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From a broom cupboard: 20 years of rural health at Monash University

Ch 04. Rural medical training

Applying the curriculum in a
rural environment

As Roger Strasser wrote in the opening chapter, much of the impetus for the establishment of the Centre for Rural Health came from recognition that the rural doctor shortage problem began at, or before, medical school. The fact that fewer medical students came from rural areas was compounded by the poor standing in which rural practice was held by city-based senior medical school teachers, and the lack of exposure to rural practice for students in the clinical years of their training.

In this chapter John Togno tells of the early rural placements for medical students and the evolution of these over time. John was head of the education stream within the school and was very active in incorporating rural placements and issues into Monash’s five-year medical curriculum. David Campbell is another long-time rural medical educator who writes of the establishment of the East Gippsland Regional Clinical School, the philosophies behind it and his passion for the merits of rural practice. Gordon Whyte was the inaugural director of the Bendigo Regional Clinical School and was involved in curriculum planning and implementation within the faculty before returning as head of school. Gordon writes of his experiences in setting up the regional clinical school and the curriculum issues he encountered. The final product is reviewed, from a student perspective, by Ryan Spencer, Elyssia Bourke and John Clark.

Positive exposure to rural practice

Dr John Togno

The objective of rural medical placements in both the old six-year curriculum and the development of the current five-year curriculum has been very straightforward: that rural clinical placements should contribute to the teaching and learning of medical students by giving them a positive exposure to clinical experiences in the rural setting, therefore aiming to develop and stimulate a longer term career interest in rural medicine.

There have been rural placements in the medical curriculum at Monash for many years. These placements date back to the mid-1970s. At this time the then recently established Department of General Practice – with the newly appointed Dr, later Professor, John Murtagh as a strong advocate of rural medicine – had a six-week block of teaching in the final year of the undergraduate curriculum. Part of this six-week block was a two-week placement with a rural GP. It was a genuine immersion experience, with medical students shadowing their rural GPs in and after hours, doing hospital rounds and theatre lists and often sharing the house of the GP and their family during their placement. The rural experience was a markedly different experience for many students compared to their metropolitan placements.

From the late 1970s onwards, urban GPs were beginning to lose many of their clinical skill sets to the rapidly growing number of specialists setting up their practices in suburban areas. In contrast, rural GPs then – as now – provided a diverse range of procedural skills to their communities; in addition, they provided the comprehensive range of non-procedural clinical skills required to manage complex medical conditions in the rural areas of Victoria where they were working. For many students, whose clinical education until then had been in tertiary hospitals – where they encountered about 3 per cent of all clinical presentations and specialists’ openly expressed bias against the skill sets of GPs – this was a truly eye-opening exposure to a style of clinical practice that they could not otherwise have encountered or comprehended.

For many students this rural placement was an experiential epiphany that led them to a career path as a rural GP, or at least to a deeper understanding of the key role that GPs provide in the delivery of health care to the other 97 per cent of the population. For others, it was possibly a more traumatic psychological experience. Some experienced the displacement anxiety of their first prolonged excursion alone outside a major metropolitan setting. Cognitive disruption resulted from the direct observation of clinical skills and procedures that were being practised well outside what students had been indoctrinated to perceive as the safety of a major clinical precinct such as the Alfred Hospital in Melbourne.

In time, this two-week rural GP placement, which was in later years delivered by the Centre for Rural Health in association with the Department of General Practice, became one of the most highly rated teaching and learning experiences in the six-year medical undergraduate curriculum.

Another medical placement in the six-year curriculum that played an important role in the development of the Centre for Rural Health – not least because of the $300 payment that went with every student – was the delivery of the rural-based electives for Year 2 and 3 medical students. At that stage of the course all medical students had to undertake a faculty-approved elective experience which was not directly linked to their core teaching and learning. Often such electives were offered by the pre-clinical departments in the medical faculty on campus and therefore were a slight variation on the laboratory or small teaching room approach usually offered to the students; there were also several relatively innovative electives offered both within the medical faculty and other faculties on the Clayton campus – especially the arts faculty.

Few if any of these metropolitan-based electives had any clinical or patient contact components. The advantage that the centre had was the ability to leverage the wide range of rural-based clinical teachers associated with the centre to offer a range of electives that gave the students direct clinical exposure. From the relatively modest beginning of Alpine electives first set up by Dr Sarah Strasser, the range of electives offered by the centre expanded to include attachments at the Bendigo Primary Care Clinic and direct observation of rural proceduralists coordinated by me. All of these electives were, out of necessity, offered outside the usual curriculum teaching hours, but the lure of ‘hands-on’ clinical experience meant that giving up holidays or weekend time was no barrier for the students in comparison to the experiences offered by the Clayton-based academics.

Of the final cohorts in the six-year curriculum, just under 50 per cent of all Year 2 and 3 medical students chose a rural elective, an achievement that was for other academics in the faculty, whether they realised it or not, a harbinger of the future impact the School of Rural Health would have on the distribution of students across the teaching sites on offer.

