The impact of an early_exposure program on medical students’ interest in and knowledge of rural medical practices: a questionnaire survey

The Australian College of Rural and Remote Medicine was established in 1997 to meet what rural doctors perceived as their unmet educational and professional needs. However, the issue of just how different rural practice is from urban practice remains a topic of debate. This paper explores the scope of rural medical practice, through the use of clinical scenarios and a synthesis of the research literature, to determine if rural medical practice is emerging as a distinct discipline in Australia. Rural and remote medical practice is different, and additional, to urban practice, in the context, content and process of care. Three of the four criteria for determining rural medical practice as a distinct discipline exist in Australia. The fourth criteria: sufficient external recognition of rural medicine as a distinct discipline, awaits resolution. This paper examines a key issue that has been a source of conflict between the relevant stakeholders for a decade. By placing the differences between rural and urban medical practice within a framework, supported by published work, this paper describes what is required to justify rural medical practice as a distinct discipline for the first time.

Background: The Australian College of Rural and Remote Medicine was established in 1997 to meet what rural doctors perceived as their unmet educational and professional needs. However, the issue of just how different rural practice is from urban practice remains a topic of debate. Methods: This paper explores the scope of rural medical practice, through the use of clinical scenarios and a synthesis of the research literature, to determine if rural medical practice is emerging as a distinct discipline in Australia. Conclusion: Rural and remote medical practice is different, and additional, to urban practice, in the context, content and process of care. Three of the four criteria for determining rural medical practice as a distinct discipline exist in Australia. The fourth criteria: sufficient external recognition of rural medicine as a distinct discipline, awaits resolution.

A persistent maldistribution of medical workforce exists across Canada, with rural areas facing a greater physician shortage. Medical education can be instrumental to increase physicians in rural communities, and medical schools have adapted strategies to generate interest in rural careers among medical students. Many of these efforts occur within formal structured curriculum. This study appraises the effectiveness of peer-led learning (PLL) as a novel approach in rural medical education to provide students with a better understanding of rural life and rural medical practice. This is mixed methods study using a survey and follow-up focus group discussion to evaluate a day-long educational experience organized and led by a medical student to their rural community. Quantitative data were summarized with descriptive statistics. Reflexive thematic analysis was conducted on qualitative insights to describe the students' experiences and perceptions about the educational rural day. Of 54 participants, 50 completed the survey and 13 consented for the follow-up focus group. Most (78%) were female, have non-rural origins (78%), with only 2 having Indigenous status. Majority (61%) have low familiarity with rural medicine. Trustworthiness scores for information about rural life and medical practice were higher for rural-origin peers and rural-origin faculty compared to other sources of information such as government websites, social media, and traditional media. Thematic analysis yielded three main themes: (i) informal teaching facilitated learning, (ii) trust in their peer enabled students to receive information more favorably, and (iii) students gained a better understanding of rural life and medical practice. This study demonstrated that medical students engage differently with peer-led learning activities about rural medical curriculum versus a formal teaching environment. Medical students are cautious about promotional information regarding rural medical education from formal sources but are less skeptical when learning from peers. Information about the way of life and healthcare needs in rural communities may be perceived as more credible and valid if coming from a peer, and hence, is more likely to be received favorably. Thus, when promoting rural education and careers, medical schools should work with rural-origin students, whose messaging may be considered more trustworthy than traditional sources.

