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.

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries

BACKGROUND

Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies).

METHODS

We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes.

RESULTS

Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%).

CONCLUSION

Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

Approaches Used to Describe, Measure, and Analyze Place of Practice in Dentistry, Medical, Nursing, and Allied Health Rural Graduate Workforce Research in Australia: A Systematic Scoping Review

Redressing the maldistribution of the health workforce in regional, rural, and remote geographical areas is a global issue and crucial to improving the accessibility of primary health care and specialist services. Geographical classification systems are important as they provide an objective and quantifiable measure of access and can have direct policy relevance, yet they are not always consistently applied in rural health research. It is unclear how research focusing on the graduate health workforce in Australia has described, measured, and analyzed place of practice. To examine approaches used, this review systematically scopes Australian rural studies focusing on dentistry, medicine, nursing, and allied health graduates that have included place of practice as an outcome measure. The Joanna Brigg's Institute Scoping Review Methodology was used to guide the review. Database searches retrieved 1130 unique citations, which were screened, resulting in 62 studies for inclusion. Included studies were observational, with most focusing on the practice locations of medical graduates and predicators of rural practice. Variations in the use of geographical classification approaches to define rurality were identified and included the use of systems that no longer have policy relevance, as well as adaptations of existing systems that make future comparisons between studies challenging. It is recommended that research examining the geographical distribution of the rural health workforce use uniform definitions of rurality that are aligned with current government policy.

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

BACKGROUND

The 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.

METHODS

Participants 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.

RESULTS

There 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.

CONCLUSION

We 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.

Survival analysis of Rural Clinical School of Western Australia graduates: the long-term work of building a long-term rural medical workforce

BACKGROUND

Deficits in the rural medical workforce is an international issue. In Australia, The Rural Clinical School intervention is effective for initial recruitment of rural doctors. However, the extent of survival is not yet established. This paper summarises rural survival over a 10-year period.

METHODS

Rural Clinical School graduates of Western Australia were surveyed annually, 2006-2015, and post Graduate Years (PGY) 3-12 included. Survival was described as "tours of service", where a tour was either a period of ≥1 year, or a period of ≥2 weeks, working rurally. A tour ended with a rural work gap of ≥52 weeks. Considering each exit from urban as an event, semi-parametric repeated measures survival models were fitted.

RESULTS

Of 468 graduates, using the ≥2 weeks definition, 239 PGY3-12 graduates spent at least one tour rurally (average 61.1, CI 52.5-69.7 weeks), and a total length of 14,607 weeks. Based on the tour definition of ≥1 year, 120 graduates completed at least one tour (average 1.89, 1.69-2.10 years), and a total of 227 years' rural work. For both definitions, the number of tours increased from one to four by PGY10/11, giving 17,786 total weeks (342 years) across all PGYs for the ≥2 weeks tour definition, and 256 years total for ≥1 year. Significantly more graduates exited from urban work for the 2007-09 middle cohort compared with 2010-11 (HR 1.876, p = 0.022), but no significant difference between 2002 and 06 and 2010-11. Rural origin, age and gender were not statistically significant.

CONCLUSIONS

PGY3-12 RCS graduates contributed substantially to the rural workforce: 51% did so by short rotations, while 26% contributed whole years of service. There was an apparent peak in entry and survival for the middle cohort and decline thereafter, likely attributable to lack of advanced/specialist vocational training. These data indicate a real commitment to rural practice by RCS graduates, and the need for rural vocational training as a key element of a successful rural survival strategy.

The impact of rural outreach programs on medical students' future rural intentions and working locations: a systematic review

BACKGROUND

Significant investment has been undertaken by many countries into 'Rural Clinical Training Placement Schemes' for medical students in order to deal with shortages of trained health care professionals in rural and remote locations. This systematic review examines the evidence base of rural educational programs within medical education and focusses on workforce intentions and employment outcomes. The study provides a detailed description of the methodological characteristics of the literature, thematic workforce outcomes and key related factors are identified, study quality is assessed, and the findings are compared within an international context.