The current model for rural medical placements was built on these successful foundations. As is the case for many other Australian medical school students, Monash medical students now have an extended immersion-like experience during their rural GP placements. In these placements, they continue to see a wider scope of clinical practice delivered by rural GPs than by their metropolitan counterparts. Overall, this style of placement continues to offer a positive exposure for students that actively demonstrates to them the benefits of taking up a career as a GP – especially as a rural GP: career satisfaction and the development of competence in delivering an extended range of procedural and non-procedural skills. In the first two clinical years of the five-year curriculum, students frequently reported their positive anecdotal experiences with clinical exposure compared with those of their metropolitan peers.

Has the overall objective of promoting rural medicine as a career, by offering a positive rural clinical placement, been achieved? In some ways it is still too early to give a definitive judgment. To date, early career choices by Monash medical students who have been through the School of Rural Health’s new curriculum have not shown a promising degree of uptake in rural-based careers. However, it may be 10 years or more – that is, after the completion of their postgraduate vocational training – before the outcomes can be judged; only when practitioners choose locations where they will spend a significant time in clinical practice can the success or failure of rural exposure for students finally be determined.

There are number of people who have profoundly influenced the evolution of rural health at Monash. Roger Strasser was not only the founder, but the original convert to rural health. Neil Carson and John Murtagh were important because they had faith in Roger’s ability to develop the Centre for Rural Health into what it has become, and supported him to do so. Marlene Drysdale fought and won the fight for inclusion of increased Aboriginal health perspectives into the medical curriculum. David Campbell and John Russell provided the clinical leadership that promoted and protected rural issues when under attack from metropolitan forces. The rural general practitioners, who selflessly and repeatedly made themselves available as clinical teachers, have been critical to the success of the program. Among others, Amanda Young and Janice Chesters have influenced the creation of a school of rural health as opposed to a school of rural medicine. And finally, all the administration staff have been crucial because without them none of this would have happened.

Clinical training in East Gippsland

Associate Professor David Campbell

The evolution of the Centre for Rural Health and then the School of Rural Health can be seen from a number of perspectives. I would like to provide the perhaps ‘peripheral’ perspective of a rural GP in East Gippsland, at one end of the school’s geographical footprint. I underwent a very gradual involvement with the Centre for Rural Health in the first decade of this 20-year period that developed into a much more significant leadership role in the second decade.

My first involvement with the centre occurred in the early 1990s, when Roger Strasser, then ‘a GP from Moe’, was travelling around Gippsland canvassing support for the establishment of a regional GP training program in Gippsland. On the face of it, the purpose of Roger’s visit to Lakes Entrance was to enlist practices to accept registrars into the Royal Australian College of General Practitioners Family Medicine Program. Of course this was the first step in Roger’s plan to establish an independent regional training program in Gippsland, which evolved into the first such regional program in the country. This was a significant move away from the traditional centrally-managed program ‘rotating registrars out’ to rural practices. Roger’s concept was to provide the means by which doctors training for general practice could undertake all their training in a rural placement.

The legacy of Roger’s approach has been significant. In Australia we have had a fully regionalised GP training program for the past decade. We now have a popular and well-funded national program supporting pre-vocational doctors to experience rural general practice before they embark on specialist or GP training. And in Gippsland we have a network of practices with a strong culture of education which has formed the basis of the Rural Clinical School Program, involving placement of medical students in general practice.

It would be a mistake to assume these developments have been a result of serendipity or perception of a ‘greenfields’ opportunity. The early days of the Centre for Rural Health were characterised by a strong reliance on research, with policy and programs developed on the basis of available evidence. Rural workforce was at the centre of this evidence base, with much of local, state and national policy arising from the Australian and international research which demonstrated that health practitioners were more likely to choose a rural career firstly if they were of rural origin, and secondly if they had a positive rural experience as part of their training.

As a result of this research, early Centre for Rural Health activities included: a network of support for GP teachers hosting short-term student placements from the University of Melbourne and Monash University medical schools; a Monash rural mentor scheme linking students interested in rural practice with experienced rural GPs; a rural secondary schools program to improve recruitment of rural students into medical training; and a rural students’ club – which evolved into Wildfire – supporting medical students with an interest in rural practice. At the same time, the centre began to exert increasing influence on the Monash medical curriculum.

Much of the centre’s development in the 1990s both contributed to, and was the beneficiary of, significant policy change at a national level. In March 2000, Dr Jack Best released his ‘Rural Health Stocktake Advisory Paper’, and among the recommendations arising from this work was the concept of a national network of rurally-based medical school programs. This was the catalyst for the development of the Rural Clinical School Program.

By that time, the Monash School of Rural Health had expanded from the original Centre for Rural Health site at Moe to include campuses at Traralgon, Bendigo and Mildura. In late 2000, universities with medical schools were invited to apply for funding under the proposed Rural Clinical School Program. Monash University’s submission initially included rural clinical school sites at Traralgon, Bendigo and Mildura. Such was the political importance of this new program at the time that Monash was invited by the government to include in its application an additional regional clinical school with campuses in East Gippsland – at Bairnsdale and Sale. As a result, on 6 February 2001, the federal Minister for Health, Dr Michael Wooldridge, came to Bairnsdale to officially launch the national Rural Clinical School Program.

