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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgments
  9. References

Medical Education 2011: 45: 455–463

Context  This paper aims to consider why general practitioners (GPs) teach, in particular by defining the longitudinal supervisory relationships between rural clinician-preceptors and students.

Methods  A total of 41 individual semi-structured interviews were conducted with GPs, practice managers and students. All interviews were audiotaped, transcribed and analysed for emergent themes.

Results  In this study preceptors identified many ways in which precepting added value to their roles. However, themes relating to the doctor–student relationship were central to GP preceptors’ experiences. These developed in chronological order and resulted in changes in the triangular relationship between doctor, patient and student in the consultation.

Discussion  Interpretive findings identify that the motivators for precepting represent a group of constantly changing interconnected factors that contribute to the defining of preceptors as central members of their professional community of practice. This critical finding challenges the simplistic organisational concept that universities can recruit and retain GPs by offering increased rewards. This paper introduces four clinical preceptor models, which involve the roles of, respectively: the student-observer; the teacher-healer; the doctor-orchestrator, and the doctor-advisor. Symbiosis between student learning and patient care was found to occur in the doctor-orchestrator model.

Conclusions  The evolution of doctor–student relationships in long-term student placements explains how students become more useful over the academic year and sheds light on how GPs are changed through precepting as part of the complex process by which they come to recognise themselves as central members of the rural generalist community.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgments
  9. References

General practice is becoming a more frequent setting for medical student training as medical schools strive to provide larger numbers of students with authentic clinical experience relevant to future medical workforce requirements.1 A number of universities have developed longitudinal integrated models of student attachment in which students benefit from continuity of supervision over a full academic year.2

General practitioners (GPs) often complain of time pressure when consulting.3–6 Despite this time pressure, GPs involved in the Flinders University Parallel Rural Community Curriculum (PRCC)7 continue to act as preceptors (teachers) to students. This study aims to consider why GPs teach by exploring the experience of continuity of supervision from the GP preceptor’s perspective. This research consists of a case study of GP preceptors from four rural general practices, which host full-year continuous integrated placements for students in the PRCC.

Many researchers have considered precepting through the lens of organisational development, in which motivation to precept is assumed to relate to the alignment of GP goals with university rewards.8 This qualitative study was undertaken using complexity theory as a conceptual framework. A complex adaptive system is defined in the social sciences as a system of interconnected elements (such as doctors, staff and patients) which have the capacity to change and learn from experience. General practices are assumed to be complex adaptive systems as, in these settings, change is constant, evolving and cumulative.9

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgments
  9. References

Twenty-one GP preceptors (pGPs), four practice managers (PMs) and seven PRCC students participated in semi-structured interviews on the GPs’ experiences of precepting medical students. Triangulation was achieved by interviewing three non-precepting GPs in PRCC clinics (npGPs), and five committed (short-term) preceptors (sGPs) and one PM (sPM) from other general practices that frequently take students on short-term attachments (Table 1). Semi-structured, open-ended interviews were used to determine the participants’ current experiences of precepting. The questions posed aimed to explore: (i) ‘How do GPs interpret the experience of precepting a medical student?’ and (ii) ‘Why is the precepting experience meaningful for GPs?’ Experiences described by interviewees were further explored using open-ended questions. Predetermined prompts were defined from the literature.5 Interviews ran for 20–55 minutes.

Table 1.   Interview participants (n = 41)
  MaleFemale
  1. PRCC = Flinders University Parallel Rural Community Curriculum

PRCC precepting GPs (pGP)Early in yearpGP2, pGP5, pGP9pGP3, pGP8
 Mid-yearpGP13, pGP14, pGP19, pGP24pGP15, pGP21, pGP22
 Late in yearpGP25, pGP26, pGP27, pGP31, pGP32, pGP33pGP28, pGP29, pGP34
PRCC non-precepting GPs (npGP) npGP30npGP18, npGP20
GP short-term preceptors (< 6-week blocks) (sGP) sGP1, sGP10, sGP12, sGP17sGP11
Practice managers (PM; sPM = PM of short-term preceptor) PM6, PM7PM4, PM16, sPM23
PRCC students (S) S37, S38S35, S36, S39, S40, S41

