Original Research Articles

Australian medical students’ desire to become a general practitioner: has it changed between 2009 and 2019?



There is major concern given the reduction in junior doctors applying for general practice training positions, which has considerably dropped in recent years. It is possible that medical student perceptions of a career in general practice influence the later decision to choose general practice as their first-choice specialty and apply for general practice training positions.


To examine the changes in Australian medical student perceptions of a career in general practice by a cross-sectional analysis of student cohorts in 2009 and 2019.


Two identical cross-sectional studies were administered in 2009 and 2019 via an online quantitative survey to understand medical student perceptions of a career in general practice.


Almost 6% of all Australian medical students responded to the survey (1129 in 2019 and 1227 in 2009). Medical students’ positive perceptions of a career in general practice increased by 6.5% from 2009 to 2019 (p<0.0001). Over the same period, the proportion of respondents who agreed that general practice provides the opportunity to pursue diverse special interests increased by 12% (p<0.001), while there was a 9.8% increase in respondents who agreed that general practitioners have a healthy work-life balance (p<0.001). One in five respondents reported not knowing or feeling neutral towards the ability for general practitioners to earn a sufficient income. General practice was perceived to be as challenging as other specialties in both surveys.


Medical students’ positive perceptions of holistic patient-centred care, ability to pursue special interests, and work-life balance are important in ensuring a sustainable primary care workforce. Further education regarding the ability of general practitioners to receive appropriate remuneration is crucial to encouraging medical students to pursue a career in general practice. Given the consistently high levels of interest from medical students, future interventions should shift to focus on promoting general practice to junior doctors.

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Original Research Articles

Exploring the reasons for medical student participation in peer mentoring programs

Reasons why students participate in an existing student lead peer-mentorship program were explored. Tailoring a mentoring program may improve participation rates.

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Original Research Articles

Enablers and obstacles to medical student satisfaction during obstetrics and gynaecology rotations


Providing care for pregnant women and responding to obstetric emergencies are tasks which medical graduates are expected to be competent in performing. To ensure this, Australian medical schools have set clinical learning objectives for students to achieve during their obstetrics rotation. Alarmingly, several studies have shown students are struggling to participate in these clinical experiences, especially the birthing process. Further evaluation of student experiences on labour ward is needed to identify common concerns and to improve the overall educational experience.

Materials and Methods

Year 5 medical students from James Cook University completed an optional anonymous questionnaire at the end of their Reproductive and Neonatal Health (RNH) rotation. A cross-sectional analysis was performed on responses. Open-ended responses underwent a content analysis and both common positive and negative themes were identified.


Assisting in deliveries and surgical procedures were regarded as highly valuable learning experiences. Male students reported that their gender was a clear drawback to their rotation experience (p <0.001). Competition with midwifery students and poor interactions with midwifery staff were common themes reported and contributed to 57% of students experiencing difficulty gaining clinical exposure whilst on labour ward.


Difficulty in gaining clinical experience within labour wards is increasing as the number of health care students continues to rise and the birth rate falls. The presence of gender bias and misunderstanding of student learning objectives by midwives further contributes to the competitive environment experienced by medical students during their obstetrics term. Greater collaboration and communication between medical schools and midwifery staff is vital to ensure quality education continues to be delivered and clinical requirements are achieved. The use of simulation training should also be further explored as a means to provide standardised educational experiences.

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Original Research Articles

Welcome to the wards: Pilot study on microbial contamination of medical students during initial clinical rotations

Background: Pathogenic bacteria can colonise the hands, medical equipment, and personal belongings of healthcare workers (HCW) exposed to clinical environments. Healthcare-associated infections (HAI) arising from the transmission of these pathogens to patients causes morbidity, mortality, and an economic burden. Despite widespread healthcare worker education and policy change, the incidence of HAI remains high in Australia.

Aim: To identify potentially pathogenic bacterial contamination of clinically unexposed medical students’ hands and items upon entry into the clinical environment and subsequent design of a definitive study.

Materials and methods: A pilot prospective cohort study was performed at a large tertiary hospital in Melbourne, Victoria. Eight medical students had two- to six-week samples taken from their dominant hand, mobile phones, and stethoscopes in the first six months of entering the clinical environment.

