Australians living in rural and remote areas have poorer access to general practice services despite higher full-time equivalent numbers of general practitioners (GPs), likely because of different service delivery models and higher levels of demand in rural areas.1
It is well recognised that positive exposure to general practice encourages doctors to choose this pathway.2 Internship is the first postgraduate step and has traditionally been spent in hospitals. Rural general practice intern terms were first implemented in 1997 in South Australia.3 From 2005 to 2014, the Prevocational General Practice Placements Program was delivered with the aim of increasing recruitment by placing junior doctors post intern training into general practice.
In December 2015, the Australian Government announced the Rural Junior Doctor Training Innovation Fund,4 one component of the Commonwealth’s Rural Integrated Training Pipeline, which aims to provide junior doctors with training in rural primary care settings. Rural general practice placements for junior doctors cover diverse curriculum goals in a short time and provide opportunities for interns to develop minor procedural skills. Despite more than two decades of delivery, there is limited research describing the implementation or outcomes of intern training in rural general practice. The small number of studies to date indicate that general practice terms are equal to or outperform hospital rotations in terms of intern academic performance, patient management knowledge, clinical and procedural skills acquisition, social support, autonomy and teaching interns about sociocultural influences on health.5–7 Previously reported disadvantages of rural general practice terms include peer isolation, financial costs, physical supervision needs, appropriate indemnity, accommodation and education infrastructure.5–7
Tasmania piloted its first rural general practice intern program in 2018. There were five rural/remote sites with four practices linked to small rural hospitals. The interns were employed by the hospital for the intern year, and most chose to have a rural term. The interns lived and worked in the communities for three months. The scheme was federally funded via a third party. General practices in the scheme had taught medical students previously but not interns.
GPs supervise interns for all patient consultations. Interns do not have access to Medicare Benefits Schedule item numbers and cannot write prescriptions outside the hospital. Actively engaging interns in consultations requires a system of ‘wave consulting’.8 This ensures that interns see patients independently, then the supervisor joins them for completion of the consultation. The supervisor oversees the management plan and generates/signs any necessary prescriptions or investigations. The junior doctors take part in a general practice–specific teaching program via videoconference, as well as being linked into their base hospital teaching program.
The study aim was to explore the experiences of interns taking part in the first general practice rotation in Tasmania.
Methods
The research was approved by the University of Tasmania Human Research Ethics Committee (reference: H16948). As a result of the small number of potential participants (14 rural general practice interns), a qualitative study design, using in-depth interviews, was adopted in order to collect rich, detailed information about intern experiences in primary care. Thematic analysis was used as it is ideal for identifying and reporting patterns, or themes, within data and providing a detailed account of the findings.9 Of the total five researchers, two researchers (JA and PA) conducted the thematic analysis and first draft of the findings. These two researchers were independent of the postgraduate training program. JA is a GP based in rural Tasmania. JA also teaches undergraduate medical students but commenced in the role after the interns graduated, so did not know any of the interns prior to recruitment. Two other researchers (LS and LH) were purposively excluded from the thematic analysis because of the potential for a perceived conflict of interest. LS was excluded on the basis of providing leadership for the undergraduate rural medical training program. LH was excluded from the thematic analysis on the basis of her involvement in intern accreditation, education and support in her role with the Postgraduate Medical Education Council of Tasmania.
Participants
This was the first time in Tasmania that interns were able to work a rotation in general practice. At the completion of their term in general practice, the 14 interns participating in the first cohort training in general practice in Tasmania were emailed an invitation to participate in the research and a study information sheet. The information sheet stated that involvement in the study was entirely voluntary, no identifiable information would be recorded during the interview and their participation would not affect their relationship with their employer or university. All participants provided written consent to participate.
Data collection and analysis
Semi-structured telephone interviews were conducted in mid-2019, at the conclusion of the intern rotation, by a researcher (JA) who was not involved in the delivery of the program. An interview guide, based on the findings of previous studies and a systematic review,7,10,11 was used to gather information about interns’ expectations and experiences of the general practice term. Detailed interview notes, with quotations, were taken by the interviewer. These notes were then thematically analysed using an exploratory analysis approach as described by Guest et al.12 First, using NVivo, the notes were separately coded by two researchers, one clinical and one non-clinical (JA and PA), to generate exploratory nodes (themes based on coded text). After initial coding, the two researchers separately identified themes, sub-themes and relationships between themes. The two researchers then met to discuss the results of their exploratory analysis, identify areas of consensus and resolve any potentially divergent findings. During this meeting, the two researchers discussed the subjectivity of the interviewer (JA) and how her own rural clinical experience may have influenced the data collection. This discussion confirmed that the interviewer’s professional experience provided insights into rural general practice workplaces and communities; however, the interviewer had not worked at any of the practices that hosted the interns. The researchers then separately conducted a confirmatory analysis (ie a secondary coding of the data to ensure data saturation on the agreed themes).
