Compulsory medical rural placements: senior student opinions of early-year experiential learning

Objective: The aim of this study was to determine senior medical student (year 3–5) opinions of their early‐year (year 1–2) rural placement. Design: We assessed the impact of MBBS early‐year rural placements through a follow up of this cohort in their later years using a cross‐sectional questionnaire. Setting: The questionnaire was administered to year 3–5 medical students at their clinical school. Participants: There were 97 participants (49% response rate) in the study. Twenty‐nine per cent were male and 71% were female; 44% were from a rural background and 56% were from a metropolitan background; 48% were year 3 students, 32% were year 4 students and 20% were year 5 students; and 59% of the students were, at the time, situated at a rural clinical school and 41% were at a metropolitan clinical school. Main outcome measure: Closed‐ended questions were quantified and statistically analysed. Open‐ended responses were thematically analysed to determine what their experience of early‐year rural placements were like. Results: Seventy‐nine per cent of students considered the year 1 placement length as ‘about right’. Overall, most students found year 1 rural placements positive and grasped the placement aims and objectives. Most students were also pleased with year 2 rural placements, mainly due to the clinical aspects. Conclusions: Medical students appear to prefer shorter early‐year rural placements and understand the benefits and importance of such placements. They also have a desire for greater clinical exposure during these early‐year placements.     

Influences on medical students' decisions to study at a rural clinical school

Objective: To identify factors that influenced medical students at Monash University to undertake their first year of clinical training (third year of the medical course) at a rural clinical school (RCS). Design: Third‐year Monash University medical students undertaking clinical placements at a RCS were surveyed in 2005. A semistructured questionnaire was used to ask students to rate the influence of a list of factors on their decision to undertake their year‐long placement at a RCS. Results: Under half (48%) of students studying at an RCS reported that they were of rural background. All surveyed items were identified as having had a positive influence. Greater clinical experience, learning opportunities and patient access were identified as having the greatest positive influence followed closely by free accommodation and other financial and supportive incentives. Future rural career intention was eight times more likely to be a positive influence in rural compared with urban background students. Conclusion: The most important positive influence on Monash third‐year medical students' decision to study at an RCS is the perception of high‐quality clinical experiences and education. This perception arises from rural exposure during pre‐clinical years.     

Short‐stay rural and remote placements in dental education,an effective model for rural exposure: A review of eight‐year experience in Western Australia

Objectives: The increase in demand for dental care over the next 10 years is expected to outstrip the supply of dental visits in Australia, resulting in an ongoing shortage of dental practitioners. As trends in medicine have shown, the greatest effect will be felt in rural and remote regions, where an undersupply of dentists already exists. It is clearly evident that it is important to provide strategies that will increase the recruitment and retention of practitioners in rural and remote areas. Previous research suggested an increased likelihood for health graduates to choose rural practice if they have a rural background, or were exposed to rural practice during their education. Short‐stay (three to four weeks) placements for final‐year dental students has been part of dental education in Western Australia for near on a decade. Methods: This paper reflects on the experiences gained from managing this placement program. Conclusions: Short‐stay placements are a quality learning initiative but need a high level of planning and a clear vision to be effective. Implications: The key factors in ensuring sustainable, student centred learning is driven through a small core group of staff who have strong direct links with rural and remote communities, students and support providers. The integration of service, education and research goals have played a critical role in sustaining placements. The philosophy underpinning the rural placements needs to be clearly articulated and applied effectively in each step of their implementation and a highly focused customer‐service driven implementation is required to make short‐stay rural and remote placements effective.     