All interviews were audiotaped, transcribed and numbered chronologically (1–41). Transcriptions of recorded interviews were reviewed by interviewees to create consensus documents. These documents were used as the research data. Consensus documents were analysed (by LW) using NVivo Version 7.70 (QSR International Pty Ltd, Doncaster, Vic, Australia), according to procedures described by Strauss and Corbin,10 which included: open coding; axial coding; selective coding; constant comparison, and theoretical saturation. Preliminary themes were critiqued by the other authors (DP, PW, JG) and a reference group consisting of PRCC GP preceptors from a different geographical region, not involved in the study. Reference group feedback was recorded and informed further analysis. Finally, the provisional conceptual model developed from the research was presented to the GPs interviewed in this study for critique; their feedback indicated their acceptance of the model as an accurate interpretation of their experiences.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgments
  9. References

In this study, preceptors identified many ways by which precepting added value to their roles (Table 2). Precepting GPs indicated that precepting provided diversity in their work. They initially expressed doubt about their subject mastery and teaching expertise, but, in time, became more confident preceptors. Precepting GPs claimed that precepting medical students made them reflect on their clinical approach, rather than acting instinctively. They were mindful of their thought processes, worked to be consistent with their clinical decisions and explicitly vocalised their clinical reasoning to students. They were motivated to keep up to date and reviewed their knowledge in order to teach. Questioning and feedback from students were sometimes uncomfortable, but encouraged further self-reflection.

Table 2.   Themes relating to professional enrichment
CategoryExampleParticipants
  1. GP = general practitioner; PM = practice manager; S = student; pGP = precepting GP involved in PRCC; npGP = non-precepting GP; sGP = precepting GP on short-term rotations; PRCC = Flinders University Parallel Rural Community Curriculum

Precepting provides variety from routine consulting‘Having a student does give a different dimension. I was just thinking this morning that it adds variety to my practice’ (sGP12)pGP2, pGP5, PM5, PM7, pGP9, sGP11, sGP12, pGP25, pGP26, pGP31, pGP32, pGP33, S37, S38
Precepting provides intellectual stimulation‘I find it more stimulating and more interesting than working alone’ (sGP10)sGP10, sGP12, pGP13, pGP25
Precepting supports self-reflection on the doctor’s clinical approach‘I don’t think it affects my capacity to provide good patient care. It may even enhance it. It makes you think. You can get through the day without thinking, and we do forget to question ourselves. “Why are you doing this? Why are you doing that? Or are there better ways?” Things I take for granted’ (pGP26)PM4, pGP5, sGP12, pGP15, PM16, sGP17, npGP18, pGP19, pGP21, pGP25, npGP30
Precepting facilitates personal learning‘The students are more up to date on the technical knowledge and we get that technical knowledge from them. We pass our practical skills on to them so that they can go out to the community when they finish. [It’s] an exchange. I find that really stimulating’ (sGP10)PM4, pGP3, pGP5, pGP9, sGP10, sGP12, pGP14, pGP15, sGP17, npGP18, pGP19, npGP20, pGP21, pGP24, pGP31
Precepting supports the perception of self as a master/teacher‘I see my role as a teacher and educator of patients and to the upcoming generation of doctors’ (sGP1)sGP1, pGP8, pGP10, sGP12, pGP13, pGP15, pGP31
Precepting enhances access to a community of practice‘If we enjoy our work we like to share with people appropriately… We can share it with doctors in training and students are just another level. I look upon a student as [an] extrapolation of [a] continuum: undergraduate student, postgraduate, doctor. They are all the same sort of people [it’s] purely [about] where they have got [to] in their skill-based learning. I think it is just a case of sharing the things that I do, and then giving them the chance to see what can be done, how some people do things and then hopefully then they can make up their minds about what things they would like to do. It’s a sense of commitment to the medical ethos, and being involved in bringing other people into it’ (sGP17)sGP12, PM16, sGP17, pGP25, pGP27, npGP30, pGP32
Precepting brings kudos and recognition‘I think that you’re becoming a more valued part of the system in helping to teach them: more valued by ourselves, by [university name] and by the community’ (pGP5)sGP1, pGP2, pGP3, pGP5, PM7, pGP8, pGP9, sGP10, PM16, pGP27, npGP30, pGP33, S35, S40
Precepting allows the preceptor to ‘give back’‘I always feel that somebody tutored me, whether they wanted to do it or not. But somebody had to do it in order for me to gain something academically and become a doctor one day. It is a way of giving back’ (pGP21)sGP1, PM4, PM7, pGP8, pGP13, pGP14, PM16, pGP21, pGP22, pGP26, npGP30, pGP31, pGP32, S36, S38
Precepting supports recruitment and succession‘I think that there always is a possible workforce advantage although that’s not why we do it. I think that if we can provide a good quality experience for students in a rural environment there is a fair chance that some of those might work in a rural environment in the future; all be it may be not here, but somewhere’ (pGP5)sGP1, pGP2, PM4, pGP5, PM6, pGP8, sGP11, pGP13, PM16, sGP17, npGP18, sPM23, pGP29, npGP30

