Rural Clinical Experience Research Articles

Routes to Rural Readiness: Enhancing Clinical Training Experiences for Physician Assistants.

The purpose of this study was to describe practices and experiences of rurally oriented physician assistant (PA) training programs in providing rural clinical training to PA students. A survey of PA program directors (PDs) included questions about program characteristics, student and clinical preceptor (CP) recruitment in rural areas, and barriers to, and facilitators of, rural clinical training. Programs that considered rural training "very important" to their goals were identified. We interviewed PDs from rurally oriented programs about their rural clinical training and rural CPs about their experiences training PA students for rural practice. We identified key themes through content analysis. Of 178 programs surveyed, 113 (63.5%) responded, 61 (54.0%) of which were rurally oriented and more likely than other programs to recruit rural students or those with rural practice interests and to address rural issues in didactic curriculum. The 13 PDs interviewed linked successful rural training to finding and supporting rural preceptors who enjoy teaching and helping students understand rural communities. The 13 rural CPs identified enthusiastic and rurally interested students as key elements to successful rural training. Interviewees identified systemic barriers to rural training, including student housing, decreased productivity, competition for training slots, and administrative burden. Physician assistant students can be coached to capitalize on their rural clinical experiences. Knowing how to "jump in" to rotations and having genuine interest in the community are particularly important. Student housing, competition for training slots, and lack of financial incentives are major system-level challenges for sustaining and increasing the availability of PA rural clinical training.

What have the Romans ever done for us?

The only privilege of being the Editor in Chief of a journal is that I get the opportunity to write an editorial for every edition. I can say, within reason, what I like, without peer review, censor or editing by anyone else. This being my last editorial for the journal that is probably even more true. So, as I sat contemplating the blank screen to write this editorial, my tongue decided it was once again time to explore the tooth that was causing me some discomfort, where a chip had come off making it extremely sensitive. My experience of managing this dental problem brought my mind to the RHMT funding for rural health workforce training and that is when the title of this paper came to the front of my mind. Yes, for those of you from my generation, I am referencing the classic scene from Monty Python's, Life of Brian. As John Cleese, playing the part of Reg goes on to say “apart from sanitation, the medicine, education, wine, public order, irrigation, roads, a fresh water system and public health, what have the Romans ever done for us?” What has that got to with the Australian rural health care. Well at times I feel like I am Reg in the Life of Brian. I struggle to see what the Romans, in the form of the RHMT funded Rural Clinical Schools, University Departments of Rural Health and Dental Training Expanding Rural Placement Programs have done for us. If I go back to my tooth. I live in a regional city, Bendigo, with both a Rural Clinical School (Monash), a University Department of Rural Health (La Trobe University) and a Dental School, solely based in Bendigo. Yet, when I saw the dentist and it was determined that I need my tooth assessed for suitability of a crown (it might need root canal work), my options were to wait a long time for an appointment with the Endodontist who comes to Bendigo from Melbourne, or travel to Melbourne to see them at their practice. In the latter case, I could get an appointment within a week, in the former, more than a month wait with ongoing pain. So, despite all the RHMT funding and rural health workforce training here in Bendigo, if I wanted a reasonably quick resolution of my tooth pain, I needed to go to Melbourne. Fortunately, I have the advantage of a good income and flexible employment, which allowed me to do that, with no financial penalty. Unfortunately, the vast majority of our rural communities do not have that privilege. So, at an individual level, I feel like Reg. Apart from “on average, graduates who had the most rural clinical placement experience are now working more in regional, rural and remote Australia” (1 p213) and “the RHMT program, has a direct economic benefit to the communities and regions with economic analyses demonstrating a positive multiplier effect of around 2 i.e. for every spent under the RHMT program another dollar is generated in the local economy” (1 p 236), I wonder what has the RHMT programme done for us. Despite these assertions, we do not have any good quality evidence anywhere that the approach we are taking is actually addressing the problems of recruiting and retaining a rural and remote health workforce. Where are the data that the workforce shortage in a city or town is less after an RCS or UDRH was established than before, or that towns without RCS's and UDRHs have more workforce shortages and worse health outcomes than communities with them. In the most recent review, that I am aware of,2 identified that 34 papers focused on health workforce retention interventions for rural and remote areas. They conclude that most of the studies were of low quality, that about only one-third applied appropriate statistical analysis to the date, less than half adjusted for key potential confounders, and many had no comparator groups.2 In no other contexts of health care would that be considered a solid literature base to make any conclusions on, yet it does not deter the authors from asserting “Policy makers seeking rural retention in the medium and longer term would be prudent to strengthen rural training pathways and limit the use of strongly coercive interventions.”2 So, my plea to the few people who read these editorials is can we please stop pretending that the RHMT programme has had a major impact on the health and health workforce of rural and remote Australia and spent the time and intellectual effort to actually determine if this approach is working because I am not seeing what the RHMT programme has done for my tooth.

