The SOMERS Index: a simple instrument designed to predict the likelihood of rural career choice

Objective: The World Health Organization has drawn up a set of strategies to encourage health workers to live and work in remote and rural areas. A comprehensive instrument designed to evaluate the effectiveness of such programs has not yet been tested. Factors such as Stated rural intention, Optional rural training, Medical sub‐specialization, Ease (or self‐efficacy) and Rural Status have been used individually or in limited combinations. This paper examines the development, validity, structure and reliability of the easily‐administered SOMERS Index. Design: Limited literature review and cross‐sectional cohort study. Setting: Australian medical school. Participants: A total of 345 Australian undergraduate‐entry medical students in years 1 to 4 of the 5‐year course. Main outcome measures: Validity of the factors as predictors of rural career choice was sought in the international literature. Structure of the index was investigated through Principal Components Analysis and regression modelling. Cronbach's alpha was the test for reliability. Results: The international literature strongly supported the validity of the components of the index. Factor analysis revealed a single, strong factor (eigenvalue: 2.78) explaining 56% of the variance. Multiple regression modelling revealed that each of the other variables contributed independently and strongly to Stated Rural Intent (semi‐partial correlation coefficients range: 0.20–0.25). Cronbach's alpha was high at 0.78. Conclusions: This paper presents the reliability and validity of an index, which seeks to estimate the likelihood of rural career choice. The index might be useful in student selection, the allocation of rural undergraduate and postgraduate resources and the evaluation of programs designed to increase rural career choice.     

Influences on medical students' decisions to study at a rural clinical school

Objective: To identify factors that influenced medical students at Monash University to undertake their first year of clinical training (third year of the medical course) at a rural clinical school (RCS). Design: Third‐year Monash University medical students undertaking clinical placements at a RCS were surveyed in 2005. A semistructured questionnaire was used to ask students to rate the influence of a list of factors on their decision to undertake their year‐long placement at a RCS. Results: Under half (48%) of students studying at an RCS reported that they were of rural background. All surveyed items were identified as having had a positive influence. Greater clinical experience, learning opportunities and patient access were identified as having the greatest positive influence followed closely by free accommodation and other financial and supportive incentives. Future rural career intention was eight times more likely to be a positive influence in rural compared with urban background students. Conclusion: The most important positive influence on Monash third‐year medical students' decision to study at an RCS is the perception of high‐quality clinical experiences and education. This perception arises from rural exposure during pre‐clinical years.     

Removing the roadblocks to medical and health student training in rural hospitals in Victoria

Objective: To assess the extent of undergraduate health student placements in regional hospitals in northern Victoria in 1999, prior to substantial changes in rural undergraduate medical education in Australia. Method: Cross sectional postal survey with telephone follow‐up in north‐east Victoria. Subjects were all 17 regional and rural hospitals involved in health student teaching in North‐east Victoria. Main outcome measures were the numbers, duration and discipline of health students placements and reported barriers to such placements. Results: Large regional hospitals accounted for two‐thirds of all undergraduate health student placements. Smaller sites placed few allied health students. Barriers to a larger, more sustainable system of rural placements and rotations included accommodation shortages and funding constraints, particularly in smaller rural hospitals. Conclusions: Adequate resourcing of placements of a meaningful duration, stronger institutional support, and improved resourcing of regional accommodation is required to facilitate a larger, more systematic and sustainable system of medical and health student placements in rural areas. What is already known: The extent of training of health professionals in rural Australia is increasing rapidly. Fears have been expressed that the capacity to deliver quality experience in rural practice may be limited. What this study adds: This cross sectional survey of rural Victorian hospitals shows that there is a major untapped potential in rural hospitals of all sizes to assist with training in rural practice, but that a number of barriers to such training need to be removed to reach full capacity.     