A longitudinal integrated placement and medical students' intentions to practise rurally

Medical Education 2012: 46 : 179–191 Context Integrated longitudinal rural placements are designed to promote favourable student attitudes towards and facilitate return to rural practice upon graduation. We explored the impact of an integrated placement on medical students’ attitudes towards rural practice. Methods Data were available from interviews with 10 medical students, 15 clinical supervisors and teachers, three community health staff, and focus groups made up of medical students. Socio‐cognitive career theory gave insight into the personal, contextual and experiential factors, as well as the career barriers, that influence students’ rural practice intentions. Framework analysis was used to develop a thematic framework illustrating the key findings. Results The longitudinal placement enabled students to achieve personal goals, and enhanced self‐efficacy beliefs and orientation towards the complex personal and professional demands of rural practice. The informal curriculum, including multifaceted interactions with patients and their families, clinical teachers and other health care staff, was a vital experiential component. Students assimilated these rich experiences into their practice and evolving notions of professional identity as rural practitioners. Some students had little intention of practising rurally, partly as a result of contextual barriers such as geographic isolation, family and relationship needs, restricted postgraduate training opportunities and limited opportunities for specialist practice. Conclusions The richness of the informal curriculum in a longitudinal rural placement powerfully influenced students’ intentions to practise rurally. It provided an important context for learning and evolving notions of professionalism and rural professional identity. This richness could be reinforced by developing formal curricula using educational activities based around service‐led and interprofessional learning. To overcome the contextual barriers, the rural workforce development model needs to focus on socialising medical students into rural and remote medicine. More generic issues include student selection, further expansion of structured vocational training pathways that vertically integrate with longitudinal rural placements and the maintenance of rurally focused support throughout postgraduate training.     

Rural and remote mental health placements for nursing students

Clinical placements can be instrumental in encouraging nursing students to consider a future career in rural Australia. Twenty nursing students from a metropolitan university were provided with the opportunity to undertake a clinical placement in mental health in a rural or remote setting. The majority of placements were between 2 and 4 weeks in length. They took place in community health centres and rehabilitation centres in New South Wales and in hospital inpatient facilities, remote areas and community health services in the Northern Territory. On return from the placement, students completed an open-question pro forma giving their views and impressions of their experiences and contrasting this with clinical experience gained in urban settings. The content of the students' responses was analysed and presented under the following themes: scale relating to urban and rural differences in population; geographical and health facility size; staffing matters; the environment; the students' perception of the clients; and professional interaction. Additional material relating to remote area placements is presented. Questions are raised about the maintenance of students' interest and the development of rural careers.     

An evaluation of the integration of theory and practice during practice education: Placement A

Background: The need to increase student placement capacity resulted in a new model for the delivery of Placement A by the Scottish Stakeholder Partnership (Transition Team Implementation Programme, 2007). A number of initiatives to increase capacity have also been implemented in London, including a pilot building on the Scottish experience where Placement A is delivered in two parts: a series of integrated ‘day placements’, followed by a 2‐week block placement at an approved placement setting. The delivery of the 4 week model for Placement A was evaluated to obtain baseline data and to ensure students’ ability to integrate campus‐based learning with placement learning was considered in the design of an alternative delivery model. Methods: A questionnaire was completed by 35 third year undergraduate students at King's College London and 14 second year undergraduate students at London Metropolitan University, after they had returned to university after a 4‐week Placement A. Using a five‐point Likert scale, students were asked to indicate the level of agreement with 29 statements, including nine relating to the tasks and integration of learning between campus and placement. Other questions related to student enjoyment, motivation, range of experiences and student perception of Placement A's impact on their preparation for Placement B. Results: The results showed that 38 of the 53 (72%) students felt that the 4‐week placement duplicated learning at university, but the same number also felt that the tasks undertaken helped them to apply what they had learned at university. Whilst the majority of students (43/53) agreed that the placement was enjoyable, 26 students responded they were bored at times during their placement. Four students indicated that after Placement A they were rethinking their decision to study dietetics. Discussion: Students’ responses reflected the role of the placement in the application of theory, and the duplication of tasks between practice and university is likely to be necessary to fulfil this role. The integration of theory and practice is an important educational outcome of practice placements, and the finding that some students’ are unable to relate placement tasks to campus‐based learning raises a concern that the theory‐practice gap could be better addressed. Improved integration may benefit the student experience and enjoyment of Placement A. Conclusions: The results from this evaluation will inform the pilot of the new delivery model for Placement A in London. Reference Transition Team Implementation Programme. (2007) Working In Partnership Towards Local Allocation of Dietetic Practice Placements – TTIP Progress Report, February 2007. Available at http://www.lmu.ac.uk/health/ttip/documents/progressreport.pdf (accessed on 18 January 2008).     