The East Gippsland Regional Clinical School proposal was based on the successful rural community curriculum model developed by Flinders University in South Australia. This involved placement of Year 4 students in rural general practice for the full academic year, providing the opportunity for students to immerse themselves in a rural town, with clinical supervision from rural clinicians, including visiting specialists. The East Gippsland program also included placement of Year 3 students, studying medicine and surgery, for the full year at Central Gippsland Health Service in Sale.

Following almost two years of planning and infrastructure development, five Year 3 students commenced in Sale in 2004. In 2005 nine students were placed in practices in Bairnsdale, Lakes Entrance and Orbost to undertake Year 4. This was significant in several ways. It was the first venture by the Monash medicine program into a fully-integrated, rural community GP-based curriculum program. It was a significant deviation from the traditional short clinical rotations through specialist-led tertiary hospital placements in the disciplines delivered in Year 4. This program ‘immersed’ students in a rural community, as they worked in a practice and lived as part of the local community for a full year.

David Campbell, Director East Gippsland Regional Clinical School (left) and John Russell, Director Mildura Regional Clinical School (right) at a rural expo in 2006. Rural expos were held annually to ‘sell’ rural placements to medical students.

The East Gippsland Year 4 program has been regularly evaluated since its inception. This has involved an annual program review incorporating student and preceptor feedback, and monthly local faculty meetings, with representation from each of the practices and other local clinicians teaching in the program, to discuss progress. The student cohort meets with the program coordinators on a weekly basis to discuss progress, curriculum issues and clinical experiences. The program underwent a major external comparative evaluation with the Flinders University Parallel Rural Community Curriculum in 2010, and a series of publications has arisen from this evaluation.

Curriculum delivery for the Year 4 program has been based on self-directed adult learning principles. Students have opportunities to undertake clinical activity in general practices, in the local hospital maternity ward and in the emergency department. They benefit from a rostered rotation through both local and visiting specialist clinics and hospital attendance relevant to the learning objectives of the curriculum. In addition, students have been encouraged to keep a log book of clinical activities, including clinical and procedural skills demonstrated outside the requirements of the curriculum.

Students have regularly and repeatedly reported that the breadth of clinical opportunities involved in the program and the large number of clinical encounters involving one-to-one supervision from an experienced rural clinician, provide a strong and valuable learning experience.

Year 4 students have undertaken identical summative assessments to those of their peers in the ‘traditional’ central program based in Clayton. The only variation has been the timing of some semester-based summative assessments, given the nature of the integrated year-long program. Students have performed as well as or better than their peers in the traditional metropolitan-based Year 4 program.

In 2010 the program was expanded to include a similar cohort of students in and around the Sale area, supported from the Sale campus of the East Gippsland Regional Clinical School based at Central Gippsland Health Service. This involved placement of students in practices in Sale, Maffra, Heyfield and Yarram, under an identical model to that of the Bairnsdale program. At this stage, the student cohort also included Year C students from the graduate entry Gippsland Medical School, undertaking a clinical year program identical to the Year 4 program of the undergraduate five-year medicine course at Clayton. The program has continued to offer year-long placements for students in Years 3 and 4 of the central program and Years B and C of the Gippsland Medical School program, with combined Year 4C and Year 3B cohorts respectively.

Participating practices have been supported with infrastructure funding from the Rural Clinical School Program, as well as an annual teaching payment to the GP teachers. This has enabled the students to have access to their own consulting room and close clinical supervision under a ‘parallel consulting’ model.

Engagement with the local communities in the towns in which the students are placed has been a strong feature of the program. This has been facilitated by an active regional community advisory committee, made up of local community leaders and representatives from local and state government, service clubs, and other local educational bodies. This committee has provided the impetus for the establishment of the East Gippsland Student Scholarship, available to local-origin students undertaking medicine with Monash, to assist them through their early university studies. Their local communities have provided the following supports: assistance with part-time employment; involvement in sporting, music and drama clubs; and local health education activities.

Students’ knowledge of Aboriginal health issues has increased with the assistance of short-term placements in local Aboriginal medical services. In addition, East Gippsland Regional Clinical School has been very active in supporting the East Gippsland Aboriginal community via the establishment of the East Gippsland School for Aboriginal Health Professionals, led by local Aboriginal community leaders. This initiative has been developed to identify the support young Aboriginals need to embark on careers in health care through enrolment in tertiary studies. In 2012, we have funded a research officer for 12 months to undertake research with the local community to identify these support requirements.

Expansion of the program has progressed steadily over the past decade, with additions to the school buildings at both the Sale and Bairnsdale campuses. As of 2012, East Gippsland hosts 30 full-time students in the Year 3B and Year 4C programs; students are placed in hospitals and practices from Sale and Heyfield in central Gippsland, to Omeo in the east. In addition, the program hosts groups of Year 1, 2 and 5D students for shorter placements, providing these students with the opportunity to understand the nature of rural communities and their health services.

