Rural Medical Workforce Research Articles

Rural generalist medicine: a developing approach to health care in rural and island Japan.

Despite universal health coverage and high life expectancy, Japan faces challenges in health care that include providing care for the world's oldest population, increasing healthcare costs, physician maldistribution and an entrenched medical workforce and training system. Primary health care has typically been practised by specialists in other fields, and general medicine has only been certified as an accredited specialty since 2018. There are continued challenges to develop an awareness and acceptance of the primary health medical workforce in Japan. The impact of these challenges is highest in rural and island areas of Japan, with nearly 50% of rural and remote populations considered 'elderly'. Concurrently, these areas are experiencing physician shortages as medical graduates gravitate to urban areas and choose medical specialties more commonly practised in cities. This study aimed to understand the views on the role of rural generalist medicine (RGM) in contributing to solutions for rural and island health care in Japan. This was a descriptive qualitative study. Data were collected via semi-structured interviews with 16 participants, including Rural Generalist Program Japan (RGPJ) registrars and supervisors, the RGPJ director, government officials, rural health experts and academics. Interviews were of 35-50 minutes duration and conducted between May and July 2019. Some interviews were conducted in person at the WONCA Asia-Pacific Conference in Kyoto, some onsite in hospital settings and some were videoconferenced. Interviews were recorded and transcribed. All transcripts were analysed through an inductive thematic process based on the grouping of codes. From the interview analysis, six main themes were identified: (1) key issues facing rural and island health in Japan; (2) participant background; (3) local demography and population; (4) identity, perception and role of RGM; (5) RGPJ experience; and (6) suggested reforms and recommendations. The RGPJ was generally considered to be a positive step toward reshaping the medical workforce to address the geographic inequities in Japan. While improvements to the program were suggested by participants, it was also generally agreed that a more systematic, national approach to RGM was needed in Japan. Key findings from this study are relevant to this goal. This includes considering the drivers to participating in the RGPJ for future recruitment strategies and the need for an idiosyncratic Japanese model of RGM, with agreed advanced skills and supervision models. Also important are the issues raised by participants on the need to improve community acceptance and branding of rural generalist doctors to support primary care in rural and island areas. The RGPJ represents an effort to bolster the national rural medical workforce in Japan. Discussions from participants in this study indicate strong support to continue research, exploration and expansion of a national RGM model that is contextualised for Japanese conditions and that is branded and promoted to build community support for the role of the rural generalist.

Rural longitudinal integrated clerkships and medical workforce outcomes: A scoping review

Introduction Internationally the medical workforce is suffering from a persistent geographic and specialist maldistribution. Longitudinal models of rural medical education such as longitudinal integrated clerkships (LIC) have been one of the strategies employed to redress this issue. Aim To map and synthesise the evidence on the medical workforce outcomes of rural LIC graduates, identifying gaps in the literature to inform future research. Methods This review followed Arksey and O’Malley’s methodological steps. Databases searched included Medline, CINAHL Complete (EBSCOhost), Scopus, Embase (Elsevier), and ISI Web of Science. Results A total of 9045 non-duplicate articles were located, 112 underwent a full review, with 25 articles meeting the inclusion criteria. Studies were commonly cohort-based (84%), with data collected by database tracking and data linkage (52%). Five themes were identified to summarise the studies: (i) Overall geographic workforce outcomes (ii) influence of non-LIC medical training, (iii) remaining in region and level of rurality, (iv) medical speciality choice and rurality, and (v) selection and preferences. Conclusion Synthesis of the evidence related to workforce outcomes of rural LIC graduates provides directions for future rural medical workforce planning and research. While rural LIC graduates were found to be more likely to work rurally and in primary care specialities compared to graduates from other training pathways there is evidence to suggest this can be enhanced by strategically aligning selection and training factors.

