A scoping review of the association between rural medical education and rural practice location

Interlinkage between health workforce availability and socioeconomic status in rural and remote Australia

INTRODUCTION

Australians living in rural and remote areas experience a higher burden of disease compared to their urban counterparts, whilst having poorer access to essential health services. Socioeconomic status and health workforce shortages are important influences on health status and access to care in these areas. This research aims to provide a local-level analysis of the association between local government area (LGA) indicators of socio-economic status and health workforce availability to enhance understanding of rural and remote workforce distribution patterns.

METHODS

Data were extracted from the Australian Bureau of Statistics and the Department of Health and Aged care, which encompassed demographic factors, socioeconomic indicators and counts for medical practitioners, allied health workers and nurses and midwives within non-metropolitan local government areas. Generalised Additive Models with Generalised Estimating Equations (GEE-GAMs) were used to test for an association between socioeconomic status (SES) and the World Health Organisation's definition of health workforce deficit.

RESULTS

The odds of being in deficit of nurses and midwives increased with increasing SES. No significant association between SES and medical practitioners or allied healthcare workers was found. Very remote areas were less likely to have a deficit of allied health professionals than inner regional areas, and the same was true for nurses and midwives in both remote and very remote areas.

CONCLUSIONS

The findings suggest that health workforce policies that target areas of need based on SES, may have contributed to better availability of nurses and midwives in these locations, but not significantly so for medical practitioners or allied health professionals. Further research is required to investigate the relative success of workforce policies in addressing health need in relation to SES and remoteness.

Attitudes of medical students in Croatia toward rural medicine education and practice

Introduction

Recruiting and retaining doctors in rural areas is challenging. In Croatia, medical school curricula lack content on rural medicine and specialized training for rural practice. This study explores the opinions and attitudes of first- and sixth-year medical students in all four medical schools in Croatia regarding working in rural areas.

Methods

An online questionnaire was administered to Croatian medical students in their first and final years between January 2022 and February 2023. Responses were obtained from 690 participants from the Universities of Osijek, Rijeka, Split, and Zagreb. The cross-sectional study included 13 questions, with 5 on socio-demographic data. Data were analyzed using descriptive statistics and non-parametric tests (chi-square) to assess group differences.

Results

Compared to first-year students, final-year students feel less prepared by their education for rural practice (χ2 = 84.287; P = 0.000) but are more interested in working in rural areas (χ2 = 26.810; P = 0.000). Most students believe rural doctors need additional financial incentives, with this belief significantly stronger among final-year students (χ2 = 14.192; P = 0.000). Both groups agree that rural doctors face poor working conditions (χ2 = 1.524; P = 0.217). No statistically significant differences were found regarding job interest outside city centers (χ2 = 2.041; P = 0.564) or choosing rural medical practice (χ2 = 4.795; P = 0.187) among medical students from the Universities of Osijek, Rijeka, Split, and Zagreb. Students from rural settlements were more often interested in jobs outside the city center (72.1%) compared to those from smaller towns (60.6%), [χ2(1) = 5.142, p = 0.023] and larger cities (44.1%), [χ2(1) = 28.978, p = 0.000].

Conclusion

Although Croatian medical students show interest in working in rural areas, their education lacks sufficient preparation for the unique challenges of rural practice. They view the current conditions for rural doctors as inadequate and believe that additional financial incentives are necessary. Interest in rural practice is consistent across medical faculties in Croatia, with students living in rural areas showing a higher interest in working there.

Medical school service regions in Canada: exploring graduate retention rates across the medical education training continuum and into professional practice

PURPOSE

To create medical school service regions and examine national in-region graduate retention patterns across the medical education continuum and into professional practice as one approach to advancing social accountability in medical education.

METHODS

Medical school service regions were created in Canada using publicly available data and mapped using Geographic Information System (GIS) software. Population size and density for each service region were calculated using census data. Retrospective data of medical graduates who completed their medical degrees between 2001-2015 (n = 19,971) were obtained from a centralized data repository and used to analyze in-region retention rates by medical specialty across the training continuum and five years into professional practice.

RESULTS

Spatial inequities were observed across medical school service regions. Graduate retention patterns also varied across service region groups and medical specialties. Quebec (86.5%) and Ontario (80.4%) had above-average retention rates across the medical education continuum. Family medicine had the highest retention rates from undergraduate to postgraduate training (81.9%), while psychiatry had the highest retention rate across the training continuum and into professional practice (71.2%). The Alberta and British Columbia service region group demonstrated high retention rates across the training continuum and into professional practice and medical specialties, except for retention from undergraduate to postgraduate medical education.

CONCLUSION

This study highlights the importance of considering both medical specialty and practice location of graduates when planning and retaining the physician workforce. The observed retention patterns among graduates are a critical aspect of addressing societal needs and represent an intermediate step towards achieving health equity. Furthermore, graduate retention patterns serve as an outcome measure for schools to demonstrate their commitment to social accountability. Tracking and monitoring graduate outcomes may lead schools to actively collaborate with government agencies responsible for healthcare policy, which may ultimately improve physician workforce planning and promote more equitable healthcare access.

Primary care in rural areas: a qualitative study on medical students' images and experiences of working in rural areas in southern Germany

BACKGROUND

Rural areas are increasingly moving back into the focus of social research, especially in the context of health care. As the shortage of general practitioners (GP) in rural areas is a significant challenge in Germany, there are several programs to counteract underuse effectively, acutely, and sustainably. One of those programs is 'Beste Landpartie Allgemeinmedizin' (BeLA), which was developed to strengthen primary care in rural areas and to sustainably promote young doctors to work as general practitioners in rural regions through didactical and financial support. The program includes an accompanying qualitative study exploring the motivational structures of medical students from a sociological perspective. For this study, the nexus of working in rural areas from the perspective of medical students with different forms of rural experiences was of interest.

METHODS

Qualitative interviews have been conducted at regular intervals on an ongoing basis since 2020 to investigate motivational retention effects during the program. The current 33 interviews were analysed using the sociological conceptual framework of spatial methods.

RESULTS

The images and experiences of working in rural areas condition medical education in various ways. In addition to general images of living and working in rural areas in a biographical dimension, the idea of working as a GP in rural areas includes images of specific medical competencies and is conditioned by different medical tasks. From such a perspective, the images and attributions of working in primary care in a rural region demonstrate particularities, challenges, and the potential attractiveness of working in rural regions.

DISCUSSION

The images and experiences of rural areas condition medical education in various ways and shape the expectations and the decision-making of possibly working in rural areas. The particularities, opportunities, and challenges of working in rural areas, which relate to both professional aspects and social life, are a major factor in the attractiveness of a potential rural practice. Didactical and educational curricula need to adapt the various attributions of working in rural areas.

Recruitment of Residents to Rural Programs: Early Outcomes From Cohort 1 of the Rural Residency Planning and Development Grants Program

Background To address rural physician workforce shortages, the Health Resources and Services Administration funded multiple Rural Residency Planning and Development (RRPD) awards, beginning in 2019, to develop rural residency programs in needed specialties. Objective To describe early resident recruitment outcomes of the RRPD grants program. Methods A cross-sectional survey of program directors or administrators of these 25 new rural residency training programs across the United States was administered at RRPD award conclusion in 2022. We performed descriptive analyses of applicant and Match data, including applications and interviews per resident position, positions filled in the main Match vs the Supplemental Offer and Acceptance Program (SOAP), and recruitment of residents from the program's state. Results The 25 Cohort 1 RRPD programs ranged from 2 to 8 residents per year. Most programs (16 of 25, 64.0%) were rural expansion tracks of an urban program. Most programs were sufficiently developed to participate in the 2022 (N=17) or 2023 (N=20) Match; we report on 13 of 17 (76.5%) programs for 2022 and 14 of 20 (70.0%) programs for 2023. Programs completed a median of 14.8 interviews per position. Most positions were filled in the Match (43 of 58, 74.1% in 2022; 45 of 58, 77.6% in 2023); most others were filled in the SOAP. On average, 34.4% of enrolled residents were from the same state as the program (range 0-78.6%). Conclusions The early resident recruitment outcomes of the RRPD model for developing new physician training in rural communities had sufficient recruitment success to support program continuation.

