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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. Cohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools. 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). 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). 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.

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.

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. 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. 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. 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.

The optimal duration of infusion set use to prevent life-threatening catheter-related bloodstream infection (CRBSI) is unclear. We aimed to compare the effectiveness and costs of 7-day (intervention) versus 4-day (control) infusion set replacement to prevent CRBSI in patients with central venous access devices (tunnelled cuffed, non-tunnelled, peripherally inserted, and totally implanted) and peripheral arterial catheters.

The study examines if the extent of professional satisfaction of Australian general practitioners (GPs) varies according to community size and location. Evidence suggests GPs working in different sized communities in Australia experience similar levels of satisfaction with most professional aspects of their work.

PurposeTo investigate whether publishing research is an important aspect of medical careers, and how it varies by specialty and rural or metropolitan location.MethodsAnnual 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).ResultsOverall, 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.ConclusionsThis 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.

Two billion peripheral intravenous catheters (PIVCs) are used globally each year, but optimal dressing and securement methods are not well established. We aimed to compare the efficacy and costs of three alternative approaches to standard non-bordered polyurethane dressings.

This study was undertaken to calculate the incidence of 8 signs and symptoms used for the diagnosis of phlebitis with peripheral intravenous catheters, or short peripheral catheters, and the level of correlation between them. A total of 22 789 daily observations of 6 signs (swelling, erythema, leakage, palpable venous cord, purulent discharge, and warmth) and 2 symptoms (painand tenderness) were analyzed of 5907 catheter insertion sites. Most signs and symptoms of phlebitis occurred only occasionally or rarely; the incidence of tendernesswas highest (5.7%). Correlations were mostly low; warmthcorrelated strongly with tenderness, swelling, and erythema.

Objective.To assess the relative importance of independent risk factors for peripheral intravenous catheter (PIVC) failure.Methods.Secondary data analysis from a randomized controlled trial of PIVC dwell time. The Prentice, Williams, and Peterson statistical model was used to identify and compare risk factors for phlebitis, occlusion, and accidental removal.Setting.Three acute care hospitals in Queensland, Australia.Participants.The trial included 3,283 adult medical and surgical patients (5,907 catheters) with a PIVC with greater than 4 days of expected use.Results.Modifiable risk factors for occlusion included hand, antecubital fossa, or upper arm insertion compared with forearm (hazard ratio [HR], 1.47 [95% confidence interval (CI), 1.28–1.68], 1.27 [95% CI, 1.08–1.49], and 1.25 [95% CI, 1.04–1.50], respectively); and for phlebitis, larger diameter PIVC (HR, 1.48 [95% CI, 1.08–2.03]). PIVCs inserted by the operating and radiology suite staff had lower occlusion risk than ward insertions (HR, 0.80 [95% CI, 0.67–0.94]). Modifiable risks for accidental removal included hand or antecubital fossa insertion compared with forearm (HR, 2.45 [95% CI, 1.93–3.10] and 1.65 [95% CI, 1.23–2.22], respectively), clinical staff insertion compared with intravenous service (HR, 1.69 [95% CI, 1.30–2.20]); and smaller PIVC diameter (HR, 1.29 [95% CI, 1.02–1.61]). Female sex was a nonmodifiable factor associated with an increased risk of both phlebitis (HR, 1.64 [95% CI, 1.28–2.09]) and occlusion (HR, 1.44 [95% CI, 1.30–1.61]).Conclusions.PIVC survival is improved by preferential forearm insertion, selection of appropriate PIVC diameter, and insertion by intravenous teams and other specialists.Trial Registration.The original randomized controlled trial on which this secondary analysis is based is registered with the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au; ACTRN12608000445370).

The millions of peripheral intravenous catheters used each year are recommended for 72–96 h replacement in adults. This routine replacement increases health-care costs and staff workload and requires patients to undergo repeated invasive procedures. The effectiveness of the practice is not well established. Our hypothesis was that clinically indicated catheter replacement is of equal benefit to routine replacement.

Objective:To outline a new index of access to primary care services in rural areas that has been specifically designed to overcome weaknesses of using existing geographical classifications. Methods:Access was measured by four key dimensions of availability, proximity, health needs and mobility. Population data were obtained through the national census and primary care service data were obtained through the Medical Directory of Australia. All data were calculated at the smallest feasible geographical unit (collection districts). The index of access was measured using a modified two‐step floating catchment area (2SFCA) method, which incorporates two necessary additional spatial functions (distance‐decay and capping) and two additional non‐spatial dimensions (health needs and mobility). Results:An improved index of access, specifically designed to better capture access to primary care in rural areas, is achieved. These improvements come from: 1) incorporation of actual health service data in the index; 2) methodological improvements to existing access measures, which enable both proximity to be differentiated within catchments and the use of varying catchment sizes; and 3) improved sensitivity to small‐area variations. Conclusion:Despite their recognised weaknesses, the Australian government uses broad geographical classifications as proxy measures of access to underpin significant rural health funding programs. This new index of access could provide a more equitable means for resource allocation. Implications:Significant government funding, aimed at improving health service access inequities in rural areas, could be better targeted by underpinning programs with our improved access measure.

Medical education in Australia is currently entering a new era, including support for the significant extension of medical students and general practitioner (GP)registrars' training programs in rural communities. This commitment to rural medical student and general practitioner recruitment and retention has made the provision of accommodation in rural communities a vital issue. This study has found that approximately half of all medical students on placement with rural GPs are currently accommodated with their GP supervisor or with other practice staff. This is a burden for many GPs and when the anticipated increase in the frequency and length of rural placements occurs what is currently a burden will become unsustainable. The changing gender and cultural demographics of medical students and rural general practitioners will also contribute to stresses on this accommodation system. It is important to have a systematic approach towards more appropriate and sustainable models of accommodation for both medical students and GP registrars.

This randomized, controlled trial involving 316 patients in the home setting found no difference in the rate of phlebitis and/or occlusion among patients for whom a peripheral intravenous catheter was routinely resited at 72-96 hours and those for whom it was replaced only on clinical indication (76.8 events per 1,000 device-days vs 87.3 events per 1,000 device-days; P= .71). There were no bloodstream infections.

Students in a new medical school were provided with laptops. This study explored the feasibility and educational benefits of mobile learning for two cohorts of students learning in two settings—university campus (first-year students) and rural clinical placements (second-year students). Evaluation involved questionnaires, focus groups (faculty and students), and document analysis. Descriptive statistics were computed. Focus groups were audio-recorded, transcribed, and analysed thematically. Response rates for questionnaires exceeded 84%. Compared with second-year students, significantly more first-year students (60%) took their laptops to campus daily (P=0.14) and used their laptops for more hours each day (P=0.031). All students used laptops most frequently to access the internet (85% and 97%) and applications (Microsoft Word (80% and 61%) and Microsoft PowerPoint (80% and 63%)). Focus groups with students revealed appreciation for the laptops but frustration with the initial software image. Focus groups with faculty identified enthusiasm for mobile learning but acknowledged its limitations. Physical infrastructure and information technology support influenced mobile learning. Document analysis revealed significant costs and issues with maintenance. If adequately resourced, mobile learning through university-issued laptops would be feasible and have educational benefits, including equitable access to learning resources, when and where they are needed. However, barriers remain for full implementation.