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Background: Most rural populations experience significant health disadvantage. Community-engaged research can facilitate research activities towards addressing health issues of priority to local communities. Connecting scholars with community based frontline practices that are addressing local health and medical needs helps establish a robust pipeline for research that can inform gaps in health provision. Rural Health Projects (RHPs) are conducted as part of the Doctor of Medicine program at the University of Queensland. This study aims to describe the geographic coverage of RHPs, the health topic areas covered and the different types of RHP research activities conducted. It also provides meaningful insight of the health priorities for local rural communities in Queensland, Australia. Methods: This study conducted a retrospective review of RHPs conducted between 2011 and 2021 in rural and remote Australian communities. Descriptive analyses were used to describe RHP locations by their geographical classification and disease/research categorisation using the International Classification of Diseases and Related Health Problems – 10th Revision (ICD-10) codes and the Human Research Classification System (HRCS) categories. Results: There were a total of 2806 eligible RHPs conducted between 2011 and 2021, predominantly in Queensland (n = 2728, 97·2%). These were mostly conducted in small rural towns (under 5,000 population, n = 1044, 37·2%) or other rural towns up to 15,000 population (n = 842, 30·0%). Projects mostly addressed individual care needs (n = 1233, 43·9%) according to HRCS categories, or were related to factors influencing health status and contact with health services (n = 1012, 36·1%) according to ICD-10 classification. Conclusions: Conducting community focused RHPs demonstrates a valuable method to address community-specific rural health priorities by engaging medical students in research projects while simultaneously enhancing their research skills. [ABSTRACT FROM AUTHOR]

Background: Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease. Objective: The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process. Methods: A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023. Results: Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early. Conclusions: This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services. [ABSTRACT FROM AUTHOR]

Objectives: Arterial catheters (ACs) are critical for haemodynamic monitoring and blood sampling but are prone to complications. We investigated the incidence and risk factors of AC failure. Methods: Secondary analysis of a multi-centre randomised controlled trial (ACTRN 12610000505000). Analysis included a subset of adult intensive care unit patients with an AC. The primary outcome was all-cause device failure. Secondary outcomes were catheter associated bloodstream infection (CABSI), suspected CABSI, occlusion, thrombosis, accidental removal, pain, and line fracture. Risk factors associated with AC failure were investigated using Cox proportional hazards and competing-risk models. Results: Of 664 patients, 173 (26%) experienced AC failure (incidence rate [IR] 37/1000 catheter days). Suspected CABSI was the most common failure type (11%; IR 15.3/1000 catheter days), followed by occlusion (8%; IR 11.9/1,000 catheter days), and accidental removal (4%; IR 5.5/1000 catheter days). CABSI occurred in 16 (2%) patients. All-cause failure and occlusion were reduced with ultrasound-assisted insertion (failure: adjusted hazard ratio [HR] 0.43, 95% CI 0.25, 0.76; occlusion: sub-HR 0.11, 95% CI 0.03, 0.43). Increased age was associated with less AC failure (60–74 years HR 0.63, 95% CI 0.44 to 0.89; 75 + years HR 0.36, 95% CI 0.20, 0.64; referent 15–59 years). Females experienced more occlusion (adjusted sub-HR 2.53, 95% CI 1.49, 4.29), while patients with diabetes had less (SHR 0.15, 95% CI 0.04, 0.63). Suspected CABSI was associated with an abnormal insertion site appearance (SHR 2.71, 95% CI 1.48, 4.99). Conclusions: AC failure is common with ultrasound-guided insertion associated with lower failure rates. Trial registration Australian New Zealand Clinical Trial Registry (ACTRN 12610000505000); date registered: 18 June 2010. [ABSTRACT FROM AUTHOR]

Background: Medical internship is a key transition point in medical training from student to independent (junior) doctor. The national Regional Training Hubs (RTH) policy began across Australia in late 2017, which aims to build medical training pathways for junior doctors within a rural region and guide students, interns and trainees towards these. This study aims to explore preferencing and acceptance trends for rural medical internship positions in Queensland. Moreover, it focuses on internship preference and acceptance outcomes prior to and following the establishment of RTHs, and their association with key covariates such as rural training immersions offered by medical schools. Methods: Data from all applicants to Queensland Health intern positions between 2014–2021 were available, notably their preference order and location of accepted internship position, classified as rural or metropolitan. Matched data from Queensland's medical schools were added for rural training time and other key demographics. Analyses explored the statistical associations between these factors and preferencing or accepting rural internships, comparing pre-RTH and post-RTH cohorts. Results: Domestic Queensland-trained graduates first preferencing rural intern positions increased significantly (pre-RTH 21.1% vs post-RTH 24.0%, p = 0.017), reinforced by a non-significant increase in rural acceptances (27.3% vs 29.7%, p = 0.070). Rural interns were more likely to have previously spent ≥ 11-weeks training in rural locations within medical school, be rurally based in the year applying for internship, or enrolled in the rural generalist pathway. Conclusions: The introduction of the RTH was associated with a moderate increase of graduates both preferencing and accepting a rural internship, though a richer understanding of the dominant reasons for and against this remain less clear. An expansion of graduates who undertook longer periods of undergraduate rural training in the same period did not diminish the proportion choosing a rural internship, suggesting there remains an appetite for these opportunities. Overall, domestic graduates are identified as a reliable source of intern recruitment and retention to rural hospitals across Queensland, with entry to the rural generalist pathway and extended rural placement experiences enhancing uptake of rural practice. [ABSTRACT FROM AUTHOR]

Background: Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action. Objective: This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building. Methods: This study collected peer-reviewed materials published in 15-year period (2005–2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems). Results: The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%). Conclusion: This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening. [ABSTRACT FROM AUTHOR]

Workers in the oil and gas industry are exposed to numerous health risks, ranging from poor health behaviours to the possibility of life-threatening injuries. Determining the most appropriate models of healthcare for the oil and gas industry is difficult, as strategies must be acceptable to multiple stakeholders, including employees, employers, and local communities. The purpose of this review was to broadly explore the health status and needs of workers in the oil and gas industry and healthcare delivery models relating to primary care and emergency responses. Database searches of PubMed, EMBASE, CINAHL, PsycINFO, and Scopus were conducted, as well as grey literature searches of Google, Google Scholar, and the International Association of Oil and Gas Producers website. Resource-sector workers, particularly those in 'fly-in fly-out' roles, are susceptible to poor health behaviours and a higher prevalence of mental health concerns than the general population. Evidence is generally supportive of organisation-led behaviour change and mental health-related interventions. Deficiencies in primary care received while on-site may lead workers to inappropriately use local health services. For the provision of emergency medical care, telehealth and telemedicine lead to favourable outcomes by improving patient health status and satisfaction and reducing the frequency of medical evacuations. [ABSTRACT FROM AUTHOR]