BackgroundMedical schools may select students for their attitudes towards rural medical practice, yet the rural–urban disparity in availability of medical practitioners and services has not diminished in recent times despite government initiatives and increasing numbers being trained for a career in medicine. One medical school, with a focus on rural and remote medicine, aims to select students with positive perceptions for rural medical practice. A research project collected data on the perceptions of these medical students in the first week of their medical studies.MethodsStudents completed a low stakes essay on the life and work of a rural doctor. Initially, this formed part of a literacy assessment to determine any students requiring remediation. All students were asked if they would consent to their essay being reviewed for a research project.Data was obtained from those students who consented and handed their essays in for review. The 103 student essays underwent thematic analysis and sentences were coded into three main themes of rural lifestyle, doctor role and rural practice. Second level themes were further elicited and results were quantified according to whether they were positive or negative. Positive themes included rural lifestyle, doctor role, views of doctor, impact on community, broader work and skills knowledge, and better relationships with community and patients. Negative themes included doctor’s health, pressure on doctor, family problems, greater workload, privacy and confidentiality issues, cultural issues, isolation, limited resources and financial impacts. Quantitisation of this data was used to transform essay sentences into a numerical form which allowed statistical analysis and comparison of perceptions using Z tests.ResultsNo significant differences on the number of positive and negative responses for rural lifestyle and rural practice were found. The rural doctor role had a significantly more positive than negative views. Significant differences were found for positive views of the rural doctor role and negative views of rural practice. Participants from a capital city background reported a significantly higher percentage of responses related to negative views of rural practice than their regional and rural counterparts. Students from capital city areas had significantly more negative views about the rural doctor role, especially related to workload, limited resources and isolation than students from rural and regional areas.ConclusionStudents entering medical school already have both positive and negative views about the life and work of a rural doctor. Those students from capital city areas have significantly more negative views despite being selected to enter a medical course with a rural focus based on their expressed rural perceptions. Further work is required to refine selection criteria and the year level experiences and learning opportunities which may positively influence student perceptions about rural medical practice to overcome early negative perceptions at the beginning of medical school.

Rural medical practice in Norway has an honourable 400 year history, but this has diminished since the end of World War II. Despite official intention to support a decentralised population, rural and remote populations have continuously reduced in Norway over the last 10 years. A consequence of the accompanying reduction in rural and remote GP services has been a distinct reduction in opportunities for medical student and intern placements. In 1999 the University of Tromso implemented some projects to stimulate rural medical practice, funded by the government. This culminated in the 2007 foundation of the Norwegian National Centre of Rural Medicine (NCRM) in Tromso. A key challenge of the NCRM is to identify factors that influence young doctors to choose rural careers. This is reflected in the three concurrent aims or perspectives of the NCRM: (1) to bridge the gap between the academy and rural medical practice (the principal perspective); (2) to promote research, education and networking among rural health professionals (the operational perspective); and (3) to contribute to the recruitment, stability and quality of rural health care (the political perspective). The NCRM has had a number of achievements that include a publication that provides a narrative perspective on rural practice, the role of the rural doctor, and how rural culture and context influence proper clinical decision-making. Another achievement is a professional development and research program that has been successful in fostering a number of major studies, and led to the formation of a supportive PhD research group. The NCRM has also facilitated networking between rural practitioners and academics, at conferences and via its rural doctor website, and promoted cooperative international activities. In these ways the NCRM has fostered the transformation of rural doctors' experience into theory to enhance medical knowledge, begun to redress the balance between community- and hospital-based services, and so made a favourable start to building a bridge between rural practice and the medical academy in Norway.

Using a novel longitudinal tracking project, this study develops and evaluates the performance of a predictive model and index of rural medical practice intention based on the characteristics of incoming medical students. Medical school entry survey data were obtained from the Medical Schools Outcome Database (MSOD) project implemented in all Australian and New Zealand medical schools and coordinated through Medical Deans Australia and New Zealand, the representative body for the Deans of 18 Australian and two New Zealand medical schools and faculties. The medical school commencement survey collects data on students' education and family background, including rural upbringing, personal circumstances and scholarships, and on their practice intentions in terms of location and specialty. The MSOD will also allow tracking of medical graduates after graduation. Logistic regression modelling was used to develop a predictive model of rural practice intention. Split-sample validation was used to gain some insight into the stability of performance of the model. Response rates to the MSOD survey exceeded 90% on average. The model findings confirm and extend previous research examining the association of medical student characteristics with intention to take up rural medical practice. The statistically significant independent factors in the model included students' rural backgrounds, financial arrangements and intentions regarding specialist versus generalist practice upon graduation. Model performance was good, with an area under the receiver-operator characteristics curve of 0.86, and reproducible, with an area in a validation sample of 0.83. The model and related index provide important insights into individual factors associated with rural practice intention among students commencing medical studies. The model can also provide a means for optimising the use of scarce medical programme resources, thereby helping to improve the supply of rural medical practitioners. This study illustrates the power and potential of a robust, consistent, systematic longitudinal tracking project.

