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Interview participants
The initial survey received responses from 15 participants. Twelve (7 females and 5 males) of these participants were available for the subsequent interviews. Of the 12 interviewees, 7 were medical students (4 females and 3 males), and 5 were graduates (3 females and 2 males) at the time of data collection, four of whom had participated 10 or more years ago. All interviewees participated in the international rural placement between 2002 and 2018. Placement locations for interviewees included Canada (n = 4), North Dakota, USA (n = 6) and Tennessee, USA (n = 2). Participants 13–15 were not interviewed but provided detailed qualitative feedback in their survey responses. Placement locations for these participants included Norway (n = 2) and Tennessee, USA (n = 1). None of the interviewees were living or working in a rural or remote community at the time of the study, although most (n = 10) were living in regional communities, and some had not yet completed specialty training or settled into a permanent position. Participant IDs, linked with their associated quotes, reflect their participant number (P1-15), their academic status at the time of data collection (undergraduate (U) or graduate (G) and placement location.
Motivations to engage with the application process
The participants found the application process enjoyable and found value in the multi-stage application process. The three-step application process, involving a book/movie review, interview, and researched oral presentation, self-selected a highly motivated group of applicants.
“I thought that the amount of steps that were required was sort of a good idea, because it meant that unless you really wanted to go on the placement and you were committed to doing all those steps, then it sort of weeded out the people who would have happily just chucked in an application if it took them five minutes. So it took me a day to write my film review and then prepare for the interview and then I also had to make a presentation on an aspect of rural health, but unless you really, really wanted to go on this trip and be a part of the experiences, it got the cream of the crop, in terms of people that were interested and willing to put in the work to get the scholarship.” [P3-U-NORTH DAKOTA]
Two themes were identified in relation to participants’ motivation: (a) experiencing eye-opening and culturally rich difference and (b) once in a lifetime opportunity.
Most motivations centred around the key theme of “different.” Participants were motivated by the opportunity to travel overseas, to experience a different country/region, different culture, different people, different climate and different healthcare system. Many reported that learning about and experiencing a different culture was a key motivator for applying. For some, this was an interest in learning more about a different indigenous culture. Others also saw this as an opportunity to learn from people from another cultural perspective.
“But being able to go to a different country where there’s different cultures, different expectations of health, different views on health is very, I think, enlightening and eye-opening. So, I think one of the primary motivating factors is being an eye-opening culturally rich experience where you can have a broader view of the world outside. It definitely makes you more tolerant, accepting, sensitive of other people’s views, rather than being a bit closed minded.” [P7-G-TENNESSEE]
“Having never been overseas, I was very, very young and very inexperienced, I guess. I certainly hadn’t travelled anywhere. So, the main thing was, just the idea of being able to travel overseas sounded really amazing and to experience something that was so different, especially climate-wise, going from somewhere like Townsville. I’d never seen snow in my life, so the idea of going to North Dakota in winter and having a white winter, that was quite appealing.” [P10-G-NORTH DAKOTA]
“It was just an opportunity for me to go and experience something completely different and see a different side of the world. I was really excited to see how the health and the health studies that I do here, and the studies regarding social circumstances surrounding health, translated to another country that had unique circumstances of its own. Yeah, that was probably what motivated me the most.” [P2-U-CANADA]
The fact that this placement included a fully funded bursary was another key motivator for many. The uniqueness of the opportunity was considered a “once in a lifetime opportunity” [P12] and an “adventure that needed to be had” [P9]. The belief in the importance of taking up available opportunities motivated the participants to apply for the scholarship.
“I worked at a CD store, making like $13 an hour. I would never have been able to afford it. My parents wouldn’t have been able to afford it either. The financial assistance was the only reason I could go.” [P9-G-NORTH DAKOTA]
“I can’t understate [laughs] that it was also just a bit of, wow, an overseas trip that I couldn’t otherwise afford and an opportunity to see a different part of the world. It was kind of just what I ended up reflecting about, knowing that I had the privilege of getting this prize and therefore I needed to take every opportunity to get out of it what I could.” [P8-U-CANADA]
Disorientating dilemmas that created transformative experiences
Some elements of the placement experience presented disorientating dilemmas that were identified to have transformative impacts on the participants. The transformative experiences can be described in terms of a trigger that challenges a person’s previous perception/view/understanding causing mental processing that causes a shift in perceptions/understandings leading to a new aspect/perception/understanding. Three themes were identified in relation to major situations that triggered deep reflections and shifts in perceptions. These were: (a) outsider view allows reassessment of one’s own country, (b) being open-minded to enjoy good company and (c) isolation experiences ginger desire to right health wrongs.