Rural medical workforce pathways: exploring the importance of postgraduation rural training time

BackgroundInadequate distribution of the medical workforce in rural regions remains a key global challenge. Evidence of the importance of postgraduation (after medical school) rural immersion time and subsequent rural practice, particularly after accounting for other key factors, remains limited. This study investigated the combined impact of three key training pathway factors: (1) rural background, (2) medical school rural immersion, and (3) postgraduation rural immersion, and duration time of each immersion factor on working rurally.MethodsData from a cross-sectional national survey and a single university survey of Australian doctors who graduated between 2000 to 2018, were utilised. Key pathway factors were similarly measured. Postgraduation rural training time was both broad (first 10 years after medical school, national study) and specific (prevocational period, single university). This was firstly tested as the dependent variable (stage 1), then matched against rural practice (stage 2) amongst consultant doctors (national study, n = 1651) or vocational training doctors with consultants (single university, n = 478).ResultsStage 1 modelling found rural background, > 1 year medical school rural training, being rural bonded, male and later choosing general practice were associated with spending a higher proportion (> 40%) of their postgraduation training time in a rural location. Stage 2 modelling revealed the dominant impact of postgraduation rural time on subsequent rural work for both General Practitioners (GPs) (OR 45, 95% CI 24 to 84) and other specialists (OR 11, 95% CI 5–22) based on the national dataset. Similar trends for both GPs (OR 3.8, 95% CI 1.6–9.1) and other specialists (OR 2.8, 95% CI 1.3–6.4) were observed based on prevocational time only (single university).ConclusionsThis study provides new evidence of the importance of postgraduation rural training time on subsequent rural practice, after accounting for key factors across the entire training pathway. It highlights that developing rural doctors aligns with two distinct career periods; stage 1—up to completing medical school; stage 2—after medical school. This evidence supports the need for strengthened rural training pathways after medical school, given its strong association with longer-term decisions to work rurally.

Evaluating the impact of the Adelaide Rural Clinical School longitudinal clinical placement on the rural medical workforce: A retrospective cohort study of graduates, 2004-2019.

To evaluate the contribution of the Adelaide Rural Clinical School (ARCS) longitudinal integrated clerkship to the rural medical workforce. Design: Retrospective cohort study. Practice location data were sourced from the Australian Health Practitioner Regulation Agency (AHPRA, January 2021) and matched using university records. University of Adelaide medical school alumni graduating between 2004 and 2019 (ARCS alumni who completed a full year of rural training [n = 423], metropolitan-trained peers [n = 1655]). The proportions of medical graduates working in a rural location (Modified Monash Model [MMM3-7] or Australian Statistical Geography Standard [ASGS-RA2-5] classifications). Logistic regression was used to examine the association between ARCS training and working rurally, and the influence of rural background and sociodemographic factors. Working in a rural location was almost three times more frequent among ARCS alumni than their metropolitan-trained peers, using the MMM3-7 (14.7% vs. 5.3%) classification; forASGS-RA2-5 classification (21.3% vs. 8.9%). In adjusted analysis, working rurally (MMM3-7) was associated with having a rural/remote residence on enrolment (OR 8.29, 95% CI 4.22-16.26) and was 3.1 times more likely for ARCS alumni (OR 3.06, 95% CI 2.06-4.53) than their peers. The magnitude of the effects of ARCS training on whether they are working rurally was similar among those with metropolitan or rural background (p-value for interaction 0.873). Similar associations were observed using ASGS-RA2-5 classifications. Extended rural placements through the Adelaide Rural Clinical School increased the rural medical workforce, with a similar impact among those with a rural or metropolitan background.

Attracting, Recruiting, and Retaining Medical Workforce: A Case Study in a Remote Province of Indonesia.

Indonesia, one of the Asia Pacific low-and middle-income countries (LMICs), has suffered from a chronic medical workforce shortage. However, there are limited published studies describing the approaches implemented by the Indonesian government regarding the recruitment and retention of the medical workforce. This case study aimed to understand the current practices for recruitment and retention of the medical workforce in Indonesian rural and remote provinces. We conducted a case study of the Maluku Province of Indonesia with a document analysis and key informant interviews with officials responsible for medical workforce recruitment and retention. We used the World Health Organization's (WHO) guidelines as an analytical matrix to examine the recruitment and retention practices under the four domains of (i) educational, (ii) regulatory, (iii) financial, and (iv) professional and personal development and classified them into either University/Medical School level or Government/Non-government level. Our findings suggest that Indonesia implemented most of the WHO-recommended medical workforce recruitment and retention strategies. However, implementation is still problematic; hence, the aim of establishing an adequate, sustainable medical workforce has not been reached. Nationwide government intervention in educational aspects is important to magnify the impact of regional medical school initiatives. Relevant programmes must be re-evaluated and re-enforced concerning significance, comprehensiveness, and effectiveness for a sustainable rural and remote medical workforce.

A qualitative perspective on what factors influence ScotGEM students' career intentions.