Despite increases in Commonwealth funded general practice (GP) Registrar training positions, workforce trends continue to show geographical maldistribution. This study aimed to identify Registrar attributes which describe a cohort choosing to work in rural practice. Cross-sectional self-report questionnaire for socio-demographics, prior training, current training pathway, measures of personality and resilience. GP Registrars (N = 452) training in either the general or rural pathways of three Registered Training Providers in three states, or training through the Australian College of Rural and Remote Medicine's independent pathway. Ordinal logistic regression tested the impact of key variables on the likelihood that Registrars would settle in rural practice. Univariate analysis explored differences between groups and effects of variables. A significantly increased interest in rural practice was to found to exist among registrars who were male, identified themselves as being rural, had a partner who identified as being rural, were enrolled in a rural training pathway and had high levels of Cooperativeness. We present a discriminating model combining socio-demographics, prior training and personality variables which challenges Australia to rethink Registrar attributes when training for rural general practice. With significant changes about to occur to GP training in Australia, this paper highlights the need for a more holistic approach which considers personal attributes such as Cooperativeness, rural identity and provision of geographically focused rural training pipelines to encourage Registrars to bond to individual rural communities and further develop their personal connectedness to country life and rural medical practice.

Although international medical graduates (IMGs) make up a substantial part of the Australian rural general practice workforce, most research on factors associated with rural practice has focused on Australian medical graduates (AMGs). This study aimed to determine whether there were differences between IMGs and AMGs in terms of these factors. Registrars in training and recent fellows (Fellowship of the Royal Australian College of General Practitioners/Fellowship of the Australian College of Rural and Remote Medicine) who participated in training in rural and regional Australia were surveyed about practice models and rural practice. Almost two-thirds of participants were practicing or intending to practice in rural areas, with no difference between AMGs and IMGs. None of the variables associated with rural practice for AMGs was found to be associated with rural practice in IMGs in univariate binary regression analysis. Two key variables that are strongly associated with rural medical practice in the current literature, namely rural background and rural exposure, were not significant predictors of rural practice among IMGs. Due to the significant number of IMGs in regional training programs, any future incentives designed to improve rural recruitment and retention need to address factors relevant to IMGs.