In 2012, the $1.5 million extensions to the East Gippsland Regional Clinical School campus based within the grounds of Bairnsdale Regional Health Service were officially opened. The extensions included:

  • enlargement and improvement of the Bairnsdale Regional Health Service hospital library

  • enlargement of office space for Bairnsdale Regional Health Service Nursing Education Unit

  • enlargement of the current clinical skills/simulation suite and creation of a separate clinical skills/simulation suite for the Monash Gippsland School of Nursing program

  • an extra eight academic offices to accommodate the Monash Gippsland School of Nursing program and the School of Rural Health program

  • two extra tutorial rooms to accommodate the School of Nursing program, as well as extra administration offices and meeting rooms

  • two offices for research staff supporting the East Gippsland School for Aboriginal Health Professionals

  • a large family meeting room for family members of hospital inpatients.

These improvements were in addition to the expansion of the Sale campus in 2011, with provision for a large, fully-equipped simulation suite and extra academic space.

In 2011, the Bairnsdale campus commenced delivery of the Monash Gippsland School of Nursing program, and in 2012 there are 28 School of Nursing students undertaking Year 2 and 3 of the nursing degree, based entirely in and around Bairnsdale. This allows for local residents, including students bridging from the East Gippsland TAFE Division 2 nursing program, to continue their studies locally without the need to travel to Monash’s Churchill campus.

The program will also continue to build on current support activities of for: intern training at Bairnsdale Regional Health Service; practice nurse education within local general practices; and paramedic training with Ambulance Victoria. The program will be enhanced with the recently-acquired grant of $480,000 from Health Workforce Australia, through the Gippsland Clinical Placement Network, to support simulation-based education in East Gippsland.

We have also developed a strong research program with two full-time research officers based in Bairnsdale. They support local and regional research projects, including the evaluation of our interdisciplinary education programs. The establishment and strengthening of academic leadership has been an essential component of the East Gippsland programs. This has involved recruiting local clinicians and providing academic support and recognition, based on a long-term strategy of succession planning and sustainability.

Finally, we have developed significant international strategic relationships with rural medical education programs in New Zealand with the University of Otago, and in South Africa with the University of Witswatersrand, as well as maintaining an ongoing close relationship with Roger Strasser at the Northern Ontario School of Medicine in Canada.

The East Gippsland Regional Clinical School has now become an integral and readily-identifiable part of the East Gippsland community. The school provides opportunities for local clinicians to receive support and recognition for teaching activities in medicine, nursing and allied health education. There is an enhanced rate of clinician retention and more opportunities for students in these disciplines to undertake their training as members of the local community which supports them. Already we are seeing the results of this program in workforce terms, with previous students returning to undertake further studies and providing health care for the community.

The regional clinical school stands as testament to the success of the Rural Clinical School Program. It provides a working example of how the infrastructure of a rural clinical school, and the presence of academic and administrative staff, can be used to support all levels of medical and health education, including continued professional development for local clinicians. Rural clinical schools can also become a focus of support for the recruitment of local community members into health professional training, with consequent benefits for the community at many levels.

Two universities meet in Bendigo

Professor Gordon Whyte

In June 2001, I was appointed to the exciting new position of interim director of the proposed new regional clinical school at Bendigo under the School of Rural Health. The appointment was within the Bendigo Health Care Group (Bendigo Health) but funded from Monash University.

Bendigo Health was taking all its interns and registrars on rotation from the Austin Hospital. It also took 12 University of Melbourne medical students on six-week rotations from the Austin for general medical and surgical experience. The University of Melbourne had a School of Rural Health based in Shepparton and Wangaratta. So a Monash link for Bendigo was seen by some as somewhat anomalous, given its comprehensive academic footprint in Gippsland. Monash became involved at Bendigo Health primarily due to a shared vision between Professor Nick Saunders, dean of medicine at Monash, and Kathy Byrne, CEO of Bendigo Health. I had the impression that the University of Melbourne students from the Austin did not value the rural experience.

My task at Bendigo was to identify, coordinate and plan the financial and skill resources, and to provide leadership to prepare for the construction of physical facilities in the new calendar year, in readiness for the following year’s medical students.

The first steps were to understand the new five-year curriculum being developed at Monash in Clayton and how the School of Rural Health was intending to expand from its base around Professor Roger Strasser at Traralgon. I also had to understand the new concepts of dispersed medical education. The consultant staff at Bendigo Health were ambivalent about teaching medical students. Some consultants saw the medical school as an opportunity to enhance their own enjoyment of medicine; others saw it as a recruitment base for residents and registrars; and yet others thought it would be a drain on an already busy life. The hospital was also concerned about the potential inefficiencies and distractions that teaching students might entail. Dr Chris Holmes, Dr John Togno and I met with Professor Paul Worley of the Riverland program and Professor Sandy Reid of the Wagga Wagga pilot scheme to understand dispersed medical education in a general practice setting. Professor Chris Browne at Monash was already working with John Togno and Janice Chesters to ensure that rural issues were embedded in the new curriculum. Adding further to the complexity, the structures that had evolved around Roger Strasser were subsequently complicated by his departure for Canada.

