학부의학교육에서 농촌/취약지 환경 활용하기: AMEE Guide No. 47

학부의학교육에서 농촌/취약지 환경 활용하기: AMEE Guide No. 47

Using rural and remote settings in the undergraduate medical curriculum: AMEE Guide No. 47

MOIRA MALEY1, PAUL WORLEY2 & JOHN DENT3

1The University of Western Australia, Western Australia, 2Flinders University, South Australia, 3University of Dundee, UK

Practice points

• 지역사회 요구에 부응할 수 있는 수련을 받아야 한다. Healthcare professionals should be trained to meet the needs of the communities they are to serve
• 농촌지역의학교육의 요구의 추진 요인 The need for medical education in rural areas is driven by:
• medical workforce undersupply and misdistribution
• changes in medical practice
• changes in medical education
• need for medical research relevant to rural practice

• 수련이 가능한 농촌의료 환경들 Rural practice contexts suitable for training include:
• rural hospitals
• rural general practices
• ‘community immersion’ utilising both local hospital
• and primary care agencies (integrated placement)

• 다음과 같은 것을 고려해야 함 In planning an RRME programme consider the:
• location
• duration of programme
• number of students required
• learning resources available
• style of learning
• provision of staff and student support
• available finances

• Remote and rural communities provide a rich learning environment in which students can rapidly acquire competences and confidence in primary care in a generalist setting

많은 나라에서 공통된 이슈가 있지만, 북미와 호주가 가장 많은 경험을 가지고 있음

Although similar rural health-care issues are present in various countries, so far North America and Australia have described more experiences with addressing these needs than Africa or Europe (Hays 2007a).

What constitutes rural and remote?

Rurality에 대한 정의. 보통 선진국에서는 인구의 15~45%가 농어촌에 거주하고 있으며, 정의가 다양함.

There is regional and international variation in the definitions of rurality and remoteness. In developed countries the rural proportion of populations ranges from approximately 15% to 45%. Many countries define rural as ‘at or beyond the fringe of urban areas’ (Statistics-Canada 2001) and Couper (2003a) has proposed a definition including characteristics of the local health-care services (Box 1).

호주에서의 정의

In Australia a number of classification scales have been published by government agencies, e.g. the rural, remote and metropolitan areas scheme (RRMA) of 1994; and the accessibility/ remoteness index of Australia scheme (ARIA) of 2001.

개발도상국과 선진국을 막론하고 농촌인구 건강의 공통점은 의료자원, 의료인력, 의료시설, 의료선택의 접근가능성에 있어서 불이익을 받는다는 점과 건강지표가 떨어진다는 것이다.

However a key common denominator in rural health for both the developed and developing worlds is disadvantage of access to resources, workforce, facilities, choice and health outcomes (Rosenblatt 2004; Rabinowitz 2005; Kamien & Cameron 2006; Price 2006).

학습자 측면의 장점

For learners, the special characteristics of the educational settings (versus urban) include:

• . more intense and sustained experiential learning (i.e. more challenges)
• . usually a much higher teacher to student ratio (i.e. better supervision, more support)
• . more opportunities for longitudinal follow up of patients (i.e. see the whole person)
• . greater emphasis on personal and professional development (i.e. setting boundaries, maintaining relationships and teamwork)
• . increased visibility and sense of collegiality.

교수자 측면의 장점

For teachers

• . the presence of students can be used to create a community of learning among the local health team
• . when students are present for periods long enough to establish competence they can ease the clinical workload
• . students can act as advocates for rural health issues on their return to the urban setting.

What drives the need for medical education in rural and remote areas?

농촌의학교육의 추진요인들

It is now helpful to conceptualise the drivers for rural medical education under four headings:

• . medical workforce undersupply and maldistribution
• . changes in medical practice
• . changes in medical education
• . need for medical research relevant to rural practice

Medical workforce undersupply and maldistribution

농촌지역학생이 더 농촌으로 간다는 다양한 국가의 연구결과

Evidence from America (Rabinowitz et al. 2008), Australia (Wilkinson et al. 2003; Kamien & Cameron 2006; Worley et al. 2008), Canada (Curran & Rourke 2004), Japan (Matsumoto et al. 2008), Norway (Magnus & Tollan 1993), South Africa (De Vries & Reid 2003) and Scotland (Richards et al. 2005) has confirmed that medical students from a rural background are more likely to take up rural medical practice than their peers from city origins

지역적 특성을 알아야 함. 도시와 달리 농촌은 지역의 특성이 건강에 큰 영향을 미침. 이는 농촌에서 실제로 일하고 있는 의사들이 수련을 받는 동안 가지게 되는 기본적 가정에 반하는 것이다. 의료전략과 의료개입에 관한 연구에서 모두 non-transferability를 결론지은 바 있다.

