Influence of a rural primary care clerkship on medical students' intentions to practice in a rural community

Connectivity is the key to longer rural placement: Retaining students on rural longitudinal integrated clerkships

PURPOSE

Recruitment and retention of medical practitioners to rural practice is an ongoing global issue. Rural longitudinal integrated clerkships (LIC) are an innovative solution to this problem, which are known to increase rural workforce. Crucially this association increases with time on rural placement. This study examines factors that promote retention in a Rural LIC.

METHODS

A two-phased, sequential design qualitative study in a cohort of students enrolled in a rural LIC at Griffith University, Queensland, Australia. Phase I consisted of an open-ended questionnaire and phase II follow-up focus groups from the same cohort. Data was transcribed and analysed using an iterative, six-step thematic analysis process to identify salient themes.

RESULTS

Twenty-four students were invited to participate, of which eight respond in phase I and thirteen participated in phase II. Participants described retention being driven by connectivity within three broad themes: current practice, future practice (immediate internship and career intention), and social networks. Participant proposals to increase connectivity were also suggested including peer-led solutions and short rotations in metropolitan hospitals.

CONCLUSION

Connectivity is key to retention on rural longitudinal integrated clerkships. Programs which enhance connectivity with current practice, future practice, and social networks will increase retention on rural medical programs.

Rural general practitioners have different personal and professional trajectories from those of their urban colleagues: a case-control study

BACKGROUND

In France, rural general practitioner (GP) numbers could reduce by 20% between 2006 and 2030 if no measures are taken to address primary care access difficulties. In countries such as Australia, the USA and Canada, intrinsic and extrinsic factors associated with GPs practising in rural areas include rural upbringing and rural training placements. However, the health systems and rural area definition differ between these countries and France making result extrapolation difficult. These factors must be studied in the context of the French heath system, to design strategies to improve rural GP recruitment and retention. This study aims to identify the intrinsic and extrinsic factors associated with GPs practising in rural areas in France.

METHODS

This case-control study was conducted between May and September 2020. Included GPs practised in Brittany, France, and completed a self-administered questionnaire. The cases were rural GPs and controls were urban GPs. National references defined rural and urban areas. Comparisons between rural and urban groups were conducted using univariate and multivariate analyses to identify factors associated with practising in a rural area.

RESULTS

The study included 341 GPs, of which 146 were in the rural group and 195 in the urban group. Working as a rural GP was significantly associated with having a rural upbringing (OR = 2.35; 95% CI [1.07-5.15]; p = 0.032), completing at least one undergraduate general medicine training placement in a rural area (OR = 3.44; 95% CI [1.18-9.98]; p < 0.023), and having worked as a locum in a rural area for at least three months (OR = 3.76; 95% CI [2.28-6.18]; p < 0.001). Choosing to work in a rural area was also associated with the place of residence at the end of postgraduate training (OR = 5.13; 95% CI [1.38-19.06]; p = 0.015) and with the spouse or partner having a rural upbringing (OR = 2.36; 95% CI [1.12-4.96]; p = 0.023) or working in a rural area (OR = 5.29; 95% CI [2,02-13.87]; p < 0.001).

CONCLUSIONS

French rural GPs were more likely to have grown up, trained, or worked as a locum in a rural area. Strategies to improve rural GP retention and recruitment in France could therefore include making rural areas a more attractive place to live and work, encouraging rural locum placements and compulsory rural training, and possibly enrolling more medical students with a rural background.

Medical education interventions influencing physician distribution into underserved communities: a scoping review

BACKGROUND AND OBJECTIVE

Physician maldistribution is a global problem that hinders patients' abilities to access healthcare services. Medical education presents an opportunity to influence physicians towards meeting the healthcare needs of underserved communities when establishing their practice. Understanding the impact of educational interventions designed to offset physician maldistribution is crucial to informing health human resource strategies aimed at ensuring that the disposition of the physician workforce best serves the diverse needs of all patients and communities.

METHODS

A scoping review was conducted using a six-stage framework to help map current evidence on educational interventions designed to influence physicians' decisions or intention to establish practice in underserved areas. A search strategy was developed and used to conduct database searches. Data were synthesized according to the types of interventions and the location in the medical education professional development trajectory, that influence physician intention or decision for rural and underserved practice locations.