Participants who went to Canada reported that the placement was light clinically, but heavy on Indigenous (First Nations) cultural aspects and social determinants of health (Indigenous and people of low socioeconomic status). This group of participants reported that they had had various prior experiences/knowledge about Australian Indigenous people’s health care, and social determinants of health (broadly) at the university. However, experiencing health care within a Canadian Indigenous peoples context, gave them new insights and better understanding of the cultural differences and challenges. Participants talked about how being taken out of their usual routine in Australia to see the conditions of First Nations peoples helped them understand the dire situation of Indigenous Australian healthcare.
“I think there are similarities to the situation. Not necessarily because there’s similarities between Aboriginal and Torres Strait Islander culture and First Nations culture [in Canada], [but] because I think they were colonized by the same sort of oppressive system, which creates the similarities. But I think because being from here [Australia], you’re so involved in our system, you grew up here, you’re inextricable from the culture. Then you go to a different culture and see a similar thing. You’re sort of looking at it with the eyes of an outsider. And I think that makes things clearer. But also, I had experiences there that I haven’t had with Aboriginal Torres Strait Islander people in Australia. So, I had more intimate experiences than I probably have in Australia, so that has value as well.” [P12-U-CANADA]
Those who went to the USA felt there was less emphasis on Indigenous cultural issues, but they gained experience in relation to the different health care/health insurance system. They reported having some awareness of the differences in health care and health insurance in the US from university and movies, etc. However, observing seriously ill patients being turned away because they lacked proper health insurance and finding out how much a medical service would cost a person, even with health insurance (e.g., helicopter ride to nearest suitable hospital), made them value the Australian healthcare system more. This experience gave this group of participants a notion of realism when thinking about “what would be an ideal model of care, so the system is accessible but not abused”. A deeper understanding of the differences in the health care system between Australia (universal – anyone can see a doctor – patients may over-present) and the USA (privatised – costs out-of-pocket to go to the doctor, so patients who need medical attention but can’t afford it may not be seen), provided better clarity, though with fewer linkages to Australian Indigenous healthcare.
“We had a patient who had a heart attack and so he came into the hospital, and just to send him to a tertiary facility would have costed him so much money. And I was really shocked by that. The doctor was telling me it was in the thousands that he would be paying because he had to get the helicopter service to the tertiary hospital. Yeah, that just blew my mind. Whereas in Australia, obviously, that doesn’t happen. Just comparing it to Australia where we have like the Royal Flying Doctor Service, and they don’t charge a thing for it. So that was really impactful.” [P11-U-NORTH DAKOTA]
All participants had an opinion about whether or not to recommend individual or shared placement opportunities. Most participants favoured having placement partners from the university and many of those who travelled together commented on the importance of having a travel companion for value, security, companionship, and familiarity. They attributed much of the comfort on the placement to having a travel companion with whom to debrief (good company). Another element to living/traveling with another, especially someone you didn’t know well before, was the opportunity to develop close social skills, which can be used in both one’s personal and professional lives. For example, one participant discussed his experience of traveling with another student, and how they both were cautious/mindful of the other’s opinions early on. This caused shifts in the ways in which he relates to other people in the form of developing tolerance and understanding of others’ opinions, being more mindful and considerate of the desires and needs of others, and to compromise.
“I was lucky in that I did get to go with one of my good friends at the time, so we were together for the four weeks. I’m thankful that I had him to kind of relate to. We were definitely debriefing together. Definitely sending people in pairs is a good idea.” [P8-U-CANADA]
“I don’t think I would have been able to navigate and move easily as a girl alone in a remote country, like a different country, especially not knowing anyone. My travelling companion was a big burly boy, and it was nice to know that he was there, and whatever we did, we were doing together, and I didn’t have to worry as much about my own personal safety.” [P2-U-CANADA]
Participants who travelled alone felt it gave them opportunities to live with host families that they did not know well, this gave them “good company” and also inspired the development of social skills such as nonverbal communication skills. Interacting with others was an important aspect of the mental processing for most participants. They talked about how the experience taught them about how to live with other people.
“I think getting to live with a family and they sort of welcome you. I think they basically said, ‘You are part of the family for this month. Whatever you want, whatever you need, it’s fine. And equally, we expect you to eat dinner with us, and we expect you to do stuff with us’. That was a pretty immersive experience. I don’t know how you can get that any other way.” [P1-G-NORTH DAKOTA]
In both cases, close interaction with another person, be it a travel companion, host family or patients, helped the participants learn the importance of avoiding assumptions, being non-judgmental (‘don’t know what they’ve been through’), demonstrating compassion, empathy and kindness.