General practitioners described precepting as affecting their perception of their own professional roles. They reported increased collegiate interaction with their clinician peers in practices within the region. General practice preceptors also identified with teaching peers and, through the formal structures of the Rural Clinical School, gained opportunities to share academic endeavour with university colleagues, who respected their contributions. There was a sense of this community of practice as intergenerational and as including registrars and students as less advanced members of its collective. Precepting GPs were motivated to ‘give back’ to the profession by providing support to the next generation of students, thus completing the cycle of professional renewal.

Precepting GPs valued the kudos they received as a result of their involvement in the PRCC programme. The students respected their clinical mastery. Patients and community members perceived that the medical practice was investing in developing the future medical workforce for the community, which affirmed the high standard of medical care being offered.

Precepting GPs reported that they were motivated to take students by the desire to influence the students’ career choice towards rural medicine. A few GPs reflected that this recruitment was more about ensuring the quality of rural general practice through the appropriate motivation of quality students, rather than about increasing rural doctor numbers. Some study participants wished to recruit to their own practices by raising their status as teaching practices.

The examples of professional enrichment described above were identified by GPs as motivators for precepting. Interestingly, however, these were not the factors on which GP preceptors focused when describing their enjoyment of precepting, and the lack of any of these factors was not recognised as a likely trigger for stopping precepting. Precepting GPs continually returned to themes relating to the doctor–student relationship as central to their experiences (Table 3).

Table 3.   Themes relating to the doctor–student relationship
CategoryExampleParticipants
  1. GP = general practitioner; PM = practice manager; S = student; pGP = precepting GP involved in PRCC; npGP = non-precepting GP; sGP = precepting GP on short-term rotations; PRCC = Flinders University Parallel Rural Community Curriculum