The most pressing problem was to find accommodation for the expected 70-odd students as well as the professional and academic staff. Our initial home was a vacant shop shared with Sandra Barrie (administration), Graham Allardice (manager) and Andrew Moon (information technology). Following initial suggestions by John Togno, the building that had formerly been the Northern District School of Nursing (and, more recently, the regional office of the Victorian Department of Health) was purchased. However, when negotiations eventually matured, the timeline was very tight. The excellent facilities on Rowan St became Monash property for about $1 million but needed significant renovation to make them useable and comfortable. The site was large enough to become a hub for medical organisations in Bendigo (including the regional GP training network as well as our own research and academic staff) for many years. However, it was physically just over a kilometre from the hospital – a chronic problem for students after a heavy night! Land was purchased between the acute and chronic care campuses of Bendigo Health in Mercy Street, and a lecture theatre, library and tutorial rooms were constructed on this site. These buildings and their recent expansion have provided a major contribution towards the sustainability of health professionals in the Loddon Mallee region.

In June 2002, I was appointed as professor/director of the Bendigo Regional Clinical School. I reported to Monash for academic issues and to Bendigo Health for clinical issues. On any one day I might be in the role of registrar in the emergency department, staff specialist on the wards or laboratory, or professor in the Monash role. Our first Monash students were expected in February 2004 for Year 3 experience in a general hospital. Meanwhile, the University of Melbourne had changed its course; its clinical year started in June, with the first of six problem-based learning style clinical rotations. These were designed for large teaching hospitals, but allowed a way to spread the Monash and University of Melbourne students through the hospital without having both groups of students in one place at the same time. The University of Melbourne blocks that overlapped with Monash units were:

  • endocrine, renal, urology and vascular surgery

  • cardiorespiratory medicine and surgery, and general medicine

  • neurosciences, ophthalmology, and ear, nose and throat

  • haematology, oncology and infectious diseases

  • emergency medicine, perioperative care, orthopaedics and rheumatology

  • gastrointestinal medicine and surgery, and general surgery.

Pathophysiology, radiology, professional development, legal medicine and evidence-based medicine were separate, parallel programs for each university and were taught continuously through the year. This meant that we could accommodate the two universities and their student rotations without overloading any one ward. However, the tutors had to keep changing between the problem-based learning set for each university, which were of rather different styles. The students were also different: University of Melbourne students focused on facts and exams, whereas Monash students wanted to explore ideas and were not too fussed about not knowing a detail which could be looked up.

In 2002 and 2003, Monash was still finalising its Year 3 problem-based learning sets and structures. In fact, one of the first curricular plans was totally unworkable. Essentially, a six-year course of three pre-clinical and three clinical years had been compressed to two and a half years of each, so that in Year 3 all Monash students would be on the wards for the second half of the year and none in the first half of the year. The dean, Professor Steve Wesslingh, and I came up with a modification that was eventually adopted so that students spent the whole of their third year in a clinical setting. However, Monash had planned to deal with head and neck anatomy and with pharmacology in the first half of Year 3, so the first few batches of students needed remediation in those areas to bring them up to speed. The disaffection of the Monash pharmacology department and the dispersed delivery of teaching meant that we waited a long time for adequate pharmacology resources.

The 36 University of Melbourne problem-based learning sets and another 36 tutorials could be fairly neatly categorised around each of the six blocks mentioned previously. However, Monash had 30 clinically-based and 33 problem-based cases to discuss which did not neatly fit into the six categories. The disease conditions broadly coincided. In addition, it was impossible to make the clinically-based cases real because of the unpredictability of patient availability for a particular condition on a particular week. Bendigo staff contributed to and strongly shaped the Monash problem-based learning curriculum as well as pushing continuously for access to good pathology tutorials to support the Bendigo pathologists. Radiology tutorials were always excellent and we recruited various outside teachers to help with pharmacology and anatomy. We were well supported in law, professional development and evidence-based medicine. We were able to appoint Professor Peter Disler in geriatrics, and Associate Professor Beth Penington in surgery, to senior academic appointments at Bendigo Health, to the benefit of both organisations.

The transition went smoothly and students were enthusiastic about their Bendigo experience in 2004 and 2005. In fact the reputation of rural training exceeded our capacity to handle the applications. The Bendigo community advisory committee was an enthusiastic supporter of the school, providing simulated patients, a grand mayoral reception for students and invitations to dinner. The students responded by joining local clubs and activities. They did well in their exams, and the academic and professional staff were justifiably proud of their achievement. The hospital had been concerned that the inefficiencies introduced by teaching students were not built into its base funding, and it mounted an argument that this issue should be recognised financially by the government. In due course, an increment was built into funding to match the grants received by the large metropolitan teaching hospitals.

Plans were finalised for the 2005 Year 4 rural students to gain their experience in children’s health, women’s health, psychiatry and general practice. Bendigo is excellently staffed in children’s health and women’s health and there was enthusiastic support to take students. Professor Fiona Judd and her department provided excellent psychiatry teaching, despite being somewhat understaffed. General practices in Castlemaine, Bendigo and Kerang provided wonderful hands-on experiences for our students, and that group has subsequently been expanded and supported by a much more sophisticated IT network than when we started.