There are still large gaps in the evidence base for the effectiveness of Australian undergraduate rural coursework and placements programs designed to increase the numbers of health graduates choosing rural practice. This article reports on an online survey conducted in 2004 of health science students at the University of Tasmania, Australia, designed as a part of a long-term study to test coursework interventions by tracking students' attitudes to, and experience of, rural practice from course entry to eventual practice. All first and final year students in medicine, nursing and pharmacy in the Faculty of Health Science were invited to complete an online survey exploring the undergraduate experience of rural health. The survey was completed by 148 first year and 87 final year students, a response rate of 32.4% and 23.1% respectively. Over one-third (38.5%) of first years and 56.3% of final years indicated a general preference for rural life and practice and almost 90% expected to spend at least some of their career in rural practice. There was a statistically significant relationship between rural practice orientation and rural origin among first years, although this relationship was weaker among final years. Of first years, 82.4%, and 82.7% of final years appear to have made at least some commitment to a particular career path, and two-thirds to a particular practice environment. Rurally oriented first year students were significantly more committed to a career path than those without that orientation, although this did not hold for final years. When asked how much of their careers they expected to spend in capital city, rural, remote and/or overseas practice, both first and final year students' responses were notable for their spread. Few ruled rural or urban practice in or out entirely with most opting for middle range responses of 'most', 'about half' or 'part' of their career. Over half of both years expected to spend some time in remote practice and 75.1% of first years and 66.6% of final years some time in overseas practice. The factors rated most important in relation to career choice were those related directly to the realities of day-to-day professional practice--professional and peer support, work conditions and variety of work. Approximately three-quarters of those entering undergraduate education felt themselves to be at least 'somewhat informed' about rural practice but, apart from medical students, were little better informed by final year. The only perception of rural practice very widely shared (by more than 80% of respondents) was the possibility of developing better patient relations. Many of the other factors frequently identified as major issues in the rural practice literature--locality, flexibility, opportunities for further study, and spouse/partner and children's needs - while recognised by some, do not appear to loom large with undergraduates either in terms of career choice or perceptions of rural practice. Most final year students recalled receiving specific rural health training through rural placements and/or rural curriculum content. Overall recall of coursework was patchy, although placements were well-remembered and there was good support for increases in both. None of those who recalled undertaking rural coursework felt that it had influenced them towards a rural career and over two-thirds (n = 37, 69.8%) felt that this exposure had actually influenced them away from such a career. Three students reported that undertaking a rural placement influenced them towards, and 35 away from, a rural/remote career. The ultimate measure of the success of undergraduate interventions will be workforce changes over time. In the meantime more research is needed into undergraduate experience of rural health to provide the data needed for the careful design of coursework, detailed planning of the placement experience and long-term strategies to address those aspects of rural practice that are of most concern to these emerging health professionals.

The ongoing rural doctor workforce shortage continues to stimulate interest in new strategies to alleviate the situation. Alongside increasingly promising approaches is the notion that attracting and nurturing the 'right' individuals may be paramount to achieving long-term success in recruitment and retention. This study compares the patterns of demographic and temperament and character trait profiles of general practice registrars in training across three Australian vocational training pathways: the Australian College of Rural and Remote Medicine independent rural pathway, and the rural and general pathways of Australian general practice training. The aim is to describe the predominant personalities of existing trainees. At its foundation, this study strives to obtain more information about those individuals choosing rural practice, which may inform ways to enhance future recruitment and training into rural medicine. This rationale has been explored with medical students using intention as the dependent variable, but registrars are that much closer to their final career choice, and therefore may provide more practical and reliable indicators of the notion of who attracts whom into rural practice. A cross-sectional design sampled four registrar training groups: one from the Australian College of Rural and Remote Medicine, one Australian general practice training rural only, and two Australian general practice training rural and general pathway regional training providers. Registrars (451) completed a questionnaire that gathered basic demographics and a personality trait profile using the Temperament and Character Inventory plus a measure of resilience. Statistical analysis explored the relationships between variables (multivariate analyses of variance) and compared levels of traits between registrar groups (analyses of variance). Registrars training via the Australian College of Rural and Remote Medicine pathway were more likely to be male, older, have a definite interest in or already practising in a rural area and were significantly (with moderate effect sizes) lower in levels of harm avoidance and higher in persistence, self-directedness and resilience compared to the other training pathways. The implications of the data to the recruitment and training of general practice registrars goes further than identifying groups of individuals with similar temperament and character trait patterns. This sample is portrayed as relatively homogenous in light of their overall trait levels as compared to population norms. However, it is the combination of the levels of individual traits that suggests a profile that differs between registrars on a rural or general training path. Importantly the combination of trait levels that tend to differentiate registrars (low harm avoidance, high self-directedness and persistence) correlates strongly with high levels of resilience. Doctors and medical students benefit from a high level of resilience to cope with and manage the challenges of the profession and arguably more so in rural practice. Along with certain demographic characteristics, the combination and levels of temperament (stable) and character (developmental) traits support the notion of a mixture of personal traits that may be indicative of individuals best suited to rural and remote medicine. Further investigation is needed to determine whether individuals with a certain pattern of personal traits are attracted to rural practice training or whether the training itself, in part by exposure to rural life and rural medical practice, selects for those who are most suited to and will eventually choose to practice in a rural location.