Results
Twelve of the total 14 interns invited to participate in the research agreed to an interview. There was an even distribution of the timing of the general practice term among participants, with three on their first rotation, three on their second rotation, three on their third rotation and three on their last rotation of internship.
Six main themes emerged from the analysis: 1) the social experience of rural/remote placements, 2) the intern role, 3) skill acquisition, 4) challenges experienced by interns, 5) placements shaping and reinforcing ideas of rural general practice and 6) advice to future general practice interns.
The social experience of rural/remote placements
Interns commented that they were welcomed into the local community, both professionally and socially. Living in the place where they worked helped to build a sense of feeling part of the community. This was reinforced through social interaction with colleagues and community members outside of work hours. For example, weekly evening meals with the practice staff, pharmacist, nurses, phlebotomist, locums and students. Interns made an effort to socialise with their colleagues and community.
I tried to do things with the communities – fishing, the pub, and got to know quite a few people here, they tend to know you after a few weeks. (#8)
Relationships with practice staff were positive. Interns noted that GPs, nurses, reception staff and locums were welcoming and supportive.
I really enjoyed the environment – all the staff were supportive and active in enhancing the learning opportunities. (#3)
Interns stated that clinics often benefited from having another set of hands, and that the nursing and medical staff were generally grateful for the help. Interns also expressed a sense of contribution to local community, which was professionally and personally rewarding.
Having patients come back to see you for follow-up, say hello in the street. A bit sad to go. Giving back and helping out, making a difference. (#2)
While small communities were welcoming, some interns had issues with negotiating boundaries. They noted, for example, patients discussing their health with the intern in the community supermarket, or members of the community enquiring about someone who had been admitted to hospital.
Confidentiality was a challenge; if someone was admitted to hospital, everyone in town would talk about it. (#8)
Interns appreciated their general practice rotation as it provided a better work–life balance when compared with hospital rotations.
So much to do outside of rotation – fantastic. Good combo of work–life balance, I would absolutely recommend it. (#1)
The intern role
Participants described performing a diverse range of tasks. For some interns, it was difficult to describe a ‘typical day’ as the type of work varied, although most days consisted of practice-based ‘wave consulting’, emergency clinics, nursing home visits, home visits and practice-based patient management tasks. The workload was variable, with interns sometimes seeing up to 14 patients per day.
A good mix of [general practice] presentations (acute and chronic), emergency triage and initial management and ward-based routine tasks (referrals, drug charts, fluids). [An] 8 am ward round of inpatients and organising any follow-up appointments, discharge summaries, scripts etc that were required. Two to three booked [general practice] presentations a day (viral upper respiratory tract infections, recently discharged from hospital, chronic disease management), and 2–3 [general practice] or emergency triage presentations (musculoskeletal injuries, falls, hypertension, confusion in the elderly). (#4)
There wasn’t really a typical day as it varied so much. (#2)
Most participants were surprised at the wide range of conditions they saw, including presentations that they would not see in hospitals.
One morning had myocardial infarct, anaphylaxis, bilateral corneal abrasions and stroke. In the one morning! (#1)
Saw two ST-elevation myocardial infarctions, a few trauma cases with motor vehicle accidents. Abrasions, injuries from farming and factories, work-related injuries. (#11)
Participants valued learning the complexities of chronic disease management and how much work is involved in keeping patients out of hospital.
It was good to see the ‘other side’ of hospital medicine, to be the person on the other end of the discharge summary being told ‘GP to follow up’. It gave me a better appreciation for the amount of effort that goes into following up chronic disease management, but also how much we can achieve in [general practice] if we utilise resources effectively. (#4)
Switching from hospital to [general practice] mindset, managing patients on long-term basis, thinking about prevention … It takes time to get used to it. (#8)
Interns initially experienced some uncertainty in their roles and in the practice staff’s awareness of their roles. This improved over time as practice staff and patients developed confidence in the skills of the interns.
The longer I was here, the other doctor got to know me and what I was comfortable with and my skillset. I was able to see more complex patients and procedures. (#10)
Interns were able to build up a small bank of regular patients during their 12-week placement. It was also noted that they provided patients with continuity of care in practices with high locum turnover.
I enjoyed the long-term (three-month) continuity of care with patients. I was able to deliver a whole [general practice] approach to care, tracking patients over months with regular follow-up. (#9)
The internships provided a valuable educational opportunity to learn that general practice is patient-centred and to learn the important roles of the team. This requires excellent interpersonal skills.
I recognised that general practice is not all just medicine – it’s medicine, personality of patients, front desk and a team to navigate. (#1)
Skill acquisition
Most interns reported intensive learning experiences. They conducted a range of procedures that allowed them to improve their skills in minor procedures and history-taking such as back slabs, fish hook removal, suturing, skin biopsies and excisions, wound care, venesection and iron infusions. The mix of clinical locations, from emergency clinic to nursing homes and general practice, was beneficial for acquiring a range of skills.
