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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. To investigate the association between LoC, and work-related behavioral factors, socio-cultural factors, and personal factors among Australian General Practitioners (GPs). 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. 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 R2 explained 22.4% of variation in predicting the LoC in our models. 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. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to develop the Remote Health Value Framework to evaluate the models of healthcare provision for workers in the oil and gas sector, predominantly situated in rural and remote areas. Methods: The framework was co-designed with the leadership team in one global oil and gas company using a multi-criteria decision analysis approach with a conjoint analysis component. This was used to elicit and understand preferences and trade-offs among different value domains that were important to the stakeholders with respect to the provision of healthcare for its workers. Preference elicitation and interviews were conducted with a mix of health, safety, and environment (HSE) team and non-HSE managers and leaders. Results: Out of five presented value domains, participants considered the attribute 'Improving health outcomes of employees' the most important aspect for the model of healthcare which accounted for 37.3% of the total utility score. Alternatively, the 'Program cost' attribute was least important to the participants, accounting for only 11.0% of the total utility score. The marginal willingness-to-pay analysis found that participants would be willing to pay A$9090 per utile for an improvement in a particular value attribute. Conclusions: This is the first value framework for healthcare delivery in the oil and gas industry, contextualised by its delivery within rural and remote locations. It provides a systematic and transparent method for creating value-based healthcare models. This approach facilitates the evaluation of healthcare investments, ensuring they align with value domains prioritised by the HSE and leadership teams. What is known about the topic? It has been challenging for oil and gas companies to deliver and evaluate value-based healthcare services to improve workers' wellbeing, supplementing essential emergency services and occupational health. What does this paper add? The Remote Health Value Framework (RHVF), developed and tested in this work, offers a blueprint for designing and evaluating models of care considering the companies' and workers' priorities. What are the implications for practitioners? The RHVF's application has the potential to improve industry standards, enabling a data-driven approach to healthcare investments that closely align with both corporate objectives and employee wellbeing. [ABSTRACT FROM AUTHOR]

Objective Setting Participants Design Results Conclusions Globally, most doctors train and work in metropolitan areas but a key strategy for developing the rural health workforce is expanding rural training. The aim of this study was to describe the scope and quality of learning along with skill acquisition of GP trainees based in regional, rural, and remote settings.Regional, rural and remote settings in Queensland Australia excluding Brisbane.Thirty‐seven general practice trainees who had undertaken their first community placement were recruited from regional, rural and remote learning settings within Queensland.Qualitative descriptive methodology based on constructionist epistemology was employed which allowed for the exploration of current GP trainees' experiences. Trainees were interviewed and data were thematically analysed as to the scope and quality of learning by the setting of training. Learning experiences were then mapped against the Dreyfus and Dreyfus model to explore skill acquisition.In terms of the scope and quality of learning, rural and remote trainees mainly focused on the diverse and unique (sometimes challenging) experiences their setting offered compared with regionally based trainees. Mapping of the trainee comments to the Dreyfus model of skill acquisition demonstrated that regardless of setting, equivalent learning occurred by GP trainees.This exploratory study provides evidence that rural and remote learning may provide a more diverse and challenging experience. It suggests an equivalence of quality of education and skill acquisition across settings rural, regional and remote. This suggests that the training distribution policies may not disadvantage GP trainees and the scope and quality of more remote learning may increase uptake of remote placements. [ABSTRACT FROM AUTHOR]

Background: Improved medical care access for rural populations continues to be a major concern. There remains little published evidence about postgraduate rural pathways of junior doctors, which may have strong implications for a long-term skilled rural workforce. This exploratory study describes and compares preferences for, and uptake of, rural internships by new domestic and international graduates of Victorian medical schools during a period of rural internship position expansion.Methods: We used administrative data of all new Victorian medical graduates' location preference and accepted location of internship positions for 2013-16. Associations between preferred internship location and accepted internship position were explored including by rurality and year. Moreover, data were stratified between 'domestic graduates' (Australian and New Zealand citizens or permanent residents) and 'international graduates' (temporary residents who graduated from an Australian university).Results: Across 2013-16, there were 4562 applicants who filled 3130 internship positions (46% oversubscribed). Domestic graduates filled most (69.7%, 457/656) rural internship positions, but significantly less than metropolitan positions (92.2%, p < 0.001). Only 20.1% (551/2737) included a rural location in their top five preferences, less than for international graduates (34.4%, p < 0.001). A greater proportion of rural compared with metropolitan interns accepted a position not in their top five preferences (36.1% versus 7.4%, p < 0.001). The proportion nominating a rural location in their preference list increased across 2013-2016.Conclusions: The preferences for, and uptake of, rural internship positions by domestic graduates is sub-optimal for growing a rural workforce from local graduates. Current actions that have increased the number of rural positions are unlikely to be sufficient as a stand-alone intervention, thus regional areas must rely on international graduates. Strategies are needed to increase the attractiveness of rural internships for domestic students so that more graduates from rural undergraduate medical training are retained rurally. Further research could explore whether the uptake of rural internships is facilitated by aligning these positions with protected opportunities to continue vocational training in regionally-based or metropolitan fellowships. Increased understanding is needed of the factors impacting work location decisions of junior doctors, particularly those with some rural career intent. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This article focuses on a research program into the patterns of rural and remote outreach work by specialists in Australia, and discusses factors affecting participation, distribution and sustainability of specialist outreach services, and the participation of female specialists in rural outreach.

