Doctors' rural practice self-efficacy is associated with current and intended small rural locations of practice

Retention of Doctors and Dentists to Serve in Remote Areas in Indonesia: A Discrete Choice Experiment

Introduction

Retaining doctors and dentists in remote areas of Indonesia remains a national priority of the Indonesian government. The purpose of this study was to analyze the interventions for retention of doctors and dentists in remote areas using the discrete choice experiment (DCE) approach.

Materials and Methods

A DCE was conducted to investigate preferences of doctors and dentists for retention in remote areas. This research was conducted in 78 primary healthcare settings across 15 provinces in Indonesia. The conditional logit model was used to explore stated preferences for each attribute.

Results

The total number of respondents was 158, including 113 doctors and 45 dentists. In general, doctors placed the highest preference on getting priority for government scholarships to facilitate retention in remote areas (OR=5.65, p<0.001). Specifically, dentists preferred security guarantees from local government (OR = 4.87, p<0.001). Both groups valued having an official residence (OR=3.6, p<0.001) as a factor for retention in remote areas.

Conclusion

Scholarship, security guarantees, housing facilities, and medical facilities were the most considered factors for retaining doctors and dentists in a remote area. This study confirms the importance of a combination of interventions in maintaining doctors and dentists in remote areas. Policy options in the form of non-financial and financial intervention packages can be combined to improve their retention.

How the training pathways and capacity of rural physicians inform their scope of practice: A qualitative study examining the experiences of Australian and international medical graduates in South-East New South Wales, Australia

INTRODUCTION

Current strategies to address shortages of rural doctors focus on developing a pipeline for rural generalist practice. Limited research has explored how doctors' professional journey engenders the skills required to practice rurally.

OBJECTIVE

This paper analyses how rural general practitioners' clinical pathway informs their scope of practice and future retention.

DESIGN

Qualitative thematic analysis using semi-structured telephone interviews. Twenty-one general practitioners appointed in their local health district of Murrumbidgee and Southern New South Wales, Australia, within the past 10 years. Participants comprised 10 Australian medical graduates (AMG) and 11 international medical graduates (IMG).

FINDINGS

AMGs and IMGs contrasted how their pathway into rural practice, and capacity to work rurally, informed their scope of practice. Australian medical graduates' familiarity with rural areas was consolidated through congruous experiences, including at rural clinical schools. Paradoxically, the fluency of their training limited the amount of unsupervised experience and confidence AMGs gained. Together with a focus on work-life balance, this limited many to providing mainstream general practice, precluding extending their scope of practice. International medical graduates described disseminated experiences, often unsupervised in high-volume contexts. However, a lack of professional opportunities prevented them from extending their scope of practice.

DISCUSSION

IMG and AMG motivation and pathway for working rurally differ. Respective cohorts have concerns regarding requisite skills and knowledge for rural practice, which incorporates opportunity and recognition. Entry points for training should be variable to allow consideration of life stage, prior skill development and extension of scope of practice.

CONCLUSION

Doctors' scope of practice is informed by their pathways into rural practice. Australian medical graduates may not gain adequate competence during expedited training programs to confidently undertake extended clinical activities. International medical graduates, however lacked the opportunities and support, to utilise their expertise in rural practice. Complementarily utilising the expertise and commitment of both AMGs and IMGs may synergistically address workforce shortages.

Rural longitudinal integrated clerkships and medical workforce outcomes: A scoping review

INTRODUCTION

Internationally the medical workforce is suffering from a persistent geographic and specialist maldistribution. Longitudinal models of rural medical education such as longitudinal integrated clerkships (LIC) have been one of the strategies employed to redress this issue.

AIM

To map and synthesise the evidence on the medical workforce outcomes of rural LIC graduates, identifying gaps in the literature to inform future research.

METHODS

This review followed Arksey and O'Malley's methodological steps. Databases searched included Medline, CINAHL Complete (EBSCOhost), Scopus, Embase (Elsevier), and ISI Web of Science.

RESULTS

A total of 9045 non-duplicate articles were located, 112 underwent a full review, with 25 articles meeting the inclusion criteria. Studies were commonly cohort-based (84%), with data collected by database tracking and data linkage (52%). Five themes were identified to summarise the studies: (i) Overall geographic workforce outcomes (ii) influence of non-LIC medical training, (iii) remaining in region and level of rurality, (iv) medical speciality choice and rurality, and (v) selection and preferences.

