Case management: a model for the recruitment of rural general practitioners

ABSTRACT: Many strategies have been trialled to recruit GPs to rural areas and to retain them once there. The West Vic Division of General Practice, a rural division in central-western Victoria, has developed and piloted a case management model. Case management is the holistic provision of services to meet an agreed outcome. Usually these processes are used to support clients with chronic or complex care needs. In this instance, the Division recognised that the sometimes puzzling and perplexing world of medical and provider registration, rural communities and the politics of bringing a doctor into a community requires specific skills and support. A dedicated and experienced case manager provides a continuous range of services to support the process from identification through to ongoing support within the community. The project has met with considerable success over the past 18 months, with 17 doctors placed in temporary and permanent positions.     

The emergency medicine training needs of rural general practitioners

This study aimed to identify the emergency medicine training needs of rural general practitioners (GPs) in the catchment area of the Hunter Rural Division of General Practice. The GPs were surveyed using a questionnaire in which they were asked about their confidence levels in a number of specific emergency medicine skills, and about the areas of emergency medicine that they saw as priorities for upskilling. More than a third of GPs who were responsible for on-call work at the hospital indicated that they had low levels of confidence in a number of their emergency medicine skills, in particular skills relating to paediatric emergencies, cardiovascular emergencies, and respiratory emergencies. These emergency medicine domains were also seen as high priorities for upskilling by the majority of the respondents. The study shows that rural doctors need the opportunity to access emergency medicine training that provides upskilling not only in the management of clinical problems, but also in practical procedures.     

Impact of support initiatives on retaining rural general practitioners

OBJECTIVE: This study aimed to evaluate the impact of the Dr DOC program, a rural doctor workforce support program, which consists of social and psychological support and practical interventions, on the well-being and retention of rural GPs. DESIGN: Rural GPs were assessed on different aspects of well-being and their intentions to leave rural general practice, and these were compared with similar data collected two years prior. SETTING: Rural general practices in South Australia. PARTICIPANTS: Two hundred and twenty-one rural GPs (55% of South Australian rural GP workforce). MAIN OUTCOME MEASURES: GPs completed a questionnaire assessing their levels of support, intention to leave rural practice, use of the dr doc program, and psychological health. RESULTS: Improvements were found in the support networks and in the physical and emotional health of rural GPs from time 1 to time 2. There was also a reduction in the number of GPs wanting to leave rural general practice in the short to medium term (from 30% to 25%). CONCLUSIONS: The initial study in this series suggested that improving psychological well-being might influence rural GPs' intentions to leave rural practice. The current study confirms these suggestions by demonstrating that programs targeted at psychological and physical well-being do indeed impact on rural GPs' intentions to leave. The results of this study highlight the role of psychological well-being in retaining rural GPs and emphasise the value of developing psychologically based programs to not only boost the physical and mental health of GPs, but also to reduce departure from rural areas.     

Nature or nurture: the effect of undergraduate rural clinical rotations on pre-existent rural career choice likelihood as measured by the SOMERS Index

Objective: Do undergraduate rural clinical rotations increase the likelihood of medical students to choose a rural career once pre‐existent likelihood is accounted for? Design: A prospective, controlled quasi‐experiment using self‐paired scores on the SOMERS Index of rural career choice likelihood, before and after 3 years of clinical rotations in either mainly rural or mainly urban locations. Setting: Monash University medical school, Australia. Participants: Fifty‐eight undergraduate‐entry medical students (35% of the 2002 entry class). Main outcome measures: The SOMERS Index of rural career choice likelihood and its component indicators. Results: There was an overall decline in SOMERS Index score (22%) and in each of its components (12–41%). Graduating students who attended rural rotations were more likely to choose a rural career on graduation (difference in SOMERS score: 24.1 (95% CI, 15.0–33.3) P < 0.0001); however, at entry, students choosing rural rotations had an even greater SOMERS score (difference: 27.1 (95% CI, 18.2–36.1) P < 0.0001). Self‐paired pre–post reductions in likelihood were not affected by attending mainly rural or urban rotations, nor were there differences based on rural background alone or sex. Conclusions: While rural rotations are an important component of undergraduate medical training, it is the nature of the students choosing to study in rural locations rather than experiences during the course that is the greater influence on rural career choice. In order to improve the rural medical workforce crisis, medical schools should attract more students with pre‐existent likelihood to choose a rural career. The SOMERS Index was found to be a useful tool for this quantitative analysis.     

