We know of no other studies directly comparing the academic performance of students learning the same curriculum in tertiary, secondary, or primary care settings. Examination performance is only a proxy for academic performance, but it is the most common measure used by universities to determine academic progression, is used by many hospitals in ranking applicants for junior doctor positions, and is a measure that students value highly.
We did not use randomization in this study. This is a common problem in educational settings, introducing the possibility of biases, including selection bias.7
It could be argued that the students who were selected for the rural and remote settings were, for example, more resourceful and talented. If this were so, it would have been evident in their previous academic performance because the first two years' study, based entirely on problem based learning, encourages and rewards these qualities. However, we saw no differences in previous academic performance by group ().
A further argument against selection bias being a serious limitation in this study is the school's selection procedure. The three elements that contribute to this process are performance in a national admission test of reasoning and problem solving in the basic sciences and humanities, performance in a previous undergraduate degree, and performance at a standardised interview that rewards evidence of self directedness, teamwork, communication skills, compassion, resourcefulness, and broad life skills. Thus, all medical students at Flinders are likely to be resourceful and talented high achievers.
Other qualities that could be over-represented in students in the rural programme and Darwin groups, such as seeking adventure, interest in rural medicine as a career, being suited to rural life, and having fewer ties with the city, show only the student centred benefits of offering different environments to suit the needs of different students. There is no suggestion that such qualities inherently affect academic performance, but when a student's self perceived traits are matched to an environment that supports them, their academic performance may be enhanced. This should, however, have been equally true for students who chose to study in the tertiary centre.
Our analysis accounted for the other possible biases of student age, sex, year 2 score, and cohort effect. The results cannot be explained by the Hawthorne effect as they have been sustained over five years and during this time the rural and Darwin programmes have become a routine part of the school's study options. The results may also be criticised for reflecting the effect of group size rather than location. However, on a day to day basis, students in all of the locations were allocated to practices or wards in pairs or alone, and tutorial group sizes were also similar.
Future of community learning
When the rural and Darwin programmes were initiated, the university had some concerns that student learning would be compromised in pursuit of the longer term workforce aims. The quality of the students' examination performance in the regional hospital, and, in particular, in the community setting, has allayed this concern. Our findings challenge the orthodoxy of a tertiary hospital being the most appropriate location for all undergraduate medical students.
In 2001, the Australian Commonwealth government announced a national programme that will require each medical school to enable a quarter of its students to undertake half of their clinical education in rural or remote settings. Although some students will learn better in large urban settings, our findings should give students confidence that they do not have to sacrifice academic performance when taking advantage of such learning opportunities.