ScotGEM is a novel graduate medicine programme in Scotland with a rural generalist focus. This survey-based study aimed to assess the career intentions of ScotGEM students and the various factors influencing them. An online questionnaire was devised from existing literature that explored students' interest regarding generalist or specialty career, geographical location, and influencing factors. Free-text responses regarding their primary care career interest and their reasoning behind geographical preferences allowed for qualitative content analysis. Responses were coded inductively and categorised into themes by two independent researchers who then compared and finalised the themes. 126/163 (77%) completed the questionnaire. Content analysis of free-text responses in relation to a negative attitude towards a prospective GP career yielded themes: personal aptitude, emotional toll of GP and uncertainty. Themes in relation to desired geographical preference included: family factors, lifestyle issues and perceptions regarding professional and personal development opportunities. The qualitative analysis of factors influencing the career intentions of students on the graduate programme is key to understanding what is important to them. Students who have decided against primary care have realised an early aptitude for specialism due to their experiences, while also witnessing the potential emotional toll of primary care. Family needs may already be dictating where they will choose to work in the future. Lifestyle reasons were in favour of both urban and rural careers, with a sizeable number of responses still uncertain. These findings and their implications are discussed in context of existing international literature on rural medical workforce.

'The word that comes to mind is polymath': medical students' perceptions of rural postgraduate careers.

Medical education is essential in strengthening the rural medical workforce globally. Immersive medical education in rural communities guided by good role models and rural-specific curricula promotes rural recruitment of recent graduates. While curricula can be rurally oriented, the mechanism of action is unclear. Comparing different programmes, this study examined medical students' perceptions of rural and remote practice and how these perceptions influence students' intentions to practice rurally. The University of St Andrews has two medical programmes: BSc Medicine and graduate-entry MBChB (ScotGEM). Commissioned to address Scotland's rural generalist crisis, ScotGEM employs high quality role modelling, alongside 40-week immersive rural longitudinal integrated clerkships. This cross-sectional study utilised semi-structured interviews with 10 St Andrews students enrolled in undergraduate or graduate-entry medical programmes. We deductively applied Feldman and Ng's 'Careers: Embeddedness, Mobility, and Success' theoretical framework to examine rural medicine perceptions in medical students exposed to different programmes. Structural themes included geographically isolated physicians and patients. Organisational themes included limited staff support in rural practices and perceived inequitable resource allocation between rural and urban communities. Occupational themes included the recognition of rural clinical generalists. Personal themes included the perception of tight-knit rural communities. Medical students' experiences (educational, personal, or working) most profoundly shaped their perceptions. Medical students' perceptions align with professionals' reasons for career embeddedness. Perceptions unique to rurally interested medical students included isolation, the need for rural clinical generalists, uncertainty in rural medicine, and tight-knit rural communities. Educational experience mechanisms, including exposure to telemedicine, GP role-modelling, methods on overcoming uncertainty, and codesigned medical education programmes, explain perceptions.

A return-on-investment analysis of impacts on James Cook University medical students and rural workforce resulting from participation in extended rural placements.

Although all James Cook University (JCU) medical students complete multiple rural placements, some undertake extended 5-10 month rural placements in their final year. This study uses return-on-investment (ROI) methodology to quantify student and rural medical workforce benefits of these 'extended placements' from 2012 to 2018. Forty-six medical graduates were sent a survey exploring the benefits to students and to the rural workforce from participation in extended placements, as well as estimated costs to students, deadweight (how much change would have occurred without participating), and attribution (how much change was due to other experiences). The key student and rural workforce benefits were each assigned a 'financial proxy' to allow calculation of ROI as a dollar value that could be compared with the costs to students and to the medical school. Of the graduates, 25/46 responded (54%), reporting the major benefit was 'greater depth and breadth of clinical skills'. The overall cost of undertaking extended placements for students was $60,264 (AUD), while the medical school costs were $32,560 (total costs: $92,824). Given the total value of benefits ($705,827) calculated for the key student benefit of increased clinical skills and confidence in the internship year ($32,197) and for the key rural workforce benefit of willingness to work rurally ($673,630), the ROI from the extended rural programs is $7.60 for every dollar spent. This study confirms significant positive impacts of extended placements on final-year medical students with longer-term benefits for rural workforce. This positive ROI is important evidence for shifting the conversation around supporting extended placements from one of cost to one of value.