Dietary Habits of Children 0 - 23 Months in Rural Kansas: Early Life Diets of Rural Children.

Children in rural areas face increased rates of obesity compared to their urban counterparts, and diet in early childhood may influence the development of diseases related to food intake. This study sought to determine current diet of children 0-23 months of age in rural Kansas. Medical students participating in 6-week, summer, rural clinical experiences offered the survey to caregivers of children 0-23 months, born at term as singletons without a specialized diet. The survey asked respondents to answer with the child's diet over the last seven days. The survey was in the style of a validated Food Frequency Questionnaire for infants with an image for estimating portion sizes. Diets were compared to guidelines set by the Dietary Guidelines for Americans, 2020-2025. Of 44 responses, 21 children were aged 0-5 months, 7 aged 6-11 months, and 16 aged 12-23 months. Breastfeeding rates were nearly double reported national averages. All children aged 0-5 months met guidelines. None of the children 6-11 months or 12-23 months met guidelines. In the 6-11 month group, four consumed food in addition to breastmilk or formula (complementary foods). In the 12-23 month group, protein and dairy foods were lower than, and whole grains and vegetables were higher than, reported national averages, respectively. Children may fall short of meeting dietary recommendations due to foods consumed in addition to breastmilk. There is a need for improved survey methods to capture the diets of young children in the rural United States.

Lessons Learned as Thomas Jefferson University's Rural Physician Shortage Area Program (PSAP) Approaches the Half-Century Mark.

To help increase the supply and retention of rural family physicians, Thomas Jefferson University initiated the Physician Shortage Area Program (PSAP) in 1974. The program selectively admits medical school applicants who both grew up in a rural area and plan to practice in a rural area. During medical school, PSAP students have ongoing mentoring and rural clinical experiences. As the program now approaches the half-century mark, this commentary summarizes several important lessons learned. First, outcomes research is critical, and program leaders have been able to publish 15 papers and a book about the PSAP and its outcomes. Second, these studies have shown that the program has been highly successful, with PSAP graduates 8.5-9.9 times more likely to enter rural family medicine than their peers, and that the PSAP contributed 12% of all rural family physicians in Pennsylvania. Other similar medical school rural programs have had comparable success, with more than half of all graduates combined (including PSAP graduates) practicing rural. Third, long-term retention has a multiplicative impact. Long-term retention of PSAP graduates in rural family medicine was greater than 70% after 20-25 years. Fourth, research has shown that the admissions component accounted for approximately three-quarters of the PSAP's success. Three factors available at the time of matriculation (rural background, plans for rural practice, and plans for family medicine) identified almost 80% of all Jefferson graduates in rural practice 3 decades later. Having a peer group with similar backgrounds, mentoring, and the rural curriculum were also very important. Fifth, wanting to live rural appears key to the rural practice decision. Finally, given that medical school programs like the PSAP produce substantial increases in the supply and retention of rural physicians while requiring modest resources, medical schools can have a critical role in addressing the rural physician shortage.

Influence of rural clinical school experience and rural origin on practising in rural communities five and eight years after graduation.

