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

IF 1.9 4区 医学 Q2 NURSING
Dean Carson
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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.</p><p>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 [<span>4, 5</span>]. 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 [<span>6</span>] 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 [<span>7</span>]. 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’ [<span>8</span>] 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 [<span>9</span>]. In Sweden, statutory barriers to discrimination in student selection make this task particularly urgent.</p><p>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.</p><p>‘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 [<span>10</span>]. 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).</p><p>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 [<span>11</span>]. 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 [<span>12</span>].</p><p>There is a global recognition of the importance of contextual learning in rural medical education, ultimately framing rural general practice as a specialty [<span>13</span>]. 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 [<span>14</span>]. 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 [<span>15</span>].</p><p>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. 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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.</p><p><b>Dean Carson:</b> conceptualization, writing – original draft, writing – review and editing, investigation.</p><p>The author is employed by Umeå University in Sweden.</p>","PeriodicalId":55421,"journal":{"name":"Australian Journal of Rural Health","volume":"33 1","pages":""},"PeriodicalIF":1.9000,"publicationDate":"2025-02-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/ajr.70021","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Australian Journal of Rural Health","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/ajr.70021","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"NURSING","Score":null,"Total":0}
引用次数: 0

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.

是时候重新思考农村医学教育了?“农村流”规划中的挑战与问题
这篇社论的灵感来自于我在2017/18[1]参与设计的ume<s:1>大学的“农村流”。该大学自1959年以来一直在瑞典北部提供“非大都市”医学教育。医学学位课程最初是在尤梅夫市提供的(自1959年以来,该市的居民从4万人增加到8万人),但自2011年以来,学生可以选择在北部其他三个小城市中的一个完成近一半的学位。尽管“农村”医学教育有着悠久的历史,但瑞典北部仍在经历医生短缺,在只有初级保健服务的较小中心(通常为5-10万居民)最为严重。农村流允许学生在其中一个中心进行临床轮转,同时继续在乌梅夫进行课堂教育。农村分科的实施受到covid - 19大流行的阻碍,但有早期迹象表明,该分科的学生对从事全科医生工作和在农村地区工作产生了更大的兴趣。在发展农村流时,我们咨询了农村医学教育专家,特别是来自澳大利亚和加拿大的纵向综合见习(LIC)模式自21世纪初以来一直是一种常见的特征。LIC模式似乎培养出的毕业生更有可能在职业生涯的早期从事农村全科医疗工作,尽管证据各不相同。当我反思农村流的发展时,我发现从长期劳动力发展的角度来看,澳大利亚和其他地方的LIC和相关的农村医学教育模式有一些方面具有挑战性。我在这里提出了其中的一些挑战,希望它们能激发一些批判性的思考,并有助于我们在应对农村医生短缺这一全球挑战方面所做的持续改进。