In 2004, Professor Geoff Solarsh arrived to take over the head of school role which Professor John Humphreys and I had carried since the departure of Professor Elaine Duffy. At this stage there were, including myself, five professors at Bendigo: Geoff Solarsh, John Humphreys, Peter Disler and Fiona Judd, and Beth Penington as an associate professor. All teaching staff had appointments as lecturers or senior lecturers and Chris Holmes has subsequently been appointed as clinical associate professor.

Gordon Whyte teaching students cardiopulmonary resuscitation.
Gordon Whyte provides clinical training to Bendigo-based students in 2005.

In 2006 a new tranche of funds had been made available and Monash had successfully bid for the graduate entry Gippsland Medical School and the Northern Victoria Regional Medical Education Network (NVRMEN) coalition with the University of Melbourne across northern Victoria. With Malaysia clinical teaching coming on line as well, Monash was suddenly faced with a quantum leap in management complexity for its clinical years. For students to be placed in the Monash regional clinical schools they had to commit, at the time of their enrolment, to the NVRMEN model or as graduates to Gippsland Medical School. This also meant that metropolitan students could not access rural teaching or subsequent recruitment into rural postgraduate positions. Boundary issues between Gippsland Medical School and School of Rural Health sites in Gippsland became acute. Under these environmental changes, the school began to fragment and lose its momentum and sense of common purpose. With the head of school based in Bendigo, the Gippsland-based clinical schools felt abandoned. Mildura Regional Clinical School also felt dominated by decisions being taken in Bendigo. Finally, the University of Melbourne was also changing to a new model of medical education and was placing great importance on the intellectual property of its clinical curriculum and control of its students, making life difficult between the NVRMEN partners.

The response of the dean, Professor Steve Wesselingh, and Geoff Solarsh was to ask me to take over as interim head of school, effective from January 2008. The position was subsequently converted into head of school from mid-2009, allowing Geoff to focus on NVRMEN. The combination of my central role in the curricular aspects of medical education and my role as head of school, allowed the School of Rural Health to continue to place its stamp on the curriculum. The other outcome was to identify and address IT connectivity issues which, in the end, also required a central Monash restructure to give proper leadership across the University. I saw my two and a half years as mostly interim head of school as a difficult change-management program. The development of relationships between Gippsland Medical School and the Gippsland and East Gippsland Regional Clinical Schools required careful nurturing. The Monash University Department of Rural and Indigenous Health continued to evolve as it struggled to establish itself. This evolution also required continued support and direction from the head of school during this time. I was proud of the School of Rural Health I passed to Professor Judi Walker when she took over as head of school at the end of 2010.

This has been a wonderful journey for the Monash School of Rural Health and for myself at Bendigo, in Sharjah, and as head of school with a central role in curriculum. The school has been instrumental in substantially increasing the intellectual and social capital of health services in rural Victoria. Interns and registrars want to return to rural and regional settings thus reflecting the changed perceptions of rural health as the place to be. Nick Saunders’s riding instructions when we set out on this journey were ‘to build so that Bendigo Health could not conceive of itself without Monash University’. I think we have achieved an excellent foundation for that outcome. We have built a unique rural clinical school; it is the most complex and complete in Australia, now poised to lead the world in rural health education and research.

Returning to rural

Dr Ryan Spencer

I came to university from the country and intended to return there. Imagine my delight on discovering a whole university department largely dedicated to ensuring that I did so. The Monash University School of Rural Health and its student-run rural health club, Wildfire, became a home away from home for me during the early years of university. Although Monash’s Clayton campus had once been surrounded by paddocks, it is now well and truly part of the concrete jungle that is Melbourne’s urban sprawl. I was soon spending as much time at the School of Rural Health’s new Clayton office, complete with Wildfire office and the ever-bubbly Teresa Neale, as I was in Monash’s lecture theatres.

Towards the end of our first year I was surprised but delighted to be elected the new Wildfire president, from which began my connection with the School of Rural Health. Among the obligatory barbecues and ice-cream days, I was also invited to help organise the rural placements for Monash’s ‘new’ medical curriculum. Dr John Togno was keen to get a student’s perspective and thus regularly sought advice from me and other Wildfire committee members, often through informal chats in the Wildfire office.

Such ‘stakeholder consultation’ is rarely done well but John’s openness to our concerns and suggestions – and lots of work by many in the school – led to such a successful roll-out the following year that the school was required to introduce a selection process due to the rural placements’ overwhelming popularity.

Our year in Bendigo was a fantastic experience, both clinically and socially. On the clinical side we were enthusiastically taught by both local doctors and patients. One particularly memorable experience involved a fellow Year 3 student being taught how to examine the respiratory system by the patient he was supposed to be examining! ‘Oh dear,’ she said as he began the examination by listening to the lungs with his stethoscope, ‘they usually start with the hands.’ Being a smaller hospital it seemed that almost all the clinical staff were involved in teaching us in some way.

Space was at a premium and ‘tute’ groups were small, meaning that there was nowhere to hide from tricky questions from senior medical staff. Nowhere was this more evident than in the legendary tutes with the local ophthalmologist. Another major advantage of the Bendigo placement was the travel time to Friday morning problem-based learning tutes. No urban clinical student could wake up at 7:55 am, walk down a flight of stairs in pyjamas and moccasins and be early for their tute on the ground floor.

