Original Research Articles

Symbiotic, medical student initiated community engagement on a rural longitudinal integrated clerkship

Background: Community engagement is an important aspect of a successful rural placement.


Materials and Methods: In this study, medical students undertaking longitudinal integrated clerkships at a rural clinical school instigated community engagement activities with a special school. Six health education sessions were delivered to eight adolescent special school students. This paper describes the perceptions of medical students and special school teachers in relation to the effect of this program on medical student personal and professional development, its acceptability by special school teachers, and the factors which contributed to the program outcomes. Two separate focus groups were conducted with seven medical students and two special school teachers.


Results: Theme 1: Symbiotic nature of the program. There was perceived improvement in the medical students’ communication, leadership and teaching skills, and their understanding of working with people with disabilities. Special school teachers noted benefits to their students from the health expertise and role modelling provided. The university experienced enhanced links with the community. Theme 2: Factors that contributed to the success of this community engagement activity. All parties wanted to engage in the program. Valuable time was spent developing relationships and preparing with all stakeholders. Constructive teamwork was paramount.


Discussion: Involvement in this program gave students a unique opportunity to develop skills in professionalism that are essential to working as health practitioners but difficult for universities to teach. The voluntary nature of the initiative was novel, promoting this skill development and enhancing the effectiveness of the program. The factors that contributed to the success of this program are potentially applicable to other settings.


Conclusion: This initiative was highly acceptable to the special school teachers involved and was perceived to have positive effects on medical student personal and professional development.


Medical student rural clinical rotations are well established in Australia and internationally [1-7]. Typically, longitudinal rotations involve students being placed into a rural community where they undertake their year’s university curriculum. These placements provide unique educational opportunities and are an important way to attract future doctors to address increasing rural workforce shortages [8].

The symbiotic clinical education model developed from research conducted on medical students completing longitudinal integrated clerkships (LICs) [9,10]. This model proposes that clinical education is underpinned by relationships between key stakeholders and that a symbiotic curriculum can be achieved if these relationships lead to mutual benefit. One of these key stakeholders is the community in which medical students are placed. Community engagement by medical students can therefore be seen as an important aspect of a successful rural placement.

Community engagement is also important for the future of our rural medical workforce. Studies indicate it is a predictor of longer duration of stay for rural doctors and that positive community engagement experiences encourage students and doctors to undertake similar activities in the future [11,12].

Monash University’s East Gippsland Rural Clinical School (RCS) was established in 2001 [13]. One of their sites is in Bairnsdale (East Gippsland, Victoria, Australia). Bairnsdale and its surrounds are classified as RA3 on the Australian Standard Geographical Classification – Remoteness Area (ASGC-RA), defined as ‘Outer Regional’ [14]. At the time of this study an integrated, community-based curriculum was provided for a group of eight fourth-year medical students during their five-year Bachelor of Medicine, Bachelor of Surgery (MBBS) undergraduate degree. Students lived and studied in East Gippsland for the entire academic year, while studying the disciplines of paediatrics, obstetrics and gynaecology, psychiatry, and general practice.


Materials and Methods


Seven fourth-year medical students from the East Gippsland RCS developed a community engagement program, which involved the delivery of six health education sessions to students at the East Gippsland Specialist School. This initiative developed after two special school teachers approached one medical student who had been volunteering at the school for assistance with health education, which they were required to deliver as part of the school curriculum. This medical student subsequently facilitated the development of links between the RCS and the special school, which led to the initiative growing and more medical students becoming involved.

The sessions were presented to one class of eight students, between 14 and 18 years of age, with autism, attention deficit hyperactive disorder, and learning disabilities. Various topics, content, and pedagogical approaches were used (Table 1). Each session was conducted by two to four medical students with the support of the two special school teachers. The sessions were developed by the medical students in consultation with the special school teachers. Resources were utilised from the local community health centre, East Gippsland RCS, and the local general practices, where the medical students were completing their clinical placements.

This paper describes the perceptions of the medical students and special school teachers in relation to the effects of the program on the personal and professional development of the medical students involved, the acceptability of the program to the special school teachers involved, and the factors which contributed to the program outcomes.


Data was collected at the conclusion of the program via two semi-structured focus groups; one with the seven medical students and another with the two special school teachers who had been involved in the program delivery. Informed consent was obtained from all participants. The focus groups were conducted by three of the authors (DGC, DCF, MAC), each of whom was employed by Monash University’s RCS in East Gippsland. These three researchers had existing relationships with the medical students whom they interviewed but had not previously met the special school teachers.