Title-blended supervision models for post-graduate rural generalist medical training in Australia: an interview study

BackgroundExpanding rural training is a priority for growing the rural medical workforce, but this relies on building supervision capacity in small towns where workforce shortages are common. This study explored factors which support the use of blended supervision models (consisting of on- and offsite components) for postgraduate rural generalist medical training (broad scope of work) in small rural communities.MethodsData were collected between June and August 2021 through semi-structured, in-depth interviews with medical training stakeholders experienced in blended supervision models for rural generalist training. Interviews were audio-recorded, transcribed verbatim and analysed using an inductive thematic analysis process.ResultsFifteen participant interviews provided almost 13 h of audio-recorded data. Four themes were developed: governance, setting, the right supervisor and the right supervisee. Blended supervision models may be effective if selectively applied including where the model is well-planned, the setting has local team supports and supervisor and supervisee characteristics are appropriate.ConclusionsUnderstanding factors involved in the application of blended supervision models can help with expanding rural generalist training places in distributed communities. Blended supervision models can be effective for rural generalist training if the model is planned, and the context is suitable.

A return-on-investment analysis of impacts on James Cook University medical students and rural workforce resulting from participation in extended rural placements.

Although all medical students at James Cook University (JCU), Queensland, Australia, undertake rural placements throughout their course, a proportion (currently about 20 per year out of 170-190 final-year students) undertake extended rural placements in rural and remote towns - 5-month Integrated Rural Placement (IRP) or 10-month Longitudinal Integrated Clerkship (LIC) programs. This study uses a return-on-investment (ROI) approach to quantify student and rural medical workforce benefits arising from these 'extended placements' between 2012 and 2018. Seventy-two JCU MBBS graduates participated in extended rural placements between 2012 and 2018. In 2019, 46 of these graduates who had reached at least postgraduate year 2 and provided consent to be contacted for health workforce research were emailed a link to an online survey. Questions explored the key benefits to students' development of competencies and to rural medical workforce as a direct result of student participation in the IRP/LIC activities, as well as estimations of costs to students, deadweight (how much change would have occurred without participating in an extended placement), and attribution (how much change was due to other programs or experiences). The key student and rural medical workforce benefits were each assigned a 'financial proxy' to allow calculation of ROI from 2013 to 2019 as a dollar value, compared with the costs to students and to the JCU medical school from implementing the IRP/LIC programs between 2012 and 2018. Twenty-five of the 46 JCU medical graduates who undertook an extended placement responded (response rate 54%), reporting that the most common (96%) and most important benefit (56%) from their extended placement was 'greater depth and breadth of clinical skills'. Seventy-five percent (18/24; one missing response for this question) of the respondents also reported intending to have a full-time career in rural and remote practice. The overall cost of undertaking an IRP or LIC program for students between 2012 and 2018 was calculated to be $60,264, while the cost to the JCU medical school for sending 72 students out on extended rural placements was calculated as $32,560, giving total costs of $92,824. Given the total value of benefits ($705,827) calculated for the key student benefit of increased clinical skills and confidence in the internship year from participating in an extended placement ($32,197) and for the key rural medical workforce benefit of willingness to work in a rural or remote town ($673,630), the ROI from the extended rural programs between 2013 and 2019 (after students graduated and entered the workforce) is calculated at $7.60 for every dollar spent. This study confirms that undertaking an extended placement has significant positive impacts on final-year medical students' clinical confidence, clinical skills and communication skills into their internship year. In addition, the extended placements have longer-term impacts on the non-metropolitan health workforce by inspiring more JCU medical graduates to take up rural generalist, rural general practitioner or generalist specialist positions in rural and remote towns. This positive ROI from extended rural placements is important evidence for shifting the conversation around supporting these programs from one of cost to one of value.

Objective Simulated Bush Engagement Experience (OSBEE): A novel approach to promote rural clinical workforce.

The mal-distributed Australian medical workforce continues to result in rural medical workforce shortages. In an attempt to increase rural medical workforce, the Australian Government has invested in the Rural Health Multidisciplinary Training (RHMT) program, involving 21 medical schools (RHMT program, 2020). This funding requires participating universities to ensure at least 25% of domestic students attend a year-long rural placement during their clinical years and 50% of domestic students experience a short-term rural clinical placement for at least four weeks.

Flinders University rural medical school student program outcomes.

