Nature of association between rural background and practice location: a comparison of general practitioners and specialists

Associations between education policies and the geographic disposition of family physicians: a retrospective observational study of McMaster University education data

The maldistribution of family physicians challenges equitable primary care access in Canada. The Theory of Social Attachment suggests that preferential selection and distributed training interventions have potential in influencing physician disposition. However, evaluations of these approaches have focused predominantly on rural underservedness, with little research considering physician disposition in other underserved communities. Accordingly, this study investigated the association between the locations from which medical graduates apply to medical school, their undergraduate preclerkship, clerkship, residency experiences, and practice as indexed across an array of markers of underservedness. We built association models concerning the practice location of 347 family physicians who graduated from McMaster University's MD Program between 2010 and 2015. Postal code data of medical graduates' residence during secondary school, pre-clerkship, clerkship, residency and eventual practice locations were coded according to five Statistics Canada indices related to primary care underservedness: relative rurality, employment rate, proportion of visible minorities, proportion of Indigenous peoples, and neighbourhood socioeconomic status. Univariate and multivariable logistic regression models were then developed for each dependent variable (i.e., practice location expressed in terms of each index). Residency training locations were significantly associated with practice locations across all indices. The place of secondary school education also yielded significant relationships to practice location when indexed by employment rate and relative rurality. Education interventions that leverage residency training locations may be particularly influential in promoting family physician practice location. The findings are interpreted with respect to how investment in education policies can promote physician practice in underserved communities.

Rural general practitioners have different personal and professional trajectories from those of their urban colleagues: a case-control study

BACKGROUND

In France, rural general practitioner (GP) numbers could reduce by 20% between 2006 and 2030 if no measures are taken to address primary care access difficulties. In countries such as Australia, the USA and Canada, intrinsic and extrinsic factors associated with GPs practising in rural areas include rural upbringing and rural training placements. However, the health systems and rural area definition differ between these countries and France making result extrapolation difficult. These factors must be studied in the context of the French heath system, to design strategies to improve rural GP recruitment and retention. This study aims to identify the intrinsic and extrinsic factors associated with GPs practising in rural areas in France.

METHODS

This case-control study was conducted between May and September 2020. Included GPs practised in Brittany, France, and completed a self-administered questionnaire. The cases were rural GPs and controls were urban GPs. National references defined rural and urban areas. Comparisons between rural and urban groups were conducted using univariate and multivariate analyses to identify factors associated with practising in a rural area.

RESULTS

The study included 341 GPs, of which 146 were in the rural group and 195 in the urban group. Working as a rural GP was significantly associated with having a rural upbringing (OR = 2.35; 95% CI [1.07-5.15]; p = 0.032), completing at least one undergraduate general medicine training placement in a rural area (OR = 3.44; 95% CI [1.18-9.98]; p < 0.023), and having worked as a locum in a rural area for at least three months (OR = 3.76; 95% CI [2.28-6.18]; p < 0.001). Choosing to work in a rural area was also associated with the place of residence at the end of postgraduate training (OR = 5.13; 95% CI [1.38-19.06]; p = 0.015) and with the spouse or partner having a rural upbringing (OR = 2.36; 95% CI [1.12-4.96]; p = 0.023) or working in a rural area (OR = 5.29; 95% CI [2,02-13.87]; p < 0.001).

CONCLUSIONS

French rural GPs were more likely to have grown up, trained, or worked as a locum in a rural area. Strategies to improve rural GP retention and recruitment in France could therefore include making rural areas a more attractive place to live and work, encouraging rural locum placements and compulsory rural training, and possibly enrolling more medical students with a rural background.

Effects of candidates' demographics and evaluation of the virtual Multiple Mini Interview (vMMI) as a tool for selection into paediatric training in Queensland

INTRODUCTION

The Queensland Basic Paediatric Training Network (QBPTN) is responsible for the selection of candidates into paediatric training in Queensland. The COVID-19 pandemic necessitated interviews to be conducted 'virtually' as virtual Multiple-Mini-Interviews (vMMI). The study aimed to describe the demographic characteristics of candidates applying for selection into paediatric training in Queensland, and to explore their perspectives and experiences with the vMMI selection tool.

METHODOLOGY

The demographic characteristics of candidates and their vMMI outcomes were collected and analysed with a mixed methods approach. The qualitative component was comprised of seven semi-structured interviews with consenting candidates.

RESULTS

Seventy-one shortlisted candidates took part in vMMI and 41 were offered training positions. The demographic characteristics of candidates at various stages of selection were similar. The mean vMMI scores were not statistically different between candidates from the Modified Monash Model 1 (MMM1) location and others [mean (SD): 43.5 (5.1) versus 41.7 (6.7), respectively, p = 0.26]. However, there was a statistically significant difference (p value 0.03) between being offered and not offered a training position for candidates from MMM2 and above. The analysis of the semi-structured interviews suggested that candidate experiences of the vMMI were influenced by the quality of the management of the technology used. Flexibility, convenience, and reduced stress were the main factors that influenced candidates' acceptance of vMMI. Perceptions of the vMMI process focused on the need to build rapport and facilitate communication with the interviewers.

DISCUSSION

vMMI is a viable alternative to face-to-face (FTF) MMI. The vMMI experience can be improved by facilitating enhanced interviewer training, by making provision for adequate candidate preparation and by having contingency plans in place for unexpected technical challenges. Given government priorities in Australia, the impact of candidates' geographical location on the vMMI outcome for candidates from MMM >1 location needs to be further explored.

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries

BACKGROUND

Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies).

METHODS

We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes.

RESULTS

Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%).

CONCLUSION

Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

Rural medical workforce pathways: exploring the importance of postgraduation rural training time

BACKGROUND

Inadequate distribution of the medical workforce in rural regions remains a key global challenge. Evidence of the importance of postgraduation (after medical school) rural immersion time and subsequent rural practice, particularly after accounting for other key factors, remains limited. This study investigated the combined impact of three key training pathway factors: (1) rural background, (2) medical school rural immersion, and (3) postgraduation rural immersion, and duration time of each immersion factor on working rurally.

METHODS

Data from a cross-sectional national survey and a single university survey of Australian doctors who graduated between 2000 to 2018, were utilised. Key pathway factors were similarly measured. Postgraduation rural training time was both broad (first 10 years after medical school, national study) and specific (prevocational period, single university). This was firstly tested as the dependent variable (stage 1), then matched against rural practice (stage 2) amongst consultant doctors (national study, n = 1651) or vocational training doctors with consultants (single university, n = 478).

RESULTS

Stage 1 modelling found rural background, > 1 year medical school rural training, being rural bonded, male and later choosing general practice were associated with spending a higher proportion (> 40%) of their postgraduation training time in a rural location. Stage 2 modelling revealed the dominant impact of postgraduation rural time on subsequent rural work for both General Practitioners (GPs) (OR 45, 95% CI 24 to 84) and other specialists (OR 11, 95% CI 5-22) based on the national dataset. Similar trends for both GPs (OR 3.8, 95% CI 1.6-9.1) and other specialists (OR 2.8, 95% CI 1.3-6.4) were observed based on prevocational time only (single university).

CONCLUSIONS

This study provides new evidence of the importance of postgraduation rural training time on subsequent rural practice, after accounting for key factors across the entire training pathway. It highlights that developing rural doctors aligns with two distinct career periods; stage 1-up to completing medical school; stage 2-after medical school. This evidence supports the need for strengthened rural training pathways after medical school, given its strong association with longer-term decisions to work rurally.

