INTRODUCTION: Flinders University in Australia has had a rural longitudinal integrated clerkship for selected medical students, the Parallel Rural Community Curriculum, since 1997. The Northern Ontario School of Medicine (NOSM) in Canada introduced a similar clerkship for all NOSM students in 2007. An external evaluation of both programs was conducted in 2006 and 2008, respectively. The aim of this article was to analyse the similarities in and differences between these two rural programs and determine key factors that could inform others interested in creating similar programs.
METHODS: The evaluation took the form of a cross-sectional descriptive study conducted in each school using focus group and individual interviews, involving students, faculty, preceptors, health service managers and community representatives. Interviews were analysed for emerging themes based on a grounded theory approach, and common themes were tabulated and validated. The themes for the two sites were compared and contrasted to assess similarities and differences.
RESULTS: Individual interviews were conducted with 87 people at Flinders and 39 at NOSM; focus groups included 45 students at Flinders and 7 at NOSM. All participants felt that the programs produce confident and skilled students. The educational value of the programs was expressed in terms of continuity of care, longitudinal exposure, development of relationships, mentoring, team work, and participatory learning. Common concerns related to issues of standardisation, ensuring exposure to all specialist disciplines, communication, support for students and preceptors, isolation, dealing with personal issues, and the process of site selection.
CONCLUSIONS: The rural longitudinal integrated clerkship approach to teaching the core clinical components of the undergraduate medical curriculum has a positive impact on both students and clinicians, as demonstrated in two different sites on two continents. Five key factors emerged that may inform development of similar programs in other institutions: (1) invest in careful site selection matching local epidemiology with curricular goals; (2) create collegiate faculty development that facilitates peer to peer relationships between rural and urban faculty; (3) integrate IT systems with the health system to create hardware synergies; (4) manage student expectations regarding isolation and expected site differences; and (5) build strong local postgraduate training that reinforces the values and workforce benefits of the undergraduate program.
BACKGROUND: The general practice workforce required for Australia in the future will depend on many factors, including geographic areas and patient utilisation of general practice services.
OBJECTIVE: This article examines the current and future general practice workforce requirements by way of an analysis of geographic areas accounting for differing patient utilisation.
DISCUSSION: The results showed that, compared with major cities, inner regional areas had 24.4% higher expected patient general practice utilisation per general practitioner, outer regional 33.2%, and remote/very remote 21.4%. Balanced distribution would mean 1129 fewer GPs in major cities: 639 more in inner regional, 423 more in outer regional and 66 more in remote/very remote. With the population projected to increase 18.6-26.1% by 2020, expected general practice utilisation will increase by 27.0-33.1%. Initiatives addressing general practice workforce shortages should account for increasing general practice utilisation due to the aging population, or risk exacerbating the unequal distribution of general practice services.
Attention to the inequitable distribution and limited access to primary health care resources is key to addressing the priority health needs of underserved populations in rural, remote and outer metropolitan areas. There is little high-quality evidence about improving access to quality primary health care services for underserved groups, particularly in relation to geographic barriers, and limited discussion about the training implications of reforms to improve access. To progress equity in access to primary health care services, health professional education institutions need to work with both the health sector and policy makers to address issues of workforce mix, recruitment and retention, and new models of primary health care delivery. This requires a fundamental shift in focus from these institutions and the health sector, to each view themselves as partners in an integrated teaching, research and service-oriented health system. This paper discusses the challenges and opportunities for primary health care professionals, educators and the health sector in providing quality teaching and clinical experiences for increasing numbers of health professionals as a result of the reform agenda. It then outlines some practical strategies based on theory and evolving experience for dealing with some of these challenges and capitalising on opportunities.
OBJECTIVE: To compare the level and determinants of job satisfaction between four groups of Australian doctors: general practitioners, specialists, specialists-in-training, and hospital non-specialists.
