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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., (© 2023. The Author(s).)

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., (© 2023. The Author(s).)

Introduction: Despite substantial investment in rural workforce support, sustaining the necessary recruitment and retention of general practitioners (GPs) in rural areas remains a challenge. Insufficient medical graduates are choosing a general/rural practice career. Medical training at postgraduate level, particularly for those 'between' undergraduate medical education and specialty training, remains strongly reliant on hospital experience in larger hospitals, potentially diverting interest away from general/rural practice. The Rural Junior Doctor Training Innovation Fund (RJDTIF) program offered junior hospital doctors (interns) an experience of 10 weeks in a rural general practice, aiming to increase their consideration of general/rural practice careers This study aimed to evaluate the educational and potential workforce impact of the RJDTIF program., Methods: Up to 110 places were established during 2019-2020 for Queensland's interns to undertake an 8-12-week rotation (depending on individual hospital rosters) out of regional hospitals to work in a rural general practice. Participants were surveyed before and after the placement, although only 86 were invited due to the disruption caused by the COVID-19 pandemic. Descriptive quantitative statistics were applied to the survey data. Four semi-structured interviews were conducted to further explore the experiences post-placement, with audio-recordings transcribed verbatim. Semi-structured interview data were analysed using inductive, reflexive thematic analysis., Results: In total, 60 interns completed either survey, although only 25 were matched as completing both surveys. About half (48%) indicated they had preferenced the rural GP term and 48% indicated strong enthusiasm for the experience. General practice was indicated as the most likely career option for 50%, other general specialty 28% and subspecialty 22%. Likelihood to be working in a regional/rural location in 10 years was indicated as 'likely' or 'very likely' for 40%, 'unlikely' for 24% and 'unsure' for 36%. The two most common reasons for preferencing a rural GP term were experiencing training in a primary care setting (50%) and gaining more clinical skills through increased patient exposure (22%). The overall impact on pursuing a primary care career was self-assessed as much more likely by 41%, but much less by 15%. Interest in a rural location was less influenced. Those rating the term poor or average had low pre-placement enthusiasm for the term. The qualitative analysis of interview data produced two themes: importance of the rural GP term for interns (hands-on learning, skills improvement, influence on future career choice and engagement with the local community), and potential improvements to rural intern GP rotations., Conclusion: Most participants reported a positive experience from their rural GP rotation, which was recognised as a sound learning experience at an important time with respect to choosing a specialty. Despite the challenges posed by the pandemic, this evidence supports the investment in programs that provide opportunities for junior doctors to experience rural general practice in these formative postgraduate years to stimulate interest in this much-needed career pathway. Focusing resources on those who have at least some interest and enthusiasm may improve its workforce impact.

Background: Locus of control (LoC) is a social cognition, that relates to the level of self-control that people have over their personal environment that influences their life. In this context, LoC is frequently associated with work-related behavioral outcomes, ranging from job attitudes, career behaviors, stress, and burnout., Objective: To investigate the association between LoC, and work-related behavioral factors, socio-cultural factors, and personal factors among Australian General Practitioners (GPs)., Methods: This study utilized data from the 2010 Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors. Locus of control (LoC) was measured by a 7-point Likert scale based on Pearlin-Schooler Mastery/Self-efficacy 7-item Scale. Higher score indicated lower internal LoC. Multivariate linear regression model was performed to determine the independent predictors of LoC., Results: Of 3,664 GP participants, LoC did not differ by gender. Poor/fair self-rated health, working in urban location, running a stressful practice, poor balance of professional and personal commitments, poor support network, financial circumstances after retirement, and perception of unrealistic expectation by patients were significant predictors for a lower Internal LoC in a multivariate linear regression model. Adjusted R 2 explained 22.4% of variation in predicting the LoC in our models., Conclusions: LoC of Australian GPs is negatively affected by poor work-life balance, inadequate support, and unrealistic patient expectation. These work-place specific factors could be targeted by interventions to improve GPs wellbeing., Competing Interests: Declaration of competing interest The authors declared no conflicts of interest., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: In Australia registrar training to become a general practitioner (GP) involves three to four years of supervised learning with at least 50% of GP registrars training wholly in rural areas. In particular rural over regional GP placements are important for developing future GPs with broader skills because the rural scope of practice is wider. Having enough GP supervisors in smaller rural communities is essential such training. We aimed to explore what makes rural GPs' based outside of major regional centres, participate in supervising or not, their experiences of supervising, and impact of their practice context., Methods: Semi-structured interviews were undertaken with 25 GPs based in rural Tasmania (outside of major regions - Hobart and Launceston), in towns of < 25,000 population, to explore the GPs' professional backgrounds, their experiences of supervising GP registrars, their practice context and their decisions about supervising GP registrars or not. Thematic analysis was undertaken; key ideas, concepts and experiences were identified and then reviewed and further refined to core themes., Results: Supervising was perceived to positively impact on quality of clinical care, reduce busy-ness and improve patient access to primary care. It was energising for GPs working in rural contexts. Rural GPs noted business factors impacted the decision to participate in supervision and the experience of participating: including uncertainty and discontinuity of registrar supply (rotational training systems), registrar competence and generating income., Conclusions: Supervising is strongly positive for rural GPs and related to job satisfaction but increasing supervision capacity in rural areas may depend on better policies to assure continuity of rural registrars as well as policies and systems that enable viable supervision models tailored to the context.

