Rural clinical school students do come back: But it may take time

The development of the rural medical workforce is a continuing challenge; Australia continues to rely on internationally trained medical graduates.¹ It is widely accepted that being of rural origin and spending extended time studying in a rural location are predictors of future rural work location.^2–4 This has prompted the establishment of extended rural student training placements in many countries:⁵ in Australia, extended placements are managed by rural clinical schools (RCSs).⁶

The Australian National University Medical School (ANUMS), including its RCS, was established in Canberra in 2004. In third year, 25% of the cohort is selected, through a competitive process, to spend the whole year in a rural town as part of the ‘rural stream’. All other students have a six-week placement in rural general practice, supervised by the RCS. The program relies on rural clinicians to supervise and support the students, with general practitioners (GPs) in key roles.

Placing medical students in rural sites places extra burden on their rural supervisors. Rural doctors supervising students have been found to be partly motivated by an obligation to the ‘next generation’.⁷ Supervisors have reported succession planning (69%) and a responsibility for future healthcare of their community (82%) as motivators.⁸ Therefore, it is important for the retention of supervisors that they see students and trainees returning.

The first ANUMS students graduated more than a decade ago. We have studied the practice location of graduates as one measure of the RCS’s effectiveness.

Method

We obtained location data for graduating years 2007–17 from the Australian Health Practitioner Regulation Agency (AHPRA) website and publicly available practice websites. The data were analysed using Microsoft Excel for descriptive statistics and SPSS v23 for the chi-square test of independence. Rurality was classified using the Australian Standard Geographical Classification – Remoteness Areas (ASGC-RA) index, currently used for the RCS program: RA1 for large metropolitan centres and RA2–5 for increasing rurality or remoteness.⁹

Ethics approval was obtained from the Australian National University Human Research Ethics Committee (protocol 2015/561).

Results

There were 965 ANUMS graduates from 2007–17; 59.1% were female and 40.9% were male. This included 215 rural stream graduates with similar gender percentages (59.5% female, 40.5% male). Location data were found for 915 (94.8%) graduates: 66 of 708 non–rural stream graduates (9.3%) are currently working in RA2–5 locations, compared with 51 of 207 rural stream graduates (24.6%). Table 1 shows the number of graduates working outside RA1 by postgraduate year (PGY). The percentage of graduates working in rural areas was highest in the later postgraduate years – PGY6 and above. More than twice as many rural stream graduates were working in RA2–5 locations in PGY6–11 (34.7%) than in PGY1–5 (16.1%; χ² = 10.73, P <0.001). The same trend was found for non–rural stream graduates: 12.9% and 5.4% respectively (χ² = 11.89, P <0.0006).

 

Table 1. Current geographical remoteness per postgraduate year cohort (2018)
Rural stream students
	PGY1	PGY2	PGY3	PGY4	PGY5	PGY6	PGY7	PGY8	PGY9	PGY10	PGY11
RA1	21	19	22	15	18	13	16	11	10	5	7
RA2	1	5	1	4	2	5	2	7	5	5	1
RA3		1		1	1	3	1	1		1	1
RA4										1
RA5			1	1
Total	22	25	23	21	21	21	19	19	15	12	9
Missing*		2			1	1		1	1	1	1
Non–rural stream students
RA1	63	67	57	70	61	58	48	58	54	62	44
RA2–5	3	1	4	3	7	9	8	4	6	11	10
Total	66	68	61	73	68	67	56	62	60	73	54
Missing*	0	2	1	2	3	7	3	5	2	10	7
*Location not found or left Australia PGY, postgraduate year; RA, remoteness area

  

Eighteen of the 116 ANUMS graduates working in rural areas (11 from the rural stream) had returned to work within the ANUMS placement region: 15 (83%) are in PGY6–11. These included a majority of GPs (procedural and non-procedural), a surgeon and an anaesthetist. Of these, eight rural stream graduates had returned to the town in which they studied during their rural year.

Discussion

Many ANUMS graduates were working in rural areas, and over 14% of these areas were in the ANUMS placement region. The highest proportion of rurally based doctors was found in the later postgraduate years (PGY6–11), where over 50% of some rural stream cohorts were working in rural areas. While a significantly larger percentage of rural stream graduates was working in rural areas, the absolute number of non–rural stream graduates was higher, and seven of these were in the ANUMS region. These findings support the ANUMS practice of providing all students with rural experience, both as a motivation and a preparation for rural practice.

We know that rural origin and student placement are important in influencing location decisions.^2–4 We also know that issues such as partner’s employment, family and lack of training positions are potential barriers to rural practice.¹⁰ However, we do not fully understand the choices that lead our graduates along a variety of pathways to rural practice, including a mix of rural and urban training. More qualitative research is underway to improve our understanding of these pathways.

Unpublished ANUMS RCS research found that 80% of rural stream graduates reported either an intention to work or interest in working in rural areas. The location results confirm that many of these graduates are continuing in metropolitan practice after PGY2–3, when more rural training options have become available. The RCS is working with other bodies, through its Regional Training Hub, on several strategies.¹¹ These include strengthening rural supervision capacity, increasing training places, and mentoring and information provision.

Limitations

These data are limited by small rural stream cohort numbers that are affected by movements of a few individuals. This is a cross-sectional study and susceptible to the effects of changed training environments, variation in student cohorts and local factors.

Conclusion

The ANUMS RCS has been operating for a decade and can now obtain meaningful tracking data for rural stream graduates. The results indicate that many graduates are following their stated rural intention, possibly strategically planning their training pathway. The current Department of Health initiatives are timely in assisting the RCS to further develop its mentoring and support of doctors after graduation – and potentially reduce or remove several of the barriers to rural practice.