The ties that bind: Social network analysis describes the social element of medical workforce recruitment to rural/remote Australia

We present the argument that medical recruitment to a previously under-recruited remote town was effected through what Social Network Analysis (SNA) measures as "brokerage" which operates amidst "structural holes". We proposed that medical graduates being generated by the national Rural Health School movement in Australia were particularly affected by the combined effect of workforce lacks (structural holes) and strong social commitments (brokerage) - all key SNA concepts. We therefore chose SNA to assess whether the characteristics of RCS-related rural recruitment had feature that SNA might be able to identify, as operantly measured using the industry-standard UCINET's suite of statistical and graphical tools. The result was clear. Graphical output from the UCINET editor showed one individual as being central to all recently recruited doctors to one rural town with recruitment issues like all the others. The statistical outputs from UCINET characterised this person as the single point of most connections. The real-world engagements of this central doctor were in accord with the description of brokerage, a core SNA construct, relationship with reported the reason for these new graduates both coming and staying in town. SNA thus proved fruitful in this first quantification of the role of social networks in drawing new medical recruits to particular rural towns. It allowed description at the level of individual actors with a potent influence on recruitment to rural Australia. We propose these measures could be helpful as key performance indicators for the national Rural Clinical School programme that is generating and distributing a large workforce in Australia, which appears from this work to have a strong social basis. This redistribution of medical workforce from urban to rural is needed internationally.

Residents' choice of a placement in periphery hospitals in Israel: the significance of personal/family and professional considerations

Physician maldistribution affects remote and rural population health indicators and as such constitutes a major concern for health systems. Various countries, including Israel, have sought to remedy this problem, often by implementing more than one intervention simultaneously. In this paper, we explored the considerations that motivated Israeli residents to opt for a position in the periphery, as well as potential factors that could facilitate their retention in these underserved areas. We found that the motivation driving young physicians to specialize in a specific hospital includes personal- and family-oriented considerations (proximity to the nuclear family, perceived quality of life and lifestyle) as well as professional considerations (prior acquaintance with a hospital and a specific hospital department, department characteristics, availability of a residence position in a preferred specialty, prospective professional advancement). We therefore argue that the key to recruitment and retention of young physicians in remote areas lies in tailored interventions that take personal, professional and regional issues into account, preferably in consultation with the physicians themselves. The prominence of personal issues in the interviews with young physicians suggests that effective interventions should support a work-life balance. Hence success in attracting residents as a first step towards correcting physician maldistribution hinges upon coordinating policies in the medical field with policies in non-medical arenas - education, welfare, local authorities.

The value of admissions characteristics for predicting the practice location of University of Saskatchewan College of Medicine graduates

BACKGROUND

The physician workforce in Saskatchewan depends upon the retention of locally trained physicians. Characteristics collected at the time of medical school application may predict future practice location, but these associations have not been explored.

METHODS

We identified the current practice location of University of Saskatchewan College of Medicine graduates who matriculated between 2000 and 2013 and extracted data from their admission applications including gender, age, high school, previous university, and current location at the time of application. We then conducted univariate and multivariate analyses to evaluate associations between these characteristics and rural- and Saskatchewan-based practice.

RESULTS

We identified the current practice location of 1,001 (98.9%) of the graduates of the included cohorts. Attending a Saskatchewan high school (p < 0.001), a high school in a smaller population center (p < 0.01), and a Saskatchewan university (p < 0.001) were predictive of Saskatchewan-based practice. Attending a high school outside of Saskatchewan (p < 0.05), a high school in a smaller population center (p < 0.001), and living in a small population centre at the time of application (p < 0.05) were predictive of rural-based practice within or outside of Saskatchewan.

CONCLUSION

Demographic characteristics collected at time of medical school application are associated with future Saskatchewan- and rural-based practice. These findings will guide admissions policies in Saskatchewan and may inform admission practices of other medical schools.

Prevalence and associations of rural practice location in early-career general practitioners in Australia: a cross-sectional analysis

OBJECTIVES

To: (1) establish the prevalence of urban, regional, rural and remote practice location of early-career general practitioners (GPs); and (2) examine demographic and training-related characteristics associated with working in regional, rural or remote areas post attainment of vocational general practice qualifications.

DESIGN

Cross-sectional, questionnaire-based study, combined with contemporaneously collected data from participants' prior vocational training.

SETTING

Australian general practice.

PARTICIPANTS

Newly vocationally qualified GPs (ie, within 6 months-2 years post fellowship) who had completed vocational training with regional training organisations in New South Wales, Australian Capital Territory, eastern Victoria, and Tasmania between January 2016 and July 2018.

PRIMARY OUTCOME MEASURE

Rurality of post-fellowship practice location, as defined by Modified Monash Model (MMM) geographical classifications, based on current practice postcode. Prevalence of regional/rural/remote ('rural') practice was described using frequencies, and associations of rural practice were established using multivariable logistic regression, considering a range of demographic factors and training characteristics as independent variables.

RESULTS

A total of 354 participants completed the questionnaire (response rate 28%) with 319 providing information for their current practice location. Of these, 100 (31.4%) reported currently practising in a rural area (MMM2-7). Factors most strongly associated with practising in a rural area included having undertaken vocational GP training in a rural location OR 16.0 (95% CI 6.79 to 37.9); p<0.001; and undertaking schooling in rural area prior to university OR 4.21 (1.98, 8.94); p<0.001.

CONCLUSIONS

The findings suggest that vocational training experience may have a role in rural general practice location post fellowship, attenuating the previously demonstrated 'leakage' from the rural practice pipeline.

Exploring Doctors' Emerging Commitment to Rural and General Practice Roles over Their Early Career

Producing enough doctors working in general practice or rural locations, or both, remains a key global policy focus. However, there is a lack of evidence about doctors' emerging commitment to these decisions. This study aimed to explore changes in the level of certainty about career interest in working in general practice and working rurally, as doctors pass through various early career stages. The participants were 775 eligible respondents to a 2019 survey of medical graduates of The University of Queensland from 2002-2018. Certainty levels of specialty choice were similar between GPs and specialists up until the beginning of registrar training. At that point, 65% of GPs compared with 80% of other specialists had strong certainty of their specialty field. Consistently (and significantly) less of those working rurally had strong certainty of the location where they wanted to practice medicine at each career time point. At the start of registrar training, a similar gap remained (strong certainty: 51% rural versus 63% metropolitan). This study provides new evidence that career intent certainty is more delayed for the cohort choosing general practice and rural practice than the other options. The low level of certainty in early career highlights the importance of regular positive experiences that help to promote the uptake of general practice and rural practice.

Increasing doctors working in specific rural regions through selection from and training in the same region: national evidence from Australia

BACKGROUND

'Grow your own' strategies are considered important for developing rural workforce capacity. They involve selecting health students from specific rural regions and training them for extended periods in the same regions, to improve local retention. However, most research about these strategies is limited to single institution studies that lack granularity as to whether the specific regions of origin, training and work are related. This national study aims to explore whether doctors working in specific rural regions also entered medicine from that region and/or trained in the same region, compared with those without these connections to the region. A secondary aim is to explore these associations with duration of rural training.

METHODS

Utilising a cross-sectional survey of Australian doctors in 2017 (n = 6627), rural region of work was defined as the doctor's main work location geocoded to one of 42 rural regions. This was matched to both (1) Rural region of undergraduate training (< 12 weeks, 3-12 months, > 1 university year) and (2) Rural region of childhood origin (6+ years), to test association with returning to work in communities of the same rural region.

RESULTS

Multinomial logistic regression, which adjusted for specialty, career stage and gender, showed those with > 1 year (RRR 5.2, 4.0-6.9) and 3-12 month rural training (RRR 1.4, 1.1-1.9) were more likely to work in the same rural region compared with < 12 week rural training. Those selected from a specific region and having > 1-year rural training there related to 17.4 times increased chance of working in the same rural region compared with < 12 week rural training and metropolitan origin.

CONCLUSION

This study provides the first national-scale empirical evidence supporting that 'grow your own' may be a key workforce capacity building strategy. It supports underserviced rural areas selecting and training more doctors, which may be preferable over policies that select from or train doctors in 'any' rural location. Longer training in the same region enhances these outcomes. Reorienting medical training to selecting and training in specific rural regions where doctors are needed is likely to be an efficient means to correcting healthcare access inequalities.