Studies of doctors' life satisfaction (subjective well-being) have largely overlooked the specific experiences of international or overseas trained doctors. This study explores any difference in life satisfaction and its determinants between international and domestic medical graduates (i.e. IMGs vs. DMGs), in Australia (a major destination country). We pooled eight waves of data from the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of Australian doctors (2009–2016). Life satisfaction was measured on a standard 10-point scale. We applied Oaxaca and Ransom's linear decomposition method to evaluate factors associated with any observed difference in satisfaction between the two groups of doctors. IMGs were more likely to report lower life satisfaction than DMGs (mean 7.37 vs 7.48, p-value < 0.001). The well-being gap (of 0.11) was largely attributable to the groups' differences in observable characteristics such as psychosocial and demographic factors. Most notably, the IMG group was worse off with respect to self-reported financial security, exposure to work-related psychosocial risk factors, and community integration. Our study highlights the importance of the workplace and community context in understanding the life satisfaction difference between IMGs and DMGs. The study results may have important implications for policies and programs that seek to promote the integration and retention of IMGs. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of the COVID‐19 pandemic on clinical supervision practices of health care workers in health care settings in one Australian state. Method: A bespoke survey was developed and administered online using Qualtrics™. The survey consisted of Likert scale and closed questions, with options for free text comments. Numerical data were analysed descriptively and using Chi‐Square tests. Textual data were analysed through content analysis. Results: Of the 178 survey respondents, 42% were from allied health disciplines, 39% from nursing and midwifery, and 19% from medicine. The type and mode (i.e., face‐to‐face, telesupervision) of clinical supervision prior to the pandemic and at the time of survey completion (i.e., July–August 2021) were similar. Eighteen percent of respondents had a change in supervision arrangements but only 5% had a change in supervisor. For the 37% who changed roles due to COVID‐19, 81% felt their current supervisor was still able to support them, 69% were still having their supervisory needs met. Analyses of textual data resulted in the development of two categories: Supervision deteriorating, and some clinical supervision functions (i.e., formative and restorative) being more impacted than others (i.e., normative). Conclusion: There were substantial disruptions to several parameters of clinical supervision due to COVID‐19, that may pose a threat to high quality supervision. Health care workers reported pandemic‐induced stress and mental health challenges that were not always addressed by effective restorative supervision practices. [ABSTRACT FROM AUTHOR]

Background: To better target rural background and rurally interested applicants during medical school admission, it is increasingly common for rural medical programs to include multiple mini-interview (MMI) scenarios designed to screen for rural interest. It remains unclear whether the inclusion of regionally/rurally focused MMI scenarios positively impacts the selection of rural background applicants and evidence is limited regarding why rural background applicants may perform worse on the MMI. Therefore, this study explored how rural and metropolitan applicants prepare for and perceive the MMI for admission to a regional medical pathway. Methods: A mixed-methods survey was sent to provisional entry regional pathway medical school applicants who had completed an MMI. The survey was distributed before any offers of admission had been released. Results: Rural applicants spent less time and money preparing for the MMI and felt less prepared (P < 0.05). However, time and money spent, and resources used to prepare were not associated with feeling more prepared (all P > 0.05). Respondents mostly felt that the MMI process aligned with their expectations (83%), is fair (64%), and helps a rural program select the most suitable applicants (61%). Rural applicants generally felt that they had an advantage over other applicants (61%) while most metropolitan applicants did not (23%; P = 0.002). Discussion: Applicants to a regional medical pathway are generally supportive of the MMI process. It appears valuable for applicants to prepare for the MMI by understanding the format and requirements; however, investing substantial time and money does not underpin feeling better prepared. MMI scenarios which include a regional focus are perceived to advantage rural applicants. [ABSTRACT FROM AUTHOR]

An expansion of Commonwealth-supported medical student places is required in rurally located end-to-end medical school programs, rather than a reliance solely on redistribution, to ensure that each state has at least one rural medical school program that provides remote or rural training from the start to the completion of the medical degree. Highlight rural medicine in medical school curricula Showcase diverse rural contexts Medical curricula and assessments shape students' views of rural career options.[30] Traditional medical school teaching is predominantly metropolitan focused and specialist led. Invest in rural training pathways Immerse students in a rural place Immersive rural training remains a cornerstone for producing more rural doctors. Keywords: Rural health services; Healthcare disparities; Education, medical; Resource allocation EN Rural health services Healthcare disparities Education, medical Resource allocation S8 S13 6 08/08/23 20230803 NES 230803 Rural communities across Australia face an ongoing shortage of doctors, which reduces access to care and leads to poorer health outcomes for people living in rural areas. [Extracted from the article]

Objective: To investigate student supervisor experiences of supervising students on clinical placements since the onset of the COVID‐19 pandemic. Background: Studies on the impact of COVID‐19 on student clinical placements have focused largely on student reports and have been specific to individual professions or topic areas. There is a need to investigate student supervisor experiences. This study was conducted in Queensland (Australia) in four regional and rural public health services and four corresponding primary health networks. Methods: The anonymous, mixed methods online survey, consisting of 35 questions, was administered to student supervisors from allied health, medicine, nursing and midwifery between May and August 2021. Numerical data were analysed descriptively using chi‐square tests. Free‐text comments were analysed using content analysis. Results: Complete datasets were available for 167 respondents. Overall trends indicated perceived significant disruptions to student learning and support, plus mental health and well‐being concerns for both students and supervisors. Extensive mask wearing was noted to be a barrier to building rapport, learning and teaching. Some positive impacts of the pandemic on student learning were also noted. Conclusions: This study has highlighted the perceived impact of the pandemic on supervisors' mental health, and on the mental health, learning and work readiness of students. This study provides evidence of the pandemic impacts on student clinical placements from a supervisor point of view. Findings can assist in future‐proofing clinical education and ensuring that students continue to receive learning experiences of benefit to them, meeting curriculum requirements, in the event of another pandemic. [ABSTRACT FROM AUTHOR]

Background: Inadequate 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. Methods: Data 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). Results: Stage 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). Conclusions: This 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. [ABSTRACT FROM AUTHOR]