Dental care provision by students on a remote rural clinical placement

Background: In 2009, the School of Dentistry and Oral Health, Griffith University, commenced a clinical placement in a remote rural and Indigenous community in Australia. This paper analyses the type of treatment services provided from 2009 to 2011 by year, type of patient and age of patient. Methods: All treatment data provided were captured electronically using the Australian Dental Association (ADA) treatment codes. Audited reports were analysed and services categorised into six broad treatment types: consultation, diagnostic, preventive, periodontics, oral surgery and restorative services. Results: The bulk of dental care episodes provided over the three‐year period were for clinical examinations, restorative and oral surgery services. Preventive and periodontic services generally comprised less than 10% of the care provided. Over time fewer clinical examinations were conducted and restorative dentistry increased in the second and third years of the placement. There were no significant differences in the types of care provided to public and private patients. Conclusion: Clinical placement of final‐year dental students in remote rural settings has helped address a largely unmet dental need in these regions. Implications: Dental student clinical placement is effective in providing care to communities in a remote rural setting. Student placements are, however, only able to deliver dental care in few remote rural communities, and therefore will make a negligible impact on the level of untreated dental disease in the short term. It is hoped that the experience will lead to more graduates serving some of their professional lives in remote communities.     

Loss of income and levels of scholarship support for students on rural clinical placements: A survey of medical, nursing and allied health students

Objective:  To quantify the financial impact of rural clinical placements on medical, nursing and allied health students in rural Australia.
Design:  The Careers in Health Tracking Survey provided data on whether students were employed, usual weekly hours of employment and a range of covariates, such as age, sex, course of study, marital status, dependants and rural or urban origin.
Participants:  A total of 121 students from a range of health professions completed the Careers in Health Tracking Survey while on rural placement at the Northern Rivers University Department of Rural Health.
Outcome measures:  Survey data.
Results:  Forty-one per cent of respondents were working immediately before their clinical placements. Nursing students worked the longest hours by far and were significantly more financially disadvantaged than both medical and allied health students ( P <  0.01). Scholarship support was unevenly distributed, with nursing and allied health students being relatively under-supported in relation to lost earnings.
Conclusion:  Recruitment of students can be an effective strategy to address the rural health workforce shortage throughout Australia. However, there are a number of financial disincentives for students to undertake rural clinical placements. Additional support for some disciplines is needed to provide equitable distribution of scholarship support to offset this financial burden. Establishing an employment scheme for students on rural clinical placements and a scholarship for income replacement where employment is not available would also alleviate income loss.     

The Rural Physician Associate Program: The Value of Immersion Learning for Third‐Year Medical Students

ABSTRACT: Context: Changes in health care and new theories of learning have prompted significant changes in medical education. Some US medical schools employ immersion learning in rural communities to increase the number of physicians who choose to practice in these areas. Founded in 1971, the rural physician associate program (RPAP) is a longitudinal immersion learning experience for students during their third year of medical school. Students are assigned to a primary care preceptor(s) in a rural community ranging in population from 1,000 to 30,000 for 36 weeks. Purpose: To describe students' perceived value of this immersion learning experience. Methods: Data from 3 classes (2004, 2005, 2006) of students (n = 95) were analyzed, including final essays that reflect on their experiences and logs of their patient encounters and procedures. Themes from students' essays related to the hands‐on learning experience are presented. Frequencies of ambulatory encounters and procedures were calculated and compared with those of metropolitan area colleagues where possible. Findings: The continuity experience allows for one‐to‐one mentoring and long‐term relationships. Students see physicians, clinic/hospital staff, and patients as their teachers. The environment is nurturing, but nudges them outside their comfort zone. Students gain increasing competence with their skills and do best if they are independent and seek out learning opportunities. They report more hands‐on experience, more confidence and autonomy than their peers in the metropolitan area. Conclusions: The RPAP experience provides a nurturing, longitudinal, immersion learning experience that facilitates the gradual but steady development of clinical skills alongside a personal and professional mentor.     