The impact of Australian Government Rural Clinical School (RCS) programs onthe geographical maldistribution ofthe Australian medical workforce isimportant to report. This data linkage study compared graduates of the Flinders University medical program who have undergone training in a metropolitan tertiary hospital (Flinders Medical Centre, Adelaide) with those who participated in the Parallel Rural Community Curriculum (PRCC) RCS Program based in rural towns of South Australia between 1999 and 2012. Australian Health Practitioners Authority data were used to determine their location of practice in 2017. In 2017, more than one-third (36.8%) ofPRCC graduates were working in non-metropolitan Modified Monash (MM) 2-7, compared with 20.7% of city campus graduates (odds ratio 2.2; 95% confidence interval: 1.6, 3.0; P <0.001). The difference was even more evident when comparing smaller rural centres inMM 3-7 and MM 5-7. The study demonstrates the strong correlation between the Flinders University RCS Program in South Australia and long-term rural medical workforce outcomes.

Rocketship and the Rural Health Workforce Revolution in the Pacific: Growing Skilled Medical Generalists Across the "Blue Continent".

Dramatic shifts are occurring in the size, shape and skill of rural health workforces in Pacific island countries (PICs) due to an unprecedented convergence of political agreement, policy commitment, donor support and technical assistance. In particular, the impact of “medical internationalism” is being felt across the Pacific region, with new doctors returning home in far greater numbers than ever before, the majority having graduated from medical schools in Cuba, China and other countries outside the region, in addition to the more typical numbers graduating and returning home from the region's main medical schools in Fiji and Papua New Guinea. With an agreed regional vision of “Healthy Islands” across the Pacific, the main objective of expanding overseas training opportunities for Pacific island medical students has been to correct the widespread centralization and maldistribution of the medical workforce in PICs and improve health access and quality of care in rural areas by deploying the new graduates to outer-island facilities. However, the return of these new graduates in several PICs has demonstrated that additional training is required to equip them with the knowledge and skills necessary to practice safely and sustainably in unsupervised settings. Thus, the development of specific postgraduate programmes has been urgently needed to provide pathways to vocational training and specialization in rural medicine appropriate to the Pacific region. Rocketship Pacific Ltd. (Rocketship) is an international health charity, based in Australia, dedicated to improving health in Pacific island countries through stronger primary care. Rocketship's particular focus to date has been on education and capacity-building for doctors and nurses working in rural communities and outer-island facilities. Since 2015, Rocketship has been working in partnership with the Ministries of Health and other key partners in Solomon Islands, Timor-Leste, Tonga and Vanuatu to design and deliver postgraduate training programmes in the core generalist disciplines family, community and rural hospital medicine. To date, this has resulted in new postgraduate Family Medicine courses being established in Timor-Leste and Tonga; a rural medical workforce support programme being delivered in Vanuatu; and a new Postgraduate Diploma in Rural Generalist Medicine being designed in Solomon Islands. These new programmes, as well as other notable initiatives elsewhere in the Pacific such as the Master of Medicine (Rural) programme in Papua New Guinea, the Diploma and Master of Family Medicine programme in Fiji and the Cook Islands Fellowship in General Practice, are transforming the health workforce in PICs with the potential to benefit island people across the “Blue Continent.” This paper describes the establishment of new postgraduate training programmes in family, community and rural hospital medicine in Timor-Leste, Tonga, Solomon Islands and Vanuatu from the perspective of Rocketship, the non-profit organization engaged by each country's Ministry of Health (or equivalent) to provide expert technical assistance with their initiative.

Intention mutability and translation of rural intention into actual rural medical practice.

Rural intention and experience during medical school have been related to subsequent rural work. However, their relative contributions and the timing of their effects are not known. These data are critical to effective educational interventions able to improve rural medical workforce numbers, an international priority. Participants were graduates of an Australian MBBS degree between 2006 and 2016, who completed both entry and exit surveys approved by the Medical Deans of Australia, including workplace intention data. Rural/urban workplace intention changes from entry to exit were analysed using multinomial logistic regression. Binary logistic regression was used to assess actual rural versus urban work, obtained from a public practitioner registration website. Of 547 eligible undergraduates, 169 completed a year-long rural clinical school (RCS). A subset of 93 of the 547 graduates practiced rurally, of whom 42 had completed RCS. Both rural background and RCS predicted rural practice intention; both were also significantly related to actual rural work. Enduring rural intention was associated with nearly sevenfold odds of actually practicing rurally, compared with an enduring urban intention. Those who changed practice intention from entry to exit were more likely to practice in the region of their exit intention. Of special note: Rural Clinical School of Western Australia (RCSWA) exposure particularly affects urban origin students such that the odds of changing from an urban to a rural orientation immediately after their rural experience were more than fourfold higher than those not so participating. Both intention and RCSWA experience are associated with subsequent rural work. The impacts of RCSWA were able to be localised after the rural educational experience. Amongst those with mutable intention, exit intention was that most strongly related to actual work, suggesting this as the most reliable point to select for further rural training.