RESULTS

There were 130 articles included in the review, categorized according to four categories: preferential admissions criteria, undergraduate training in underserved areas, postgraduate training in underserved areas, and financial incentives. A fifth category was constructed to reflect initiatives comprised of various combinations of these four interventions. Most studies demonstrated a positive impact on practice location, suggesting that selecting students from underserved or rural areas, requiring them to attend rural campuses, and/or participate in rural clerkships or rotations are influential in distributing physicians in underserved or rural locations. However, these studies may be confounded by various factors including rural origin, pre-existing interest in rural practice, and lifestyle. Articles also had various limitations including self-selection bias, and a lack of standard definition for underservedness.

CONCLUSIONS

Various educational interventions can influence physician practice location: preferential admissions criteria, rural experiences during undergraduate and postgraduate medical training, and financial incentives. Educators and policymakers should consider the social identity, preferences, and motivations of aspiring physicians as they have considerable impact on the effectiveness of education initiatives designed to influence physician distribution in underserved locations.

From pipeline to practice: Utilizing tracking mechanisms for longitudinal evaluation of physician recruitment across the health workforce continuum

PURPOSE

Area Health Education Centers work with community partners to prepare a diverse, primary care workforce particularly among rural and underserved communities. We set out to assess our impact on the physician workforce across a multitude of short-term, intermediate, and long-term benchmarks METHOD: We used a comprehensive evaluation scaffolding to assess benchmarks of success across the workforce pipeline including short-term (i.e. pre-medical intent to pursue a health career or medical students' intent to practice in primary care), intermediate (college matriculation and primary care residency match rates) and longterm measures (licensure and medical practice location of program participants).

RESULTS

We identified significant findings in each part of the AHEC program continuum. Among our alumni, we found a significant increase in the pre-medical learner's intent to pursue a health care career. Among medical students, we found a significant increase in intent to practice in primary care, rural areas, and medically underserved communities and a high rate of primary care residency match (compared to peers). Approximately one-third of licensed physicians are now practicing medicine serve in an underserved community CONCLUSIONS: Our findings confirm the value of longitudinal evaluation on confirming that participation in an AHEC supported program strengthen the physician workforce development.

How we incorporated service learning into a medical student rural clinical training experience

BACKGROUND

Many medical schools have developed admission policies and clinical training programs designed to address the rural physician workforce shortages in their state.

AIM

To enhance medical student rural clinical training experiences, and assist in preparing students for living and working in rural communities.

METHODS

As part of their Rural Track Clerkship (RTC) Program, the University of Missouri School of Medicine developed the Community Integration Program (CIP). Students, individually or in groups, voluntarily identify a health need and implement a community-based project to meet that need.

RESULTS

From 2007 to 2013, 80 (53%) students participated in the CIP and 86% completed the 11-item post-experience questionnaire. After the experience, participants reported a deeper understanding of the broad impact of a rural physician and the impact of rural culture on physician interactions. Participants reported they felt more integrated into the community, had a greater understanding of community health needs and resources, and were more likely to participate in future community service activities.

CONCLUSIONS

The CIP exposes students to rural culture and helps them understand community health needs. Replication of this program can increase student interest in rural medicine and better prepare students for rural practice.

Public health and community medicine instruction and physician practice location

BACKGROUND

Experts have historically recommended better integration of public health content into medical education. Whether this adoption is associated with physician practice location has not been studied.

PURPOSE

To examine the association between medical student perception of their public health and community medicine instruction and practice location in a Health Professional Shortage Area.

METHODS

Descriptive analysis and a regression model assessed the significance and strength of the association between medical student perception of their public health and community medicine instruction and practice location using data from the Medical School Graduation Questionnaire 1997-2004, 2013 American Medical Association Physician Masterfile, and 2013 Health Professional Shortage Areas.

RESULTS

A higher proportion of medical students with an intent to practice in underserved areas reported inadequate instruction in public health and community medicine than those without such intentions. Students reporting adequate public health and community medicine instruction are slightly more likely to practice in a Health Professional Shortage Area, controlling for their intent to practice in underserved areas.

CONCLUSIONS

Findings suggest an association between perceptions of public health and community medicine instruction and practice location. Improved public health and community medicine instruction may support medical students' preparation and ability to integrate public health skills into practices in underserved settings. More research is needed to ascertain factors enabling better incorporation of public health and community medicine in medical education.