Background: An equitable supply and distribution of medical practitioners for all the population is an important issue, especially in Australia where 28% of the population live in rural and remote areas. Research identified that training in rural/remote locations is a predictor for the uptake of rural practice, but training must provide comparable learning and clinical experiences, irrespective of location. Evidence shows GPs in rural and remote areas are more likely to be engaged in complex care. However, the quality of GP registrar education has not been systematically evaluated. This timely study evaluates GP registrar learning and clinical training experiences in regional, rural, and remote locations in Australia using assessment items and independent evaluation. Methods: The research team retrospectively analysed GP trainee formative clinical assessment reports compiled by experienced medical educators during real-time patient consultations. Written reports were assessed using Bloom’s taxonomy classified into low and high cognitive level thinking. Regional, rural, and remotely located trainees were compared using Pearson chi-squared test and Fisher’s exact test (for 2 × 2 comparisons) to calculate associations between categorical proportions of learning setting and ‘complexity’. Results: 1650 reports (57% regional, 15% rural and 29% remote) were analysed, revealing a statistically significant association between learner setting and complexity of clinical reasoning. Remote trainees were required to use a high level of clinical reasoning in managing a higher proportion of their patient visits. Remotely trained GPs managed significantly more cases with high clinical complexity and saw a higher proportion of chronic and complex cases and fewer simple cases. Conclusions: This retrospective study showed GP trainees in all locations experienced comparable learning experiences and depth of training. However, learning in rural and remote locations had equal or more opportunities for seeing higher complexity patients and the necessity to apply greater levels of clinical reasoning to manage each case. This evidence supports learning in rural and remote locations is of a similar standard of learning as for regional trainees and in several areas required a superior level of thinking. Training needs to seriously consider utilising rural and remote clinical placements as exceptional locations for developing and honing medical expertise. [ABSTRACT FROM AUTHOR]

Background: The aim of this national study was to explore the learning experiences of Australia's medical students who trained rurally during the COVID-19 pandemic in 2020. Methods: A cross-sectional, national multi-centre survey was conducted in 2020, through the Federation of Rural Australian Medical Educators (FRAME). Participants were medical students who had completed an extended Rural Clinical School (RCS) training placement (≥ 12 months). A bespoke set of COVID-19 impact questions were incorporated into the annual FRAME survey, to capture COVID-19-related student experiences in 2020. Pre-pandemic (2019 FRAME survey data) comparisons were also explored. Results: FRAME survey data were obtained from 464 students in 2020 (51.7% response rate), compared with available data from 668 students in 2019 (75.6% response rate). Most students expressed concern regarding the pandemic's impact on the quality of their learning (80%) or missed clinical learning (58%); however, students reported being well-supported by the various learning and support strategies implemented by the RCSs across Australia. Notably, comparisons to pre-pandemic (2019) participants of the general RCS experience found higher levels of student support (strongly agree 58.9% vs 42.4%, p < 0.001) and wellbeing (strongly agree 49.6% vs 42.4%, p = 0.008) amongst the 2020 participants. Students with more than one year of RCS experience compared to one RCS year felt better supported with clinical skills learning opportunities (p = 0.015) and less affected by COVID-19 in their exam performance (p = 0.009). Conclusions: This study has provided evidence of both the level of concern relating to learning quality as well as the positive impact of the various learning and support strategies implemented by the RCSs during the pandemic in 2020. RCSs should further evaluate the strategies implemented to identify those that are worth sustaining into the post-pandemic period. [ABSTRACT FROM AUTHOR]

Objective: The COVID‐19 pandemic has adversely impacted medical students' learning experiences. Students in one Australian Rural Clinical School were surveyed to investigate the impact of disruptions to clinical placements and satisfaction with educational changes implemented as a result of the pandemic. Design: Cross‐sectional survey. Setting: The University of Queensland Rural Clinical School. Methods: Students undertaking one or two years of study at the participating Rural Clinical School in November 2020. Main outcome measure: A 20‐item anonymised survey with questions on personal health and safety, quality of clinical training experience, response to changes in learning and student environment, and progression to completion of the medical degree. Results: The survey was completed by 124 students (76% response rate). Students were satisfied with the changes made to their learning to accommodate the disruptions to health service delivery and placements. Final year students were more satisfied with their learning experiences compared to their third‐year counterparts. Conclusions: The Rural Clinical School implemented a range of academic and psychological support strategies which appear to have helped with mitigating mental health concerns experienced by students completing rural placements, who are already prone to experiencing social isolation. Strengthening communication between the academic and health service sectors can improve the quality of learning for medical students on placements. [ABSTRACT FROM AUTHOR]

Objective: To 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, participants: Cohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools. Main outcome measures: Practice 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). Results: Data 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). Conclusion: The 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. [ABSTRACT FROM AUTHOR]

Abstract Although countries have implemented pro-competitive reforms in health care to reduce costs and improve quality, there is limited evidence on the effect of competition on quality of care provided by physicians. We study the effect of competition on the provision of low-value—ineffective or harmful—health care by general practitioners (GPs). We use rich patient-level data on GP consultations in Australia and measure competition as distance to other GPs. Our study found that GPs facing more competition provide lower quality of care by ordering more imaging for low back pain and uncomplicated acute bronchitis. We find similar but smaller and insignificant effects of competition on prescribing antibiotics for coughs and colds. Competition can have mixed effects across different conditions because of differences in GPs' beliefs and patient expectations about the effectiveness of care, as well as differences in demand, costs, and profit. [ABSTRACT FROM AUTHOR]

To develop theory about how contexts and mechanisms interact to contribute to openness to future rural practice by medical students undertaking immersive rural training. A realist evaluation based on RAMESES II protocol. We interviewed 23 students exploring Contexts (C) which were external (place-based) and internal (the student's characteristics), Mechanisms (M) (that drive a response) and Outcomes (O) (openness to rural work). 'Openness to rural work' related to: a desire to live rurally, work in rural medicine, or consider this as a possibility. This was triggered by responses to experience in rural places of an aspirational, intellectual and emotional nature (mechanisms). Students most affected were those with a strong motivation to help others and who value teamwork. Students with clearly envisaged career paths suited to metropolitan areas, or those retaining/prioritising strong social and community ties in metropolitan areas were less likely to commit to future rural work. Our theory indicates multi-level stimuli activates openness. Implications are that rural immersion programs could select students with an orientation towards teamwork, without pre-set professional ideation, and with a strong commitment to helping others. Experiencing rural immersion will trigger aspirational, intellectual and emotional responses leading to rural work openness for such students. [ABSTRACT FROM AUTHOR]

