The Rural Clinical Schools (RCS) Program was launched in 2000 to enable medical students to undertake extended blocks of their clinical training in regional areas. It differs from other, pre-existing regional medical training placement programs (e.g. the Rural Undergraduate Support and Coordination Program and the John Flynn Placement Program) because of its scale and scope: rural clinical schools are charged with delivering significant components of the medical curriculum in a rural environment, and are an integral structure within the host university medical school, with students undertaking a year or more of their medical training in a rural location. The RCS Program complements other placement programs which provide students with short-term opportunities to experience rural medical practice, and in many instances students who have undertaken short-term placements have been inspired to apply to an RCS for part of their training. The development of the Rural Clinical Schools Program has allowed construction and furnishing of teaching and learning facilities and student accommodation in dozens of rural and regional locations across Australia.
In broad terms, rural clinical schools exist to:
- encourage medical students (and medical professionals) to take up a career in rural practice;
- encourage rural health professionals to take up academic positions;
- improve the range of rural health care services in rural communities across Australia; and
- strengthen the health workforce in rural communities across Australia.
Of the 14 rural clinical schools across Australia, 10 were established between 2000-2001 and another four were launched in 2006-2007. This second round of RCS funding (including additional funding for the older RCSs) occurred in the wake of the 2006 announcement from COAG that 25% of all Commonwealth-funded medical students are to undertake at least one year of their clinical training in rural and regional communities. This decision recognised the influence of rural exposure during medical training upon students’ decisions to undertake rural medical practice. A majority of medical schools in Australia are now in receipt of RCS funding.
The Department's Parameters for Funding Rural Clinical Schools are as follows (emphasis added):
- Minimum student numbers are to be met, based on 25% of DEEWR-funded places undertaking one year or more of their rural clinical training in a rural area (RRMA 3-7);
- Students are to be provided with a range of experience consistent with Australian Medical Council requirements for medical curriculum;
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- Universities are to recruit and appoint staff who (will) live and work locally, including a full time coordinator, academics and administrative staff;27
- A maximum of 5% of the budget is to be utilised in the capital city, unless otherwise approved by the Department;
- Universities are to engage and maintain links with their local community/ies. This includes organisation and chairing of a Community Advisory Board that comprises a broad range of representatives from the local community and government service delivery agencies;
- Universities are to work collaboratively with the local community, the state health department and other local tertiary institutions to maximise the utilisation of local facilities and expertise (e.g. student accommodation, travel and information technology resources);
- Universities are to maintain close liaison with the Department about ongoing needs regarding information technology, telecommunications, accommodation and infrastructure;
- Universities are to develop transparent internal evaluation mechanisms that will support external evaluation processes; and
- Schools are to endeavour to progress the rural health agenda (including research) within the medical faculty, other relevant health faculties and university departments to maximise the efficient use of resources across rural health programs (including RUSC and UDRH).
The traditional model of clinical medical education (still dominant in metropolitan settings) is for medical students to undertake consecutive terms that each cover a certain field of clinical practice (e.g. 6 weeks in the paediatrics ward, followed by 6 weeks in general practice, then 6 weeks back in hospital on a general surgery rotation).
Rural clinical schools have developed a number of alternative models for clinical education - divergent from the traditional model described above, and also different from each other.
Many of those that operate in large regional centres have retained a hospital-based approach but, in a departure from the traditional model, provide what the University of New South Wales RCS describes as an 'integrated teaching program' of patient-centred learning:
'Students work closely with several patients, following them through their treatment and closely observing and participating in total patient care, and gaining a holistic view of medicine. The Year 5 curriculum in paediatrics, obstetrics and gynaecology, psychiatry and community medicine is integrated into two semesters rather than distinct terms. This allows students to be attached to, for instance, a woman in the late stages of pregnancy, to follow her through the delivery and see how the baby progresses over its first few months.'29Top of page
Essentially, this integrated teaching program means that rather than having separate clinical disciplines taught in separate blocks of six or twelve week terms, the disciplines are integrated across the entire year’s curriculum. This model of medical education is reportedly better suited to the health workforce dynamics of regional centres, where specialists on the wards are often visiting medical officers (rather than hospital staff) and sometimes work only part time. The model also accommodates the lower incidence of certain patient presentations in regional areas - i.e. six weeks may be too short a time period to provide a sufficient variety of cases in a field of clinical specialty.
A further diversion from the traditional model is for students to undertake this integrated clinical education based in community settings rather than hospital settings. This model originated from Flinders University, and is sometimes referred to as the 'Riverland model' after the area in which it was developed (in the late 1990s):
'The PRCC (Parallel Rural Community Curriculum) students who move to the … regions for the academic year are based in General Practice and local health services to prepare for the [Year 3] exams.'