A key aspect to understanding the requirements of rural and remote medical education (RRME) is its regional context. Local and regional factors have a greater influence on health outcomes in rural as distinct from urban areas (Galea et al. 2005); such factors also preclude global assumptions regarding training requirements for doctors working in rural communities. Both health-care strategy research (Wells & Banaszak- Holl 2000) and health-care intervention studies (Johns et al. 2005) have concluded a non-transferability across regions of the world.

2차세계대전동안 발전한 의학교육의 모델은 고도의 기술이 활용가능한 대도시 병원에서 근무하는 전문가를 양성해왔으나, 이런 상황에서 일차의료나 비도시 지역의 환경에서 진료할 수 있는의사는 양성하지 않았음. 

The predominant model of medical education that evolved after the Second World War was oriented towards the specialist practitioner in large, high-tech city medical centres (Fiedler 1981); such an educational environment did not train doctors for primary care practice in non-urban areas and its deep systemic entrenchment has made implementing change a slow process. A curriculum model which promotes competency in a wide range of specialties is required to produce a doctor comfortable with practice in a rural area (Ellis 2008; Price 2008; Rabinowitz et al. 2008).

Changes in medical practice

영국의 상황

In the UK, two drivers can be identified for the changes seen in medical practice:

• . changes in patients’ expectations, especially the desire for investigations and treatment to be available nearer to the home community
• . an increasing number of medical students.

의과대학 입학생이 최근 40% 증가함에 따라 농촌지역을 교육의 목적으로 활용하게 되었음

England and Wales have seen a 40% increase in recent years in the number of students admitted to medical school (Dent & Harden 2005). These factors are driving educators to consider the increased use of rural locations for medical teaching.

미국과 캐나다

Strategies to address the shortage of health-care workers in rural areas in the US and Canada have included establishing medical school campuses in regional areas as part of a rural pipeline programme (Crump et al. 2006) and refocusing academic health centres in the service of rural populations (Mennin et al. 1996; Curran & Rourke 2004; Gazewood et al. 2006).

호주

Australia has relatively few urban centres and vast rural/ remote areas, so the increasing trend for doctors to practise in city rather than rural communities has led to a critical shortage rurally (Department of Health and Ageing 2001).

Changes in medical education

기존의 도시의 시설에서 학생 교육을 모두 감당하지 못하게 되었음. 한편 노르웨이, 스코트랜드, 크로아티아 등은 remoteness가 주된 촉진요인임. 

The increasing number of students who cannot be accommodated in traditional urban facilities has stimulated interest in RRME in the majority of Europe with the exception of Norway, Scotland and Croatia, where remoteness has been a driver (Hays 2007a).

영국

In the UK, the development of ambulatory diagnostic and treatment centres (ADTCs) (Hall 2002, 2006) in rural areas has provided a new venue for student clinical placements (Dent et al. 2007).

호주

In Australia, students have been placed amongst or embedded in the rural/remote populations for short or extended periods (Maley et al. 2006; Worley et al. 2006); the latter has resulted in the evolution of programmes with improved alignment of learning environment, curriculum approach and assessment to rural clinical needs (Maley et al. 2007). 

미국

In the US, data from non-traditional rural clinical programmes and traditional programmes show equivalent academic outcomes for students (Schauer & Schieve 2006), and also equivalent educational value for junior medical students and senior trainees (Rourke 2005; Goertzen 2006).

BEME의 체계적종설에서 보면 학생, 교사, 환자에게 여러 장점이 있음을 보여준 바 있고, 특히 학생들이 그 환경에 전문가로서 적응하게 되면서 자신감을 길러준다.

The Best Evidence Medical Education (BEME) systematic review of the contribution of experience in clinical and community settings to early medical education (Dornan et al. 2006) describes several benefits to students, teachers and patients. In particular it helps students to develop confidence as they adjust to their professional environment.

RRME에서는 community가 중요하다. 졸업생이 교육과정 설계에 참여하고, 이후 실제로 지역사회에서 필요한 것이 무엇인가를 기준으로 성과평가도 하게 됨.

RRME could be considered a form of community-oriented/ community-based medical education (COME/CBME). RRME adopts the principles of a community-oriented approach, in that it engages the community that its graduates aim to serve in the curriculum design process, and then evaluates its outcomes specifically in relation to what is required by that community (Hays 2007b).

Immersion learning

RRME is however evolving as an entity with distinct educational characteristics as outlined in this guide, particularly the impact of ‘immersion learning’ (Zink et al. 2008).

학부교육과 졸업후교육을 관련기관들이 협력하여 노력해야 함.

