Rural longitudinal integrated clerkships: lessons from two programs on different continents

Flinders University in Australia has had a rural longitudinal integrated clerkship for selected medical students, the Parallel Rural Community Curriculum, since 1997. The Northern Ontario School of Medicine (NOSM) in Canada introduced a similar clerkship for all NOSM students in 2007. An external evaluation of both programs was conducted in 2006 and 2008, respectively. The aim of this article was to analyse the similarities in and differences between these two rural programs and determine key factors that could inform others interested in creating similar programs.

The evaluation took the form of a cross-sectional descriptive study conducted in each school using focus group and individual interviews, involving students, faculty, preceptors, health service managers and community representatives. Interviews were analysed for emerging themes based on a grounded theory approach, and common themes were tabulated and validated. The themes for the two sites were compared and contrasted to assess similarities and differences.

Individual interviews were conducted with 87 people at Flinders and 39 at NOSM; focus groups included 45 students at Flinders and 7 at NOSM. All participants felt that the programs produce confident and skilled students. The educational value of the programs was expressed in terms of continuity of care, longitudinal exposure, development of relationships, mentoring, team work, and participatory learning. Common concerns related to issues of standardisation, ensuring exposure to all specialist disciplines, communication, support for students and preceptors, isolation, dealing with personal issues, and the process of site selection.

The rural longitudinal integrated clerkship approach to teaching the core clinical components of the undergraduate medical curriculum has a positive impact on both students and clinicians, as demonstrated in two different sites on two continents. Five key factors emerged that may inform development of similar programs in other institutions: (1) invest in careful site selection matching local epidemiology with curricular goals; (2) create collegiate faculty development that facilitates peer to peer relationships between rural and urban faculty; (3) integrate IT systems with the health system to create hardware synergies; (4) manage student expectations regarding isolation and expected site differences; and (5) build strong local postgraduate training that reinforces the values and workforce benefits of the undergraduate program.