Like many countries, Australia faces a long-standing uneven distribution of the health workforce, with fewer doctors per capita in rural areas and a trend toward high specialization. Longitudinal Integrated Clerkship (LIC) is a model of medical education that is more likely than other clerkship models to produce graduates working in rural, increasingly remote communities and in primary care. While this quantitative data is critical, project-specific data to explain this phenomenon is lacking.
To address this knowledge gap, a constructivist approach grounded in qualitative theory was used to determine how Deakin University’s integrated rural LIC influenced the career decisions of graduates (2011–2020) in terms of medical specialty and geographic location.
Thirty-nine alumni participated in qualitative interviews. A rural LIC career decision framework is developed, suggesting that a combination of personal and programmatic factors within the central concept of “participation choice” may influence graduates’ geographic and vocational career decisions, both personally and symbiotically. Once integrated into practice, the concepts of learning design capabilities and on-site training increase engagement by providing participants with the opportunity to experience and compare health care disciplines in a holistic way.
The developed framework represents the contextual elements of the program that are considered influential in graduates’ subsequent career decisions. These elements, combined with the program’s mission statement, contribute to achieving the program’s rural workforce goals. The transformation occurred whether graduates wanted to participate in the program or not. Transformation occurs through reflection, which either challenges or confirms graduates’ preconceived notions about career decision-making, thereby influencing the formation of professional identity.
Like many countries, Australia faces long-standing and persistent imbalances in the distribution of the healthcare workforce [1]. This is evidenced by the lower number of doctors per capita in rural areas and the trend of transition from primary care to highly specialized care [2, 3]. Taken together, these factors negatively impact health in rural areas, especially because primary health care is key to the health care workforce of these communities, providing not only primary health care services but also emergency department and hospital care [4]. ]. The Longitudinal Integrated Clerkship (LIC) is a medical education model that was originally developed as a way to train medical students in small rural communities and was created to encourage eventual practice in similar communities [5, 6]. This ideal is achieved because graduates of rural LICs are more likely than graduates of other staff (including rural rotations) to work in rural, increasingly remote communities and in primary health care [7,8,9 ,10]. How medical graduates make career choices has been described as a complex process involving a number of internal and external factors, such as lifestyle choices and the structure of the health care system [11,12,13]. Little attention has been paid to factors within undergraduate medical training that may influence this decision-making process.
The pedagogy of LIC differs from traditional block rotation in structure and setting [5, 14, 15, 16]. Low-income rural centers are typically located in small rural communities with clinical links to both general practice and hospitals [5]. A key element of LIC is the concept of “continuity,” which is facilitated by longitudinal attachment, allowing students to develop long-term relationships with supervisors, health care teams, and patients [5,14,15,16]. LIC students study courses comprehensively and in parallel, in contrast to the time-limited sequential subjects that characterize traditional block rotations [5, 17].
Although quantitative data on the LIC workforce is critical to assessing program outcomes, there is a lack of specific evidence to explain why rural LIC graduates are more likely to work in rural and primary care settings compared to health professions graduates from other clerkship models [8, 18]. Brown et al (2021) conducted a scoping review of occupational identity formation in low-income countries (urban and rural) and suggested that more information is needed on the contextual elements that facilitate low-income work to provide insight into the mechanisms influencing graduates’ decisions about career [18]. In addition, there is a need to retrospectively understand the career choices of LIC graduates, engaging them after they have become qualified physicians making professional decisions, as many studies have focused on the perceived views and intentions of students and junior doctors [11, 18, 19].
It would be interesting to study how LIC’s comprehensive rural programs influence graduates’ career decisions regarding medical specialty and geographic location. A constructivist theoretical approach was used to answer the research questions and develop a conceptual framework describing the elements of staff work that influenced this process.
This is a qualitative constructivist theory project. This was identified as the most appropriate grounded theory approach because (i) it recognized the relationship between researcher and participant that formed the basis for data collection, which was essentially co-constructed by both parties (ii) it was considered appropriate methods for social justice research. , for example, fair distribution of medical resources, and (iii) it can explain a phenomenon such as “what happened” rather than simply explore and describe it [20].