Background: 'Grow your own' strategies are considered important for developing rural workforce capacity. They involve selecting health students from specific rural regions and training them for extended periods in the same regions, to improve local retention. However, most research about these strategies is limited to single institution studies that lack granularity as to whether the specific regions of origin, training and work are related. This national study aims to explore whether doctors working in specific rural regions also entered medicine from that region and/or trained in the same region, compared with those without these connections to the region. A secondary aim is to explore these associations with duration of rural training.Methods: Utilising a cross-sectional survey of Australian doctors in 2017 (n = 6627), rural region of work was defined as the doctor's main work location geocoded to one of 42 rural regions. This was matched to both (1) Rural region of undergraduate training (< 12 weeks, 3-12 months, > 1 university year) and (2) Rural region of childhood origin (6+ years), to test association with returning to work in communities of the same rural region.Results: Multinomial logistic regression, which adjusted for specialty, career stage and gender, showed those with > 1 year (RRR 5.2, 4.0-6.9) and 3-12 month rural training (RRR 1.4, 1.1-1.9) were more likely to work in the same rural region compared with < 12 week rural training. Those selected from a specific region and having > 1-year rural training there related to 17.4 times increased chance of working in the same rural region compared with < 12 week rural training and metropolitan origin.Conclusion: This study provides the first national-scale empirical evidence supporting that 'grow your own' may be a key workforce capacity building strategy. It supports underserviced rural areas selecting and training more doctors, which may be preferable over policies that select from or train doctors in 'any' rural location. Longer training in the same region enhances these outcomes. Reorienting medical training to selecting and training in specific rural regions where doctors are needed is likely to be an efficient means to correcting healthcare access inequalities. [ABSTRACT FROM AUTHOR]

Background: Medical training is a long process that is not complete until doctors finish specialty training. Getting into specialty training is challenging because of strong competition for limited places, depending on doctors' chosen field. This may have a negative impact on doctor well-being and reduce the efficiency of the medical training system. This study explored the barriers of pre-registrar (junior) doctors getting into specialty training programs to inform tailored support and re-design of speciality entry systems. Methods: From March to October 2019, we conducted 32 semi-structured interviews with early-career doctors in Australia, who had chosen their specialty field, and were either seeking entry, currently undertaking or had recently completed various fields of specialty training. We sought reflections about barriers and major influences to getting into specialty training. In comparing and contrasting generated themes, different patterns emerged from doctors targeting traditionally non-competitive specialty fields like General Practice (GP) and other specialties (typically more competitive fields). As a result we explored the data in this dichotomy. Results: Doctors targeting entry to GP specialties had relatively seamless training entry and few specific barriers. In contrast, those pursuing other specialties, regardless of which ones, relayed multiple barriers of: Navigating an unpredictable and complex system with informal support/guidance; Connecting to the right people/networks for relevant experience; Pro-actively planning and differentiating skills with recurrent failure of applications. Conclusions: Our exploratory study suggests that doctors wanting to get into non-GP specialty training may experience strong barriers, potentially over multiple years, with the capacity to threaten their morale and resilience. These could be addressed by a clearinghouse of information about different speciality programs, broader selection criteria, feedback on applications and more formal guidance and professional supports. The absence of challenges identified for doctors seeking entry to GP could be used to promote increased uptake of GP careers. [ABSTRACT FROM AUTHOR]

Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia. Design, setting and participants: Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (<5years since Fellowship); and consultants. Main outcome measures: Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians. Results: Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8). Conclusion: Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. [ABSTRACT FROM AUTHOR]

Chapter 1: Characterising Australia's rural specialist physician workforce: the professional profile and professional satisfaction of junior doctors and consultants Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia. Design, setting and participants: Cross‐sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008–2016). Participants were specialist physicians from four career stage groups: pre‐registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants. Main outcome measures: Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians. Results: Participants included 1587 pre‐registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre‐registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3–0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2–2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4–0.8). Conclusion: Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. Chapter 2: General physicians and paediatricians in rural Australia: the social construction of professional identity Objective: To explore the construction of professional identity among general physicians and paediatricians working in non‐metropolitan areas. Design, setting and participants: In‐depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018–19. Main outcome measures: Individual and collective descriptors of professional identity. Results: We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location — geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation. Conclusion: Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. Chapter 3: Sustainable rural physician training: leadership in a fragile environment Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality. Design, setting and participants: A cross‐sectional mixed‐methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters. Main outcome measures: Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location. Results: Fellows and trainees reported high levels of satisfaction, with one exception — inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors. Conclusion: Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. Chapter 4: Principles to guide training and professional support for a sustainable rural specialist physician workforce Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action. Design: We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles. Results: Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion — not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles. Conclusion: These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce. [ABSTRACT FROM AUTHOR]

The article focuses on the Selection, training and employment to encourage early-career doctors to pursue a rural postgraduate training pathway. Topics discussed include Australian medical students are increasingly undertaking rural clinical training during their undergraduate course; and the literature points to the strong connection between both selecting rural background medical students and giving them undergraduate rural training experience and the uptake of rural work in early career.

Objective: To review the selection policies and models used by speciality colleges to select candidates for entry to vocational training, exploring whether these processes are rural‐focused. Design: A systematic desktop audit of college selection processes and criteria was done via college websites (Australian Medical Council (AMC) requires selection information to be publicly available). Setting and main outcomes: Material was extracted into a structured template, in 2020. Information extracted related to (i) training entry and selection steps; (ii) selection criteria and elements; (iii) rural‐focused components; and (iv) rural outcomes. Findings were critically reviewed to explore their degree of rural focus. Results: Of 14 specialist colleges included, rural‐focused selection mostly related to college‐led selection models rather than employer‐led. Six colleges had rural‐focused selection criteria (four college‐led), with the Australian College of Rural and Remote Medicine strongest, utilising a 'suitability assessment' for rural practice. Of the remaining five, childhood background or rural work experience contributed between 5% and 20% of the curriculum vitae assessment. Of eight specialist colleges without rural‐focused selection, six used employer‐led selection models. Conclusions: The majority of specialty colleges have no rural‐focused selection criteria and colleges using employer‐led models are weakest. Given that the colleges are required to adhere to the AMC's accreditation standards, it follows that the best way to mobilise change is by including rural selection policies within the AMC standards and requiring reporting of selection outcomes, regardless of the selection models used. This will substantially strengthen ongoing rural pathways in medicine. [ABSTRACT FROM AUTHOR]

