STRENGTHS AND LIMITATIONS OF THIS STUDY

This study repeated the same post-placement survey over 12 years, providing a consistent outcome measure.

It used a retrospective natural experiment design, providing strong evidence of the impact of replacing face-to-face rural immersion with online learning experiences.

Response rates to the survey were consistently high across all rotation cohorts.

Outcome measures were designed to be quick and easy to capture but were limited in the ability to further explore reasons associated with response.

External factors beyond the study’s natural allocation to groups were not controlled and, hence, may have influenced levels of intention to practice rurally.

Introduction

Immersion experiences are an essential component of medical education. By providing medical students the opportunity to engage and learn in real-world settings, these immersions can help develop the necessary clinical knowledge, skills and attitudes that are required to become proficient healthcare professionals within the context of local communities.1 Community-engaged medical education and learning encourages a student’s active participation within the communities they will practice in, while also meeting community needs.1 2 This is commonly undertaken in under-served and rural populations, who face unique and increased health and medical challenges.3 Medical students with immersion experiences in rural communities become better prepared to meet local patient needs and provide high-quality care to rural populations.4–6

Encouraging rural medical practice after graduation and retaining a rural medical workforce is strongly associated with students having a positive clinical and educational experience in similar rural settings where they can actively participate in community immersion opportunities (ie, immersive community-engaged education (ICEE)).7 8 Several studies have demonstrated that a student’s intention to practice rurally is strongly associated with having a positive rural immersion experience.9 10 The impact of rural medical ICEE is also dependant on the immersion length, with longitudinal rural experiences demonstrated to further increase student’s intention to practice in a rural location after graduation.10 11

The COVID-19 pandemic became a major catalyst for adapted solutions in medical education and necessitated a shift to blended or online-only learning solutions. These solutions have many benefits from both a teaching and learning perspective, and many have persisted as teaching approaches after the pandemic.12 Medical institutions traditionally dependent on a purely face-to-face mode of teaching were forced to restructure and dismantle traditional teaching for a more flexible and virtual approach.13–16 Using a combined face-to-face and online learning teaching approach frequently facilitated the continuation of student education during the pandemic despite facing restrictions, lockdowns and social isolation.17

Like other countries across the world, the COVID-19 pandemic in Australia caused significant disruption in the delivery of medical education.18 Notably, some students missed rural immersions, which were their only opportunity to experience a rural community and clinical setting within the course. A significant focus of research and evaluation with respect to the COVID epidemic was on urban or metropolitan-based medical schools and the impact of medical education delivery in these contexts during the pandemic.13 18 19 To the best of our knowledge, there have been limited investigations of the impact of COVID-19 on rural-based medical education and student immersion experiences.20 21 Furthermore, there is limited knowledge regarding online learning and its impact on student satisfaction and future rural practice intent.

The University of Queensland’s (UQ) Doctor of Medicine (MD) programme provides medical education experiences for most students in various small and usually isolated (<15 000 town population) rural communities across Queensland. All domestic medical students complete clinical placements in a smaller rural or remote community while undertaking comprehensive integrated learning from UQ’s Mayne Academy of Rural and Remote Medicine (RRM). The RRM term consists of a structured programme that includes a rural-based orientation week followed by a 6-week clinical immersion placement.

At the onset of the COVID-19 pandemic, like many other medical teaching institutions, the RRM programme rapidly implemented several changes to enable the continuation of its programme delivery. Moreover, during different time periods, based on the level of restrictions and impact of COVID-19, variations in modes of learning were implemented. This provided an opportunity to explore the impact of online learning versus rural immersion on student satisfaction and future rural practice intent. The direct impact of immersion on a student’s intention to practice rurally after graduation has not been able to be previously studied in such a discrete and controlled fashion within a rural environment.

