Is Australian rural practice changing? Findings from the National Rural General Practice Study

The impact of localised general practice training on Queensland's rural and remote general practice workforce

BACKGROUND

The diverse rural medical education initiatives that have been developed in Australia to address the medical workforce maldistribution have been less successful in many smaller and remote communities. This study explored the factors that attract and retain GP registrars and supervisors and the impact that localised training (i.e., rural and remote workplace-based training and support) has on both GP registrars and supervisors, and the GP workforce in rural and remote underserved areas.

METHODS

A purposive sample of 79 GP registrars, supervisors, practice managers, health services staff and community representatives living and working in areas of low GP workforce in rural and remote Australia were invited to participate in semi-structured interviews and one focus group divided over two phases. Thematic analysis was used to explore themes within the data.

FINDINGS

Attractors and barriers to rural and remote practice were identified as the main themes. Attractors include family and community lifestyle factors, individual intrinsic motivators, and remote medicine experiences. In contrast, barriers include work related, location, or family factors. Further, localised GP training was reported to specifically influence GP registrars and supervisors through education, social and financial factors.

CONCLUSION

The current study has provided a contemporary overview of the issues encountered in expanding GP training capacity in rural and remote communities to improve the alignment of training opportunities with community and workforce needs. Strategies including matching scope of practice to registrar interests have been implemented to promote the attractors and lessen the barriers associated with rural and remote practice.

Interpreting rural career intention in medical workforce research

Rural medical educators have devised strategies based on research evidence to help shape a medical workforce that will choose to serve in rural and other under-served communities, where the health care needs are often high. Based on evidence that students from rural communities are more likely to work later in rural practice, many medical programmes now have targets for rural background students in addition to rural curriculum and placement initiatives. However, just how strong is the evidence that this is effective? Australian medical schools now have data for up to 20 years since the rural medical education initiatives were first introduced. Rural background still appears to be a strong predictor or rural practice outcomes, although combining multiple strategies appears strongest. There remain some methodological issues, such as defining both 'rural' and 'background', and determining how intention relates to ultimate location of practice. We may yet have to await longer follow-up periods before we can be confident about what works best in rural medical education.

The 'rural pipeline' and retention of rural health professionals in Europe's northern peripheries

The major advance in informing rural workforce policy internationally over the past 25 years has been the recognition of the importance of the 'rural pipeline'. The rural pipeline suggests that people with 'rural origin' (who spent some childhood years in rural areas) and/or 'rural exposure' (who do part of their professional training in rural areas) are more likely to select rural work locations. What is not known is whether the rural pipeline also increases the length of time professionals spend in rural practice throughout their careers. This paper analyses data from a survey of rural health professionals in six countries in the northern periphery of Europe in 2013 to examine the relationship between rural origin and rural exposure and the intention to remain in the current rural job or to preference rural jobs in future. Results are compared between countries, between different types of rural areas (based on accessibility to urban centres), different occupations and workers at different stages of their careers. The research concludes that overall the pipeline does impact on retention, and that both rural origin and rural exposure make a contribution. However, the relationship is not strong in all contexts, and health workforce policy should recognise that retention may in some cases be improved by recruiting beyond the pipeline.

Influence of rurality on diagnosing dementia in Australian general practice

This article reviews the literature concerning barriers in making a diagnosis of dementia in general practice and examines these from a rural perspective. It is proposed that the increasing prevalence of dementia in coming years in Australia will be felt most keenly in rural communities where there are already shortages of GPs and dementia-specific services to manage growing demand. Evidence suggests that dementia is often not specifically diagnosed by GPs and that this is a global issue. There are many barriers to the diagnosis of dementia in general practice, including time constraints, diagnostic uncertainty, denial of symptoms by patients and families, and stigma. This review examines these barriers and their impact on making a dementia diagnosis from a rural general practice perspective. Identification of these practice issues and their influence on service delivery is essential to inform relevant policy decisions and to improve dementia management in rural general practice.

Palliative care referral practices and perceptions: The divide between metropolitan and non-metropolitan general practitioners

Objective:

Late or non-referral of patients to specialist palliative care (SPC) services may affect patients' and their carers' quality of care. General practitioners (GPs) are key professionals in linking people with SPC. The aim of this article is to assess GPs' perceptions and SPC referrals for their patients with advanced cancer and differences between metropolitan (M GPs) and non-metropolitan GPs (NM GPs).