Vertical integration of undergraduate rural tracks with visible postgraduate career pathways is fundamental to attracting doctors to future rural practice. Significant efforts to achieve this have been pioneered in Australia yielding some early indications of success (Worley et al. 2008), a key factor being the joint management of undergraduate and postgraduate tracks by rurally focused organisations (Skinner & Ingham 2008).

The need for medical research relevant to rural practice

근거-기반 가이드라인이 중요하다. 그러나 도시 맥락을 바탕으로 한 가이드라인은 농촌이나 자원이 부족한 환경에서는 적합하지 않다.

Clinicians are familiar with the requirement to practice in a legal environment where using evidence-based guidelines is crucial. However, these guidelines will almost certainly have been developed in an urban, high-resource settings and so may not necessarily be best practice in a rural, poor-resource setting.

A taxonomy of models of medical education that have been applied in rural and remote settings

Tesson et al. (2005) designate schools as either mixed urban/rural, defacto rural or stand-alone rural schools. These all followed to some degree a ‘pipeline approach’ including – early recruitment, admissions, locating clinical education in rural settings, a rural health focus in the curriculum and support for rural practice.

In rural hospitals

• A day visit to a rural hospital
• Structured placements in a rural hospital 
• A rural internship with full in-patient and outpatient responsibilities.

In rural general practice

농촌지역에 장기간 있는 것의 장점은 학생과 환자가 밀접한 관계를 맺어서 건강문제의 자연경과를 볼 수 있다는 점이다.

One advantage of longer rural attachments in primary care is the opportunity for patient/student coupling (Delaney et al. 2002) which gives students opportunities to see the natural progression of healthcare problems with a particular patient.

다양한 프로그램 사례들

• In the Alternative curricular options in rural networks (ACORNS) course in the department of general practice at the University of Western Australia even a short placement of 4 days with a rural general practitioner (GP) has been shown to positively influence student perceptions of rural health (Talbot & Ward 2000).

• During a 1 week immersion with primary healthcare professionals in remote communities in New Zealand students experienced the impact of cultural issues on community health-care needs (Dowell et al. 2001) and emerged with an increased understanding of health-care issues in those communities (Williamson et al. 2003).

• A 4–6 week programme in rural general practice gives students a non-urban experience of healthcare provision (Deaville et al. 2007) in the UK.

• A 6 week ‘satellite rural education’ experience comprising a set of three 2 week attachments in each of internal medicine, surgery and general practice was initiated by the University of Tampere in 1991 in the hospital district of South Ostrobothnia, Finland. The students experienced diagnosis and treatment of common diseases in ordinary health-care units and developed team skills with other health professionals (Virjo et al. 2006).

• The Australian Commonwealth funded University Department of Rural Heatlh (UDRH) at the Universtiy of Melbourne found that the required community-based rural health courses of 4 weeks positively influenced students views of rural general practice (Critchley et al. 2007).

• A 4 month programme was developed as a parallel track in New Mexico (Kaufman et al. 1989).

• The University of Queensland, Australia, describes a 1 year attachment with a private, solo general practice in a rural area (RRMA 5/6) to students in their penultimate year of a 4 year postgraduate course (Margolis et al. 2005). Similarly the University of Aberdeen, Scotland, offers fourth year students a year-long placement in a remote urban location with vocational attachments with rural general practitioners in the Highlands which can be continued into final year (Wilson & Laing 2007).

• During the third and fourth years of a 4 year course, one or more of the 6 week clerkships in clinical disciplines can be completed in a rural community setting as part of the decentralised medical education programme over five states in the US, The Washington, Alaska, Montana and Idaho (WAMI) group (Schwarz 2004).

Integrated rural placements with both rural hospital and general practice components

최소 4주의 기간으로도 잘 관리하면 효과를 볼 수 있음

Well-supervised student visits for a minimum of 4 weeks are the most effective for allowing students to see the full range of rural health service activities (Couper 2003b).

프로그램과 각 프로그램을 운영하는 학교 내용

• Integrated community and ambulatory care programme (ICAP)

This follows work by Grant et al. (1997) where fourth year students were attached for 3 months to community hospital-based general practices and were found to achieve satisfactory portfolios of learning experiences and practical clinical skills. In a similar programme (Dent et al. 2007) students at the University of Dundee can spend 4 weeks in community general practice followed by 4 weeks in the nearby rural hospital and finish with a further 4 weeks back in the same general practice. This programme is designed to give students the opportunity to observe the continuity of care which can be provided in the rural community and may positively influence students’ perception of rural general practice.

• Rural medical education programme (RMED)

A State University of New York rurally focused programme stream which supplements the standard curriculum in a 4 year course. Its final capstone is a 16 week rural family medicine preceptorship (Stearns et al. 2000)

• Rural opportunities in medical education (ROME)

This is a 7 month programme in North Dakota, US, in which designated clinical rotations are undertaken in an approved rural setting and the remaining rotations completed back in the urban hospital centre (Schauer & Schieve 2006).