Removing the roadblocks to medical and health student training in rural hospitals in Victoria

Objective: To assess the extent of undergraduate health student placements in regional hospitals in northern Victoria in 1999, prior to substantial changes in rural undergraduate medical education in Australia. Method: Cross sectional postal survey with telephone follow‐up in north‐east Victoria. Subjects were all 17 regional and rural hospitals involved in health student teaching in North‐east Victoria. Main outcome measures were the numbers, duration and discipline of health students placements and reported barriers to such placements. Results: Large regional hospitals accounted for two‐thirds of all undergraduate health student placements. Smaller sites placed few allied health students. Barriers to a larger, more sustainable system of rural placements and rotations included accommodation shortages and funding constraints, particularly in smaller rural hospitals. Conclusions: Adequate resourcing of placements of a meaningful duration, stronger institutional support, and improved resourcing of regional accommodation is required to facilitate a larger, more systematic and sustainable system of medical and health student placements in rural areas. What is already known: The extent of training of health professionals in rural Australia is increasing rapidly. Fears have been expressed that the capacity to deliver quality experience in rural practice may be limited. What this study adds: This cross sectional survey of rural Victorian hospitals shows that there is a major untapped potential in rural hospitals of all sizes to assist with training in rural practice, but that a number of barriers to such training need to be removed to reach full capacity.     

The John Flynn Placement Program: evidence for repeated rural exposure for medical students

Objective: This paper reports on an evaluation of the John Flynn Placement Program (JFPP) for medical students. JFPP aims for medical students to experience both rural medicine and rural life as a way of increasing rural career intentions. Design: Medical students experience two weeks a year over four years with a rural doctor. Students are evaluated at the end of each placement for clinical and social experiences and career intent. They are followed up annually to monitor career intent. Mentors are evaluated annually on clinical and rural experiences during a placement. Setting: The Australian Government has several initiatives to encourage recruitment into rural medicine. One initiative is the JFPP. Students from all medical schools are placed with experienced general practitioners in rural and remote areas 4–7 locations across Australia. Participants: Evaluation data from 1450 placements from 2005–2009 are reported. Outcome measures: Data are presented highlighting evaluation of student and mentor perceptions of clinical and social experiences. Longitudinal tracking data provide an indication of the success of the program in terms of recruitment into the rural workforce. Results: Overall mean for clinical and rural experiences is extremely positive for both students and mentors. After four JFPP placements 65% of students intend to work in rural areas. After one JFPP experience 9% indicate intent to practise as a rural general practitioner while after their fourth JFPP nearly 20% are indicating intent to practise as a rural general practitioner. Conclusions: Longitudinal experiences, such as the JFPP, are positively influencing intention to enter the rural workforce but the impact of urban centric vocational training might be negating this impact.     