Gender equity at last: a national study of medical students considering a career in rural medicine

BackgroundThe rural medical workforce internationally suffers from a significant imbalance between male- and female- identifying practitioners. Not only do male doctors outnumber female doctors, but additionally female doctors work fewer hours than their male counterparts. This has health implications for rural communities. In response, In Australia, Rural Clinical Schools (RCSs) are a national training strategy to increase the number of graduates entering the rural medical workforce. It has been observed that RCSs attract a greater number of female students than male students. However, the future work intentions of male versus female RCS students is not known. This paper therefore asked whether male and female RCS students have equivalent intent for future rural practice.MethodsParticipants were all students who attended RCSs from 2015 to 2017, who completed an exit survey that gathered data on demographic, experiential and intentional variables. Univariate analyses examined differences between the sexes. A multivariate model was constructed to determine the independent predictors for rural intention.ResultsThere were 2017 respondents across the 3 years, of whom 937 identified as male, and 1138 identified as female. In univariate analysis, female-identifying students had significantly higher rural intention than male-identifying students. There were no other sex-based differences in age, rural background, overall perception of support, and overall excellence of clinical education whilst in RCS.However, in multivariate analysis, sex was not a significant predictor for rural work intention, whereas older age, rural background, and first preference for RCS were all predictive of increased rural intent, as expected from the literature. There were no differences between male and female students in their perceptions of the overall support and the clinical education provided by RCS.ConclusionWe conclude from this national study that sex is not an independent predictor for future rural work intention among RCS students. Considering the disproportionate number of female students entering RCS, this is reassuring for ultimately achieving rural workforce gender equity.

Medical student well‐being during rural clinical placement: A cross‐sectional national survey

Understanding rural student well-being is essential to inform the development and training of the future rural medical workforce so as to ensure a pipeline of rural doctors to meet rural communities' needs. However, little is known about the well-being of students who are on rural placement. This study aims to identify the predictors of well-being amongst a national sample of medical students on rural clinical placement. The Federation of Rural Australian Medical Educators (FRAME) 2015 national exit survey of medical students, completed at the end of rural terms, was used (n=644) to test the associations between well-being and demographic, financial, academic, supervisor, placement and clinical skills factors, and attitude to future rural work. Univariate and logistic regression were used. Students aged 18-24years (odds ratio [OR], 8.07 [95% confidence interval {CI}, 2.07-31.46]) and 25-34years (OR, 4.06 [95% CI, 1.35-12.18]) reported higher levels of well-being compared to students aged over 35years. Academic support from the rural clinical school (OR, 5.74 [95% CI, 2.59-12.73]), perceived respect from supervisors (OR, 3.13 [95% CI, 1.23-7.99]), not feeling socially isolated (OR, 2.7 [95% CI, 1.40-5.20]), access to counselling services (OR, 2.05 [95% CI, 1.10-3.83]), rural placement being a first choice (OR, 3.04 [95% CI, 1.58-5.86]) and positive attitudes to being part of a rural workforce in the future (OR, 4.0 [95% CI, 2.0-8.3]) were associated with higher odds of well-being compared to students who felt the opposite. Gender, rural background, financial support, clinical skills and role clarity were not found to be associated with well-being (P>.5). This study may provide guidance to rural clinical schools, policymakers and medical educators in developing rural placement programmes that enhance student well-being so we can address workforce shortages in rural areas.

Effective dimensions of rural undergraduate training and the value of training policies for encouraging rural work.