Solutions for Addressing the Dermatologist Shortage in Rural Canada: A Review of the Literature

In Canada, there is a maldistribution of dermatologists, with as many as 5.6 dermatologists per 100,000 population in urban areas and as low as 0.6 per 100,000 in rural areas. Considering trends of dermatologists to work in group practices in urban areas, and the low number of rural dermatologists, one solution may be to incentivize dermatologists to practice rurally. Several solutions using the following themes are discussed: dermatology program-specific incentives, dermatology practice-specific incentives, and other indirect incentives. The low number of dermatologists in rural areas in Canada is concerning and has negative consequences for access to care for patients in rural areas, ultimately resulting in worse patient outcomes. Future research is needed to evaluate the impact of these initiatives and assess future access to dermatological care.

The Landscape of Rural and Remote Radiology in Canada: Opportunities and Challenges

Diagnostic and interventional radiology play a crucial role in healthcare, facilitating diagnosis of disease, treatment planning, interventional therapies, and assessment for response to treatment. However, many rural and remote regions are disproportionately limited in accessing high-quality radiological services. Challenges include limited imaging infrastructure in these communities, geographic isolation, and workforce shortages impacting provision of interventional image-guided procedures and subspecialty imaging in particular. However, a career in rural or remote radiology also presents unique opportunities including a deep sense of community, broad scope of practice, and immense benefit to patient care. This review aims to explore the landscape of rural and remote radiology with a focus on Canada, including opportunities, challenges, and potential strategies. Some of the challenges are shared by both rural and remote communities while others are distinct. Factors that have contributed to challenges in recruitment and retention of rural and remote radiologists include workload burden, inadequate or suboptimal imaging and interventional equipment, and limited exposure during training. Additionally, strategies to improve the provision of radiology services in rural and remote communities are highlighted, addressing both the workforce shortage and the lack of essential equipment and other resources.

[How to Motivate Medical Students to Practice in Rural Areas]

BACKGROUND

The excellent project "LandArztMacher" is an attempt to work against the predicted shortage of rural doctors in Germany with diverse approaches.

METHOD

"LandArztMacher" is a clinical traineeship with four weeks of practical training in general practices and clinics in the Bavarian countryside, accompanied by joint professional teaching. Participants were asked before and after the internship about the topics "importance of an internship in rural areas"; "attractiveness of rural areas" (scale: 0/no agreement to 10/full agreement). Ideas about the tasks of a general practitioner were assessed (scale: 0/no idea at all to 100/exact idea). The present study is a repeated cross-sectional study. The median is reported as the location measure and the interquartile range as the dispersion measure.

RESULTS

Participants (n=363, 74% female, n=267, age: range 19-46 years, mean: 23.2 years, SD: 2.41 years) from the clinical section of the medical studies considered an internship in the rural area before and after the internship very important (median: 8 and 9, respectively) and could well imagine working in the countryside (median: 7 and 8, respectively). Their attitude towards the cultural offerings or the infrastructure did not change (median: 6 in each case). After the internship, the students had a more precise idea of what a general practitioner tasks are (median: 65 and 90, respectively).

SUMMARY

A well-structured four-week rural internship can enhance the appeal of future rural employment through individual supervision and collaborative training.

Preparing occupational therapy students for practice in rural areas: a scoping review protocol

INTRODUCTION

Despite greater needs in rural areas, occupational therapists are maldistributed to urban spaces which limits service access and health outcomes for rural people and communities. Preparation of students for rural practice may improve rural workforce recruitment and retention; however, the range and scope of preparation strategies employed by education providers are unclear. This scoping review aims to understand and describe the range of strategies education services use to prepare occupational therapy students for rural practice across the globe.

METHODS AND ANALYSIS

The study will include all publications about strategies used to prepare occupational therapy students for future rural practice, prior to enrolment, during the programme or on graduation. MEDLINE (Ovid), Emcare (Ovid), APA PsychInfo (Ovid), CINAHL (EBSCOhost), Health Source: Nursing/Academic (EBSCOHost), Educational Resources Information Centre (ERIC), Open Access Theses and Dissertations (OATD), and Scientific Electronic Library Online (SciELO) databases will be systematically searched in English, Spanish, French and Portuguese languages. Citations will be screened by two or more independent researchers against inclusion criteria and data extracted from included publications using a customised extraction tool. Frequency counts will be provided for study type, student location and sociodemographics, and the timing/educational strategy. The extracted data will be analysed using a matrix framework and presented in diagrammatic/tabular form and accompanied by a narrative summary which will describe how the results relate to the reviews' questions.

ETHICS AND DISSEMINATION

This study will not involve human/animal subjects and does not require ethics approval. Results will be disseminated to relevant groups in peer-reviewed journal(s) and at relevant occupational therapy, higher education and/or rural health conferences. Results will also be translated and shared in blogs/social media to support access for non-research audiences and shared with other regional universities to influence curriculum design.

Exploring recent trends (2014-21) in preferencing and accepting Queensland medical internships in rural hospitals

BACKGROUND

Medical internship is a key transition point in medical training from student to independent (junior) doctor. The national Regional Training Hubs (RTH) policy began across Australia in late 2017, which aims to build medical training pathways for junior doctors within a rural region and guide students, interns and trainees towards these. This study aims to explore preferencing and acceptance trends for rural medical internship positions in Queensland. Moreover, it focuses on internship preference and acceptance outcomes prior to and following the establishment of RTHs, and their association with key covariates such as rural training immersions offered by medical schools.

METHODS

Data from all applicants to Queensland Health intern positions between 2014-2021 were available, notably their preference order and location of accepted internship position, classified as rural or metropolitan. Matched data from Queensland's medical schools were added for rural training time and other key demographics. Analyses explored the statistical associations between these factors and preferencing or accepting rural internships, comparing pre-RTH and post-RTH cohorts.

RESULTS

Domestic Queensland-trained graduates first preferencing rural intern positions increased significantly (pre-RTH 21.1% vs post-RTH 24.0%, p = 0.017), reinforced by a non-significant increase in rural acceptances (27.3% vs 29.7%, p = 0.070). Rural interns were more likely to have previously spent ≥ 11-weeks training in rural locations within medical school, be rurally based in the year applying for internship, or enrolled in the rural generalist pathway.

CONCLUSIONS

The introduction of the RTH was associated with a moderate increase of graduates both preferencing and accepting a rural internship, though a richer understanding of the dominant reasons for and against this remain less clear. An expansion of graduates who undertook longer periods of undergraduate rural training in the same period did not diminish the proportion choosing a rural internship, suggesting there remains an appetite for these opportunities. Overall, domestic graduates are identified as a reliable source of intern recruitment and retention to rural hospitals across Queensland, with entry to the rural generalist pathway and extended rural placement experiences enhancing uptake of rural practice.

The Effect of Rural Underserved Opportunities Program Participation on Medical Graduates' Decision to Work in Rural Areas

PURPOSE

There is a persistent rural physician shortage in the United States. Policies to scale up the health workforce in response to this shortage must include measures to draw and maintain existing and newly trained health care workers to rural regions. Prior studies have found that experience in community medicine in rural practice settings increases the likelihood of medical graduates practicing in those regions but have not accounted for selection bias. This study examined the impact of a community-based clinical immersion program on medical graduates' decision to work in rural regions, adjusting for covariates to control for selection bias.

METHOD

Data on sociodemographic characteristics and career interests and preferences for all 1,172 University of Washington School of Medicine graduates between 2009 and 2014 were collected. A logistic model (model 1) was used to evaluate the impact of Rural Underserved Opportunities Program (RUOP) participation on the probability of physicians working in a rural region. Another model (model 2) included the propensity score as a covariate in the regression to control for possible confounding based on differences among those who did and did not participate in the RUOP.

RESULTS

Of the 994 students included in the analysis, 570 (57.3%) participated in RUOP training, and 111 (11.2%) were currently working in rural communities after their training. Regression analysis results showed that the odds of working in a rural region were 1.83 times higher for graduates who participated in RUOP in model 1 ( P = .03) and 1.77 times higher in model 2 ( P = .04).

CONCLUSIONS

The findings of this study emphasize that educational programs and policies are crucial public health interventions that can promote health equity through proper distribution of health care workers across rural regions of the United States.