Building a sustainable rural physician workforce

CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants.

MAIN OUTCOME MEASURES

Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians.

RESULTS

Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8).

CONCLUSION

Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas.

DESIGN, SETTING AND PARTICIPANTS

In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19.

MAIN OUTCOME MEASURES

Individual and collective descriptors of professional identity.

RESULTS

We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation.

CONCLUSION

Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters.

MAIN OUTCOME MEASURES

Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location.

RESULTS

Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors.

CONCLUSION

Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action.

DESIGN

We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles.

RESULTS

Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles.

CONCLUSION

These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce.

How rural is rural? The relationship between rural background of medical students and their career location intentions

OBJECTIVE

Rural background is associated with greater interest in rural practice. However, there is no universally agreed definition of 'rural' background used in medical school selection. This study explored the association between definitions of 'rural' background and students' intended career locations.

DESIGN

Prospective cohort study using survey data on career intention, hometown size, rurality of background, home address, high school and intended career location.

SETTING

University of Auckland, New Zealand (NZ).

PARTICIPANTS

Commencing medical students 2009-2017, inclusive.

MAIN OUTCOME MEASURES

Univariate associations between student background according to 7 definitions of 'rural', and 3 definitions of intended practice location based on population size: urban intention (>100 000); regional intention (25 000-100 000); rural intention (<25 000).

RESULTS

The sample size was 1592 students. 27.4% had a rural background by at least one definition. All definitions of rural background were associated with a greater rural intention. Applying a restrictive definition of rural (population<25 000) was associated with a higher likelihood of rural intention, but captured a smaller number of students. There was strong agreement between the population size of a student's background and intended practice location (chi-square P < .0001).

CONCLUSION

Rural intention varies by definition, but the number of students captured by each definition is important. Applying a binary or overly restrictive definition may limit interested students. Medical schools should adopt a definition of 'rural' that optimises the number of eligible students and their propensity to work rurally. Further, alternative ways of identifying students with rural intentions without a rural background should be explored.

Factors associated with medical students' interest in remote and very remote practice in Australia: A national study

Objective

To investigate the factors that are associated with medical student interest in remote and very remote practice in Australia.

Design

Aggregated data of an annual cross‐sectional survey from 2013 to 2017.

Setting

Australia.

Participants

Medical students from 17 medical schools, at the point of finishing one year of clinical training in a rural or remote location in Australia.

Main outcome measures

Intention for working in a remote or very remote location as a doctor.

Results

Responses were analysed from 3328 medical students. From this cohort, 37.6%, 54.0% and 7.0% of students reported future career intent in capital or major cities; regional Australia; and remote or very remote Australia respectively. Multivariable analysis indicated students interested in remote and very remote practice compared to those interested in regional practice were more likely to be from a rural background, have prior generalist intentions, felt as though their rural clinical school (RCS) experience increased interest in remote and very remote practice, and had higher rural practice self‐efficacy. Odds ratios were larger for these factors when students interested in remote or very remote practice were compared with students interested in practicing in capital or major cities.

Conclusions

Rural background, prior generalist intentions, rural practice self‐efficacy and the overall influence of the RCS experience are associated with interest in remote and very remote practice.

Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects

OBJECTIVE

To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas.

STUDY DESIGN

Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas.

DATA SOURCES

MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature.

DATA SYNTHESIS

Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle-Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12-3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48-2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80-7.46; eight studies).

CONCLUSION

GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce.

PROTOCOL REGISTRATION

PROSPERO, CRD42017074943 (updated 1 February 2018).

Understanding the professional satisfaction of hospital trainees in Australia

CONTEXT

Ensuring that specialty trainees are professionally satisfied is not only important from the point of view of trainee well-being, but is also critical if health systems are to retain doctors. Despite this, little systematic research in specialist trainees has identified policy-amenable factors correlated with professional satisfaction. This study examined factors associated with trainee professional satisfaction in a national Australian cohort.

METHODS

This study used 2008-2015 data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, a national study of doctor demographics, characteristics and professional and personal satisfaction. Our study examined specialist trainees using a repeat cross-sectional method pooling first responses across all waves. A multivariate logistic regression analysis was used to assess correlates with professional satisfaction.

RESULTS

The three factors most strongly correlated with professional satisfaction were feeling well supported and supervised by consultants (odds ratio [OR] 2.59, 95% confidence interval [CI] 2.42-2.77), having sufficient study time (OR 1.54, 95% CI 1.40-1.70) and self-rated health status (OR 1.65, 95% CI 1.53-1.80). Those working >56 hours per week were significantly less professionally satisfied (OR 0.76, 95% CI 0.70-0.84) compared with those working the median work hours (45-50 hours per week). Those earning in the lower quintiles, those earlier in their training and those who had studied at overseas universities were also significantly less likely to be satisfied.

CONCLUSIONS

Our study suggests that good clinical supervision and support, appropriate working hours and supported study time directly impact trainee satisfaction, potentially affecting the quality of clinical care delivered by trainees. Furthermore, the needs of junior trainees, overseas graduates and those working >56 hours per week should be given particular consideration when developing well-being and training programmes.

Likelihood of rural practice in medical school entrants with prior tertiary experience

Background: Workforce decisions of medical students with prior tertiary education, relative to those without, are not known. Methods: Rural workforce outcomes for three separate streams of medical students were compared: school leaver entry (SLE) entered medical school direct (N = 682), non-standard entry (NSE) had some prior tertiary education (N = 123), and graduate entry (GE) (N = 317), had a prior completed degree. All students were at least in postgraduate year 3 in 2018, when current urban or rural medical workforce participation was ascertained. Results: Multivariate logistic regression allowing for the influences of rural background, rural clinical school participation, gender, being born overseas, socioeconomic status, and being a bonded rural scholar, showed that NSE students and GE students had increased odds of being in rural practice relative to SLE students. This increase was more than three-fold for NSE students (OR = 3.41, 95% CI 1.94, 5.99, p < 0.001) and greater than two-fold for GE students (OR = 2.54, 95% CI 1.57, 4.10, p < 0.001). Conclusion: Graduates with prior tertiary education were more likely to enter the rural medical workforce than direct school entrants. This suggests that increasing graduate entry programs may augment the rural medical workforce and that undergraduate programs allowing non-standard entry may have the same benefit.

[Shortage of physicians in rural areas and in the public health service : A critical analysis of the evidence on the role of medical education and training]

BACKGROUND

A shortage of medical personnel has been seen for several decades in at least two sectors of the healthcare system: primary care in remote areas as well as medical care in the state public health departments (Öffentliches Gesundheitswesen). Strategies to reduce these problems are being sought.

OBJECTIVE

This review examines the proposals, practical initiatives and empirical studies in under- and postgraduate medical education in order to estimate their potential impact on the solution of these problems. The analysis covers both Germany and Anglo-Saxon countries.

MATERIALS AND METHODS

The study is based on a literature search in PubMed and Medline covering the last 20 years. With regard to Germany, programmatic documents and studies published in the German Journal of General Practice (Zeitschrift für Allgemeinmedizin) were also included.

RESULTS AND DISCUSSION

Foreign empirical studies identify almost equal two factors with regard to primary care in remote areas: the recruitment of students from rural areas combined with special educational programs with a rural primary care orientation both in under- and postgraduate medical education. These programs should include several and longer practical working periods in primary care units and be well coordinated between the medical school and the local teaching physicians. As for the state public health sector, comparable initiatives are still lacking.

