Reimagining rural clinical education from lessons learnt during COVID

Securing access to sufficient and focussed learning experiences is a perennial challenge for medical trainees. This challenge was accentuated during the COVID‐19 pandemic lockdowns and with physical isolation processes that decreased in‐person patient presentations and a shift to telehealth consultations. This situation has prompted the need to optimise the available experiences and educational responses to overcome the limitations in the number, quantum and range of available clinical learning experiences.

such as digital health consultations, it is timely to re-imagine how medical trainees' clinical education in rural general practices might be orientated to optimise the available experiences.The specific focus here is on how to optimise those experiences in the development of trainees' ability to generate effective and applicable learning, including the development of mental models through engaging in medical tasks.
Mental models refer to those we create to imagine and mentally rehearse an activity before we conduct it and also to monitor its progress. 1,2This phenomenon is also described as simulations that include using existing knowledge to fill in for parts of a process that we cannot access through our senses (e.g.sight, sound). 3e learning potential of engaging in everyday healthcare activities and interactions is well acknowledged. 4Moreover, the sequencing and kinds of engagement in workplace activities, referred to as the practice curriculum, 5,6 are important for the structuring of and enhancing educative experiences, and that particular work activities are pedagogically rich, that is, having great potential to support that learning. 7Yet, these activities tend to rely on interpersonal interactions amongst healthcare practitioners, which were reduced due to physical distancing.Therefore, given restrictions on providing clinical experiences, there is a need to identify how trainees' clinical experiences can be most effectively organised and utilised for both patient care and their learning to support structured clinical training that meets the exigencies of general practice.
The learning potential of engaging in everyday healthcare activities and interactions is well acknowledged.
Many experienced general practitioners (GPs) know how to organise the sequencing of trainees' activities and interactions, based upon tried-and-tested practices, 8 and these are often reflected within the learning curriculum in practice settings/communities. Thus, it is important for the trainees (i.e.novices) to experience the process to participate in the healthcare community, becoming part of a community of practice. 9Yet, some of these practices were disrupted and transformed during COVID-19 pandemic lockdowns.For instance, medical practitioners preferred to work from home than in the surgery, and only the most urgent and necessary of patients attending face-to-face consultations have limited the range of clinical educational experiences. 10The most likely consultations taken through telehealth were routine cases that can be effective for novice practitioners to engage.
Those telehealth consultations were universally reported as being through conventional mobile phones as these were widely used by patients in rural communities and offered a convenient technology for medical practitioners.
It seems the effective facilitation of practice-based learning by general practice trainees includes educational alliances amongst GPs and trainees, 5 the availability of timely support and guidance and stimulating and manageable workloads.The question is how these qualities can be sustained under the changed circumstances and regimes of interactions amongst supervisors, trainees and patients.The quality of these learning experiences per se is found in the kinds of activities and interactions available to trainees (i.e.workplace affordances) and how they engage with them. 11The quality of that engagement is central to the development of the knowledge required for effective clinical practice mental models or simulations.This is likely to be a particularly salient attribute when engaging in telephone consultations, when the kinds and qualities if immediate engagements (i.e.observations) are not available.
The effective facilitation of practice-based learning by general practice trainees includes educational alliances amongst GPs and trainees, the availability of timely support and guidance and stimulating and manageable workloads.
Importantly, as indicated, the ability to simulate in this way is premised on the kinds and extent of previous experiences that allow them to be effective, including filling in parts of observations that are not available through telehealth (e.g.being unable to conduct a physical examination).Whilst the experiences afforded provide a basis for that development, ultimately, it is individuals' active construction, utilisation and appraisal of what they experience that is central to their effectiveness.That is not to underplay the importance of access to expert guidance.Indeed, recent work on trainee help-seeking during consultations has identified the importance of identifying and reducing barriers for trainees to engage with and seek assistance from practice staff. 12 all, providing an adequate quantum and quality of experiences for occupational preparation is a perennial issue within healthcare, and those in rural general practices are no exception.Yet, the risk of further disruptions (e.g.other pandemics and climate crisis events) accentuates the need to adjust medical work and clinical education to identify effective responses to this long-standing problem.Thus, the project reported and discussed here sought to address the following research question: How can the available experiences be organised and enacted to optimise the development of medical trainees in the face of ongoing disruptions?This question was addressed in the context of rural general practices.There are differences between urban and rural general practices that might influence training and learning experiences.Rural general practices typically extend their primary care to an underserviced population, thus providing the opportunity to experience a greater diversity of patient population. 13They are more likely to be small businesses, having practice managers, GPs, practice nurses, receptionists, registrars and medical students (i.e.practice team) working in a general practice and across other community settings (e.g.aged care or public hospitals). 14To address rural healthcare workforce shortages, trainees will continue to be overrepresented in rural practices. 14