ObjectiveTo examine associations between extended medical graduates’ rural clinical school (RCS) experience and geographic origins with practising in rural communities five and eight years after graduation.Design, participantsCohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools.Main outcome measuresPractice location types eight years after graduation (2019/2020) as recorded by the Australian Health Practitioner Regulation Agency, classified as rural or metropolitan according to the 2015 Modified Monash Model; changes in practice location type between postgraduate years 5 (2016/2017) and 8 (2019/2020).ResultsData were available for 1321 graduates from ten universities; 696 were women (52.7%), 259 had rural backgrounds (19.6%), and 413 had extended RCS experience (31.3%). Eight years after graduation, rural origin graduates with extended RCS experience were more likely than metropolitan origin graduates without this experience to practise in regional (relative risk [RR], 3.6; 95% CI, 1.8–7.1) or rural communities (RR, 4.8; 95% CI, 3.1–7.5). Concordance of location type five and eight years after graduation was 92.6% for metropolitan practice (84 of 1136 graduates had moved to regional/rural practice, 7.4%), 26% for regional practice (56 of 95 had moved to metropolitan practice, 59%), and 73% for rural practice (20 of 100 had moved to metropolitan practice, 20%). Metropolitan origin graduates with extended RCS experience were more likely than those without it to remain in rural practice (RR, 2.0; 95% CI, 1.3–2.9) or to move to rural practice (RR, 1.9; 95% CI, 1.2–3.1).ConclusionThe distribution of graduates by practice location type was similar five and eight years after graduation. Recruitment to and retention in rural practice were higher among graduates with extended RCS experience. Our findings reinforce the importance of longitudinal rural and regional training pathways, and the role of RCSs, regional training hubs, and the rural generalist training program in coordinating these initiatives.

A qualitative exploration of the factors which influence rural nursing and midwifery placement experience: Benefits and challenges identified by students and health service staff

Background: Positive rural clinical experiences strongly correlate with future rural health career intention. It is therefore important to understand the factors which contribute to positive rural clinical placement experiences. Aims: To understand the benefits and challenges of rural nursing and midwifery placements for students, and to explore factors which influence positive clinical placement experiences. Methods: Semi-structured interviews were undertaken to explore the experiences and perspectives of nursing and midwifery students (n=17) and staff working at health services where students are placed (n=36). Data were subject to thematic analysis. Results: Five themes were identified: variety of experiences in a rural health context; supervision and support; engaging with a rural community; placement type and duration influence on rural placement experience; and inspiring, reaffirming or challenging future rural career intentions. Conclusion: This study reiterates the importance of ensuring that students are actively engaged and supported during rural clinical placements to encourage students to consider future rural career pathways. The findings highlight the important role of education providers and health services in supporting student placement experiences to enable positive rural career intentions.

Targeting the nurse practitioner workforce: Influences and barriers in choosing rural practice

Background and objective: Recruitment and retention of primary care providers are projected to worsen in rural regions. Nurse practitioners (NPs) are a crucial solution to the shortage of primary care providers in rural America. Little research exists regarding factors influencing new NPs’ decisions to practice in rural settings, as well as practice readiness. The purpose of this study is to explore factors influencing new NPs’ decision to practice in rural settings.Methods: A survey of family nurse practitioner (FNP) graduates in a rural state was conducted. The survey measured rural background, current practice environment, the impact of rural clinical experiences on readiness to practice, and perceptions of rural NP practice.Results: The data collected over five years (N = 42) indicated several factors that influenced an NP’s decision to choose a position in a rural or underserved setting. A wide scope of practice, rural roots, a desirable job offer, and strong relationships were influential when choosing rural practice.Conclusions: Most respondents (69%) were not practicing in rural or underserved areas. Among those who were, the ability to practice to the full scope of education and autonomy were the most important factors. However, respondents were also apprehensive and intimidated with the broad skill set required in rural care. Implications: This study provides insight into factors and barriers for new graduate NPs in choosing a rural practice setting as well as possible solutions to the rural workforce shortage.

Health professional students’ observations about interprofessional collaborative practice during rural clinical rotations

Students’ participation in rural interprofessional collaborative practices (ICP) environments is critical to transforming healthcare. To describe health professional learners’ observations of ICP core competencies (Values/Ethics for Interprofessional Practice, Roles and Responsibilities, Interprofessional Communication, and Teams and Teamwork) during their rural clinical rotations. Facilitated discussions or interviews were conducted in person or by phone with 65 Oregon AHEC scholars across four universities and eight health professions programs, including schools of medicine (MD, DO), physician assistant, graduate (FNP/DNP) and undergraduate nursing, dentistry and pharmacy. Our grounded theory analysis identified and verified emergent themes. Students' observations contributed to emergent themes that aligned favorably and unfavorably with ICP's core competencies. Learners reported a typology related to being included as members of the health care teams in rural settings that includes active, limited or observer role. Rural clinical experiences appear to enable or create barriers to students’ ICP learning.

What do dental students value about their rural placements-Is clinical experience enough?

