Influence of a rural Longitudinal Integrated Clerkship on medical graduates’ geographic and specialty decisions: a constructivist grounded theory study | BMC Medical Education

Regardless of the level of self-selection, participants predominately reflected on their experience positively, stating the LIC was a formative training year that not only introduced them to the clinical environment but provided a strong foundation for their learning and career continuum. They were introduced to rural living, rural medicine, general practice, and various medical specialties through the integrated manner of program delivery.

Some participants reflected that if they had not participated in the program and had completed all their training in a metropolitan setting, they would never have considered and been introduced to how both their personal and professional needs could be met in the rural environment. This culminated in the merging of personal and professional factors such as the type of doctor they aspired to be, the community they wished to practice in, and lifestyle aspects such as access to the outdoor environment and the affordability of living rurally.

I feel like if I had just stayed in X [metropolitan site] or something like that then we’d probably would’ve just stayed in the one place, I don’t think we (partner) would’ve made that, that jump (to work rural) without a push to do it (GP registrar, rural practice).

Confirming

Participation in the program provided the opportunity to reflect and confirm the graduate’s intent to work rurally. This was often associated with growing up in a rural environment and having an intent to practice in a similar location upon graduation. Confirming was also evident in participants who had a pre-existing intent to work in general practice with the experience meeting their expectations and consolidating their pursuit of this pathway.

And it (participation in LIC) just sort of solidified what I thought was already going to be my preference and it just was kind of sealed the deal really, I didn’t… even consider applying for metro places in my intern year or have never even thought of working in metro really (Psychiatrist, rural practice).

For others, participation confirmed that rural living/medicine did not align with their personal and professional needs. Personal concerns were distance from family and friends and access to services such as education, and healthcare. The frequency of on-call work they perceived that rural clinicians undertake was a professional deterrent.

The supervisors in my town were on call quite a lot. So that lifestyle, I think, wouldn’t suit me (General Physician, metropolitan practice).

Learning design affordance

Learning design affordance, and how the students’ learning was structured were influential in facilitating career decisions. The central LIC elements of continuity and integration afforded participants autonomy and a range of opportunities that enabled them to actively participate in patient care, developing skills and facilitating real-time discovery and comparison of the type of medical practice that was compatible with their personal and professional needs.

Autonomy

As medical disciplines within the curriculum were learned in an integrated manner, participants had a high level of autonomy to self-direct and seek out their own learning opportunities. Participants’ autonomy progressively grew throughout the year as they gained an innate understanding and feeling of safety within the confines of the program’s structure, gaining agency for in-depth self-exploration of a range of clinical settings. This enabled the comparison of medical disciplines in real-time with participants reflecting that they were drawn to particular clinical areas which they have often eventually pursued as a specialty.

In RCCS just having access to those specialties earlier and then actually being able to get a lot more time in the disciplines that you actually are interested in, so, of course, the more metro students weren’t able to choose when and where they’d actually go in the hospital on any given day… and so that meant for me I was able to spend more time in the emergency department, a little bit more time in theatre, doing things that I found more interesting (Anesthetist, rural practice).

The structure of the program allowed students to encounter undifferentiated patients providing a safe level of autonomy to take patient histories, develop clinical reasoning skills and present differential diagnoses and management plans to clinicians. This autonomy was contrasted against returning to a block rotation in year four where there was a perception of less access to undifferentiated patients and a transition back into an observer role. For example, one student reflected that if their only clinical experience in general practice had been the time-limited fourth-year rotation where they described being an observer, they would not have understood the breadth of general practice and suggested they would have pursued another specialty.

And I didn’t have a great experience at all (GP block rotation). So, I felt that maybe my career choice would have been different if that was my only experience in general practice…I just felt like it was a bit of a waste of a placement like I was just observing (GP, rural practice).

Compatibility

The longitudinal attachment allowed participants to develop continuous relationships with clinicians who became mentors and role models. Participants actively sought out and spent extended periods with clinicians for a variety of reasons such as the time and support they gave them, teaching acumen, approachability, admiration for their model of practice, and compatibility of their personality and values with their own or those they aspired to develop. Role models/mentors were not only participants allocated primary GP supervisors but came from a variety of medical specialties including physicians, surgeons, and anesthetists.

A couple of things. I was out in X (LIC location). There was (an) anesthetist slash ICU I guess he looked after the ICU at X (rural) hospital, the calm attitude and most of the anesthetists I’ve met are pretty unfazed by most things. Just that kind of unflappable attitude really resonated with me. (Anesthetist, metropolitan practice)

A realistic understanding of the intersection of clinicians’ professional and personal lives was described as an invaluable insight into their lifestyle and was credited with encouraging participants to follow similar paths. There was also an idealization of clinicians’ lives that was gleaned by socialization at their homes.