The focus group questions centred on three areas:

  • Perceptions of the program content and delivery methods
  • Perceived impact of the program on the special school students, medical students, institutions, and other groups or individuals
  • Challenges and future improvements

All information was audio recorded and transcribed. A mixed deductive and inductive analysis was completed. We hypothesised that the program impacted on the medical students, special school teachers, school students, and potentially other stakeholders, and thus used this as a framework to guide our analysis. Data coding was completed by hand. The initial data analysis was completed by AD, a staff member working with the East Gippsland RCS and was not involved in the program delivery. Three other authors (TAW, DCF, and DGC), one of whom (TAW) was a medical student involved in the program, coded sections of the data independently. The four authors (AD, TAW, DCF, and DGC) then cross-checked codes and subsequently came to a consensus on the themes.

Ethics approval

Ethics approval was obtained from the Monash University Human Research Ethics Committee (Approval Number: A8/2009 2009001726). Consent was obtained from study participants for publication.



Two main themes were identified: the symbiotic nature of the program, and the factors that contributed to the success of this community engagement activity.

Symbiotic nature of the program

The program was perceived to have mutual benefits for all involved. Its symbiotic nature was reflected by one student stating “… it was a real reciprocal thing. It felt like you were really giving… [the special school students] an opportunity to learn, but at the same time it was a personal experience of growth and learning.”

Table 1. Descriptions of the six topics covered in the health education sessions.
  1.  Benefits to the medical students and university:

Development of communication, organisation, leadership, & teaching skills

The medical students reflected that “it [community engagement] really helped us grow as people and as future doctors.” They felt that they improved their communication, organisation, leadership, and teaching skills, with another medical student commenting, “It gave me the opportunity to teach… It was a challenge at times to keep [the special school students’]… attention… and you had to learn techniques to hold the audience.”

 Insight into interacting with and caring for a person with a disability

The program encouraged the medical students to develop their understanding of developmental disability, as “…it was an opportunity for… [medical students] to appreciate what it was like to interact with these… children.” One medical student reflected on parallels with the medical curriculum by stating, “…the range of issues these… [special school students] face might not be as wide as the whole developmental disability curriculum encompasses… but the teaching gave us a much deeper insight than I think we would have got reading text or listening perhaps to a lecture, because you meet these kids one-on-one…” The medical students felt that they would be more comfortable in the future when seeing patients with a disability. One student commented: “…when we are interns… and someone with a disability comes in we might change the way we interact with them.”

 A desire for future community engagement

Medical students were enthusiastic to continue their involvement in community engagement activities. They felt that the experience had opened their eyes to the possibilities to help in their community, with comments such as “it was a good example for me of how you can become engaged in a community [as a doctor].” Another stated, “the difference you can make as a clinician and as a teacher is really inspiring.”


Table 2. Themes and sub-themes identified from the focus groups.
  1. Benefits to the special school teachers and students:

It was perceived that this program benefited the special school students and its teachers. The teachers were positive in their reflections, stating “…it has been very impressive…”

 Health expertise and behaviour change

The teachers at the special school were positive about the impact on their students, saying “…I really do believe that they have got a lot out of it. It has been hugely beneficial.” It was not compulsory for special school students to attend these sessions, however “…[special school students] kept turning up and staying in the sessions… if they didn’t like it, they wouldn’t have stayed there.” The teachers were impressed by the focus shown by special school students during the sessions, which they believed indicated their level of engagement with the medical students.

 This was reiterated in the reflections of the medical students, who also thought they had provided the special school students with a foundation to influence future decision-making. One medical student expressed, “They were actually responding and getting engaged in these issues. I hope that is a step in the right direction.” Another added, “It is not going to change massive things but it plants a seed, I think.”

The teachers felt they too gained a greater knowledge of the topics: “There were different terminologies and things that I learnt as well.” They believed an important factor was that the information presented was tailored to their students, acknowledging “…[the medical students] targeted everything very well in relation to the issues that… [special school students] are going through at the moment.”

Breaking down barriers

It was suggested that the program helped in breaking down barriers between the special school students and health professionals, making it more likely that these students would seek medical help when needed. One medical student reflected “… maybe it will make doctors seem less intimidating later if they need to see one.”

 Links within the community

Overall, the medical students and special school teachers believed that the program had enhanced relationships between the East Gippsland Clinical School, the medical students, and the local community.

Factors that contributed to the success of this community engagement activity.


  1. All parties wanted to engage:

It was suggested that the program would not be as successful if it was compulsory for the medical students. One student stated, “if anyone went there and didn’t really want to, it could be destructive both from our point of view and for the kids.”

 Support from both organisations was essential for this engagement. In addition to permitting medical students to take time out of scheduled activities, the RCS gave them access to equipment and facilities. One student said, “We contacted people at the community health centre or we used equipment from … [East Gippsland RCS] …” The special school was equally supportive and accommodative of the program, providing staff, a workplace, equipment, and remaining very flexible with teaching times.