'Through the year the students must learn all of their medicine, surgery, paediatrics, obstetrics and gynaecology, general practice and psychiatry in exactly the same way as students based at Flinders Medical Centre. However instead of rotating through a sequence of discrete terms (medicine, surgery, etc) as their city-based peers do, the PRCC students learn these disciplines in an integrated way throughout the year. Although students are allocated to a specific general practice and have a GP Supervisor, the year itself is NOT only a general practice experience.
'Students are expected to attend clinical activities related to all medical domains. They will encounter patients in the general practices to which they are attached and then follow them through primary care and the hospital system. At the end of the year the PRCC students sit exactly the same exams as their FMC-based colleagues in all clinical domains.'30
There are variations of the above two models, and some RCSs run hospital- or community-based models in different locations, depending on the health service infrastructure available. The RCS in Western Australia has developed its own framework, called the Clinical Learning Embedded in Rural Communities (CLERC) program.
'The students' clinical placements occur in General Practices, local Hospitals, Community and remote Clinics, Aboriginal Medical Services and other health facilities. The  sites are heterogeneous in many respects, and accordingly are granted significant autonomy in the delivery of the program…
'The content (and outcome) of the curriculum is identical to the urban curriculum, but it is delivered in a significantly different way. The students are taught and assessed (examined) to the same standard as the urban students and the results are entirely comparable to the urban programme.'31
James Cook University (JCU), the University of Newcastle and the University of Wollongong are the only three RCS-funded universities whose main campuses are located outside of capital cities. All three universities have a regional focus across their entire medicine program, so from a student perspective there is little (if any) distinction drawn between clinical terms made possible by the RCS Program and those that would have been available otherwise. While to date the University of Newcastle's approach has been similar to an urban-based program, with the focus on metropolitan hospitals, the introduction of its Joint Medical Program with the University of New England at Armidale will mean a significant proportion of students will spend most of their undergraduate time in a rural area.
For James Cook University, the RCS can be considered as:Top of page
'…the distributed rural clinical teaching infrastructure that supports longer rural and remote clinical teaching across Years 4-6 of the course. This includes 8-week rural attachments in Years 4 and 6 for all students as well as Years 5 and 6 for the group of students based at Mackay and Cairns.'32
JCU has developed a model with a particular emphasis on regionalised community capacity building, partnerships and infrastructure delivery across sites.
For the University of Wollongong, the RCS activity is even more seamless - all students will undertake extended rural placements and do their third year clinical training through what the university calls 'Community-Based Medical Education' (based on the Riverland model).
Most RCSs have their 'head office' at one of the RCS training sites off the main university campus. However, UNSW and the Australian National University (ANU) are two universities that have an RCS 'campus' at their base location, in Sydney and Canberra respectively. For UNSW this is a function of history: the 'Kensington office' of the RCS is the former Rural Health Unit of the School of Community Medicine, which predated both the UDRH and RCS Programs. Among other things, this small office administers special entry programs and coordinates RUSC-funded student services; the UNSW RCS 'head office' is located at the Wagga Wagga RCS.
The plurality of models evident between (and within) RCSs demonstrates a strength of the Program's administration by the Department, as RCSs have been free to design and deliver programs that utilise the capacity of the health services in their region (hospital and otherwise) to provide the range of clinical experience required by their university’s medical curriculum.
While the expansion of clinical education into 'alternative teaching settings' has been enabled in rural settings by the RCS Program, there has been no such funding program available for metropolitan clinical schools. As a result, rural clinical schools are at the forefront of this developing area of medical education.33 This has been recognised by many within the university environment, leading to some suggestions by consultation participants that medical schools could also develop alternative teaching settings in urban and suburban locations.
This evaluation has found no evidence to promote any particular model as 'better' than any other, in terms of educational or workforce outcomes. Each university (and its RCS) has placed an explicit focus on the quality of the educational experience provided to students; this is regarded by RCSs as fundamental to their raison d'etre, and is not an area where RCSs would (or would be allowed by their university to) cut corners. Indeed, the diversity across the RCS Program is considered to be a strength in modelling the diversity of clinical practice in rural environments while at the same time demonstrating the quality of care, and thus training opportunities, provided in such environments. This demonstration that clinical medicine can successfully be taught in rural Australia is considered by some to be the greatest achievement of the RCS Program to date.
'[The founders] had a vision to say there are GPs out there who can teach everything a 5th year needs to know.' (RCS Head)Top of page
27 If it is not possible to appoint a coordinator who lives and works in the region, universities are to appoint a senior academic who lives and works locally.
28 Medical degrees in Australia have been changing over the past decade, with ten medical schools now providing four-year
graduate entry programs, and 12 maintaining traditional six-year undergraduate entry programs.
33 See, for example, the Committee of Deans of Medical Schools (CDAMS) 2006 submission to the DEST Medical Education