ional 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 broad theme rows. Leveraging the case study research design, the six practices studied were conceived to provide representations of the first three levels of academic engagement: beginning, emerging and consolidating. The features of an established academic rural general practice were supposed from the literature, from extrapolation of the progression of beginning to consolidating rural academic practice, and from the experience of the research team in the rural general practice and academic environments.
Table 5: Framework for rural academic general practices
Considerations were identified for progressing on a trajectory from a rural general practice without a training focus to one that has extensive training activity to one that undertakes both training and research and thus could be described as a rural academic general practice. Stages on this pathway have been conceptualised as beginning, emerging, consolidating and established. To effectively foster education and research activity in rural general practices, the considerations identified in the thematic analysis and represented in the framework need to be addressed.
A beginning practice may be reluctant to host learners because of uncertainty about the impact of learners on the patient population and on the doctor-patient relationship. They may be concerned about the additional workload that learners might bring and how to manage this. They may be unsure of the financial consequences of hosting learners, may not have the physical space and may be uncertain of their knowledge and capacity for teaching. To encourage these practices to take on learners, training providers and universities need to be able to clearly articulate how these concerns might be addressed.
Emerging practices in the framework have had some involvement in education while health service delivery remains the primary focus. Usually only one level of learner and a single supervisor are present in the practice. A culture of teaching is appreciated but is not significant. Patients may or may not b