Educational Strategies to Reduce Physician Shortages in Underserved Areas: A Systematic Review

The shortage of physicians in rural and underserved areas is an obstacle to the implementation of Universal Health Coverage (UHC). We carried out a systematic review to analyze the effectiveness of initiatives in medical education aimed to increase the supply of physicians in rural or underserved areas. We searched for studies published between 1999 and 2019 in six databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Interventional or observational controlled studies were defined as inclusion criteria. A total of 955 relevant unique records were selected for inclusion, which resulted in the identification of 17 articles for analysis. The admission of students from rural areas associated with a rural curriculum represented 52.95% of the interventions. Medical practice after graduation in rural or underserved areas was the most evaluated outcome, representing 12 publications (70.59%). Participants of these educational initiatives were more likely to work in rural or underserved areas or to choose family medicine, with significant differences between the groups in 82.35% of the studies. Educational strategies in undergraduate and medical residencies are effective. However, it is necessary to expand these interventions to ensure the supply of physicians in rural or urban underserved areas.

Perceived Impact of a Core Rotation on Hawai'i Island on Future Career Intentions among Obstetrics and Gynecology Residents

Hawai'i Island faces a growing shortage of obstetric and gynecology providers. Increased exposure of obstetrics and gynecology residents to rural rotations during their core training may increase their interest in rural practice after graduation. In an effort to address the health care needs of women on Hawai'i Island, the University of Hawai'i Obstetrics and Gynecology Residency Program established a 4-week required gynecology rotation in the town of Hilo. Between July 2019 and June 2020, third- and fourth-year obstetrics and gynecology residents provided outpatient gynecologic care and participated in gynecologic surgeries at Hilo-based medical facilities. A total of 9 residents participated in this Hilo-based rotation. This retrospective study extracted data from post-rotation evaluations. Eight out of 9 participating residents (89%) felt that the rotation slightly or far exceeded their expectations. After the rotation, 7 residents (78%) reported an interest in practicing in a rural community, while only 3 residents (33%) reported having this interest prior to the rotation. Underserved rural areas seeking to recruit and retain obstetrics and gynecology physicians may benefit from partnering with residency training programs.

The value of extended short-term medical training placements in smaller rural and remote locations on future work location: a cohort study

OBJECTIVES

To investigate the effects of extended short-term medical training placements in small rural and remote communities on postgraduate work location.

DESIGN AND SETTING

Cohort study of medical graduates of The University of Queensland, Australia.

PARTICIPANTS

Graduating medical students from 2012 to 2021 who undertook a minimum of 6 weeks training in a small rural or remote location. Some participants additionally undertook either or both an extended short-term (12-week) placement in a small rural or remote location and a long-term (1 or 2 years) placement in a large regional centre.

PRIMARY OUTCOME MEASURE

Work location was collected from the Australian Health Practitioner Regulation Agency in 2022, classified as either rural, regional or metropolitan and measured in association with rural placement type(s).

RESULTS

From 2806 eligible graduates, those participating in extended small rural placements (n=106, 3.8%) were associated with practising rurally or regionally postgraduation (42.5% vs 19.9%; OR: 2.2, 95% CI: 1.1 to 4.6), for both those of rural origin (50% vs 30%; OR: 4.9, 95% CI: 2.6 to 9.2) or metropolitan origin (36% vs 17%; OR: 2.8, 95% CI: 1.7 to 4.8). Those undertaking both an extended small rural placement and 2 years regional training were most likely to be practising in a rural or regional location (61% vs 16%; OR: 8.6, 95% CI: 4.5 to 16.3). Extended small rural placements were associated with practising in smaller rural or remote locations in later years (15% vs 6%, OR: 2.7, 95% CI: 1.3 to 5.3).

CONCLUSION

This work location outcome evidence supports investment in rural medical training that is both located in smaller rural and remote settings and enables extended exposure with rural generalists. The evaluated 12-week programme positively related to rural workforce outcomes when applied alone. Outcomes greatly strengthened when the 12-week programme was combined with a 2-year regional centre training programme, compared with either alone. These effects were independent of rural origin.

A Study of Arizona Physician Relocation Patterns by Rurality and Primary Care Status

BACKGROUND AND OBJECTIVES

Physician location is an important element of health care access. However, physician shortages and disparities in geographic distribution exist. This study examines physician locations, relocation patterns, and factors associated with relocating.

METHODS

We used Arizona licensure data and rural-urban commuting area (RUCA) codes to identify Arizona physicians and their office or mailing address locations. Our sample included Arizona physicians estimated to be younger than 70 years of age who had an active license between in 2014 and 2019. We used multivariable logistic regression to assess physicians' adjusted odds of relocating in Arizona by RUCA code, primary care status, age, gender, and medical education location.

RESULTS

We identified 11,202 Arizona physicians in our sample, 33% of whom changed practice addresses within Arizona between 2014 and 2019. Primary care physicians (PCPs) in large rural areas had lower odds of relocating in Arizona (0.62, 95% CI 0.43-0.90) than PCPs in urban areas. Compared to 64-69-year-old physicians, those less than 34 and 34-43 years old had statistically higher odds of relocating within Arizona.

CONCLUSIONS

Primary care status and rurality are important factors consider to understand physician relocation patterns. We found that a substantial number of Arizona physicians relocated within Arizona between 2014 and 2019, and few of those who relocated (2%) moved to a more rural area.

Possible relationship between rural surgical rotations during a residency period and an increased number of general surgeons in rural areas: a systematic review

Objective: Rural surgical training for residents is expected to increase the number of general surgeons working in rural areas; however, the impact of rural training programs to ensure such surgeons remains to be determined. Therefore, we reviewed the relevance of rural surgical rotation to the increase of general surgeons in rural areas. Materials and Methods: Studies on the outcomes of rural surgical rotations during the residency period in comparison to non-rural surgical rotations were retrieved using electronic databases through April 2022. Results: Among the 514 articles, five were eligible for review. All studies were published in the United States. Four studies reported an increased number of general surgeons in rural areas owing to rural surgical rotations. A meta-analysis of all studies showed a positive impact on the number of general surgeons in rural areas (odds ratio=2.19, 95% confidence interval=1.23-3.91). The programs generally ranged from 2 to 12 months with extensive experience with minor surgery and subspecialties necessary for surgery. Conclusions: Rural surgical rotations during the residency period can increase the number of general surgeons working in rural areas. Further studies are needed to evaluate the placement of general surgeons in rural areas.

Supervisor experiences of extended clinical placements in optometry: a mixed methods study

BACKGROUND

In Australia, optometry students have traditionally undertaken their clinical training in short-block rotations at University-led teaching clinics in metropolitan locations. Demand for clinical placements is growing as the number of optometry students steadily increases. As such, universities and clinical education providers must look for more diverse methods of student placement. Extended clinical placements in community-based settings are one alternative: a model similar to the longitudinal clerkships in medicine. This study aimed to explore the experience of extended clinical placements from the perspective of the optometrists who supervised students. It also sought to determine whether there were differences in views between metropolitan and rural practitioners.

METHODS

This mixed methods study included a survey and interviews with optometrists who had previously supervised Deakin University optometry students on an extended 26-week (2 x 13-weeks) clinical placement. Lines of enquiry focused on; the benefits and challenges associated with extended placements; areas for improvement; duration of the placement; and willingness to supervise further students. Interviews were transcribed verbatim and analysed using Braun and Clarke's 6 step method of thematic analysis with a qualitative descriptive approach.

RESULTS

Supervisors felt that hosting a student prompted greater reflective practice and critical appraisal of clinical decisions. The extended nature of the placement was thought to foster greater immersion in the clinical setting and community for the students and establish a stronger relationship between supervisor and student. Supervisors recognised the importance of role-modelling and mentoring the next generation of optometrists however noted that taking on a student was a sizeable commitment. Willingness to host a student was not dependent on the supervisor's location (rural vs metropolitan) p = 0.57. However, interviews uncovered motivations that were unique to supervisors residing in rural locations, such as succession planning.

CONCLUSION

Overall, supervisors were positive about the value of student extended clinical placement in optometry and felt that it was a fulfilling and professionally beneficial experience. Lack of time and financial remuneration were the key downsides highlighted. Schools of optometry might carefully consider engaging in discussion about the duration of such placements, but 26 weeks was considered appropriate by supervisors.

Factors associated with selection of practice in primary care and rural health among medical and nursing students in China

BACKGROUND

China has a shortage of physicians and nurses in primary care and rural health. This study explores factors that influence the choices of medical and nursing students in China to select a career in primary care, or in rural health.