| METHODS
To address this question, a focussed investigation was conducted of four rural general practices in the state of Queensland, Australia.The intention was to map the changes that occurred in these rural general practices during the pandemic, and we sought to identify features of sustainable learning processes for trainees, which accommodate the changing requirements of rural medical practice, including telehealth consultations.Ethical approval of the research was granted from Griffith University Human Research Ethics Committee (approval number 2020/573).
Semi-structured interviews were conducted with practice team in four rural general practices.As noted, these rural practices are small businesses in which the informants comprised one practice manager, one practice nurse, one receptionist, one registrar and one medical student (if available).The informants were asked to gauge the extent of the changes brought about by the COVID-19 pandemic on the general practice, their role as workers, patient engagement and care and teaching processes and outcomes.Common questions were addressed by all informants, with specific queries directed to GPs, registrars and medical students about their clinical education experiences during the pandemic.That is, GPs were asked about key issues for supervision, whereas registrars and medical students were asked about key issues for their learning.These were directed to addressing what might constitute effective clinical education in the future.By capturing and delineating the emerging needs brought about by innovations such as telehealth, working with patients remotely and new modes of patient engagement, both the goals and processes of medical trainees' learning in that period were identified.
Six-phase thematic analysis, using a hybrid approach of inductive and deductive analysis, 15 was conducted to identify changes in practice, changes in the roles of the practice team, activities and interactions occurring during COVID-19 pandemic.That is, a combination of 'theory-driven'/'analyst-driven' (i.e.deductive-producing codes relative to a pre-specified conceptual framework or codebook) and 'data-driven' (i.e.inductive-producing codes solely reflective of the content of the data) approaches was adopted.
During phase 1, 'familiarisation with the data', the researchers read through the entire data set and actively engaged with it by searching for patterns of meaning.In fact, the interviews were manually transcribed by the researchers in addition to notes taken during the interviews, thus facilitating a deep immersion into the data.In phase 2, 'generating initial codes', segments of data (e.g.phrases/sentences, interview extract or brief summary of an interview extract) were noted.The generated list of codes was collated to be considered in phase 3, 'searching for themes'.This phase involved the researchers' active interpretation of the codes, conceptualising patterns and their relationships within the data.Codes relating to changed roles, for instance, were assessed against activities or interactions-those relating to challenges against clinical or operational decision-making, thus overcoming these challenges entailing clinical or operational solutions.These codes were reviewed in phase 4 to develop provisional sub-themes/themes.Theme interpretation was discussed amongst the research team to accurately represent the dataset.In phase 5, 'defining and naming theme', individual themes and sub-themes were expressed in relation to both the dataset and the research questions.The final phase, 'producing the report', involved writing in detail about the thematic analysis process from phase 1 to phase 6 as briefly discussed above.
However, the process reported in this paper aimed to move away from an orthodox reporting of interview data, that is, reporting themes and data extracts as interview quotes, which best represent a particular theme that emerged from the analysis.Alternatively, it reported findings emerged from the aggregated data and analysis (i.e.themes and sub-themes), with a particular focus on learning processes identified for trainees to accommodate changing requirements of rural medical practices.To add rigour to the analyses and the process of developing propositions that synthesised key findings and recommendations, the research team engaged in the exercise of identifying and summarising (i) key changes that each of the informant categories (i.e. the practice team) faced, (ii) the implications for changes in the operation of rural general practices in the future and (iii) the ways these changes would be operationalised.In this way, the researchers engaged in reflexive thematic analysis 16 in which all researchers were involved in the analytic process; thus, the coding approach was collaborative and reflexive, developing a richer more nuanced reading of the data, rather than seeking a consensus on meaning.That is, themes were constructed through researchers' reflective and thoughtful engagement with the data and their reflexive and thoughtful engagement with the analytic process.
The analysis was also undertaken to identify the impacts of those changes on trainees' learning experiences.These impacts were assessed to be positive or negative for associated implications to be generated.The key changes the informants reported to have encountered during the pandemic were synthesised into six key propositions.In Table 1, these propositions are listed on the left-hand column and associated illustrative quotes on the right.

| FINDINGS
From the data aggregated under these propositions, it was possible to identify both positive and negative impacts reported by informants' experiences during the periods of lockdowns.These impacts are summarised in Table 2.
Together, these data suggest that there had been significant changes within these four rural general practices in terms of how they operate, practitioners' roles and processes of patient engagement and care, because of the coronavirus and that there may be significant benefits to be obtained through learning from these experiences and how these could be used in the future to organise rural general practice, the enactment of its healthcare provisions and the reordering of work roles.The findings associated with registrar and student learning warrant careful consideration to maintain the quality of teaching and learning experiences.
T A B L E 1 Key changes to trainees' education.