Context: Ensuring that specialty trainees are professionally satisfied is not only important from the point of view of trainee well‐being, but is also critical if health systems are to retain doctors. Despite this, little systematic research in specialist trainees has identified policy‐amenable factors correlated with professional satisfaction. This study examined factors associated with trainee professional satisfaction in a national Australian cohort. Methods: This study used 2008‐2015 data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, a national study of doctor demographics, characteristics and professional and personal satisfaction. Our study examined specialist trainees using a repeat cross‐sectional method pooling first responses across all waves. A multivariate logistic regression analysis was used to assess correlates with professional satisfaction. Results: The three factors most strongly correlated with professional satisfaction were feeling well supported and supervised by consultants (odds ratio [OR] 2.59, 95% confidence interval [CI] 2.42‐2.77), having sufficient study time (OR 1.54, 95% CI 1.40‐1.70) and self‐rated health status (OR 1.65, 95% CI 1.53‐1.80). Those working >56 hours per week were significantly less professionally satisfied (OR 0.76, 95% CI 0.70‐0.84) compared with those working the median work hours (45‐50 hours per week). Those earning in the lower quintiles, those earlier in their training and those who had studied at overseas universities were also significantly less likely to be satisfied. Conclusions: Our study suggests that good clinical supervision and support, appropriate working hours and supported study time directly impact trainee satisfaction, potentially affecting the quality of clinical care delivered by trainees. Furthermore, the needs of junior trainees, overseas graduates and those working >56 hours per week should be given particular consideration when developing well‐being and training programmes. Training a strong workforce only helps if our trainees remain in the workforce. The authors explored factors associated with specialist trainee satisfaction and found 3 that stand out: Good clinical supervision, Appropriate working hours, and Supported study time. #traineewellbeing #medtwitter. [ABSTRACT FROM AUTHOR]

Context: 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. Objectives: 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. Methods: 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. Results: 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 (>1 year: 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. Conclusions: 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. The authors demonstrate that multiple dimensions (duration, remoteness and number) of rural undergraduate medical training are relevant to develop rural doctors. National policies for rural training can increase rural background selection and rural training participation. [ABSTRACT FROM AUTHOR]

Globally there is an urban/rural divide in relation to health and healthcare access. A key strategy for addressing general practitioner shortages in rural areas is GP vocational training in rural places, as this may aid in developing practitioners' scope, values and community orientation, and increase propensity for rural practice. This creates a need for deeper understanding of the nature and quality of this training. Rural GPs are well-positioned to reflect on vocational learning in 'place'. We aimed to explore rural GPs' perceptions and experiences of GP vocational learning in relation to rural places. Semi-structured interviews were conducted with 25 GPs based in smaller rural communities in Tasmania. Inductive and theoretical thematic analysis was undertaken. Rural places provide learning opportunities for GP registrars, which shape the relationships between GPs and registrars and their communities. Rural GPs are committed to developing the next generation and improving access to primary care for their communities. Rural places provide unique learning environments for general practice, including rich learning, relationships and community commitment. [ABSTRACT FROM AUTHOR]

Objective: Junior doctors, in their first four years of medical work, are an important part of the health care team. Attracting and retaining these doctors to rural areas underpins the development of the future rural workforce. This is the first national‐scale study about satisfaction of junior doctors, based on their work location, to inform recruitment and retention. Design: Repeat cross‐sectional data 2008 and 2015, pooled for analysis. Setting: Medicine in Australia: Balancing Employment and Life survey. Participants: First responses of 4581 pre‐vocational doctors working as interns up to their fourth postgraduate year. Main outcome measures: Differences between metropolitan and rural respondents in satisfaction and positivity on two inventories. Results: Overall work satisfaction was approximately 85% amongst rural and metropolitan junior doctors, but controlling for other factors rural junior doctors had significantly higher overall satisfaction. Rural junior doctors were significantly more satisfied with their work‐life balance, ability to obtain desired leave and leave at short notice, personal study time and access to leisure interests compared with metropolitan junior doctors. Metropolitan junior doctors were more satisfied with the network of doctors supporting them and the opportunities for family. Conclusion: While both metropolitan and rural junior doctors are generally satisfied, many professional and personal aspects of satisfaction differ considerably by work location. In order to attract early career doctors, the benefits of rural work should be emphasised and perceived weaknesses mitigated. [ABSTRACT FROM AUTHOR]

This finding is consistent with broader evidence supporting the quality and safety of distributed general practice training.[[6]] General practice training in remote areas provides equivalent opportunities for learning and progression toward the fellowship, justifying the national strategy to offer general practice training in more remote locations.[8] Whether the results are also equivalent in later years of general practice training or in other states should be investigated. Keywords: General practice; Education, medical, continuing; Rural health services EN General practice Education, medical, continuing Rural health services 408 409 2 05/17/23 20230515 NES 230515 General practice training is provided in geographically diverse locations across Australia to promote the development of the rural and remote medical workforce. [Extracted from the article]

This paper evaluates rural work location outcomes of an Extended Rural Cohort (ERC) program in medical school. Students nominate a preference and are contracted to the program at entry to the medical course, involving 2–3 years continuous rural training. Data included 2412 graduates from a large university medical school cohort study. Regression modeling compared 2017 work location of ERC participants, by their level of preference for the ERC and students who had other (similar or shorter duration) rural training with a metropolitan-only trained group. Students who entered medicine with ERC as their first preference commonly had rural background (95.5%) compared with second or lower preferences (61.5% and 40.4%, respectively). Multivariate regression modeling identified ERC participants were more likely to work rurally (OR: 2.69–3.27, compared with metropolitan-trained), though higher odds were associated with lower preference for ERC. However, non-ERC students undertaking a similar duration rural training by opting for this "year by year" after course entry, had the strongest odds of rural work (OR: 4.62, 95%CI: 3.00–7.13) and work in smaller rural towns (RRR: 4.08, 95%CI: 2.36–7.06). The ERC attracts rural background students and increases rural work outcomes. However, students choosing a rural training path of equivalent duration after course entry may be more effective and improve rural workforce distribution. [ABSTRACT FROM AUTHOR]