Reviewing reliance on overseas-trained doctors in rural Australia and planning for self-sufficiency: applying 10 years' MABEL evidence

BACKGROUND

The capacity for high-income countries to supply enough locally trained doctors to minimise their reliance on overseas-trained doctors (OTDs) is important for equitable global workforce distribution. However, the ability to achieve self-sufficiency of individual countries is poorly evaluated. This review draws on a decade of research evidence and applies additional stratified analyses from a unique longitudinal medical workforce research program (the Medicine in Australia: Balancing Employment and Life survey (MABEL)) to explore Australia's rural medical workforce self-sufficiency and inform rural workforce planning. Australia is a country with a strong medical education system and extensive rural workforce policies, including a requirement that newly arrived OTDs work up to 10 years in underserved, mostly rural, communities to access reimbursement for clinical services through Australia's universal health insurance scheme, called Medicare.

FINDINGS

Despite increases in the number of Australian-trained doctors, more than doubling since the late 1990s, recent locally trained graduates are less likely to work either as general practitioners (GPs) or in rural communities compared to local graduates of the 1970s-1980s. The proportion of OTDs among rural GPs and other medical specialists increases for each cohort of doctors entering the medical workforce since the 1970, peaking for entrants in 2005-2009. Rural self-sufficiency will be enhanced with policies of selecting rural-origin students, increasing the balance of generalist doctors, enhancing opportunities for remaining in rural areas for training, ensuring sustainable rural working conditions and using innovative service models. However, these policies need to be strongly integrated across the long medical workforce training pathway for successful rural workforce supply and distribution outcomes by locally trained doctors. Meanwhile, OTDs substantially continue to underpin Australia's rural medical service capacity. The training pathways and social support for OTDs in rural areas is critical given their ongoing contribution to Australia's rural medical workforce.

CONCLUSION

It is essential for Australia to monitor its ongoing reliance on OTDs in rural areas and be considerate of the potential impact on global workforce distribution.

Using financial incentives to attract medical residents to the periphery: The Israeli experience

BACKGROUND

In 2011, Israel instituted financial incentives as part of a larger program to attract doctors to residency programs in peripheral hospitals.

OBJECTIVE

To explore the impact of these incentives and related changes on the choices of locations for residency training in Israel.

METHODS

We performed (A) an analysis of administrative data on the location of all new medical residencies in 2005-2014 (B) an internet/phone survey of residents who began specialty training in 2013-2014, with a response rate of 71%.

RESULTS

(A) Of all entrants to residency training programs in Israel, those in peripheral hospitals constituted 16-20% in 2005-2010, 19% in 2011, 23% in 2012, and 23% in 2013; the increase consisted predominantly of physicians who were graduates of non-Israeli medical schools (B) About half of all residents in the periphery reported that the incentives contributed to their choice of residency location. About 40% of that group also reported that they had planned already in medical school to practice in the periphery, while 60% of that group (30% of all residents in the periphery) did not have such plans prior to medical school. About 70% of the residents in peripheral hospitals grew up in the periphery; for the southern periphery this was 40% and for the northern periphery this was 80%.

CONCLUSIONS

The changes instituted in 2011 apparently affected residency location preferences for a non-negligible proportion of young physicians, particularly among those who grew up in the periphery. Policymakers should consider combining targeted incentives with measures to increase the supply of physicians who grew up in the periphery.

Preoperative heart rate and myocardial injury after non-cardiac surgery: results of a predefined secondary analysis of the VISION study

Background

Increased baseline heart rate is associated with cardiovascular risk and all-cause mortality in the general population. We hypothesized that elevated preoperative heart rate increases the risk of myocardial injury after non-cardiac surgery (MINS).

Methods

We performed a secondary analysis of a prospective international cohort study of patients aged ≥45 yr undergoing non-cardiac surgery. Preoperative heart rate was defined as the last measurement before induction of anaesthesia. The sample was divided into deciles by heart rate. Multivariable logistic regression models were used to determine relationships between preoperative heart rate and MINS (determined by serum troponin concentration), myocardial infarction (MI), and death within 30 days of surgery. Separate models were used to test the relationship between these outcomes and predefined binary heart rate thresholds.

Results

Patients with missing outcomes or heart rate data were excluded from respective analyses. Of 15 087 patients, 1197 (7.9%) sustained MINS, 454 of 16 007 patients (2.8%) sustained MI, and 315 of 16 037 patients (2.0%) died. The highest heart rate decile (>96 beats min⁻¹) was independently associated with MINS {odds ratio (OR) 1.48 [1.23–1.77]; P<0.01}, MI (OR 1.71 [1.34–2.18]; P<0.01), and mortality (OR 3.16 [2.45–4.07]; P<0.01). The lowest decile (<60 beats min⁻¹) was independently associated with reduced mortality (OR 0.50 [0.29–0.88]; P=0.02), but not MINS or MI. The predefined binary thresholds were also associated with MINS, but more weakly than the highest heart rate decile.

Conclusions

Preoperative heart rate >96 beats min⁻¹ is associated with MINS, MI, and mortality after non-cardiac surgery. This association persists after accounting for potential confounding factors.

Clinical trial registration

NCT00512109.

Predictors of rural family medicine practice in Canada

OBJECTIVE

To examine the attributes of Canadian medical students at matriculation that predicted later practice in a rural location, with the goal of enhancing evidence-based approaches to increasing the numbers of rural family physicians.

DESIGN

Demographic, attitudinal, and career choice data were collected from medical students at matriculation. Students were followed prospectively, and these data were linked to postresidency practice location.

SETTING

Eight Canadian medical schools.

PARTICIPANTS

Study participants were 15 classes of medical students entering medical school between 2002 and 2004.

MAIN OUTCOME MEASURES

Backward stepwise logistic regression analysis was used to identify the entry characteristics that predicted postresidency practice as a rural family physician.

RESULTS

Data from 1542 students were analyzed. A strong association was found between career interest in rural family medicine at entry into medical school and postresidency rural practice as a family physician. Logistic regression analysis that did not include entry career interest found older age, being in a relationship, having completed school in a rural community, having a societal orientation, and expressing a desire for a varied scope of practice to be predictive of practising in a rural location. When entry career interest in a rural setting was included in the multivariate model, only this variable and older age predicted postresidency rural family practice.

CONCLUSION

This study identified a number of demographic and attitudinal variables at medical school entry that predict postresidency practice in a rural setting. These results suggest multiple potential areas where the pipeline to rural family practice can be further supported in order to address the shortage of rural family physicians.

Physician perceptions of recruitment and retention factors in an area with a regional medical campus

BACKGROUND

The factors that influence physicians to establish and maintain their practice in a region are variable. The presence of a regional medical campus (RMC) could influence physicians' choice. The objective of this study was to explore the factors influencing physician recruitment and retention, and in particular the role of a RMC, in a region of Quebec.

METHODS

A literature review of factors influencing physicians to stay in a rural area was conducted in order to create an interview guide. Questions were divided into sections: general information, family situation, medical training, career choice, current practice, intent to stay in the region, and impact of the RMC. Thirteen semi-structured individual interviews were conducted with practicing physicians. Data were analyzed using QDAMiner.

RESULTS

Recruitment factors were divided into six major themes: type of practice, spousal interest, opportunity for teaching, training in a region, workforce planning, and quality of life. Participants identified positive and negative factors associated with retention. In both cases, family and quality of work environment were mentioned. The RMC was perceived as having important impacts on the quality of professional life, research, medical practice, and regional development.

CONCLUSION

This study highlights the role of RMCs in physician recruitment and retention via multiple impacts on the quality of practice of physicians working in the same area.

A review of characteristics and outcomes of Australia's undergraduate medical education rural immersion programs

BACKGROUND

A key strategy for increasing the supply of rural doctors is rurally located medical education. In 2000, Australia introduced a national policy to increase rural immersion for undergraduate medical students. This study aims to describe the characteristics and outcomes of the rural immersion programs that were implemented in Australian medical schools.