  1. Taking time to develop relationships:

The trust and rapport established between the medical students, special school students, and teachers was perceived to be paramount to the program’s success. A special school teacher commented, “A big part with these kids is trust… They did so well to attend these sessions and ask questions and I think they felt comfortable enough to be able to ask questions.” The medical students also believed their relationship with the special school students grew over the course of the program. One student commented, “I was involved in three sessions… and definitely by the third one [engagement improved]. …I felt like I got to know… [the special school students] reasonably well …and the sessions got better.”

Teachers felt that the medical students’ contact with the specific special school class prior to beginning the program assisted in tailoring the sessions appropriately. They stated that the “… [medical students] knew what type of kids they were going to deal with, so that prior knowledge… definitely helped to make these sessions a success… If you were just sending medical students into a classroom you would really be running blind because you don’t know the personalities of the students…”

The medical students also stated that the prior knowledge of the school, students, and staff helped them feel comfortable and was integral to the success of the program. It was suggested that if the program were to be repeated in the future, “…you would need one or two people… to go into the school for a few months and just… get to know how things work.”


  1. Collaborative input into the development of the program and activities:

Both medical students and the teachers agreed that cross-checking the content of each individual session helped both parties prepare for the sessions. One teacher stated, “…[the medical students] rang me before the sessions… [and] went over everything.” A medical student concurred, “…the teachers appreciated… the process of going back to them before a session and checking [the content] with them.”


  1. Leadership:

Having one person dedicated to liaising with all the stakeholders and to delegating the planning and implementation of each session was seen to be important. A medical student stated, “[One of the medical students] …has put in a huge amount of work and unless someone is prepared to be that person then I don’t think it will work as well [in the future].”


  1. Facilitators worked as a team:

Knowing each other was perceived to help the medical students facilitate the sessions effectively as a team. One medical student observed, “…we really tried to look at the strengths of different people in the group… As a group of students running the sessions we need to be comfortable with each other as well.” The teachers reiterated that “…[medical students] worked as a team” and “…were well organised.”


  1. Preparation of teaching sessions:

Both the teachers and medical students frequently mentioned the need for well-prepared sessions. There were however difficulties for the medical students, with one stating that “…one of the downsides is the time it takes to prepare for it, on top of everything else we are doing.”

 Special school teachers felt it would be helpful to have a set schedule, noting “There were a couple of times where the sessions had to be changed… That is the only drawback… [some special school students] don’t take change very well.”

The medical students reflected that the best way to run the sessions was to plan activities and refresh their knowledge of the topic, but to also be flexible and to adjust the sessions as they proceeded. One medical student commented, “…for me it was about having as much information in my mind ready for the session and just sort of letting the group go with it a bit and still bringing it back on track… it was really quite fluid.” The teachers were impressed by this approach, stating that “… [medical students] prepared the lessons but they would also get a feel for what …[the special school students] knew.”

  1. Non-didactic facilitation techniques:

Hands-on activities and discussions were reportedly preferable to didactic lessons. One special school teacher recalled, “There was only one session… that didn’t really have a lot of visuals. You could tell when they didn’t have the handson activities and visuals that… [special school students] weren’t as attentive.” Special school teachers went on to say that more hands-on activities would make sessions even more effective at engaging the special school students. They also suggested that having the key session content in writing would be beneficial.

One important aspect of the medical students’ approach to teaching was said to be a focus on informing special school students about consequences of their behaviour, rather than simply telling them that it is wrong. One student said, “The sessions… [were about] educating and saying ‘look, these are the risks and these are the issues’…rather than saying… ‘you shouldn’t do this because it is wrong.’ That helped with the engagement.”

  1. Intra-generational education

The teachers thought that having medical students conduct the sessions was particularly beneficial, as their ages and experiences were more identifiable to their students. It was noted, “… [special school students] connect with that … [medical students are] not old, they’re still cool!”



The results reflect our hypothesis that the program impacted stakeholders in positive ways, as well as presenting challenges for those involved. Of particular note was the perceived importance of the symbiotic nature of the program in contributing to its success. We had not foreseen the enhanced relationship that was thought to develop between the East Gippsland RCS and the local community. This was an important institutional benefit, as relationships of this nature are essential for the success of the LIC model in East Gippsland. Furthermore, universities have community engagement responsibilities and need to remain ‘socially accountable’ [15].

We also noted the responses of the medical students in relation to the perceived impact of the program on their personal and professional development. The skills in communication, teamwork, leadership, and organisation that the medical students were reported to have developed were important outcomes of the program. These are key skills highlighted in the Australian Curriculum Framework for Junior Doctors [16], and are difficult skills for a university to teach.

Determining the impact of this program on the special school students is beyond the nature of this research. Our paper does however highlight how this program provided an innovative and engaging way for the special school teachers to deliver areas of their health education curriculum.