The John Flynn Placement Program: evidence for repeated rural exposure for medical students

Objective: This paper reports on an evaluation of the John Flynn Placement Program (JFPP) for medical students. JFPP aims for medical students to experience both rural medicine and rural life as a way of increasing rural career intentions. Design: Medical students experience two weeks a year over four years with a rural doctor. Students are evaluated at the end of each placement for clinical and social experiences and career intent. They are followed up annually to monitor career intent. Mentors are evaluated annually on clinical and rural experiences during a placement. Setting: The Australian Government has several initiatives to encourage recruitment into rural medicine. One initiative is the JFPP. Students from all medical schools are placed with experienced general practitioners in rural and remote areas 4–7 locations across Australia. Participants: Evaluation data from 1450 placements from 2005–2009 are reported. Outcome measures: Data are presented highlighting evaluation of student and mentor perceptions of clinical and social experiences. Longitudinal tracking data provide an indication of the success of the program in terms of recruitment into the rural workforce. Results: Overall mean for clinical and rural experiences is extremely positive for both students and mentors. After four JFPP placements 65% of students intend to work in rural areas. After one JFPP experience 9% indicate intent to practise as a rural general practitioner while after their fourth JFPP nearly 20% are indicating intent to practise as a rural general practitioner. Conclusions: Longitudinal experiences, such as the JFPP, are positively influencing intention to enter the rural workforce but the impact of urban centric vocational training might be negating this impact.     

Factors associated with rural doctors' intention to continue a rural career: a survey of 3072 doctors in Japan

Objective: To show the relationship between the personal and educational backgrounds of rural doctors and their intention to continue a rural career. Design: Nationwide postal survey. Setting: Public clinics or hospitals in municipalities that are classified as ‘rural’ by the national government. Subjects: A total of 4896 doctors working for 828 public clinics and hospitals. Measurements: A questionnaire was mailed. The questionnaire inquired about the subject's age, sex, hometown, exposure to rural practice in undergraduate education, postgraduate training, continuing medical education, current position and affiliation status with a medical school, as well as his or her intention to continue a rural career. Results: Response rate was 64%; 26% answered that they intended to continue a rural career. Postgraduate training in general internal medicine, general surgery, anaesthesiology, paediatrics and gastroenterology were positively related with the intention to continue a rural career (odds ratio = 2.045, 1.59, 1.30, 1.48, 1.38). Rural background, undergraduate exposure to rural practice, multispecialty‐rotation in postgraduate training and current administrative position had positive correlations with the intention to continue in logistic regression analysis (odds ratio = 1.80, 2.47, 1.54, 2.17). Affiliation with a medical school department was negatively related with the intention to continue (odds ratio = 0.45). Conclusion: In addition to the rural background of physicians, some undergraduate and postgraduate factors were independently associated with the intention to continue a rural career.     

Letter to the Editor: Barriers to effective asthma care in inner city general practice: Reply by the Authors

Objective: To monitor the future career preferences of medical students throughout their undergraduate years and into their postgraduate career, and to evaluate which factors may influence career choice intentions, and when this happens, over time. Design: Longitudinal study. Methods: Questionnaire to all Aberdeen, United Kingdom, Medical School entrants in 1996, and five annual follow-ups (four undergraduate, one postgraduate). Results: Response rates: year 1, 100%; year 2, 78%; year 3, 70%; year 4, 64%; year 5, 65%; pre-registration house officer (PRHO), 60%. Throughout the study, females were more positive about a career in general practice. General practice was the first choice for 13% of students in year 1; year 2, 9%; year 3, 22%; year 4, 24%; year 5, 27%; PRHO, 29%. Those choosing general practice were more likely than those choosing other specialties to be female, have their family home in Scotland, rate their academic abilities lower and their non-academic abilities as average, and have decided on their future career earlier. Reasons for general practice included: working in and being part of a community; continuity of patient contact; variety of illnesses and people encountered; undergraduate teaching experiences; dislike of or disillusionment with hospital medicine; and an increasing awareness of part-time opportunities.

Conclusion: As medical undergraduates progressed through the curriculum and became PRHOs, general practice became more popular as a career choice, particularly with females. This may be partly explained by the increased exposure to general practitioners and patients in the new community-based teaching programme and the increasing awareness of lifestyle advantages with the particular benefits of more regular hours and working part time.     