Melbourne Dental School's (MDS) rural dental clinical placement program operates in two Victorian rural areas and offers final year dental students an integrated program of practical clinical experience and rural lifestyle exposure. The objective of this study was to understand the student's experiences to determine whether they increased the likelihood of them seeking rural employment after graduation. The University of Melbourne final year dental students attended 5-week mandatory rural clinical placements in 2018 and 2019. At the completion of their placement, students were invited to complete an anonymous questionnaire about their experiences, which had both quantitative and qualitative questions. This study examined the qualitative data using thematic analysis to identify common themes. Rural clinical dental placements at Goulburn Valley Health and Latrobe Community Health Service. Final year Dentistry and Oral Health students. Clinical placementevaluation questionnaire. To examinedentalstudents interest in rural practicepost rural clinical placement. Of the 129 students who completed the survey, 116 completed the open-ended questions and four themes were identified. Rich clinical experience; social capital; rural life and infrastructure. High levels of satisfaction were reported across all themes. This study demonstrated the rural clinical program to be a positive and enjoyable placement which increased dental students' clinical practice experience and their interest in considering rural practice upon graduation. Exposure to rural lifestyle and supportive clinical and social relationships were shown to be important influences. The current survey can benefit from refinement and further research following up MDS graduate workplace locations is recommended.

Urban ideals and rural realities: Physiotherapists navigating paradox in overlapping roles.

Rural practitioners who develop a sense of belonging in their community tend to stay; however, belonging means neighbours become patients and non-clinical encounters with patients become unavoidable. Rural clinical experiences expose students to overlapping personal and professional relationships, but students cannot be duly prepared to navigate them because ethical practice standards primarily reflect urban, and not rural, contexts. To inform such educational activities, this study examines rural physiotherapists' strategies for navigating overlapping relationships. Constructivist grounded theory guided iterative recruitment of 22 physiotherapists (PTs) living and practising in rural, northern or remote (RNR) communities in British Columbia, Canada, and analysis of their experiences navigating overlapping relationships. PTs routinely navigate overlapping relationships while mindful of practice standards, neighbourly and community expectations, personal well-being and patient welfare. While off-duty, they balance opposing expectations and manage various responsibilities to achieve contradictory goals such as being a professional who protects patient confidentiality while being an active and cordial community member. While on-duty, they face ethical dilemmas where deciding not to treat acquaintances potentially denies access to care but allows for clearer personal-professional boundaries and deciding to treat contravenes (urban) practice standards but could allow for customised patient care based on knowledge gained through both clinical and social interactions. Overlapping relationships are a rural norm. Urban ethical practice standards imposed on rural contexts put RNR practitioners in a paradoxical situation where clinical and social interactions must be but cannot be partitioned. Examining the identified strategies through the lens of paradox theory shows sophisticated cognitive framing of the conflicting and interrelated aims inherent to living and practising in RNR communities. Consequently, introducing a paradox mindset in educational activities could be explored as a way to prepare students for the ethically complex overlapping relationships that they will need to navigate during RNR clinical experiences.

Pipelines to Pathways: Medical School Commitment to Producing a Rural Workforce.

Despite the efforts of numerous medical schools to produce rural physicians, many rural communities in the United States still experience physician shortages. This study describes the current landscape of rural efforts in US undergraduate medical education and catalogs medical school characteristics and activities that evidence has suggested, and that many experts in rural medical education believe, may result in more graduates choosing rural practice. This is a descriptive study of publicly available and rurally relevant characteristics of all 182 allopathic and osteopathic medical schools operating in the 50 states and the District of Columbia in 2016, with rural program information for these schools updated in 2019. The authors constructed a "rural program" definition in order to systematically catalog coordinated and strategic medical school efforts to produce a rural physician workforce. Few (8.2%) medical schools expressed an explicit commitment to producing rural physicians in public mission statements. However, most (64.8%) provided rural clinical experiences and many demonstrated their commitment in other ways. Only 39 (21.4%) did so through a formal rural program. In establishing an explicit rural program definition and documenting other markers of rural commitment, this paper provides a baseline for future studies of rural workforce production and medical school investment in these programs, activities, and personnel. Demonstrating the effectiveness of schools' rural physician education efforts will require collaboration across institutions and more intensive evaluations of programs involving students who, though relatively few in number, have great potential for contributing to the health of rural communities across the nation.

Recruiting and retaining general practitioners in rural practice: systematic review and meta‐analysis of rural pipeline effects

To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas. Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas. MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature. Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle-Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12-3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48-2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80-7.46; eight studies). GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce. PROSPERO, CRD42017074943 (updated 1 February 2018).