Method:

Self-report survey mailed to a stratified random sample of 1,680 Australian GPs was used.

Results:

Thirty-one percent (469) of eligible GPs returned surveys. More M GPs than NM GPs reported referring >60% of their patients for SPC (p = 0.014); and that a more comprehensive range of SPC services was available. The most frequently reported referral prompts were: presence of terminal illness (M GPs, 71%, NM GPs, 66%, ns (not significant)); future need for symptom control (69% vs. 59%, ns) and uncontrolled physical symptoms (63% vs. 54%, ns). Reasons for not referring were: doctor's ability to manage symptoms (62% vs. 68%, ns) and the absence of symptoms (29% vs. 18%, p = 0.025). Higher referral was associated with: having a palliative care physician or consultative service available; agreeing that all patients with advanced cancer should be referred, and agreeing that with SPC, the needs of the family are better met.

Significance of results:

Referrals for SPC were primarily disease-related rather than for psychological and emotional concerns. Measures are needed to encourage referrals based upon psychosocial needs as well as for physical concerns, and to support GPs caring for people with advanced cancer in areas with fewer comprehensive SPC services.

A rural/urban comparison of the roles of the general practitioner in colorectal cancer management

OBJECTIVE

To identify and compare the roles of urban, rural and remote general practitioners (GPs) in colorectal cancer (CRC) management.

DESIGN

Semistructured interviews exploring GP views of their role in CRC management.

SETTING

Urban, rural and remote general practices in north Queensland.

PARTICIPANTS

Fifteen GPs in urban, rural and remote practice.

MAIN OUTCOME MEASURES

Self-reported roles in the management of CRC patients and factors influencing these roles.

RESULTS

All GPs, regardless of location of practice, played a role in diagnosis, referral, postoperative care, psychosocial counselling, follow up and palliative care. Involvement in treatment of CRC patients was only performed by remote GPs. In general, rural and remote GPs played greater roles in care coordination, clinical and psychosocial care. Rural and remote GPs were more heavily involved throughout the entire illness progression when compared with their urban counterparts.

CONCLUSIONS

The results of this study indicate that rural and remote GPs in north Queensland play a greater role than urban GPs in the management of CRC. In order to maintain and enhance the roles of rural and remote GPs in CRC care, appropriate guidelines and remuneration should be provided. Palliative care support might also be useful to rural and remote GPs.

Medical students and rural general practitioners: congruent views on the reality of recruitment into rural medicine

OBJECTIVE

In-depth exploration of the perceptions, experiences and expectations of current long-term rural GPs and medical students intent on a rural career, regarding the current and future state of rural medicine.

DESIGN

Qualitative study using semistructured interviews.

SETTING

Rural and remote towns in Central and Southern Queensland and the School of Medicine, University of Queensland.

PARTICIPANTS

Thirteen rural GPs with 10-40 years experience. Medical students (five second- and seven third-year), all of whom are members of a rural students' club and have an intention to pursue rural practice. Interviews were conducted between August and December 2004.

MAIN OUTCOME MEASURES

Emergent themes relating to participant perceptions of the current and future state of rural medicine.

RESULTS

Despite large differences in generation and experience, medical students and rural GPs hold similar perceptions and expectations regarding the current and future state of rural practice. In particular, they cite a lack of professional support at the systems level. This includes specific support for: continuing medical education to obtain and retain the skills necessary for rural practice; dealing with the higher risks associated with procedural work; and consequences of medico-legal issues and workforce shortage issues such as long hours and availability of locums.

CONCLUSIONS

Issues relating to recruitment and retention of the rural health workforce are identified by both cohorts as relating to professional support. Medical schools and institutional support systems need to join forces and work together to make rural practice a viable career in medicine.

Competencies and skills for remote and rural maternity care: a review of the literature

AIM

This paper reports a review of the literature on skills, competencies and continuing professional development necessary for sustainable remote and rural maternity care.

BACKGROUND

There is a general sense that maternity care providers in rural areas need specific skills and competencies. However, how these differ from generic skills and competencies is often unclear.