METHODS

A systematic review looking at international literature of rural placement programs within medical education between January 2005 to January 2017 from databases including; Medline, Embase, NursingOVID, PubMed and Cochrane. The study adopted the PRISMA protocol. A quality assessment of the literature was conducted based on the Health Gains Notation Framework.

RESULTS

Sixty two papers met the inclusion criteria. The review identified three program classifications; Rural Clinical Placement Programs, Rural Clinical Placement Programs combined with a rural health educational curriculum component and Rural Clinical School Programs. The studies included were from Australia, United States, Canada, New Zealand, Thailand and Africa. Questionnaires and tracking or medical registry databases were the most commonly reported research tools and the majority were volunteer programs. Most studies identified potential rural predictors/confounders, however a number did not apply control groups and most programs were based on a single site. There was a clear discrepancy in the ideal rural clinical placement length. Outcomes themes were identified related to rural workforce outcomes. Most studies reported that an organised, well-funded, rural placement or rural clinical school program produced positive associations with increased rural intentions and actual graduate rural employment.

CONCLUSIONS

Future research should focus on large scale methodologically rigorous multi-site rural program studies, with longitudinal follow up of graduates working locations. Studies should apply pre-and post-intervention surveys to measure change in attitudes and control for predictive confounders, control groups should be applied; and in-depth qualitative research should be considered to explore the specific factors of programs that are associated with encouraging rural employment.

A review of characteristics and outcomes of Australia's undergraduate medical education rural immersion programs

BACKGROUND

A key strategy for increasing the supply of rural doctors is rurally located medical education. In 2000, Australia introduced a national policy to increase rural immersion for undergraduate medical students. This study aims to describe the characteristics and outcomes of the rural immersion programs that were implemented in Australian medical schools.

METHODS

Information about 19 immersion programs was sourced in 2016 via the grey and published literature. A scoping review of the published peer-reviewed studies via Ovid MEDLINE and Informit (2000-2016) and direct journal searching included studies that focused on outcomes of undergraduate rural immersion in Australian medical schools from 2000 to 2016.

RESULTS

Programs varied widely by selection criteria and program design, offering between 1- and 6-year immersion. Based on 26 studies from 10 medical schools, rural immersion was positively associated with rural practice in the first postgraduate year (internship) and early career (first 10 years post-qualifying). Having a rural background increased the effects of rural immersion. Evidence suggested that longer duration of immersion also increases the uptake of rural work, including by metropolitan-background students, though overall there was limited evidence about the influence of different program designs. Most evidence was based on relatively weak, predominantly cross-sectional research designs and single-institution studies. Many had flaws including small sample sizes, studying internship outcomes only, inadequately controlling for confounding variables, not using metropolitan-trained controls and providing limited justification as to the postgraduate stage at which rural practice outcomes were measured.

CONCLUSIONS

Australia's immersion programs are moderately associated with an increased rural supply of early career doctors although metropolitan-trained students contribute equal numbers to overall rural workforce capacity. More research is needed about the influence of student interest in rural practice and the duration and setting of immersion on rural work uptake and working more remotely. Research needs to be more nationally balanced and scaled-up to inform national policy development. Critically, the quality of research could be strengthened through longer-term follow-up studies, adjusting for known confounders, accounting for postgraduate stages and using appropriate controls to test the relative effects of student characteristics and program designs.

Does a mandatory rural exposure change medical students' rural practice intent?

While rural background has consistently been the strongest predictor of rural practice, the Australian medical schools have a vital role to play in changing rural intention. Research on rural exposure during medical training has to date resulted in inconsistent findings. The purpose of this paper is to examine what occurs during a short conscripted rural exposure. A post-test self-report questionnaire evaluating the University of Queensland Rural Medicine Rotation eight-week clinical rotation was completed by 1609 domestic medical students from 2007 to 2011. The most effective single learning outcome was students who strongly agree that the rural rotation experience had increased their appreciation of the greater depth of clinical responsibility inherent in rural practice. These students were more likely to indicate that their intention to practise rurally had been positively rather than negatively influenced and more like to indicate they were very encouraged by the experience rather than merely encouraged to practise rurally. The most powerful group of learning outcomes, in positively changing rural intention from a short mandated exposure were aligned with developing an understanding of the context of rural medical practise. These contribute to our understanding of the role rural exposure.