Deakin University’s Doctor of Medicine (MD) degree (formerly Bachelor of Medicine/Bachelor of Surgery) was offered in 2008. The Doctor of Medicine degree is a four-year postgraduate entry program offered in both urban and rural areas, primarily in western Victoria, Australia. According to the Australian Modified Monash Model (MMM) geographical distance classification system, MD course locations include MM1 (metropolitan areas), MM2 (regional centres), MM3 (large rural towns), MM4 (medium sized rural towns) and MM5 (small rural towns) )[21].
The first two years of the preclinical phase (medical background) were conducted in Geelong (MM1). In the third and fourth years, students undertake clinical training (professional practice in medicine) at one of five clinical schools in Geelong, Eastern Health (MM1), Ballarat (MM2), Warrnambool (MM3) or the LIC – Rural Community Clinical Schools (RCCS) program; ), officially known as the IMMERSE Program (MM 3-5) until 2014 (Fig. 1).
RCCS LIC enrolls approximately 20 students each year working in the Grampians and South Western Victoria region during their penultimate (third) year of MD. The selection method is through a preference system in which students choose a clinical school in their second year. The program accepts students with a variety of preferences from first to fifth. Specific cities are then assigned based on student preference and interview. Students are distributed across cities mainly in groups of two to four people.
Students work with GPs and local rural health services, with a general practitioner (GP) as their primary supervisor.
The four researchers involved in this study come from different backgrounds and careers, but share a common interest in medical education and equitable distribution of the medical workforce. When we use constructivist theory, we consider our backgrounds, experiences, knowledge, beliefs, and interests to influence the development of research questions, the interview process, data analysis, and theory building. JB is a rural health researcher with experience in qualitative research, working at LIC and living in a rural area of LIC’s training area. L.F. is an academic therapist and clinical director of the LIC program at Deakin University and is involved in teaching LIC students. MB and HB are rural researchers with experience in implementing qualitative research projects and living in rural areas as part of their LIC training.
Reflexivity and the researcher’s experience and skills were used to interpret and find meaning from this rich data set. Throughout the data collection and analysis process, frequent discussions occurred, especially between JB and MB. HB and LF provided support throughout this process and through the development of advanced concepts and theory.
Participants were Deakin University medical graduates (2011–2020) attending LIC. An invitation to participate in the study was sent by RCCS professional staff via a recruitment text message. Interested participants were asked to click on a registration link and provide detailed information via a Qualtrics survey [22], indicating that they (i) had read a plain language statement outlining the purpose of the study and participant requirements, and (ii) were willing to participate in research. who were contacted by the researchers to arrange a suitable time for interviews. The geographic location of participants’ work was also recorded.
Recruitment of participants was carried out in three stages: the first stage for graduates of 2017–2020, the second stage for graduates of 2014–2016, and the third stage for graduates of 2011–2013 (Fig. 2). Initially, purposive sampling was used to contact interested graduates and ensure job diversity. Some graduates who initially expressed interest in participating in the study were not interviewed because they did not respond to the researcher’s request for time to be interviewed. The staged recruitment process allowed for an iterative process of data collection and analysis, supporting theoretical sampling, conceptual development and refinement, and theory generation [20].
Participants recruitment scheme. LIC graduates are participants in the Longitudinal Integrated Clerkship Program. Purposive sampling means recruiting a diverse sample of participants.
Interviews were conducted by researchers JB and MB. Verbal consent was obtained from participants and audio recorded before the start of the interview. A semi-structured interview guide and associated surveys were initially developed to guide the interview process (Table 1). The manual was subsequently revised and tested through data collection and analysis to integrate research directions with theory development. Interviews were conducted by telephone, audio recorded, transcribed verbatim, and anonymized. Interview length ranged from 20 to 53 minutes, with an average length of 33 minutes. Before data analysis, participants were sent copies of the interview transcripts so they could add or edit information.
Interview transcripts were uploaded into the qualitative software package QSR NVivo version 12 (Lumivero) for Windows to complement data analysis [ 23 ]. Researchers JB and MB listened, read, and coded each interview individually. Note-writing is often used to record informal thoughts about data, codes, and theoretical categories [20].
Data collection and analysis occur simultaneously, with each process informing the other. This constant comparative approach was used throughout all stages of data analysis. For example, comparing data with data, decomposing and refining codes to develop further research directions in accordance with the development of theory [20]. Researchers JB and MB met frequently to discuss initial coding and identify areas of focus during the iterative data collection process.
