Dr. Paul Worley, Academic Rural Doctor and Dean of Medicine at Flinders University
Oct 2, 2015
Professor Paul Worley is an academic rural doctor and Dean of Medicine at Flinders University. His work in the science of rural community based medical education and its impact on addressing the maldistribution of doctors for rural and underserved areas has changed the face of medical education and rural medical workforce policy, nationally and internationally. His leadership of junior doctor training in general practice has transformed the transition from medical school to post-graduate training for general practice. In addition, he is a former President of the Rural Doctors Association of South Australia, a former National Vice President of the Australian College of Rural and Remote Medicine, and a current Council Member of the Australian Medical Association (South Australia).
How did you first become interested in medicine?
My interest in medicine was sparked by my family. My mother was in a car accident when I was only 5 and became paraplegic. As a result, I grew up in a context of having my mum looked after by doctors from that time onward. She was a paraplegic for 47 years after that, so the majority of her life was spent in a wheelchair. Whilst I was really interested in science as a student, it became clear to me that one way of using that science to help people was to become a doctor. So that personal experience was very important in terms of: what can I do to help people like my mum?
The other thing was probably due to my uncle, a PhD scientist who’s worked in biomedical research. When I told him I was interested in science, his very candid advice to me was that if I wanted to be the head of a research team, I should be a doctor, not a PhD; or preferably do both! He very strongly suggested that rather than me going into a Bachelor of Science program that I pursue a medical degree. Thankfully when I was in medical school, I found that I also loved being with people - so it wasn’t just the fascination of how could I apply science to help people anymore; I actually enjoyed being with people! Medicine proved to be a very fulfilling way of being able to be with people as well as being able to do something positive for them.
Can you share your background on how you got to where you are right now?
I studied medicine directly out of high school, on the basis of my interest in science as well as my family background. During medical school, the area that interested me most was working with people in the developing world. As a result, when I finished my medical training I looked around at what would prepare me best to work there. The area I determined would serve me best was rural practice. Rural practice would give me the generalist skills to be able to handle whatever I was confronted by in low resource settings. Through visiting a number of developing world locations during my training, I found that these locations didn’t need a person who was highly trained in anesthetics, obstetrics, surgery, psychiatry, pediatrics and general medicine, which is what my training had given me. Instead, they needed better sanitation, better roads, better homes; they needed public health approaches, which I hadn’t been trained in.
I was also confronted by the fact that many people in rural Australia weren’t happy. In fact, they were really stressed, largely due to healthcare. I came to the conclusion that with my more technology focused skills, around obstetrics, anesthetics and in-patient care of people, and the fact that rural communities at that time were really in quite a depressed state, that I could actually do more benefit at home, than I could overseas. As a result, I chose to go in and use my skills in rural communities in Australia, rather than internationally.
You have been highly influential in the development of the rural community based medical education program, can you tell us some more about this and how it all began?
As a rural doctor taking in medical students, I noticed two important things. One, students really enjoyed it when they came and spent time with me. Secondly, they treated it as a holiday from the real work of the university, which was learning how to be a doctor in a tertiary hospital setting. However, universities at that time were seeing rural practice as an addendum, or an optional extra, but not really a core part of being a doctor. Rural doctors in general, and me in particular, were disappointed in the way universities were training medical students. So we lobbied the federal government to be able to do something about that.
The federal government responded with a package of proposals to promote rural practice which involved recruitment and retention incentives, CME (continuing medical education), family support, and package proposals to get rural practice to be an essential part of the curricula in medical schools, and to get recruitment of rural students and academics into those medical schools. The problem was there weren’t any rural medical academics to recruit, and there weren’t many people who had the skills. In fact, I didn’t have the skills either. But then I thought to myself, seeing as I’d been lobbying for these positions, I should raise my hand up and have a go at being a new rural medical academic. So that’s what I did!
I applied for the job here at Flinders (University), under the supervision of an amazing Professor of general practice, Professor Chris Silagy. He mentored me even though at the time I was only a passionate rural clinician who’d been involved in rural medical politics as a president of the rural doctors association in South Australia and had very little experience on the academic side. Further involvement in the development of rural curricula reinforced to me that rural medicine was still on the periphery. It was an optional extra, but it wasn’t part of the core, and it became obvious that what was the core was defined by ‘the big exam’, at the end of the penultimate year in our course. That defined who and what was important. The content of that exam, and therefore the rotations that occurred prior to that, were all tertiary hospital based: surgery, medicine, pediatrics, psychiatry, obstetrics and gynecology. Our challenge was getting rural medicine to become a part of that core.
Still, students were really enjoying the rotations that I was conducting. They continued to come back and often claimed that it was the best part of their medical school experience. They stated that they had the opportunities to do and feel like real doctors practicing real medicine, rather than simply shadowing and observing.Unfortunately, I couldn’t get a student to go out to a small rural town and do an 8 week surgical term or obstetrics term. This was because, in that given period of time, there would only be a limited number of cases. There just wasn’t enough clinical experience to learn what you needed to know for obstetrics or surgery in the 8 week blocks.
At this time, it occurred to me, what if we transformed the curriculum from being a vertically silo-ed curriculum to being a horizontal one, where instead of learning all of your obstetrics or surgery discretely in 8 weeks, you could learn it all together at the same time with the other rotations in 40 weeks. In other words you didn’t change the curriculum, but you changed the way it was learned, and the time period. I knew from my experience in rural practice that if a student was there for the whole year, they would meet the requirements of the whole curriculum.