METHODS

Approaches used to access the research studies included a comprehensive search in relevant electronic databases using relevant keywords (e.g. 'remote', 'midwifery', 'obstetrics', 'nurse-midwives', education', 'hospitals', 'skills', 'competencies', etc.). Experts were approached for (un-)published literature, and books and journals known to the authors were also used. Key journals were hand searched and references were followed up. The original search was conducted in 2004 and updated in 2006.

FINDINGS

Little published literature exists on professional education, training or continuous professional development in maternity care in remote and rural settings. Although we found a large literature on competency, little was specific to competencies for rural practice or for maternity care. 'Hands-on' skills courses such as Advanced Life Support in Obstetrics and the Neonatal Resuscitation Programme increase confidence in practice, but no published evidence of effectiveness of such courses exists.

CONCLUSION

Educators need to be aware of the barriers facing rural practitioners, and there is potential for increasing distant learning facilitated by videoconferencing or Internet access. They should also consider other assessment methods than portfolios. More research is needed on the levels of skills and competencies required for maternity care professionals practising in remote and rural areas.

General practitioners' attitudes to palliative care: A Western Australian rural perspective

BACKGROUND

People with a terminal illness and their families who live in rural or remote areas of Australia face difficulties in accessing palliative care services as a result of physical isolation. This leads to rural general practitioners (GPs) carrying the burden of care, which is often exacerbated by a lack of support staff.

OBJECTIVE

This research addressed the following questions: What are GPs' attitudes to palliative care in a rural center of Western Australia? What factors contribute to GPs' attitudes to palliative care in a rural center of Western Australia? What are the perceived barriers to the provision of palliative care in a rural center of Western Australia?

DESIGN

A qualitative in-depth research design was used for this study due to the exploratory nature of the research. A model of attitudes that considers an attitude as a summary evaluation of an issue based on: cognitive information, (thoughts and beliefs), affective or emotional information, and information concerning behavior, was used.

PARTICIPANTS

Participants were 10 registered GPs located within the Greater Bunbury Division of General Practice in Western Australia.

RESULTS

Six themes emerged from the research: maintaining patients' quality of life, providing continuity of care, experiencing emotional issues, collaborating with a multidisciplinary team, acknowledging the need for education and training, and dealing with the wider context.

CONCLUSION

Education and training for rural GPs needs to be relevant to the local context and needs to focus on emotions and beliefs.

Orientation for general practice in remote Aboriginal communities: A program for registrars in the Northern Territory

BACKGROUND

Remote general practice can be a highly rewarding career, but poses many personal and professional challenges. It is characterised by significant geographical, professional and social isolation and a requirement for practitioners with public health, emergency and extended clinical skills. The remote practitioner faces further challenges in the remote Aboriginal community setting, including language and cultural barriers.

OBJECTIVES

This paper discusses the specific components of a remote Aboriginal community general practice registrar orientation program in the Northern Territory, and their particular importance and relevance to remote training and practice in this context.

DISCUSSION

Northern Territory General Practice Education, the regional general practice training provider in the Northern Territory, has developed a model for a comprehensive orientation program for general practice registrars planning to work in remote Aboriginal community locations. This comprises a number of core components, including communication and cultural safety training; clinical and procedural skill development; population health; self-care and personal/professional role delineation; and organisational issues. We believe it is a program that is applicable to other disciplines undertaking work in remote Aboriginal communities.

Do the learning needs of rural and urban general practitioners differ?

INTRODUCTION

The challenges of rural general practice have given rise to a separate rural training stream and a separate rural professional body. The differences are characterised by the nature of the work undertaken by rural GPs and reflected in the continuing medical education topic choices made when surveyed.

METHODS

In 2001 a survey was designed and distributed by the Royal Australian College of General Practitioners and Divisions of General Practice in South Australia and Northern Territory. The survey utilised a list of 104 topics. The topic choices of rural and urban GPs were compared.

RESULTS

The survey was distributed to approximately 1762 GPs and yielded 578 responses (33%). Rural GPs were more likely to select the following topics: Anaesthetics, Aboriginal Torres Strait Islander health, Population Health, Renal medicine, Cardiology, Teaching skills, Obstetrics, Neonates, Arrhythmias, Fracture management, Tropical medicine and Therapeutics. Urban GPs were more likely to select Menopause, Travel medicine and Palliative care (P < 0.05).

DISCUSSION

Many of the areas of difference reflected aspects of rural general practice. There were also many similarities in topic choices between these two groups.