• Rural physician associate programme (RPAP)

The University of Minnesota RPAP, commenced in 1971, is a 36 week, community-based continuity primary care experience during which 3rd year students live, learn and work alongside a physician in a rural community (Halaas et al. 2007a). Based on the students’ logging of case exposure in the local hospital and clinics their requirements for time in specialty rotations can be met, as well as a primary care clerkship (Halaas 2005a). Students are assessed for competence on site by both local preceptors and central faculty through written papers, case presentations and objective structured clinical examinations (OSCE).

• Parallel rural curriculum (PRCC)

At Flinders University in South Australia, the PRCC is a longitudinal integrated clerkship that enables Year 3 students to undertake their entire major clinical year (40 weeks) based in rural towns of between 5000 and 20,000 in population. Students follow patients from the rural clinic through the local health system which may include admission to the local hospital, referral to a visiting or resident specialist and interaction with allied health professionals. Students learn concurrently the disciplines of surgery, paediatrics, medicine, obstetrics and gynaecology, psychiatry and general practice. They give their major clinical examinations at the end of the PRCC (Worley et al. 2000b).

The programme commenced with eight students in the Riverland region of South Australia and now incorporates 30 students over four regions of the state. Flinders has more recently created a half year version of the PRCC for remote aboriginal settings in the Northern Territory. The Northern Territory programme is complemented by half a year of specialist rotations in the regional referral hospital in Darwin.

• Clinical learning embedded in rural communities (CLERC)

This programme is listed separately from the PRCC even though both are year long ‘community immersions’ in the fifth year of a 6 year undergraduate course. They are distinct in the finer detail of curriculum approach and the degree of rurality/remoteness of their respective contexts. The CLERC programme has evolved out of the Rural Clinical School (RCS) of Western Australia (RCSWA) over a 5 year period, from a pilot with nine students in 2003 to 74 students in 2009. The evolution was from a transplanted city, specialty-siloed curriculum framework to a horizontally integrated, case-based approach during which the students begin the process of building a portfolio of clinical experience for active reflection. In the RCSWA, the programme is delivered to 10 sites ranging from 300 km to 2200 km in distance from the capital city, each with three to 10 students. Of the 10 sites, three are classified as ‘small rural centres’ (RRMA 4), one as a ‘rural area’ (RRMA 5), five as ‘remote centres’ (RRMA 6) and one as “remote area” (RRMA 7) (Maley et al. 2006).

설계 단계 Design: Matching curriculum to cause and context

In rural hospitals

농촌병원에서 학생들의 학습기회과 학습목표와 매칭될 수 있다.

In schools which have adopted outcome-based education (Harden et al. 1999), such as ‘The Scottish Doctor’ (Simpson et al. 2002) (Figure 2), the learning opportunities available to students in the rural hospital can be mapped to the desired learning outcomes of the curriculum. 

기존에 잘 활용되지 않았던 임상자원들을 활용할 수 있다.

A previously under-utilised clinical resource may be identified in the rural hospital which may be appropriate as a new teaching venue. This may be a single location such as a day case theatre which can be used to increase student exposure to peri-operative care and the patient journey (Hanna & Dent 2006).

ambulatory diagnostic and treatment centres (ADTCs)도 acute service는 없지만 다양한 시설을 제공할 수 있다.

Alternatively the ADTC can provide a range of facilities which illustrate other learning outcomes despite there being no acute services on site (Dent et al. 2007). Students document their learning by completing structured logbooks (Dent & Davis 1995). The acronym EPITOMISE (Figure 3) is used to help them relate clinical cases to the learning outcomes.

In rural general practice

Structured packs for independent learning in the community developed for third year students at Kings College School of Medicine and Dentistry, London, led to more efficient use of contact time (Graham et al. 1999). In a 4 week attachment in rural general practice Teague et al. (2000) found that the quality of the teaching programme was improved by issuing students with laptop computers. These helped to decrease their feeling of isolation, increased engagement with course outcomes and helped rural teachers to be more involved.

Integrated programmes

Furthermore the rural hospital visit can be linked to a rural placement in general practice. This integrated programme provides opportunities to experience elements of community care, holistic practice and the continuity of care between the ambulatory care unit and the community.

• Although the RMED programme has successfully produced more primary care physicians from its participants than from the non-rurally streamed students, a recent decreased enrolment is linked to the removal of supporting scholarships and a need to target students with a rural background (Smucny et al. 2005). This highlights the importance of student selection and support, a design component, in the viability of rural learning programmes.

