Going country: rural student placement factors associated with future rural employment in nursing and allied health

OBJECTIVE: To measure the rate and predictors of health science graduates joining the rural health workforce following a rural placement. DESIGN: Longitudinal survey including the years immediately prior to and post graduation. SETTING: Western Australian health sciences graduates contacted by email and/or phone. Participants: Allied health and nursing students from urban campuses of three Western Australian universities who had taken a rural placement in their final year of study between 2000 and 2003. MAIN OUTCOME MEASURES: Location of employment six months or more after graduation. RESULTS: Of 429 participating allied health and nursing graduates, 25% had entered the rural workforce. Factors with a positive bivariate association with rural employment were: rural background, health discipline, self-reported value of placement, non-compulsory rural placement, and placements of four weeks or less. After controlling for rural background, the value and duration of the placement were significantly associated with rural employment. CONCLUSIONS: This study augments previous work showing that any prior rural background is a significant predictor of rural work. Rural practitioners of both urban and rural origin who undertake voluntary rural placements are more likely to enter rural practice and consequently mandatory placements may not be helpful to increasing the rural workforce. The quality of a placement is a highly significant factor associated with future workplace choice, the details of which need to be further investigated.     

Characteristics of medical students with rural origin: implications for selective admission policies

OBJECTIVES: Selective admission policies of medical schools favoring students of rural origin have been implemented in many countries in hope of increasing rural physicians. This study evaluated the characteristics of medical students from rural origins and their choice of future practice location. METHODS: Personal, familial, and academic information of 1929 graduates of Jichi Medical University (JMU), a Japanese medical school with a special mission to produce rural doctors, was collected on admission and graduation between 1972 and 1997, and follow-up information on workplace addresses were collected in 2000, 2004, and 2006. Jichi Medical University has a unique contract system under which all the graduates have the obligation to work in rural areas in exchange for having their tuition fee during their 6 years of undergraduate medical education waived. RESULTS: Subjects with rural origin were more likely to have parents with lower academic background, improve their academic standing throughout undergraduate medical education, and engage in rural practice than those from urban origins. Positive linear relationships between places of upbringing and workplaces were recognized in various geographic/demographic indicators. CONCLUSIONS: The selective admission policy seems to be a reasonable way of increasing the number of rural physicians without placing an undue burden on medical schools.     

Graduate entry to medical school? Testing some assumptions

BACKGROUND: Debate abounds regarding the most appropriate candidates to admit to medical school. This paper examines whether there is any advantage to admitting 'graduate' entrants over secondary school leavers on selected medical school and practice outcomes. AIM: To compare the medical school experiences, research and academic achievements and practice outcomes of graduates who entered 1 medical school in Australia directly from high school (secondary school entry) to those of graduates who entered with tertiary level education (tertiary entry). DESIGN AND METHODS: Cross-sectional study using a mail-out survey to graduates from the first 16 graduating years (1983-98 inclusive) of the University of Newcastle Medical School. RESULTS: Secondary school entrants were, on average, 8 years younger than tertiary entrants and were less likely to have received rural-based schooling. However, there were no differences with respect to gender or type of secondary school attended (public or private). Motivations for studying medicine did not generally differ according to entry type, except that more secondary students were motivated by parental expectations and more tertiary entrants were motivated by the need for professional independence and the desire to prevent disease. A greater proportion of tertiary entrants experienced stress at medical school. However, secondary students experienced more stress due to doubts about being a doctor, while tertiary entrants experienced more stress due to lack of leisure time, finances and balancing commitments. There were no significant differences between the groups in terms of academic performance (as measured by the award of medical school honours) or research outcomes (as measured by completion of a research degree during or after medical school training, publication of scientific papers or holding career posts in the research sciences). There were no differences in career positions held by clinicians, choice of general practice or another specialty as a career, practice location (rural or urban) or employment sector (public or private). CONCLUSION: There is no clear advantage, at least on the outcomes measured in this study, to limiting medical school entry to either those candidates from secondary school or those with tertiary backgrounds. Medical schools could reasonably broaden their selection criteria to include more graduate entry candidates in addition to secondary school leavers without compromising medical school and practice outcomes.     