METHODS

A total of 3826 medical students and 1771 nursing students were surveyed in China. Data were analysed using descriptive statistics, Chi-squared tests, and logistic regression models.

RESULTS

The majority of medical and nursing students were willing to practice primary care (55% and 59%, respectively). Yet, only 16% and 5% of medical and nursing students, respectively, desired to work in a village or small city. The most common reasons cited to not practice primary care is the lack of opportunities for clinical skills improvement, academic and personal development, and networking. Medical students who were living in a rural residence between ages 1 and 15years were more likely to report a willingness to work in a rural location (OR: 2.18, 95% CI: 1.33-3.58) or in primary care (OR: 1.72, 95% CI: 1.31-2.25).

CONCLUSION

More efforts are needed to understand how preferences among medical and nursing students influence their career choices and change in choices over time. Understanding the concerns of students can help to tailor interventions in healthcare education and training to increase student satisfaction with their career choice and enrolment counts in medical and nursing fields.

What are the impacts of setting up new medical schools? A narrative review

BACKGROUND

The growth of the UK's population together with an aging society with increasingly complex health and social care needs has placed a greater demand on statutory care services. In view of this emerging landscape, the UK Government has sought to increase its medically trained workforce in order to better respond to the demands placed on the health service. Five universities were announced as homes to new medical schools offering undergraduate places to boost the numbers of doctors training in England. The aim of this narrative review was to explore how new medical schools could improve the health outcomes of the local population and evaluate the potential contribution it may make to the local economy, workforce and to research and innovation.

METHODS

A narrative review was undertaken using a systematic approach for the search literature strategy. The articles were evaluated by undertaking a critical assessment evaluating the fitness of a paper for review according to results, methods used to test the hypothesis, conclusions and impact and limitations. Thematic analysis was employed to organise and summarise the findings across a heterogeneous body of literature included in the review. The analysis was developed in an inductive manner and there were not any predefined themes to guide data extraction and analysis.

RESULTS

Thirty-six articles were selected for inclusion for this narrative review. The review identified six key themes: influence of prior rural exposure, medical school environment and rural enrichment programmes, workforce, health outcomes of local populations, social accountability, economic contribution of medical schools to communities and impact on rural research.

CONCLUSIONS

The studies included found a wealth of information on a wide-range of topics on the expansion of undergraduate education and its implications on the future medical workforce. It was shown that medical schools can have a positive effect on the health, social, economic and research activity of a region, but this literature tended to be heterogeneous in focus without consideration of the inter-connections between the wider societal and economic impacts arising from long-term sustainable change being brought to a region.

Strategies to Facilitate Improved Recruitment, Development, and Retention of the Rural and Remote Medical Workforce: A Scoping Review

BACKGROUND

Medical workforce shortages in rural and remote areas are a global issue. High-income countries (HICs) and low- and middle-income countries (LMICs) seek to implement strategies to address this problem, regardless of local challenges and contexts. This study distilled strategies with positive outcomes and success from international peer-reviewed literature regarding recruitment, retention, and rural and remote medical workforce development in HICs and LMICs.

METHODS

The Arksey and O'Malley scoping review framework was utilised. Articles were retrieved from electronic databases Medline, Embase, Global Health, CINAHL Plus, and PubMed from 2010-2020. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guideline was used to ensure rigour in reporting the methodology in the interim, and PRISMA extension for scoping review (PRISMA-ScR) was used as a guide to report the findings. The success of strategies was examined against the following outcomes: for recruitment - rural and remote practice location; for development - personal and professional development; and for retention - continuity in rural and remote practice and low turnover rates.

RESULTS

Sixty-one studies were included according to the restriction criteria. Most studies (n=53; 87%) were undertaken in HICs, with only eight studies from LMICs. This scoping review found implementation strategies classified as Educational, Financial, and Multidimensional were successful for recruitment, retention, and development of the rural and remote medical workforce.

CONCLUSION

This scoping review shows that effective strategies to recruit and retain rural and remote medical workforce are feasible worldwide despite differences in socio-economic factors. While adjustment and adaptation to match the strategies to the local context are required, the country's commitment to act to improve the rural medical workforce shortage is most critical.

Examining students' perception of rural practice following an educational strategy aimed at preparing postsecondary students for rural careers: a systematic review protocol for qualitative studies

INTRODUCTION

Rural areas are widely acknowledged as being at a workforce disadvantage when compared with urban populations. One of the factors contributing to this disparity is the paucity of workforce professionals who live and practice in rural areas. Educational strategies used to train these workforce professionals may help better prepare students for rural careers and thus increase retention. The purpose of this systematic review is to examine students' perceptions of rural practice following an educational strategy used to prepare students for rural careers.

METHODS AND ANALYSIS

Searches will be conducted in the following databases: Medline (Ovid), CINAHL (Ebscohost), ERIC (Proquest), Social Services Abstracts (Proquest), PsycINFO (Proquest) and IEEE Xplore. The literature search will be limited to articles published in English in the last 20 years. Data will be extracted for author(s), year of publication (2001-2021), country of origin, research question, research design, participants, where the study takes place (eg, classroom, community), educational strategies used, theoretical approach and findings related to the research question (ie, student perceptions). Methodological validity will be assessed using standardised tools. Two independent reviewers will conduct data extraction and quality appraisal, and any disagreement will be adjudicated by discussion or with a third reviewer. Results will be presented in tabular and narrative formats.

ETHICS AND DISSEMINATION

This review does not require formal ethical approval as it does not involve direct student contact or student-identifiable data. The final systematic review will be submitted to a peer-reviewed journal.

Promoting cultural competency and osteopathic medicine awareness among premedical students through a summer premedical rural enrichment program

CONTEXT

Premedical preparatory programs at osteopathic medical schools that recruit students from medically underserved areas (MUAs) may promote interest in practicing osteopathic medicine in underserved or rural areas. In these programs, emphasis on cultural competency may increase diversity among medical school applicants and decrease healthcare disparities in the future.

OBJECTIVES

The goal of this study is to determine whether a summer premedical rural enrichment program (PREP) held at an osteopathic medical school located in a MUA will foster greater prioritization of cultural competency in medicine, enhance interest in practicing in rural or underserved areas, and increase familiarity with osteopathic medicine.

METHODS

An eight-week summer PREP was hosted at the California Health Sciences University College of Osteopathic Medicine (CHSU-COM) in Clovis, California. Seventy-eight diverse participants were recruited from the Central Valley, an underserved region of California. Attendees were required to finish the formal application process and were recommended to have completed medical school prerequisite courses. The curriculum included Medical College Admission Test (MCAT) preparation through team-based learning sessions, introduction to the osteopathic medical school curriculum, osteopathic philosophy, and osteopathic manipulative medicine, as well as integrated anatomy and physiology sessions, medical school application workshops, mock interviews, simulation workshops, and sociology and cultural competency sessions. Data were collected via a voluntary and anonymous survey administered before and after the program with questions about familiarity with osteopathy, interest in practicing in underserved areas, medical school preparedness, and a post-course survey about cultural competency. The surveys had students rate statements on a Likert scale.

RESULTS

Seventy-four of the 78 premedical students (95%) completed the pre-and postsurvey. There was a significant increase in agreement to statements evaluating medical school preparedness, osteopathic familiarity, and desire to practice medicine locally in the postprogram survey, compared to the preprogram survey. In the cultural competency postsurvey, 75.0% of the responses to questions that evaluated the positive effect of the course were "Agree" or "Strongly Agree." Of the reported postcourse outcomes, the average MCAT score was 504 ± 6.2 (38 students reported, 50.7%). Of the 27 participants who reported matriculation, 16 (59.2%) were admitted to osteopathic medical schools, 9 (33.3%) to allopathic medical schools, and 2 to other health programs.

CONCLUSIONS

After completing the PREP program, premedical participants reported that they have better understanding of cultural competency and improvement in preparation for medical school, including familiarity with osteopathic medicine, and interest in serving MUAs. These findings indicate that similar programs may have a positive impact on MUAs. These programs may help create diverse and culturally competent osteopathic physicians.