Factors associated with rural doctors' intention to continue a rural career: A survey of 3072 doctors in Japan

OBJECTIVE

To show the relationship between the personal and educational backgrounds of rural doctors and their intention to continue a rural career.

DESIGN

Nationwide postal survey.

SETTING

Public clinics or hospitals in municipalities that are classified as 'rural' by the national government.

SUBJECTS

A total of 4896 doctors working for 828 public clinics and hospitals.

MEASUREMENTS

A questionnaire was mailed. The questionnaire inquired about the subject's age, sex, hometown, exposure to rural practice in undergraduate education, postgraduate training, continuing medical education, current position and affiliation status with a medical school, as well as his or her intention to continue a rural career.

RESULTS

Response rate was 64%; 26% answered that they intended to continue a rural career. Postgraduate training in general internal medicine, general surgery, anaesthesiology, paediatrics and gastroenterology were positively related with the intention to continue a rural career (odds ratio = 2.045, 1.59, 1.30, 1.48, 1.38). Rural background, undergraduate exposure to rural practice, multispecialty-rotation in postgraduate training and current administrative position had positive correlations with the intention to continue in logistic regression analysis (odds ratio = 1.80, 2.47, 1.54, 2.17). Affiliation with a medical school department was negatively related with the intention to continue (odds ratio = 0.45).

CONCLUSION

In addition to the rural background of physicians, some undergraduate and postgraduate factors were independently associated with the intention to continue a rural career.

A baseline study of the demographics of the oral health workforce in rural and remote Western Australia

BACKGROUND

A shortage of dental practitioners in Australia is predicted for the future, and the greatest effect of this will be felt in rural and remote areas. Strategies are needed to increase the recruitment and retention of dental practitioners in these areas. Part of this process is to assess the demographics of the oral health workforce.

METHODS

A postal questionnaire survey was undertaken in 2002, that involved all registered dentists, therapists and hygienists in rural and remote Western Australia.

RESULTS

Rural dentists are predominantly male, early middle aged, married, UWA trained, Australian born with one to two children. Rural dental therapists are predominantly female, in their mid-thirties, married, Australian born, trained in Western Australia, with two children. Male dentists worked slightly more hours per week than female dentists. The majority of the workforce does have access to email and the internet. Taking leave is a problem for most dentists because of difficulties in finding locums.

CONCLUSIONS

The rural dental workforce capacity and demographic distribution need monitoring and analysis. This will determine the dental workforce's future ability to deliver the necessary services in rural and remote regions, where currently there is a dental workforce shortage.

Is rural medicine a separate discipline?

BACKGROUND

The Australian College of Rural and Remote Medicine was established in 1997 to meet what rural doctors perceived as their unmet educational and professional needs. However, the issue of just how different rural practice is from urban practice remains a topic of debate.

METHODS

This paper explores the scope of rural medical practice, through the use of clinical scenarios and a synthesis of the research literature, to determine if rural medical practice is emerging as a distinct discipline in Australia.

CONCLUSION

Rural and remote medical practice is different, and additional, to urban practice, in the context, content and process of care. Three of the four criteria for determining rural medical practice as a distinct discipline exist in Australia. The fourth criteria: sufficient external recognition of rural medicine as a distinct discipline, awaits resolution.

WHAT THIS PAPER ADDS

This paper examines a key issue that has been a source of conflict between the relevant stakeholders for a decade. By placing the differences between rural and urban medical practice within a framework, supported by published work, this paper describes what is required to justify rural medical practice as a distinct discipline for the first time.

Why 4 years when 3 will do? Enhanced knowledge for rural nursing practice

In Australia, debates over the appropriate length of undergraduate nursing programs have a long history. Submissions from both universities and industry to key government reports have consistently argued that the current minimum entry level of practice, a three-year program, is too short to enable students to gain the knowledge and skills necessary for the contemporary nursing role. Despite these submissions, the established entry level for nursing practice in Australia remains a three-year undergraduate bachelor degree. However, there is a small group of high-achieving students who will begin practice at the end of a four-year program. Little is known about these programs, or the students who are currently enrolled in them. Designed as a collaborative endeavour, based on co-operative inquiry, the study discussed in this article aimed to provide an insight into aspects of a four-year undergraduate nursing program. Potentially, the broader theoretical and clinical preparation that is possible in a four-year program provides students with enhanced learning opportunities that will enable them to graduate with more confidence and greater ability. In this study a four-year program provided an opportunity for a regional university to prepare students for the demanding realities of a complex area of practice, rural nursing.