Prevocational Integrated Extended Rural Clinical Experience (PIERCE): cutting through the barriers to prevocational rural medical education.

Despite an increase in the number of undergraduate training positions, Australia faces a critical shortage of medical practitioners in regional, rural and remote communities. Extended rural clinical placements have shown great utility in undergraduate medical curricula, increasing training capacity and providing comparable educational outcomes while promoting rural medicine as a career. The Prevocational Integrated Extended Rural Clinical Experience (PIERCE) was developed to increase the training capacity of the Queensland Rural Generalist Pathway (QRGP) and strengthen trainee commitment to rural practice by offering an authentic, extended 15-week rural term that provided an integrated experience in anaesthetics, obstetrics and gynaecology, and paediatrics, while meeting the requirements for satisfactory completion of prevocational rural generalist training. This study sought to evaluate whether trainees believed PIERCE and/or traditional regional hospital specialty placements achieved their learning objectives and to identify elements of the placements that contributed to, or were a barrier to, their realisation. This translational qualitative study explored the experiences and perceptions of QRGP trainees who undertook a PIERCE placement in three Queensland rural hospitals (Mareeba, Proserpine and Stanthorpe) in 2015, with a matched cohort of trainees who undertook regional hospital placements in anaesthetics, obstetrics and gynaecology, and paediatrics at a regional referral hospital (Cairns, Mackay and Toowoomba base hospitals). The study used a realist evaluation framework that investigates What works, for whom, in what circumstances, in what respects and why? PIERCE provided an enjoyable and valued rural training experience that promoted trainee engagement with, and contribution to, a rural community of practice, reinforcing their commitment to a career in rural medicine. However, QRGP trainees did not accept that PIERCE could be a substitute for regional hospital experience in anaesthetics, obstetrics and gynaecology, and paediatrics. Rather, trainees thought PIERCE and regional hospital placements offered complementary experiences. PIERCE offered integrated, hands-on rural clinical experience in which trainees had more autonomy and responsibility. Regional hospital placements offered more traditional caseload learning experiences based on observation and the handing down of knowledge and skills by hospital-based supervisors. Both PIERCE and regional hospital placements provided opportunities and threats to the attainment of the curriculum objectives of the Australian Curriculum Framework for Junior Doctors, the Australian College of Rural and Remote Medicine and the Royal Australian College of General Practitioners Fellowship in Advanced Rural General Practice curricula. PIERCE trainees enjoyed the opportunity to experience rural medicine in a community setting, a broad caseload, hands-on proficiency, continuity of care and an authentic role as a valued member of the clinical team. This was reinforced by closer and more consistent clinical and educational interactions with their supervisors, and learning experiences that address key weaknesses identified in current hospital-based prevocational training. Successful achievement of prevocational curriculum objectives is contingent on strategic alignment of the curricula with supportive learning mechanisms focused by the learning context on the desired outcome, rural practice. This study adds weight to the growing consensus that rural community-based placements such as PIERCE are desirable components of prevocational training.

Exploration of the factors that influence new Australian dental graduates to work rurally and their perspectives of rural versus metropolitan employment

The challenges in the recruitment and retention of dentists in rural Australia have contributed to a lack of dental service provision to rural communities. This paper explores the workforce factors involved in the employment location decisions of dentists' post-graduation. Graduates between 2009 and 2013 from the University of Sydney, Dental School, were asked to complete a telephone interview related to their employment history. A total of 135 interviews were conducted, with 63% (135/214) of contactable graduates, or 33.4% (135/404) of all the graduates (2009-2013). Interviews followed a semi-structured script. Key factors which positively impacted on rural employment included the following: job competition in metropolitan areas, good rural salaries, financial incentives, clinical experience, rural lifestyle and professional mentorship. Barriers were as follows: proximity to friends and family, building a social and professional network, isolation, less professional support and reduced access to education. Recommendations to increase rural employment include: competitive rural salaries, financial incentives and formal mentorship during both recruitment and integration into a rural community. Dental schools should consider advertising identified drivers of rural employment, namely good salaries, full-time employment, clinical experience and rural lifestyle. This study provides important information related to rural employment and rural retention.

A Qualitative Investigation of the Experiences of Students and Preceptors Taking Part in Remote and Rural Community Experiential Placements During Early Medical Training.