A number of potential limitations must be considered when interpreting the results. Pre-existing relationships existed between the researchers conducting the focus groups and the medical student participants. This, along with a lack of anonymity within a focus group format, may have prevented participants from discussing concerns they had with the program. The results are also potentially limited by small participant numbers. Including additional stakeholders in the focus group discussions, most particularly the special school students, would have been beneficial but was difficult due to ethical considerations around interviewing a potentially vulnerable group.

We consider the East Gippsland RCS’ role and the fact that this was a voluntary, student-driven initiative to be of key importance. This is highlighted through the comparison of our program with a similar program where medical students based at a RCS (in NSW, Australia) were placed at a special school as part of their paediatric studies [17]. The main difference between both initiatives was that the program in NSW was designed and implemented by the university whereas our program was student initiated and directed. In both cases benefits were experienced by all stakeholders. There were however drawbacks to the NSW program. Its compulsory nature may have forced some medical students to engage against their will, which, as highlighted by one of the respondents in our focus groups, could have negative ramifications. Furthermore, the medical students in our study had far greater opportunities to develop their leadership, teamwork, communication, and organisation skills as they were the drivers of the initiative. There were also drawbacks to our program. The medical students found it challenging at times to balance their existing curricular commitments with this extra activity. Furthermore, the non-compulsory nature of our program means that its future is uncertain and depends on the motivation of subsequent medical student groups. Overall, we consider the positive aspects of this voluntary, student-driven model to outweigh the negative aspects.



This voluntary, medical student-initiated community engagement activity which took place during LICs was perceived to impact positively on the personal and professional development of the medical students involved, as well as being acceptable to the special school teachers. The factors that contributed to the perceived success of this program could be applied to other settings where students have the opportunity to engage with their local community. We encourage universities to play a supportive role by linking students with the local community and fostering any constructive opportunities that arise.


Conflict of interest

None declared.



[1] Heddle W, Roberton G, Mahoney S, Walters L, Strasser S, Worley P. Challenges in transformation of the “traditional block rotation” medical student clinical education into a longditudinal integrated clerkship model. Educ Health (Abingdon). 2014;27(2):138-42.

[2] Sturmberg JP, Reid S, Khadra MH. A longitudinal, patient centred, integrated curriculum: facilitating community-based education in a rural clinical school. Educ Health (Abingdon). 2002;15(3):294-304.

[3] Walters L, Greenhill J, Richards J, Ward H, Campbell N, Ash J, et al. Outcomes of longitudinal integrated clinical placements for students, clinicians and society. Med Educ. 2012;46(11):1028-41.

[4] Bonney A, Albert G, Hudson J, Knight-Billington P. Factors affecting medical students’ sense of belonging in a longitudinal integrated clerkship. Aust Fam Physician. 2014;43(1):53-7.

[5] Strasser R, Lanphear J, McCready W, Topps M, Hunt D, Matte M. Canada’s new medical school: the Northern Ontario School of Medicine: social accountability through distributed community engaged learning. Acad Med. 2009;84(10):1459-64.

[6] Tesson G, Strasser R, Pong R, Curran V. Advances in rural medical education in three countries: Canada, the United States and Australia. Rural Remote Health. 2005;5(4):397-405.

[7] Talbot J, Ward A. Alternative curricular options in rural networks (ACORNS): impact of early rural clinical exposure in the University of West Australia medical course. Aust J Rural Health. 2002;8(1):17-21.

[8] Orpin P, Gabriel M. Recruiting undergraduates to rural practice: what the students can tell us. Rural Remote Health. 2005;5(4):412.

[9] Prideaux D, Worley P, Bligh J. Symbiosis: a new model for clinical education. Clin Teach. 2007;4:209-12.

[10] Worley P, Prideaux D, Strasser R, Magarey A, March R. Empirical evidence for symbiotic medical education: a comparitive analysis of community and tertiary based programmes. Med Educ. 2006;40:109-16.

[11] Page S, Birden H. Twelve tips on rural medical placements: what has worked to make them successful. Med Teach. 2008;30(6):592-6.

[12] Smith J, Weaver D. Capturing medical students’ idealism. Ann Fam Med. 2006;4(S1):S32-S7.

[13] Celebrating 25 years of rural health education 1992-2017 [Internet]. Monash University; 2017 Sep [updated 2017 Sep; cited 2017 Nov 11]. Available from:

[14] Australian standard geographical classification – remoteness area (ASGC-RA) [Internet]. Department of Health; 2016 [cited 2016 Mar 7]. Available from:

[15] Boelen C, Dharamsi S, Gibbs T. The social accountability of medical schools and its indicators. Educ Health (Abingdon). 2013;25(3):180-94.

[16] Australian curriculum framework for junior doctors. Confederation of Postgraduate Medical Education Councils; 2009.

[17] Jones P, Donald M. Teaching medical students about children with disabilities in a rural setting in a school. BMC Med Educ. 2007;7(1):12.