Creation of a mobile rural workforce following undergraduate longitudinal rural immersion

BACKGROUND

This study followed the workforce choices of 10-years of graduates from a longitudinal rural immersion programme, which involved living for one academic year in a rural location as a medical student. The Rural Clinical School of Western Australia is a whole-of-state Rural Clinical School partnership involving two medical schools and fourteen rural/remote towns.

METHOD

For this longitudinal cohort study, all consenting graduates were contacted annually after graduation, with the outcome measure being rural work location (defined by the Australian Standard Geographical Classification -Remoteness Area) of any duration.

RESULTS

There were 417 consenting graduates. Between 16 and 50% of contacted alumni worked rurally for a period of each post-graduate year. Aggregated over time, the majority took up to 30% of their postgraduate training rurally. There was considerable movement in and out of rural work. About 17% of contacted and practicing graduates were working full time rurally at the 2013 contact point. The majority remained in their state of training. The majority identified with GP and other rural-related colleges, and College-affiliation predicted amount of rural training time. Entry into rural work was equivalent for urban-origin and rural origin alumni, suggesting one year of RCS is sufficient to convert commitment to rural work.

CONCLUSION

Undergraduate rural immersion is sufficient to create a graduate rural workforce that is far more mobile that was previously appreciated.

A scoping review of the association between rural medical education and rural practice location

BACKGROUND

Inequitable distribution of the medical workforce is an international problem that undermines universal access to healthcare. Governments in many countries have invested in rural-focused medical education programs to increase the supply of rural doctors.

METHODS

Using a structured five-step approach, a scoping review was conducted to map the existing evidence on the relationship between professional entry-level, pre-vocational medical education delivered in rural settings and rural workforce outcomes. Key search terms were developed, with database searches yielding 37 relevant articles. During data charting, a set of types of studies emerged, and we developed a typology to assist with article sorting and information structuring.

RESULTS

Medical students attending a rural campus or spending time in a rural area are more likely to practise in non-metropolitan areas upon graduation than students studying at a city campus. In many cases, these positive findings could be confounded by students having a rural origin or being predisposed to want rural work. There is some evidence to suggest that the longer a person spends time as a medical student in a rural area, the more likely they are to work rurally following graduation. Overall, the articles located had limitations related to small sample size, inconsistent definition of rurality and lack of attention to controlling for variables that might influence rural practice decision, for example, rural background. Comparative data were lacking, and most studies were conducted by staff from the medical schools that were the focus of the research. There was no consideration given in any study found to the cost-effectiveness of entry-level medical education delivered in rural settings versus other ways of producing rural practitioners.

CONCLUSIONS

Given limitations, available evidence suggests that medical education in a rural location does increase the number of medical graduates that will work in a rural place. There are indications of a gradient effect where increased rural practice exposure during medical education leads to more rurally located graduates; however, robust studies are needed to verify this finding. Given the significant funding being directed to universities to increase graduates that will work rurally, appropriate future research is recommended.

A short-term rural placement can change metropolitan medical students' knowledge of, and attitudes to, rural practice

OBJECTIVE

To determine whether a short-term placement of metropolitan medical students in a rural environment can improve their knowledge of, and change their attitudes to, rural health issues.

DESIGN AND PARTICIPANTS

Medical students taking part in the March and May 2013 3-week Rural Health Modules (RHMs) were invited to participate in focus groups and complete questionnaires before undertaking the RHM, after a 2-day rural orientation and at the end of the RHM. Students were asked to comment on a range of issues affecting rural health care including their attitude to pursuing a rural career. Focus group transcripts were thematically analysed and questionnaire data were statistically analysed.