Strategies are urgently needed to foster rural general practitioners (GPs) with the skills and professional support required to adequately address healthcare needs in smaller, often isolated communities. Australia has uniquely developed two national-scale faculties that target rural practice: the Fellowship in Advanced Rural General Practice (FARGP) and the Fellowship of the Australian College of Rural and Remote Medicine (FACRRM). This study evaluates the benefit of rural faculties for supporting GPs practicing rurally and at a broader scope. Data came from an annual national survey of Australian doctors from 2008 and 2017, providing a cross-sectional design. Work location (rurality) and scope of practice were compared between FACRRM and FARGP members, as well as standard non-members. FACRRMs mostly worked rurally (75-84%, odds ratio (OR) 8.7, 5.8-13.1), including in smaller rural communities (<15,000 population) (41-54%, OR 3.5, 2.3-5.3). FARGPs also mostly worked in rural communities (56-67%, OR 4.2, 2.2-7.8), but fewer in smaller communities (25-41%, OR 1.1, 0.5-2.5). Both FACRRMs and FARGPs were more likely to use advanced skills, especially procedural skills. GPs with fellowship of a rural faculty were associated with significantly improved geographic distribution and expanded scope, compared with standard GPs. Given their strong outcomes, expanding rural faculties is likely to be a critical strategy to building and sustaining a general practice workforce that meets the needs of rural communities., Competing Interests: The authors declare no conflict of interest

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.

Background and Objectives: 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., Method: 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 Australian-trained, 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.

Many countries use financial incentive programs to attract physicians to work in rural areas. This paper examines the effectiveness of a policy reform in Australia that made some locations newly eligible for financial incentives and increased incentives for locations already eligible. The analysis uses panel data (2008-2014) on all Australian general practitioners (GPs) aggregated to small areas. We use a difference-in-differences approach to examine if the policy change affected GP entry or exit to the 755 newly eligible locations and the 787 always eligible locations relative to 2249 locations which were never eligible. The policy change increased the entry of newly-qualified GPs to newly eligible locations but had no effect on the entry and exit of other GPs. Our results suggest that location incentives should be targeted at newly qualified GPs., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

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.

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., (© 2016 National Rural Health Alliance Inc.)