METHODS

Information about 19 immersion programs was sourced in 2016 via the grey and published literature. A scoping review of the published peer-reviewed studies via Ovid MEDLINE and Informit (2000-2016) and direct journal searching included studies that focused on outcomes of undergraduate rural immersion in Australian medical schools from 2000 to 2016.

RESULTS

Programs varied widely by selection criteria and program design, offering between 1- and 6-year immersion. Based on 26 studies from 10 medical schools, rural immersion was positively associated with rural practice in the first postgraduate year (internship) and early career (first 10 years post-qualifying). Having a rural background increased the effects of rural immersion. Evidence suggested that longer duration of immersion also increases the uptake of rural work, including by metropolitan-background students, though overall there was limited evidence about the influence of different program designs. Most evidence was based on relatively weak, predominantly cross-sectional research designs and single-institution studies. Many had flaws including small sample sizes, studying internship outcomes only, inadequately controlling for confounding variables, not using metropolitan-trained controls and providing limited justification as to the postgraduate stage at which rural practice outcomes were measured.

CONCLUSIONS

Australia's immersion programs are moderately associated with an increased rural supply of early career doctors although metropolitan-trained students contribute equal numbers to overall rural workforce capacity. More research is needed about the influence of student interest in rural practice and the duration and setting of immersion on rural work uptake and working more remotely. Research needs to be more nationally balanced and scaled-up to inform national policy development. Critically, the quality of research could be strengthened through longer-term follow-up studies, adjusting for known confounders, accounting for postgraduate stages and using appropriate controls to test the relative effects of student characteristics and program designs.

In-Place Training: Optimizing Rural Health Workforce Outcomes through Rural-Based Education in Australia

The medical workforce shortfall in rural areas is a major issue influencing the nature of undergraduate medical education in Australia. Exposing undergraduates to rural life through rural clinical school (RCS) placements is seen as a key strategy to address workforce imbalances. We investigated the influence of an extended RCS placement and rural origin on the rural principal place of practice (PPP) of the first 3 graduate cohorts (2012–2014) from a Joint Medical Program offered by two universities based in northern New South Wales. Data was available for 426 eligible graduates. Participation in an extended RCS placement (odds ratio (OR), 6.075, 95% confidence interval (CI) 2.716–13.591), rural background (OR 3.613, 95% CI 1.752–7.450) and being 25 years or older at completion of a medical degree (OR 2.550, 95% CI 1.252–5.194) were all independently associated with rural PPP. Being bonded into a program to practice rurally was not associated with rural PPP. Participation in an extended RCS placement is strongly associated with rural practice in the first 3 to 5 years of practice for graduates from both rural and metropolitan backgrounds. This finding indicates that strategies to improve the rural workforce should focus on the promotion of rural placements, in addition to rural background.

Family effects on the rurality of GP's work location: a longitudinal panel study

BACKGROUND

Reduced opportunities for children's schooling and spouse's/partner's employment are identified internationally as key barriers to general practitioners (GPs) working rurally. This paper aims to measure longitudinal associations between the rurality of GP work location and having (i) school-aged children and (ii) a spouse/partner in the workforce.

METHODS

Participants included 4377 GPs responding to at least two consecutive annual surveys of the Medicine in Australia: Balancing Employment and Life (MABEL) national longitudinal study between 2008 and 2014. The main outcome, GP work location, was categorised by remoteness and population size. Five sequential binary school-age groupings were defined according to whether a GP had no children, only preschool children (aged 0-4 years), at least one primary-school child (aged 5-11 years), at least one child in secondary school (aged 12-18 years), and all children older than secondary school (aged ≥ 19). Partner in the workforce was defined by whether a GP had a partner who was either currently working or looking for work, or not. Separate generalised estimating equation models, which aggregated consecutive annual observations per GP, tested associations between work location and (i) educational stages and (ii) partner employment, after adjusting for key covariates.

RESULTS

Male GPs with children in secondary school were significantly less likely to work rurally (inclusive of > 50 000 regional centres through to the smallest rural towns of < 5000) compared to male GPs with children in primary school. In contrast, female GPs' locations were not significantly associated with the educational stage of their children. Having a partner in the workforce was not associated with work location for male GPs, whereas female GPs with a partner in the workforce were significantly less likely to work in smaller rural/remote communities (< 15 000 population).

CONCLUSIONS

This is the first systematic, national-level longitudinal study showing that GP work location is related to key family needs which differ according to GP gender and educational stages of children. Such non-professional factors are likely to be dynamic across the GP's lifespan and should be regularly reviewed as part of GP retention planning. This research supports investment in regional development for strong local secondary school and partner employment opportunities.

The rural pipeline to longer-term rural practice: General practitioners and specialists

BACKGROUND

Rural medical workforce shortage contributes to health disadvantage experienced by rural communities worldwide. This study aimed to determine the regional results of an Australian Government sponsored national program to enhance the Australian rural medical workforce by recruiting rural background students and establishing rural clinical schools (RCS). In particular, we wished to determine predictors of graduates' longer-term rural practice and whether the predictors differ between general practitioners (GPs) and specialists.

METHODS

A cross-sectional cohort study, conducted in 2012, of 729 medical graduates of The University of Queensland 2002-2011. The outcome of interest was primary place of graduates' practice categorised as rural for at least 50% of time since graduation ('Longer-term Rural Practice', LTRP) among GPs and medical specialists. The main exposures were rural background (RB) or metropolitan background (MB), and attendance at a metropolitan clinical school (MCS) or the Rural Clinical School for one year (RCS-1) or two years (RCS-2).

RESULTS

Independent predictors of LTRP (odds ratio [95% confidence interval]) were RB (2.10 [1.37-3.20]), RCS-1 (2.85 [1.77-4.58]), RCS-2 (5.38 [3.15-9.20]), GP (3.40 [2.13-5.43]), and bonded scholarship (2.11 [1.19-3.76]). Compared to being single, having a metropolitan background partner was a negative predictor (0.34 [0.21-0.57]). The effects of RB and RCS were additive-compared to MB and MCS (Reference group): RB and RCS-1 (6.58[3.32-13.04]), RB and RCS-2 (10.36[4.89-21.93]). Although specialists were less likely than GPs to be in LTRP, the pattern of the effects of rural exposures was similar, although some significant differences in the effects of the duration of RCS attendance, bonded scholarships and partner's background were apparent.

CONCLUSIONS

Among both specialists and GPs, rural background and rural clinical school attendance are independent, duration-dependent, and additive, predictors of longer-term rural practice. Metropolitan-based medical schools can enhance both specialist and GP rural medical workforce by enrolling rural background medical students and providing them with long-term rural undergraduate clinical training. Policy settings to achieve optimum rural workforce outcomes may differ between specialists and GPs.

Mobility of US Rural Primary Care Physicians During 2000-2014

PURPOSE

Despite considerable investment in increasing the number of primary care physicians in rural shortage areas, little is known about their movement rates and factors influencing their mobility. We aimed to characterize geographic mobility among rural primary care physicians, and to identify location and individual factors that influence such mobility.

METHODS

Using data from the American Medical Association Physician Masterfile for each clinically active US physician, we created seven 2-year (biennial) mobility periods during 2000-2014. These periods were merged with county-level "rurality," physician supply, economic characteristics, key demographic measures, and individual physician characteristics. We computed (1) mobility rates of physicians by rurality; (2) linear regression models of county-level rural nonretention (departure); and (3) logit models of physicians leaving rural practice.

RESULTS

Biennial turnover was about 17% among physicians aged 45 and younger, compared with 9% among physicians aged 46 to 65, with little difference between rural and metropolitan groups. County-level physician mobility was higher for counties that lacked a hospital (absolute increase = 5.7%), had a smaller population size, and had lower primary care physician supply, but area-level economic and demographic factors had little impact. Female physicians (odds ratios = 1.24 and 1.46 for those aged 45 or younger and those aged 46 to 65, respectively) and physicians born in a metropolitan area (odds ratios = 1.75 and 1.56 for those aged 45 or younger and those aged 46 to 65, respectively) were more likely to leave rural practice.