Results: Pathogenic bacteria were detected throughout the six-month testing period on five of the eight students’ hands, mobile phones, or stethoscopes. Pathogenic bacteria grown included methicillin-sensitive Staphylococcus aureus, Enterococcus faecalis, and Gram-negative pathogens, such as Serratia marcescens, Pseudomonas spp. and Acinetobacter baumanii. No multi-resistant organisms were detected. Low decontamination rates of items, universal use of phones while on the toilet, and recent hand hygiene credentialing were reported by participants.

Conclusion: Colonisation by nosocomial pathogens on medical students’ hands, mobile phones, and stethoscopes was identified during the first six months of clinical study. Further research to characterise bacterial contamination of new HCW, risk factors, and strategies to improve infection control practices has the potential to reduce HAI.

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Original Research Articles

Organisational process and patient factors contributing to hospital outpatient clinic nonattendance

Organisational and patient factors which may lead to hospital clinic non-attendance at two sites were examined to identify opportunities to reduce rates of missed appointments.

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Original Research Articles

Change in the cardiopulmonary exercise testing response in patients with coronary artery disease who do not choose to participate in cardiac rehabilitation

Nikhil Kumar and Andrew Victor report a decrease in aerobic capacity in patients who do not participate in cardiac rehabilitation.

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Original Research Articles

The association between pre-pregnancy body mass index and gestational weight gain (GWG) among women in rural NSW, Australia

Background: Pre-pregnancy body mass index (BMI) and excessive gestational weight gain (GWG) are associated with adverse outcomes of pregnancy. The Institute of Medicine (IOM) provides recommendations for weight gain during pregnancy based on pre-pregnancy BMI.

Objectives: To evaluate the proportion of pregnant women in a rural medical practice not meeting the IOM guidelines and to assess a link between pre-pregnancy BMI or excessive GWG and delivery method in this population.

Methods: A clinical audit of 168 patients in a rural NSW Medical Centre with a search criterion of ‘pregnancy’ was performed. Relevant patient details were collected and linked to patient files; pre-pregnancy weight, height, weights recorded during pregnancy, and delivery method.

Results: Among the 87% of gestating women who did not meet the current GWG recommendations, 57% gained weight excessively and 30% inadequately. There was a statistically significant association between pre-pregnancy BMI and excessive GWG with overweight women more likely to gain excessively (Fisher’s exact test 29.04, p<0.001). Pre-pregnancy BMI was also associated with delivery method, with normal weight women more likely to have a normal vaginal delivery and obese women more likely to have an instrumental delivery or planned Caesarean-section (Fisher’s exact test 20.89; p<0.001). Gestational weight gain was not associated with delivery method, regardless of pre-pregnancy BMI.

Conclusion: Given that the majority of women in this rural medical practice showed gestational weight gains outside the recommended limits and that pre-pregnancy BMI was associated with delivery method, there is a role for pre-conception and antenatal programs educating women regarding healthy pre-pregnancy weight and GWG.

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Original Research Articles

Xanthomas seen on capsule endoscopy: What are they saying about your patient’s health?

Background: There is long-standing evidence of an association between cutaneous xanthomas and underlying lipid metabolism disorders, impaired glucose tolerance, secondary hyperlipoproteinemia and diabetes mellitus. Since the advent of capsule endoscopy (CE), substantial numbers of endoscopies have shown evidence of small bowel xanthomas. These have unknown significance to the patient and, consequently, are not routinely reported when identified. Our research is the first study to investigate the significance of small bowel xanthomas identified on CE with underlying lipid disorders or diabetes mellitus.

Methods: 54 patients participated in this prospective cohort study. We recorded patients’ demographic details, medical history, medication list, height, weight, and waist circumference measurements. A blood sample for fasting lipids, fasting glucose and HbA1c was collected. A blinded gastroenterologist reported whether xanthomas were present and quantified the number of xanthomas.

Results: 37% of participants had small bowel xanthomas visualised during CE. The presence of xanthomas was associated with a previous diagnosis of hyperlipidaemia currently treated with anti-lipid medication (IRR 4.43; 95%CI 1.32 to 14.9; p=0.048) and was also associated with increasing units of alcohol consumption (IRR 1.91; 95%CI 1.32 to 2.78; p=0.0007).