Do General Practitioners in a Visiting Medical Officer Arrangement Improve the Perceived Quality of Care of Rural and Remote Patients? A Qualitative Study in Australia

Background: In rural and remote Australia, general practitioners (GPs) provide care across the continuum from primary to secondary care, often in Visiting Medical Officer (VMO) arrangements with a local hospital. However, little is known about the role of GP-VMOs in improving the perceived quality of care and health outcomes for rural and remote communities. Methods: We collected qualitative data from three GP-VMOs (all aged >55 years) and 10 patients (all aged over 65 years) in three local health districts of New South Wales, Australia. Thirteen in-depth interviews were conducted between October 2020 and February 2021. We employed thematic analysis to identify key roles of GP-VMOs in improving the perceived quality of care and health outcomes of rural and remote patients. Results: Our study advances the current understanding regarding the role of GP-VMOs in improving the perceived quality of services and health outcomes of rural and remote patients. Key roles of GP-VMOs in improving the perceived quality of care include promoting the continuity of care and integrated health services, cultivating trust from local communities, and enhancing the satisfaction of patients. Conclusions: GP-VMOs work across primary and secondary care creating better linkages and promoting the continuity of care for rural and remote communities. Employing GP-VMOs in rural hospitals enables the knowledge and sensitivity gained from their ongoing interactions with patients in primary care to be effectively utilised in the delivery of hospital care.

Medical education interventions influencing physician distribution into underserved communities: a scoping review

BACKGROUND AND OBJECTIVE

Physician maldistribution is a global problem that hinders patients' abilities to access healthcare services. Medical education presents an opportunity to influence physicians towards meeting the healthcare needs of underserved communities when establishing their practice. Understanding the impact of educational interventions designed to offset physician maldistribution is crucial to informing health human resource strategies aimed at ensuring that the disposition of the physician workforce best serves the diverse needs of all patients and communities.

METHODS

A scoping review was conducted using a six-stage framework to help map current evidence on educational interventions designed to influence physicians' decisions or intention to establish practice in underserved areas. A search strategy was developed and used to conduct database searches. Data were synthesized according to the types of interventions and the location in the medical education professional development trajectory, that influence physician intention or decision for rural and underserved practice locations.

RESULTS

There were 130 articles included in the review, categorized according to four categories: preferential admissions criteria, undergraduate training in underserved areas, postgraduate training in underserved areas, and financial incentives. A fifth category was constructed to reflect initiatives comprised of various combinations of these four interventions. Most studies demonstrated a positive impact on practice location, suggesting that selecting students from underserved or rural areas, requiring them to attend rural campuses, and/or participate in rural clerkships or rotations are influential in distributing physicians in underserved or rural locations. However, these studies may be confounded by various factors including rural origin, pre-existing interest in rural practice, and lifestyle. Articles also had various limitations including self-selection bias, and a lack of standard definition for underservedness.

CONCLUSIONS

Various educational interventions can influence physician practice location: preferential admissions criteria, rural experiences during undergraduate and postgraduate medical training, and financial incentives. Educators and policymakers should consider the social identity, preferences, and motivations of aspiring physicians as they have considerable impact on the effectiveness of education initiatives designed to influence physician distribution in underserved locations.

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.

Evaluation of a pilot rural mentorship programme for and by pre-clerkship medical students

Introduction

While medical school interventions can help address rural physician shortages, many urban Canadian medical students lack exposure to rural medicine. The Rural Mentorship Programme (RMP) is a 4-month pilot initiative designed by medical students to bridge this gap by pairing preclerkship medical students at an urban medical school with rural physician mentors to provide exposure to rural careers.

Methods

A realist-influenced methodology evaluated perceived benefits and challenges of RMP, assessed how RMP influenced mentee perceptions and intentions towards rural careers, and investigated factors leading to success. Quantitative and qualitative data were collected through evaluative pre-, post-, and 4-month post intervention surveys, mentor interviews and a mentee focus group. Likert scales assessed satisfaction, attainment of objectives and mentee changes in perceptions and intentions.

Results

18/23 mentees and 11/15 mentors completed at least 1 survey; 5 mentees joined the focus group and 3 mentors were interviewed. Most mentees were of non-rural backgrounds and initially neutral about pursuing rural practice. RMP helped mentees better understand rural careers. They especially valued the mandatory community clinical visit and forming relationships with mentors. Mentors enjoyed teaching, reflecting on their careers and demonstrating the merits of rural practice. Transportation and scheduling were major programme challenges.

Conclusions

This pilot suggests that structured mentorship programmes can improve understanding of, and provide exposure to, careers in rural medicine for urban medical students. Results will inform future programme development.

Stakeholder perspectives on proposed policies to improve distribution and retention of doctors in rural areas of Uttar Pradesh, India

Background

In India, the distribution and retention of biomedical doctors in public sector facilities in rural areas is an obstacle to improving access to health services. The Government of Uttar Pradesh is developing a comprehensive, ten-year Human Resources for Health (HRH) strategy, which includes policies to address rural distribution and retention of government doctors in Uttar Pradesh (UP). We undertook a stakeholder analysis to understand stakeholder positions on particular policies within the strategy, and to examine how stakeholder power and interests would shape the development and implementation of these proposed policies. This paper focuses on the results of the stakeholder analysis pertaining to rural distribution and retention of doctors in the government sector in UP. Our objectives are to 1) analyze stakeholder power in influencing the adoption of policies; 2) compare and analyze stakeholder positions on specific policies, including their perspectives on the conditions for successful policy adoption and implementation; and 3) explore the challenges with developing and implementing a coordinated, ‘bundled’ approach to strengthening rural distribution and retention of doctors.

Methods

We utilized three forms of data collection for this study – document review, in-depth interviews and focus group discussions. We conducted 17 interviews and three focus group discussions with key stakeholders between September and November 2019.

Results

We found that the adoption of a coordinated policy approach for rural retention and distribution of doctors is negatively impacted by governance challenges and fragmentation within and beyond the health sector. Respondents also noted that the opposition to certain policies by health worker associations created challenges for comprehensive policy development. Finally, respondents believed that even in the event of policy adoption, implementation remained severely hampered by several factors, including weak mechanisms of accountability and perceived corruption at local, district and state level.

Conclusion

Building on the findings of this analysis, we propose several strategies for addressing the challenges in improving access to government doctors in rural areas of UP, including additional policies that address key concerns raised by stakeholders, and improved mechanisms for coordination, accountability and transparency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06765-x.

Nurse practitioner led model of after-hours emergency care in an Australian rural urgent care Centre: health service stakeholder perceptions

Background

The challenges of providing and accessing quality health care in rural regions have long been identified. Innovative solutions are not only required but are also vital if effective, timely and equitable access to sustainable health care in rural communities is to be realised. Despite trial implementation of some alternative models of health care delivery, not all have been evaluated and their impacts are not well understood. The aim of this study was to explore the views of staff and stakeholders of a rural health service in relation to the implementation of an after-hours nurse practitioner model of health care delivery in its Urgent Care Centre.

Methods

This qualitative study included semi-structured individual and group interviews with professional stakeholders of a rural health service in Victoria, Australia and included hospital managers and hospital staff who worked directly or indirectly with the after-hours NPs in addition to local GPs, GP practice nurses, and paramedics. Thematic analysis was used to generate key themes from the data.

Results

Four themes emerged from the data analysis: transition to change; acceptance of the after-hours nurse practitioner role; workforce sustainability; and rural context.

Conclusions

This study suggests that the nurse practitioner-led model is valued by rural health practitioners and could reduce the burden of excessive after-hour on-call duties for rural GPs while improving access to quality health care for community members. As pressure on rural urgent care centres further intensifies with the presence of the COVID-19 pandemic, serious consideration of the nurse practitioner-led model is recommended as a desirable and effective alternative.

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.

Effects of employing primary care doctors in hospital to improve the quality of care and health outcomes of rural patients: A systematic scoping review

OBJECTIVE

To describe effects of employing primary care doctors in hospital care and their roles in improving the quality of care and health outcomes of rural and remote patients.

DESIGN

A systematic scoping review.

SETTING

Peer-reviewed publications were sourced from 3 online journal databases (PUBMED, SCOPUS and Web of Science).

PARTICIPANTS

All study designs from peer-reviewed journals that discussed effects of employing primary care doctors in hospital care Interventions: employing primary care doctors in hospital care.

MAIN OUTCOME MEASURES

Positive and negative consequences of employing primary care doctors in hospital care, and the roles of primary care doctors in improving the quality of care and health outcomes.