While gaining knowledge and skills is important, understanding the environment and context is also critical to develop positive attitudes to practising in rural environments.22 23 There has been some evidence of the influence immersion that experiences have in allowing students to fully comprehend and become exposed to specific environmental, geographic and clinical contexts.24 25 The shift from face-to-face to online experiences during COVID-19 allowed us to isolate this effect from the learning experience and, more reliably than before, ascertain the contribution of this to future intent. This study aimed to explore the impact of the replacement of immersive learning with online learning on medical students’ levels of satisfaction and their intentions to practice in a rural area after graduation. This natural cross-sectional study based in rural Australia provides a unique understanding on the scope of blended online and in-person medical education learning in rural settings.

MethodsStudy design

We conducted a retrospective natural quasi-experimental cross-sectional study during 2011–2022 of each cohort of UQ’s third-year MD students who had completed their RRM placement. RRM course evaluation data were collected using an anonymous survey consisting of questions with Likert scales using ordinal-ratings. The main outcome measure was the self-assessed change in the students’ intention to pursue a rural medical career. The other key measure was their overall placement satisfaction level.

Participant characteristics and setting

RRM placements are conducted in small towns (most with less than 15 000 people) in rural (Modified Monash Model classification,26 MMM3-5) or remote (MMM6-7) locations. Students are allocated to hospitals or with general practitioners or a combination of both. All students participating in the RRM programme were invited to complete an online or paper-based survey at the end of their placement administered by UQ staff. The UQ Human Research Ethics Committee provided approval for the study (APP: 2022/HE000748). It was not appropriate or possible to involve patients or the public in the design, conduct, reporting or dissemination plans of this research.

Students undertake their RRM placements during one of the available blocks throughout the year. Every RRM placement block consists of two main parts:

An immersive face-to-face orientation week at the start of each semester prior to students going on placements. During this introductory week, medical students spend 1 week in one of four regional or up to six rural locations to become familiar with the rural culture and lifestyle and to learn skills in preparation for their rural placement. This orientation week provides students with onsite exposure to experience the skills that may be required or acquired during their RRM placements, for example, simulated emergency procedures, commonly used clinical skills, rural-specific conditions and working as a generalist.

A face-to-face placement for 6 weeks. Students are provided accommodation and clinical placement to live and learn within the local rural or remote clinical setting. Supervision of teaching and learning is provided by local medical practitioners, who also live and work within these communities.

As a result of the COVID-19 pandemic, changes to both the placement duration and mode of delivery for both the orientation and placements were implemented, often in response to government rule changes and at short notice. Table 1 describes the duration and mode of delivery for orientation and placements since 2011 until the beginning of 2023. A detailed description of all changes, restrictions and disruptions during the COVID-19 pandemic in this context and jurisdiction is described in online supplemental appendix 1. See online supplemental figures to demonstrate the consistency of survey results over time. Data displayed for 2011–2019 have been merged to best display changes in intention and satisfaction before COVID-19 restrictions (figure 1) and to compare these during and after these restrictions.

Figure 1

Changes in intention and satisfaction because of the Rural and Remote Medicine programme between 2011 and 2022, for every rotation.

Table 1

Overview of the RRM orientation and placement duration and mode of delivery between 2011 and 2023

Data analysis

An administrative survey to assess students’ intentions and overall programme satisfaction was initially created in 2011. Since then, the survey has undergone several revisions. However, the two survey questions cited in this study remain consistent during the 2011–2022 data collection phases.

First, students were asked about how the placement has changed their intention to pursue a rural medical career, through the question, ‘As a result of your RRM placement, how has your intention to pursue a medical career in a rural or remote location changed?’ Responses were generated through an 11-point Likert scale, with labels on the extreme options indicating ‘strongly discouraged’ and ‘strongly encouraged’. For analysis, 1–5 was re-classified as a negative change, 6 as no change and 7–8 as a weak positive change, and 9–11 as a strong positive change. For binary presentation, ‘positive intention’ was defined by those scoring 7–11.