Compulsory medical rural placements: senior student opinions of early-year experiential learning

Objective: The aim of this study was to determine senior medical student (year 3–5) opinions of their early‐year (year 1–2) rural placement. Design: We assessed the impact of MBBS early‐year rural placements through a follow up of this cohort in their later years using a cross‐sectional questionnaire. Setting: The questionnaire was administered to year 3–5 medical students at their clinical school. Participants: There were 97 participants (49% response rate) in the study. Twenty‐nine per cent were male and 71% were female; 44% were from a rural background and 56% were from a metropolitan background; 48% were year 3 students, 32% were year 4 students and 20% were year 5 students; and 59% of the students were, at the time, situated at a rural clinical school and 41% were at a metropolitan clinical school. Main outcome measure: Closed‐ended questions were quantified and statistically analysed. Open‐ended responses were thematically analysed to determine what their experience of early‐year rural placements were like. Results: Seventy‐nine per cent of students considered the year 1 placement length as ‘about right’. Overall, most students found year 1 rural placements positive and grasped the placement aims and objectives. Most students were also pleased with year 2 rural placements, mainly due to the clinical aspects. Conclusions: Medical students appear to prefer shorter early‐year rural placements and understand the benefits and importance of such placements. They also have a desire for greater clinical exposure during these early‐year placements.     

Graduate status and age at entry to medical school as predictors of doctors' choice of long-term career

OBJECTIVE: To determine whether graduate entry to medical school, taking an intercalated degree during medical school, and age at entry to medical school are related to choice of eventual career. DESIGN: Postal questionnaires. SETTING: United Kingdom (UK). SUBJECTS: All doctors who qualified in the UK in 1993 or 1996. RESULTS: We analysed whether graduate status and age on entry to medical school, and taking an intercalated degree during medical school, were predictors of the choice of eventual career, adjusting for differences by sex, year of qualification and medical school. General practice was the career choice of 27.0% (79/293) of graduate entrants and 21.6% (1095/5073) of non-graduate entrants, a difference of borderline significance (P=0.04). Of the non-graduate entrants, general practice was the career choice of 15.3% (319/2081) of doctors who took an intercalated degree and 25.9% (776/2992) of doctors who did not (P < 0.001). Within the hospital specialties, those who took an intercalated degree were more likely than others to choose the hospital medical specialties or pathology. Age alone was not a predictor for choice of any area of practice. CONCLUSIONS: There was no evidence of an association between age at entry to medical school and choice of eventual career. Graduates at entry to medical school were a little more likely than non-graduates to choose general practice but the relationship was not a strong one. In these respects, changing the entry profile of medical students is unlikely to result in major shifts of career choice towards general practice.     

Impact of undergraduate and postgraduate rural training,and medical school entry criteria on rural practice among Australian general practitioners: national study of 2414 doctors

OBJECTIVE: To determine the association between rural undergraduate training, rural postgraduate training and medical school entry criteria favouring rural students, on likelihood of working in rural Australian general practice. METHODS: National case-control study of 2414 rural and urban general practitioners (GPs) sampled from the Health Insurance Commission database. Participants completed a questionnaire providing information on demographics, current practice location and rural undergraduate and postgraduate experience. RESULTS: Rural GPs were more likely to report having had any rural undergraduate training [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.32-1.95] than were urban GPs. Rural GPs were much more likely to report having had rural postgraduate training (OR 3.14, 95% CI 2.57-3.83). As the duration of rural postgraduate training increased so did the likelihood of working as a rural GP: those reporting that more than half their postgraduate training was rural were most likely to be rural GPs (OR 10.52, 95% CI 5.39-20.51). South Australians whose final high school year was rural were more likely to be rural GPs (OR 3.18, 95% CI 0.99-10.22). CONCLUSIONS: Undergraduate rural training, postgraduate training and medical school entry criteria favouring rural students, all are associated with an increased likelihood of being a rural GP. Longer rural postgraduate training is more strongly associated with rural practice. These findings argue for continuation of rural undergraduate training opportunities and rural entry schemes, and an expansion in postgraduate training opportunities for GPs.     