CONCLUSION

Synthesis of the evidence related to workforce outcomes of rural LIC graduates provides directions for future rural medical workforce planning and research. While rural LIC graduates were found to be more likely to work rurally and in primary care specialities compared to graduates from other training pathways there is evidence to suggest this can be enhanced by strategically aligning selection and training factors.

Exploring the Varying Interest in Rural Medicine and Associated Factors Among Medical Students in Japan: A Cross-Sectional Study

Background and objective Examining the factors influencing the career aspirations of medical students is imperative for understanding their orientation toward rural medicine. Such an investigation can serve as a basis for shaping medical education curricula dedicated to nurturing rural focus. Although previous studies have categorized students based on the presence or absence of orientation toward rural medicine and explored their sociodemographic characteristics, these students may not constitute a homogeneous group; their interests can range from aspiring to establish residence and professional practice in a specific region to being merely willing to endure brief regional placements. There is a scarcity of comprehensive examination of the extent and potential variations of rural orientation in the literature. Our survey addresses this gap by exploring the variations in rural orientation among medical students and the differences in their sociodemographic characteristics and preferred specialties based on their degree of rural orientation. Methods We classified medical students into four groups according to their levels of rural orientation: demonstrating proactive engagement towards it, considering it for a defined duration, indicating a preference for avoiding it, and considering it unfeasible. The distribution within each group was investigated. A subsequent analysis of rural orientation and its associated sociodemographic characteristics was performed: a conventional dichotomous study was conducted based on the presence or absence of rural orientation, and a focused study compared students actively interested in rural healthcare with other students. This approach enabled us to explore differences in the degree of rural orientation and associated factors. Results The study included 531 students, with 89 participants demonstrating proactive engagement towards rural medicine, 283 considering it for a defined period, 95 indicating an inclination to avoid it, and 63 students stating that it is unfeasible for them. Associated sociodemographic characteristics were explored based on the presence or absence of rural orientation and included recommendations for admission by a designated high school, the presence of a physician role model, and aspirations for obstetrics and gynecology departments. Conversely, when exclusively focusing on students with a desire for proactive engagement in rural medicine, positive correlations were observed with characteristics such as being from the same non-urban prefecture as that of the university where the study was conducted, having a history of residing in a rural area, having a physician role model, and expressing aspirations for general practice or family medicine. Aspiring to be an organ-specific specialist showed a negative correlation with high levels of rural orientation. Conclusions Based on our findings, rural orientation is not uniform among medical students; distinct levels of this aspect were observed, each associated with different sociodemographic factors.

The Presence of a Physician Role Model and the Career Preference of Medical Students Are Associated With Rural Self-efficacy

Rural career preference is known to be affected by rural self-efficacy. This study aims to explore whether the presence of a physician role model and having a medical department of interest influence rural self-efficacy among medical students. The study sample comprised 813 students (464 male and 349 female). We assessed rural self-efficacy using a validated scale that comprised 15 questions. The effect of the presence of a physician role model and the choice of medical department on rural self-efficacy score was examined. Multivariable-adjusted regression analysis showed that the presence of a physician role model was significantly associated with the rural self-efficacy score (β = 0.236, p < 0.001), as were gender (β = -0.096, p = 0.004), admission while living in hometown (β = 0.077, p = 0.041), receiving a scholarship for regional duty (β = 0.079, p = 0.025), admission based on school recommendation (β = 0.077, p = 0.031), and subjective difficulty with living in a rural area (β = -0.201, p < 0.001). Moreover, a higher rural self-efficacy score was significantly associated with students who listed general medicine/family medicine (β = 0.204, p < 0.001), pediatrics (β = 0.098, p = 0.004), or obstetrics and gynecology (β = 0.108, p = 0.002) as their department of choice, while anesthesiology (β = -0.075, p = 0.023) was significantly associated with a lower rural self-efficacy score. These relationships were consistent for both males and females. The presence of a physician role model and the choice of medical department are important factors for higher rural self-efficacy scores.

Undergraduate rural medical training experiences and uptake of rural practice: a retrospective cohort study in South Australia

BACKGROUND

Rural medical training experiences provided by Rural Clinical Schools (RCS) can encourage future practice in rural locations. However, the factors influencing students' career choices are not well understood. This study explores the influence of undergraduate rural training experiences on graduates' subsequent practice location.