Background:Medical education can help alleviate the chronic undersupply of physicians to rural communities. Providing students with early rural clinical experiences may allow the gaining of necessary knowledge and skills to practice and live rurally, as well as the desire to do so.Purpose:This study aims to provide a detailed understanding of Remote and Rural Community Placements (RRCPs) which occur in the second year of a Doctor of Medicine programme.Methodology/Approach:Using a thematic analysis approach, we examined the experiences of students and preceptors in the RRCP. Data were collected using semi-structured interviews and focus groups.Findings/Conclusions:Students valued RRCPs as a formative clinical experience and preceptors gained professionally from participating. The RRCPs enhanced students regard for, and knowledge of, rural medicine. Yet, contrary to the stated aims of the placement, students spent very little time in activities outside of the clinic, neither learning about the community nor about the life of a physician as a community member.Implications:Medical educators should recognise that students and preceptors will inevitably place different value on the different sociocultural and perceptual aspects of placements, namely clinical and non-clinical. As such, the curriculum should draw clearly articulated links between each.

Shaping medical student\u2019s understanding of and approach to rural practice through the undergraduate years: a longitudinal study

BackgroundOver the last two decades medical schools have increased rural practice learning opportunities for students in an effort to improve recruitment to the rural workforce. James Cook University’s (JCU) medical school was established in northern Australia in 2000 with a specific focus on meeting the health needs of people in rural and remote areas.As part of a longitudinal study this paper explores the situational and motivational learning factors contributing to the development of JCU’s medical students’ understanding of and approaches to rural medical practice.MethodsAfter completing each consecutive, compulsory rural clinical placement in Year Two, Four and Six of their MBBS program, JCU medical students were asked to complete a survey about their rural learning experiences. The survey consisted of a combination of single choice, Guttman and Likert scales and open response questions. Data from two open response questions were coded and thematically analysed. Content analysis enabled the predominant value of each theme to be calculated.ResultsCollation of the survey data revealed 680 answers to both questions resulting in 1322 comments for analysis. Nine themes were categorized into clinical practice issues and person issues. The evolution of scope of practice across the years, the importance of inspirational mentors, access to urban areas and a sense of community were key findings. Positive rural clinical placement experiences inclusive of supportive ongoing learning opportunities and rural community living contribute positively to medical students’ interest in future rural medical practice. However, the ability to work for periods of time in both rural and urban settings suggested a possible need for a new additional model of practice.ConclusionClear links between a sense of community and belonging both professionally and socially as well as combined rural-urban practice options were important factors in the education and development of future rural practitioners. Ways to establish and support practice models incorporating both rural and urban locations needs to be investigated.

The big city by-pass: Origin is important in medical students’ preference for future practice in regional cities and large towns

Background: Rural clinical placement during medical training has been identified as important in addressing workforce mal-distribution in Australia. The University of Wollongong (UOW) medical school is unique in Australia in that all students undertake a 12-month continuous longitudinal-integrated-clerkship (LIC) placement in rural or regional NSW, or in the non-capital city urban centre where the university main campus is located. This paper investigates whether origin is important in medical students’intentions and preferences for future practice. Methods: Between 2010 and 2015, rural clinical school (RCS) students from Australian medical school programmes, including UOW, completed the same survey. The responsesfrom UOW students were compared to other students. The main outcome measuresinvestigated were preference for location of future practice and training, and careerpreferences. These were investigated with respect to location of origin of students. Results: UOW students preferred regional city/large town locations for future practicecompared to other RCS students. This finding strongly correlated with the non-capital city origin of UOW students. General practice/rural medicine was the career preference for one third of UOW students compared to one quarter of other students. Generalist specialist was the preference for almost half of other students. Skills developmentexperiences and outcomes were similar in both groups. Conclusions: Many students who have experienced a LIC placement in a regional or rural setting during training prefer smaller regional cities, towns or rural locations for future practice. Augmenting the rural clinical experience by affirmative action in preferential selection of students of non-capital city origin can result in more medical graduates wanting to “by-pass” the big cities.