• ‘Continuity of care’ learning was a conscious design focus for the rural/primary care experience in the ROME programme (Schauer & Schieve 2006).

• In the RPAP, education for competency is the design template, adopting apprenticeship-style learning and teaching approach in an immersion context (Zink et al. 2008). ‘Immersion’ is common to health professions education generally.

• In the PRCC, the learning objectives of the six separate disciplines are compared with the epidemiology of what is seen and done at the local clinics and hospital; if there is a match, then a PRCC is possible! The next step in design is to map the clinical learning opportunities available in the community and determine what, if any, needs to be imported through videoconference or visiting faculty.

• The CLERC programme (Figure 4) is delivered throughout the academic year as sequential phases of foundations study, skills development, skills consolidation and skills review; these are punctuated by school-wide synchronous formative assessment exercises and an options period. The learning environment has a primary care, generalist framework, includes the students as ‘student colleagues’ and is set in the reality of rural or remote practice. It adopts an experiential learning cycle in which the interactions of student with patient and student with mentor (medical teachers) form ‘the experience’; the process of the guided logging of patient encounters (a web-based personal log), and of student engagement in regular log-stimulated discussions, forms ‘the reflection on action’; ‘the reflection in action’ is facilitated by the emphasis on longitudinal patient follow-up and by the partitioned spiral structure of the programme itself. Virtual patients are made available to fill gaps in experience that are evident from the students’ logs. Initially, it was considered a ‘model’ teaching programme for the week included six clinical sessions (half days), three tutorial sessions and a reflection/documentation session, as well as taking out of hours opportunities in the emergency room (Denz-Penhey & Murdoch 2008b). However experience has shown that as the teaching confidence and competence of the local medical teachers grows, a ‘best fit model’ is formed for each site which matches the local clinical opportunities and teaching styles.

도입 단계 Implementation: Capacity, collaboration and creativity

몇 가지 준비 단계가 필요함.

Several preparatory steps are necessary before it is possible to initiate a new development in clinical teaching in a new location (Dent 2003). 

• It is usually necessary to gain the support of all stakeholders in the institution and form a steering/implementation group. 
• This may involve a site manager and senior administrator in the new location as well as clinicians and other healthcare providers who will act as clinical tutors. 
• A formal memorandum of understanding may need to be drawn up between the university medical school and the health service or other hospital owners. 
• An adequate budget to sustain the programme must be identified and active support from the local community fostered (Walker 1999; Albert et al. 2004; Walker 2007).
• The most appropriate year of the medical course to benefit from the programme must be identified, a study guide and other support material provided and space for student/patient interaction identified. 
• Staff development opportunities will also be required.

In rural hospitals

사전준비에 필요한 것들

Before sending students on a day visit to a rural centre care must be taken to be sure that structures are in place to help them integrate the experience to learning they have acquired elsewhere. As with any new venture the cooperation of all participants is imperative to the implementation of a new programme. Planning meetings should highlight the advantages and identify the potential problems of the proposed teaching programme at an early stage. For instance it may be perceived that the increased prestige which will come to the local hospital from being associated with the university medical school is an important benefit. On the other hand, a programme heavily dependent on one person may be unsustainable. The method of delivery of the curriculum will be determined by the resources available in the location which may range from paper-based study guides to computer-based logbooks.

A day visit focused on the patient journey – Local clinicians motivated to devote time to teaching, a day surgery-based tutor in the unit (DSU) who can supervise the students is necessary. (후략)

Short-term placement – A 4 week programme focused on integrated learning in core clinical problems

A low-budget innovation can be achieved with the support of colleagues with enthusiasm for teaching. (후략)

농촌 일차진료 In a rural general practice

A 12 week programme focused on health-care provision in a rural setting

(...)

Staff development: 뉴스레터, 유인물

Regular communication in the form of a staff newsletter distributed to all participating staff is important to maintain enthusiasm and ownership of the programme. Formal staff development sessions are not always well attended but printed material, such as ‘Getting started …’ (Dent & Davis 2008) can provide a readily available source of practical information to clinical teachers.

Evaluation : 만족도 평가 

A questionnaire pitched at level 1 of Kirkpatrick's model (Kirkpatrick 1959) was circulated to participating students and both teaching and administrative staff.

융합 프로그램 In integrated programmes

Parallel rural curriculum 

필요한 것들

For each regional cluster of eight to ten students, a local clinician takes responsibility for academic coordination of the faculty in the practices and hospitals, with two full time general staff responsible for the complex individualised student timetables and managing accommodation, transport, learning resource availability and other student support.

