as larger urban centres (and even metropolitan centres) appear to grab an ever larger share of ‘rural’ workforce resources. There is a very loose understanding of what is ‘rural’ in rural health professional education, at policy and pedagogical levels [11]. Having experienced this urban-centrism in northern Sweden for 60 years, the rural stream now aims to (re)centre the ‘small rural’ while preserving the gains that decentralised education has made for larger urban centres. This likely involves shifting more resources to (truly) rural-based education and training, but exactly how this might be done is unclear [12].

There is a global recognition of the importance of contextual learning in rural medical education, ultimately framing rural general practice as a specialty [13]. The evidence suggests that those who undertake rural specialist training are more likely to work in rural areas. The counter-argument is rarely considered—that those who do not have rural specialist education are less likely to work in rural areas. They may even be actively dissuaded from working in rural areas as education, training and accrediting institutions enforce an increasingly narrow ‘rural path’. This particularly makes it difficult for physicians to choose rural at later points in their career when we know rural areas become more attractive for other professionals [14]. While we clearly need strategies to encourage later-career physicians to enter rural practice, I am not aware of substantial research into this issue. In Sweden, at least, we found that a proportion of older doctors working in urban areas wanted to enter rural practice but were uncertain how to pursue this goal [15].

Older doctors who have not trodden the rural path may be unwelcome in rural areas because of their lack of contextual knowledge. They may also be unwelcome because their potential length of stay is short compared to that of fresh graduates. In practice, however, the lengths of stay of those entering rural practice in early career appear (to a human geographer, at least) to be quite short. While it is difficult to compare retention studies because of the lack of analytical standards (for time, location type, calculation of retention/mobility rates and so on), it appears that as many as one third of entrants to rural practice, even through the rural path, are likely to leave within one, three or five years [16, 17]. While these results are often reported as positive (and certainly rates of retention are higher than for non-rural path practitioners), when compared to other populations in similar locations, these exit rates are very high [14].

While we need more sophisticated retention studies, the short stays of many rural practitioners are not necessarily a problem if they can be factored into workforce planning. It might be possible to increase lengths of stay by accepting that high proportions of practitioners will only stay a few years and encouraging them to maximise that period. It may be that the expectation of rural as a ‘life sentence’ for those on the path dissuades newcomers and stimulates early departure. Just like we need multiple paths IN to rural practice, we also need to provide smooth paths OUT.

Dean Carson: conceptualization, writing – original draft, writing – review and editing, investigation.

The author is employed by Umeå University in Sweden.