A symbiotic curriculum where relationships are established and maintained between the key stakeholders in healthcare, is considered an ideal model for delivery of medical education [25]. As medical students are placed in the center of these fundamental symbiotic relationships, recruitment and support of students who acknowledge the unique learning environment of rural LIC is imperative to its success. This PeArLS has resulted in a paradigm to guide recruitment and support the transition of students from metropolitan locations into rural longitudinal placements based on the combined experience of the participants.
Local and central leadership is vital in marketing rural LICs to the target audience [26]. Champions at both levels must develop and sustain relationships with key stakeholders and help facilitate rural LIC placements through early incorporation of rural sites and promotion of LIC programs. Early incorporation could be achieved through excursions, activities or electives on site with an aim to demystify and raise awareness of rural LIC placements. Peer-to-peer promotion and engagement through students was reported as the most efficient way to effectively raise awareness and recruit students. To strengthen this approach, champions may need to deliberately formalize these interactions into the program in a highly visible and accessible manner.
Bridging logistics in a rural LIC requires collaboration with relevant stakeholders, an autonomous yet flexible curriculum and considered student allocation. Collaboration with local and other partners was described as a key strength of rural LIC. Fostering collaborative relationships is mutually beneficial and enhances the sustainability of health services and medical schools [25]. The educational benefits achieved through delivering an LIC model could be used to drive positive change and curriculum renewal. This was seen to help promote the “best-practice” educational principles associated with LICs and hence a desire for students to participate in rural LIC. In addition, changes to standard curriculums may impact positively on the future integration of LICs as the educational principles and delivery of curriculum become more aligned. Achieving change requires establishment and fostering of relationships with clinicians, academics, students and rural communities [26]. The relationships built should be perpetual and achieve a shared understanding of LIC expectations and learning outcomes whilst recognizing the value of each curriculum in their different educational contexts [27].
To further enhance recruitment strategy, known positive influences on workforce retention such as recruitment of students with a rural background should be given careful consideration [28]. The PeArLS’ participants recognized that commencing medical school in a larger clinical site negatively influenced transition to a rural location in the subsequent clinical years. Overcoming this could involve the early career exposure and peer-to-peer recruitment outlined previously. Other suggested solutions were engaging with rural background students, especially those from the LIC’s placement footprint and specific enrolment in a rural stream on admission. Therefore, strengthening rural connections and building on existing rural relationships may be a useful approach to optimize engagement in rural LICs.
During recruitment, attributes believed to be most suited for successful rural placements should be considered, with the goal of improving future rural workforce supply. Eley et al. [29] described the “ideal” personality traits for medical students suited to rural practice as low harm avoidance, persistence, self-directedness, and cooperativeness. Aspects of rural LIC such as the flexible learning structure and hands-on experience may be more attractive to individuals with these personality traits. Emphasizing these aspects of rural LIC during recruitment may assist in recruiting students who are most suited to rural practice. This clear articulation of alternative learning outcomes and expectations is supported by other researchers [26]. While medical students who express an interest in rural placements are more likely to hold “ideal” personality traits, rural and metropolitan medical students exhibit similar trait profiles overall [29]. Caution must be taken if incorporating a concept of ideal characteristics as it may have exclusionary, harmful and discriminatory repercussions [30].
A strong support structure should be in place to facilitate the transition to rural LIC regardless of the personality traits or characteristics of the students enrolled. Transitioning to a rural LIC involves a sudden change to an unfamiliar educational environment, often without adequate signposting. This may be anxiety-provoking, lead to initial confusion or contribute to burnout in students. Whilst the process follows the J-curve [23], eventually resulting in gains in confidence and proficiency [31], contributors to the PeArLS recognized that the transition to a rural LIC requires implementing supportive structures and providing scaffolding. This vital role requires orientation to placement, practical skill building, managing student uncertainty, utilizing support staff and understanding the learning philosophies or processes involved in LIC programs [26]. Effective orientation to site including clear descriptions of the systems, pressures, and differences between rural LICs and metropolitan sites, was thought to reduce disorientation. This view is supported by Chou et al. [32], who found that clarification of roles and tasks, management of interpersonal challenges and addressing social and educational isolation helped to tackle disorientation. Development of clinical skills improved the students’ perceptions of their own authenticity as part of the clinical team. Early teaching of these skills prior to or at the commencement of clinical placements was suggested as the most successful approach. Participants described an example of the completion of an advanced life support course immediately prior to clinical placement.
Supportive relationships are needed at all levels of the symbiotic model [26]. This support can operate as a formal scaffolding for the student’s placement or as an informal confidante. The PeArLS participants emphasized the contributions made by on-site clinical and administrative staff in creating a supportive learning environment. The role of local champions is highlighted in previous work by Bartlett et al. [26]. A stable medical workforce was seen as a key element of a welcoming environment as well as continuity of formal and informal leadership on-site. Furthermore, integration into the community through consultation and engagement with community leaders and groups was noted as an important aspect of rural LICs. This approach has also been shown to deliver wider benefits to the community including workforce recruitment, retention, social benefits and local economic development [33].
Limitations to the study included the small participant sample of self-selecting delegates attending this session. The session was conducted live and subsequently crossed multiple time zones potentially impacting participation.