Conclusion: This demonstrates an association between the presence of small bowel xanthomas with hyperlipidaemia, mainly in patients with hyperlipidaemia controlled by medication. We also detected an association between small bowel xanthomas and increased alcohol intake. The presence of small bowel xanthomas might trigger lipid evaluation, in future clinical practice.

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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.



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[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.

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[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.

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[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.

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

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Original Research Articles

Medical students in Aboriginal Community Controlled Health Services: identifying the factors involved in successful placements for staff and students


Background: To identify the facilitators and barriers to positive medical student placements at Aboriginal Community Controlled Health Services (ACCHSs).

Materials and Methods: A total of 15 focused interviews were conducted with medical students from Victorian universities and staff from two Victorian ACCHSs. Staff and students were asked about their expectations of students’ placements; the learning outcomes for students; the structural elements that have an influence on student placements; and the overall benefits and challenges of placements within these settings. This data was then thematically analysed.

Results: The study found that student placements in ACCHSs were of benefit to both the student and the organisation. However, areas for improvement were identified, including avenues for administrative assistance from universities in managing placements and clarifying expectations with regard to learning objectives. Overall, it was the opinion of participants that placements in this setting should be encouraged as a means of medical and cultural education.

Conclusion: The study contributes to building an understanding of the elements that lead to good practice in student placement design, and developing relationships between medical schools and ACCHSs. The study provides grounding for further research into the development of a framework for assisting successful student placements in the ACCHS setting.



Medical education can be a powerful tool for social reform [1]. The teaching that occurs within medical schools, and the manner and context in which it is delivered, has the potential to influence the practice of future doctors and have an effect on addressing social inequities. One of the greatest heath inequities in Australia is between Indigenous and non-Indigenous Australians [2].

In an effort to address this health disparity, there has been increasing emphasis on the teaching and learning of Indigenous health issues in medical schools within Australia, with a range of initiatives guiding the development and improvement of the medical curriculum and associated activities [3,4]. One of the most significant is the inclusion in 2006 of Indigenous health in the Australian Medical Council’s guidelines for Assessment and Accreditation of Medical Schools [5]. An important element of the Standards for Accreditation is the emphasis on offering student placements in Aboriginal Community Controlled settings and the development of relationships between medical schools and Aboriginal Community Controlled Health Services (ACCHSs) to facilitate this (see Standards 1.6.2 (regarding effective community partnerships) and 8.3.3 (regarding exposure to culturally competent healthcare) [6].

Student placements in such a setting offer an opportunity for students to develop cultural competency in the area of Indigenous health. This was outlined in the National Best Practice Framework for Indigenous Cultural Competency in Australian Universities as a critical area of need, and defined as:

“Student and staff knowledge and understanding of Indigenous Australian cultures, histories and contemporary realities and awareness of Indigenous protocols, combined with the proficiency to engage and work effectively in Indigenous contexts congruent to the expectations of Indigenous Australian peoples [7]”.

While ACCHSs have played host to medical students for some time, there has been little formal research regarding ACCHS as a setting for student placements, locally or at other universities across Australia [8-11]. The purpose of this study is to investigate the key facilitators and barriers to positive medical student placements in this sector.


Methods and analysis

Participants for this research included Victorian medical students who had completed a placement at an ACCHS and staff members of Victorians ACCHSs who had been involved in medical student placements. Students were recruited on a voluntary basis by responding to an electronic noticeboard announcement. ‘Snowball’ sampling was also employed. A total of seven student interviews were recorded. Of these, six had been involved in placements in ACCHSs, and one in a remote Aboriginal community government-run health service. The duration of placements ranged from one to six weeks, and were conducted in ACCHSs located across Australia in Queensland, Victoria, New South Wales, Western Australia, and the Northern Territory.

The ACCHSs involved in this study were all located in Victoria and selected on the basis of having a pre-existing relationship with the University of Melbourne. Each organisation provided approval for involvement in the research following internal protocols, and staff members were nominated by the ACCHSs on the basis of their direct involvement in medical student placements. A total of eight interviews were conducted with the staff members from Victorian ACCHSs.

