The RRHiME track has been formally evaluated since its introduction in 2011, and although evaluation instruments have been modified over the years, a core set of questions has continued to be asked of the students. To date, four surveys have been carried out at the end of academic sessions 2012/13, 2013/14, 2014/15 and 2015/16. Each survey invites all students on the Track at that time, from across all four years of the GEM course, to respond. Responses are anonymous as student numbers are small, quotes are therefore identified by survey year rather than individuals.
The surveys and responses are clustered under five themes:
Reasons for joining RRHiME
The main reasons for applying for the RRHiME track can be summed up by this respondent: “to gain more experience in practising medicine in rural locations. To gain a better understanding the unique challenges faced by those providing healthcare in such settings and the innovative strategies used to overcome them” (2012/13 survey). Many identified that they had a keen interest in practising in rural health once qualified and wanted to gain more experience of rural Wales and work in local communities to make a more informed career choice.
About RRHiME: what went well, what could be changed or added and what could be improved?
The RRHiME track has grown and developed since its 2010 launch, and student feedback on the Track from all cohorts is overwhelmingly positive. The way in which the curricular components are designed works very well, enabling students to have a lot of choice in placement location and projects. In response to student feedback, the co-curricular components have evolved into a much more structured experience with formally scheduled meetings which have time for student engagement activities and discussions around RRHiME and more variety of guest speakers with experience in a RRHiME related topic. Students particularly value the way in which RRHiME is networked with other student-led societies and activities and hearing from ‘speakers with a portfolio career and the variety of options open to careers in rural/remote medicine rather than the usual ‘run of the mill’ training in hospitals’ (2016/17 survey). Students very much value the visits to different types of service such as Air Ambulance or Mountain rescue, however these are not always easy to organise as students are dispersed around Wales. Students can have individual placements with such services however.
The online RRHiME portfolio, introduced in 2015, has encouraged students to stay engaged with RRHiME in between meetings, not merely as a box-ticking administrative exercise, but an interactive way to inspire and motivate their interest and development as rural medics, and clearly outline what is expected of them as RRHiMErs, as students felt this was unclear in the early years of the Track.
Examples of experiences and activities: clinical placements, projects and assessments
Students fully engaged with a range of clinical placements in primary, community and hospital settings and clearly valued the effort made to place them in such varied rural and remote contexts. As well as working in family medicine practices and small general hospitals, they had opportunities to engage in integrated and varied community based and regional services, such as outreach (peripatetic) clinics, homecare, pre-hospital care, small cottage hospitals, nurse and midwife led services, and mountain rescue.
Students were also able to apply a RRHiME lens to formal continuous assessments. Examples included giving an oral or poster presentation or undertaking a literature review on an area that interest has been stimulated on through RRHiME (e.g. on frostbite or Ebola). The longer case studies (Year 1 Family case study; Year 2 Living with a diagnosis and Year 3/4 Developing professional practice) gave rich opportunities for students to gain an in-depth understanding of what life is like for patients and families living in rural communities. Some students struggled with identifying topics and obtaining specific RRHiME supervision and this has been strengthened over the last few years.
Insights gained about rural and remote health
The RRHiME students more clearly recognise the distinction between urban and rural healthcare needs and delivery. Integral to the RRHiME track is learning that healthcare needs and delivery of services vary greatly according to, and as a consequence of, the population demographics and geography of the area. “As I am from a rural background myself, I have an interest in how delivery of healthcare differs in rural and remote settings. Learning about how we can adapt our practice to do this is a great opportunity” (2012/13 survey).
Direct exposure to and experience of rural clinical practice also increases awareness of the challenges and barriers of both being a patient and of healthcare delivery in rural areas. Due to the challenging environments of rural settings, many obstacles need to be overcome in order to try to obtain a degree of consistency and quality of care. Direct insight into the potential challenges faced in rural healthcare has altered and enhanced students’ perspectives with regard to adaptation and innovation of healthcare delivery based on availability of resources. For example, “on the community based placement, I got to accompany the District Nurse to patients that live too far from the practice. This has allowed me to understand the logistical implications of trying to match staff availability with patient need in remote areas” (2013/14 survey). Another example is “I have learned about the risks posed to women giving birth in rural communities and the support and training given to midwives … I have also learned more about accidents and injuries in rural communities and how these are dealt with” (2013/14 survey).
Without direct experience in rural settings, the RHHiME students would also not have gained such appreciation of the struggles some patients face in travelling and managing their home lives when secondary and tertiary centres are such long distances from one another (e.g. a mother with twin neonates who had to be cared for in different centres) and of the impact of “social isolation for elderly patients” (2014/15 survey). Transport difficulties were mentioned by many as a key issue for patients, particularly for an ageing population.
Overall, students gained great appreciation of the difficulties in recruitment and retention, of the need to use resources more efficiently, and how to treat patients who might not have access to centralised, specialist services, investigations or treatment. It is clear that these students are starting to think differently about pathways of care, integration between health and social care, referral and the role of technologies such as telemedicine and point of care services. Many mentioned that their experiences had given them a new perspective on the role of specialist nurses, GP led services, community hospitals and the way in which healthcare is integrated into the local community. They also demonstrate insight into how to obtain a balance between centralised and devolved, community based services: a big issue in Wales.
From a Welsh language perspective, the RHHiME track raises students’ awareness of the importance of being able to communicate with patients and staff in their preferred language and stimulated many to learn more Welsh.
Influences of RRHiME on career choice and locality
Direct exposure to and experience of rural clinical practice has a positive effect on potential careers in rural locations (Laven and Wilkinson, 2003, Barrett, Lipsky and Lutfiyya, 2011, Sen Gupta et al., 2014). The RRHiME experience aims to prepare and equip our medical students for clinical practice in many different environments, both in Wales and world-wide. For example, one student commented: “I intend to return to my native country, the Virgin Islands, to practice and the experiences that I can gain from the RRHiME track will allow me to perform better in my country” (2012/13 survey). Some students learned that there can be a better life balance working in rural communities and to gain appreciation of the opportunities provided for sports and other recreational pursuits when living and working out of a city.
In each of the surveys, students were asked about the likelihood that they would practice (a) in a rural setting and (b) in Wales. Whilst some (predominantly from the early years of the GEM course) said they were unsure and/or that it was too early to decide, the vast majority of respondents stated that they did intend to practice in a rural setting and that the RRHiME track (specifically the inspiring speakers and the range of clinical experiences) had positively influenced this intention. Regarding intention to practice in Wales, the main impact of the Track is that it reveals the range of interesting and varied opportunities available, about which students had not been aware before, for example “Wales is such a diverse place to study and work and has so much more to offer than I had previously realised” (2014/15 survey).