Skill development

Throughout the year participants developed clinical, personal, and professional skills through hands-on learning opportunities afforded by the relationships they built with clinicians, patients, and medical teams. Development of these clinical and communication skills often pertained to specific clinical areas such as general practice or anesthetics. For example, there were several instances where graduates who were anesthetists and GP anesthetists described their foundational skill development in this discipline commenced during the LIC year, and the self-efficacy they developed was reinforced in subsequent training when their more advanced skills were recognized and rewarded with further opportunities to develop.

It was incredible. And I got to do intubation, and spinal anesthetics and things where like now I’m going to be well, after next year… doing training in anesthetics. I’ll be a GP anesthetist, I think it is a large part of my experiences there (LIC program) (GP anesthetics registrar, rural work).

Learning in place

Learning in place or the program setting was described as influential on participants’ career decisions. Place was described as the rural setting, general practice clinic, rural hospital, and specific clinical settings (e.g., operating theatre) or a combination of settings. Place-related concepts including a sense of community, comfort in the environment, and type of clinical exposure influenced participants’ decisions to work rurally and/or in general practice.

Community

A sense of community influenced participants’ decisions to pursue general practice. The attractiveness of general practice as a specialty was centered around experiencing a friendly environment, with minimal hierarchy, where participants interacted and observed both practice staff and GPs who seemed to enjoy and derive a sense of fulfillment from their work.

Participants also acknowledged the importance of a relationship with a community of patients. A sense of personal and professional fulfillment was derived from getting to know patients and developing sustained relationships over time where they followed their journey sometimes only in general practice, but often over multiple clinical settings. This was contrasted against a less favorable preference for episodic care such as what occurs in Emergency Departments where there may be an absence of closing the loop in following patient outcomes.

So, it’s really you know your patients, sort of well and I think that’s actually what, what I enjoy probably the most about the GP is that ongoing relationship you have with patients…And sort of build that relationship with them rather than sometimes in hospitals and other specialties, you can just… you see them once or twice, and often you never really see them again (GP, metropolitan practice).

Exposure

The exposure to general practice and participation in parallel consulting, opened participants’ eyes to the breadth of medicine within general practice, notably rural general practice. Prior to the clerkship, some participants thought they might enter general practice, but many participants who eventually became GPs described being initially unsure the specialty would be the correct choice for them, believing the clinical presentations would be of a low acuity therefore not sustaining their professional interest’s long term.

Doing GP practice, as an Immerse student I guess that was my first exposure to the wide spectrum of GP and I guess how challenging some of the patients are, and the wide variety of patients, and how interesting GP was (GP, metropolitan practice).

The breadth of exposure and type of care provided (high and low acuity) across both the general practice and hospital setting was deemed an attractive element of rural general practice. This was particularly evident in participants who have since pursued careers in rural generalism as they placed a high personal value on the additional scope of practice they observed and the value this could provide to a rural community. GPs who were not rural generalists also felt the experience awakened them to the extended skills GPs could pursue. As such undertaking specialized interests in areas such as women’s, sexual, or mental health.

And then, previous to doing rural clinical school (RCCS) GP was always a career path option but when I actually was in X [RCCS location] and got to spend time with a GP obstetrician I was like oh this is, this is actually what I want to do, I like general practice and I like obstetrics, I want to be able to do these (GP obstetrics registrar, rural practice).

The parallel consulting experience also provided formative experiences with particular patient groups such as children and patients with mental health presentations, where the available appointment time allowed for honing participants’ communication skills and strengthened their understanding of the social context of illness. This experience was acknowledged as influential in pursuing careers in medical specialties such as pediatrics and mental health.

Comfort

Learning in place over a longitudinal period was described as providing a feeling of comfort or making participants comfortable in particular clinical settings, and/or the rural medicine environment. The development of comfort and self-efficacy in the rural environment translated to participants feeling confident to work rurally and instilled a sense of social accountability as they were contributing to increasing access to care for patients in need.

I guess it’s somewhere (rural) that I feel more comfortable with from my training, particularly. That’s probably one of the main reasons I guess that there’s, there’s a fairly significant demand and workforce shortage, so there’s not only an availability of jobs, but it feels like, a very worthwhile thing to pursue professionally in terms of meeting that public need as well (Hospital Medical Officer, rural practice).

Learning in place also contributed to participants feeling comfortable with particular groups of patients or the types of presentations they encountered within these settings. This enhanced participants’ self-efficacy and contributed to them following certain career paths.

I was quite comfortable with kids, I’d see a lot of them, examined their ears, nose, throat, yeah play with them, just mucking around with kids in the GP land … so you’re chatting to them, you’re building rapport, you’re examining them it’s that sort of exposure that you wouldn’t really get in a pediatric ward. So, I think yeah there’s a level of comfort in seeing children is definitely IMMERSE related for sure (Pediatrician, rural practice)”.

Some participants contrasted their comfort level in the smaller rural clinical settings with their aversion to, or discomfort in, larger tertiary hospitals which stemmed from factors such as perceived lack of support, absence of a sense of community, and preference for rural living. Participants who valued living rurally and were more comfortable in this environment described selecting their specialty based on what training could be completed entirely rurally.