Objective: To investigate associations between general practitioner vocational training location and subsequent practice location, including the effect of rural origin., Design and Participants: Annual panel survey of GPs (from the MABEL study) who completed their vocational training and transitioned to independent practice, 2008-2014., Main Outcome Measures: Rural practice location in the 5 years after vocational registration for participants in four primary cohorts: (1) rural origin/rural training; (2) metropolitan origin/rural training; (3) rural origin/metropolitan training; and (4) metropolitan origin/metropolitan training., Results: During the study period, 610 doctors completed GP vocational training and commenced independent practice. 74-91% of rural origin/rural training cohort GPs remained in rural areas during their first 5 years after completing training, with 61-70% remaining in the same community. Conversely, 87-95% of metropolitan origin/metropolitan training cohort GPs remained in metropolitan areas. GPs from the other two cohorts initially remained in their training location type, but gradually moved towards their origin type. Generalised estimating equation logit models identified a highly significant association between rural training pathways and subsequent rural practice that was sustained for 5 years after vocational registration; it was substantially strengthened when combined with rural origin (cohort 2 v cohort 4: odds ratio [OR], 24; 95% CI, 13-43; cohort 1 v cohort 4: OR, 52; 95% CI, 24-111)., Conclusion: This study provides new quantitative evidence of strong associations between rural GP vocational training location and subsequent rural practice location, which is strengthened when combined with rural origin. This evidence supports current government policy supporting rural GP vocational training and quotas for medical student selection based on rural origin.

Objective: To describe the geographical mobility of general practitioners in Australia, both within rural areas and between rural and metropolitan areas., Design and Participants: Annual panel survey of GPs between 2008 and 2012., Main Outcome Measures: Work location, categorised by a typology based on geographical location and community size; frequency of mobility (change of location category); and characteristics of those who moved., Results: There were 3906 participants in 2008 (representative cohort, 19% of Australia's GP workforce) and 3502, 3514, 3287 and 3361 in subsequent years. 1810 GPs participated in all 5 years, and 10 900 origin-destination pairs were observed after removing GP registrars from the dataset. A total of 133 GPs moved from rural to metropolitan locations, 103 moved from metropolitan to rural locations, and 271 observed location changes were within rural areas. Annual location retention rates were 95% in regional centres, 90% in small rural towns and 82% in very remote areas. GPs in small towns of < 5000 residents had the highest risk of leaving rural practice. Mobility rates were significantly higher for GPs who had worked in a location for under 3 years and those working as either contracted or salaried employees, and somewhat higher for international medical graduates. Younger age was a small predictor of increased mobility, while sex and family status had no association with mobility., Conclusion: GPs working in small communities and those in a rural location for less than 3 years are most at risk of leaving rural practice.

Many governments have implemented incentive programs to improve the retention of doctors in rural areas despite a lack of evidence of their effectiveness. This study examines rural general practitioners' (GPs') preferences for different types of retention incentive policies using a discrete choice experiment (DCE). In 2009, the DCE was administered to a group of 1720 rural GPs as part of the "Medicine in Australia: Balancing Employment and Life (MABEL)" study. We estimate both a mixed logit model and a generalized multinomial logit model to account for different types of unobserved differences in GPs' preferences. Our results indicate that increased level of locum relief incentive, retention payments and rural skills loading leads to an increase in the probability of attracting GPs to stay in rural practice. The locum relief incentive is ranked as the most effective, followed by the retention payments and rural skills loading payments. These findings are important in helping to tailor retention policies to those that are most effective., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