Influencing residency choice and practice location through a longitudinal rural pipeline program

PURPOSE

The University of Missouri School of Medicine developed the Rural Track Pipeline Program (MU-RTPP) to increase the supply and retention of rural physicians statewide. The MU-RTPP features a preadmissions program for rural students (Rural Scholars), a Summer Community Program for rising second-year students, a six-month Rural Track Clerkship (RTC) Program for third-year students, and a Rural Track Elective Program for fourth-year students. The purpose of this study is to report the specialty choices and first practice locations of Rural Scholars, RTC-only participants, and Rural Track Clerkship Plus (RTC+) participants (students who participated in the RTC Program plus an additional MU-RTPP component).

METHOD

The authors compared the residency specialty choices of 48 Rural Scholars (tracked since 2002) with those of 506 nonparticipants and the residency specialty choices of 83 RTC participants and 75 RTC+ participants (tracked since 1997) with those of 840 nonparticipants. The authors calculated the relative risk (RR) for the likelihood of participants matching into primary care compared with nonparticipants and analyzed first practice location.

RESULTS

Rural Scholars were more than twice as likely to match into family medicine (RR=2.6; 95% confidence interval 1.5-4.4). RTC and RTC+ participants entered primary care, especially family medicine, at rates significantly higher than nonparticipants. Over 57% of students who participated in the RTC program (and potentially other MU-RTPP offerings) chose a rural location for their first practice.

CONCLUSIONS

The longitudinal MU-RTPP successfully recruits students for rural and primary care practice to address the health care needs of Missouri.

The value of a rural medicine rotation on encouraging students toward a rural career: clear benefits from the RUSC program

BACKGROUND

The Australian government has addressed rural medical workforce shortages through strategies such as the Rural Undergraduate Support and Co-ordination program, based on the premise that increased exposure to rural medicine within the curricula will contribute to more students adopting a rural career.

PURPOSE

This article reports on how an Australian Rural Clinical School is meeting the aims of this initiative.

METHODS

Year 3 students (n = 463) from 10 eight-week rural rotations in 2005-2006 evaluated the content and value of rural lectures/workshops and a 6-week rural clinical placement.

RESULTS

The aggregate results suggest overall favourable evaluation of the various components of this rotation.

CONCLUSIONS

A rural rotation can encourage students' interest in and understanding of rural medicine. The longitudinal nature and ongoing evaluation of this program may in time provide more conclusive evidence for this. Challenges such as increasing student numbers, decreasing clinical placements, and logistically complicated programs remain. Research toward alternatives to a "real-life" rural experience may be needed.

Going country: Rural student placement factors associated with future rural employment in nursing and allied health

OBJECTIVE

To measure the rate and predictors of health science graduates joining the rural health workforce following a rural placement.

DESIGN

Longitudinal survey including the years immediately prior to and post graduation.

SETTING

Western Australian health sciences graduates contacted by email and/or phone.

PARTICIPANTS

Allied health and nursing students from urban campuses of three Western Australian universities who had taken a rural placement in their final year of study between 2000 and 2003.

MAIN OUTCOME MEASURES

Location of employment six months or more after graduation.

RESULTS

Of 429 participating allied health and nursing graduates, 25% had entered the rural workforce. Factors with a positive bivariate association with rural employment were: rural background, health discipline, self-reported value of placement, non-compulsory rural placement, and placements of four weeks or less. After controlling for rural background, the value and duration of the placement were significantly associated with rural employment.

CONCLUSIONS

This study augments previous work showing that any prior rural background is a significant predictor of rural work. Rural practitioners of both urban and rural origin who undertake voluntary rural placements are more likely to enter rural practice and consequently mandatory placements may not be helpful to increasing the rural workforce. The quality of a placement is a highly significant factor associated with future workplace choice, the details of which need to be further investigated.

Medical students' reported barriers to training at a Rural Clinical School

OBJECTIVE

To understand and address students' concerns about attending one of the new Commonwealth-funded Rural Clinical Schools.

DESIGN

Analysis of students' reported reasons for clinical school selection from 2003 to 2004.

SETTING

The School of Medicine and the Rural Clinical School, University of Melbourne.

PARTICIPANTS

Data were obtained from de-identified preference documents submitted by the medical student cohort assigned to the University of Melbourne clinical schools to begin in July, 2004.