While having the student accommodation and tute rooms on separate floors of the recently renovated Lister House was great for the morning commute, it meant the staff offices were also on the ground floor. Thankfully, apart from an issue with the heating – which led to the top floor being a balmy 28 degrees most of the year – this never caused any trouble. Instead it fostered a better relationship between students and staff, and led to many combined social events throughout the year. Many other social events occurred without staff as they were unable to keep up with the hectic social calendar – described by some of them as one year-long party! Nonetheless, everyone passed – and most with improved marks compared with previous years – and thus it was time to move on.

In 2005 the small group I had met at Wildfire moved to far-east Gippsland for another clinical year in the country. Again, engaging clinical experiences and dedicated School of Rural Health staff marked the year, this time in the picturesque setting of Lakes Entrance. As we were out of the reach of – and largely forgotten by – the University bureaucracy back at Clayton, we got on with learning medicine. The system must have worked as the end of the year saw good exam results for all and signalled the end of my association with the school as a student. It was time to spend some time in the city.

Like any organisation, the School of Rural Health is only as good as its staff. It has been an amazing experience to be educated and guided by and, more recently, to collaborate with such a dedicated group of people.

The School of Rural Health’s first 20 years of success, like all successes, has been built on personal relationships, both between staff members and between staff and students. The challenge for the future is maintaining these relationships among an incredible increase in student – and therefore staff – numbers. Making students feel more than a number was once a major strength of the rural clinical schools. Maintaining this point of difference from the urban clinical schools will be significantly challenging, with the shine of the new program gone and overwhelming numbers of students entering the school’s various clinical programs. Future research success relies similarly on fostering relationships and supporting collaborations across the wide geographical and interprofessional landscape of the school. The issues around rural health have changed over the last 20 years, but the importance of the school’s role in both education and research is stronger than ever. It will be fascinating to see what the next 20 years bring.

Not for the faint-hearted

John Clark

For a country high school student, entry to medicine was a daunting idea. The numbers of students applying, scores required for entry, and expectations were ominous. A new program called the Extended Rural Cohort had just begun for medical students, offering greater length of clinical training in regional and rural Victoria. Joining the Extended Rural Cohort was not for the faint-hearted, with a two-and-a-half-year commitment to stay in the country, but it had an adventure-like appeal. Growing up in rural Victoria, I knew that, yes, there was still electricity and running water outside Melbourne and that I did not have to hunt for my dinner! However, a number of surprises and learning experiences were in store.

Being part of a medical team in a rural hospital forced us to step up both our professional and clinical skills from day one. We went from a group of 300 students in Melbourne, to just 12 in Mildura. Not only did we stand out when we first arrived, with our fresh faces and sometimes disorientated air in the hospital; we also stood out even more if we were not on time for early-morning ward rounds. It was not long, though, before we were adopted by the staff, and the ladies in the cafeteria were giving us an excessive number of chocolate freckles to have with our morning coffee! We also found ourselves writing up the notes, ordering investigations and admitting patients to the hospital in a very short space of time.

The staff got to know our skills and capabilities which was an amazing advantage, considering that many of our city peers needed to re-introduce themselves to a new team every week. Our advantage began in Year 3 with writing medical notes and inserting cannulas, and built up to Year 4 when doctors were confident enough in us to sign off on the more complex management plans we had written. During our placements in the country we spent time in a variety of health services and groups. On numerous occasions I would coincidentally refer a general practice patient to myself as the ‘apprentice paediatric resident’ and see them later at the hospital clinic. Similarly, women I would see for final antenatal checks in general practice would before long be breathing through contractions in the labour ward, and we would be delivering the baby with an experienced assistant. This continuity was unique to our rural experience.

Even closer was our relationship with the clinical school staff. In Mildura, the whole clinical school team would partake in The Age superquiz. We would be stocked up with farm produce, courtesy of Kate, the lovely student administrator, who even gave private golf lessons on request. Being 600 km from Melbourne, we immersed ourselves in town life, joining the gym and netball team, working at the pool, playing in the orchestra and attending opening nights of exhibitions at Art Vault – a gallery run by a local surgeon’s wife. We also found our own fun, hosting our own first birthday party, Halloween and a progressive formal dinner through our homes in the town. Phenomenally, almost every student maintained some kind of student leadership role despite being so far from the rest of the student body in Clayton.

The chance to build relationships with patients in rural communities was challenging and rewarding. In a general practice in Woodend, we performed our own consultations, checking our plans off with the supervising doctors at the end. In one of these consultations I met a teenage girl who came in with her mother; the daughter wanted to begin taking the oral contraceptive pill. Using the skills we had learnt through our women’s health study, I completed a history and examination and recommended a pill based on the needs of the patient. I then gave a summary of this to the GP, who was happy with my reasoning. Everything about the visit appeared to be routine, which was why I was surprised when our receptionist pulled me aside that afternoon to ask what had happened with the patient. I was initially worried that I had done something wrong and that a complaint had been made, but my fears were soon dismissed. The family wanted my name so that they could come back for appointments in the future. The receptionist then explained that before going into the room, the girl’s mother had been upset that they had to see a medical student – despite the consent process in place – yet I had completely changed their attitude in the 30 minutes I had spent with them. I do not believe I am an exceptional student, but rather that instances such as this are possible due to the immersion experience of the rural clinical schools.