CONCLUSIONS

These flndings provide national-level evidence of rural physician mobility rates and factors associated with both county-level retention and individual-level departures. Outcomes were notably poorer in the most remote locations and those already having poorer physician supply and professional support. Rural health workforce planners and policymakers must be cognizant of these key factors to more effectively target retention policies and to take into account the additional support needed by these more vulnerable communities.

Selecting for a sustainable workforce to meet the future healthcare needs of rural communities in Australia

An undersupply of generalists doctors in rural communities globally led to widening participation (WP) initiatives to increase the proportion of rural origin medical students. In 2002 the Australian Government mandated that 25% of commencing Australian medical students be of rural origin. Meeting this target has largely been achieved through reduced standards of entry for rural relative to urban applicants. This initiative is based on the assumption that rural origin students will succeed during training, and return to practice in rural locations. One aim of this study was to determine the relationships between student geographical origin (rural or urban), selection scores, and future practice intentions of medical students at course entry and course exit. Two multicentre databases containing selection and future practice preferences (location and specialisation) were combined (5862), representing 54% of undergraduate medical students commencing from 2006 to 2013 across nine Australian medical schools. A second aim was to determine course performance of rural origin students selected on lower scores than their urban peers. Selection and course performance data for rural (461) and urban (1431) origin students commencing 2006-2014 from one medical school was used. For Aim 1, a third (33.7%) of rural origin students indicated a preference for future rural practice at course exit, and even fewer (6.7%) urban origin students made this preference. Results from logistic regression analyses showed significant independent predictors were rural origin (OR 4.0), lower Australian Tertiary Admissions Rank (ATAR) (OR 2.1), or lower Undergraduate Medical and Health Sciences Admissions Test Section 3 (non-verbal reasoning) (OR 1.3). Less than a fifth (17.6%) of rural origin students indicated a preference for future generalist practice at course exit. Significant predictors were female gender (OR 1.7) or lower ATAR (OR 1.2), but not rural origin. Fewer (10.5%) urban origin students indicated a preference for generalist practice at course exit. For Aim 2, results of Mann-Whitney U tests confirmed that slightly reducing selection scores does not result in increased failure, or meaningfully impaired performance during training relative to urban origin students. Our multicentre analysis supports success of the rural origin WP pathway to increase rural student participation in medical training. However, our findings confirm that current selection initiatives are insufficient to address the continuing problem of doctor maldistribution in Australia. We argue for further reform to current medical student selection, which remains largely determined by academic meritocracy. Our findings have relevance to the selection of students into health professions globally.

Factors related to doctors' choice of rural pathway in general practice specialty training

OBJECTIVE

To investigate the factors eligible applicants consider in electing for a rural pathway into specialty training.

DESIGN

Cohort study.

SETTING

Australia.

PARTICIPANTS

Applicants to the Australian General Practice Training program.

MAIN OUTCOME MEASURES

Applicants' initial preference of either a general or rural pathway to undertake specialty training.

RESULTS

Of the 2,221 applicants, 45% were Australian Medical Graduates (AMGs), 27% Foreign Graduates of Accredited Medical Schools (FGAMS) and 29% International Medical Graduates (IMGs). Through government regulation, two thirds (70%) were eligible to train on both general and rural pathways and a third (30%) were required to train rurally. For applicants eligible for general pathway (n = 1552), those with rural background [Odds Ratio (OR) = 3.7, 95% CI 2.7-5.2] and rural clinical school experience (OR = 2.0, 95% CI 1.5-2.8) were more likely to choose the rural pathway. In addition, FGAMS who were eligible for the general pathway were less likely to choose a rural pathway when compared with IMGs (OR = 0.33, 95%CI 0.1 = 0.7). In applicants who changed their training pathway from their initial to revised preference, lower Multiple-Mini-Interview (OR = 0.54, 95% CI 0.43-0.66) and Situational Judgement Test z-scores (OR = 0.68, 95% CI 0.56-0.83) were associated with a higher probability of changing from a general to rural pathway preference.

CONCLUSION

For those eligible for a general or rural pathway, rural background and rural clinical school experience are associated with the decision to elect for rural training. Targeted support for international and foreign graduates of Australia/New Zealand schools may influence them to train rurally.

Education for rural practice in rural practice

Despite the substantial differences between developing and developed countries, access is the major rural health issue. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: (1) a rural upbringing; (2) positive clinical and educational experiences in rural settings as part of undergraduate medical education; (3) targeted training for rural practice at the postgraduate level. This paper presents examples of successful rural primary care-based education in different parts of the world, then introduces the Wonca Rural Medical Education Guidebook which was launched at the 2014 Wonca Rural Health World Conference and concludes with a brief report of the 2015 conference held in Dubrovnik Croatia.

How do rural placements affect urban-based Australian junior doctors’ perceptions of working in a rural area?

Objectives The aim of the present study was to provide qualitative insights from urban-based junior doctors (graduation to completion of speciality training) of the effect of rural placements and rotations on career aspirations for work in non-metropolitan practices. Methods A qualitative study was performed of junior doctors based in Adelaide, Brisbane and Melbourne. Individual face-to-face or telephone semistructured interviews were held between August and October 2014. Thematic analysis focusing on participants’ experience of placements and subsequent attitudes to rural practice was undertaken. Results Most participants undertook rural placements in the first 2 years after graduation. Although experiences varied, positive perceptions of placements were consistently linked with the degree of supervision and professional support provided. These experiences were linked to attitudes about working outside metropolitan areas. Participants expressed concerns about being ‘forced’ to work in non-metropolitan hospitals in their first postgraduate year; many received little warning of the location or clinical expectations of the placement, causing anxiety and concern. Conclusions Adequate professional support and supervision in rural placements is essential to encourage junior doctors’ interests in rural medicine. Having a degree of choice about placements and a positive and supported learning experience increases the likelihood of a positive experience. Doctors open to working outside a metropolitan area should be preferentially allocated an intern position in a non-metropolitan hospital and rotated to more rural locations. What is known about the topic? The maldistribution of the Australian medical workforce has led to the introduction of several initiatives to provide regional and rural experiences for medical students and junior doctors. Although there have been studies outlining the effects of rural background and rural exposure on rural career aspirations, little research has focused on what hinders urban-trained junior doctors from pursuing a rural career. What does this paper add? Exposure to medical practice in regional or rural areas modified and changed the longer-term career aspirations of some junior doctors. Positive experiences increased the openness to and the likelihood of regional or rural practice. However, junior doctors were unlikely to aspire to non-metropolitan practice if they felt they had little control over and were unprepared for a rural placement, had a negative experience or were poorly supported by other clinicians or health services. What are the implications for practitioners? Changes to the process of allocating junior doctors to rural placements so that the doctors felt they had some choice, and ensuring these placements are well supervised and supported, would have a positive impact on junior doctors’ attitudes to non-metropolitan practice.

The longer term impact of a novel rural mental health recruitment strategy: A quasi-experimental study

INTRODUCTION

This study examines the longer term impact of the Gippsland Mental Health Vacation School program, an initiative designed to orientate preregistration allied health and nursing students to rural mental health employment and career opportunities.

METHODS

Student participants from vacation schools held from July 2010 to August 2013 were invited to complete on-line surveys prior to, immediately following and 6 months after the event. Participant rating of Interest in rural work, mental health work and rural mental health work and responses to the student attitudes to rural practice and life questionnaire were analyzed using repeated measure analyses of variance.

RESULTS

There was a large and significant positive increase in pre to post scores for student interest and attitudes to working in and career in the rural mental health sector. These gains in interest and attitudes fell away by approximately 50% in the six months following the program. The changes in attitudes toward rural work remained significant six months after the program, while attitudes to rural life at six months following the program were not-significantly different to the preprogram scores.