Professional and social support networks of rural general practitioners

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

Profile of the rural allied health workforce in northern New South Wales and comparison with previous studies

Objective: To survey allied health professionals in one region of New South Wales. Design: A questionnaire designed to give a profile of the allied health workforce was mailed to 451 practitioners from 12 health professions between July and September 2005. Setting: The region included the upper Hunter Valley, Liverpool Plains, New England Tablelands and North-west Slopes and Plains of New South Wales. Main outcome measures: The overall response was 49.8%, although the response rates varied between disciplines. Data were collected for a wide range of dependent variables. Results: Pharmacists were the most numerous respondents (21.8%), followed by physiotherapists (17.3%), psychologists (12.4%), radiographers (11.1%) and occupational therapists (10.6%). These five professions made up 73.3% of respondents. Approximately 75% of the sample worked in Rural, Remote and Metropolitan Areas (RRMA) 3 and 4 sized towns. The female to male ratio was 3:1. The mean age was 43 years, the average time since qualification was 20 years and the mean time in the current position was 10 years. Half of the respondents said they intended leaving within 5 years. Some 65% were of rural origin. The ratio of private to public sector employment was 0.75:1, with 64.0% working full-time. Conclusions: Comparison is made between this and previous studies. The results highlight the need for further regional allied health workforce profiling and for a recruitment and retention strategy that targets new graduates of rural origin and encourages them to stay.     

Recruitment and retention of rural general practitioners: a marketing approach reveals new possibilities

OBJECTIVE: This paper repositions the challenge of attracting and retaining rural GPs in a marketing context as a new focus for future research and policy development. DESIGN: Case study with mixed design of surveys of GPs and medical students and depth interviews with GPs, medical students, regional-division administrators and GP recruitment agents. SETTING: GP recruitment and retention in the Limestone Coast region of South Australia. PARTICIPANTS: Twenty-seven Limestone Coast (LC) GPs; random sample of medical students from Adelaide University, Adelaide University Rural Health Society and Flinders University; snowball sampling two adjacent rural regions (20 GPs); and administrators from LC and adjacent regions and GP recruitment agencies in Adelaide. MAIN OUTCOME MEASURES: Drawing from marketing theory, creative suggestion of 'promotion of the practice and not the region' offers a means of GP recruitment and retention for structured succession planning for rural general practices. RESULTS: Structural attempts to broaden the GP market with overseas recruitment have done little for improving full-time equivalent GP levels. Market segmentation and market orientation offer a new emphasis on value exchange between the corporation (the practice), customer (GPs) and competition (all practices) to influence future mobility. CONCLUSION: A marketing orientation to the GP challenge emphasises individual's perceptions of value, GP expectations and practice offerings. Failure to acknowledge benefits of this marketing approach means that solutions such as those developed in the Limestone Coast region are unlikely. Research is now required to define GP satisfaction and value for long-term viability of general practices.     

Community participation in the recruitment and retention of rural doctors: methodological and logistical considerations

ABSTRACT: Two Queensland rural communities with histories of poor general practitioner (GP) recruitment and retention participated in a process aimed at developing broadly based community action plans to recruit and retain GPs. Despite their very different physical and social characteristics, the two communities developed many similar objectives and strategies, which had the possiblility of being implemented more widely. The community participation process can be both time- and cost-effective if consideration is given to a variety of methodological and logistical issues. The process is a means by which communities, Divisions of General Practice, government, academic institutions and others can work together to recruit and retain medical practitioners.     