A key policy issue in many countries is the maldistribution of doctors across geographic areas, which has important effects on equity of access and health care costs. Many government programs and incentive schemes have been established to encourage doctors to practise in rural areas. However, there is little robust evidence of the effectiveness of such incentive schemes. The aim of this study is to examine the preferences of general practitioners (GPs) for rural location using a discrete choice experiment. This is used to estimate the probabilities of moving to a rural area, and the size of financial incentives GPs would require to move there. GPs were asked to choose between two job options or to stay at their current job as part of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. 3727 GPs completed the experiment. Sixty five per cent of GPs chose to stay where they were in all choices presented to them. Moving to an inland town with less than 5000 population and reasonable levels of other job characteristics would require incentives equivalent to 64% of current average annual personal earnings ($116,000). Moving to a town with a population between 5000 and 20,000 people would require incentives of at least 37% of current annual earnings, around $68,000. The size of incentives depends not only on the area but also on the characteristics of the job. The least attractive rural job package would require incentives of at least 130% of annual earnings, around $237,000. It is important to begin to tailor incentive packages to the characteristics of jobs and of rural areas., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to define an improved classification for allocating incentives to support the recruitment and retention of doctors in rural Australia., Design and Setting: Geo-coded data (n = 3636 general practitioners (GPs)) from the national Medicine in Australia: Balancing Employment and Life study were used to examine statistical variation in four professional indicators (total hours worked, public hospital work, on call after-hours and difficulty taking time off) and two non-professional indicators (partner employment and schooling opportunities) which are all known to be related to difficulties with recruitment and retention., Main Outcome Measures: The main outcome measure used for the study was an association of six sentinel indicators for GPs with practice location and population size of community., Results: Four distinct homogeneous population size groups were identified (0-5000, 5001-15,000, 15,001-50,000 and >50,000). Although geographical remoteness (measured using the Australian Standard Geographical Classification-Remoteness Areas (ASGC-RA)) was statistically associated with all six indicators (P < 0.001), population size provided a more sensitive measure in directing where recruitment and retention incentives should be provided. A new six-level rurality classification is proposed, based on a combination of four population size groups and the five ASGC-RA levels. A significant increase in statistical association is measured in four of six indicators (and a slight increase in one indicator) using the new six-level classification versus the existing ASGC-RA classification., Conclusions: This new six-level geographical classification provides a better basis for equitable resource allocation of recruitment and retention incentives to doctors based on the attractiveness of non-metropolitan communities, both professionally and non-professionally, as places to work and live., (© 2012 The Authors. Australian Journal of Rural Health © National Rural Health Alliance Inc.)

The objectives of this study were to measure the relative strength, significance and contribution of factors associated with rural and remote medical workforce retention. Length of stay data from two Australian GP workforce datasets, the 2008 National Minimum Data Set (4223 GPs) and a subset of the 2008 Medicine in Australia: Balancing Employment and Life dataset (1189 GPs), were separately analysed using multiple linear regression models and the results compared. Length of employment in their current practice location was the outcome measure. Consistent results were obtained across both datasets. The most important factors associated with the retention of rural and remote GPs, after adjusting for GP age, were primary income source, registrar status, hospital work and restrictions on practice location (which are linked to geographic location). Practice ownership was associated with -70% higher retention than average, whilst undertaking hospital work in addition to routine general practice was associated with at least 18% higher retention compared with if no hospital work was undertaken. Less important factors included geographic location, procedural skills, annual leave, workload and practice size. Our findings quantify a range of financial and economic, professional and organisational, and geographic factors contributing to the retention of rural GPs. These findings have important implications for future medical workforce policy, providing an empirical evidence base to support the targeting and 'bundling' of retention initiatives in order to optimise the retention of rural GPs.

Rural communities continue to experience shortages of doctors, placing increased work demands on the existing rural medical workforce. This paper investigates patterns of geographical variation in the workload and work activities of GPs by community size. Our data comes from wave 1 of the Medicine in Australia: Balancing Employment and Life longitudinal study, a national study of Australian doctors. Self-reported hours worked per usual week across eight workplace settings and on-call/ after-hours workload per usual week were analysed against seven community size categories. Our results showed that a GP's total hours worked per week consistently increases as community size decreases, ranging from 38.6 up to 45.6h in small communities, with most differences attributable to work activities of rural GPs in public hospitals. Higher on-call workload is also significantly associated with smaller rural communities, with the likelihood of GPs attending more than one callout per week ranging from 9% for metropolitan GPs up to 48-58% in small rural communities. Our study is the first to separate hours worked into different work activities whilst adjusting for community size and demographics, providing significantly greater insight to the increased hours worked, more diverse activities and significant after-hours demands experienced by current rural GPs.