The student was personable‘He had a pleasant personality and was able to see the funny side of things and that obviously made life interesting. He fitted in quite well with the practice team here in the practice. He was quite relatable [sic] and had a down-to-earth manner’ (sGP12)pGP3, pGP5, pGP6, pGP9, PM16, sGP12, pGP19, pGP26, pGP32, pGP33
The student was clinically safe‘Knowledge base and medical techniques is what I would call fair to good’ (sGP17)pGP3, pGP8, sGP11, sGP12, pGP15, sGP17, pGP25, npGP30, pGP32, pGP33
Sharing enthusiasm‘It’s not really the business side of it. It’s more the altruism and the joy of letting people know that you are having a good time’ (sGP11)pGP5, pGP8, sGP12, pGP13, pGP14, pGP17, pGP22, pGP25
Scrutiny on the part of the student‘Having a student present has the effect of keeping me more intellectually honest. I know that any decision needs to make sense to the student… So it does put some pressure on me to at least maintain some element of consistency in clinical decision making. And that’s not a bad thing’ (pGP25)pGP15, npGP18, npGP20, pGP22, pGP25, pGP29, npGP30, pGP33
Clinical mastery‘It is good for my ego that after 20 years of practice there is someone there that you can teach something to and pass on some of your skills. And that is appreciated. It does make you feel good’ (sGP10)sGP1, pGP2, sGP10, sGP11, pGP22, pGP24, pGP32
Student learning‘Seeing someone have an understanding of something for the first time or putting new skills into use. Sometimes they come back and tell you they understand it now. That’s rewarding’ (sGP1)sGP1, pGP2, pGP8, sGP10, pGP22, pGP31
Social inclusion‘I wanted to involve him in some of my professional activities other than direct patient contact. I developed a rapport with [student name] when he was here last year so I have a bit of a connection there’ (sGP12)PM4, PM7, pGP8, sGP12, pGP32, pGP33
Student development‘It’s rewarding that you see them when they come in they have very little clinical experience and they don’t have the confidence that they do at the end of the year. The first 2 months the students are getting used to the clinical environment. The next 6 months they are really improving. And the last few months they are working more confidently. So there is a reward in seeing them develop’ (pGP14)pGP2, pGP3, pGP5, pGP13, pGP14, sGP17, npGP18, pGP25, pGP28, pGP31
Progressive authentic clinical participation‘To start off at the beginning of the year, the students try to take a history and a bit of examination but they didn’t really formulate any management plans so that when I come in there sometimes is still a lot to do. I think you look forward to coming to this stage of the year. At the beginning of the year there is a lot of input and you are not sure how they will go, but now you are starting to see results. The students start thinking for themselves and it pays off. The more you put in with them early on, the more it pays off’ (pGP14)pGP3, pGP8, pGP14, pGP24, pGP25, pGP33
Companionship‘I know from being a student, a doctor builds up a rapport with the student and they are more confident with that doctor… You can’t build that rapport with someone in that sort of student–teacher situation in a week. It does take a while before the students feel confident’ (pGP31)pGP2, pGP5, pGP8, pGP15, pGP19, pGP22, pGP31, pGP32, pGP33, S35, S38
Friendship‘Students become friends and it is easy to think of them as future colleagues. You hope future colleagues will respect your knowledge and get on with you’ (pGP2)pGP2, pGP8, pGP33
Mentorship‘To see people grow and to think that they develop their medical career as a result of being with me and in [town name]. That is exciting’ (pGP32)pGP2, pGP8, sGP12, pGP13, npGP18, pGP21, pGP25, pGP29, pGP31

Initially, students were often assigned a spectator role in the patient consultation process (sGP11, sGP17, pGP28, S35). When students engaged in a clinical role, it indicated that the doctor had entrusted them with some agency for the doctor–patient relationship (pGP8, sGP11, pGP21, pGP24, pGP30). If the student was deemed personable and safe, and demonstrated respect for the GP preceptor’s subject mastery, he or she was given the opportunity to actively participate in the consulting process. Doctors then reported that they frequently enacted dual roles of teacher and clinician (pGP3, sGP11, pGP13). In short-term rotations, GP preceptors gained positive feedback by seeing students learn discrete skills and through sharing their mutual interest in clinical medicine. In rural settings, personable students were often included in social activities to help them gain a perception of life as a rural doctor. There was little evidence that the personal or professional relationship matured beyond this superficial nature during short-term student attachments.

When students spent a full academic year learning in the practice setting, GPs were able to witness their development over time and to assist them towards progressively more authentic clinical participation. Students became sensitive to the pressures that affect GPs and described becoming helpful in the clinical setting. A sense of companionship would develop as GP and student worked together. Mentorship also occurred at times when a GP connected with a student to foster his or her professional values.

As doctors became more familiar with a student’s clinical performance, some doctors conceptualised their role in terms of facilitating the consultation in a manner that allowed the student and patient to meet one another’s needs. Precepting GPs continued to accept responsibility for patient care while ensuring that students took lead roles in consultations more frequently (pGP2, pGP8). In this process, both student and patient contributed to meeting the needs of the other party (pGP24, pGP28, S36). Patients received part of their health care from students (pGP8, pGP9, pGP25). Students benefited from experiential learning, from patients’ knowledge of their own illnesses and from direct patient feedback (pGP24, S36, S37, S38). Doctors described some initial feelings of awkwardness in using this symbiotic precepting style as the consultation felt disjointed (sGP1, pGP14, npGP20, pGP29) and reported a sense of holding themselves back (sGP1, pGP15, pGP17, npGP18). The effort of directing the flow of the consultation to allow the student and patient to meet their complementary agendas was initially demanding (pGP2, pGP28).