Data for this project was collected through a series of one-on-one semi-structured interviews with participants, conducted by the first author, either in workplaces of participants or university campus interview rooms. Interviewees understood the context and purpose of the research, as explained prior to interviews. Interview questions focused on the benefits and challenges both groups experienced during student placements at the services. Transcripts were returned to participants for comment and correction.

The data gathered from the transcribed interviews was arranged according to questions asked, and then further under thematic headings. Shared themes were derived from the data, without use of supportive software.

This project was conducted as part of the Scholarly Selective program of the University of Melbourne Doctor of Medicine. The first author at time of writing was a fourth-year postgraduate medical student, supervised by two experienced researchers. Ethics approval for this project was obtained through School of Population and Global Health Human Ethics Advisory Group of the University of Melbourne (approval no. 1443395).



In total, 15 interviews were recorded for this research. All students were studying medicine at universities in Victoria. The ACCHS placements were undertaken as either GP placements or electives. Staff from the ACCHSs had a variety of roles including general practitioner, nurse, Aboriginal health worker, medical director, clinical director, and executive director of health services. Points of discussion arising from the data fell largely under six major themes:

  • Student exposure
  • Burden on health services
  • Interpersonal value
  • Community benefits
  • Educational value
  • Student engagement

All participants, on direct questioning, agreed that medical student placements in ACCHSs are important. The data was, therefore, considered on the basis that there is strong support from both students and staff to make these placements a positive and constructive experience for all.

Student exposure

A strong theme that emerged from the responses of both groups was that these placements offered medical students practical exposure to Indigenous health, culture, and community, with several students stating that they offered an important insight into Indigenous health that was not possible through theoretical teachings delivered elsewhere in the curriculum:

“I mean, you hear it, you read it, and so you know it superficially, but when you’re sitting in front of multiple people who can tell you the details of their story, you get a much better understanding as to why these families have had opportunities denied to them” (Student 6).

Students and staff also recognised that placements provided an opportunity to teach students about the ACCHS model of healthcare, which involves not only the delivery of medical services, but also health prevention, social outreach and advocacy programs that address the social determinants of health [12-15]. For one Aboriginal health worker, the value lies in teaching the principles of self-determination upon which ACCHS are founded [15]:    

“I just like the fact that they’re in our setting, our community, and learning from us, not being told by someone else that this is how it is” (Staff member 6).

Community benefits

Staff and students cited the potential benefits for Indigenous communities, such as recruiting medical staff and strengthening ties between the medical profession and Indigenous communities, as a primary benefit of student placements:

“… we see it as an opportunity to expose people to what it’s like working in Aboriginal health, and that helps us with recruitment” (Staff member 8).

Several staff and students commented on the role of placements to promote awareness of ACCHSs amongst the medical community, thereby increasing the likelihood of referrals and support for the services:

“… it’s very good for the organisation and the community to see that students come here to learn because it gives them the message that this is a place of excellence … I think that builds confidence on their part in the service” (Staff member 8).

In addition, placements provided ACCHSs and their patients the opportunity to engage in the medical education process:

“… it makes medical education more transparent for Aboriginal people … and in turn I think that has the potential to create more trust between the patient and the doctor in Aboriginal health centres” (Student 6).

Participants also saw that placements could have a broader impact on the healthcare system outside of the ACCHS setting, in that the students who have had this experience would go on to work in practices and hospitals across the country in a more culturally appropriate way. As such, these placements are “… seeding the medical workforce with people who have some understanding and experience in Aboriginal health” (Staff member 4).

Burden on health services

Participants recognised that the administrative and organisational duties required for placements were very time-consuming, and that supervising students put pressure on practitioners’ time, increasing delays for patients and overall demand on the practice. The administrative duties for ACCHS staff include scheduling time for teaching, co-ordinating the student’s timetable to allow them to spend time in various parts of the organisation, and working through requests for placements from different universities and faculties.