# Propositions
Representative quotes

Trainees had fewer and different learning opportunities
Insufficient educational session opportunities: 'It was because people were involved in planning meetings and all the rest of it that tied up the teacher's time or the medical staff or the nursing staff time so that they didn't then have time to engage in teaching as they normally would' 'Some of the content had to be reshuffled around so that you and some of the emphasis taken away from practical hands-on learning to more theoretical because of the restrictions with hand hygiene and PPA and the numbers that you're allowed and the space allocations' 2 Medical students had fewer opportunities to perform physical examinations 'Students were excluded from clinical settings in general practice because of COVID, unable to see patients, less observation of the clinical consultation' 'Less personal contact with patients meant for me less physical exams.And that was something we like positioning people, not doing it on different body habitus and things like.I think that's a really good learning point.And I felt like I missed out on that because of the pandemic' 3 Trainees experienced a sense of isolation 'Most of education sessions are online so it's harder to engage and it's a bit isolating for not being able to get interaction with other doctors' 'It's just harder to engage when you're sitting staring at a screen for three hours compared to sitting in a room with colleagues.And I suppose that's a little bit more isolating as well.So getting that interaction with other doctors at your level is not they don't really get to just chit chat.I assume it doesn't facilitate that' 4 Effective training and support for registrars in telehealth was needed 'As a registrar, the challenge was to get to know their patients that adds an extra layer of difficulty and the patient doctor relationship' 'Our books were very quiet for the registrars.And also, I guess that's a patient's preference while wanting to see their own GP during the pandemic, which is, you know, mental health challenge' 5 The online learning provided to trainees was of high quality 'One of the things I really liked was the emphasis of education remotely.So, for example, there were educational sessions that are now recorded that are now able to be seen online' 'We've done all of our education sessions online this year, so that would normally be, you know, fortnightly of every three weeks face to face with all the other registrars at my level.And that's all been over overconsume.And the educators have done the very best that they can to make it, you know, worthwhile and quality' 6 Face-to-face collegial interactions between supervisors and registrars needed to be maintained 'The key thing here is direct supervision, and I've certainly spoken to people about this, you know, actually having somebody sitting with you for he doesn't have to be a whole session, half a session, whatever it is, and watching you and then giving you some feedback' 'The negatives there's been a loss of face-to-face time, loss of supervision time, loss of teaching time' To learn in and through clinical practice is to participate actively, authentically and incrementally in the practice community. 9Through these learning experiences, trainees can develop the capacity to generate mental models (i.e.simulations) [1][2][3] that permit them to plan and enact effective clinical care.Therefore, providing experiences for trainees to participate in fully as possible in clinical activities is imperative.The investigation identified key focuses for developing trainees' capacities to participate fully in clinical practice through a set of experiences that incrementally develops their ability to simulate 1-3 effectively.Through providing experiences for these trainees, it is proposed this engages them in ways that can develop the kind of cognitive representations that permits them to effectively engage in clinical practice through being able to mentally rehearse and consider strengths and limitations, alternatives as well as potential and likely outcomes.All of these can be imagined as part of differential diagnosis.To optimise this development, the sets and sequencing of activities (outlined below) are premised on incrementally preparing the trainee to engage in and conduct clinical consultations remotely using mobile telephones.In the early phases, there were fewer consultations overall, so registrars had less patient exposure and were also less likely to sit in with their supervisor as medical students did.There were difficulties with engagement across the practice team (including when working from home); training in technology and issues of poor connectivity; and patients with impaired hearing added to the challenges they faced.Yet, experiences with phone triaging were reported to be helpful and offered a means of enacting a learning curriculum in terms of engaging activities progressively through which they will build capacity and reduced risk of causing harm and the trainees' readiness to participate in these activities.

Practice processes ensuring trainees' in-person clinical consultations with patients
Prior to engaging with patients remotely or through electronic or phone consultations, it is important that trainees have experience with in-person clinical consultations to develop the initial capacities required to conduct that work then later perform these tasks through remote means.The fact that human cognitive capacities can 'fill in' elements of human experiences that are not accessible or visible, we can simulate these.However, the ability to use those imaginative processes arises from having had the initial experiences that enable those activities to occur, a result of the mental models created.
Prior to engaging with patients remotely or through electronic or phone consultations, it is important that trainees have experience with in-person clinical consultations to develop the initial capacities required to conduct that work then later perform these tasks through remote means.
2. Practice processes ensuring trainees' opportunities to engage with

GPs and other staff
Throughout medical procedures, it is important that trainees engage with GPs and other practice staff as routinely as possible, not the least, because there are increasing numbers of activities enacted by a need to be coordinated across the entire practice team.Given the reduced opportunities for this to occur, it may be necessary to consciously structure these interactions rather than relying on it arising through the day-to-day activities.