Interviews at the beginning, middle and end of the academic year demonstrated that themes pertaining to the doctor–student relationship developed in chronological order (Fig. 1). Doctors who precepted students on short attachments described the same steps in the development of their relationships with students as those who precepted students on longitudinal integrated placements; however, the shorter-term relationships failed to develop beyond a sharing of enthusiasm, social inclusion and the witnessing of isolated examples of student learning. As the relationship between doctor and student matured, doctors more frequently described changes in the way they managed the three-way relationship among doctor, patient and student within the consultation.

image

Figure 1.  Maturation of the doctor–student relationship. GP = general practitioner

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgments
  9. References

Factors described by GP preceptors in this study as adding value to their clinical role have been recognised in the medical education literature previously. They included variety from routine consulting, intellectual stimulation, reflective practice and personal learning, perception of oneself as a master clinician and preceptor, community of practice membership, kudos, the act of giving back, and recruitment.5 In this study, however, the benefits derived from all of these factors were demonstrated to be inconsequential in comparison with those derived from the doctor–student relationship. The lack of any of these factors was not recognised as a likely trigger for stopping precepting.

The primary significance of the doctor–student relationship in precepting has been suggested in previous studies, which have described positive student responses as the most significant factor in preceptor recruitment and retention.5,11

As the student and doctor developed their roles over time, the dynamics of the triangular relationship among doctor, patient and student were demonstrated to evolve. The student role progressed from being frequently passive, to one in which the student competed with the patient for the preceptor’s focus, until fulfilment of the student’s needs became symbiotic with the delivery of patient care. Precepting GPs described four distinct models of managing the triangular relationship in the precepting consultation (Fig. 2).

image

Figure 2.  Types of triangular interactions recognised in precepting consultations. (A) The student-observer model is focused on the doctor–patient relationship. (B) The teacher-healer model is expert-centric. (C) The doctor-orchestrator model allows the doctor to step back from interactions within the consultation. (D) The doctor-advisor model encourages the learner–patient relationship

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Early in any precepting relationship, when the GP did not know the student, the student was often found to have a passive role in consultations. At this stage, the student-observer model of precepting was more likely to be used (Fig. 2A). Doctors tended to behave as if the student was not present and sought to remain in control of the consultation.

Precepting GPs felt they were under pressure to meet the competing needs of patients and students and moved to act as the expert and primary providers of both patient care and student learning. They frequently adopted the teacher-healer model of precepting early in the attachment (Fig. 2B). This expert-centric model of consulting occurred when GPs felt uncomfortable about transferring agency of the doctor–patient relationship to the student, either because they were unfamiliar with the student or uncomfortable about his or her skills, or because they were protective of the doctor–patient relationship. Precepting GPs were aware of being more instructional in their consulting style in a manner that encouraged information to flow only one way, from doctor to student. This is similar to the ‘traditional transmission approach’ to precepting described by Bleakley and Bligh.12 In full-year attachments, this model of precepting often represented a transitional model which faded as the doctor developed a relationship with the student, or was used intermittently throughout the year to assess student progress.

Some experienced GP preceptors developed a precepting model in which they stepped back from their role as the primary participant in the relationship with the patient. These doctors conceptualised their role in terms of facilitating the student and patient to meet one another’s needs in this doctor-orchestrator model (Fig. 2C). These GPs continued to accept responsibility for patient outcomes, but worked to ensure that students took lead roles in consultations. Precepting GPs who adopted the doctor-orchestrator model of consulting described it as being easier when they knew the student well and when they considered the student to be highly competent and to use a systematic clinical approach. In this model, the student responded to the competing needs to achieve maximal patient outcomes and manage time constraints in partnership with his or her GP supervisor. In this way, the doctor-orchestrator model increased the student’s capacity to contribute towards fulfilling his or her preceptor’s needs. This precepting model is conceptually similar to the strong patient-centred model described by Bleakley and Bligh.12

In the traditional GP–registrar model of supervision (Fig. 2D), assistance is initiated and coordinated by the learner, rather than by the precepting GP. In this study, GPs rarely reported using the doctor-advisor model because it does not allow the preceptor to retain control of patient safety.