More of a hands-on experience; [general practice] has more limited resources compared to hospital, [you] tend to rely on clinical judgement. (#11)
I felt very prepared for emergency given lots of practice with focused history and examination, and minor procedures. (#6)
Challenges experienced by interns
While interns were mainly positive about their rural general practice rotations, they also experienced some personal and professional challenges. Foremost among these was their isolation from peers and other sources of support.
At times I felt isolated from colleagues, even to just debrief, or when situations arise. [It is] valuable in hospital to bounce ideas and experiences off other interns. (#10)
Interns who had medical students in their practices were grateful for the peer support and social interaction. The 5–10 minutes spent debriefing with the other general practice interns online once a week before the tutorial was helpful.
Participants had varied experiences of wave consulting. In some practices, the model worked well. In other practices, the model did not work initially because of a combination of poor receptionist knowledge of the intern role, inadequate space within the practice, lack of access to the practice management system and limited time for general practice supervision. This was resolved by providing resources to practice managers about wave consulting.
Difficult – [the] space issue. Students had no way to do wave consulting, so [the] student experience was probably negatively affected. (#7)
There were challenges for some interns in managing workload.
Initially working too hard – skipping lunch breaks, working after five and offering help. [I] needed to set limits for leaving on time and having breaks. Self-care improved over time and was supported by the GPs who were very understanding. (#2)
The limited resources within rural general practice also presented a challenge to interns. Interns were required to rely more on their own clinical judgement and less on ordering investigations.
In hospital if you want a CT [computed tomography scan], you get a CT. Here if you want it you have to arrange transport, and really think about the indication. (#8)
Placements shaping and reinforcing ideas of rural general practice
Most interns commented that the placement reinforced their plans to work in rural general practice.
[General practice] and in particular rural [general practice] is now higher on the list; I enjoyed being more involved with community. (#3)
There were three interns who did not choose the general practice rotation but had been assigned because of shortages of placements in hospital. While these interns did not consider a career in general practice likely, they acknowledged the learning opportunity as well as feeling the experience would improve their communication with community care in the future. However, it was also noted among interns who were interested in pursuing a career in rural general practice that interns with other career goals would ‘struggle’ in the role. They would not recommend the placement to interns with other career preferences.
Advice to future general practice interns
Interns emphasised the importance of being prepared for the role. This included specific knowledge about immunisation schedules, GP Management Plans and common medications, for example by knowing which resources to use and referring to Murtagh’s General Practice.13 Being skilled in clinical examination and the management of common emergency presentations, and completing an Advanced Life Support course prior to placement were also seen as important.
Having some understanding of the basic management of common emergency presentations. Brushing up on clinical examination and not only relying on imaging and bloods for diagnosis. (#4)
Would have found it helpful to understand management plans and cycles of care. (#6)
Participants suggested that interns should approach the role with flexibility and motivation, and actively seek learning opportunities. It was also noted that interns considering the Australian College of Rural and Remote Medicine pathway should bring their logbooks and have tasks signed off.
Don’t be afraid to say you want help, speak out for what you want to learn if you feel like learning needs aren’t being met. Look for learning opportunities. (#5)
Three interns were based in the practices in which they had completed their placements in as fifth-year Rural Clinical School students. This prior experience of the rural general practice environment was considered helpful in preparing them for their rural general practice intern role.
Being there as a student helped. I had an idea of how it worked; the on call, the hospital, emergency department, and I knew the nursing staff. (#7)
Discussion
Providing intern placements in rural general practice is part of the Government’s Stronger Rural Health Strategy14 to promote greater numbers of rural GPs. The present study showed that rural general practice intern posts can reinforce junior doctors’ desire to work in rural areas.
An important determinant of the enjoyment of the term, and whether the term was rewarding, was the choice to opt-in to the rotation in rural general practice. In order to succeed in securing a rural general practice workforce for the future, programs should permit interns to choose their preferred rotations. Interns should also have knowledge and experience of rural environments before commencing a rural term. It is also notable that those who aspired to a career in general practice were more likely to find the rotation rewarding.
Rural placements provided interns with an opportunity to see patients with a wide range of conditions and complex chronic diseases, to learn and consolidate clinical skills. Similarly to previous studies of intern training in primary care,5–7 this study showed that rural general practice terms provide diverse curriculum learning opportunities and the opportunity to acquire new skills that would not be available in hospital rotations, such as minor procedural skills, chronic condition management skills, dermatology, occupational medicine and opportunities to consult with paediatric patients. Another important aspect was the opportunity to work with undifferentiated, unreferred presentations that required evaluation and management in the outpatient setting. Interns have less experience with chronic disease management and undifferentiated presentations, so having an effective induction program and easy access to online resources for common issues will help with this preparation.
