October 2016

Training rural health professionals: is

there a fitting formula for Timor Leste?

Adrian Schoo, FANZAHPE

Professor of Rural Health Professional Education
Flinders Rural Health SA, Australia

Dean Carson
Professor of Rural and Remote Research
Northern Institute, Charles Darwin University, Australia.
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Glesbygdsmedicinbskt Centrum, Sweden
Why rural training?
To improve the recruitment and retention of
rural doctors (and other health professionals)
is a global challenge

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But not a new challenge!
Mesopotamia
3000bc
Hard to get
physicians to work
outside the city walls
Donkeys, goats,
wives, housing,
holidays...

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 Many solutions have been tried
Wilson, N. W., I. D. Couper, E. De Vries, S. Reid, T. Fish and B. J. Marais (2009). "A
critical review of interventions to redress the inequitable distribution of healthcare
professionals to rural and remote areas." Rural and Remote Health

Coercion
Financial incentives
Personal and social support
Limited evidence of success successful cases,
but no universal indicators

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 The best evidence
Rural background
Family home
Schooling
Rural Exposure
Clinical training
Maybe other rural based activities like research or community projects
The Rural Pipeline

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 When does rural training work?

When the quality of education and exposure to real

practice is high
When training is immersive (students live the rural
doctor/health professional life, not just visit it)
When the community is involved
When it happens at the right scale (usually one or
two students per supervising health professional) -
2 students can work very well (peer learning)

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What could be done here? (evidence so far)
QA Rural clinical placement through partnerships with regional hospital, community
health and private practice in the Maubisse area. Home base for students remains the
same, allowing continuous monitoring. Evaluation processes from Australia or Canada.
Host Hospitals, Health Centres & Practices Rural hosts can form a network
to support clinical supervisors, and share experiences and resources.
Student Selection Participating communities can host student visits prior to
selection. Community representative can help interview students.
Student Costs formal contracts can secure housing (and internet and transport) at no
cost to the student.
Social Satisfaction students can have a local buddy from the community to help
them get involved in community life (it works!).
Community Demand Demonstrated in many communities who host student
research and other visits. Community engagement process can be implemented.

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 Expected benefits
Medical, nursing and other health students learn from each
other when placed together
Preparation for interprofessional practice and optimal outcomes
(e.g., orthopaedics, rehabilitation, obstetrics, preventative
health)
Affinity to rural practice, and job opportunities for new
graduates
The Servisu Integrado du Saude Comunidade (SISCa) program
(adapted from Cuban & Indonesian models) may suit as the basis for
an optimal and integrated model of care (Martins & Trevena 2014)
Health and wellbeing of rural communities
 Quick Summary
Rural training/exposure works to improve recruitment
and retention (Canada, Australia, South Africa, USA)
It is not easy and it does not solve everything, so we need
to find out how to do this here in the context of other
things that need to be done
A good opportunity to start moving forward with a
Maubisse pilot that, for example:
Provides scholarships to rural students
Provides clinical placement opportunities in different rural
settings (also, link with community work, teaching health at schools)
Provides clinical supervision training and network support to
clinical educators
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 Symbiotic clinical education

Prof Adrian Schoo

Dr Koshila Kumar
Prof Jennene Greenhill
Ms Lori Tietz
What is Symbiotic Clinical Education?

A symbiotic curriculum is predicated on a mutually

reinforcing relationship between education facilities
and health services, where both gain.

Students gain good learning opportunities, while the

health services (and communities) benefit from the
contributions of students and their university.
(Ash et al 2012; Prideaux, Worley & Bligh, 2007)
Symbiotic Clinical Education

Worley 2002
Four interconnected relationships

Personalprofessional (Personal Axis)

Clinicianpatient (Clinical axis)

Universityhealth service (Institutional axis)

Governmentcommunity (Social axis)

 Clinical Supervision Training
Dr Narelle Campbell
Interprofessional & Clinical Education
Northern Territory Medical Program
School of Medicine
Flinders University Australia
narelle.campbell@flinders.edu.au
Dr Helen Wozniak
e-Learning, Evaluation and
Research
Northern Territory Medical
Program
School of Medicine
Flinders University Australia
Helen.wozniak@flinders.edu.au
Possible modules
Learning and teaching in the workplace
Planning workplace learning
Teaching clinical skills
Promoting learning through feedback
Engaging learners: The One Minute Preceptor
Assessing workplace-based learners
Supporting learners in difficulty
Understanding how learners develop expertise
Developing as a supervisor through a peer review process
 How Rotary & Maubisse committee could
help
Liaise with communities - Engagement process
Funding rural scholarships (to study in Dili & return to country)
Selecting students for rural scholarships
Finding local mentors for students who connect them
with community, incl. sport, teaching at school
Safe accommodation for students & young graduates
Assist training of rural health professionals in student
supervision (clinical education)
Getting the universities on site to allow for rural clinical
placements in their health courses

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 Some references
Paul Worley, David Prideaux, Roger Strasser, Anne Magarey, & Robyn March.
(2006). Empirical evidence for symbiotic medical education: a comparative analysis
of community and tertiary-based programmes. MEDICAL EDUCATION 2006; 40:
109116
Prideaux, D., Worley, P. and Bligh, J. (2007), Symbiosis: a new model for clinical
education. The Clinical Teacher, 4: 209212. doi: 10.1111/j.1743-498X.2007.00188.x
Kumar K & Greenhill J. Factors shaping how clinical educators use their educational
knowledge and skills in the clinical workplace: a qualitative study. BMC Medical
Education 2016, 16 :68.
Schoo A, Lawn S, Carson D. Towards Equity and sustainability of rural and remote
health services access: Supporting social capital and integrated organisational and
professional development. BMC Health Services Research. 2016, 16:111 DOI:
10.1186/s12913-016-1359-9. http://www.biomedcentral.com/1472-6963/16/111
Martins N & Trevena LJ (2014) Implementing what works: a case study of integrated
primary health care revitalisation in Timor-Leste. Asia Pacific Family Medicine 2014,
13:5. https://apfmj.biomedcentral.com/articles/10.1186/1447-056X-13-5