In this study, students gradually took responsibility for carrying out more complete and more complex consultation tasks. Precepting GPs described how student precepting took less effort over the course of the year. This corresponded with the reduced frequency in which they acted in a teacher-healer role. Walters et al.13 have previously shown that consultation times with this group of participants does not reduce as the end of the year approaches. This finding suggests that, with experience, operating within the doctor-orchestrator model takes less mental effort, but not less time.

The reciprocity between medical student learning and patient care in the doctor-orchestrator model builds on the model of four relationships described by Worley and colleagues by considering how symbiosis is achieved along the clinical axis (clinician–student–patient) from the perspective of the GP preceptor.14,15

The maturation of the doctor–student relationship over time not only explains how students become more useful over the academic year, but sheds light on how GPs are changed through the process of precepting. Students gradually developed identities as novice members of the medical profession.16 Precepting GPs then identified themselves as clinical teachers and this recognition of difference led to changes in their perceptions of self.12 The respect gained by GP preceptors from students, peers and patients reaffirmed their roles as experts in their field. This reinforced their motivation to ‘give back’ to the profession as this ensured the continuation of rural practice through the recruitment of new members.

The interactions and transformations that take place in this system of mutual learning and reinforcement have many similarities to those that occur with legitimate peripheral participation and situated learning in a community of practice.17 As Lave and Wenger describe:

‘Learning is, as it were, distributed among co-participants, not a one-person act. While the apprentice may be the one transformed most dramatically by increased participation in the production process, it is the wider process that is the crucial locus and pre-condition for this transformation. How do the masters of apprentices themselves change through acting as co-learners and, therefore, how does the skill being mastered change in the process? The larger community of practitioners reproduces itself through the formation of apprentices, yet it would presumably be transformed as well.’17

The central role of the maturation of the doctor–student relationship over time brings into question the assumption that previously recognised motivators for precepting were simply discrete positive factors, which can be weighed against negative factors in order to entice GPs to precept.18 Rather, these motivators may represent a group of constantly changing interconnected factors which contribute to defining preceptors as central members of their professional community of practice. This is a critical finding as it challenges the simplistic organisational development concept that universities can recruit and retain GP preceptors by increasing the rewards they offer. This finding presents an important alternative view which recognises the emergent, self-organising nature of precepting in the general practice setting.9,19 Further research using this new paradigm is required, especially with regard to how this finding may be apparent in and relevant to other clinical education settings, such as tertiary teaching hospitals.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgments
  9. References

Year-long student attachments allowed time for doctor–student relationships to mature, resulting in progressive changes in the dynamics of precepting consultations as students progressed in their authentic clinical participation. The evolution of doctor–student relationships in long-term student placements and the interconnected nature of the motivating factors explain how GPs come to recognise themselves as central members of their community of practice and how they respond to the drivers that sustain and renew this collective by embracing long-term students as novice members of this community.

Contributors:  all authors made substantial contributions to the study conception and design. LW acquired all the research data as part of her PhD research. LW analysed the data in a process overseen by DP, PW and JG. All authors contributed to the interpretation of data. LW was responsible for drafting the article. DP, JG and PW revised it critically for important intellectual content. LW and PW were responsible for drafting changes in line with referee comments. All authors approved the final manuscript for publication.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgments
  9. References

Acknowledgements:  the research team would like to thank the rural doctors, practice managers and medical students who participated in this study, and Dr Heidi Rolfe, the research assistant who interviewed the students.

Funding:  this study was funded through the core Rural Clinical School grant from the Australian Commonwealth Department of Health and Ageing. The funding source had no involvement in the study.

Conflicts of interest:  LW is academic director of the Flinders University Parallel Rural Community Curriculum.

Ethical approval:  this study was approved by the Flinders University Social and Behavioural Research Ethics Committee (Project 2872).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgments
  9. References
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