Current practice patterns and training status of selected graduates at the King Abdulaziz University College of Medicine, Saudi Arabia

Graduate doctors are the primary output of medical education programmes. It is important for institutions to identify systematically the types of medical activities in which their former students are involved in order to determine the effectiveness of the curriculum, assessing academic standards and reviewing admissions policies. Information was obtained from a survey of men and women graduates from three of the early graduation classes of King Abdulaziz University College of Medicine in Saudi Arabia about postgraduate medical training, certification, practice patterns, and other curriculum issues. Information collected from 151 graduates (90%) indicated that 96% were practising medicine in a variety of medical specialties and subspecialties. Six were not practising at the time of the study. Significant differences were found in the specialties being practised when men and women were compared. Men tended to practise in medicine, surgery, dermatology, urology, ENT, ophthalmology and orthopaedics, while women concentrated in obstetrics and gynaecology and paediatrics. Certification beyond medical school was earned by 49% with no significant difference being found comparing men to women. Men earned the majority of their postgraduate certifications outside Saudi Arabia while most women earned theirs in Saudi Arabia. Graduates indicated that departments in the basic sciences were least helpful in preparing them as doctors, while selected clinical departments were most helpful. It was concluded from the study that the curriculum goals of the College of Medicine, namely a curriculum of international standards producing graduates to take leadership roles in both teaching and medical practice, were realized in part by the graduates surveyed.     

Development of an interest in a career in public health during medical school

OBJECTIVES: In The Netherlands, approximately 12% of medical graduates spend their professional life in public health, but it is the authors' belief that few of them become interested in such a career during medical school. The aim of this study was to investigate students' development of interest in a career in a public health specialty during medical school. METHODS: A written questionnaire was completed by students of all years at a Dutch medical school in 2002 (n=1371) and 2003 (n=1293). Students indicated their interest in a career in 37 Dutch medical specialties. Three public health specialties were distinguished and compared with the least popular specialty, the most popular specialty and with the average interest over all specialties. RESULTS: Interest in a career in occupational health and social insurance health was low throughout medical school. However, almost 15% of students indicated a high level of interest in youth health care in the first year of medical school, which is over twice as many as for the average specialty. This percentage decreased dramatically during medical school. At graduation, all three public health specialties had interest figures well below the average. CONCLUSIONS: Students have little interest in careers in public health. However, given that approximately 12% of medical graduates spend their professional life in public health, the factors that influence career preferences should be investigated. Targeted measures may yield more primary career preference in this direction. Reasons for the loss of interest in youth health care need to be investigated.     

Medical school type and physician income

We wanted to determine whether the type of medical school attended--private US, public US, or foreign medical school--is associated with practice characteristics or incomes of physicians. Therefore, we used survey responses obtained during the 1990s from 10,436 actively practicing white male physicians who worked in one of 13 medical specialties and who graduated from a public US (5,702), private US (3,797), or international (937) medical school. We used linear regression modeling to determine the association between type of medical school attended and physicians' annual incomes after controlling for specialty, work hours, provider characteristics, and practice characteristics. We found that, for most specialties, international medical school graduates worked longer hours, were less likely to be board certified, had practiced medicine for fewer years, and were less likely to work in rural settings than US medical school graduates. After controlling for key variables, international medical school graduates' annual incomes were 2.6 percent higher (95% CI: 0.1%, 4.4%, p = .043) and public US medical school graduates' were 2.2 percent higher (95% CI: -0.9% -6.1%, p = 0.2) than private US medical school graduates' incomes. Because of their lower tuition expenses, international and public US medical school graduates may experience higher returns on educational investment than their counterparts who graduated from private US medical schools.     

Do students from rural backgrounds engage in rural family practice more than their urban‐raised peers?