This was a prospective study of adverse drug reactions (ADRs) over a 3-month study period reported by 3 urban physicians who were in general practice in southwestern France. A total of 2094 patients were examined and 20 ADRs were observed. Results of this study of ADRs by urban physicians were compared with a similar study by a French physician in rural medical practice using the same method. In the present study, cutaneous (n = 6) and neurological (n = 6) ADRs were the most frequent untoward effects observed. The main drugs involved in the study were psychotropic (5 cases), nonsteroidal anti-inflammatory (n = 5) and anti-infectious (n = 4) agents. The prevalence rate of ADRs was 1% of the consultations/visits (2.2 ADRs/general practitioner/month), which was identical to that previously observed in a rural medical practice. ADRs involving psychotropic drugs were more frequent (p < 0.05) in urban (25%) than in rural (6%) medical practices. We compared the 1% rate in this study with the ADR rate based on spontaneous reports by general practitioners throughout the ‘departement’ to the Midi-Pyrenees regional Pharmacovigilance Centre. On the basis of this comparison, we estimated that the under-reporting rate of ADRs was approximately 1/3000.

Recruiting and retaining doctors in rural areas is challenging. In Croatia, medical school curricula lack content on rural medicine and specialized training for rural practice. This study explores the opinions and attitudes of first- and sixth-year medical students in all four medical schools in Croatia regarding working in rural areas. An online questionnaire was administered to Croatian medical students in their first and final years between January 2022 and February 2023. Responses were obtained from 690 participants from the Universities of Osijek, Rijeka, Split, and Zagreb. The cross-sectional study included 13 questions, with 5 on socio-demographic data. Data were analyzed using descriptive statistics and non-parametric tests (chi-square) to assess group differences. Compared to first-year students, final-year students feel less prepared by their education for rural practice (χ2 = 84.287; P = 0.000) but are more interested in working in rural areas (χ2 = 26.810; P = 0.000). Most students believe rural doctors need additional financial incentives, with this belief significantly stronger among final-year students (χ2 = 14.192; P = 0.000). Both groups agree that rural doctors face poor working conditions (χ2 = 1.524; P = 0.217). No statistically significant differences were found regarding job interest outside city centers (χ2 = 2.041; P = 0.564) or choosing rural medical practice (χ2 = 4.795; P = 0.187) among medical students from the Universities of Osijek, Rijeka, Split, and Zagreb. Students from rural settlements were more often interested in jobs outside the city center (72.1%) compared to those from smaller towns (60.6%), [χ2(1) = 5.142, p = 0.023] and larger cities (44.1%), [χ2(1) = 28.978, p = 0.000]. Although Croatian medical students show interest in working in rural areas, their education lacks sufficient preparation for the unique challenges of rural practice. They view the current conditions for rural doctors as inadequate and believe that additional financial incentives are necessary. Interest in rural practice is consistent across medical faculties in Croatia, with students living in rural areas showing a higher interest in working there.