Coding began with an initial line-by-line coding in which the data was “broken down” and open codes were assigned that described the activities and processes associated with “what was happening” in the data. The next stage of coding is intermediate coding, in which line-by-line codes are reviewed, compared, analyzed, and conceptualized together to determine which codes are most analytically meaningful for classifying the data [20]. Finally, extended theoretical coding is used to build theory. This involves discussing and agreeing on the analytical properties of the theory across the entire research team, ensuring that it clearly explains the phenomenon.
Demographic data were collected through a quantitative online survey prior to each interview to ensure a broad range of participants and to complement the qualitative analysis. Data collected included: gender, age, year of graduation, rural origin, current place of employment, medical specialty, and location of fourth year clinical school.
The findings inform the development of a conceptual framework that illustrates how rural LIC influences graduates’ geographic and occupational career decisions.
Thirty-nine LIC graduates participated in the study. Briefly, 53.8% of participants were women, 43.6% were from rural areas, 38.5% worked in rural areas, and 89.7% had completed a medical specialty or training (Table 2).
This rural LIC career decision framework focuses on the elements of a rural LIC program that influence graduates’ career decisions, suggesting that a combination of individual and program factors within the central concept of “participation choice” may also influence graduates’ geographic location. as professional career decisions, whether solitary or symbiotic (Figure 3). The following qualitative findings describe the elements of the framework and include quotes from participants to illustrate the implications.
Clinical school assignments are completed through a preference system, so participants can choose programs differently. Among those who nominally chose to participate, there were two groups of graduates: those who intentionally chose to participate in the program (self-selected), and those who did not choose but were referred to RCCS. This is reflected in the concepts of implementation (last group) and confirmation (first group). Once integrated into practice, the concepts of learning design capabilities and on-site training increase engagement by providing participants with the opportunity to experience and compare health care disciplines in a holistic way.
Regardless of the level of self-selection, participants were generally positive about their experience and stated that LIC was a formative year of learning that not only introduced them to the clinical environment, but also provided them with continuity in their studies and a strong foundation for their careers. Through an integrated approach to delivering the programme, they learned about rural life, rural medicine, general practice and various medical specialties.
Some participants reported that if they had not attended the program and completed all the training in a metropolitan area, they would never have thought or understood how to meet their personal and professional needs in a rural area. This ultimately leads to a convergence of personal and professional factors, such as the type of doctor they aspire to become, the community in which they want to practice, and lifestyle aspects such as access to the environment and accessibility to rural life.
It seems to me that if I had just stayed at X [metropolitan facility] or something like that, then we probably would have just stayed in one place, I don’t think we (the partners) would have done it, this jump (on work in rural areas) would not have to be pressured (general practice registrar, rural practice).
Participation in the program provides an opportunity to reflect and confirm graduates’ intentions to work in rural areas. This is often due to the fact that you grew up in a rural area and intend to undertake an internship in a similar location after graduation. For those participants who initially intended to enter general practice, it was also clear that their experience had met their expectations and strengthened their commitment to pursuing this path.
It (being in LIC) just solidified what I thought was my preference and it just really sealed the deal and I didn’t even think about applying for a metro position in my internship year or even thought about it. about working in the metro (psychiatrist, rural clinic).
For others, participation confirmed that rural life/health did not meet their personal and professional needs. Individual challenges cause distance from family and friends, as well as access to services such as education and health care. They viewed the frequency of on-call work performed by rural doctors as a career deterrent.
My city manager is always in touch. Therefore, I think that this lifestyle is not suitable for me (GP at a capital clinic).
Study planning opportunities and student learning structure influence career decisions. The core elements of LIC’s continuity and integration provide participants with autonomy and a range of opportunities to actively participate in patient care, develop skills, and facilitate the discovery and comparison of types of medical practice in real time that are compatible with their personal and professional needs.
Because the medical subjects on the course are taught comprehensively, participants have a high degree of autonomy and can self-direct and find their own learning opportunities. Participants’ autonomy grows over the course of the year as they gain an innate understanding and safety within the structure of the program, gaining the ability to engage in deep self-exploration in a variety of clinical settings. This allowed participants to compare medical disciplines in real time, reflecting their attraction to specific clinical areas that they often end up choosing as a specialty.
At RCCS you are exposed to these majors earlier and then actually get more time to focus on the subjects you are truly interested in, so of course more metro students don’t have the flexibility to choose their time and place. In fact, I go to the hospital every day… which means I can spend more time in the emergency room, more time in the operating room, and do what I’m more interested in (anesthesiologist, rural practice).