Effect of medical student preference on rural clinical school experience and rural career intentions

The key parameter for rural clinical schools (RCSs) is to provide at least 1 year of clinical training in rural areas for 25% of Australian Commonwealth supported medical students with the intent to influence future rural medical workforce outcomes. The objective of this study was to describe the association between a medical student's selection preference and their RCS experience and rural career intent. Medical students completing an RCS placement in 2012 and 2013 were encouraged to complete a survey regarding their experience and future career intent. Data were analysed to compare medical students for whom the RCS was their first choice with students who described the RCS as other than their first preference. Students for whom RCS was their first choice (724/1092) were significantly more likely to be female, come from a rural background and be from an undergraduate program. These students reported more positive experiences of all aspects of the RCS program (costs, access, support and networks, safety) and were 2.36 times more likely to report intentions to practice in a non-metropolitan area (odds ratio(OR)=2.36 (95% confidence interval(CI)=1.82-3.06), <i>p</i><0.001). This was true for students of rural (OR=3.11 (95%CI=1.93-5.02), <i>p</i><0.001) and metropolitan backgrounds (OR=2.07 (95%CI=1.48-2.89), <i>p</i><0.001). More students in the first-choice group (68.8%) intended to practice in a regional area (not a capital or major city), significantly higher than the 48.4% of participants in the other-preference group (&#967;2 (1) 42.79, <i>p</i><0.001). The decision to choose an RCS placement is a marker of rural career intention and a positive rural training experience for students of both rural and metropolitan backgrounds. It may be important to identify other-preference students and their specific social support needs to ensure a positive perception of a future rural career.

Using area health education centers to promote interest in rural practice

In the USA, area health education centers (AHECs) work to recruit and educate students to serve in medically underserved communities, primary care, and rural settings. One important aspect of their work is connecting students with rural clinical experiences. Within these experiences, AHECs incorporate a community health/socioeconomic experience within the family medicine clerkship that may not be as prevalent in the standard family medicine clerkship experiences. The purpose of the study was to assess the relationship between AHEC-sponsored family medicine clerkships with a self-reported intent to practice in a rural setting upon graduation. The study compared third-year medical students with the Indiana University School of Medicine, which participated in AHEC-sponsored family medicine clerkships to the standard family medicine clerkship. Following the 4-week clerkship, students were asked to report their intent to work in a rural setting using a five-point Likert scale. A &#967;2 test was used to determine the association of AHEC sponsorship, clerkship site location (rural/urban) and intent to practice in a rural setting. The study consisted of 587 students. There was a statistically significant association between self-reported intent and rural clerkship site, &#967;2 (1, <i>N</i>=587)=6.542, <i>p</i>=0.01. Furthermore, 21.6% (<i>n</i>=25) of students with a rural clerkship experience reported a greater intent compared to 12.3% (<i>n</i>=58) of students with non-rural clerkship experience. The study confirmed a significantly positive association between participation in medical clerkship experiences in a rural primary care setting and the intent to practice in a rural setting upon graduation. The results also support the potential value-added benefits through academic-community partnerships with AHECs, family medical and other primary care specialty clerkship programs may perhaps succeed in increasing student interest in pursuing a practice serving in rural communities upon graduation.

Factors related to doctors' choice of rural pathway in general practice specialty training.

To investigate the factors eligible applicants consider in electing for a rural pathway into specialty training. Cohort study. Australia. Applicants to the Australian General Practice Training program. Applicants' initial preference of either a general or rural pathway to undertake specialty training. Of the 2,221 applicants, 45% were Australian Medical Graduates (AMGs), 27% Foreign Graduates of Accredited Medical Schools (FGAMS) and 29% International Medical Graduates (IMGs). Through government regulation, two thirds (70%) were eligible to train on both general and rural pathways and a third (30%) were required to train rurally. For applicants eligible for general pathway (n=1552), those with rural background [Odds Ratio (OR)=3.7, 95% CI 2.7-5.2] and rural clinical school experience (OR=2.0, 95% CI 1.5-2.8) were more likely to choose the rural pathway. In addition, FGAMS who were eligible for the general pathway were less likely to choose a rural pathway when compared with IMGs (OR=0.33, 95%CI 0.1=0.7). In applicants who changed their training pathway from their initial to revised preference, lower Multiple-Mini-Interview (OR=0.54, 95% CI 0.43-0.66) and Situational Judgement Test z-scores (OR=0.68, 95% CI 0.56-0.83) were associated with a higher probability of changing from a general to rural pathway preference. For those eligible for a general or rural pathway, rural background and rural clinical school experience are associated with the decision to elect for rural training. Targeted support for international and foreign graduates of Australia/New Zealand schools may influence them to train rurally.