Background: Rural and remote areas are characterised by a shortage of medical practitioners. Rural background has been shown to be a significant factor associated with medical graduates' intentions and decisions to practise within a rural area, though most studies have only used simple definitions of rural background and not previously looked at specialists. This paper aims to investigate in detail the nature of the association between rural background and practice location of Australian general practitioners (GPs) and specialists, Methods: Data for 3156 GPs and 2425 specialists were obtained from the Medicine in Australia: Balancing Employment and Life (MABEL) study. Data on the number of childhood years resident in a rural location and population size of their rural childhood location were matched against current practice location. Logistic regression modelling was used to calculate adjusted associations between doctors in rural practice and rural background, sex and age., Results: GPs with at least 6 years of their childhood spent in a rural area were significantly more likely than those with 0-5 years in a rural area to be practising in a rural location (OR 2.28, 95% CI 1.69-3.08), whilst only specialists with at least 11 years rural background were significantly more likely to be practising in a rural location (OR 2.27, 95% CI 1.77-2.91). However, for doctors with a rural background, the size of the community that they grew up in was not significantly associated with the size of the community in which they currently practise. Both female GPs and female specialists are similarly much less likely to be practising in a rural location compared with males (GPs: OR 0.53, 95% CI 0.45-0.62)., Conclusions: This study elucidates the association between rural background and rural practice for both GPs and specialists. It follows that increased take-up of rural practice by new graduates requires an increased selection of students with strong rural backgrounds. However, given the considerable under-representation of rural background students in medical schools and the reluctance of females to practise in rural areas, the selection of rural background students is only part of the solution to increasing the supply of rural doctors.

The purpose of this research is to investigate the extent to which Australia's northern cities have become increasingly important mediators of migration of nurses and general practitioners (GPs) to the regional north since the 1980s. Over that period, national and provincial policy has focused on 'regionalisation' of health workforce development, including creating education and training infrastructure outside of metropolitan areas. This paper hypothesises that the effectiveness of regionalisation in northern Australia should be reflected in an increased net flow of GPs and nurses from northern cities (which are the hubs of education and training) to the regional north. Data from the seven Australian Census between 1986 and 2016 are used to model changing patterns of migration. Overall, there was limited evidence of substantial change in migration patterns, although for GPs there was a reduction in migration from the key metropolitan source markets (Brisbane and Adelaide) matching an increase in supply from northern cities. Northern cities have consistently been the source of about one quarter of new nurse and GP migrants to the regional north, but the regional north has become a much less favoured destination for professionals leaving northern cities as cities' populations have grown much faster than regional populations. Net flows have remained small and for nurses have favoured the cities while for GPs favoured the regional north. The paper concludes that, while there is limited evidence of increased 'spillover' of labour from the cities to the regional north, there is also no evidence of the cities increasingly 'spongeing' regional labour. Cities and regional migration systems may be increasingly disconnected as labour demands diverge, but new connections are being created with the rest of non-metropolitan Australia. The research is the first to analyse health professional migration over such a long period, and contributes to the debates about the roles of cities in sparsely populated areas in the development of their rural and remote hinterlands. • There is no evidence of increasing 'sponge' or 'spillover' relationships between northern cities and the regional north. • Large investment in 'regionalisation' of workforce development has not led to an increase in intra-northern migration. • There is evidence of increasing net loss of health professionals from the regional north to other regional Australia. • Regionalisation may be an ineffective strategy for growing the health professional workforce in the regional north. [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]

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]

Objective Access to primary healthcare (PHC) services is key to improving health outcomes in rural areas. Unfortunately, little is known about which aspect of access is most important. The objective of this study was to determine the relative importance of different dimensions of access in the decisions of rural Australians to utilise PHC provided by general practitioners (GP). Methods Data were collected from residents of five communities located in 'closely' settled and 'sparsely' settled rural regions. A paired-comparison methodology was used to quantify the relative importance of availability, distance, affordability (cost) and acceptability (preference) in relation to respondents' decisions to utilise a GP service for non-emergency care. Results Consumers reported that preference for a GP and GP availability are far more important than distance to and cost of the service when deciding to visit a GP for non-emergency care. Important differences in rankings emerged by geographic context, gender and age. Conclusions Understanding how different dimensions of access influence the utilisation of PHC services is critical in planning the provision of PHC services. This study reports how consumers 'trade-off' the different dimensions of access when accessing GP care in rural Australia. The results show that ensuring 'good' access requires that policymakers and planners should consider other dimensions of access to services besides geography. [ABSTRACT FROM AUTHOR]