Second, overall satisfaction with the placement was asked in response to the statement, ‘Overall, I was satisfied with this placement’. Responses were generated using a five-point Likert scale, ranging from Strongly Disagree to Strongly Agree. For binary presentation, ‘positive satisfaction’ was defined by those scoring 4–5.

Students in the block 3 placement in 2020 were asked the same questions; however, only one word was changed to acknowledge the online nature of the learning experience: ‘As a result of your RRM online experiences, has your intention to pursue a medical career in a rural or remote location changed?’ and ‘Overall, I was satisfied with the RRM block online learning experience’ instead.

Descriptive analysis was used to determine overall student intention and satisfaction rates, demonstrating the frequency of each score. Data from each cohort are presented longitudinally to illustrate trends in students’ intention and overall satisfaction during the duration of the study from 2011 until 2022. All missing or incomplete data were removed from the analysis. The statistical software package SPSS V27.0 was used to analyse data.

Results

A total of 2695 students (average 37 per rotation) undertook an RRM placement between 2011 and 2022 and 81% completed the survey. Most students undertook the 6-week placement in a rural location (n=2032, 75.4%), with 15.8% (n=427) undertaking a placement in a remote location and the remainder (<9%) in regional areas.

Traditional face-to-face orientation and placement experiences showcased a steady and strong intention to pursue a rural medical career following the RRM programme, during 2011 until 2019 (figure 1). However, with the removal or disruption of the ICEE experience and the consequent implementation of online learning during some placements in 2020 and 2021, this was strongly associated with a decline in students’ intention to pursue a rural medical career where interruptions were most prominent. The removal of the immersive orientation in regional and rural areas seemed to have a lesser but still important effect in reducing intent (most notably in 2021, when immersions were moderately affected) but was largely not impactful when placements were generally unaffected in 2022.

The biggest drop in intention levels occurred when face-to-face community immersion could not take place at all because of COVID-19 restrictions during Rotation Block 3 in 2020. As a one-off solution, these students were provided the opportunity to complete additional placement weeks in Block 7 in 2020 (table 1). This delayed immersion increased their intent which improved somewhat but remained lower than the average proportion reporting similar intent of the other rotations in that semester. In 2021, the lack of an immersive orientation was exacerbated by sudden short-term lockdowns, mandatory restrictions and ongoing strict regulations that led to disruption to ICEE placements and with that, a compounding of the drop in intention was witnessed in Rotation Block 2 2021. In the second semester of 2021, a face-to-face immersive orientation followed by less affected terms showed a return to previous intent before a drop in rotation Block 6 in 2021, which may be associated with the imposition of compulsory vaccination of health workers and students, and the institution of compulsory fit testing. This delayed and shortened some students’ placements.

A reduction in the medical workforce with the easing of restrictions and increased COVID-19-related work absence meant the orientation week returned to online in 2022, but placements were not affected. With this, students’ intention to pursue a rural medical career returned to prepandemic levels.

Looking at each calendar year as a whole during the placement, disruptions of the RRM programme show an overall significant decrease in the positive change of intent which is evident in 2020 (61% vs 69% in 2019) and then further in 2021 (56%) when only 26.7% of students indicated a strong positive intention (figure 2). In 2022, a strong positive change in intention increased back to 37% and combined positive change of 74%, both being higher than the aggregate 2011–2019 level.

Figure 2

Changes in intention to pursue a rural medical career because of the Rural and Remote Medicine programme yearly.

In contrast to the rural intention, the student’s combined satisfaction with the RRM programme remained consistently very high across all four periods, ranging between 85% and 91%. Specific components were either somewhat agreed (44%–30%) or strongly agreed (41%–61%; figure 3). Moreover, there was a steady increase over the four periods of the proportion who were highly satisfied with their RRM experience, despite a lack of face-to-face immersion placement experiences and disruptive learning during the pandemic in 2020 and 2021. In 2011–2019, very high satisfaction levels (strongly agreed) were 41%; in 2020 and 2021 during the COVID-19 period, they increased to 51% and 57%, respectively, and in 2022 further increased to 61%.