CONCLUSIONS

The findings highlight that although a short term program designed to attract students to rural mental health work can positively change participants' interest in and attitudes toward rural work and life, the change diminishes over time. However, interest in rural work and career and rural work attitudes generally maintain significant improvement in the longer term. These differential findings have important implications for developing strategies to overcome rural mental health workforce shortages.

Widening access to medicine may improve general practitioner recruitment in deprived and rural communities: survey of GP origins and current place of work

BACKGROUND

Widening access to medicine in the UK is a recalcitrant problem of increasing political importance, with associated strong social justice arguments but without clear evidence of impact on service delivery. Evidence from the United States suggests that widening access may enhance care to underserved communities. Additionally, rural origin has been demonstrated to be the factor most strongly associated with rural practice. However the evidence regarding socio-economic and rural background and subsequent practice locations in the UK has not been explored. The aim of this study was to investigate the association between general practitioners' (GPs) socio-economic and rural background at application to medical school and demographic characteristics of their current practice.

METHOD

The study design was a cross-sectional email survey of general practitioners practising in Scotland. Socio-economic status of GPs at application to medical school was assessed using the self-coded National Statistics Socio-Economic Classification. UK postcode at application was used to define urban-rural location. Current practice deprivation and remoteness was measured using NHS Scotland defined measures based on registered patients' postcodes.

RESULTS

A survey was sent to 2050 Scottish GPs with a valid accessible email address, with 801 (41.5 %) responding. GPs whose parents had semi-routine or routine occupations had 4.3 times the odds of working in a deprived practice compared to those with parents from managerial and professional occupations (95 % CI 1.8-10.2, p = 0.001). GPs from remote and rural Scottish backgrounds were more likely to work in remote Scottish practices, as were GPs originating from other UK countries.

CONCLUSION

This study showed that childhood background is associated with the population GPs subsequently serve, implying that widening access may positively affect service delivery in addition to any social justice rationale. Longitudinal research is needed to explore this association and the impact of widening access on service delivery more broadly.

The age profile of the location decision of Australian general practitioners

The unbalanced distribution of general practitioners (GPs) across geographic areas has been acknowledged as a problem in many countries around the world. Quantitative information regarding GPs' location decision over their lifecycle is essential in developing effective initiatives to address the unbalanced distribution and retention of GPs. This paper describes the age profile of GPs' location decision and relates it to individual characteristics. I use the Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors (2008-2012) with a sample size of 5810 male and 5797 female GPs. I employ a mixed logit model to estimate GPs' location decision. The results suggest that younger GPs are more prepared to go to rural and remote areas but they tend to migrate back to urban areas as they age. Coming from a rural background increases the likelihood of choosing rural areas, but with heterogeneity: While male GPs from a rural background tend to stay in rural and remote areas regardless of age, female GPs from a rural background are willing to migrate to urban areas as they age. GPs who obtain basic medical degrees overseas are likely to move back to urban areas in the later stage of their careers. Completing a basic medical degree at an older age increases the likelihood of working outside major cities. I also examine factors influencing GPs' location transition patterns and the results further confirm the association of individual characteristics and GPs' location-age profile. The findings can help target GPs who are most likely to practise and remain in rural and remote areas, and tailor policy initiatives to address the undesirable distribution and movement of GPs according to the identified heterogeneous age profile of their location decisions.

Medical student selection criteria and socio-demographic factors as predictors of ultimately working rurally after graduation

BACKGROUND

We have previously demonstrated that both coming from a rural background and spending a year-long clinical rotation in our Rural Clinical School (RCS) have independent and additive effects to increase the likelihood of medical students practicing rurally following graduation. The current study assesses the extent to which medical school selection criteria and/or the socio-demographic profile of medical students may further facilitate or hamper the selection of students ultimately destined for the rural medical workforce.

METHODS

The study comprised 729 students, admitted from secondary school since 1999 and having graduated by 2011, whose actual workplace location in 2014 was classified as either urban or rural using the Australian Health Practitioner Regulation Agency database. Selection factors on entry (score from a standardised interview, percentile scores for the 3 components of the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and prior academic performance as assessed by the Australian Tertiary Admissions Rank) together with socio-demographic factors (age, gender, decile for the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD)), were examined in relation to ultimate rural destination of practice.

RESULTS

In logistic regression, those practicing in a rural location in 2014 were more likely to have come from the lower 6 IRSAD deciles (OR 2.75, 95% CI 1.44, 5.23, P = 0.002), to be older (OR 1.86, 95% CI 1.09, 3.18, p = 0.023) and to have a lower UMAT-3 (Non-verbal communication) score (OR 0.98, 95% CI 0.97, 0.99, P = 0.005). After further controlling for either rural background or RCS participation, only age and UMAT-3 remained as independent predictors of current rural practice.

CONCLUSIONS

In terms of the socio-demographic profiles of those selected for medical school entry from secondary school, only older age weakly augmented the selection of graduates likely to ultimately work in a rural destination. Among the selection factors, having achieved higher scores in UMAT-3 tended to mitigate this outcome. The major focus in attempts to grow the rural medical workforce should therefore remain on recruiting medical students from a rural background together with providing maximal opportunity for prolonged immersion in rural clinical environments during their training.

Improving chlamydia knowledge should lead to increased chlamydia testing among Australian general practitioners: a cross-sectional study of chlamydia testing uptake in general practice

Background

Female general practitioners (GPs) have higher chlamydia testing rates than male GPs, yet it is unclear whether this is due to lack of knowledge among male GPs or because female GPs consult and test more female patients.

Methods

GPs completed a survey about their demographic details and knowledge about genital chlamydia. Chlamydia testing and consultation data for patients aged 16-29 years were extracted from the medical records software for each GP and linked to their survey responses. Chi-square tests were used to determine differences in a GP’s knowledge and demographics. Two multivariable models that adjusted for the gender of the patient were used to investigate associations between a GP and their chlamydia testing rates ― Model 1 included GPs’ characteristics such as age and gender, Model 2 excluded these characteristics to specifically examine any associations with knowledge.

Results

Female GPs were more likely than male GPs to know when to re-test a patient after a negative chlamydia test (18.8% versus 9.7%, p = 0.01), the correct symptoms suggestive of PID (80.5% versus 67.8%, p = 0.01) and the correct tests for diagnosing PID (57.1% versus 42.6%, p = 0.01). Female GPs tested 6.5% of patients, while male GPs tested 2.2% (p < 0.01). Model 1 found factors associated with chlamydia testing were being a female GP (OR = 2.5, 95% CI: 1.9, 3.3) and working in a metropolitan clinic (OR = 3.2; 95% CI: 2.4, 4.3). Model 2 showed that chlamydia testing increased as knowledge of testing guidelines improved (3-5 correct answers – AOR = 2.0, 95% CI: 1.0, 4.2; 6+ correct answers – AOR = 2.9, 95% CI: 1.4, 6.2).

Conclusions

Higher rates of chlamydia testing are strongly associated with GPs who are female, based in a metropolitan clinic and among those with more knowledge of the recommended guidelines. Improving chlamydia knowledge among male GPs may increase chlamydia testing.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0584-2) contains supplementary material, which is available to authorized users.

Medical student selection criteria as predictors of intended rural practice following graduation

BACKGROUND

Recruiting medical students from a rural background, together with offering them opportunities for prolonged immersion in rural clinical training environments, both lead to increased participation in the rural workforce after graduation. We have now assessed the extent to which medical students' intentions to practice rurally may also be predicted by either medical school selection criteria and/or student socio-demographic profiles.