Many of the challenges that students experienced in their placements related to how well the organisation was able to handle these tasks. This was, as several students noted, a feature of clinical placements that is not unique to the ACCHS setting. Challenges for some students included an apparent lack of structure to the placement, staff being unaware in advance of the student’s arrival, finding the clinic to be underprepared for the student or understaffed, or doctors simply not having the time available to teach the student. As one student commented, the service was, “… definitely very welcoming … but they were very space-limited and time-limited in terms of how much attention they can pay to students” (Student 6).

Several students mentioned the value of a careful introduction and orientation to the practice as a way of helping students to feel comfortable in the new environment, and as a result, improving student engagement and relieving some of the administrative stress on the organisation:

“If the host organisation gives a good introduction to the student, it will be easier for them right the way through the placement because the student will know what they’re doing and where they fit, so they won’t be constantly having to direct them” (Student 6).

Educational value

Responses in regards to the education value of the placement varied both between and within the two groups. Most staff at the ACCHSs were generally very happy with the educational experience they provided, not only in terms of general practice knowledge, but also holistic care, community medicine, and Aboriginal culture. Several staff, however, recognised that the emphasis placed on cultural and holistic care may not have been in line with what students expected from placements:

“… I don’t know if they come with that same perspective of the holistic model of care … yes, the clinical side is important, but that’s not the whole reason why they’re coming to [ACCHS]s” (Staff member 2).

Conversely, some of the staff interviewed said that some students were surprised by the degree of emphasis placed on the general practice aspect of the placement.

While all students reported that the placement had been a valuable learning experience, more than half of those interviewed commented that in terms of examinable material for a general practice rotation, the ACCHS placement was perhaps not as rewarding as a placement in a ‘mainstream’ practice:

“I don’t think I learned a lot of examinable material” (Student 3).

One student noted the fact that the longer consultations, which staff regarded as a virtue, meant fewer patients were seen, and the opportunity for learning through repetition was diminished on a purely quantitative basis.

In contrast to the opinions of some of their peers, several students stated explicitly that they believed the educational experience was better for being in an ACCHS setting, and many said that the cultural and community teachings had enriched their learning.

“I can only say that I think if anything it was an advantage because not only did I get the clinical experience I also got the community, social aspect of it as well which might be harder to grasp if you hadn’t done that” (Student 1).

This discrepancy in opinions to some extent reflects a differing of expectations both within the student group and between the students and staff.

Student engagement

Participants were asked what they defined as a ‘successful’ placement. Responses from students varied, and largely focused on basic principles of medical education such as patient contact and fulfilling the curriculum requirements, but also included having clear expectations and an orientation to the ACCHS.

While staff responses also varied, the majority of comments related to student engagement—with the staff, the service as a whole, and with the community:

“If … I get a sense that they’re starting to integrate with the broader team … that sort of marrying in with the team well, I think, is a very good sign” (Staff member 8).

Several staff commented that students who were confident in the ACCHS and able to seek out their own learning opportunities were ‘easier’, more engaged and more likely to be active learners:

“Some of them are much easier and more outgoing. Whereas some of them you have to spend a bit of time engaging and making them feel confident…that’s not a bad thing but it’s harder work” (Staff member 5).

Interpersonal value

The value of the human interactions that arose from placements emerged as a common theme in the interviews. Several students spoke of the relationships with staff, and the trust that developed with community members returning to the clinic, as particularly rewarding experiences:

“I got to see a number of patients quite a few times so that made it a very good learning experience, and a lot of the patients were very trusting, and so I got to do a lot in terms of their care. That … was really rewarding” (Student 6).

Staff from the ACCHSs spoke enthusiastically of having engaged students around the clinics and the organisations more broadly:

“It’s enjoyable, honestly, to see someone who wants to come here and work with Aboriginal people” (Staff member 7).

They cited the benefits of a fresh perspective on health, a new skill set, at times a helping hand, and importantly, a sense of goodwill toward the Indigenous community and the health organisation in the form of a demonstration of interest in Indigenous people and their health.



Major benefits and challenges

This study highlights strong support for student placements in ACCHSs. The most commonly cited reasons for this support centre on the ability to offer students first-hand experience in an Aboriginal community health setting, and the reciprocal benefit to the community in creating a more culturally educated workforce.