Comparing the academic performance of graduate‐ and undergraduate‐entry medical students

Medical Education 2010 44 : 197–204 Objective This study compared the academic performance of graduate‐ and undergraduate‐entry medical students completing the same pre‐clinical curriculum and assessment at a large metropolitan university. Arguments have been made for the relative merits of both graduate‐ and undergraduate‐entry medical programmes. However, data on the academic performance of graduate and undergraduate entrants are relatively scarce. Methods This retrospective study adopted a quasi‐experimental design to compare data from assessments of bioscience knowledge and clinical skills undertaken across 2 years for four cohorts of medical students (who commenced their studies between 2002 and 2005). Percentage final results for four bioscience knowledge subjects and four clinical skills assessments (based on objective structured clinical examination [OSCE] results) were compared for 240 graduates and 464 undergraduates using multivariate analysis of variance (manova ). Results Graduate‐entry students performed marginally better than undergraduate‐entry students on all four bioscience knowledge assessments (partial eta‐squared [) and also on early clinical skills assessments (. Conclusions Graduate‐entry students had a marginal academic performance advantage during the early years of this medical course. Most graduate‐entry students had a first degree in a science discipline; thus their advantage may be explained by prior bioscience knowledge. Their performance advantage in clinical skills is less easily attributed to prior learning. Instead, this result provides some evidence for a possible advantage related to age. The marginal differences in early academic and clinical performance probably suggest that both graduate and undergraduate entry should exist in parallel to preserve multiple points of entry to the medical profession.     

What happens to medical students who complete an honours year in public health and epidemiology?

BACKGROUND: Around one-third of medical students in the UK take an intercalated honours degree in addition to their basic undergraduate course. The honours year has been reported to have a major influence on subsequent career choice; honours students show greater interest in research and laboratory medicine careers and less in general practice and public health.1,2 AIMS: To examine the career choice of Nottingham medical students who completed an honours year in public health and epidemiology (including general practice). METHODS: Postal questionnaire and telephone follow-up of a cohort of 266 students who entered the honours year in Public Health and Epidemiology between 1973 and 1993. RESULTS: Career information was available on 203 students; 78% (195) of those are currently employed in medicine. 44% were working in general practice (expected 40-45%) and 8% in public health medicine (expected 2%). Overall 19% (expected 4-11%) had chosen academic careers including nine of the 15 choosing an academic career in public health. The majority (60%) reported that the honours year had influenced their career choice, while 55% reported that the year had increased their likelihood of choosing an academic career. CONCLUSIONS: The honours year does encourage entry into academic and research careers in general and the type of honours year department strongly influences the subsequent choice of specialty.     

A seven‐year retrospective analysis of students entering medicine via a Rural Student Recruitment program in Western Australia

Objective: This research aimed to evaluate the effectiveness of the Rural Student Recruitment (RSR) program. This program was an initiative to address the low number of rural students enrolled in medicine at the University of Western Australia. RSR identifies students throughout rural and remote areas of Australia interested in pursuing a career in medicine. The program provides support to these students through the various stages of the selection process and subsequently through the course. Setting: Medical School, the University of Western Australia. Participants: Rural students enrolled in medicine at the University of Western Australia. Results: Of the 1591 participants in the RSR program, 11.6% have been successful in being offered a place. Participation was consistently higher for women, although men were proportionately more successful at gaining entry (14.5% versus 10.4%). It was found that the distribution of successful students in the RSR program generally reflects population density across rural Western Australia, with the majority of students coming from the South West, and the minority from the Pilbara and Kimberley. However, over the last three years (2006–2008) an increase in access from very remote regions was noted. This has been associated with a modification to the entry process that now includes a remoteness weighting for the secondary school attended. Conclusions: The conclusion from this analysis was that the RSR program in concert with refinements in entry criteria has been effective in increasing the number of medical students from a rural background.     