There were many factors that shaped a positive experience for the interns. They identified community integration as key to their enjoyment of the placement. Practice factors were vital in making the intern feel welcome. General practice is well placed to set up community links for interns to promote community integration and help interns meet people with shared interests. The intern post was a new addition to established practices; therefore, the first term had issues that can be resolved by programs working closely with practices. Program support related to setting up intern placements for practices is vital to future success. Other practice factors that contributed to positive experiences were access to: an appropriate physical workspace (eg a separate consultation room), IT resources (eg best-practice patient management system using the intern’s own log-in) and medical resources (eg Therapeutic Guidelines). This emphasises the importance of practice staff being knowledgeable of resource requirements. Weekly video-linked tutorials with other interns, which provided opportunities to debrief, were also valued by the interns.
The challenges described by interns were similar to those found in other research.5–7 These challenges, once identified, were remediated throughout the year as the program became more established. The main challenges were uncertainty about the intern role within the practice, initially poorly set up consulting schedules that affected supervision, and peer isolation.
Feeling isolated from peers and social support was the greatest challenge faced by interns. While interns welcomed the presence of medical students in easing peer isolation and providing vertical integrative teaching opportunities, the physical capacity and extra supervision requirements caused some difficulty. To alleviate isolation, training program managers should consider parallel placements of undergraduates and interns. Interns were mindful that their term could affect the experiences of medical students undertaking a rural general practice placement. Medical students associate positive general practice experiences with inclusion in the team, opportunities for procedural skills and independent consulting.15 It is therefore important to identify any negative effects on the student and work to address concerns and promote positive rural experiences.
Practices taking on an intern should ensure all staff understand the intern role and the differences between a student, an intern and a fully trained GP. The wave consulting model, in which patients are booked with an intern prior to a GP review, was identified as a useful consulting setup. Using this model relies on key staff being trained in the booking system to deliver wave consulting and highlights the importance of supporting practice staff in this endeavour. While not specifically established as a component of the program, all of the practices used wave consulting models during intern terms.
The recommendation of specific intern preparation prior to placement was important feedback. Interns felt that future rural interns should ideally have done their emergency term but should also complete their Advanced Life Support and emergency course prior to rural general practice placement.
It is prudent to reflect on some of the intended long-term outcomes that a rural general practice intern program provides. Rural medical workforce shortages, both locally and nationwide, require thorough consideration of how junior doctors are trained. Orda et al16 reported that rural workforce shortages can be improved by increased junior doctor placements in the short and long term. The finding in the present study that general practice terms reinforced career preferences for rural primary care suggest that the model will prove successful in helping to build a sustainable rural general practice workforce.
Limitations of the study
One limitation of this study is that the interns interviewed had volunteered for the intern posts. Participants felt that it would not be a good experience for interns who did not have rural general practice career aspirations. The researchers were unable to interview interns who left early (one of whom did not have rural experience or preference a rural general practice career). It is possible that these interns had some negative experiences during their general practice terms, but this information could not be captured in the present study. While these factors are likely to have resulted in positive response bias, it reinforces the observation that interns should self-select and have experience of rural placements during their undergraduate training.
The decision to write detailed interview notes rather than audio-tape interviews was made in the project design phase to maximise recruitment and, given the small pool of potential participants, to reduce the risk of identification. Documenting interviews by writing detailed notes rather than tape recording introduces the possibility of bias as there is potential for interviewers to omit comments or neglect to write down controversial statements. The researchers sought to reduce this bias by having a single trained interviewer conducting the interviews. This interviewer was aware of the importance of comprehensive and accurate note-taking to reduce the potential for study bias.
The researchers did not interview hospital-based interns who had not had a rural intern placement for a direct comparison of experience. The interns’ experiences were based on their prior rotations or perceptions. Future studies could explore this in more detail, including how different workplace arrangements affect the intern experience.
Conclusion
The findings of this study showed that a rural intern training term can be delivered in rural Tasmania. General practice terms diversify the prevocational experiences of interns and help consolidate rural career pathways. This finding requires further investigation in longitudinal research comparing the career intentions and trajectories of hospital-based interns with those of interns who complete general practice terms. Rural intern general practice programs need to provide training for GPs and practice staff on how best to support for the role of the intern. Practices developing placements for rural interns need to have processes in place to integrate interns into the rural practice environment. Future research could explore this in more detail, including how different workplace arrangements affect the intern experience and skill acquisition in general practice rotations when compared with hospital rotations.
Implications for general practice
- Rural intern terms are a good learning environment for interns and can reinforce their desire to be rural GPs.
- Interns need to be well supported by their base hospital, the general practice and training organisations.