Aims: Aim of study was to determine the perception of rural medical practice among final year medical students in medical schools of southeast Nigeria and the associated factors. Study Design: Descriptive cross-sectional study. Original Research Article Ossai et al.; BJMMR, 8(2): 192-205, 2015; Article no.BJMMR.2015.439 193 Place and Duration of Study: The six medical schools in southeast Nigeria, between March and May 2014. Methodology: All the final year medical students in southeast Nigeria were recruited and were eligible for voluntary participation in the study. The students were interviewed using a pretested, self-administered questionnaire. Data analysis was done using STATA statistical software; version 13 and level of significance was determined at a p value of less than 0.05. Results: Four hundred and fifty seven medical students participated in the study representing a response rate of 86.7%. The mean age of the students was 25.5±2.9 years and majority (57.1%) were male. A minor proportion of the students (13.6%) were willing to practice in the rural area after graduation. Majority of the students (80.1%) were of the opinion that doctors working in rural area should earn more than their urban counterparts. Factors associated with willingness to practice in rural area included family residence in an urban area (AOR= 0.4, 95% CI: 0.2 – 0.9); work experience before admission into medical school (AOR= 2.0, 95% CI: 1.13.9); intention to specialize in Community Medicine (AOR= 3.1 95% CI: 1.27.7) and satisfaction with rural community posting, (AOR=2.1, 95% CI: 1.23.9). Conclusion: Majority of the students were unwilling to work in rural area after graduation. Knowing the need for doctors in rural practice, a re-orientation of the students on rural practice through adequate community exposure during rural posting is essential. There is also need for increased allowances for doctors working in rural areas and opportunities for training and or further studies should be encouraged.

BackgroundRural medical training experiences provided by Rural Clinical Schools (RCS) can encourage future practice in rural locations. However, the factors influencing students’ career choices are not well understood. This study explores the influence of undergraduate rural training experiences on graduates’ subsequent practice location.MethodsThis retrospective cohort study included all medical students who completed a full academic year at the University of Adelaide RCS training program between 2013–2018. Details of student characteristics, experiences, and preferences were extracted from the Federation of Rural Australian Medical Educators (FRAME, 2013–2018) survey and linked to graduates’ recorded practice location obtained from the Australian Health Practitioner Regulation Agency (AHPRA, January 2021). The rurality of the practice location was defined based on the Modified Monash Model (MMM 3–7) or Australian Statistical Geography Standard (ASGS 2–5). Logistic regression was used to examine associations between student rural training experiences and rural practice location.ResultsA total of 241 medical students (60.1% females; mean age 23.2 ± 1.8 years) completed the FRAME survey (response rate 93.2%). Of these, 91.7% felt well supported, 76.3% had a rural-based clinician mentor, 90.4% reported increased interest in a rural career, and 43.6% preferred a rural practice location after graduation. Practice locations were identified for 234 alumni, and 11.5% were working rurally in 2020 (MMM 3–7; 16.7% according to ASGS 2–5). In adjusted analysis, the odds of working rurally were 3–4 times more likely among those with a rural background or lived the longest in a rural location, 4–12 times more likely among those preferring a rural practice location after graduation, and increased with the student’s rural practice self-efficacy score (p-value < 0.05 in all cases). Neither the perceived support, having a rural-based mentor, or the increased interest in a rural career were associated with the practice location.ConclusionsThese RCS students consistently reported positive experiences and increased interest in rural practice after their rural training. Student reported preference for a rural career and rural practice self-efficacy score were significant predictors of subsequent rural medical practice. Other RCS could use these variables as indirect indicators of the impact of RCS training on the rural health workforce.

Many countries in the developing world are plagued with challenges of inadequate and inequitable distribution of the health workforce. The Paucity of qualified health workers in rural areas is a critical challenge for India’s Health Sector. In view of the continuing challenges of Physician shortage in India, an understanding of our medical students’ attitude and perception towards rural medical practices is essential for appropriate planning of human resources. To assess the attitude and perception of medical students towards rural medical practices and identified the associated factors in order to fill these information gaps. A descriptive cross-sectional study was conducted among 282 MBBS students of the Government Medical College in Uttarakhand state, India. First, Third and Fifth semesters MBBS students were the study participants. Participants were enrolled by convenient sampling method. Ethical approval was sought and obtained from the Institutional Ethics Committee. Data was entered and analyzed with SPSS Software Version 22. Among 282 MBBS Students, 68% females showed willingness to work in rural area compared to 57.6% of males. All the reasons for willingness as well as non-willingness to work in rural areas of Uttarakhand had statistically significant difference. Medical student’s attitude and perception to work in rural health services need much improvement towards positive side by intervention and implementation by joint collaborative efforts of Medical Education Department, Health department and State Government.