Comparison of the results of two rural allied health workforce surveys in the Hunter New England region of New South Wales: 2005 versus 2008

Objective: To compare the results of the 2005 and 2008 surveys of the rural allied health workforce in the study region. Design: Comparative analysis of two cross‐sectional surveys. Setting: The rural, northern sector of the Hunter New England region of NSW, Australia. Participants: Both surveys targeted 12 different allied health professions. There were 225 respondents in 2005 and 205 in 2008. Main outcome measures: Comparison is made for 15 dependent variables. Results: There was no significant difference for most variables between 2005 and 2008. Mean age and mean years qualified decreased slightly, from 43 to 41 years and from 20 to 17 years, respectively. The proportion of respondents of rural origin was about two‐thirds in both studies and about half had a rural placement during training. While more than half supervised students, only about one‐third had received training for that role. In both 2005 and 2008, the proportion working 35 or more hours each week was about 66% but the proportion working more than 40 hours had doubled to about 36%. In both surveys about half intended leaving their job within 10 years, while the proportion satisfied with continuing professional development access had halved, from 70% to 35%. Conclusions: Most results of the 2005 Hunter New England survey were verified. It was confirmed that a large proportion of the allied health workforce in the region intend leaving their job in the next 5 to 10 years. This is a concern for the development of new service delivery models.     

Junior medical officer recruitment: challenges and lessons from the Northern Territory

OBJECTIVE: To examine the influence of newspaper and Internet advertising, word-of-mouth endorsement and student experience in attracting applicants for junior medical officer positions in the Northern Territory. DESIGN: A retrospective study. PARTICIPANTS: Fifty-four applicants for junior medical officer positions. MAIN OUTCOME MEASURE: Proportion of applicants who reported newspaper advertising, Internet advertising, word of mouth or personal experience in attracting their application for an intern or resident medical officer position. RESULTS: Nineteen per cent of applicants saw the newspaper advertisement and 52% of the Internet advertisement. Eighty-seven per cent of applicants were influenced by word-of-mouth endorsement and 52% by student experience in the Northern Territory or Indigenous health. CONCLUSION: These results suggest that word-of-mouth endorsement has the greatest influence in attracting applicants for junior medical officer positions in Northern Territory hospitals.     

Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence‐based policy

Background: Poor retention of health workers is a significant problem in rural and remote areas, with negative consequences for both health services and patient care. Objective: This review aimed to synthesise the available evidence regarding the effectiveness of retention strategies for health workers in rural and remote areas, with a focus on those studies relevant to Australia. Design: A systematic review method was adopted. Six program evaluation articles, eight review articles and one grey literature report were identified that met study inclusion/exclusion criteria. Results: While a wide range of retention strategies have been introduced in various settings to reduce unnecessary staff turnover and increase length of stay, few have been rigorously evaluated. Little evidence demonstrating the effectiveness of any specific strategy is currently available, with the possible exception of health worker obligation. Multiple factors influence length of employment, indicating that a flexible, multifaceted response to improving workforce retention is required. Conclusions: This paper proposes a comprehensive rural and remote health workforce retention framework to address factors known to contribute to avoidable turnover. The six components of the framework relate to staffing, infrastructure, remuneration, workplace organisation, professional environment, and social, family and community support. In order to ensure their effectiveness, retention strategies should be rigorously evaluated using appropriate pre‐ and post‐intervention comparisons.     

Retention of general practitioners in rural Nepal: a qualitative study

Objectives:  To explore the key issues that influence GP retention in rural areas of Nepal.
Design:  A qualitative study using triangulation of data from one postal questionnaire, one hand-delivered questionnaire with semistructured interview and focus group discussions. Data from a small community survey from 13 rural districts also included.
Participants:  Sixty-two Nepali GPs, 25 doctors in General Practice training programs, 11 individuals involved in policy development and rural health care.
Results:  The key issues identified by this study as critical to the retention of Nepali GPs in rural areas were:
•  Career/promotion prospects
•  Status/recognition
•  Financial incentives
•  Working conditions
•  Education for children
•  Continuing medical education
•  Political stability and security
Conclusions:  The strongest theme was that of career development. This must be addressed by the Government of Nepal if there is to be any hope of improving retention of GPs in rural areas. GPs need to have a clear career ladder, with recognition of the value of service in rural areas. There is, however, no one single answer to the complex interacting factors that impact on GP retention in rural Nepal. A multifaceted, holistic response is necessary. From the level of community awareness, a career structure and financial remuneration to adequately set up hospitals, functional teams, family support, continuing professional development and a secure working environment – each area must be addressed for the whole to function.     