Comparative academic performance of medical students in rural and urban clinical settings

OBJECTIVE: To determine whether the academic performance of medical students learning in rural settings differs from those learning in urban settings. DESIGN: Comparison of results of assessment for 2 full cohorts and 1 part cohort of medical students learning in rural and urban settings in 2002 (209 students), 2003 (226 students) and 2004 (220 students), including results for each specialist rotation in the 3rd year and end-of-year examinations in the 2nd and 4th years. SETTING: University of Queensland School of Medicine, Brisbane. Students spent the whole 3rd year (of a 4-year graduate entry programme) conducting 5 specialist 8-week rotations in either the rural clinical division (rural students) or in Brisbane (urban students), all following the same curriculum and taking the same examinations. RESULTS: For the 2002 cohort there were no statistically significant differences in academic performance between rural and urban students. For the 2003 cohort the only significant difference was a higher score for rural students in the end of the 4th-year clinical skills examination (65.7 versus 62.3%, P = 0.025). For the 2004 cohort, rural students scored higher in the 3rd-year mental health rotation (79.3 versus 76.2%, P = 0.038) and lower in the medicine rotation (65.5 versus 68.6%, P = 0.037). CONCLUSION: Academic performance among students studying in rural and urban settings is comparable.     

At what stage in the undergraduate curriculum is it best to train in family medicine? A study from two medical schools in Spain

Background: A course in family medicine (FM) could dispel the possibility of negative stereotyping about this speciality, and instil in students a greater interest. However, when is it preferable: at the beginning or at the end of undergraduate training?

Objectives: To determine changes in knowledge and attitudes towards FM by medical students completing a course in primary care at the beginning or the end of the undergraduate training and whether those changes anticipate the choice of speciality.

Methods: Students from Albacete and Seville medical schools (primary care course in second and sixth years, respectively) were asked to respond to the ‘valuation of attitudes towards and knowledge of family medicine questionnaire’ (CAMF). Students from Albacete answered before and after the course, and in Seville second-year students answered at the end of the first trimester. All students were invited to respond again at the end of their undergraduate training. Afterwards, we investigated the score on the speciality exam (order for the election from highest to lowest score) and their choice of speciality. The outcome measures were the MIR exam score, the number in the ranking, the chosen speciality and the result of the CAMF.

Results: In Albacete 88 and 64 and in Seville 50 and 98 students responded in their second and sixth years, respectively. In Albacete, mean CAMF scores were 15.4, 22.7 before and after the course, and 21.8 at the end while in Seville, 13.9 in the second year, and 23.5 in the sixth year. Logistic regression analysis showed an association of the choice of FM only with the score on the speciality exam (OR: 0.667; 95%CI: 0.553–0.806).

Conclusion: There were no significant differences between CAMF scores at the end of undergraduate training. Only the score on the speciality exam predicts FM choice: the higher the score, the lower the probability of choosing FM.     

Undergraduate nursing students' experiences in a rural clinical placement

Objective: This paper draws on questionnaire findings and analysis of students' comments to demonstrate the aspects of rural placements that were effective in engaging students in the learning process. It also examined how a primary health care clinical placement in Aboriginal communities can provide nursing students with a rich and varied learning experience and an insight into the complex aspects of rural life including Aboriginal health. Design: A cohort of eight second‐year nursing students from the Australian Catholic University, North Sydney, in partnership with the Broken Hill University Department of Rural Health (BHUDRH), participated in a 4 weeks' rural placement in far western New South Wales. A pre‐test/post‐test questionnaire was used to capture their experiences with the students completing the questionnaires before and after their clinical placements. Such placements offer students opportunities to deepen their understanding of issues related to rural health in clinical, professional, social and community contexts. Results: The results suggest that clinical experience in rural areas can positively influence attitudes, preparedness for practice and engage students on many levels, deepened their understanding of rural communities and issues related to rural health. Conclusion: This group of undergraduate nursing students indicated they all had a positive learning experience in their rural clinical placement. The value of rural placements as a method for increasing nursing student's practical experience should be promoted.     