RESULTS

A total of 12 articles met the inclusion and exclusion criteria. Positive outcomes included improved access to specialised treatment, improved continuity of care, reduced waiting list and admission rates, improved skills, competence and confidence of primary care doctors, and increased satisfaction from both health providers and patients/families. Negative consequences reported included increased prescriptions and poorly documented history and physical examinations.

CONCLUSION

Employing primary care doctors in hospital care can fill the gaps in the delivery of acute care, emergency medicine and maternity care. Primary care doctors bring advanced clinical skills and a patient-centred approach to the hospital care. They also improve the quality of referrals leading to freed-up clinical capacity of tertiary hospitals to treat more serious conditions. The provision of acute or emergency care and secondary care in rural and remote areas should be directed towards patient-oriented not provider-oriented policies.

Destinations of nursing and allied health graduates from two Australian universities: A data linkage study to inform rural placement models

OBJECTIVE

Combined, nursing and allied health constitute most of the Australian health workforce; yet, little is known about graduate practice destinations. University Departments of Rural Health have collaborated on the Nursing and Allied Health Graduate Outcomes Tracking to investigate graduate entry into rural practice.

DESIGN

Data linkage cohort study.

SETTING

Monash University and the University of Newcastle.

PARTICIPANTS

Graduates who completed their degree in 2017 across seven disciplines.

MAIN OUTCOME MEASURE(S)

The outcome variable was Australian Health Practitioner Regulation Agency principal place of practice data. Explanatory variables included discipline, age, gender, location of origin, and number and duration of rural placements.

RESULT

Of 1130 graduates, 51% were nurses, 81% females, 62% under 21 years at enrolment, 23% of rural origin, 62% had at least one rural student placement, and 23% had over 40 cumulative rural placement days. At the time of their second Australian Health Practitioner Regulation Agency registration, 18% worked in a 'Rural principal place of practice.' Compared to urban, rural origin graduates had 4.45 times higher odds ratio of 'Rural principal place of practice.' For graduates who had <20 cumulative rural placement days, compared to zero the odds ratio of 'Rural principal place of practice' was the same (odds ratio = 1.10). For those who had 20-40 rural placement days, the odds ratio was 1.93, and for >40 rural placement days, the odds ratio was 4.54).

CONCLUSION

Rural origin and more rural placement days positively influenced graduate rural practice destinations. Outcomes of cumulative placements days may compare to immersive placements.

Training for Transformation: Opportunities and Challenges for Health Workforce Sustainability in Developing a Remote Clinical Training Platform

Background: In 2018, Stellenbosch University's Ukwanda Centre for Rural Health led a faculty initiative to expand undergraduate health professions training to a new site, 9 hours drive from the health sciences campus in the sparsely populated Northern Cape Province of South Africa in the town of Upington. This is part of a faculty strategy to extend undergraduate health sciences training into an under-resourced part of the country, where there is no medical school. During 2019, the first year of implementation, four final year medical students undertook a longitudinal integrated clerkship at this site, while final year students from other programmes undertook short 5-week rotations, with plans for extending rotations and including more disciplines in 2020. The aim of this study was to understand stakeholder perceptions regarding the development of Upington as a rural clinical training site and how this influenced existing services, workforce sustainability and health professions education.

Methods: An iterative thematic analysis of qualitative data collected from 55 participants between January and November 2019 was conducted as part of the case study. A constructivist approach to data collection was utilized to explore participants' perceptions, experiences and understanding of the new training site. Triangulation of data collection and reflexive thematic analysis contributed to the trustworthiness of the data and credibility of the findings.

Findings: The perceptions of three key groups of stakeholders are reported: (1) Dr. Harry Surtie Hospital and Academic Programme Managers; (2) Supervising and non-supervising clinical staff and (3) Students from three undergraduate programs of the Faculty. Five themes emerged regarding the development of the site. The themes include the process of development; the influence on the health service; workforce sustainability; a change in perspective and equipping a future workforce.

Discussion: This case study provides data to support the value of establishing a rural clinical training platform in a resource constrained environment. The influence of the expansion initiative on the current workforce speaks to the potential for improved capacity and competence in patient management with an impact on encouraging a rural oriented workforce. Using this case study to explore how the establishment of a new rural clinical training site is perceived to influence rural workforce sustainability and pathways, may have relevance to other institutions in similar settings. The degree of sustainability of the clinical training initiative is explored.

How might access to postgraduate medical education in regional and rural locations be best improved? A scoping review

Rural medical education is known as one of the most effective strategies in improving rural recruitment and retention. The aim was to identify modes of delivery to improve access to rural postgraduate medical education. Arksey and O'Malley's methodological framework was used for conducting scoping reviews. CINAHL, Google Scholar, ERIC, PsycINFO, Medline and PubMed were searched to identify peer-reviewed English-language literature published between 2000 and 2019 focusing on postgraduate rural and regional medical education. A total of 102 articles were identified, with 51 included in the final analysis after applying inclusion and exclusion criteria. Outcome measures included: article type; research methodology; date of publication; country of origin; and study population. Through iterative reading, common themes were identified. A typology of 6 content themes emerged as follows: rural curriculum; procedural skills; rurally based learning; service delivery; workforce; and distance learning. The majority of articles focused on rural curriculum, and rurally based learning, with half originating from Australia or New Zealand. Although results strongly emphasised context and curriculum in rural environments, lack of specific and pragmatic approaches was noted. Surprisingly, few articles focused on rural distance learning utilising information and communication technology. Pathways to improve rural education access include recognition of the unique rural context in curriculums; development of rural educational faculty; and creation of opportunities for rural specialist training. Emphasis should be given for education provided through rural centres rather than urban facilities. Use of information technology could be increased, for example in remote trainee supervision programs.

Perceptions and Attitudes toward Community Health and Interprofessional Education in Students with and without an Additional Community Medicine-Focused Program

The Rural Medical Education (RMED) Program at the University of Illinois College of Medicine Rockford campus, and part of the National Center for Rural Health Professions, strives to recruit students from rural areas, who, after completing residency, return to rural Illinois as primary care physicians. RMED students meet monthly to learn about the community and public health in rural communities. Furthermore, they complete a 16-week rural preceptorship during their fourth year. During the fourth year of medical school, all RMED students, as well as the students following the regular curriculum, are asked to complete a survey, related to the understanding of medical students' views of community and interprofessional education. We aimed to identify how the community-based curriculum affects the students' understanding and appreciation of community as they go into rural health practice. The results showed that students in the RMED Program are more aware of the community they are part of, as well as being more interested in becoming part of their community. RMED students reported a statistically significantly higher rating of feeling appreciated and accepted by their community and rated their confidence in their abilities in the community statistically significantly higher. Interestingly, RMED students were not more likely to be more familiar with several health professions and programs within their community, compared to non-RMED students. Results comparing self-rated capabilities for RMED students within the community both before and after adding components of an interprofessional education curriculum showed no statistically significant changes. These results support previous research, while also providing more support for the development of successful interprofessional education courses.

Profile and rural exposure for nursing and allied health students at two Australian Universities: A retrospective cohort study

Objective

Linking enrolment and professional placement data for students' from 2 universities, this study compares characteristics across universities and health disciplines. The study explores associations between students' location of origin and frequency, duration and type of placements.

Design

Retrospective cohort data linkage.

Setting

Two Australian universities, Monash University and the University of Newcastle.

Participants

Students who completed medical radiation science, nursing, occupational therapy, pharmacy or physiotherapy at either university between 2 February 2017 and 28 February 2018.

Interventions

Location of origin, university and discipline of enrolment.

Main outcome measure(s)

Main measures were whether graduates had multiple rural placements, number of rural placements and cumulative rural placement days. Location of origin, discipline and university of enrolment were the main explanatory variables. Secondary dependent variables were age, sex, socio‐economic indices for location of origin, and available placements.

Results

A total of 1,315 students were included, of which 22.1% were of rural origin. The odds of rural origin students undertaking a rural placement was more than 4.5 times greater than for urban origin students. A higher proportion of rural origin students had multiple rural placement (56.0% vs 14.9%), with a higher mean number of rural placement days. Public hospitals were the most common placement type, with fewer in primary care, mental health or aged care.

Conclusions

There is a positive association between rural origin and rural placements in nursing and allied health. To help strengthen recruitment and retention of graduates this association could be further exploited, while being inclusive of non‐rural students

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.