METHODS

This retrospective cohort study included all medical students who completed a full academic year at the University of Adelaide RCS training program between 2013-2018. Details of student characteristics, experiences, and preferences were extracted from the Federation of Rural Australian Medical Educators (FRAME, 2013-2018) survey and linked to graduates' recorded practice location obtained from the Australian Health Practitioner Regulation Agency (AHPRA, January 2021). The rurality of the practice location was defined based on the Modified Monash Model (MMM 3-7) or Australian Statistical Geography Standard (ASGS 2-5). Logistic regression was used to examine associations between student rural training experiences and rural practice location.

RESULTS

A total of 241 medical students (60.1% females; mean age 23.2 ± 1.8 years) completed the FRAME survey (response rate 93.2%). Of these, 91.7% felt well supported, 76.3% had a rural-based clinician mentor, 90.4% reported increased interest in a rural career, and 43.6% preferred a rural practice location after graduation. Practice locations were identified for 234 alumni, and 11.5% were working rurally in 2020 (MMM 3-7; 16.7% according to ASGS 2-5). In adjusted analysis, the odds of working rurally were 3-4 times more likely among those with a rural background or lived the longest in a rural location, 4-12 times more likely among those preferring a rural practice location after graduation, and increased with the student's rural practice self-efficacy score (p-value < 0.05 in all cases). Neither the perceived support, having a rural-based mentor, or the increased interest in a rural career were associated with the practice location.

CONCLUSIONS

These RCS students consistently reported positive experiences and increased interest in rural practice after their rural training. Student reported preference for a rural career and rural practice self-efficacy score were significant predictors of subsequent rural medical practice. Other RCS could use these variables as indirect indicators of the impact of RCS training on the rural health workforce.

Work-related, socio-cultural, and personal factors associated with locus of control among Australian general practitioners

BACKGROUND

Locus of control (LoC) is a social cognition, that relates to the level of self-control that people have over their personal environment that influences their life. In this context, LoC is frequently associated with work-related behavioral outcomes, ranging from job attitudes, career behaviors, stress, and burnout.

OBJECTIVE

To investigate the association between LoC, and work-related behavioral factors, socio-cultural factors, and personal factors among Australian General Practitioners (GPs).

METHODS

This study utilized data from the 2010 Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors. Locus of control (LoC) was measured by a 7-point Likert scale based on Pearlin-Schooler Mastery/Self-efficacy 7-item Scale. Higher score indicated lower internal LoC. Multivariate linear regression model was performed to determine the independent predictors of LoC.

RESULTS

Of 3,664 GP participants, LoC did not differ by gender. Poor/fair self-rated health, working in urban location, running a stressful practice, poor balance of professional and personal commitments, poor support network, financial circumstances after retirement, and perception of unrealistic expectation by patients were significant predictors for a lower Internal LoC in a multivariate linear regression model. Adjusted R² explained 22.4% of variation in predicting the LoC in our models.

CONCLUSIONS

LoC of Australian GPs is negatively affected by poor work-life balance, inadequate support, and unrealistic patient expectation. These work-place specific factors could be targeted by interventions to improve GPs wellbeing.

Health workforce retention in low-income settings: an application of the Root Stem Model

The World Health Organization (WHO) recognizes a critical shortage of health workers as a growing global crisis. The shortage persists despite local and global efforts to recruit health workers ethically. Unequal migration of healthcare professionals, most often from low to high-resource countries, overwhelmingly defeats the objective of achieving Universal Health Coverage (UHC). If not addressed, especially given emerging global pandemics like COVID-19, the critical shortage of health workers could decimate vulnerable public health systems. This Viewpoint describes the Root-Stem Model, a six-stage process of strategic factors affecting work life that could help policymakers address the challenge of brain-drain among healthcare workers in low-income countries.

Relationship between rural self-efficacy and rural career intent after rural clinical training: a study on medical students in Japan

BACKGROUND

In Japan, community medicine clerkships facilitate positive attitudes toward rural medical practice and encourage rural recruitment. Rural self-efficacy has been shown to influence rural career intent following a rural clinical placement. However, the impact of subjective difficulties of living in a rural area on future rural career intent is also important. This study aims to explore whether rural self-efficacy influences the relationship between difficulty with living in a rural area and rural career intent.  METHODS: The subjects included 308 male and 255 female participants aged 20-41 [median (interquartile range): 22 (21-22)] years. Rural self-efficacy was based on a validated scale consisting of 15 questions. Difficulty with living in a rural area was measured asking students. A cohort survey was conducted to evaluate the effect of the rural self-efficacy score on the rural career intent of Japanese medical students after they completed their rural clinical training.