Curriculum delivery options are still limited by the poor access to the internet in many of the teaching sites. This has led to the concept of ‘redundancy’ for learning resource staff, i.e. students must be provided with more than one way of accessing/learning core material. For example, this may mean having lectures available for both web streaming and delivered on DVD, or key references available in both electronic and hard copy. This approach also allows for different student learning styles.

A key component of the quality and sustainability of rural practice-based education has been university investment in consulting and learning space for the students in the rural clinics. In addition, providing comfortable accommodation, especially suitable for families, is critical to the year being a positive experience and thus having a positive, not negative, impact on subsequent career choice.

짧은 것보다 기간을 길게 하는 것(5~6개월)이 향후 농촌 진료에 관심을 갖게 하는데 좋으며, 학생들의 학습에도 좋다.

It is now becoming evident that longer attachments are more effective in awakening future interest in rural practice. Extended placements of at least 5–6 months have been shown to be more economically sustainable than shorter rotations (Worley & Kitto 2001) and also more beneficial to student learning (Denz-Penhey et al. 2005).

Clinical learning embedded in rural communities

필요한 것들

The educational entity that CLERC now represents is in existence because ‘the system’ allowed an evolutionary, (‘action research’) approach to be implemented. A realistic budget was provided and sound leadership was sourced.

Aside from the educational programme and its delivery, there are other key factors for successful implementation, including the recruitment of students, their further selection and the organisational response to student needs. The students in a CLERC programme have been uprooted and placed in a strange, new physical environment; the impact of this should not be under-estimated by managers and adequate pastoral care is a wise investment (Maley et al. 2006).

The RCSWA programme is promoted to students in their fourth year starting from April; this is via a package of paper-based materials and a DVD disk containing a website including student snippets and specific study and administrative information. A formal information evening is held in June; applications close in July; all applicants are interviewed 2 weeks later and advice of outcome and an offer is made in August. The RCS academic year commences in mid-January and end of year exams are held late in November. This timetable is tight administratively leaving little down time at year turnaround and obviously requires significant commitment from all team members.

Evaluation is another key element for success. In the early years of the RCSWA, the programme of evaluation comprises a mid-year series of confidential student and staff interviews at all sites; these are conducted by an experienced evaluation officer and issues for inclusion are canvassed from both administrative and academic staff. Responding appropriately to feedback from stakeholders was critical to the safe evolution of the programme. More recently the Dundee Ready Educational Environment Measure (DREEM) (Roff 2005) evaluation has been trialled and appears to approximate the feedback from the more labour intensive evaluation which was applied in the early years (Denz-Penhey & Murdoch 2009).

Staff development/support for the medical teachers had priority in the early life of the RCSWA; this included not only the salaried medical coordinator(s) at the sites, but also their local colleagues who contributed as preceptors by hosting students in general practice/hospital/clinic settings. Of key importance is to keep this initiative rolling at a local level in sites as these staff often have a high turnover in rural healthcare and the camaraderie and networking that results is paramount to maintaining optimal learning opportunities for students (Walters et al. 2005).

Cultural including indigenous cultural aspects of communication impact greatly in rural/remote areas of Australia. Understanding Aboriginal health issues is important in any rural curriculum and the appointment of staff with specific expertise or formal networks into local indigenous peoples greatly facilitates this.

흔한 문제들 Common problems in implementation

삼차병원이 유일한 장소라는 통설에 반하는 것이다. 당연히 다양한 문제가 생길 수 있다.

Transferring aspects of undergraduate medical teaching to a new programme in a remote or rural location challenges the orthodoxy that the tertiary referral teaching hospital is the only place where students can be taught (Worley et al. 2004b). Not surprisingly there may be problems with the implementation and running of the new programme. Barriers to change may come from both the parent medical school and the new venue.

학생의 관점에서 인터넷 접근이 어려울 수 있다. 고립된 느낌을 받을 수 있다.

From the students’ perspective there is often a problem relating to IT access to the medical school server when in a remote location. Both Internet and Intranet access may be difficult. This adds to the isolation which students may feel when away from their usual base with its social, family and academic support (Maley et al. 2006).

멀리 떨어진 임상교사와의 의사소통이 필요한 때 이루어지지 못하거나 효과적이지 않을 수 있다.

Similarly, there may be difficulties of communicating effectively over a large distance with clinical tutors and supplying them with the timely support and dialogue they need.

학생들의 불안감도 주요한 문제이다. 교육의 질 뿐만 아니라 교통과 경제적 문제도 중요하다.

Student anxiety is quoted as the main problem for recruiting students to a rural programme (Denz-Penhey et al. 2004). Anxiety may relate to social/family isolation and missing out on city experience and centre medical school support. There may be concern about the quality of the teaching as well as transport and financial issues. It is probably most useful if the rural practice experience is spread throughout the medical curriculum (Curran & Rourke 2004; Jones et al. 2007).