DESIGN, PARTICIPANTS AND SETTING: National cross-sectional questionnaire survey as part of the baseline cohort of a longitudinal survey of Australian doctors in clinical practice (Medicine in Australia - Balancing Employment and Life [MABEL]), undertaken between June and November 2008, including 5193 Australian doctors (2223 GPs, 2011 specialists, 351 hospital non-specialists, and 608 specialists-in-training).
MAIN OUTCOME MEASURES: Job satisfaction scores for each group of doctors; the association between job satisfaction and doctor, job and geographical characteristics.
RESULTS: 85.7% of doctors were moderately or very satisfied with their jobs. There were no differences in job satisfaction between GPs, specialists and specialists-in-training. Hospital non-specialists were the least satisfied compared with GPs (odds ratio [OR], 0.56 [95% CI, 0.39-0.81]). For all doctors, factors associated with high job satisfaction were a good support network (OR, 1.72 [95% CI, 1.41-2.10]), patients not having unrealistic expectations (OR, 1.48 [95% CI, 1.25-1.75]), and having no difficulty in taking time off work (OR,1.48 [95% CI, 1.20-1.84]). These associations did not vary across doctor types. Compared with GPs, on-call work was associated with lower job satisfaction for specialists (OR, 0.48 [95% CI, 0.23-0.98]) and hospital non-specialists (OR, 0.25 [95% CI, 0.08-0.83]).
CONCLUSION: This is the first national survey of job satisfaction for doctors in Australia. It provides an important baseline to examine the impact of future health care reforms and other policy changes on the job satisfaction of doctors.
BACKGROUND: Rural and remote areas are characterised by a shortage of medical practitioners. Rural background has been shown to be a significant factor associated with medical graduates' intentions and decisions to practise within a rural area, though most studies have only used simple definitions of rural background and not previously looked at specialists. This paper aims to investigate in detail the nature of the association between rural background and practice location of Australian general practitioners (GPs) and specialists
METHODS: Data for 3156 GPs and 2425 specialists were obtained from the Medicine in Australia: Balancing Employment and Life (MABEL) study. Data on the number of childhood years resident in a rural location and population size of their rural childhood location were matched against current practice location. Logistic regression modelling was used to calculate adjusted associations between doctors in rural practice and rural background, sex and age.
RESULTS: GPs with at least 6 years of their childhood spent in a rural area were significantly more likely than those with 0-5 years in a rural area to be practising in a rural location (OR 2.28, 95% CI 1.69-3.08), whilst only specialists with at least 11 years rural background were significantly more likely to be practising in a rural location (OR 2.27, 95% CI 1.77-2.91). However, for doctors with a rural background, the size of the community that they grew up in was not significantly associated with the size of the community in which they currently practise. Both female GPs and female specialists are similarly much less likely to be practising in a rural location compared with males (GPs: OR 0.53, 95% CI 0.45-0.62).
CONCLUSIONS: This study elucidates the association between rural background and rural practice for both GPs and specialists. It follows that increased take-up of rural practice by new graduates requires an increased selection of students with strong rural backgrounds. However, given the considerable under-representation of rural background students in medical schools and the reluctance of females to practise in rural areas, the selection of rural background students is only part of the solution to increasing the supply of rural doctors.
INTRODUCTION: Retention of GPs in the more remote parts of Australia remains an important issue in workforce planning. The Northern Territory of Australia experiences very high rates of staff turnover. This research examined how the process of forming 'place attachment' between GP and practice location might influence prospects for retention. It examines whether GPs use 'adjustment' (short term trade-offs between work and lifestyle ambitions) or 'adaptation' (attempts to change themselves and their environment to fulfil lifestyle ambitions) strategies to cope with the move to new locations.
METHODS: 19 semi-structured interviews were conducted mostly with GPs who had been in the Northern Territory for less than 3 years. Participants were asked about the strategies they used in an attempt to establish place attachment. Strategies could be structural (work related), personal, social or environmental.
RESULTS: There were strong structural motivators for GPs to move to the Northern Territory. These factors were seen as sufficiently attractive to permit the setting aside of other lifestyle ambitions for a short period of time. Respondents found the environmental aspects of life in remote areas to be the most satisfying outside work. Social networks were temporary and the need to re-establish previous networks was the primary driver of out migration.