Purpose: To investigate whether publishing research is an important aspect of medical careers, and how it varies by specialty and rural or metropolitan location.Methods: Annual national panel survey (postal or online) of Australian doctors between 2008 and 2016, with aggregated participants including 11 263 junior doctors not enrolled in a specialty ('pre-registrars'), 9745 junior doctors enrolled as specialist trainees, non-general practitioner (GP) ('registrars') and 35 983 qualified as specialist consultants, non-GP ('consultants'). Main outcome was in agreement that 'research publications are important to progress my training' (junior doctors) or 'research publications are important to my career' (consultants).Results: Overall, the highest proportion agreeing were registrars (65%) and pre-registrars (60%), compared with consultants (36%). After accounting for key covariates, rural location was significantly associated with lower importance of publishing research for pre-registrars (OR 0.69, 95% CI 0.61 to 0.78) and consultants (OR 0.69, 95% CI 0.63 to 0.76), but not for registrars. Compared with anaesthetics, research importance was significantly higher for pre-registrars pursuing surgery (OR 4.46, 95% CI 3.57 to 5.57) and obstetrics/gynaecology careers, for registrars enrolled in surgery (OR 2.97, 95% CI 2.34 to 3.75) and internal medicine training, and consultants of internal medicine (OR 1.84, 95% CI 1.63 to 2.08), pathology, radiology and paediatrics.Conclusions: This study provides new quantitative evidence showing that the importance of publishing research is related to medical career stages, and is most important to junior doctors seeking and undertaking different specialty training options. Embedding research requirements more evenly into specialty college selection criteria may stimulate uptake of research. Expansion of rural training pathways should consider capacity building to support increased access to research opportunities in these locations. [ABSTRACT FROM AUTHOR]

Background and objective General practice training in Australia is uniquely structured to allow half of all registrars to train in rural areas, in order to increase rural workforce development and access to rural primary care. There is, however, limited national-scale information about rural general practice supervisors who underpin the capacity for rural general practice training. The objective of this research was to explore the factors related to rural general practitioners (GPs) supervising general practice registrars. Methods Results were obtained using multivariate analysis of the 2016 Medicine in Australia: Balancing Employment and Life survey data. Results Overall, 57.8% of rural GPs were supervising registrars. Supervising was strongly related to being Australiantrained, working in a larger practice, and supervising medical students and interns. Discussion Rural supervising capacity could be increased through supporting GPs in smaller practices to engage in supervision and maintaining the strong involvement of GPs in larger practices. Other important factors may include a greater number of Australian-trained graduates working in rural general practice and increased support for international medical graduates to Fellow and feel confident to supervise. [ABSTRACT FROM AUTHOR]

Context: Providing year‐long rural immersion as part of the medical degree is commonly used to increase the number of doctors with an interest in rural practice. However, the optimal duration and setting of immersion has not been fully established. This paper explores associations between various durations and settings of rural immersion during the medical degree and whether doctors work in rural areas after graduation. Methods: Eligible participants were medical graduates of Monash University between 2008 and 2016 in postgraduate years 1‐9, whose characteristics, rural immersion information and work location had been prospectively collected. Separate multiple logistic regression and multinomial logit regression models tested associations between the duration and setting of any rural immersion they did during the medical degree and (i) working in a rural area and (ii) working in large or smaller rural towns, in 2017. Results: The adjusted odds of working in a rural area were significantly increased if students were immersed for one full year (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.15–2.79), for between 1 and 2 years (OR, 2.26; 95% CI, 1.54–3.32) and for 2 or more years (OR, 4.43; 95% CI, 3.03–6.47) relative to no rural immersion. The strongest association was for immersion in a mix of both regional hospitals and rural general practice (OR, 3.26; 95% CI, 2.31–4.61), followed by immersion in regional hospitals only (OR, 1.94; 95% CI, 1.39–2.70) and rural general practice only (OR, 1.91; 95% CI, 1.06–3.45). More than 1 year's immersion in a mix of regional hospitals and rural general practices was associated with working in smaller regional or rural towns (<50 000 population) (relative risk ratios [RRR] 2.97; 95% CI, 1.82–4.83). Conclusion: These findings inform medical schools about effective rural immersion programmes. Longer rural immersion and immersion in both regional hospitals and rural general practices are likely to increase rural work and rural distribution of early career doctors. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The purpose of this arm of the study was to investigate the impact of medication on healing times of the various wound types, including acute wounds and leg ulcers. A prospective longitudinal study design was used, with de-identified data collected using an electronic mobile wound care database system. Three main categories of data were collected, including patients' demographics, wounds types and treatment characteristics. For acute wounds, there was a total of 1732 patients with 2089 acute wounds. The average healing time was about 35 days. The only significant association was with chemotherapy, which increased healing time by 21 days ( P = 0·048). There were non-significant trends towards reduced healing times with antibiotics (0·5 days; P = 0·853), anticoagulants (1·7 days, P = 0·673) and corticosteroids (4·98 days, P = 0·303). Non-steroidal anti-inflammatory drugs ( NSAIDs) were associated with a non-significant increase in healing time (2·17 days, P = 0·707). For leg ulcers, there was a total of 264 patients with 370 leg ulcers. We only examined the impact of antibiotics, anticoagulants, corticosteroids and NSAIDs on healing times as they had an adequate number of wounds to analyse. The average healing times of leg ulcers were found to be 73 days. None of the classes of medications had any significant impact on healing time. Both anticoagulants and NSAIDs increased healing time by (22·5 days, P = 0·08) and (12·5 days, P = 0·03), respectively. On the other hand, antibiotics and corticosteroids decreased healing times non-significantly by (9·1 days, P = 0·33) and (21·6 days, P = 0·84), respectively. [ABSTRACT FROM AUTHOR]

Objective Systematically describe the characteristics of rural specialists, their work and job satisfaction by geographical location of work. Design Cross-sectional. Setting and participants Three thousand, four hundred and seventy-nine medical specialists participating in the 2014 Medicine in Australia: Balancing Employment and Life ( MABEL) survey of doctors. Main outcome measure Location of practice, whether metropolitan, large (>50 000 population) or small regional centres (<50 000 population). Result Specialists working in large regional centres had similar characteristics to metropolitan specialists, however, those in small regional centres were more likely men, later career, overseas-trained and less likely to work privately. Rural specialists had more on-call requirements and poorer professional development opportunities. However, satisfaction with work hours, remuneration, variety of work, level of responsibility, opportunities to use abilities and overall satisfaction did not differ. Specialists in general medicine and general surgery were significantly more likely to work rurally compared with anaesthetists, particularly in small regional centres, whereas a range of other relevant specialists had lower than the average rural distribution and paediatricians and endocrinologists were significantly less likely to work in large regional centres. Conclusion Rural specialists are just as satisfied as metropolitan counterparts reporting equivalent variety and responsibility at work. Better support for on-call demands and access to professional development could attract more specialists to rural practice. Increased rural training opportunities and regional workforce planning is needed to develop and recruit relevant specialties. Specifically, targeted support is warranted for training and development of specialists in general medicine and general surgery and overseas-trained specialists, who provide essential services in smaller regional centres. [ABSTRACT FROM AUTHOR]