대학과 보건당국 사이의 영역 다툼도 있을 수 있다.

In a new venue there may be territorial problems of perceived ownership of resources and sharing of space between the university and the health authority.

학생이 농촌에 도착하면 다음의 아홉 개 영역에 영향을 준다.

The arrival of students in a rural general practice may impact in nine areas; 

• personal, 
• time, 
• patient care, 
• professional relationships and 
• professional development, 
• business and 
• infrastructure, 
• recognition and 
• remuneration (Walters et al. 2005).

임상경험자체가 교육과정을 결정한다는 생각이 일부 학교들에게는 불편할 수 있다.

The idea that the clinical experiences themselves can be made to determine the curriculum, may be difficult for some schools to accept (Murdoch, personal communication)

스테프들에 대한 지원

Finally, staff support; GP preceptors may receive no formal preparation or support for their role. A study in the University of Tasmania found that many did not know how their contribution fitted into the overall curriculum (Baker et al. 2003).

가장 좋은 해결책은 미리 예상하고 준비하는 것이다.

The best solution to these problems is to anticipate them; to build in strategies to minimise their impact by careful forward planning, good communication amongst all stakeholders and ongoing evaluation of these relationships.

Further development

'더 적합한 학생이 더 적절한 의학을 가장 그러한 환자를 만날 가능성이 높은 곳에서 배운다.'

The inequalities of medical education in Africa are summarised by Gibbs (2007) in a commentary to a series of papers in Medical Teacher. A recent government directed change in medical education in South Africa has focused on the increasing role of generalist training and the establishing of Family Medicine as a subject in universities (Hellenberg & Gibbs 2007). The result is that ‘more appropriate students are being taught more relevant medicine in places that are more likely to see them practice in underserved areas’ (Kent & De Villiers 2007). ‘Training according to the community-orientated approach’, say Mash & De Villiers (1999), ‘does not equal delivering the same training as previously merely in a decentralised facility. It requires embracing the paradigm of horizontal thinking as opposed to a vertical approach to health care’.

학생이 GP와의 관계에서 공생적 파트너십을 형성한다는 인식이 자리잡기 시작했다. 학생이 대학측에 어떠한 교육을 받고 있는가를 전달하는 것도 중요할 것이다.

Recent years have also seen the development of rural medicine as an independent discipline (Curran & Rourke 2004), (Murdoch & Denz-Penhey 2007) as evidenced by the Journal of Remote and Rural Health. University awareness of the role of RRME is increasing. There is a growing realisation of the impact of students on GPs leading to the formation of symbiotic partnerships between GPs and universities. It will benefit students to keep universities informed as to how the teaching practices are affected (Walters et al. 2005). An increasing capacity for more and longer opportunities in RRME and for more student cohorts to take part can be expected.

구조적 측면과 지원이 중요함을 강조하였다. 12개의 팁이 있다.

Page and Birden (2008) emphasise the importance of the structure and supports required to ensure quality and enjoyment in rural placements. Their 12 tips (Table 2) apply to any placement regardless of context or duration.

. Focus training in appropriate areas

. Select students wisely

. Provide adequate practice infrastructure support

. Provide good (not merely adequate) accommodation

. Provide strong student support

. Provide strong preceptor/supervisor support

. Take advantage of the potential to provide trans-disciplinary health-care team earning (and doing) experiences

. Provide adequate learning supports for the home campus

. Capitalise on the opportunity to provide an immersion learning experience 

. Evaluate

. Involve rural clinicians and students in course development and evaluation

. Foster involvement of the community at large

RRME와 다른 혁신적 교육접근법을 함께 사용하는 것이 좋다. 기존의 대형병원 중심의 교육과 농촌의학교육이 좀 더 어우러질 필요가 있다. RCS경험의 우수한 결과가 대형병원 중심의 교육에도 영향을 주고 있다는 근거들이 있지만, 분절된, 블록화된 임상과목 중심의 로테이션을 조금 더 벗어날 필요가 있다. 

A blended learning approach between RRME and innovative curriculum approaches, such as the extended use of virtual patients, is anticipated (Maley et al. 2007, 2008). However a further evolution of the relationship between a rural and remote medicine undergraduate curriculum and the endorsed curriculum of the ‘urban centre’ also needs to occur. Some evidence exists that the latter is being influenced by proven excellence in the outcomes from RCS experiences (Worley et al. 2004a). Yet, a visible casting off from the urban model of discrete/blocked clinical discipline-based rotations still needs to be achieved when the learning is in a generalist context rather than in a siloed specialist context. With possibly only one exception, even the longer term immersion-type models still feign a parallelism with traditional rotations. The landmark for this paradigm shift will be the adoption and endorsement of benchmarked assessment practices which match the generalist learning environment. The benchmarking will be a key step as it requires the engagement of rural teachers as assessors who are endorsed as such by urban academia.

