A model for research supervision in rural and remote areas

A model for research supervision in rural and remote areas

What was the main aim of this project? 

MD students of the Sydney Medical Program (SMP) undertake a 14-week research block to develop an understanding of the principles and requirements of medical research and thereby facilitate their practice of evidence-based medicine. Students on extended placements in Dubbo, Orange and Broken Hill in western and far western New South Wales (NSW) are offered rural research projects with local supervision.

This MD Project block reflects the vision of the SMP: “To develop compassionate, diverse, and innovative lifelong learners, who work in partnership with individuals and communities to improve health through clinical care, education and research”. It also enables students at graduation to meet the Australian Medical Council’s Graduate outcomes (Table 1).

Table 1: Australian Medical Council’s Graduate outcomes (Domain 1 – Science and Scholarship)Source: Standards for Assessment and Accreditation of Primary Medical Programs by the Australian Medical Council 2012. 

For rural students, this research experience fosters meaningful connections to local communities, clinicians and services, and a deeper understanding of health care delivery in a rural context. Advantages also accrue to rural communities and health services through the projects: by undertaking a rural MD Project, students provide a much-needed boost to rural research outputs and support for evidence-based rural health care.

Learning outcomes

By the end of the MD Project block students can conduct a health research project from conception to completion (Table 2).

Table 2: Learning Objectives of the University of Sydney SMP MD Research Block

The MD Project is a compulsory part of the MD 2022 curriculum and an important element of the vertical theme of Research, Evidence and Informatics, which runs throughout the four-year graduate MD program. Research methods are introduced in Year 2 of the program and refreshed in Year 3. The Programmatic assessment strategy used requires students to meet standards in the 14-week MD Project to be eligible to progress to Year 4.

The MD program is based on the “pedagogical framework of active, experiential, project-based learning”[1]  applied here in a rural context.  Each rural research project is supervised by rural academic staff and rural clinical topic experts. Learning is scaffolded to the individual interests of the student. Having topic experts who are practicing clinicians, health service workers or community members helps students to see their project in the context of the community and health service.

How was the project implemented?

A subset of University of Sydney students live and study in rural and remote NSW whilst undertaking their medical degree. Extended rural placement students undertake one or two year-long placements; students in the new Dubbo Medical Stream of the SMP are permanently located in Dubbo for the four years of their degree. The School of Rural Health (SRH) and University Department of Rural Health (UDRH) provide supervision for these students.

While overall leadership of the MD Project block is provided by the SMP, the rural team is supported by a local academic coordinator. In 2022, 25 Year-3 MD students worked across 19 different projects in Dubbo, Orange and Broken Hill, supervised by nine academics and 18 local clinical topic experts. This was possible as a result of the long-term relationships built between SRH/UDRH academics and Aboriginal communities and services, Local Health District clinicians and Health Intelligence Unit staff.

The number of students will increase in 2024 as students in the University of Sydney Dubbo Medical Stream Year 3 cohort join the extended placement students to do their MD Project.

Students in rural sites choose projects from a list presented to them six months prior to the MD Project block. In 2022, 18 (72%) received their first preference and the remainder received their second preference. A broad range of topics were offered (cancer, cardiovascular disease, diabetes, pregnancy, virtual healthcare, public health, gout, falls, emergency medicine, psychiatry, mental health, drug and alcohol, paediatrics), with a range of priority populations (Indigenous, rural, adolescent) (Table 3).

Table 3: Examples of rural and clinically relevant research projects completed in 2022

Several types of research report are acceptable (Table 4 shows report types submitted in 2022).

Table 4: Type of MD Project report submitted for assessment in 2022

Students worked with their rural academic supervisor and clinical topic experts (and often community members) to understand issues in the field of study in a rural context and scope the appropriate literature. Establishing a rationale for their project, they formulated a research question and considered relevant, feasible research methods to answer the question. The ethical issues regarding the proposed project in a rural area were carefully considered as rural populations are more likely to include Aboriginal people and those who can be easily identified. Students completed a literature review to find, appraise and integrate existing knowledge relevant to their research question. They collected and analysed data and presented their findings to an audience which included their team, peers, academics and clinicians. Finally, they prepared a 3,000-word scientific report.  

Achievement of learning objectives was assessed at key milestones as the students progressed through the block, to support completion of their projects. The final reports were marked by University of Sydney academics or affiliates, with no conflict of interests, using a standard rubric. Dissemination of research can follow through the direct incorporation of the findings into local practice, policy briefs, the submission of abstracts to local and national conferences, and the drafting of manuscripts for journal publication.

HREC processes were determined by the nature of the project: projects such as systematic or narrative literature reviews, or those using publicly available data, did not require HREC review; students were added to ongoing HREC-approved projects by a modification in some cases. Alternatively, low/negligible risk research was undertaken, such as interrogating existing databases. All HREC processes were finalised prior to the commencement of student involvement and local supervisory teams were supported by the rural clinical schools’ research governance officer to ensure these were in place.

How has the impact of this program been evaluated?

Student reflection

Students commenced the block with varying levels of prior research experience, ranging from no experience to holding a higher degree by research (Table 5).