Training in use of digital health technologies for all staff
Trainees should have opportunities to develop the capacities in the digital health technologies, databases and practice software prior to engaging directly with patients.That is, having addressed these technical aspects competently and easily, the trainees can focus on patient engagement.

Training and experiences with triaging patients for appointments
Before engaging with patients remotely for clinical assessments, medical students could be provided with experiences of engaging with patients to make initial judgements about whether a faceto-face or remote consultation is initially more appropriate then triaging patients accordingly, following clear guidelines.Again, the sequence is of developing the capacities to interact with patients in activities in which communication skills can be honed and an overall clinical assessment undertaken, prior to exercising these capacities in the more demanding tasks of entire telehealth consultations.

Training in effective patient consultation via telephones
Having developed understandings about and procedures for engaging with patients remotely, trainees could engage with training experiences on how to conduct effective patient consultation, albeit more consciously enacted in these circumstances.Such experiences might include listening in to those being conducted by more experienced GPs to gain access to and insights about models of approaches to and processes of these clinical activities and then engaging with a debrief at the end of these consultations.

Trainees' involvement in telephone consultations
The sequencing of trainees' direct involvement in telephone consultations was premised upon their familiarity with patients and personal readiness.Their first few engagements in these consultations might be monitored by a more experienced practitioner to provide guidance, support and evaluation of how they are progressing.

| CONCLUSIONS AND IMPLICATIONS FOR THE POST-COVID ERA
Using the data about changed work and educational circumstances during lockdowns and drawing on practice theory, 9 our analysis proposes the optimisation of these experiences to develop trainees' capacities to effectively undertake clinical work, including telephone consultations.The answers are found in the practices of the healthcare community. 9The listed six sets of activities are set out as bases for trainees to engage in clinical education through restricted access to patients and through telehealth.Our findings offer important insights for how to sequence learning in clinical setting to develop trainees' capabilities in conducting telehealth consultations and in the post-Covid era.Central here is the reminder that the sequencing of medical trainees' experiences (i.e. the learning curriculum) needs to progress in ways that promote the capacities for more informed diagnoses.This sequencing likely includes (i) an initial period of observation 'sitting in' on consultations by a general practitioner; (ii) progressing to parallel practice in which the student/junior doctor engages in history taking and examinations and then consults with general practitioner; and (iii) independent practice in face-to-face consultations, if possible, before moving on to online or phone consultations, triaged in ways that progress from routine type of consultations into those that might be more challenging.The principle enacted here in progressively building capacity also includes enhancing the ability to engage with patients online, informed by what they experienced and come to know through initial face-to-face interactions.It is these earlier experiences that provides the basis for imagining and simulations 3 and that provide the ability to 'fill in' what might not be able to be experienced directly.Such an approach may not always be easy or possible to fully enact.However, it offers a pathway of experiences that are most likely to lead to positive outcomes for the trainees whilst maintaining patient care and safety considerations.These suggestions are borne out of data from the relatively constrained circumstances that arose through rural general practices coping with the social distancing requirements of COVID-19 pandemic.However, they also point to addressing the long-standing problem of how best to provide the adequacy of workplace learning experiences and circumstances of reduced access to patients and increasingly working through electronic technology.The required responses from these rural general practices provide insights into how those practices might be enhanced and structured more effectively.Central here is having practice communities that are conscious of and actively seeking to secure these experiences for trainees, whether these are medical students, junior doctors or registrars.

A
total of 23 informants were interviewed, comprising doctors (n = 3), junior doctor (n = 1), registrars (n = 4), medical students (n = 3), practice managers (n = 4) and practice nurses (n = 4) and receptionists (n = 4).Significant changes (i.e.changes to aspects of the practice) to patient engagement and care were reported by 16 of the informants.Many of these informants (n = 11) claimed there were major changes (i.e.transformation of how the practice operates) to their roles.These data suggest that key changes have occurred in the organisation of the general practices and the enactment of the patient care processes that are enacted within them.This suggests that considerations associated with reorganising and restructuring general practices may be required, as well as the development of skills associated with roles within the general practice, and in particular, patient engagement and care.Hence, both organisational development and healthcare practitioner learning are indicators being warranted here.
T A B L E 2 Impacts of changes for trainees' education (i.e.registrars, junior doctors and medical students).