농촌이 교육-학습 환경으로서 더 우월하다는 것을 홍보하는 것도 필요하다.

The marketing of the rural context as a superior learning and teaching environment is facilitated by its expanding community of teaching practices and student alumni who experience its special characteristics (Table 3).

졸업후교육에 대해서도 조기발탁(fast-tracking), 수직유입(vertical streaming)을 접하게 될 것이고, 네트워킹과 멘토링에 있어서 CME의 발달도 있을 것이다.

In the postgraduate arena we will see fast-tracking or vertical streaming of interested students into careers as rural practitioners and the development of continuing medical education opportunities with networking and mentoring frameworks. Although at present, the extent to which the use of rural and remote settings for undergraduate medical education may have a positive impact on the personal professional development of rural practitioners is still to be evaluated.

스테프 개발은 언제나 중요하다.

Staff development as always will be a key issue. Strategies, such as the Preceptor Onsite Preparatory Programme for Information, Education and Support (POPPIES) programme (Baker et al. 2003) will be necessary to support GP tutors. Courses offering a Masters in Rural and Remote Medicine which are attractive to course coordinators are already emerging (Maley et al. 2009).

Conclusions

To quote from Fiedler (1981) ‘The issue of quality is an evasive one. Its slippery character has complicated efforts to measure the progress toward the goal of equity of health care’ (across urban and rural communities). The solution lies in effectively harnessing the rich learning environment provided by rural/remote community settings. A key approach is to engage all stakeholders (students, teachers and community) in a community of practice towards a common outcome.

다양한 모델이 있으므로, 지역 환경에 가장 잘 맞는 것을 선택해야 한다. 또한 지속가능성을 위해 노력해야 한다.

A variety of models with various degrees of complexity and integration have been described. An approach is to select the model from the taxonomy that best fits the local context and availability of resources. Following initial successful implementation the insurance of sustainability and a plan for ongoing development are essential. Local community engagement is fundamental to all phases of this continuum.

RCS모델은 의과대학생 뿐만 아니라, 졸업후교육(인턴, 레지던트), 그리고 이미 농촌에서 진료를 하고 있는 일반의의 수련에까지 확대되어야 한다. 이를 통해서만이 2010년이후 예상되는 '의대생 증가 쓰나미'를 미래 농촌/취약지의 일반의로 유도할 수 있을 것이다.

Appropriate investment by government/university/community partnerships will, in the long term, open the path to redressing the migration of doctors away from rural areas, provide better care locally, support community development and present the rural setting as a viable/exciting generalist/primary care career path for students and trainees. To quote Murdoch and Denz-Penhey (2007) in an Australian context, ‘The Rural Clinical Schools model needs to be expanded to provide a platform for appropriate education and a training pathway not only for medical students, but also for prevocational, vocational and established rural generalists. Only in this way will we be able to convert the ‘Tsunami of medical graduates’ expected in 2010 to an adequate supply of rural and remote generalist into the future’.

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Med Teach. 2009 Nov;31(11):969-83. doi: 10.3109/01421590903111234.

Using rural and remote settings in the undergraduate medical curriculum: AMEE Guide No. 47.

Maley M1, Worley P, Dent J.

Author information

• 1The University of Western Australia, Western Australia. moira.maley@uwa.edu.au

Abstract

The goal of global equity in health care requires that the training of health-care professionals be better tuned to meet the needs of the communities they serve. In fact medical education is being driven into isolated communities by factors including workforce undersupply, education pedagogy, medical practice and research needs. Rural and remote medical education (RRME) happens in rural hospitals and rural general practices, singly or in combination, generally for periods of 4 to 40 weeks. An effective RRME programme matches the context of the local health service and community. Its implementation reflects the local capacity for providing learning opportunities, facilitates collaboration of all participants and capitalises on local creativity in teaching. Implementation barriers stem from change management, professional culture and resource allocation. Blending learning approaches as much as technology and local culture allow is central to achieving student learning outcomes and professional development of local medical teachers. RRME harnesses the rich learning environment of communities such that students rapidly achieve competence and confidence in a primary care/generalist setting. Longer programmes with an integrated (generalist) approach based in the immersion learning paradigm appear successful in returning graduates to rural practice and a career track with a quality lifestyle.

Comment in

• From medicine's margins--why all the interest in rural and remote education? [Med Teach. 2009]
• Using rural and remote settings in the undergraduate medical curriculum: Guide supplement 47.1 - viewpoint. [Med Teach. 2011]

PMID:

 

19909036

 

[PubMed - indexed for MEDLINE]