So we proposed this radical transformation with the support of Professor Chris Silagy to our Dean, and to our surprise he said he was prepared to think about it, that it sounded very innovative, and that it might just work. We’d have to find the money, practices, and the students who were prepared to do this, but if we found all these things he would back us in it. So we did that. We chose 6 students, all of whom were really interested in this endeavor. They could see that this was something new, different, and exciting where they could be co-creators of the curriculum as well as learn to be a real doctor in a different way. We found the practices who were prepared to give this new curriculum a go. They were actually more nervous than the students since they were taking on a huge responsibility and felt responsible for preparing the students for their major exams entirely under their supervision. To alleviate this we developed it in a way that was not an “us and them” in terms of the tertiary hospital and the rural curriculum. We overcame a lot of the rural doctors’ anxiety by engaging the specialists to be co-teachers with them. We created a curriculum that enabled the students to still engage with the tertiary specialists, but to be supervised by the rural doctors in the rural community. We got the chance to do it for a year as an experiment, with the full knowledge that if it didn’t work it would stop at the end of the year.
We had 8 students in that first group, of which 5 ended in the top 10 for their class, and the rest finished in the top quarter. No one at the university could believe the results. There were all sorts of doping accusations that were being made, but since the exam had been set and conducted by the tertiary specialists in the university hospital, people had to accept the results. More than that, they actually started owning the results. The medical school started owning this project as their project, it wasn’t “someone else’s” project, it wasn’t “my” project, it was “our” project. That joint ownership was really important in the longevity of the program. That was 1997.
What we decided to do right from the onset was to treat it as an experiment, and to treat it therefore with the rigorous study that was due to an experiment. We not only looked at what the students learned and how well they learned, but why and how they learned. It was that study that led to the publication of a lot of the evidence that has constructed our symbiotic medical education approach, of how students learn in this environment. It’s that information that has gone on and informed the replication of this approach in multiple other environments, both in Australian universities and around the world. People have looked at what has been done, the principles that made it work and how those principles can be applied in their own contexts to work for their students.
The key principles are that learning is relationship based - it’s based on meaning, and it’s meaning that students extract from their relationships with patients as people, not as a disease but as people; and their relationships with their supervisors as people, not just as someone in a white coat who walks in and out of the room and tells you what you have or haven’t learned, or shows off in front of you with their amazing knowledge and skills and makes you think “I could never be like that”. So it’s that long term relationship that builds meaning and that meaning gives a purpose for the learning, that motivates the students to actually engage in far more learning, and that’s why they do better, because they do a lot more in that environment. It’s those principles that we’ve been using in those other contexts of how we can get students to learn better in tertiary hospital contexts, secondary hospital, urban hospitals, and remote contexts. Those same sorts of principles, are now seen as the principles of community based medical education, and inform the principles of longitudinal integrated clerkships or LICs, which is a version of this that is being used around the world.
What are 2-3 changes you would like to see in the current Australian medical education system?
I think there’s still a lot of work to be done around the selection of medical students, and getting selection tools that have predictive value not in how a student will do in year 1 of the medical course, but in how they will actually do as a doctor, how they will actually be as a doctor. I don’t believe that our current selection tools are accurately predictive of that. I think they are fair in terms of giving students a transparent approach to selection, but I don’t believe they are necessarily giving society what it is expecting out of medical education in terms of high quality, ethical doctors who will work where and how society wants them, rather than where and how the doctor wants to work.
Second thing is I believe that our assessment processes could be targeted far more towards assisting students in learning, rather than just assessing the knowledge that they’ve accumulated. Our approaches to that could help in reducing the burden of stress that students suffer in medical education in Australia at the moment. I think student well-being is a real issue in our medical courses, and a lot of that is around our assessments. If we could change those assessments to be far more oriented around improving student learning, rather than just assessing what they don’t know, then that could be a big step forward.
Thirdly, I think medical education in Australia is still incredibly focused in classrooms and university campuses, and could be far more focused in the workplace. With the changes of technology, the knowledge of, and the access to the medical sciences can now be much more ubiquitous, and therefore we could get medical education and medical science far more located in medical practices; and that’s not just hospitals, but also private clinics, rural communities, remote urban, the whole breadth of practice. That to me would become a much more authentic learning environment for the students, and would have the benefit of speeding up the translation of medical research and knowledge into the practice in those locations, through the presidents of the universities and the medical students.
Do you have any final thoughts regarding the medical profession as a whole?
What a blessing to society that we have doctors. I think we sometimes take it for granted, that we have the doctors that we have. Despite some of the inconsistencies and difficulties in the system, some great people still become doctors, and do amazing things. Despite the system that sometimes doesn’t support them as practitioners, they work around it and still do amazing things. However, I think the profession is having to face a decreased trust by society, and that’s because a few doctors have been very self centered, and have been very unethical in what they’ve done. It’s unfortunate that a few bad apples can spoil the whole barrel, but that to me is something that as doctors we have to take very seriously, our professional regulation of our peers, and recognize that our peers can be unwell, can be under-performing and we need better ways of being able to pick that up and support them. If that means supporting them not to work, or to work differently, we need to do that because the trust is a problem. Without trust, we can’t practice, and that’s a pity for all the amazing people that are in practice, and are deserving of the trust of society.