res to manage the organisational requirements of hosting the learners: 'I have everyone marked on there as all the new learners are coming and leaving. So I really do keep a strict eye on that.' (Practice manager M1 - multi-level learner practice).
For educational considerations there were four subthemes. Educational processes exhibited increasing complexity with greater numbers of learners. Practices with multiple levels of learners used a range of teachers and educational processes, were aware of each learner's curriculum and facilitated formal and informal peer assisted learning. For example:
The teaching sessions always had a plan on, you know, we'll talk up to this level and make sure that we get the student involved to this level and then we go through to the next level. (Practice manager M1 - multi-level learner practice).
Clinical supervision became more structured with greater engagement of learners. Practices with multiple levels of learners had several senior doctors identified as supervisors and there were examples of senior learners being supported to supervise other learners: '..part of me trying to learn exam stuff has been helped by supervising other people.' (Registrar M2 - multi-level learner practice). These practices may have supervisors that have allocated clinical sessions where they supervised without having their own booked patients:
There are times when my role as the supervisor is just supervising ... there'd be some sessions where I won't see any patients booked in for myself. (Supervisor M3 - multi-level learner practice).
Educational networks, facilitated by universities and regional training providers, were important in supporting educational skills and resources:
Well the RTP provided not only payment for us to do the work, but educational material and educational forums for learning ... and the university would be providing educational material ... as well. (Supervisor M1 - multi-level learner practice).
Educational networking was a greater feature of practices with a strong educational engagement.
The impact of learner presence on the practice environment was the fourth educational subtheme. The part that the learners themselves played in the practice environment became much more significant with increasing educational engagement. When one or two learners are present, they tended to be absorbed into the established working community. When there are a number of learners present in a practice at a time, they generated their own social and educational networks. With multiple learners in a practice, learners took on the role of teaching other learners and bringing senior staff up to date:
The registrars taught the interns, the registrars and the interns taught the medical students. In fact that's where most of the teaching happened for the medical students. (Supervisor M1 - multi-level learner practice).
Although not a dominant theme, research considerations had two subthemes. Attitude to research while mixed was on the whole positive across all practices and participants:
... if there is no research everything stagnates and you've absolutely got to have research ... (Patient S1 - single-learner practice).
There were reflections from two supervisors that research processes may be at odds with the way that general practitioners think and operate:
It's time consuming, it's tedious, it's methodologically rigorous. None of those things sit well with most GPs I know. (Supervisor 2 M2 - multi-level learner practice).
There was very little research activity in any of the practices other than clinical audits and being participants in research undertaken by external organisations.
Table 4: Themes and subthemes, with example quotes
Developing a rural academic general practice framework
This rural academic general practice framework was based on the thematic analysis above and published literature (Table 5). Four levels of academic engagement by rural general practices are described in the columns beginning, emerging, consolidating and established. All subthemes are reflected in the cells under the broa