Table 5: Prior research experience of MD Project students in 2022

Students were asked to undertake a self-assessment of their research experience using the Research Spider [2] on commencement and completion of the MD Project. This tool asks respondents to score their level of experience in ten aspects of the research process on a scale from 1, no experience, to 5, very experienced, and plots responses on a diagram that resembles a spider’s web. In a post-research experience survey, they were asked the three most important things learnt from doing the MD Project and what advice they would give to incoming students. Responses were received from 24 of the 25 students.

Prior to the MD Project, Research Spider group mean scores ranged from 1.4 (Applying for research funding) to 3.2 (Finding relevant literature). After completion of the MD Project the scores ranged from 1.3 (Applying for research funding) to 3.9 (Finding relevant literature) (n=15). The biggest changes in group mean scores were on the dimensions of Writing and presenting a research report (increase 2.7 to 3.7), Critical review of the literature (2.9 to 3.9), Analysing and interpreting results (2.8 to 3.6) (Figure 1).

Figure 1: University of Sydney School of Rural Health and University Department of Rural Health MD student self-assessment of research experience prior to commencement and on completion of the MD Project block 2022

Schmidt et al[3] published Research Spider scores of a group of experienced rural clinicians, but novice researchers, who undertook a workplace-based research training program known as the Rural Research Capacity Building Program (RRCBP)[4]. Post program Research Spider scores for the MD Project students and RRCBP participants were similar, with a maximum difference of +/- 0.5 for all dimensions except applying for research funding, where RRCBP candidates had more experience. The post-program Research Spider data are limited (n=10 or 40% missing), but nevertheless show that the MD Project block prepares rurally based medical students to a level of research experience like that reported by rurally-based clinician researchers.

Students described research-related skills they had learnt during the MD Project, such as generating hypotheses and presenting an argument in a research paper. Students also described ‘soft’ skills, such as the importance of being consistent and time management, as the most important things learned during their MD Project.

Students were asked to share their advice for future students. These comments also refer to research-related skills and transferrable ‘soft’ skills (Figures 2, 3 & 4).

Figure 2: Student S5 shares advice to future MD Project students

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Figure 3: Student S6 shares advice to future MD Project students

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Figure 4: Student S23 shares advice to future MD Project students

Staff reflection

The rural supervisors and rural clinical topic experts were invited to reflect on how the block prepares students to be clinician researchers. All nine supervisors and two of 18 topic experts responded, identifying curriculum, local and general strengths of the MD Project.

The structured nature of the placement with dedicated time for the MD Project, existing projects and focused tasks with clear criteria were strengths that reflected the curriculum’s influence.

Locally, there was a strength in having a team approach which included supervision from clinical topic experts and researchers for projects that were practical, and had local relevance and impact for improving health outcomes. Clinician content experts provided the students with role models of clinicians who collaborate to research and advance their practice.

Generally, the projects supported practical research skill development (collection, cleaning, analysis and presentation of data). The team approach required organisation and collaboration to provide local lectures and workshops that enhanced the centrally provided university lectures with local context. The two topic expert respondents noted the value of being included in the research projects and the support of the team approach with access to researcher skills. “Collaboration is the key in any research and this is one of the most important behaviours [the students] can learn.”

Although we did not ask, almost everyone shared challenges. This was a short intense block with milestone schedules that made completion or revision difficult. The short block also removed important engagement and skill development in project design and ethics processes, and favoured existing projects with pre-approvals. There were also practical challenges with data availability, student time management, student engagement with the projects and the research process.

The weekly meeting of the team of local supervisors was valued as a collegiate way to problem solve and benchmark. Supervisors recognised that they could improve their communication about student expectations to enhance preparedness and dedication of students undertaking their MD Project in a rural location. It was noted that the MD Project was a clear opportunity to help students understand research and its impact and embrace or at least support it in their future.

Conclusion

We present here a model of supervision for medical students undertaking a research block in rural locations. Rural clinical schools have fewer research academics than metropolitan schools and our unique supervisory teams, comprising rural researchers and rural clinical topic experts, have been successful. Students have learned both research skills and other transferable skills. Projects have resulted in practical and academic outputs, and have given students a deeper understanding of health care delivery in a rural context.

Acknowledgments

Artwork by David Schmidt of Battered Old Wreck Comics https://m.webtoons.com/en/challenge/battered-old-wreck-comics/list?title_no=83262&page=1

References

[1] Hart, J., Hakim, J., Kaur, R. et al. Research supervisors’ views of barriers and enablers for research projects undertaken by medical students; a mixed methods evaluation of a post-graduate medical degree research project program. BMC Med Educ 22, 370 (2022). https://doi.org/10.1186/s12909-022-03429-0

[2] Smith, H., et al., The ‘Research Spider’: a simple method of assessing research experience. Primary Health Care Research & Development, 2002. 3(3): p. 139-140.

[3] Schmidt, D., Webster, E., Duncanson, K. (2019). Building research experience: Impact of a novice researcher development program for rural health workers. Australian Journal of Rural Health, 27(5), 392-397.

[4] Webster, E., Thomas, M., Ong, N., Cutler, L. (2011). Rural research capacity building program: capacity building outcomes. Australian Journal of Primary Health, 17(1), 107-113.