Ethnic disparities in undergraduate pre-clinical and clinical performance

Medical Education 2012: 46: 575–585 Context Research from numerous medical schools has shown that students from ethnic minorities underperform compared with those from the ethnic majority. However, little is known about why this underperformance occurs and whether there are performance differences among ethnic minority groups. Objectives This study aimed to investigate underperformance across ethnic minority groups in undergraduate pre‐clinical and clinical training. Methods A longitudinal prospective cohort study of progress on a 6‐year undergraduate medical course was conducted in a Dutch medical school. Participants included 1661 Dutch and 696 non‐Dutch students who entered the course over a consecutive 6‐year period (2002–2007). Main outcome measures were performance in Year 1 and in the pre‐clinical and clinical courses. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre‐university grade point average (pu‐GPA), additional socio‐demographic variables (first‐generation immigrant, urban background, first‐generation university student, first language, medical doctor as parent) and previous performance at medical school. Results Compared with Dutch students, Surinamese and Antillean students specifically underperformed in the Year 1 course (pass rate: 37% versus 64%; adjusted OR 0.40, 95% CI 0.27–0.60) and the pre‐clinical course (pass rate: 19% versus 41%; adjusted OR 0.57, 95% CI 0.35–0.93). On the clinical course all non‐Dutch subgroups were less likely than Dutch students to receive a grade of ≥ 8.0 (at least three of five grades: 54–77% versus 88%; adjusted ORs: 0.17–0.45). Conclusions Strong ethnic disparities exist in medical school performance even after adjusting for age, gender, pu‐GPA and socio‐demographic variables. More subjective grading cannot be ruled out as a cause of lower grades in clinical training, but other possible explanations should be studied further to mitigate the disparities.     

Career choices of medical students: a national survey of 1780 students

Medical Education 2010: 44: 603–612 Objectives Many factors influence the career specialty decisions made by medical students. The aim of this study was to broaden consideration of the determinants of specialty choice in a large population of medical students in their sixth year of study. Methods A total of 2588 students distributed across all of the 39 medical schools in France participated in a National Practice Examination in December 2008, after which an electronic questionnaire was administered. Study criteria were: population characteristics; demographics, and motivation for and drawbacks to medical specialty choice. Results A total of 1780 students (1111 women, 62%) responded to the questionnaire (69% response rate). The mean age of respondents was 23.8 years (22–35 years). Of these, 1555 students (87%) stated their preferred medical specialty. Surgical and medical specialties were the two specialties selected most frequently by students (n = 729, 47%). General practice was chosen by 20%. Gender influenced the choice of specialty: 88% of future paediatricians, 82% of gynaecologists and 77% of general practitioners (GPs) were women (p < 0.05). Main motivating factors included interesting diseases, opportunities for private practice and patient contact. Main drawbacks limiting the choice of other specialties were poor quality of life, an exclusively hospital‐based career and loss of patient contact. Gender was the criterion most associated with significant differences in factors of motivation for or discouragement from a career. Patient contact and opportunities for private practice were significantly highlighted by future GPs compared with students opting for the medical or surgical specialties (p < 0.0001). Conclusions Students’ career choices regarding specialties or general practice result from the interplay among several factors. Career interest in general practice is particularly low. Initiatives to address the factors affecting student career choices regarding less favoured specialties and to deal with the growing feminisation of the profession, which will lead to irreversible changes in clinical practice, are required.     

Starting rural,staying rural: How can we strengthen the pathway from rural upbringing to rural practice?