Using Design Thinking to Explore Rural Experiential Education Barriers and Opportunities

INTRODUCTION

Design thinking is a creative problem-solving framework that can be used to better understand challenges and generate solutions in health professions education, such as the barriers to rural education. Rural education experiences can benefit students, providers, and patients; however, placement in and maintenance of rural education experiences offer unique challenges. Design thinking offers strategies to explore and address these challenges.

METHODS

This study used a design thinking framework to identify barriers of student placement in rural locations; this was accomplished using strategies to empathize with users (eg, students, practitioners, and administrators) and define the problem. Data were collected from focus groups, interviews, and a design thinking workshop. Design activities promoted participant discussion by drawing pictures, discussing findings, and creating empathy maps of student experiences. Qualitative data were analyzed to identify salient barriers to rural experience selection and opportunities for support.

RESULT

Focus group (n = 6), interview (n = 13), and workshop participants (n = 18) identified substantial advantages (eg, exposure to a wider variety of patients, less bureaucracy and constraints, more time with faculty) and disadvantages (eg, isolation, lack of housing, and commuting distances) of rural experiences. Participants identified physical, emotional, and social isolation as a significant barrier to student interest in and engagement in rural experiences. Workshop participants were able to generate over 100 ideas to address the most prominent theme of isolation.

DISCUSSION

Design thinking strategies can be used to explore health professions education challenges, such as placement in rural settings. Through engagement with students, practitioners, and administrators it was identified that physical, social, and emotional isolation presents a significant barrier to student placement in rural experiences. This perspective can inform support systems for students, preceptors, and communities that participate in rural educational experiences.

Approaches to Facilitate Improved Recruitment, Development, and Retention of the Rural and Remote Medical Workforce: A Scoping Review Protocol

BACKGROUND

Medical workforce scarcity in rural and remote communities is a global problem, severely challenging healthcare delivery and health equity. Both developed and developing countries report geographically uneven distributions of the medical workforce. This scoping review synthesizes evidence from peer-reviewed and grey literature concerning approaches implemented to improve the recruitment, development, and retention of the rural medical workforce in both developed and developing countries.

METHODS

We will utilize the Arksey and O'Malley (2005) framework as the basis for this scoping review. The databases to be searched include Medline, Embase, Global Health, CINAHL Plus, and PubMed for articles from the last decade (2010-2019). Searches for unpublished studies and grey literature will be undertaken using the Google Scholar - Advanced Search tool. Quantitative and qualitative study designs will be included. Two authors will independently screen and extract relevant articles and information, with disagreements resolved by a third. Quantitative and qualitative analyses (thematic) will be conducted to evaluate and categorize the study findings.

DISCUSSION

The scoping review will aid in mapping the available evidence for approaches implemented to advance the process of recruitment, development, and retention of the medical workforce in the rural and remote areas in developed and developing nations.

Distribution of Physician Specialties by Rurality

PURPOSE

Physicians of all specialties are more likely to live and work in urban areas than in rural areas. Physician availability affects the health and economy of rural communities. This study aimed to measure and update the availability of physician specialties in rural counties.

METHODS

This analysis included all counties with a Rural-Urban Continuum Code (RUCC) between 4 and 9. Geographically identified physician data from the 2019 American Medical Association Masterfile was merged with 2019 County Health Rankings, the Census Bureau's 2010 county-level population data, and 2010 Topologically Integrated Geographic Encoding and Referencing shapefiles. Multivariate logistic regression was performed to assess the availability of physicians by specialty in rural counties.

FINDINGS

Of the 1,947 rural counties in our sample, 1,825 had at least 1 physician. Specialties including emergency medicine, cardiology, psychiatry, diagnostic radiology, general surgery, anesthesiology, and OB/GYN were less available than primary care physicians (PCPs) in all rural counties. The probability of a rural county having a PCP was the highest in RUCC 4 (1.0) and lowest in RUCC 8 (0.93). Of all primary care specialties, family medicine was the most evenly distributed across the rural continuum, with a probability of 1.0 in RUCC 4 and 0.88 in RUCC 9.

CONCLUSIONS

Family medicine is the physician specialty most likely to be present in rural counties. Policy efforts should focus on maintaining the training and scope of practice of family physicians to serve the health care needs of rural communities where other specialties are less likely to practice.

Factors associated with increasing rural doctor supply in Asia-Pacific LMICs: a scoping review

BACKGROUND

More than 60% of the world's rural population live in the Asia-Pacific region. Of these, more than 90% reside in low- and middle-income countries (LMICs). Asia-Pacific LMICs rural populations are more impoverished and have poorer access to medical care, placing them at greater risk of poor health outcomes. Understanding factors associated with doctors working in rural areas is imperative in identifying effective strategies to improve rural medical workforce supply in Asia-Pacific LMICs.

METHOD

We performed a scoping review of peer-reviewed and grey literature from Asia-Pacific LMICs (1999 to 2019), searching major online databases and web-based resources. The literature was synthesized based on the World Health Organization Global Policy Recommendation categories for increasing access to rural health workers.

RESULT

Seventy-one articles from 12 LMICs were included. Most were about educational factors (82%), followed by personal and professional support (57%), financial incentives (45%), regulatory (20%), and health systems (13%). Rural background showed strong association with both rural preference and actual work in most studies. There was a paucity in literature on the effect of rural pathway in medical education such as rural-oriented curricula, rural clerkships and internship; however, when combined with other educational and regulatory interventions, they were effective. An additional area, atop of the WHO categories was identified, relating to health system factors, such as governance, health service organization and financing. Studies generally were of low quality-frequently overlooking potential confounding variables, such as respondents' demographic characteristics and career stage-and 39% did not clearly define 'rural'.

CONCLUSION

This review is consistent with, and extends, most of the existing evidence on effective strategies to recruit and retain rural doctors while specifically informing the range of evidence within the Asia-Pacific LMIC context. Evidence, though confined to 12 countries, is drawn from 20 years' research about a wide range of factors that can be targeted to strengthen strategies to increase rural medical workforce supply in Asia-Pacific LMICs. Multi-faceted approaches were evident, including selecting more students into medical school with a rural background, increasing public-funded universities, in combination with rural-focused education and rural scholarships, workplace and rural living support and ensuring an appropriately financed rural health system. The review identifies the need for more studies in a broader range of Asia-Pacific countries, which expand on all strategy areas, define rural clearly, use multivariate analyses, and test how various strategies relate to doctor's career stages.

A Checklist for Implementing Rural Pathways to Train, Develop and Support Health Workers in Low and Middle-Income Countries

Background: There is an urgent need to scale up global action on rural workforce development. This World Health Organization-sponsored research aimed to develop a Rural Pathways Checklist. Its purpose was to guide the practical implementation of rural workforce training, development, and support strategies in low and middle-income countries (LMICs). It was intended for any LMICs, stakeholder, health worker, context, or health problem. Method: Multi-methods involved: (1) focus group concept testing; (2) a policy analysis; (3) a scoping review of LMIC literature; (4) consultation with a global Expert Reference Group and; (5) field-testing over an 18-month period. Results: The Checklist included eight actions for implementing rural pathways in LMICs: establishing community needs; policies and partners; exploring existing workers and scope; selecting health workers; education and training; working conditions for recruitment and retention; accreditation and recognition of workers; professional support/up-skilling and; monitoring and evaluation. For each action, a summary of LMICs-specific evidence and prompts was developed to stimulate reflection and learning. To support implementation, rural pathways exemplars from different WHO regions were also compiled. Field-testing showed the Checklist is fit for purpose to guide holistic planning and benchmarking of rural pathways, irrespective of LMICs, stakeholder, or health worker type. Conclusion: The Rural Pathways Checklist provides an agreed global conceptual framework for the practical implementation of "grow your own" strategies in LMICs. It can be applied to scale-up activity for rural workforce training and development in LMICs, where health workers are most limited and health needs are greatest.

Exploring preference for, and uptake of, rural medical internships, a key issue for supporting rural training pathways

Background

Improved medical care access for rural populations continues to be a major concern. There remains little published evidence about postgraduate rural pathways of junior doctors, which may have strong implications for a long-term skilled rural workforce. This exploratory study describes and compares preferences for, and uptake of, rural internships by new domestic and international graduates of Victorian medical schools during a period of rural internship position expansion.