INTRODUCTION: In a previous prospective study, students from rural backgrounds were found to be significantly more likely to consider rural practice than their urban-raised peers. The purpose of this study was to determine whether the students with rural backgrounds who participated in the original investigation were more likely than their urban-raised peers to be currently engaged in rural family practice. METHOD: In Canada, family doctors have the greatest opportunity to practise in rural communities. Consequently, rural and urban background students from the original study who entered the discipline of family medicine as a career were identified for practice location follow-up. Participants were categorised as either rural (population less than 10 000) or urban practitioners according to the population of the community in which they practised. The proportion of rural and urban background students engaged in rural or urban practice was analysed using chi-square and relative risk probability. RESULTS: A total of 78 students from the original cohort were found to be practising family medicine; 22 of them had been rurally raised. Seven (32%) of the rural background students were practising in a rural community, compared to 7 (13%) of the 56 urban background students (RR = 2.55; P < 0.05). CONCLUSIONS: Rural background students who went on to complete family medicine residency training were approximately 2.5 times more likely to be engaged in rural practice than their urban-raised peers. Altering medical school admission policy to recruit more rural background applicants should be part of a multi-dimensional approach to increasing the number of rural practitioners.     

Expected benefits of streamlining undergraduate medical education by early commitment to specific medical specialties

Undergraduate medical education is too long; it does not meet the needs for physicians’ workforce; and its content is inconsistent with the job characteristics of some of its graduates. In this paper we attempt to respond to these problems by streamlining medical education along the following three reforms. First, high school graduates would be eligible for undergraduate medical education programs of 4 years duration. Second, medical school applicants would be required to commit themselves to a medical specialty and choose one of four undergraduate paths: (1) “Interventions/consultations” path that would prepare its graduates for residencies in secondary and tertiary specialties, such as cardiology and surgery, (2) “continuous patient care” path for primary care specialties, such as family medicine and psychiatry, (3) “diagnostic laboratory medicine and biomedical research” path that would prepare for either laboratory-based careers, such as pathology, biochemistry and bacteriology, or research in e.g., immunology and molecular genetics, and (4) “epidemiology and public health” path that would include population-based research, preventive medicine and health care administration. Third, the content of each of these paths would focus on relevant learning outcomes, and medical school graduates would be eligible for residency training only in specialties included in their path. Hopefully, an early commitment to a medical specialty will reduce the duration of medical education, improve the regulation of physicians’ workforce and adapt the curricular content to the future job requirements from medical school graduates.     

A Comparison of Metropolitan and Rural Medical Schools in China: Which Schools Provide Rural Physicians?

ABSTRACT: To compare the role of metropolitan and rural medical schools in the provision of rural physicians, a survey was conducted in 12 metropolitan and 10 rural medical schools. Rural medical schools enrolled fewer students (P = 0.019), and produced fewer graduates (P = 0.023) than metropolitan medical schools. Students in rural medical schools were mainly from surrounding regional cities and counties, whereas those in metropolitan schools were from cities nationwide (P < 0.001). All rural medical schools produced rural physicians; one rural school reported that of its 256 graduates, 88 (34.4%) entered rural practice. Ten of the 12 metropolitan medical schools did not produce any rural physicians, whereas the remaining two metropolitan schools registered a total of 73 graduates who selected a rural practice location. These results indicate that rural medical schools may play a key role in overcoming the shortage of physicians in rural communities in China.     

Medical education and the retention of rural physicians.

OBJECTIVE. This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN. Design is a prospective cohort study. PARTICIPANTS. Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION. In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS. Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS. These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.     