CONCLUSION: GPs primarily use adjustment strategies to temporarily secure their position within their practice community. There were few examples of adaptation strategies that would facilitate a longer term match between the GPs' overall life ambitions and the characteristics of the community. While this suggests that lengths of stay will continue to be short, better adjustment skills might increase the potential for repeat service and limit the volume of unplanned early exits.
INTRODUCTION: General practitioner proceduralists are a distinct and highly trained cohort of doctors who provide procedural services in hospitals and emergency rooms throughout Australia. However, their value is not well recognised in the wider system of primary health care. Consequently, an understanding of the landscape of GP procedural practice is an essential element of health service planning now and in the future. Therefore, empirical data from a 2008 study of GP procedural medicine in the Bogong region of north-east Victoria and southern New South Wales is presented. The implications of shifting trends in the demand for and supply of the GP procedural workforce on future health services is examined. A comprehensive literature review established past and future trends in procedural medicine and provided a context for three research questions: (1) What procedures are being performed by GP proceduralists in the Bogong region? (2) What procedures are no longer performed and why? (3) What is the likely future of GP procedural practice in the next 5 to 10 years?
METHOD: A qualitative case study methodology was chosen to explore the factors that influence the nature of GP procedural medicine. A population of 70 GPs were initially identified as practising obstetric, surgical or anaesthetic procedures. Of these, 38 participated in structured interviews, 21 were electronically surveyed and 11 were excluded from the study. Combined interview and survey responses gave a response rate of 81%. Five health service executives and a senior Department of Human Services manager were interviewed to gather their perspectives about the research questions. Content and thematic analysis revealed key issues of importance. Data-sets were examined to analyse themes associated with trends in GP procedural medicine over time.
RESULTS: General practitioner proceduralists are attracted by diversity, challenge and passion for procedural work. However, there has been a gradual but sustained decline in the volume and complexity of procedural work due, in part, to shifts in community demography, changing medical practices, the rise of specialisation, the centralisation of services, infrastructure and other costs, and fear of litigation. Moreover, an ageing workforce and a shift in the demographic profile of GPs and the pressures of procedural life have contributed to a decline in GP proceduralist numbers. Nevertheless, there remains a substantial demand for GP procedural medicine in rural communities.
CONCLUSIONS: Rural towns are dependent upon GP proceduralists to ensure the continuing health and sustainability of local communities. However, the existence of a viable and robust workforce of GP proceduralists is at a 'breaking point'. Until GP proceduralists are recognised and counted as a distinct cohort of valued and highly trained medical practitioners they will remain the 'hidden heart' of primary care in rural and regional Australia. An holistic approach must be adopted to attract, train, maintain and recognise the GP proceduralists' unique place in rural health. With the Australian health system under government review, there are opportunities to revitalise GP procedural practice as a long term, viable and challenging career choice and ensure on-going support for rural in-patient and emergency department services.
BACKGROUND: The Remote Vocational Training Scheme trains doctors in remote communities using distance education and supervision.
AIMS: To document the training location, outcomes of training, current location and services provided by program graduates and assess the effectiveness of their training.
RESULTS: Twenty-four doctors graduated from the Remote Vocational Training Scheme program. Registrars provided over 44 years of clinical service in very remote areas during training. Of those working in Australia, 17 out of 21 (81%) still work in rural areas and 20 (95%) gained dual qualification of Fellowship of the Australian College of Rural and Remote Medicine and Fellowship of The Royal Australian College of General Practitioners. Registrars evaluated the program as effective preparation for clinical practice.
CONCLUSION: The first medical specialist training program in Australia and comparable western countries to use remote supervision achieved its targets of increasing retention of the rural and remote workforce during and after training.