Students’ experiences and perceptions of the use of portfolios in UK preregistration dietetic placements: a questionnaire‐based study

Background: Reflective portfolios were introduced to dietetic practice placements in 2005, providing evidence for learning outcomes achieved and acting as a summative assessment tool. Portfolios may measure clinical competence more effectively than conventional examinations, but can be time consuming and subjective. The present study investigated current dietetic students’ experiences and perceptions of the use and effectiveness of portfolio based learning and assessment during practice placements. Methods: Current UK dietetic students, who had completed a B or B and C placement, were invited to participate, via University course leaders, in an online questionnaire exploring opinions and experiences of portfolio preparation, generation, assessment, and personal and professional development and reflection. Results: One hundred and fourteen students from 11 Universities participated. Seventy‐seven percent would have liked more information about portfolio construction prior to placement. Eighty percent of students believed that reflection helped monitor their strengths and weaknesses. Perceived reflective skills were significantly positively correlated with students’ perceived writing skills (P < 0.0005) and academic ability (P = 0.002). Of the respondents, 92% agreed the portfolio was a valuable learning experience; however, 76% agreed that the amount of paperwork involved was excessive and 67% felt there were inconsistencies in portfolio assessment by different supervisors. Conclusions: Portfolio weaknesses identified are not specific to dietetics but are inherent to portfolio assessment across many professions. The introduction of national standardised assessment processes, practices, tools and training for assessors may help improve inter‐departmental and inter‐rater reliability, respectively.     

Teaching pathology via online digital microscopy: positive learning outcomes for rurally based medical students

Introduction: Technology has revolutionised teaching. Teaching pathology via digital microscopy (DM) is needed to overcome increasing student numbers, a shortage of pathology academics in regional medical schools, and difficulties with teaching students on rural clinical placement. Objective: To identify whether an online DM approach, combining digital pathology software, Web‐based slides and classroom management software, delivers effective, practical pathology teaching sessions to medical students located both on campus and on rural placement. Methods: An online survey collected feedback from fourth and fifth year undergraduate James Cook University medical students on the importance of 16 listed benefits and challenges of using online DM to teach pathology, via a structured five‐point Likert survey. Results: Fifty‐three students returned the survey (response rate = 33%). Benefits of online DM to teach pathology rated as ‘very important’ or ‘extremely important’ by over 50% of students included: higher quality images; faster learning; more convenient; better technology; everyone sees the same image; greater accessibility; helpful annotations on slides; cost savings; and more opportunity for self‐paced learning out‐of‐hours and for collaborative learning in class. Challenges of online DM rated as ‘very important’ or ‘extremely important’ by over 50% of students included: Internet availability in more remote locations and potential problems using online technology during class. Conclusions: Nearly all medical students welcomed learning pathology via online digital technology. DM should improve the quantity, quality, cost and accessibility of pathology teaching by regional medical schools, and has significant implications for the growing emphasis in Australia for decentralised medical education and rural clinical placements.     

Occupational therapy students' contribution to occasions of service during practice placements in health settings

Introduction: Currently in the Australian higher education sector, the productivity benefits of occupational therapy clinical education placements are a contested issue. This article will report results of a study that developed a methodology for documenting time use during placements and investigated the productivity changes associated with occupational therapy clinical education placements in Queensland, Australia. Supervisors’ and students’ time use during placements and how this changed for supervisors compared to pre‐ and post‐placement is also presented. Methods: Using a cohort survey design, participants were students from two Queensland universities, and their supervisors employed by Queensland Health. Time use was recorded in 30 minute blocks according to particular categories. Results: There was a significant increase in supervisors’ time spent in patient care activities (F = 94.011_{2,12.37 df}, P < 0.001) between pre‐ and during placement (P < 0.001) and decrease between during and post‐placement (P < 0.001). Supervisors’ time spent in all non‐patient care activities was also significant (F = 4.580_{2,16 df}, P = 0.027) increasing between pre‐ and during placement (P = 0.028). There was a significant decrease in supervisors’ time spent in placement activities (F = 5.133_{2,19.18 df}, P = 0.016) from during to post‐placement. Students spent more time than supervisors in patient care activities while on placement. Discussion: A novel method for reporting productivity and time‐use changes during clinical education programs for occupational therapy has been applied. Supervisors spent considerable time in assessing and managing students and their clinical education role should be seen as core business in standard occupational therapy practice. This paper will contribute to future assessments of the economic impact of student placements for allied health disciplines.     