“I think I needed a lot more confidence going to North Dakota by myself, and just being open minded as well and getting to know everyone. So, I really had to be open minded, get to know other people, which can be scary sometimes, because they’re pretty much like strangers, but you just have to trust the process.” [P11-U-NORTH DAKOTA]
The interview triggered deep reflective moments for participants about the placement experience. Major areas of consideration were personal, clinical/professional, and rural/remote isolation experiences. Drawing comparisons with self, life in Australia and the Australian Indigenous population gave the participants a better understanding of self that included an enhanced sense of independence/confidence, personal growth in embracing personal differences and limitations as it relates to degree of remoteness and independence as well as rural healthcare issues. For example, the experience of living in a very rural/remote area acted as a trigger in relation to the physical and social isolation, and access to supplies. The physical isolation caused a shift in understanding of self: participants left with a better understanding of their personal limitations in terms of the degree of remoteness and where they would like to live in the future. The social aspects of the isolation caused a shift in understanding of the world around them, leaving them with a greater appreciation of what they have in Australia and possibly the importance they place on having access to social support. The limited access to supplies that the rural/remote living offered also triggered shifts in the way they thought about things as it relates to social determinants of health.
“I have acquired a better understanding of the role of social determinants of health and health outcomes in rural/remote areas. (1) It can be really hard to get access to fresh food living in rural/remote communities – both in Canada and in Australia. (2) The limited access to supplies can influence mental health. (3) There are things related to social determinants of health that you as a doctor cannot control; you just have to work with or around it”. [P8-U-CANADA]
It also elicited a deeper understanding of the world around them, with greater appreciation and gratitude for what they have. One of the participants reported that by experiencing a world different to her own, she came to find greater appreciation for the things she has in Australia which she had previously taken for granted. Most importantly, the experience brought about thoughts on how they would want to practise medicine and the emergence/development of their professional identity. It elicited the desire to temporarily work in low- and middle-income countries, with organisations such as Médecins Sans Frontières.
“I struggled a bit because I was in Canada in the middle of winter. It was so dark and so cold and having grown up in Australia where it’s like sunshine for 18 hours a day, and warm; I, struggled a bit more than I thought I would. It definitely made me appreciate where I’ve grown up and where I live. Not that I didn’t enjoy it, but it definitely made me thankful for what I have.” [P8-U-CANADA]
“The experiences that I had then have shaped who I am, and they have had an impact on how I practice and what I chose to do subsequently and where I work.” [P5-G-NORTH DAKOTA]
“I think it definitely reiterated that I want to work with those people [in underserved communities] and Aboriginal Torres Strait Islander people as well. Try and slightly right some of the health wrongs. And at the time, it definitely showed me that you can live rurally and still have a fulfilling life. I’m not sure if I’m still leaning towards working rurally, but I definitely wouldn’t work in a big city and I definitely would want to be involved with Aboriginal Torres Strait Islander patients, wherever I work.” [P12-U-CANADA]
Processing transformative experiences
The various triggers led to shifts in the ways in which bursary recipients viewed themselves, others, the world, thought about things, and interacted with others in the world around them through a variety of mental processing techniques. The ways in which the experiences were incorporated into the interviewee’s lives began while still on placement and continued upon their return to Australia, third-year studies, and into the present. Two themes were identified in relation to processing transformative experiences: (a) challenging new experiences through critical self-reflection and (b) recalling memories with significant others.
While most recipients demonstrated some level of unprompted critical self-reflection, some also reported the utility of keeping a diary or writing a reflective blog after the placement as helpful tools to further facilitate their personal reflection of the experience. Some recipients reported that their home and/or host university requested that they write a reflective blog entry about their experiences for publication on their university website.
“We had to keep a record basically of our thoughts and reflections from each week. We documented what we learnt, what we’d been challenged by, and what we thought about that we hadn’t thought of before. I remember documenting in that diary some of these things, thinking about it and reporting back to the university during the time but also communicating with friends and other students who were having different but also enlightening experiences in other places.” [P5-G-NORTH DAKOTA]
Participants pointed out the value of keeping reflection diaries during the placement and stated that they often revisited the diaries as processing tool. They also talked about how JCU’s curriculum has helped them to build a habit of self-reflection as part of their routine processing of learning. They highlighted how the critical self-reflection process had primed them for life-long learning and fostered transformative experiences.