We learnt how living in these communities had an impact on the medical services that could be provided, and we discovered the reasons patients present to health services. This also had an impact on the types of medical problems that emerged; for instance, cellulitis – a bacterial skin infection – was highly prevalent in visiting fruit pickers in Mildura; they worked with bare legs and feet, would get scratches, and then go swimming in the Murray River. Knowing when, why and how patients present to their GP or to hospital is a valuable skill to have as a doctor; this was something we were able to quickly discover in the rural clinical schools.

Even now in Melbourne, the rural clinical school experience is still having an impact on our learning and understanding of medical practice. I am currently completing a medical science honours year with the intensive care unit at the Royal Children’s Hospital. Our team runs the Paediatric Emergency Transfer Service (PETS), bringing the sickest children in Victoria to hospital. I have now been at both the sending and receiving ends of this service and, more often than not, know the referring doctor and the services and skills available in the town from which the child is referred. Being given a state-wide context for health care delivery has been an incredible experience and one that I believe will make our new medical graduates outstanding in their field.

Welcoming patients

Elyssia Bourke

In my five years as a student with the School of Rural Health, I have spent many hours on placement at sites all around Victoria, as well as being involved with the student rural health club, Wildfire. This connection has been one of the most important and rewarding throughout my time as a medical student.

I am an Extended Rural Cohort student hailing from Cardigan, near Ballarat. I spent two years in Clayton, completed my Year 3 placement in Mildura, and in Year 4 I completed six months of general practice in Gisborne and six months of specialty placements in Bendigo.

For me, the most rewarding part of undertaking my medical placements in these regional and rural areas has been the patients. It may be a generalisation, but patients in these regional and rural areas are really welcoming. Every single patient I encountered opened up not only their medical history to me, but also their personal history.

From pregnant mothers to men with testicular lumps, to people with drug addiction problems, patients knew that I was a training doctor and were more than willing to let me in on their consultations and their lives. Some of the personal details that people shared with me during those times had not even been shared with their close friends and family, and some had not shared this information with anyone. To have that level of trust placed in me was a very humbling experience. I learnt so much thanks to those amazing people – even though many of them probably did not realise it. I hope in the future I can give back to them some of what they gave to me.

The second thing that I have noticed in rural clinical sites is the incredible selflessness of the clinical school staff. I do not know what I would have done without Jenny Timmis and Kate Murdoch in Mildura when things went wrong, or when I needed a mum away from home! Likewise, having a cup of tea with Carole Meade in Woodend was often the highlight of our academic week and a great chance to get much-needed advice and de-stress.

One of the greatest experiences that I had during my time as a medical student on placement was my mentor week with Dr Cullen, local obstetrician and gynaecologist in Bendigo. The mentor week consisted of shadowing my allocated doctor. Wherever he went, I went – even if this was to a birth at 2 am! This meant doing everything from assisting with caesareans at the private hospital in Bendigo to watching IVF, to sitting in with gynaecological consults in Echuca. This was an amazing experience and has seriously made me consider obstetrics and gynaecology as a potential career path – something I never thought I would do!

Another memorable experience was the time that I spent in general practice and the amount of autonomy I was given as a student during that placement. Being able to see patients independently, organise scripts and pathology slips for the doctor to sign, and counsel patients regarding results they had received was really rewarding. I felt like I was actually a practising doctor! I always looked forward to my days in general practice – even when it was in Rochester, an hour’s drive from Bendigo, because I knew that those days were going to be interesting and that I would always have to use my clinical reasoning skills. In other rotations that is usually done by the senior doctors.

The teaching culture at the regional clinical schools is remarkable. Clinical school staff and hospital staff are all available and willing to teach students everything and anything. The number of hours spent in tutorials – both scheduled and impromptu – was extensive. The smaller class sizes were most helpful, especially because all the students knew each other so well that the phrase ‘no such thing as a dumb question’ really rang true. Everyone supported one another and this created a great environment for learning. I also have to commend the dedication of the teaching staff at the sites where I was based – they were awesome, especially when tutes were conducted at 4–7 pm over their dinner time and arguably during some of the best TV viewing.

Without a doubt I will look back on these years as some of the best experiences of my life. The people I have met, the things I have learnt and the amazing friendships I have made have been incredible. The School of Rural Health is arguably the greatest addition to the medical faculty. People do not realise how good the clinical experiences are in these areas until they have done the course themselves. I owe a lot to the School of Rural Health – so thank you, and happy twentieth anniversary!

Togno, John, Campbell, David, Whyte, Gordon, Spencer, Ryan, Clark, John, and Bourke, Elyssia. 2012. ‘Rural medical training: Applying the curriculum in a rural environment’, in From a Broom Cupboard: 20 Years of Rural Health at Monash University, edited by Robert Clough. Melbourne: Monash University Publishing. Pp. 49–71.

From a broom cupboard: 20 years of rural health at Monash University

   by Robert Clough, editor