Figure 3

Changes in satisfaction with the Rural and Remote Medicine programme yearly.

Discussion

These results highlight the difference between education and inspiration in medical education, especially as it applies to rural practice. Most medical education happens in metropolitan or regional centres and the dominance of the citycentric exposure, and the hidden curriculum has been noted extensively.27 28 Studies have shown how exposure to rural practice can partially overcome this bias and help correct the workforce shortage.29 This effect seems to be dose related, but it has been shown that even short exposures have a significant effect on both career intention and outcome according to this study.30 This study shows that while students have great satisfaction with education regarding rural practice, only a real-life experience appeared to inspire them to increase their intent to being rural doctors—you cannot be what you cannot see.

The impact of a lack of ICEE experience on students’ intentions to practice rurally, particularly in the context of replacement with online learning, has not been previously investigated in rural areas. This study’s natural experiment demonstrates that the omission of community-engaged immersive rural experience was directly associated with a negative impact on a student’s intention level to practice in rural areas, despite an online programme with maintained programme satisfaction. There was a lesser effect with the omission of an immersive orientation especially when combined with a disrupted ICEE experience.

This study, instigated because of the COVID-19 pandemic, demonstrates the value and importance of ICEE experience as an essential component for supporting medical students to increase their interest in or intention to practice in rural areas after graduation. These findings are consistent with previous studies that have demonstrated the role of rural immersive medical education and learning;4 31 32 however, using 12 years of consistently collected evaluation data of each cohort, this study clearly demonstrates the value of face-to-face engagement, community networking and practical hands-on rural experiences on a medical student’s intention to practice rurally, directly comparing outcomes where it was or was not in place.

Despite the significant reduction in intent, the students remained very satisfied with the programme. In fact, while the proportion who were satisfied in each cohort did not change much over time, the number who were very highly satisfied substantially grew during the 3 years impacted by COVID-19. The reasons behind this are not clear, but the feedback was that students were appreciative that these placements could continue despite multiple COVID-19-related interruptions continuing around these. Of particular interest, this programme’s satisfaction generally was not strongly associated with the drop in intention results during the acute disruption in term 3 of 2020 or the most disrupted year 2021 and especially when the immersion experiences were disrupted mid-rotation.

Globally, a variety of strategies by medical programmes aim to promote the choice of rural practice among medical students.33 In Australia, around one in four Australians, or 29% of the population, live in a rural area, and significant efforts to sustain a rural medical workforce to meet their health needs are made.34 Sustaining a rural medical workforce in Australia is essential for ensuring that all Australians have access to high-quality healthcare, regardless of where they live.5 35 Investing in in situ rural medical education and training, providing opportunities for medical students to train and fully immerse themselves in rural communities, is essential to sustain and increase rural health workforce.5 35 36 Many rural workforce initiatives may bear little fruit if the fundamental importance of ICEE experience is not recognised.

Limitations

Methodologically, the study did not control for other external factors beyond the study’s natural allocation to groups, which may have influenced intention levels. All surveys were anonymised, designed for programme evaluation rather than specifically for research purposes, without collection of other demographic variables or the ability to link them to future observed location choices.

Conclusion

The value of face-to-face engagement, networking and education through a hands-on rural ICEE experience for optimal medical education learning is fundamentally an important contributor to providing quality rural medical training. When students experience and benefit from a positive rural immersion experience, the intention to practice rurally after graduation is consistently high. This study demonstrates that the omission of these experiences can have a significant negative impact on rural intent, thus elucidating the value of in-place rural immersions.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not Applicable.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by The University of Queensland Human Research Ethics Committee provided approval for the study (APP: 2022/HE000748). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors acknowledge the RRM administrative team for their valuable insights and factual review of the information reported in this manuscript.