Objective: To determine if selecting rural background students into the Monash Bachelor of Medicine and Bachelor of Surgery (MBBS) program affects vocational training location and intended practice location after training. Design: Retrospective cohort mail survey. Setting: Australia. Participants: Rural‐background students at Monash 1992–1994 (n = 24/40) and 1995–1999 (n = 59/120) and urban background students (n = 36/93 and 104/300, respectively). Overall study population: 62% female, average age of 28 years; 79% Australian‐born; and 60% married/partnered. Interventions: Rural or urban background, rural undergraduate exposure. Main outcome measures: Intent towards rural medical practice, vocational training location and subsequent practice location. Results: There was a positive and significant (P ≤ 0.05) association between rural background and rural practice intent when respondents began (10‐times higher than urban graduates) and completed (three times higher) their MBBS course. Rural practice intent increased fourfold in urban background graduates. There was a positive and significant association between rural background and preferred place of practice in 5–10 years in a Rural, Remote and Metropolitan Area (RRMA) 3–7 community (three times higher). There was a positive, but non‐significant association between rural background and RRMA 3–7 community as their current location and first place of practice once vocationally qualified. Conclusions: Interest in rural practice is not fully reflected in location during or after vocational training. The beneficial effects of rural undergraduate exposure might be lost if internship and vocational training programs provide insufficient rural clinical experiences and curriculum content. Continuation of the rural pathway might be needed to maintain rural practice intent.     

Student attitudes to surgical teaching in provincial hospitals

Objective: The ever‐increasing pressure on metropolitan teaching hospitals to rationalise budgets and increase productivity has resulted in a dwindling amount of teaching opportunity for the medical student population. One solution to the problem was to utilise a largely untapped resource in South Australia, namely the provincial hospitals, however, student opinion regarding such a radical change had yet to be determined. Design: A questionnaire was circulated among an entire year group of medical students who would be undertaking the revised surgical curriculum with rural attachments. Setting: In October 1997, a decision was made by the Department of Surgery at the University of Adelaide to proceed with optional rural surgical attachments in 1998. Subjects: The survey was distributed to the 125 members of the 1997 fifth year medical student group. Results: A total of 92 questionnaires were returned giving a response rate of 75%. Thirty‐nine students ranked a rural term in their top half of preferences, while a further 18 indicated that they would go to a rural centre if they had to. Conclusion: Despite having little warning of the impending changes to their surgical curriculum, the majority of students who responded to the questionnaire stated that they would be willing to venture to the country locations. Before planning significant changes to an established curriculum, the student group should be consulted to gauge their opinion. What is already known: Within the medical literature, studies have been performed with regard to student opinions regarding postgraduate internships in rural locations, but to our knowledge, this survey represents the first study into student opinion with particular reference to rural surgical attachments prior to their commencement within a medical school curriculum. What this study adds: As a result of this study, it can now be concluded that a considerable amount of interest exists within the student population to undertake rural surgical rotations.     

Payback time: the associations of debt and income with medical student career choice

Medical Education 2012: 46 : 983–991 Context With impending health care reform in the USA, there is an imperative to increase the number of students choosing primary care (PC) careers. Research is needed to better understand the roles of economic factors in medical student career choice. The objective of this study was to examine the relationships among debt, income and career choice by comparing students planning PC careers with those aspiring to one of the 12 non‐PC fields in which median income exceeds US$300 000 (‘high‐paying non‐primary care’ [HPNPC]). Methods Surveys (response rate = 81%) were administered to Year 1 students scheduled to graduate between 1996 and 2012, and Year 4 students graduating between 1993 and 2010. Respondents were students at New York Medical College and East Carolina University’s Brody School of Medicine. Analyses focused on the 2674 Year 1 respondents choosing a PC (n = 1437, 54%) or HPNPC (n = 1237, 46%) career, and the 2307 Year 4 respondents intending to pursue PC (n = 992, 43%) or HPNPC (n = 1315, 57%). Longitudinal analyses examining changes in career goals during medical school were based on students who completed surveys in both Years 1 and 4. The outcome measures studied were self‐reported debt, anticipated income and self‐rated value placed on income. Results Relative to their PC counterparts, students intending to pursue HPNPC careers anticipated an average of US$24 904 (Year 4 students) or US$29 237 (Year 1 students) greater debt, placed a higher importance value on income, and anticipated earning an average of US$58 463 (Year 1 students) and US$89 909 (Year 4 students) more in annual income after graduation. Debt was associated with the value placed on income in the choice of career and the amount of future income anticipated. Students who valued income highly were especially inclined to switch from PC during medical school. The switch away from PC was associated with debt, as well as with a marked increase in anticipated income. Conclusions Debt and anticipated income are important concerns which may shape future supplies of PC doctors.