title: 'What makes it really good, makes it really bad.' An exploration of early student experience in the first cohort of the Rural Clinical School in the University of Western Australia.
abstract: BACKGROUND
  The Australian Commonwealth Department of Health and Ageing has implemented the Government's Regional Health Strategy. This strategy provides funding to universities for the establishment of Rural Clinical Schools (RCS) on a national basis. The strategy aims to secure a rural education and training network to increase the availability and viability of rural health services in the long term. The University of Western Australia set up the RCS in 2002 with the objective of setting up a full 5th year medical course in remote communities (RRAMA [Rural Remote and Metropolitan Area Classification] 4-7) for the 2003 academic year. There were 21 students in five areas: Kalgoorlie/Esperance (9 students), Broome (4 students), Port Hedland (3 students) and Geraldton (5 students). These students covered the 5th year curriculum with internal assessment and final examinations, in the same manner as city students. Only the delivery was different, according to geographical location.
  
  
  METHODS
  Structured questionnaires using open-ended questions were distributed to students on two occasions. At the sixth month, semi-structured interviews were held with each student. The interviews were transcribed and a thematic analysis of the data was undertaken. Constant comparison of data was undertaken, themes identified and relationships among the themes clarified.
  
  
  RESULTS
  In general, students were very happy with the teaching and learning opportunities they had during the first half of the year. However the initial themes of curriculum content, curriculum delivery, and assessment, were eclipsed by an overarching theme of anxiety and its management. The issue of student anxiety was addressed during the analysis. A number of factors were identified which ameliorated student anxiety or contributed to increased anxiety. From this evaluation a number of contributory factors to such student anxiety were identified. The investigators became more cognisant of the impact of group dynamics and of the need to structure the 'unstructured' environment of rural and remote medicine. In this way, students focus on only a few learning tasks at a time. They complete each topic with at least one other student so they can share the experience. The key role of each site coordinator also became apparent. The site coordinator should know the curriculum thoroughly and transmit this information to other teachers and preceptors at their site. It was also found desirable that the RCS was clear as to which assessment processes were flexible and which were 'fixed'. The medical school must clarify which curriculum content is essential, which is desirable and which is additional. Issues of workload must be monitored, and good work practices must be encouraged and supported. It was found that the high level of commitment to learning lead to the potential for burnout, generating the student comment: 'What makes the RCS really, really good makes it really bad...'
  
  
  CONCLUSIONS
  Setting up an innovative program is always a major task, but setting up five different offices with four centers of learning separated by thousands of kilometers has not been undertaken, apparently, anywhere else in the world. It has been a 'fast uphill journey' that has been subject to evolving change as the RCS has adapted to conditions not expected from an academic point of view. Key contributory factors to student anxiety were identified and organizational strategies were implemented immediately, where possible, to reduce such anxiety. These insights were also used in the preparation for, and implementation of, the 2004 curriculum.
authors.affiliation: Rural Clinical School, University of Western Australia, Perth, Western Australia, Australia . hpenhey@rcs.uwa.edu.au
authors.forename: H
authors.initials: H
authors.lastname: Denz-Penhey
authors.forename: J C
authors.initials: JC
authors.lastname: Murdoch
authors.forename: V J
authors.initials: VJ
authors.lastname: Lockyer-Stevens