A Contract‐Based Training System for Rural Physicians: Follow‐Up of Jichi Medical University Graduates (1978‐2006)

ABSTRACT: Context: The number of studies on long‐term effects of rural medical education programs is limited. Personal factors that are associated with long‐term retention of physicians in rural areas are scarcely known. Purpose: The authors studied the outcomes of Jichi Medical University (JMU), whose mission is to produce rural doctors, and analyzed the characteristics of its graduates who engaged in rural practice even after their 9‐year obligation of rural practice. Method: A retrospective cohort study was conducted including 2,988 JMU students who graduated between 1978 and 2006. Baseline data were collected at matriculation and graduation. Workplace addresses were surveyed in 2000, 2004, and 2006. Follow‐up rates were 98.7%, 98.2%, and 98.0% respectively. Findings: After their obligation period, JMU graduates were 4 times more likely than non‐JMU graduates to work in rural areas. The higher proportion of JMU graduates in rural areas did not change significantly between 1994 and 2004. The rural recruitment rate of post‐obligation JMU graduates was somewhat lower than rates reported for top rural medical education programs in the United States. In multivariate analyses, rural upbringing and primary care specialty were positively associated with having a rural address in at least one post‐obligation study year (OR 1.89 [95% CI 1.27‐2.81]; and 7.63 [4.37‐13.34], respectively) and settlement (ie, having a rural address over multiple years) after the contract (1.90 [1.04‐3.48]; and 32.07 [4.43‐232.24], respectively). Graduation from a private high school had a negative association with recruitment (0.56 [0.33‐0.96]). Conclusions: JMU was successful in increasing the number and retention of rural physicians. Rural origin and primary care specialty have a positive impact on both recruitment and retention after the rural obligation.     

Predicting doctor performance outcomes of curriculum interventions: problem-based learning and continuing competence

Context  Problem-based learning (PBL) is an educational strategy designed to enhance self-assessment, self-directed learning and lifelong learning. The present study examines a peer review programme to determine whether the impact of PBL on continuing competence can be detected in practice.
Objectives  This study aimed to establish whether McMaster graduates who graduated between 1972 and 1991 were any less likely to be identified as having issues of competence by a systematic peer review programme than graduates of other Ontario medical schools.
Methods  We identified a total of 1166 doctors who had graduated after 1972 and had completed a mandated peer review programme. Of these, 108 had graduated from McMaster and 857 from other Canadian schools. School of graduation was cross-tabulated against peer rating. A secondary analysis examined predictors of ratings using multiple regression.
Results  We found that 4% of McMaster graduates and 5% of other graduates were deemed to demonstrate cause for concern or serious concern, and that 24% of McMaster doctors and 28% of other doctors were rated as excellent. These differences were not significant. Multiple regression indicated that certification by family medicine or a specialty, female gender and younger age were all predictors of practice outcomes, but school of graduation was not.
Conclusions  There is no evidence from this study that PBL graduates are better able to maintain competence than graduates of conventional schools. The study highlights potential problems in attempting to link undergraduate educational interventions to doctor performance outcomes.     

Interactional skills of students from traditional and non-traditional medical schools before and after alcohol education

OBJECTIVE: To compare alcohol-related intervention and general interactional skills performance of medical students from a traditional (Sydney) and a non-traditional (Newcastle) medical school, before and after participation in an alcohol education programme about brief intervention. DESIGN: In two controlled trials, students received either a didactic alcohol education programme or didactic input plus skills-based training. Prior to and after training, all students completed videotaped interviews with simulated patients. SETTING: The Faculties of Medicine at the University of Newcastle and the University of Sydney, Australia. SUBJECTS: Fifth-year medical students (n=154). RESULTS: Both alcohol-related intervention and general interactional skills scores of the Newcastle students were significantly higher than those of the Sydney students at pre-test but not after training. Although alcohol-related interactional skills scores improved after training at both universities, they did not reach a satisfactory level. The educational approach used had no effect on post-test scores at either university. CONCLUSIONS: Significant baseline differences in interactional skills scores favouring non-traditional over traditional students were no longer evident after both groups had been involved in an alcohol education programme. Further research is required to develop more effective alcohol intervention training methods.     