这些反思也将引起其他卫生专业人员的兴趣,这些专业人员同样经历空间分布不均,并有自己的(有时非常长期的)农村教育模式。我从一开始就承认,我不是一个教育学家,瑞典的经验,其重点是一种特殊的农村环境,可能会或可能不会对更广泛的澳大利亚观众感兴趣或相关。农村医疗(和其他卫生专业)教育项目的毕业生被吸引到高舒适的农村地区(大多数农村移民也是如此),并且/或者将他们的实践限制在他们长大或接受培训的地区[4,5]。这巩固了一种“有与无”的农村社区制度,至少导致教育工作者倾向于把精力集中在更有可能取得成功的“富人”身上。对“本土”劳动力bbb的关注给较小的农村社区带来了一个紧迫的人口问题(他们在多个卫生和其他专业领域面临劳动力短缺)。随着农村社区的老龄化,即使人口下降或增长非常缓慢,潜在的本土劳动力也在减少,而对专业工人的需求却在增加。很容易看出为什么本土的方法可能对农村医学教育者有吸引力——农村出身的学生是劳动力树上“低挂的果实”。然而,地理分布的真正改善只能通过增加吸引力来实现,永远不需要将100万城市学生“转换”到农村地区。需要更多的研究来了解如何改进吸引来自不同地理背景的学生的机制。在瑞典,在学生选拔中存在歧视的法定障碍,这使得这项任务尤为紧迫。进一步巩固“有与无”的是支撑LIC模式的学徒制方法。只有有合格且积极的医生愿意担任LIC主管的社区才能参与LIC计划,这使得某些类型的医生难以参与,包括在服务不足地区占主导地位的海外培训医生和当地人。如果你想要“填补地理分布的空白”,这将是一个问题。需要做更多的思考(并采取行动)来鼓励医生从服务相对较好的地区“推出”到需求更大的地方。“没有”的地点往往是那些较小且远离二级和三级医疗服务中心的地方,这正是我们希望农村流影响的地点类型。最近的证据表明,这些地方,至少在澳大利亚北部,没有从农村教育模式中受益,事实上,即使拥有相对较近的先进教学设施(如昆士兰州北部),似乎也没有对积极的劳动力发展做出贡献。 更确切地说,这些邻近的教学设施似乎只是提供了过去来自更遥远设施的劳动力的替代(没有更多,但谢天谢地也没有更少)。如果农村教育的目的不是为这些小地方增加卫生专业人员队伍,而是确保这些地方的工作人员在具体情况下接受教育,这就不是问题。然而,这也带来了自己的挑战(参见下一节)。随着较大的城市中心(甚至大都市中心)似乎占据了越来越多的“农村”劳动力资源,提供与之相关的“农村”教育变得越来越困难。在政策和教学层面上,人们对农村卫生专业教育中什么是“农村”的理解非常松散。在瑞典北部经历了60年的城市中心主义之后,农村流现在的目标是(重新)集中“小农村”,同时保留分散教育为大城市中心带来的收益。这可能需要将更多的资源转移到(真正的)以农村为基础的教育和培训上,但具体如何做到这一点尚不清楚。全球都认识到背景学习在农村医学教育中的重要性,最终将农村全科实践作为一门专业。有证据表明,那些接受过农村专业培训的人更有可能在农村地区工作。相反的观点很少被考虑——那些没有接受过农村专业教育的人不太可能在农村工作。由于教育、培训和认证机构实施了一条越来越狭窄的“农村道路”,他们甚至可能被积极劝阻不要在农村地区工作。当我们知道农村地区对其他专业人员更具吸引力时,这尤其使医生在职业生涯的后期选择农村变得困难。虽然我们显然需要一些策略来鼓励后来的职业医生进入农村实践,但我不知道关于这个问题的大量研究。至少在瑞典,我们发现有一部分在城市地区工作的老年医生想进入农村执业,但不确定如何实现这一目标。没有涉足农村的老医生在农村可能不受欢迎,因为他们缺乏相关知识。他们可能不受欢迎的另一个原因是,与应届毕业生相比,他们的潜在逗留时间较短。然而,在实践中,那些在早期职业生涯中进入农村实践的人(至少对人类地理学家来说)停留的时间相当短。虽然由于缺乏分析标准(时间、地点类型、保留/流动率的计算等),很难对保留研究进行比较,但似乎有多达三分之一的进入农村实践的人,即使是通过农村路径,也可能在一年、三年或五年内离开[16,17]。虽然这些结果通常被报道为积极的(当然,保留率高于非农村路径从业人员),但与类似地区的其他人群相比,这些退出率非常高。虽然我们需要更复杂的保留研究,但如果可以将许多农村从业人员的短期停留考虑到劳动力规划中,就不一定是一个问题。通过接受高比例的从业者只会呆几年并鼓励他们最大限度地延长这段时间,可能会增加停留时间。这可能是因为对农村的期望对那些走上这条路的人来说是“无期徒刑”,阻止了新来者,并促使他们提前离开。就像我们在农村实践中需要多条路径一样,我们也需要提供畅通的路径。狄安卡森:概念化,写作-原稿,写作-审查和编辑,调查。作者受聘于瑞典尤梅夫大学。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Australian Journal of Rural Health
Australian Journal of Rural Health 医学-公共卫生、环境卫生与职业卫生
CiteScore
2.30
自引率
16.70%
发文量
122
审稿时长
12 months
期刊介绍: The Australian Journal of Rural Health publishes articles in the field of rural health. It facilitates the formation of interdisciplinary networks, so that rural health professionals can form a cohesive group and work together for the advancement of rural practice, in all health disciplines. The Journal aims to establish a national and international reputation for the quality of its scholarly discourse and its value to rural health professionals. All articles, unless otherwise identified, are peer reviewed by at least two researchers expert in the field of the submitted paper.
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