Background: Reduced opportunities for children's schooling and spouse's/partner's employment are identified internationally as key barriers to general practitioners (GPs) working rurally. This paper aims to measure longitudinal associations between the rurality of GP work location and having (i) school-aged children and (ii) a spouse/partner in the workforce.Methods: Participants included 4377 GPs responding to at least two consecutive annual surveys of the Medicine in Australia: Balancing Employment and Life (MABEL) national longitudinal study between 2008 and 2014. The main outcome, GP work location, was categorised by remoteness and population size. Five sequential binary school-age groupings were defined according to whether a GP had no children, only preschool children (aged 0-4 years), at least one primary-school child (aged 5-11 years), at least one child in secondary school (aged 12-18 years), and all children older than secondary school (aged ≥ 19). Partner in the workforce was defined by whether a GP had a partner who was either currently working or looking for work, or not. Separate generalised estimating equation models, which aggregated consecutive annual observations per GP, tested associations between work location and (i) educational stages and (ii) partner employment, after adjusting for key covariates.Results: Male GPs with children in secondary school were significantly less likely to work rurally (inclusive of > 50 000 regional centres through to the smallest rural towns of < 5000) compared to male GPs with children in primary school. In contrast, female GPs' locations were not significantly associated with the educational stage of their children. Having a partner in the workforce was not associated with work location for male GPs, whereas female GPs with a partner in the workforce were significantly less likely to work in smaller rural/remote communities (< 15 000 population).Conclusions: This is the first systematic, national-level longitudinal study showing that GP work location is related to key family needs which differ according to GP gender and educational stages of children. Such non-professional factors are likely to be dynamic across the GP's lifespan and should be regularly reviewed as part of GP retention planning. This research supports investment in regional development for strong local secondary school and partner employment opportunities. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to explore the association between career stage and rural medical workforce supply among Australian-trained medical graduates. Design and Setting Descriptive analysis using the national Medicine in Australia: Balancing Employment and Life ( MABEL) longitudinal study. Participants Australian-trained GPs and other specialists who participated in the MABEL study, 2008-2013. Main outcome measure(s) Proportions of GPs and specialists working in rural locations, according to career stage (establishing, early, mid and late), gender and childhood-origin type (rural versus metropolitan). Results Logistic regression models revealed that establishing- and early-career GPs had significantly higher likelihood ( OR 1.67 and 1.38, respectively) of working rurally, but establishing and early-career doctors were significantly less likely ( OR 0.34 and 0.43, respectively) to choose general practice, contributing proportionally fewer rural GPs overall ( OR 0.77 and 0.75, respectively) compared to late-career doctors. For specialists, there were no significant associations between career cohorts and rural practice. Overall, there was a significantly lower likelihood ( OR 0.83) of establishing-career doctors practising rurally. Women were similarly likely to be rural GPs but less likely to be rural specialists, while rural-origin was consistently associated with higher odds of rural practice. Conclusions The supply of Australia's rural medical workforce from its medical schools continues to be challenging, with these data highlighting both their source and associations with doctors at different career stages. Despite large investments through rural medical training and rural workforce recruitment and retention policies, these data confirm continued reliance on internationally trained medical graduates for large proportions of rural supply is likely. [ABSTRACT FROM AUTHOR]

Objective Improving access to primary health care (PHC) remains a key issue for rural residents and health service planners. This study aims to show that how access to PHC services is measured has important implications for rural health service and workforce planning. Methods A more sophisticated tool to measure access to PHC services is proposed, which can help health service planners overcome the shortcomings of existing measures and long-standing access barriers to PHC. Critically, the proposed Index of Access captures key components of access and uses a floating catchment approach to better define service areas and population accessibility levels. Moreover, as demonstrated through a case study, the Index of Access enables modelling of the effects of workforce supply variations. Results Hypothetical increases in supply are modelled for a range of regional centres, medium and small rural towns, with resulting changes of access scores valuable to informing health service and workforce planning decisions. Conclusions The availability and application of a specific 'fit-for-purpose' access measure enables a more accurate empirical basis for service planning and allocation of health resources. This measure has great potential for improved identification of PHC access inequities and guiding redistribution of PHC services to correct such inequities. [ABSTRACT FROM AUTHOR]

Objectives To investigate patterns of Australian GP procedural activity and associations with: geographical remoteness and population size, hours worked in hospitals and in total; and, availability for on-call, Design and participants National annual panel survey (Medicine in Australia: Balancing Employment and Life) of Australian GPs, 2011-2013. Main outcome measures Self-reported geographical work location, hours worked in different settings, and on-call availability per usual week, were analysed against GP procedural activity in anaesthetics, obstetrics, surgery or emergency medicine. Results Analysis of 9301 survey responses from 4638 individual GPs revealed significantly increased odds of GP procedural activity in anaesthetics, obstetrics or emergency medicine as geographical remoteness increased and community population size decreased, albeit with plateauing of the effect-size from medium-sized (population 5000-15 000) rural communities. After adjusting for confounders, procedural GPs work more hospital and more total hours each week than non-procedural GPs. In 2011 this equated to GPs practising anaesthetics, obstetrics, surgery, and emergency medicine providing 8% (95% CI 0, 16), 13% (95% CI 8, 19), 8% (95% CI 2, 15) and 18% (95% CI 13, 23) more total hours each week, respectively. The extra hours are attributable to longer hours worked in hospital settings, with no reduction in private consultation hours. Procedural GPs also carry a significantly higher burden of on-call. Conclusions The longer working hours and higher on-call demands experienced by rural and remote procedural GPs demand improved solutions, such as changes to service delivery models, so that long-term procedural GP careers are increasingly attractive to current and aspiring rural GPs. [ABSTRACT FROM AUTHOR]