RESULTS

Thirteen categories of student concerns (social) were identified from written student preference documents.

CONCLUSIONS

Evaluation of the students' concerns about social dislocation if they were assigned to a rural clinical school has provided important information about perceived barriers to rural training. These issues must be systematically addressed at the school, university and community level.

Assessment of a curricular component designed to introduce physical therapy students to rural practice issues

A rural health curricular component was designed for students enrolled in a physical therapy program in Nevada to change student attitudes about rural practice and to encourage more physical therapy students to seek employment in rural areas postgraduation. Student attitudes and beliefs related to rural practice were investigated following participation in a rural health conference and a full-time rural clinical affiliation. Twelve students (N = 12) participated. All reported positive impressions of rural practice after participating in the rural clinical affiliation and nine (75%) were favorable toward seeking employment in a rural setting. Two (17%) accepted rural health positions following graduation. Clinical experience in a rural setting was found to have the greatest influence on student attitudes about rural practice.

The reported value of rural internal medicine residency electives and factors that influence rural career choice

This study examines how rural electives affect medical residents' opinions about rural practice and which factors encourage or discourage choice of rural practice. Participants in a one- to two-month rural elective and a matched group of randomly selected nonparticipants were surveyed. Seventy percent of the elective participants (n = 58) and 61% of the matched nonparticipants (n = 51) completed the questionnaire. The groups' responses to scaled response measures and open-ended questions were analyzed using t , chi-square and Mann-Whitney U tests. A majority of participants stated that the elective was a beneficial experience (n = 36), and participants' interest in rural practice increased significantly after the elective. Elective participants were more likely than nonparticipants to see breadth of practice, continuity of care, quality of life in rural areas, and experiences with mentors as encouraging rural practice. Elective participation did not demonstrably increase rural career choice, although this finding may be attributable to small sample size. Respondents identified means to encourage rural practice, as well as barriers to rural practice: Elective participants suggested that electives may be more effective if they occurred earlier in medical training, lasted for longer periods of time, and addressed the needs of spouses or partners. Generalizability is limited by several factors, including small sample size and the possibility of pre-existing differences between elective participants and nonparticipants.

Does a rural educational experience influence students' likelihood of rural practice? Impact of student background and gender

CONTEXT

The family medicine clerkship at the University of Calgary is a 4-week mandatory rotation in the final year of a 3-year programme. Students are given the opportunity to experience rural practice by training at 1 of several rural practices.

OBJECTIVE

To determine whether exposure to a rural educational experience changes students' likelihood of doing a rural locum or rural practice and whether student background and gender are related to these practice plans.

METHOD

Clinical clerks from the Classes of 1996-2000, who trained at rural sites, responded to questionnaire items both before and after the rural educational experience. Responses to the questionnaire items and discipline of postgraduate training served as dependent variables. Student background and gender were independent variables.

RESULTS

As a result of the rural educational experience all students were more likely to do a rural locum. Compared to their urban-raised peers, students from rural backgrounds reported a significantly greater likelihood of doing a rural locum and practising in a rural community, irrespective of gender or participating in a rural educational experience. There was no relationship between background and career choice.

CONCLUSION

A rural educational experience at the undergraduate level increases the stated likelihood of students participating in rural locums and helps to solidify existing rural affiliations. Students with rural backgrounds have a more favourable attitude toward rural practice. This pre-post study provides further support for the preferential admission to medical school of students with rural backgrounds to help alleviate the rural physician shortage.

Community-based education and problem solving: the Community Health Scholars Program at the University of Florida

BACKGROUND

Although many medical schools understand and support the need for community service as part of educational training, this goal has been difficult to operationalize.

DESCRIPTION

The Community Health Scholars program, a joint effort between the Area Health Education Center and the University of Florida, places 1st-year medical students in clinical settings with underserved populations, both rural and urban. The stated goal of the experience is to solve a problem identified by the communities as well as provide exposure to community practice and environment.

EVALUATION

The program provided notable services to many communities. More than 80% of participating students believed it was a good or excellent learning experience; more than 90% believed that the program affected their career choice; and 100% believed that the program should be continued. Although this is a 1st-year program, students were not surveyed until their last year, suggesting that the program may have a lasting effect.

CONCLUSIONS

This collaborative program successfully provided a service-learning experience for students while promoting solutions to problems in underserved communities.