“In JCU, they encourage a lot of self-reflection, and there are actually quite a significant number of assessment tasks, which are important in sort of focusing on reflection and sort of force you to self-reflect. I was actually reading one of my reflections on my rural experience, just to jog my memory of those specific examples of the ones that I gave you tonight. Yeah, being able to sort of self-reflect through writing and assignments during university, but also, as you experience new experiences, you always compare that with your previous experiences as well – how those new experiences are either challenged or shaped by your previous experiences.” [P7-G-TENNESSEE]
While on placement, important others who helped to facilitate the processing of the experience included the people they met on placement, the family and friends back in Australia with whom they kept in touch while on placement, and where relevant their fellow JCU travel companion.
“XXX and I have kind of lost touch now but even in the years afterwards, we’d have lots of funny memories together and jokes about it, even though we weren’t close and we weren’t even part of the same friend group. I think it was a kind of nice connection to have with him when we came back.” [P2-U-CANADA]
Upon returning to JCU, recipients are asked to give a number of presentations to potential future bursary applicants. Each of these experiences, even participating in the interviews for this study all offered opportunities for further reflection, processing, and integration.
“I did those blog posts while I was over in Canada, which was a good opportunity to reflect on what I’d been learning and what I was enjoying. Then chatting to the girl I went with about the placement was another opportunity. Then I just guess I continued to reflect with friends and family when I returned, just chatting to them about my experiences of what I found over there. Yeah, that was – and then also interviewing. So I interviewed for the panel for the selection of the students to go the following year, so that was my other opportunity where I guess it reminded me of going on the trip and stuff and just talking to people there about what it was like.” [P3-U-NORTH DAKOTA]
When memories of the placement experience were triggered in other areas of their lives, these offered new contexts to further process and integrate their learning outcomes from the placement experience.
“I’m surprised how often it comes up and comes to mind [laughs], to be honest. So there’ll often be things that I’ll say, oh, when I was in North Dakota, you know, actually being this focus of reflecting on [this indistinct thinking] that made me realise, well, that was nearly 20 years ago, and I still think about so many of the experiences that are still [indistinct] to this day. I still bring that [experience] up with patients. I still talk to the students about it. You know, I still talk to the kids about it and say, oh, oh, when we were in North Dakota or when Dr Kratcha did this, you know. They probably get sick of hearing me talk about it but it comes up surprisingly often. The experiences that I had then have shaped who I am and they have had an impact on how I practice and what I chose to do subsequently and where I work. Yeah, so because of that it does come up quite often, actually.” [P5-G-NORTH DAKOTA]
Impact of the placement experience on longer-term learning and clinical practice
The various triggers had significant impact on the bursary recipients and opened their eyes to new horizons and inspired life-long learning opportunities. The ways in which the experiences were incorporated into the interviewees’ lives began while still on placement and continued upon their return to Australia, including from third year of study to graduation, and into the present. The experience opened the participants’ eyes to career opportunities that they had not previously considered. It also emphasised the value of rural practice and interactions with role model clinicians increased their passion to go rural. Four themes were identified: (a) inspirational new horizon, (b) navigating/ embracing challenges to gain respect and trust, (c) role model for life-long learning and (d) confidence to try new ways of doing things.
The international rural placement allowed most of the bursary recipients to observe a range of medical practice in rural settings, creating a lasting impression of the value of rural generalist practice. The prospect of serving a whole community in a range of medical disciplines as a rural generalist was considered to be both fulfilling for the doctor and beneficial to the community. However, other interviewees reported that observing several specialists working in rural communities broadened their prospects to the possibility of working as a specialist in a rural setting.
“So I guess I had always thought about rural generalist when I was applying to medicine as well, and I heard about it. But seeing a doctor, who pretty much was a rural generalist, where he was able to do GP work but also work in the ED and the hospital, and do procedures like a gastroenterologist would do, it made me very excited about that pathway as well, and I could see how in the future if I was in a rural location, how I could be a rural generalist as well, or the things that I could do. So I think I realised the real value in becoming a rural generalist and really serving the community in multiple ways and not just having one specialist for obstetrics, one specialist for GP – yeah, I could see the value that a rural generalist has in the community.” [P4-U-NORTH DAKOTA]
“It was probably seeing how a specialist was working in a rural place, like the paediatrician. But also, a generalist, the family doctor, was also working in a similar place. So it showed me that it didn’t really matter so much what you did in your career, it just mattered that you had a passion for doing what you do in a rural area. So it showed me that you could do both a specialty like paediatrics or a generalist specialty like family medicine in the same place. Essentially, they were in the same town. So it sort of opened my eyes to the fact that it didn’t just have to be generalists working in a rural area.” [P6-U-TENNESSEE]
In addition to shaping the career direction of many participants, the experience also provided them with experiences that challenged their thinking.