Purpose: Despite considerable investment in increasing the number of primary care physicians in rural shortage areas, little is known about their movement rates and factors influencing their mobility. We aimed to characterize geographic mobility among rural primary care physicians, and to identify location and individual factors that influence such mobility.Methods: Using data from the American Medical Association Physician Masterfile for each clinically active US physician, we created seven 2-year (biennial) mobility periods during 2000-2014. These periods were merged with county-level "rurality," physician supply, economic characteristics, key demographic measures, and individual physician characteristics. We computed (1) mobility rates of physicians by rurality; (2) linear regression models of county-level rural nonretention (departure); and (3) logit models of physicians leaving rural practice.Results: Biennial turnover was about 17% among physicians aged 45 and younger, compared with 9% among physicians aged 46 to 65, with little difference between rural and metropolitan groups. County-level physician mobility was higher for counties that lacked a hospital (absolute increase = 5.7%), had a smaller population size, and had lower primary care physician supply, but area-level economic and demographic factors had little impact. Female physicians (odds ratios = 1.24 and 1.46 for those aged 45 or younger and those aged 46 to 65, respectively) and physicians born in a metropolitan area (odds ratios = 1.75 and 1.56 for those aged 45 or younger and those aged 46 to 65, respectively) were more likely to leave rural practice.Conclusions: These flndings provide national-level evidence of rural physician mobility rates and factors associated with both county-level retention and individual-level departures. Outcomes were notably poorer in the most remote locations and those already having poorer physician supply and professional support. Rural health workforce planners and policymakers must be cognizant of these key factors to more effectively target retention policies and to take into account the additional support needed by these more vulnerable communities. [ABSTRACT FROM AUTHOR]

Introduction Around 30% of peripherally inserted central catheters (PICCs) fail from vascular, infectious or mechanical complications. Patients with cancer are at highest risk, and this increases morbidity, mortality and costs. Effective PICC dressing and securement may prevent PICC failure; however, no large randomised controlled trial (RCT) has compared alternative approaches. We designed this RCT to assess the clinical and cost-effectiveness of dressing and securements to prevent PICC failure. Methods and analysis Pragmatic, multicentre, 2×2 factorial, superiority RCT of (1) dressings (chlorhexidine gluconate disc (CHG) vs no disc) and (2) securements (integrated securement dressing (ISD) vs securement device (SED)). A qualitative evaluation using a knowledge translation framework is included. Recruitment of 1240 patients will occur over 3 years with allocation concealment until randomisation by a centralised service. For the dressing hypothesis, we hypothesise CHG discs will reduce catheter-associated bloodstream infection (CABSI) compared with no CHG disc. For the securement hypothesis, we hypothesise that ISD will reduce composite PICC failure (infection (CABSI/local infection), occlusion, dislodgement or thrombosis), compared with SED. Secondary outcomes: types of PICC failure; safety; costs; dressing/securement failure; dwell time; microbial colonisation; reversible PICC complications and consumer acceptability. Relative incidence rates of CABSI and PICC failure/100 devices and/1000 PICC days (with 95% CIs) will summarise treatment impact. Kaplan-Meier survival curves (and log rank Mantel-Haenszel test) will compare outcomes over time. Secondary end points will be compared between groups using parametric/non-parametric techniques; p values <0.05 will be considered to be statistically significant. Ethics and dissemination Ethical approval from Queensland Health (HREC/15/QRCH/241) and Griffith University (Ref. No. 2016/063). Results will be published. [ABSTRACT FROM AUTHOR]

Objective. Targeting rural outreach services to areas of highest relative need is challenging because of the higher costs it imposes on health workers to travel longer distances. This paper studied whether subsidies have the potential to support the provision of specialist outreach services into more remote locations. Methods. National data about subsidies for medical specialist outreach providers as part of the Wave 7 Medicine in Australia: Balancing Employment and Life (MABEL) Survey in 2014. Results. Nearly half received subsidies: 19% (n = 110) from a formal policy, namely the Australian Government Rural Health Outreach Fund (RHOF), and 27% (n = 154) from other sources. Subsidised specialists travelled for longer and visited more remote locations relative to the non-subsidised group. In addition, compared with non-subsidised specialists, RHOF-subsidised specialists worked in priority areas and provided equally regular services they intended to continue, despite visiting more remote locations. Conclusion. This suggests the RHOF, although limited to one in five specialist outreach providers, is important to increase targeted and stable outreach services in areas of highest relative need. Other subsidies also play a role in facilitating remote service distribution, but may need to be more structured to promote regular, sustained outreach practice. [ABSTRACT FROM AUTHOR]

Objective To synthesise key Australian empirical rural retention evidence and outline implications and potential applications for policymaking. Design A comprehensive search of Medline, Psych INFO, CINAHL plus, Scopus and EMBASE revealed eight peer-reviewed empirical studies published since 2000 quantifying factors associated with actual retention. Setting and participants Rural and remote Australian primary health care workers. Main outcome measures Hazard ratios (hazard of leaving rural), mean length of stay in current rural position and odds ratios (odds of leaving rural). Results A broad range of geographical, professional, financial, educational, regulatory and personal factors are strongly and significantly associated with the rural retention of Australian primary health care workers. Important factors included geographical remoteness and population size, profession, providing hospital services, practising procedural skills, taking annual leave, employment grade, employment and payment structures, restricted access to provider numbers, country of training, vocational training, practitioner age group and cognitive behavioural coaching. These findings suggest that retention strategies should be multifaceted and 'bundled', addressing the combination of modifiable factors most important for specific groups of Australian rural and remote primary health care workers, and compensating health professionals for hardships they face that are linked to less modifiable factors. Conclusions The short retention of many Australian rural and remote Allied Health Professionals and GPs, particularly in small, outer regional and remote communities, requires ongoing policy support. The important retention patterns highlighted in this review provide policymakers with direction about where to best target retention initiatives, as well as an indication of what they can do to improve retention. [ABSTRACT FROM AUTHOR]

Background: The purpose of the study is to explore the reasons why specialist doctors travel to provide regular rural outreach services, and whether reasons relate to (1) salaried or private fee-for-service practice and (2) providing rural outreach services in more remote locations.Methods: A national cross-sectional study of specialist doctors from the Medicine in Australia: Balancing Employment and Life (MABEL) survey in 2014 was implemented. Specialists providing rural outreach services self-reported on a 5-point scale their level of agreement with five reasons for participating. Chi-squared analysis tested association between agreement and variables of interest.Results: Of 567 specialists undertaking rural outreach services, reasons for participating include to grow the practice (54%), maintain a regional connection (26%), provide complex healthcare (18%), healthcare for disadvantaged people (12%) and support rural staff (6%). Salaried specialists more commonly participated to grow the practice compared with specialists in fee-for-service practice (68 vs 49%). This reason was also related to travelling further and providing outreach services in outer regional/remote locations. Private fee-for-service specialists more commonly undertook outreach services to provide complex healthcare (22 vs 14%).Conclusions: Specialist doctors undertake rural outreach services for a range of reasons, mainly to complement the growth and diversity of their main practice or maintain a regional connection. Structuring rural outreach around the specialist's main practice is likely to support participation and improve service distribution. [ABSTRACT FROM AUTHOR]