Collaboration and referral practices of general practitioners and community mental health workers in rural and remote Australia

OBJECTIVE: To assess an important part of Australia's National Mental Health Strategy by examining the collaboration and referral practices between general practitioners and community mental health workers in rural and remote areas. DESIGN: Semistructured interviews. SETTING: Rural and remote health service region in Australia. PARTICIPANTS: In total, 31 general practitioners and 14 mental health workers. RESULTS: Meaningful collaboration and referral practices between general practitioners and mental health workers are prevented by contradictory and ambiguous definitions involving professional roles and mental health. A pattern of negative collaboration was further magnified by the rural and remote context. CONCLUSION: The implementation of Australia's National Mental Health Strategy faces serious problems in rural and remote area due to the negative collaboration and referral practices between general practitioners and mental health workers.     

Personal-professional boundary issues in the satisfaction of rural clinicians recruited from within the community: findings from an exploratory study

Objective: The objective of this paper is to highlight, from within a broad study of recruitment/retention, findings that identify personal–professional boundaries as key challenges for rural child and youth mental health clinicians recruited from within the community. Design: Two mixed methods online questionnaires followed by semistructured telephone interviews with a small subset of respondents were administered to clinicians, team leaders, supervisors and managers whose practice responsibilities encompass rural settings in three regions of British Columbia, Canada. Participants: Forty‐four clinicians and 27 team leaders/managers participated in the survey while eight clinicians and one team leader/manager participated in the semistructured interviews. Half the clinician respondents were recruited from within the community. Of those recruited from outside the community, half had prior experience living or working in a rural community. Main outcome measures: Levels of satisfaction with lifestyle, practice and preparation for practice were compared across categories of respondents identified earlier. Open‐ended comments were coded by theme and also compared across categories of respondents. Results: While expressing their higher levels of satisfaction with rural lifestyle and professional practice, clinicians recruited from within rural communities report significant initial and ongoing stress related to personal–professional boundaries and dual relationships. They also report lower levels of satisfaction with orientation and preparation for practice relevant to dealing with these stressors. Conclusion: Prior attachment to rural communities, increasingly viewed as an effective recruitment and retention strategy, requires better preparation and ongoing supports to enable practitioners to deal with dual relationships and the personal–professional boundary issues that are a direct consequence of their attachments.     

'Shared Care - Shared Dream': Model of shared care in rural Australia between mental health services and general practitioners

OBJECTIVE: To identify a working model between rural and remote mental health services and the local GPs in Australia. DESIGN: Postal questionnaire to assess the GPs' satisfaction level with the involvement of the mental health services in their ongoing management of mentally ill in the community. RESULT: There was a greater sense of satisfaction with the mental health services over the five years this program was implemented. CONCLUSION: This study offers a model on how a rural mental health service could enter into a shared care program with the local GP practice and achieve a greater level of satisfaction in serving the rural communities in Australia.     

Interpractitioner communication: telephone consultations between rural general practitioners and specialists

ABSTRACT: The results of a study that sought to investigate the utility of and satisfaction with telephone consultations from the perspective of general practitioners and specialists are reported. Semi-structured interviews with rural general practitioners and specialists were used to elicit information about their most recent telephone consultations. The telephone was found to be an important means of communication for rural practitioners, primarily in terms of organising referrals. General practitioners tended to called specialists who they knew and appeared to have fairly well-formed networks of specialists who they called for most of their concerns. Trust is an important element of interpractitioner communication as it increases understanding and confidence in the reliability of the information exchanged. Good working relationships ensure that rural general practitioners have an accessible source of acceptable specialist support.