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.     

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.     

Medical career choice and practice location: early factors predicting course completion, career choice and practice location

AIMS: The overall aim of the study was to identify the factors that best predict medical career choice and practice location. METHOD: A longitudinal, cohort study was conducted. This followed 2 cohorts of students, numbering a total of 229 students, who commenced medical studies at the University of Western Australia in 1984 and 1989. Data concerning the students' sociodemographic backgrounds, admission scores and personality characteristics were collected in Year 1. Regression analyses were performed to identify the student characteristics that best predicted course completion, a choice of general practice 4 years after graduation and a rural location of practice. OUTCOMES: We found that students who had lower university admission scores and who were less outgoing were less likely to complete the course. Students who were male, had a father in medicine and were more creative and abstract in their thinking and more conscientious and rule-bound were more likely to choose a specialist career. A rural background was found to be the most important predictor of both rural general and specialist practice.     

Challenges to rural medical education: a student perspective

ABSTRACT: The key feature of the Greater Murray Clinical School model is the attachment of students to patients. Students follow their patients through the health care system, in contrast to the standard approach where students are attached to doctors or speciality based clinical units. The patient/student coupling occurs at the primary care level, which mostly but not exclusively will occur in the GP's office. Students anchor their knowledge by seeing the natural progression of common illnesses, the impact of behavioural aspects on health and disease, and by experiencing continuity of care. Along their path they develop good problem solving skills and learn to understand the health care system they will become part of. The main obstacle in teaching a medical undergraduate curriculum in a rural setting is that large geographical distances separate students, teachers and resources. Consequently, information technology will play an important role in terms of delivery of the GMCS curriculum. Moreover, there is potential for flow-on benefits to the community following integration of new information technology into the local health infrastructure.     

Medical students and rural general practitioners: congruent views on the reality of recruitment into rural medicine

OBJECTIVE: In-depth exploration of the perceptions, experiences and expectations of current long-term rural GPs and medical students intent on a rural career, regarding the current and future state of rural medicine. DESIGN: Qualitative study using semistructured interviews. SETTING: Rural and remote towns in Central and Southern Queensland and the School of Medicine, University of Queensland. PARTICIPANTS: Thirteen rural GPs with 10-40 years experience. Medical students (five second- and seven third-year), all of whom are members of a rural students' club and have an intention to pursue rural practice. Interviews were conducted between August and December 2004. MAIN OUTCOME MEASURES: Emergent themes relating to participant perceptions of the current and future state of rural medicine. RESULTS: Despite large differences in generation and experience, medical students and rural GPs hold similar perceptions and expectations regarding the current and future state of rural practice. In particular, they cite a lack of professional support at the systems level. This includes specific support for: continuing medical education to obtain and retain the skills necessary for rural practice; dealing with the higher risks associated with procedural work; and consequences of medico-legal issues and workforce shortage issues such as long hours and availability of locums. CONCLUSIONS: Issues relating to recruitment and retention of the rural health workforce are identified by both cohorts as relating to professional support. Medical schools and institutional support systems need to join forces and work together to make rural practice a viable career in medicine.     

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.     

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.     

Interdisciplinary health education and career choice in rural and underserved areas

PURPOSE: To assess the association between an educational rural health interdisciplinary programme (RHIP) and subsequent practice in US rural and underserved locations. METHODS: We carried out a longitudinal cohort study of RHIP students and randomly selected classmate controls for the years 1990-2001, using a mailed survey. OUTCOMES: Main outcome measures were first rural, any rural, first underserved and any underserved practice locations. Multivariate statistical methods were used to calculate prevalence ratios (PRs) by discipline while controlling for possible extraneous variables. RESULTS: Of 1396 surveys delivered, 820 were returned, giving a response rate of 59%. After exclusions, results from 255 RHIP and 534 control students were analysed for outcomes. Pharmacy students on the RHIP chose first and any rural practice locations more often than reference controls (PRs = 2.59 and 1.97, respectively; P < 0.05). Therapies (occupational, physical and speech therapy) RHIP students were associated with all 4 practice outcomes more often (PRs = 2.07, 1.85, 1.68 and 1.65, respectively; P < 0.05). Pharmacy and Therapies control students with rural training chose first rural and any rural practices more often (PRs = 2.58 and 1.62, respectively; P < 0.05 for both). Medicine and Nursing students did not choose outcome practice locations more often, but had small sample sizes and large numbers of controls with rural training. Rural health interdisciplinary students rated participation in rural training more highly as a factor in choosing first rural practices than did the controls who chose similar practices. CONCLUSIONS: Participation in RHIP and other rural training experiences may stimulate subsequent career choices in rural and underserved locations for Pharmacy and Therapies students. Other studies are needed to confirm these findings and answer questions raised by these data.     

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.     

Internet-based mental health programs: a powerful tool in the rural medical kit

OBJECTIVE: To discuss, using two case examples, the potential utility of Internet-based depression information and automated therapy programs in rural regions. DESIGN: Systematic review of evaluations of two Australian web-based mental health programs: MoodGYM and BluePages Depression Information. SETTING: Community, school, university. PARTICIPANTS: A total of 12 papers and reports derived from nine separate studies of MoodGYM and BluePages involving sample sizes ranging from 78 to 19 607 people. OUTCOME MEASURES: Depressive symptoms, anxiety symptoms, dysfunctional thoughts, depression literacy, stigma, help seeking and cost-effectiveness. RESULTS: Internet-based applications were effective in reducing depressive symptoms and stigmatising attitudes to depression and in improving depression literacy. School-based programs also showed promise in decreasing depressive symptoms. CONCLUSIONS: Depression self-help and information programs can be delivered effectively by means of the Internet. As accessibility of face-to-face mental health services in rural areas is poor and as there is a strong culture of self-reliance and preference for self-managing health problems among rural residents, the Internet might offer an important platform for the delivery of help for depression in rural regions. Consideration should be given to developing programs tailored to rural settings and future research should evaluate the efficacy and effectiveness of such programs in rural settings.     

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.     

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.