Use of clinical placements as a means of recruiting health care students to underserviced areas in Southeastern Ontario: part 1 - student perspectives

OBJECTIVE: This two-part study examines the present gap between financial and educational incentives required and the recruitment strategies used to draw health science students to underserviced areas in Southeastern Ontario. Part 1 explores the impact of offering travel stipends, rent-free accommodation and interprofessional educational opportunities to health science students on their willingness to participate in clinical placements in underserviced areas. DESIGN: Mixed-method two-part study using a self-administered questionnaire. SETTING: Canadian university campus. PARTICIPANTS: Four hundred and sixty-eight senior level medical, nursing, occupational therapy, physical therapy and X-ray technology students from a Canadian university and affiliated professional school. MAIN OUTCOME MEASURES: The influence of currently established incentives on student willingness to complete a clinical placement in designated underserviced communities in Southeastern Ontario. RESULTS: Based on a 75% response rate, the results demonstrate that, in general, students agree that they are more willing to complete a clinical placement in an underserviced community if provided travel stipends (75%), rent-free housing (92%) and interprofessional educational opportunities (65%). Students also identified 15 additional factors influencing willingness. CONCLUSIONS: Students are more willing to complete clinical placements in underserviced communities if provided incentives. The findings of this study support an interprofessional clinical education and recruitment enhancement program in Southeastern Ontario.     

Going country: rural student placement factors associated with future rural employment in nursing and allied health

OBJECTIVE: To measure the rate and predictors of health science graduates joining the rural health workforce following a rural placement. DESIGN: Longitudinal survey including the years immediately prior to and post graduation. SETTING: Western Australian health sciences graduates contacted by email and/or phone. Participants: Allied health and nursing students from urban campuses of three Western Australian universities who had taken a rural placement in their final year of study between 2000 and 2003. MAIN OUTCOME MEASURES: Location of employment six months or more after graduation. RESULTS: Of 429 participating allied health and nursing graduates, 25% had entered the rural workforce. Factors with a positive bivariate association with rural employment were: rural background, health discipline, self-reported value of placement, non-compulsory rural placement, and placements of four weeks or less. After controlling for rural background, the value and duration of the placement were significantly associated with rural employment. CONCLUSIONS: This study augments previous work showing that any prior rural background is a significant predictor of rural work. Rural practitioners of both urban and rural origin who undertake voluntary rural placements are more likely to enter rural practice and consequently mandatory placements may not be helpful to increasing the rural workforce. The quality of a placement is a highly significant factor associated with future workplace choice, the details of which need to be further investigated.     

Undergraduate nursing students' clinical experiences in rural and remote areas: recruitment implications

ABSTRACT: Providing rural and remote clinical experiences for undergraduate nursing students could help address future recruitment in these areas, but adequate financial support for students during clinical placements is also necessary. Strategies to address nursing shortages to date have emphasised funding for rural re-entry programs, or supporting students from rural backgrounds to attend university courses. Assisting current undergraduate nursing students, especially those from urban backgrounds, to experience living and working in rural areas has been overlooked as a potential recruitment strategy. Ongoing qualitative evaluation of a clinical placement program shows students respond positively and with increased interest in returning to rural nursing after graduation. Unfortunately, many are disadvantaged financially by the added expense of their rural clinical rotation. Finding ways to support students from both urban and non-urban backgrounds to undertake rural and remote clinical placements should be an important strategic and funding priority.     