The article discusses the crucial period of rural general practice (GP) in Australia including the distribution of GPs, occurrence of extensive range of policy and increasing undergraduate medical education and training

Background Globally, abundant opportunities exist for policymakers to improve the accessibility of rural and remote populations to primary health care through improving workforce retention. This paper aims to identify and quantify the most important factors associated with rural and remote Australian family physician turnover, and to demonstrate how evidence generated by survival analysis of health workforce data can inform rural workforce policy making. Methods A secondary analysis of longitudinal data collected by the New South Wales (NSW) Rural Doctors Network for all family physicians working in rural or remote NSW between January 1st 2003 and December 31st 2012 was performed. The Prentice, Williams and Peterson statistical model for survival analysis was used to identify and quantify risk factors for rural NSW family physician turnover. Results Multivariate modelling revealed a higher (2.65-fold) risk of family physician turnover in small, remote locations compared to that in small closely settled locations. Family physicians who graduated from countries other than Australia, United Kingdom, United States of America, New Zealand, Ireland, and Canada also had a higher (1.45-fold) risk of turnover compared to Australian trained family physicians. This was after adjusting for the effects of conditional registration. Procedural skills and public hospital admitting rights were associated with a lower risk of turnover. These risks translate to a predicted median survival of 11 years for Australian-trained family physician non-proceduralists with hospital admitting rights working in small coastal closely settled locations compared to 3 years for family physicians in remote locations. Conclusions This study provides rigorous empirical evidence of the strong association between population size and geographical location and the retention of family physicians in rural and remote NSW. This has important policy ramifications since retention grants for rural and remote family physicians in Australia are currently based on a geographical 'remoteness' classification rather than population size. In addition, this study demonstrates how survival analysis assists health workforce planning, such as through generating evidence to assist in benchmarking 'reasonable' lengths of practice in different geographic settings that might guide service obligation requirements. [ABSTRACT FROM AUTHOR]

The article presents a study which aimed to examine whether community size and location are factors that affect the levels of professional satisfaction experienced by Australian general practitioners (GPs). The study was conducted to discover the reasons for the shortage of medical practitioners in rural and remote areas of Australia from 1990 to 2010. It concludes that GPs express similar levels of satisfaction with most aspects of their professional work regardless of community size and suggests a more active marketing of rural medicine.

Background: The capacity for high-income countries to supply enough locally trained doctors to minimise their reliance on overseas-trained doctors (OTDs) is important for equitable global workforce distribution. However, the ability to achieve self-sufficiency of individual countries is poorly evaluated. This review draws on a decade of research evidence and applies additional stratified analyses from a unique longitudinal medical workforce research program (the Medicine in Australia: Balancing Employment and Life survey (MABEL)) to explore Australia's rural medical workforce self-sufficiency and inform rural workforce planning. Australia is a country with a strong medical education system and extensive rural workforce policies, including a requirement that newly arrived OTDs work up to 10 years in underserved, mostly rural, communities to access reimbursement for clinical services through Australia's universal health insurance scheme, called Medicare.Findings: Despite increases in the number of Australian-trained doctors, more than doubling since the late 1990s, recent locally trained graduates are less likely to work either as general practitioners (GPs) or in rural communities compared to local graduates of the 1970s-1980s. The proportion of OTDs among rural GPs and other medical specialists increases for each cohort of doctors entering the medical workforce since the 1970, peaking for entrants in 2005-2009. Rural self-sufficiency will be enhanced with policies of selecting rural-origin students, increasing the balance of generalist doctors, enhancing opportunities for remaining in rural areas for training, ensuring sustainable rural working conditions and using innovative service models. However, these policies need to be strongly integrated across the long medical workforce training pathway for successful rural workforce supply and distribution outcomes by locally trained doctors. Meanwhile, OTDs substantially continue to underpin Australia's rural medical service capacity. The training pathways and social support for OTDs in rural areas is critical given their ongoing contribution to Australia's rural medical workforce.Conclusion: It is essential for Australia to monitor its ongoing reliance on OTDs in rural areas and be considerate of the potential impact on global workforce distribution. [ABSTRACT FROM AUTHOR]