Access to well trained and motivated health workers is the major rural health issue. Without local access, it is unlikely that people in rural and remote communities will be able to achieve the Millennium Development Goals. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: (i) a rural background; (ii) positive clinical and educational experiences in rural settings as part of undergraduate medical education; and (iii) targeted training for rural practice at the postgraduate level. This paper presents evidence for policy initiatives involving the training of medical students from, in and for rural and remote areas. We give examples of medical schools in different regions of the world that are using an evidence-based and context-driven educational approach to producing skilled and motivated health workers. We demonstrate how context influences the design and implementation of different rural education programmes. Successful programmes have overcome major obstacles including negative assumptions and attitudes, and limitations of human, physical, educational and financial resources. Training rural health workers in the rural setting is likely to result in greatly improved recruitment and retention of skilled health-care providers in rural underserved areas with consequent improvement in access to health care for the local communities.
Journal»Canadian journal of rural medicine : the official journal of the Society of Rural Physicians of Canada = Journal canadien de la médecine rurale : le journal officiel de la Société de médecine rurale du Canada
INTRODUCTION: In 2008, the Canadian Medical Association (CMA) conducted a survey of rural practitioners. The survey covered incentives to choose rural medicine, current satisfaction, plans for future migration and strategies for retention.
METHODS: The CMA Canadian Collaborative Centre for Physician Resources, in collaboration with the Society of Rural Physicians of Canada, surveyed 1960 rural practitioners and received 642 responses (33% response rate). Because of similarities with earlier surveys, longitudinal analyses were possible.
RESULTS: More than 70% of physicians older than 45 years received no incentives for setting up rural practice, compared with 41% of younger physicians. Younger physicians attached greater importance to financial incentives than older physicians, but personal incentives, such as accommodations in the community, were also important. The opportunity to practise one's full skill set was considered important (84%) as was liking the lifestyle (82%). One in 7 (14%) respondents planned to move from their communities within the next 2 years. They reported they might stay if they had a more reasonable workload, professional backup and locums.
CONCLUSION: Although increasingly common, cash incentives are not the main reason physicians choose rural practice. Practice and lifestyle factors are even more important. Communities need to focus as much on retention issues to protect their investment in the long term.
Flinders University in Australia has had a rural longitudinal integrated clerkship for selected medical students, the Parallel Rural Community Curriculum, since 1997. The Northern Ontario School of Medicine (NOSM) in Canada introduced a similar clerkship for all NOSM students in 2007. An external evaluation of both programs was conducted in 2006 and 2008, respectively. The aim of this article was to analyse the similarities in and differences between these two rural programs and determine key factors that could inform others interested in creating similar programs.
METHODS:
The evaluation took the form of a cross-sectional descriptive study conducted in each school using focus group and individual interviews, involving students, faculty, preceptors, health service managers and community representatives. Interviews were analysed for emerging themes based on a grounded theory approach, and common themes were tabulated and validated. The themes for the two sites were compared and contrasted to assess similarities and differences.
RESULTS:
Individual interviews were conducted with 87 people at Flinders and 39 at NOSM; focus groups included 45 students at Flinders and 7 at NOSM. All participants felt that the programs produce confident and skilled students. The educational value of the programs was expressed in terms of continuity of care, longitudinal exposure, development of relationships, mentoring, team work, and participatory learning. Common concerns related to issues of standardisation, ensuring exposure to all specialist disciplines, communication, support for students and preceptors, isolation, dealing with personal issues, and the process of site selection.
CONCLUSIONS:
The rural longitudinal integrated clerkship approach to teaching the core clinical components of the undergraduate medical curriculum has a positive impact on both students and clinicians, as demonstrated in two different sites on two continents. Five key factors emerged that may inform development of similar programs in other institutions: (1) invest in careful site selection matching local epidemiology with curricular goals; (2) create collegiate faculty development that facilitates peer to peer relationships between rural and urban faculty; (3) integrate IT systems with the health system to create hardware synergies; (4) manage student expectations regarding isolation and expected site differences; and (5) build strong local postgraduate training that reinforces the values and workforce benefits of the undergraduate program.