“I think it demonstrated to me that I would like to be challenged in the same ways I was on placement when I was put in cultural situations that are different to my own and I’m forced to learn how to navigate within those and gain respect and trust within a community; and how to be culturally respectful, and I’m going to use them in the future if I want to do rural and remote medicine.” [P2-U-CANADA]
Working closely alongside role model clinicians inspired the interviewees to pursue work in rural settings and/or undertake further specialisation.
“Well, I chose to follow a fairly similar training pathway, so I joined the same pathway that Lynn Kratcha had been on years before. I also went down the Australian GP Training pathway, the rural branch of the Australian rural GP training pathway. Then with a special interest in obstetrics and being involved in that, as he had been.” [P5-G-NORTH DAKOTA]
“That experience I think has put me in good stead for doing more rural activities in Australia, examples being last year I did about nine months in Mount Isa. I’ve done – I’ve preferenced a lot of really rural places, like Longreach, for fourth year, and I’ve really tried to get into it. I think that was sparked by Tennessee and having that experience and being lucky enough to be given that opportunity really made me feel like I should be putting everything I have into trying the rural practice area and giving it a go and actually seeing if it will work. So in that respect, I am interning in Toowoomba next year. It renewed my passion for living in a rural community in the community sense as well, in that you get to know everyone in the town and you are known yourself as the student, or as whatever you are in the town. So I’ve made it a big goal of mine in the future. Whether or not I end up working completely in a rural town or not, I want to be doing some sort of work in a rural area. [P6-U-TENNESSEE]
Interviewees also reported that this aspect of the experience motivated them to continue their studies on return to Australia and fostered their life-long learning.
“No issues. If anything, I was very excited. I had even more interest in now learning other new skills, and I was just more excited to keep practising my skills and acquiring the knowledge to then understand certain procedures and things like that. So I was actually more excited about coming back to classes. I think I maybe wanted to finish medicine as quickly as possible, so I could do what [the doctor I worked closely with on the placement] does [laughs]”. [P6-U-TENNESSEE]
“I guess you could say that I was reinvigorated to study medicine because, you know, in the early years, we don’t do much clinical stuff, it can all seem a bit pointless and fuzzy sometimes, all the study without any patient contact. So there was definitely some inspiration that made it easy to go back and study.” [P12-U-CANADA]
Exposure to clinical experience so early in their training, and encouragement from role-model clinicians, also built confidence in the bursary recipients. Upon returning to Australia, and their undergraduate studies, they were able to practise and apply the skills and knowledge obtained from the experience.
“It gave me confidence because we were doing you know, what I did in North Dakota, I know there was a lot more clinical staff and clinical skills that I learnt compared to my peers. So I felt far more confident that I was doing okay, in medicine.” [P9-G-NORTH DAKOTA]
“Lynn taught me this new way of doing it. I still put it into that framework, because it was helpful. It was useful – you know, it was a short summary, and it was really good for recording notes rather than the more longwinded way they were trying to teach us to record for assessment tasks.” [P5-G-NORTH DAKOTA]
The bursary recipients also reported increased confidence in advocating for their needs in order to maximise their learning during subsequent clinical placements, having been able to learn new skills while on the international rural placement.
“When I go to placements from that point onwards, I realised what I want out of placements now, just because of what [the doctor I worked closely with on the placement] has taught me. So I’m not afraid of – like now, if the doctor says do you want to have a go, I would say, “Yes, would you be able to supervise me?”. Even if I hadn’t seen anything or haven’t tried it yet, I would let them know, “Is it okay if I watch you do it for the first time?”. Because I’m sort of now using his philosophy to then get the ’most out of my placement ’experiences, and I’ve found that it’s worked wonders.” [P4-U-NORTH DAKOTA]
Overall, interviewees reported positive associations with the placement. Participants largely described the experience as not only meeting their expectations, but in many cases exceeding their expectations. Indeed, many reported that it was the degree of impact the experience had on their life and the extreme gratitude they have for having had this opportunity that motivated them to participate in this study. One participant reported that the experience was so great it just had to be talked about, which is why they signed up for an interview.
“It’s a pleasure to talk about this because I am so thankful that I had the opportunity. This is something that warrants being talked about. It’s something that should continue for other students and I can’t praise the program enough for what it gave me.” [P2-U-CANADA]
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