The implementation of rural undergraduate medical education can be improved by collecting national evidence about the aspects of these programmes that work well and the value of investing in national policies. This study aimed to explore how different durations, degree of remoteness and number of rural undergraduate medical training placements relate to working rurally, and to investigate differences after the introduction of formal national training policies that fund short- and long-term rural training experiences for medical students. A cohort of 6510 Australian-trained doctors who completed the Medicine in Australia: Balancing Employment and Life survey recalled their participation in rural undergraduate medical training. Responses were categorised by duration, remoteness as defined by the Modified Monash Model levels 3-4 and 4-7 compared with 1, and total number of placements. Multivariate regression was used to test associations with working rurally in 2017, and differences between cohorts of students who graduated pre- and post-2000, of which the latter were exposed to formal national training policies. Any rural undergraduate training was associated with working rurally (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.3-1.9) with incrementally stronger associations for longer duration (>1year: OR 3.0, 95% CI 2.3-4.0), greater remoteness (OR 1.8, 95% CI 1.5-2.1) and three placements (OR 2.4, 95% CI 1.9-3.0) compared with none. Rural background (OR 2.6, 95% CI 2.3-3.0) and general practice (OR 2.6, 95% CI 2.2-2.9) were independently associated with working rurally; being female was negatively associated with rural work (OR 0.7, 95% CI 0.6-0.8). The cohort of doctors who trained in a period when national rural training policies had been implemented included more graduates with a rural background and experience of undergraduate rural training but returned equivalent proportions of rural doctors to pre-policy cohorts, and included proportionally more women and fewer general practitioners. Rural undergraduate training should focus on multiple dimensions of duration, remoteness and number of rural undergraduate training experiences to grow the rural medical workforce. Formal national rural training policies may be an important part of the broader system for rural workforce development, but they rely on the uptake of general practice and the participation of female doctors in rural medicine.

Approaches to Facilitate Improved Recruitment, Development, and Retention of the Rural and Remote Medical Workforce: A Scoping Review Protocol.

Background: Medical workforce scarcity in rural and remote communities is a global problem, severely challenging healthcare delivery and health equity. Both developed and developing countries report geographically uneven distributions of the medical workforce. This scoping review synthesizes evidence from peer-reviewed and grey literature concerning approaches implemented to improve the recruitment, development, and retention of the rural medical workforce in both developed and developing countries. Methods: We will utilize the Arksey and O’Malley (2005) framework as the basis for this scoping review. The databases to be searched include Medline, Embase, Global Health, CINAHL Plus, and PubMed for articles from the last decade (2010-2019). Searches for unpublished studies and grey literature will be undertaken using the Google Scholar - Advanced Search tool. Quantitative and qualitative study designs will be included. Two authors will independently screen and extract relevant articles and information, with disagreements resolved by a third. Quantitative and qualitative analyses (thematic) will be conducted to evaluate and categorize the study findings. Discussion: The scoping review will aid in mapping the available evidence for approaches implemented to advance the process of recruitment, development, and retention of the medical workforce in the rural and remote areas in developed and developing nations.

Call to expand teaching opportunities in rural family medicine.

In an attempt to become less dependent on international medical graduates, the Australian government has invested heavily in increased number of medical school places over the last decade. There is now consensus that workforce shortages, particularly in rural practice, general practice and rural generalist medicine are due to maldistribution of medical workforce rather than a national shortage. A rural generalist is defined as a general practitioner who provides emergency after-hours, inpatient services and one or more additional skills such as anaesthetics, palliative care or mental health. Since 2002, the Australian Commonwealth Government has invested in rural medical workforce development through the Rural Health Multidisciplinary Training (RHMT) program.

Defining rural teaching hospitals in Canada: Developing and testing a new definition.

The current definition of 'teaching hospital' provided by Canadian Institute of Health Information (CIHI) focuses on large academic teaching hospitals. High-quality rural training experiences have been identified as a key component of training the future rural medical workforce. Identifying communities and hospitals where this training is currently available and taking place is important in understanding the current landscape of available rural training but is hampered by the lack of an agreed upon definition of 'rural teaching hospital'. This limits the understanding of current rural training landscapes, comparison across regions and research in this area. We propose a definition of a 'rural teaching hospital'. Using the CIHI definition of rural as an initial reference point, we used accessible data from the University of Calgary and University of Alberta Distributed Medical Education (DME) programs to develop a definition of a 'rural teaching hospital'. We then identified rural Alberta hospitals to show how this definition would work in practice. Our definition of a rural teaching hospital is a hospital situated in a town of <30,000 people, teaching occurs at least 36 h a week and that teaching includes at least Family Medicine clerkship OR Family Medicine residency rotations. We identified 104 Alberta rural hospitals. The University of Calgary and University of Alberta DME programs included 70 communities and 44 of these communities met all three proposed criteria for rural teaching hospitals. Creating a working definition of a 'rural teaching hospital' is of high importance for both research and for day-to-day operations of rural educational units.