A qualitative evaluation of a mentoring program for Aboriginal health workers and allied health professionals

Objective: Effective partnerships between Aboriginal Health Workers and non‐Aboriginal health professionals are essential to achieve Aboriginal health outcomes. This study aimed to evaluate a mentoring workforce development strategy for Aboriginal Health Workers and non‐Aboriginal allied health professionals. Methods: Thirty‐four Aboriginal Health Workers and non‐Aboriginal health professionals were recruited to the mentoring program where they were paired and established a learning relationship for approximately six months. A qualitative evaluation with thirty of the participants was undertaken involving in‐depth interviews at the completion of the program. Results: A total of 18 mentoring partnerships were formed across Victoria. The data revealed three key themes in relation to the evaluation of the program: (1) The mentoring program facilitated two‐way learning, (2) The Aboriginal Health Workers and non‐Aboriginal health professional participants reported being able to meet their identified learning needs through the partnership, (3) The capacity to improve practice was facilitated through readiness to learn and change practice and personal attributes of the participants, as well as organisation and management support. Conclusions: Peer mentoring between Aboriginal and non‐Aboriginal health workforce was found to be a powerful mechanism to promote two‐way learning that has the capacity to meet learning needs and promote practice improvement. Implications: Peer mentoring may be part of a multi‐strategy approach to the development of the Aboriginal health workforce.     

Early clinical experience: do students learn what we expect?

Medical Education 2011: 45 : 731–740 Context Early clinical experience is thought to contribute to the professional development of medical students, but little is known about the kind of learning processes that actually take place. Learning in practice is highly informal and may be difficult to direct by predefined learning outcomes. Learning in medical practice includes a socialisation process in which some learning outcomes may be valued, but others neglected or discouraged. Objectives This study describes students’ learning goals (prior to a Year 1 nursing attachment) and learning outcomes (after the attachment) in relation to institutional educational goals, and evaluates associations between learning outcomes, student characteristics and place of attachment. Methods A questionnaire containing open‐ended questions about learning goals and learning outcomes was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in either a hospital or a nursing home. Two confirmatory focus group interviews were conducted and data were analysed using qualitative and quantitative content analyses. Results Students’ learning goals corresponded with educational goals with a main emphasis on communication and empathy. Other learning goals included gaining insight into the organisation of health care and learning to deal with emotions. Self‐reported learning outcomes were the same, but students additionally mentioned reflection on professional behaviour and their own future development. Women and younger students mentioned communication and empathy more often than men and older students. Individual learning goals, with the exception of communicating and empathising with patients, did not predict learning outcomes. Conclusions Students’ learning goals closely match educational goals, which are adequately met in early nursing attachments in both hospitals and nursing homes. Learning to deal with emotions was under‐represented as a learning goal and learning outcome, which may indicate that emotional aspects of medical students’ professional development are neglected in the first year of medical education.     

If the land's sick, we're sick:* the impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales

Objective: To report Aboriginal communities' views of how prolonged drought in rural NSW has affected their social and emotional well‐being, and of possible adaptive strategies. Design: Content analysis of issues, priorities and adaptive strategies raised in semistructured community forums. Setting: Rural centres across NSW. Participants: Aboriginal people, service providers and other stakeholders. Voluntary participation by invitation with consent to record discussions. Results: Three themes (containing six issues) emerged: (i) impacts on culture (harm to traditional family structure, culture and place; bringing shame to culture); (ii) sociodemographic and economic impacts (skewing of the population profile; loss of livelihood and participation; aggravation of existing socioeconomic disadvantage); and (iii) loss. In addition to continuing well‐being programs that were already successful, proposed adaptive strategies were: capturing the spirit of Aboriginal knowledge and traditions; knowing your land; and Aboriginal arts. Conclusion: Prolonged drought presented substantial and unique adversity for rural NSW Aboriginal communities, compounding existing, underlying disadvantage. Drought‐induced degradation of and, sometimes, the necessity to leave traditional land drove people apart and disrupted Caring for Country activities. Some people reported despair at not being able to discharge cultural obligations. At the same time, the drought prompted increased love of and concern for land and a renewed enthusiasm for expressing connectedness to land through all forms of art. Modern Aboriginal and wider community well‐being programs helped frame a response to drought alongside traditional Aboriginal dreaming and cultural approaches to emotional health and well‐being.