The challenges reported by staff and students emphasise areas in need of improvement in the placement process, and provide a foundation for refinement. The foremost of these is the administrative and organisational burden on the health services, how the co-ordination of placements can be improved, and what the implications are for the relationships between universities and ACCHS in this process. Nelson et al [10] suggest that there is a role to be played by university-appointed administrators to assist ACCHSs in the processes required to ensure students and the ACCHSs themselves are adequately prepared for placements. Their study highlights the positive feedback received when such appointments have been made, and the interviews here reinforce the message that good preparation and coordination improves the experience of both staff and students [10].


Ensuring that students feel both socially and culturally oriented in the placement environment is an important element of a successful experience for both staff and students. Students who feel at ease, or more confident in the environment, tend to be more proactive with their learning, and less demanding on the organisation. An important way of fostering this is through a formal orientation.

At the sites where an orientation was undertaken and involved specific cultural awareness training, students felt more confident and engaged. While this responsibility sat with the ACCHS, several participants noted that cultural awareness training should be a core part of medical education in the university environment. Preliminary training would then be the basis for, and be complementary to, the localised and more specific learning provided once students are in the ACCHS setting. Improved coordination between the universities and the ACCHSs is therefore important to ensure that appropriate training and orientation is completed before the student begins their work in the clinical environment.

Educational value of placements in ACCHSs

A successful placement requires that all parties have a clear understanding of the nature and purpose of the placement, with shared expectations of learning objectives. Most placements are either part of general practice rotations or student-initiated electives. While the interviews included positive accounts of both types of placements, the flexibility of student-initiated electives was noted as an advantage in the ACCHS context. Electives, as distinct from other in-semester rotations, are not intended to fulfil precise curriculum requirements, and allow students to engage more freely in learning about Indigenous health and culture and the broader healthcare delivery services provided by ACCHS. However, participants also noted the importance of ACCHSs being included in general practice rotations. It must also be recognised that the medical curriculum is not limited to clinical decision-making, and the educational value of these placements should not be restricted to these domains.

Selection of students

The administrative burden and over-demand for student placements in ACCHSs raises the issue of whether students should be required to demonstrate an interest in Indigenous health to be granted a placement, a requirement that already exists in some ACCHSs. The interview data clearly identified that the burden on the heath service was greater if students were unenthusiastic, disinterested, and unable to self-manage. Approximately half the respondents agreed that an expression of interest should be requisite. The remainder of respondents suggested that those students who do not express an interest in Indigenous health placements might have the most to gain from the experience. Adequate orientation may provide a solution in terms of familiarising the student, managing expectations, and facilitating a positive experience for the student and health service.


This study was limited in its breadth by the nature of the research as a University of Melbourne Scholarly Selective project. The study therefore had limited scope and a small sample size, and while strongly-shared themes arose from the data, the interviews did not reach saturation. The authors also acknowledge that students interviewed had all voluntarily selected Aboriginal health placements, and therefore a selection bias may exist with regard to their views of the value of these placements. The authors further acknowledge that while students interviewed were placed in ACCHSs across Australia, the ACCHS staff were from Victorian ACCHSs only, and therefore the placements they describe are not necessarily shared experiences. No community members visiting the ACCHSs were interviewed. Their opinions on the presence of students in the organisations may form a basis for further research.

For ACCHSs to continue to be an active part of medical education, as mandated by the AMC, it is important to ensure that they have the resources to provide a good learning environment, and that the presence of students is not an impediment to the organisations. Placements should contribute to cultivating trust between Indigenous communities and the medical profession, and this is more likely with careful planning and co-ordination of placements. It is hoped that the findings of this research will help guide student placements into the future and contribute to ensuring a mutually beneficial system. Further research and larger trials in this area may include investigation of the perspectives of community members on the presence and engagement of students in ACCHSs, as well as a deeper exploration of the effects of student placements in other settings, including remote areas.


Conflict of interest
None declared.

Abbreviations and notes

ACCHS- Aboriginal Community Controlled Health Service

* Note: the term ‘Indigenous’ is used in this article to refer to the Aboriginal and Torres Strait Islander peoples of Australia.

St x– student no. x

Sf x– staff member no. x



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