The program’s structure allows students to encounter undifferentiated patients while providing a safe level of autonomy to obtain a clinical history, develop clinical reasoning skills, and present a differential diagnosis and treatment plan to the clinician. This autonomy contrasts with the return to block rotation in the fourth year, when it is felt that there are fewer opportunities to influence undifferentiated patients and there is a return to the supervisory role. For example, one student noted that if their only clinical experience in general practice had been a time-limited fourth-year rotation, which he described as an observer, he would not have understood the breadth of general practice and suggested pursuing training in another specialty. .
And I didn’t have a good experience at all (rotating GP blocks). So, I feel that if this had been my only experience in general practice, perhaps my career choice would have been different… I just feel like it’s a waste of time as I’m just observing (GP, rural practice) how this is a place of work. .
Longitudinal attachment allows participants to develop ongoing relationships with physicians who serve as mentors and role models. Participants actively sought out physicians and spent extended periods of time with them for a variety of reasons, such as the time and support they provided, training in acumen, availability, admiration for their practice model, and their personality and values. Compatibility with yourself or others. The desire to develop. Role models/mentors were not only participants assigned under the supervision of a lead GP, but also representatives from a variety of medical specialties, including physicians, surgeons and anaesthetists.
There are several things. I am at point X (LIC location). There was an anesthesiologist who was indirectly in charge of the ICU, I think he took care of the ICU at X (rural) hospital and had a calm demeanor, most anesthesiologists I have met had a calm attitude about most things. It was this unflappable attitude that really resonated with me. (anesthesiologist, city doctor)
A realistic understanding of the intersection of physicians’ professional and personal lives was described as providing valuable insight into their lifestyles and was believed to encourage participants to follow similar paths. There is also an idealization of the doctor’s life, drawn from the social activities of the home.
Throughout the year, participants develop clinical, personal and professional skills through hands-on learning opportunities provided through relationships developed with physicians, patients and healthcare staff. The development of these clinical and communication skills often involves a specific clinical area, such as general medicine or anesthesia. For example, in many cases, graduating anesthesiologists and general anesthesiologists described their development of basic skills in the discipline from their LIC year, as well as the self-efficacy they developed when their more advanced skills were recognized and rewarded. This feeling will be strengthened with subsequent training. and there will be opportunities for further development.
It’s really cool. I have to do intubations, spinal anesthesia, etc., and after next year I will complete rehabilitation… anesthesiology training. I will be a general anesthetist and I think that was the best part of my experience working there (LIC scheme) (general anesthesia registrar, working in a rural area).
On-site training or project conditions were described as having an impact on participants’ career decisions. Settings were described as a combination of rural settings, general practice, rural hospitals and specific clinical settings (eg operating theatres) or settings. Concepts related to place, including sense of community, environmental comfort, and type of clinical exposure, influenced participants’ decisions to work in rural areas and/or general practice.
A sense of community influenced participants’ decisions to continue in general practice. The appeal of general practice as a profession is that it creates a friendly environment with minimal hierarchy where participants can interact with and observe practitioners and GPs who appear to enjoy and gain a sense of satisfaction from their work.
Participants also recognized the importance of building relationships with the patient community. Personal and professional satisfaction is achieved by getting to know patients and developing ongoing relationships over time as they follow their path, sometimes only in general practice, but often across multiple clinical settings. This contrasts with less favorable preferences for episodic care, such as in emergency departments, where there may not be a closed loop of follow-up patient outcomes.
So, you really get to know your patients, and I think actually, probably what I love most about being a GP is the ongoing relationship that you have with your patients… and building that relationship with them, and not sometimes in hospitals and other specialties, you can… you see them once or twice, and often you never see them again (general practitioner, metropolitan clinic).
Exposure to general practice and participation in parallel consultations gave participants an understanding of the breadth of traditional Chinese medicine in general practice, especially in rural general practice. Before becoming trainees, some participants thought they might go into general practice, but many participants who eventually became GPs said they were initially unsure whether the specialty was the right choice for them, feeling that acuity clinical picture was less low and therefore unable to sustain their professional interest in the long term.
Having done GP practice as an immersion student, I think it was my first exposure to a wide range of GPs and I thought how challenging some patients were, the variety of patients and how interesting GPs (GP) can be , capital practice). ).
Post time: Jul-31-2024