RESULTS

The following variables were significantly associated with a higher rural self-efficacy score: female sex (p = 0.003), age < 21 years (p = 0.013), having a doctor as a role model (p < 0.001), gaining admission through a school recommendation (p = 0.016), living in a rural or remote area until the age of 18 years (p = 0.018), and orientation towards general medicine (p < 0.001). In addition, baseline difficulty with living in a rural area was significantly associated with a lower self-efficacy score (p < 0.001). Participants with a stronger intent to practice in a rural area before rural clinical training had higher rural self-efficacy and showed a stronger positive rural career intent after rural clinical training (p < 0.001). A multivariable logistic regression analysis demonstrated that difficulty with living in a rural area [odds ratio (OR): 0.61; 95% confidence interval (CI), 0.39-0.84] was still associated with lower rural career intent after rural clinical training, independent of all confounders such as gender, age, scholarship for regional duty, rural background, and orientation towards general medicine. However, when rural self-efficacy (OR, 1.12; 95% CI, 1.07-1.16) was added as a factor for rural career intent, difficulty with living in a rural area (OR, 0.68; 95% CI, 0.43-1.06) was no longer observed as an associated factor.

CONCLUSION

Subjective difficulty with living in a rural area was shown to reduce future rural career intent, but high rural self-efficacy ameliorated this decline.

Approaches Used to Describe, Measure, and Analyze Place of Practice in Dentistry, Medical, Nursing, and Allied Health Rural Graduate Workforce Research in Australia: A Systematic Scoping Review

Redressing the maldistribution of the health workforce in regional, rural, and remote geographical areas is a global issue and crucial to improving the accessibility of primary health care and specialist services. Geographical classification systems are important as they provide an objective and quantifiable measure of access and can have direct policy relevance, yet they are not always consistently applied in rural health research. It is unclear how research focusing on the graduate health workforce in Australia has described, measured, and analyzed place of practice. To examine approaches used, this review systematically scopes Australian rural studies focusing on dentistry, medicine, nursing, and allied health graduates that have included place of practice as an outcome measure. The Joanna Brigg’s Institute Scoping Review Methodology was used to guide the review. Database searches retrieved 1130 unique citations, which were screened, resulting in 62 studies for inclusion. Included studies were observational, with most focusing on the practice locations of medical graduates and predicators of rural practice. Variations in the use of geographical classification approaches to define rurality were identified and included the use of systems that no longer have policy relevance, as well as adaptations of existing systems that make future comparisons between studies challenging. It is recommended that research examining the geographical distribution of the rural health workforce use uniform definitions of rurality that are aligned with current government policy.

Doctors' rural practice self-efficacy is associated with current and intended small rural locations of practice

Objective

Key factors which positively influence recruitment and retention of doctors to rural practice include rural background and positive rural training experience. Despite this knowledge, there is no well‐established conceptual framework to explain how these factors influence intention. The aim of this study was to consider rural practice self‐efficacy and its influence on rural career choice by doctors. Questions relating to self‐efficacy were formulated using Bandura's four proposed sources of self‐efficacy, which include mastery experiences, vicarious experience, social persuasion and emotional and physical response to experiences.

Design

Cross‐sectional study.

Setting and participants

Medical school graduates from Flinders University, who completed a rural year as a part of the clinical component of the course between 1997 and 2015.

Main outcome measures

Rural self‐efficacy; current and intended location of practice in small rural communities (<25 000 people).

Result

It was found that 28.5% of participants were currently working in communities of <25 000 people. Levels of intent for future small town rural practice were consistent across career stages after internship. Higher rural practice self‐efficacy scores were found in doctors working in smaller towns (<25 000) and small communities (<10 000). Higher self‐efficacy was also associated with rural background, more senior career status, earlier speciality decision time and smaller expectation‐experience gap.

Conclusion

An independent association exists between rural self‐efficacy and intention to remain or return to small rural practice. The article offers rural clinical schools the opportunity to consider how they can influence future rural career outcomes.