Methods

We used administrative data of all new Victorian medical graduates’ location preference and accepted location of internship positions for 2013–16. Associations between preferred internship location and accepted internship position were explored including by rurality and year. Moreover, data were stratified between ‘domestic graduates’ (Australian and New Zealand citizens or permanent residents) and ‘international graduates’ (temporary residents who graduated from an Australian university).

Results

Across 2013–16, there were 4562 applicants who filled 3130 internship positions (46% oversubscribed). Domestic graduates filled most (69.7%, 457/656) rural internship positions, but significantly less than metropolitan positions (92.2%, p < 0.001). Only 20.1% (551/2737) included a rural location in their top five preferences, less than for international graduates (34.4%, p < 0.001). A greater proportion of rural compared with metropolitan interns accepted a position not in their top five preferences (36.1% versus 7.4%, p < 0.001). The proportion nominating a rural location in their preference list increased across 2013–2016.

Conclusions

The preferences for, and uptake of, rural internship positions by domestic graduates is sub-optimal for growing a rural workforce from local graduates. Current actions that have increased the number of rural positions are unlikely to be sufficient as a stand-alone intervention, thus regional areas must rely on international graduates. Strategies are needed to increase the attractiveness of rural internships for domestic students so that more graduates from rural undergraduate medical training are retained rurally. Further research could explore whether the uptake of rural internships is facilitated by aligning these positions with protected opportunities to continue vocational training in regionally-based or metropolitan fellowships. Increased understanding is needed of the factors impacting work location decisions of junior doctors, particularly those with some rural career intent.

The Overlap Between Rural Hospital Needs and Medical Student Goals in Texas

INTRODUCTION

The rural health workforce in the United States is difficult to maintain and harder to increase. This may contribute to worse health outcomes in rural areas and threaten the sustainability of rural hospitals. Previous studies have attempted to identify medical student characteristics and strategies to help grow this workforce. In this study, we aimed to understand the needs of medical students and hospital administrators to identify potential strategies to improve the rural health workforce.

METHODS

We conducted medical student and hospital administrator focus groups. We analyzed focus group data separately to identify themes, and reviewed these themes for overlap between groups and potential actionable areas. We calculated Cohen κ statistics.

RESULTS

We identified 26 themes in the medical student focus groups, and 14 themes in the hospital administrator focus group. Of these themes, three were identical between groups (scope of practice, loan repayment and financial concerns, and exposure to rural health in training), and two were similar between the groups (family and leadership).

CONCLUSION

The identification of two themes that are similar but not identical between medical students and hospital administrators may serve as part of future strategies to improving rural physician recruitment. Future studies should determine if a shift in language or focus in these areas specifically help to improve the rural health workforce.

Faculties to Support General Practitioners Working Rurally at Broader Scope: A National Cross-Sectional Study of Their Value

Strategies are urgently needed to foster rural general practitioners (GPs) with the skills and professional support required to adequately address healthcare needs in smaller, often isolated communities. Australia has uniquely developed two national-scale faculties that target rural practice: the Fellowship in Advanced Rural General Practice (FARGP) and the Fellowship of the Australian College of Rural and Remote Medicine (FACRRM). This study evaluates the benefit of rural faculties for supporting GPs practicing rurally and at a broader scope. Data came from an annual national survey of Australian doctors from 2008 and 2017, providing a cross-sectional design. Work location (rurality) and scope of practice were compared between FACRRM and FARGP members, as well as standard non-members. FACRRMs mostly worked rurally (75-84%, odds ratio (OR) 8.7, 5.8-13.1), including in smaller rural communities (<15,000 population) (41-54%, OR 3.5, 2.3-5.3). FARGPs also mostly worked in rural communities (56-67%, OR 4.2, 2.2-7.8), but fewer in smaller communities (25-41%, OR 1.1, 0.5-2.5). Both FACRRMs and FARGPs were more likely to use advanced skills, especially procedural skills. GPs with fellowship of a rural faculty were associated with significantly improved geographic distribution and expanded scope, compared with standard GPs. Given their strong outcomes, expanding rural faculties is likely to be a critical strategy to building and sustaining a general practice workforce that meets the needs of rural communities.

Medical students on long-term rural clinical placements and their perceptions of urban and rural internships: a qualitative study

BACKGROUND

There is some anecdotal evidence that anxiety about the responsibility of an intern influences rural future intentions. Additionally, research has shown that urban interns have reported that they are worried about being 'forced' to work in non-metropolitan hospitals in their first year after graduation. This study sought to explore rural medical students' perceptions and expectations of a rural internship and how local health services and/or their medical school can prepare them best for a rural intern position.

METHODS

Four focus groups were conducted with 62 final-year medical students upon completion of a 12-month rural clinical school placement. Focus groups were audio-recorded and transcribed verbatim for thematic analysis to identify key themes.

RESULTS

Most students have high levels of anxiety around starting work but they acknowledge that this may be exaggerated. They believe that in rural areas they get higher quality supervisory support than in urban hospitals as people know you better, whereas in the city you are more anonymous. However, the level of responsibility placed on rural interns was considered to be a double-edged sword. While rural interns were allowed to do more than be a 'paper-pusher' this level of responsibility means they are more accountable. The majority felt that doing your first training years in a metropolitan hospital can be crucial to getting on a training program in your chosen speciality.

CONCLUSIONS

There appears to be a relatively high level of anxiety about rural internships amongst final-year medical students. Students need more targeted information around specialisation, particularly around regional training hubs, if we want to achieve higher levels of interns choosing a rural career path.

Human resources for health interventions in high- and middle-income countries: findings of an evidence review

Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United States of America. The studies were relatively balanced across occupational groups. The largest number focused on availability, followed by performance and then distribution. Study numbers peaked in 2013-2016. A range of study types was included, with a high number of descriptive studies. Some topics were more deeply documented than others-there is, for example, a large number of studies on human resources for health (HRH) planning, educational interventions, and policies to reduce in-migration, but much less on topics such as HRH financing and task shifting. It is also evident that some policy actions may address more than one area of challenge, but equally that some policy actions may have conflicting results for different challenges. Although some of the interventions have been more used and documented in relation to specific cadres, many of the lessons appear to apply across them, with tailoring required to reflect individuals' characteristics, such as age, location, and preferences. Useful lessons can be learned from these higher-income settings for low- and middle-income settings. Much of the literature is descriptive, rather than evaluative, reflecting the organic way in which many HRH reforms are introduced. A more rigorous approach to testing HRH interventions is recommended to improve the evidence in this area of health systems strengthening.

Medical student well-being during rural clinical placement: A cross-sectional national survey

CONTEXT

Understanding rural student well-being is essential to inform the development and training of the future rural medical workforce so as to ensure a pipeline of rural doctors to meet rural communities' needs. However, little is known about the well-being of students who are on rural placement. This study aims to identify the predictors of well-being amongst a national sample of medical students on rural clinical placement.

METHODS

The Federation of Rural Australian Medical Educators (FRAME) 2015 national exit survey of medical students, completed at the end of rural terms, was used (n = 644) to test the associations between well-being and demographic, financial, academic, supervisor, placement and clinical skills factors, and attitude to future rural work. Univariate and logistic regression were used.

RESULTS

Students aged 18-24 years (odds ratio [OR], 8.07 [95% confidence interval {CI}, 2.07-31.46]) and 25-34 years (OR, 4.06 [95% CI, 1.35-12.18]) reported higher levels of well-being compared to students aged over 35 years. Academic support from the rural clinical school (OR, 5.74 [95% CI, 2.59-12.73]), perceived respect from supervisors (OR, 3.13 [95% CI, 1.23-7.99]), not feeling socially isolated (OR, 2.7 [95% CI, 1.40-5.20]), access to counselling services (OR, 2.05 [95% CI, 1.10-3.83]), rural placement being a first choice (OR, 3.04 [95% CI, 1.58-5.86]) and positive attitudes to being part of a rural workforce in the future (OR, 4.0 [95% CI, 2.0-8.3]) were associated with higher odds of well-being compared to students who felt the opposite. Gender, rural background, financial support, clinical skills and role clarity were not found to be associated with well-being (P > .5).

CONCLUSIONS

This study may provide guidance to rural clinical schools, policymakers and medical educators in developing rural placement programmes that enhance student well-being so we can address workforce shortages in rural areas.