SETTING

The RHM is a 3-week program designed and run by the University of Melbourne's Rural Health Academic Centre.

MAIN OUTCOME MEASURES

Responses to questionnaire items from before and after completing the RHM, scored on a seven-point Likert scale.

RESULTS

69 of the 101 RHM students took part in this study. The focus groups identified five main themes in rural health care: access; teamwork, models of care and generalist practice; overlapping relationships; indigenous health; and working in a rural career. In all five areas, a change was seen in the depth of knowledge students had about these issues and in the students' attitudes towards rural health care. The questionnaires also showed a significant shift in the students' appreciation of, and positivity towards, rural health issues.

CONCLUSION

Undertaking a 3-week RHM changed students' perceptions of rural health and significantly improved their knowledge of issues facing rural health practitioners and patients.

Is the National Registration website (Australian Health Practitioner Regulation Agency) effective in tracking Australian medical graduates' rural work?

OBJECTIVE

This study compared rural location identified through the National Registration (AHPRA) registry with location obtained through labour-intensive personal contact.

DESIGN

Longitudinal cohort study with two methods to identify the work locations of medical graduates from The Rural Clinical School of Western Australia (RCSWA).

PARTICIPANTS

Consenting alumni from the University of Western Australia and the University of Notre Dame Fremantle participating in RCSWA between 2002 and 2009 inclusive and available to contact in 2011.

MAIN OUTCOME MEASURE

Percentage location matches between two contact methods.

RESULTS

There was 80% agreement for principal suburb, 92% agreement for principal city and 94% agreement for principal state between RCSWA personal contact and the AHPRA registry. AHPRA identified nearly two times as many graduate locations. However, there was only 31% agreement for a rural placement location (of any length). In more detail, for year-long rural placement, personal contact was 88% concordant with AHPRA; work six months or more were less concordant (44% agreement); work less than six months were not concordant (4% agreement).

CONCLUSIONS

AHPRA data matched RCSWA alumni data only for graduates in full-time rural work. Since medical alumni spend up to 10 years in pre-vocational and vocational training, which includes many rural options, personal contact was able to pick up the myriad of rural choices, whereas the AHPRA database was not sensitive enough to identify them. Until graduates have stably finished training, the optimal method to identify rural work is through personal contact but statistical correction for missing data needs to be considered.

Are rural placements positively associated with rural intentions in medical graduates?

CONTEXT

Medical school curricula remain one of the key levers in increasing the future supply of rural doctors. Data from Australia and overseas have suggested exposure to rural practice via rural placements during basic medical training is positively associated with graduates becoming rural doctors. However, previous studies have suffered from serious methodological limitations.

OBJECTIVES

This study sought to determine whether rural clinical placements are associated with a higher proportion of graduating students planning rural careers and to explore associations with timing, duration and location of placements.

METHODS

Data were obtained from the Medical Schools Outcomes Database and Longitudinal Tracking Project, which is a longitudinal study with a high response rate that prospectively collects data, including practice location intention, from all Australian medical schools. Using logistic regression analysis, the association between placements and rural career intention was assessed, controlling for a number of demographic and contextual variables.

RESULTS

The association between rural/remote placements later in the programme and rural practice intention was strongly positive whether viewed as simple occurrence or as duration, in contrast to later urban placements, which were strongly negative. A longer duration of placement enhanced the associations reported. Non-metropolitan medical schools were also associated with higher odds of intention to take up rural practice. However, the association with rural placements was overshadowed by the strong positive associations with rural background of students and their stated intention to become a rural doctor at the start of their studies.

CONCLUSIONS

Exposure to rural practice during basic medical training, and the location and curriculum focus of a medical school are confirmed as factors that are positively associated with students' intention to become rural doctors after graduation. However, rural origin and the early intentions at the start of their medical training are better predictors of expressed intention to take up rural practice than rural clinical placements.