A medical school for rural areas

Jichi Medical School (JMS) was established in 1972 to supply graduates to rural areas where medical resources are scarce. JMS has several unique characteristics aimed at motivating graduates to work in a rural practice. These include financial aid for students, a home prefecture recruiting scheme, location in a non-urban area, management by prefectures and support from the national government. The achievements of JMS over the 24-year period since its foundation have been evaluated. A questionnaire has been mailed to all JMS graduates since the first year of graduation. Using a pro-active approach to follow-up, the return rate has been virtually 100%. The authors investigated annual changes in the distribution of the graduates as well as the present status of the graduates in 1995. At that time, JMS graduates were distributed all over Japan. Among the 1871 graduates, 792 (42%) were working in rural areas in 1995. Nine-hundred and twenty-four graduated in the period from the first to the ninth output of graduates. Among these, 858 (93%) completed the requisite 9 years of work contracted between JMS and the graduates, 620 (67%) had practised in the same prefecture, and 305 (33%) were still practising in a rural area. Although there are still improvements to be made, JMS has succeeded in achieving its aim of supplying doctors to rural areas. The recruiting system of JMS is an effective approach to overcoming the shortage of rural doctors, which has continued to be an unresolved global problem.     

Predicting medical students' intentions to take up rural practice after graduation

Objectives Using a novel longitudinal tracking project, this study develops and evaluates the performance of a predictive model and index of rural medical practice intention based on the characteristics of incoming medical students. Methods Medical school entry survey data were obtained from the Medical Schools Outcome Database (MSOD) project implemented in all Australian and New Zealand medical schools and coordinated through Medical Deans Australia and New Zealand, the representative body for the Deans of 18 Australian and two New Zealand medical schools and faculties. The medical school commencement survey collects data on students’ education and family background, including rural upbringing, personal circumstances and scholarships, and on their practice intentions in terms of location and specialty. The MSOD will also allow tracking of medical graduates after graduation. Logistic regression modelling was used to develop a predictive model of rural practice intention. Split‐sample validation was used to gain some insight into the stability of performance of the model. Results Response rates to the MSOD survey exceeded 90% on average. The model findings confirm and extend previous research examining the association of medical student characteristics with intention to take up rural medical practice. The statistically significant independent factors in the model included students’ rural backgrounds, financial arrangements and intentions regarding specialist versus generalist practice upon graduation. Model performance was good, with an area under the receiver‐operator characteristics curve of 0.86, and reproducible, with an area in a validation sample of 0.83. Conclusions The model and related index provide important insights into individual factors associated with rural practice intention among students commencing medical studies. The model can also provide a means for optimising the use of scarce medical programme resources, thereby helping to improve the supply of rural medical practitioners. This study illustrates the power and potential of a robust, consistent, systematic longitudinal tracking project.     

Factors in Recruiting and Retaining Health Professionals for Rural Practice

CONTEXT: Rural communities, often with complex health care issues, have difficulty creating and sustaining an adequate health professional workforce. PURPOSE: To identify factors associated with rural recruitment and retention of graduates from a variety of health professional programs in the southwestern United States. METHODS: A survey collecting longitudinal data was mailed to graduates from 12 health professional programs in New Mexico. First rural and any rural employment since graduation were outcomes for univariate analyses. Multivariate analysis that controlled for extraneous variables explored factors important to those who took a first rural position, stayed rural, or changed practice locations. FINDINGS: Of 1,396 surveys delivered, response rate was 59%. Size of childhood town, rural practicum completion, discipline, and age at graduation were associated with rural practice choice (P < .05). Those who first practiced in rural versus urban areas were more likely to view the following factors as important to their practice decision: community need, financial aid, community size, return to hometown, and rural training program participation (P < .05). Those remaining rural versus moving away were more likely to consider community size and return to hometown as important (P < .05). Having enough work available, income potential, professional opportunity, and serving community health needs were important to all groups. CONCLUSION: Rural background and preference for smaller sized communities are associated with both recruitment and retention. Loan forgiveness and rural training programs appear to support recruitment. Retention efforts must focus on financial incentives, professional opportunity, and desirability of rural locations.     