METHODS

The study cohort included 538 secondary school-leaver entrants to The University of Western Australia Medical School from 2006 to 2011. On entry they completed a questionnaire indicating intention for either urban or rural practice following graduation. Selection factors (standardised interview score, percentile score from the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and prior academic performance (Australian Tertiary Admissions Rank), together with socio-demographic factors (age, gender, decile for the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) and an index of rurality) were examined in relation to intended rural or urban destination of practice.

RESULTS

In multivariate logistic regression, students from a rural background had a nearly 8-fold increase in the odds of intention to practice rurally after graduation compared to those from urban backgrounds (OR 7.84, 95% CI 4.10, 14.99, P < 0.001). Those intending to be generalists rather than specialists had a more than 4-fold increase in the odds of intention to practice rurally (OR 4.36, 95% CI 1.69, 11.22, P < 0.001). After controlling for these 2 factors, those with rural intent had significantly lower academic entry scores (P = 0.002) and marginally lower interview scores (P = 0.045). UMAT percentile scores were no different. Those intending to work in a rural location were also more likely to be female (OR 1.93, 95% CI 1.08, 3.48, P = 0.027), to come from the lower eight IRSAD deciles (OR 2.52, 95% CI 1.47, 4.32, P = 0.001) and to come from Government vs independent schools (OR 2.02, 95% CI 1.15, 3.55, P = 0.015).

CONCLUSIONS

Very high academic scores generally required for medical school entry may have the unintended consequence of selecting fewer graduates interested in a rural practice destination. Increased efforts to recruit students from lower socioeconomic backgrounds may be beneficial in terms of an ultimate intended rural practice destination.

Rural outreach by specialist doctors in Australia: a national cross-sectional study of supply and distribution

BACKGROUND

Outreach has been endorsed as an important global strategy to promote universal access to health care but it depends on health workers who are willing to travel. In Australia, rural outreach is commonly provided by specialist doctors who periodically visit the same community over time. However information about the level of participation and the distribution of these services nationally is limited. This paper outlines the proportion of Australian specialist doctors who participate in rural outreach, describes their characteristics and assesses how these characteristics influence remote outreach provision.

METHODS

We used data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, collected between June and November 2008. Weighted logistic regression analyses examined the effect of covariates: sex, age, specialist residential location, rural background, practice arrangements and specialist group on rural outreach. A separate logistic regression analysis studied the effect of covariates on remote outreach compared with other rural outreach.

RESULTS

Of 4,596 specialist doctors, 19% (n = 909) provided outreach; of which, 16% (n = 149) provided remote outreach. Most (75%) outreach providers were metropolitan specialists. In multivariate analysis, outreach was associated with being male (OR 1.38, 1.12 to 1.69), having a rural residence (both inner regional: OR 2.07, 1.68 to 2.54; and outer regional/remote: OR 3.40, 2.38 to 4.87) and working in private consulting rooms (OR 1.24, 1.01 to 1.53). Remote outreach was associated with increasing 5-year age (OR1.17, 1.05 to 1.31) and residing in an outer regional/remote location (OR 10.84, 5.82 to 20.19). Specialists based in inner regional areas were less likely than metropolitan-based specialists to provide remote outreach (OR 0.35, 0.17 to 0.70).

CONCLUSION

There is a healthy level of interest in rural outreach work, but remote outreach is less common. Whilst most providers are metropolitan-based, rural doctors are more likely to provide outreach services. Remote distribution is influenced differently: inner regional specialists are less likely to provide remote services compared with metropolitan specialists. To benefit from outreach services and ensure adequate remote distribution, we need to promote coordinated delivery of services arising from metropolitan and rural locations according to rural and remote health need.

Discontinuities between maternity and child and family health services: health professional's perceptions

BACKGROUND

Continuity in the context of healthcare refers to the perception of the client that care has been connected and coherent over time. For over a decade professionals providing maternity and child and family health (CFH) services in Australia and internationally have emphasised the importance of continuity of care for women, families and children. However, continuity across maternity and CFH services remains elusive. Continuity is defined and implemented in different ways, resulting in fragmentation of care particularly at points of transition from one service or professional to another.This paper examines the concept of continuity across the maternity and CFH service continuum from the perspectives of midwifery, CFH nursing, general practitioner (GP) and practice nurse (PN) professional leaders.

METHODS

Data were collected as part of a three phase mixed methods study investigating the feasibility of implementing a national approach to CFH services in Australia (CHoRUS study). Representatives from the four participating professional groups were consulted via discussion groups, focus groups and e-conversations, which were recorded and transcribed. In total, 132 professionals participated, including 45 midwives, 60 CFH nurses, 15 general practitioners and 12 practice nurses. Transcripts were analysed using a thematic approach.

RESULTS

'Continuity' was used and applied differently within and across groups. Aspects of care most valued by professionals included continuity preferably characterised by the development of a relationship with the family (relational continuity) and good communication (informational continuity). When considering managerial continuity we found professionals' were most concerned with co-ordination of care within their own service, rather than focusing on the co-ordination between services.

CONCLUSION

These findings add new perspectives to understanding continuity within the maternity and CFH services continuum of care. All health professionals consulted were committed to a smooth journey for families along the continuum. Commitment to collaboration is required if service gaps are to be addressed particularly at the point of transition of care between services which was found to be particularly problematic.

Recruiting doctors from and for underserved groups: Does New Brunswick's initiative to recruit doctors for its linguistic minority help rural communities?

OBJECTIVES

Within health care, there are underserved groups. New Brunswick's French-speaking minority, which also mostly lives in rural communities, is one such group. A physician shortage potentially prevents this population from accessing health promotion and clinical prevention services. This study analyzes whether New Brunswick Francophone doctors with rural backgrounds are more likely than doctors from urban regions to set up practice in rural communities of the province.

METHODS

A questionnaire was sent to 390 New Brunswick Francophone physicians admitted in medicine between 1973 and 2000. It collected information on geographic origin and history of medical practice. Multivariate logistic regressions were used to identify whether a rural background is associated with the likelihood of ever and currently practicing in rural communities. We used the General Practice Rurality Index-simplified to quantify the rurality level of communities.

RESULTS

In total, 264 (67%) physicians participated. A rural background was positively associated with the establishment of a first medical practice in a rural community. This relationship was only significant among family physicians. There was no statistically significant relationship between rurality of community of origin and rurality of current community of practice among either family or specialty physicians.

CONCLUSION

Although Francophone doctors with a rural background were more likely than their urban counterparts to set up their first practice in a rural community, this effect was not sustained. This raises questions as to why they leave rural communities and highlights the importance of measures to retain doctors as a way to promote public health for underserved rural groups.

Recruiting doctors from and for underserved groups: Does New Brunswick's initiative to recruit doctors for its linguistic minority help rural communities?

OBJECTIVES

Within health care, there are underserved groups. New Brunswick's French-speaking minority, which also mostly lives in rural communities, is one such group. A physician shortage potentially prevents this population from accessing health promotion and clinical prevention services. This study analyzes whether New Brunswick Francophone doctors with rural backgrounds are more likely than doctors from urban regions to set up practice in rural communities of the province.

METHODS

A questionnaire was sent to 390 New Brunswick Francophone physicians admitted in medicine between 1973 and 2000. It collected information on geographic origin and history of medical practice. Multivariate logistic regressions were used to identify whether a rural background is associated with the likelihood of ever and currently practicing in rural communities. We used the General Practice Rurality Index-simplified to quantify the rurality level of communities.

RESULTS

In total, 264 (67%) physicians participated. A rural background was positively associated with the establishment of a first medical practice in a rural community. This relationship was only significant among family physicians. There was no statistically significant relationship between rurality of community of origin and rurality of current community of practice among either family or specialty physicians.

CONCLUSION

Although Francophone doctors with a rural background were more likely than their urban counterparts to set up their first practice in a rural community, this effect was not sustained. This raises questions as to why they leave rural communities and highlights the importance of measures to retain doctors as a way to promote public health for underserved rural groups.