Rural Doctors' Satisfaction in Japan: A Nationwide Survey

OBJECTIVES

The purpose of this paper was to discover to what degree Japanese rural doctors are satisfied with various aspects of their jobs and lives, and to find out whether they intend to continue their rural careers.

DESIGN

Nationwide postal survey.

SETTING

Public clinics or hospitals in municipalities that are authorised as 'rural' by the national government.

SUBJECTS

A total of 4896 doctors working for public clinics or hospitals.

INTERVENTIONS

Self-evaluation questionnaires were mailed. The rural doctors were asked to evaluate their satisfaction with 19 items related to their job conditions and 10 items concerning life conditions, using a four-point scale. They also were asked to evaluate their intent to stay in rural practice until retirement.

RESULTS

The response rate was 64%. Overall, rural doctors were satisfied with both their work and life conditions. However, only 27% of respondents hoped to continue rural practice beyond the usual age of retirement. Among job-related items, continuing medical education and interactions with municipal governments were rated as least satisfactory. Among lifestyle-related items, duration of holidays and workload were unsatisfactory. Subgroup analysis revealed male doctors showed greater intent to stay in rural practice. Doctors aged > 50 years were more satisfied with most aspects of their job and lifestyle than younger doctors. A strong correlation was found between the degree of intent to stay and several items such as interactions with municipal government, human interactions salary and job fulfillment.

CONCLUSIONS

Strategies, based on the results of this survey, should be implemented. Particularly in Japan, positive interaction between doctors and municipal governments is crucial.

WHAT THIS PAPER ADDS

Though rural doctors in Japan in general were satisfied with their lifestyle and work conditions, they have low intentions to stay in rural areas. Among the various factors that can cause this dissociation between satisfaction and intention to stay, doctors' interactions with municipal governments play a pivotal role.

Educating for rural nursing practice

BACKGROUND

Rural hospitals in Australia, as in many countries, face challenges in ensuring that appropriate, quality services are provided.

AIMS

The overall aim of this study was to explore the issues that impact on the ability of rural hospitals to provide effective health care.

METHODS

We used a qualitative descriptive method and purposive sampling, and conducted interviews in hospitals in rural Victoria, Australia. The data collected enabled major issues that impact on hospital service delivery to be identified. Using thematic analysis, global themes were extracted and organized around a thematic network.

FINDINGS

The workforce was an important theme. Whilst the impact of medical shortages on hospital function has been considered in other studies, little consideration has been given to the rural nursing workforce. The need to maintain an appropriately educated rural nursing workforce emerged as one of the major issues that impact on rural hospital service delivery. In Australia, there has been a great deal of discussion about the educational preparation required for rural nursing practice, with the emphasis on postgraduate study. However, the majority of rural nurses do not have postgraduate qualifications and face significant barriers in obtaining them. Although the vast majority of literature claims that postgraduate preparation is vital for rural nursing practice, this research suggests that the future rural nursing workforce will be recruited from undergraduate courses in regional universities. However, there is a need to include specific theoretical and operational preparation in undergraduate education, to enable nurses to make the transition to rural practice more readily.

CONCLUSIONS

Rural nurses are central to the delivery of health services in rural hospitals. Future rural nursing recruitment and retention hinges on ensuring that they have the confidence, knowledge and skills to deliver safe, appropriate and effective care.

Professional and social support networks of rural general practitioners

This study explored the nature of rural general practitioners' (GPs) professional and personal support networks. A qualitative design was employed, using in-depth interviews with a diverse sample of GPs in rural Queensland. The support network of the rural GPs in this study incorporated the domains of clinical, workforce and social support, with clinical support as the most important domain. There was a preference for face-to-face contact wherever possible. Such contact was particularly important in the process of developing the network and for personal support. Despite this, many network contacts were by telephone out of necessity. There were few notable differences between male and female rural GPs on the issues explored in the present study. General Practitioners' satisfaction with their professional interactions was varied across the sample. The findings suggest that level of satisfaction may be associated with intentions to leave or stay for this group.