Attitude of medical students towards psychiatry

Findings are presented from a survey of all medical students at the College of Medicine, Abha, Saudi Arabia dealing with students' attitudes towards specialization in psychiatry. The health region of Asir in south-west rural Saudi Arabia, of about one million inhabitants, needs Saudi Nationals to specialize in psychiatry to provide planned future delivery of services. Medical students all over Saudi Arabia, however, have not been choosing psychiatry for their specialization after graduation. The Scientific Committee for Mental Health, convened at the Ministry of Health in Riyadh in February 1986, invited representatives of psychiatry from medical schools in the nation to discuss this priority topic. A year later, a new course called 'Introduction to Psychosomatic Medicine' was introduced as an elective for medical students with its practice at the general hospital. It tries to introduce students to 'voluntary and active as against passive learning ... and problem-solving rather than imposed memorizing' of medicalized forms of psychiatry, an innovation compared with the previous conventional method. A significant difference in attitude was demonstrated between students who had their exposure to psychiatry from this course and those who followed only the conventional methods of learning.     

Careers in medicine: appointment to specialist training posts in Queensland in 1988

Appointments to accredited specialist training positions in the State of Queensland, Australia in 1988 were analysed to show the success rates of applicants. Women were less likely to apply for training, but gained proportionately more appointments than men. Other factors in success were application from a major teaching hospital, graduation from the State medical school and, for new applicants, an honours degree. The success rates in various specialties differed significantly as did their appeal to women and to honours graduates. It is concluded that new graduates need better information and advice on career choice and that individual disciplines need to look carefully at the image and organization of their training programmes.     

Evaluation of a Medical School for Rural Doctors

CONTEXT: Jichi Medical School (JMS) is the first and only medical school in Japan that was founded exclusively to graduate/prepare rural doctors. PURPOSE: To evaluate the long-term effect of JMS on the nationwide distribution of doctors. METHODS: Data from the Japanese population census of 1995 and from the Japanese physician census of 1994 were combined for use in this study. We extracted the JMS graduates from the physician census and compared the distribution of JMS graduates to that of non-JMS graduates. JMS graduates have an obligation to work in rural areas for 9 years after graduation. Therefore, we divided them into those doctors who were either "under rural duty" or "after rural duty."FINDINGS: JMS graduates were more likely than non-JMS physicians to practice in rural municipalities. The percentage of JMS graduates practicing under rural duty in communities meeting at least 1 of 4 possible criteria for being considered rural was 2.7 times greater than the percentage of non-JMS graduates in such communities. The percentage of JMS graduates practicing after rural duty in communities meeting at least 1 rural criterion was 2 times that of non-JMS graduates. The JMS graduates accounted for only 0.7% of all the physicians in Japan. However, they accounted for 4.2%, 1.5%, 1.8%, and 3.0% of the physicians in small population, remote, mountain, and medically underserved municipalities, respectively. CONCLUSIONS: The goal of JMS to produce rural doctors in Japan has made an impact on doctor distribution nationwide.     

Participation in the workforce by Australian medical graduates

OBJECTIVE: To investigate workforce participation patterns among Australian medical graduates and the extent of cohort differences in these patterns. DESIGN: We carried out a retrospective longitudinal cohort study, with data collected by postal survey on current occupation, location, absences from the workforce and occupation since graduation. PARTICIPANTS: Graduates who had completed their basic medical training at Monash University, Melbourne, Australia, in 1980, 1985, 1990 and 1995 were invited to participate (n = 546); 368 took part in the study (69%). OUTCOME MEASURES: The proportion of graduates in the Australian medical workforce, the equivalent full-time contribution to the Australian medical workforce, and the proportion taking temporary absences from the workforce were determined. RESULTS: The rate of participation in the Australian medical workforce was 96% 2 years after graduation. It then declined to reach 85% by 10 years and regained slightly to reach 88% by 15 years after graduation. There was no indication that the 1995 cohort made a lower contribution to the Australian medical workforce than the earlier cohorts in their first 7 years after graduation. CONCLUSION: Although there are few indications of differences between these cohorts during the first 7 years after graduation, the main contributing factors to losses from the Australian medical workforce -- medical work overseas and parental leave -- do not exert their maximum influence until a later time point. Longitudinal cohort data are essential for monitoring trends in medical workforce participation and hence for effective workforce planning.