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]

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: Limited evidence exists about the extent to which doctors are returning to rural region(s) where they had previously trained. This study aims to investigate the rate at which medical students who have trained for 12 months or more in a rural region return to practice in that same region in their early medical career. A secondary aim is to investigate whether there is an independent or additional association with the effect of longer duration of rural exposure in a region (18-24 months) and for those completing both schooling and training in the same rural region.Methods: The outcome was rural region of work, based on postcode of work location in 2017 for graduates spanning 1-9 years post-graduation, for one large medical program in Victoria, Australia. Region of rural training, combined with region of secondary schooling and duration of rural training, was explored for its association with region of practice. A multinomial logistic regression model, accounting for other covariates, measured the strength of association with practising in the same rural region as where they had trained.Results: Overall, 357/2451 (15%) graduates were working rurally, with 90/357 (25%) working in the same rural region as where they did rural training. Similarly, 41/170 (24%) were working in the same region as where they completed schooling. Longer duration (18-24 vs 12 months) of rural training (relative risk ratio, RRR, 3.37, 1.89-5.98) and completing both schooling and training in the same rural region (RRR: 4.47, 2.14-9.36) were associated with returning to practice in the same rural region after training.Conclusions: Medical graduates practising rurally in their early career (1-9 years post-graduation) are likely to have previous connections to the region, through either their basic medical training, their secondary schooling, or both. Social accountability of medical schools and rural medical workforce outcomes could be improved by policies that enable preferential selection and training of prospective medical students from rural regions that need more doctors, and further enhanced by longer duration of within-region training. [ABSTRACT FROM AUTHOR]

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. [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]

Background: Outreach has been endorsed as an important global strategy to promote universal access to health care but it depends on health workers who are willing to travel. In Australia, rural outreach is commonly provided by specialist doctors who periodically visit the same community over time. However information about the level of participation and the distribution of these services nationally is limited. This paper outlines the proportion of Australian specialist doctors who participate in rural outreach, describes their characteristics and assesses how these characteristics influence remote outreach provision.Methods: We used data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, collected between June and November 2008. Weighted logistic regression analyses examined the effect of covariates: sex, age, specialist residential location, rural background, practice arrangements and specialist group on rural outreach. A separate logistic regression analysis studied the effect of covariates on remote outreach compared with other rural outreach.Results: Of 4,596 specialist doctors, 19% (n = 909) provided outreach; of which, 16% (n = 149) provided remote outreach. Most (75%) outreach providers were metropolitan specialists. In multivariate analysis, outreach was associated with being male (OR 1.38, 1.12 to 1.69), having a rural residence (both inner regional: OR 2.07, 1.68 to 2.54; and outer regional/remote: OR 3.40, 2.38 to 4.87) and working in private consulting rooms (OR 1.24, 1.01 to 1.53). Remote outreach was associated with increasing 5-year age (OR1.17, 1.05 to 1.31) and residing in an outer regional/remote location (OR 10.84, 5.82 to 20.19). Specialists based in inner regional areas were less likely than metropolitan-based specialists to provide remote outreach (OR 0.35, 0.17 to 0.70).Conclusion: There is a healthy level of interest in rural outreach work, but remote outreach is less common. Whilst most providers are metropolitan-based, rural doctors are more likely to provide outreach services. Remote distribution is influenced differently: inner regional specialists are less likely to provide remote services compared with metropolitan specialists. To benefit from outreach services and ensure adequate remote distribution, we need to promote coordinated delivery of services arising from metropolitan and rural locations according to rural and remote health need. [ABSTRACT FROM AUTHOR]

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]

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. [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]

In the general population, people with mental disorders have increased mortality. This association, however, has not been explored in a population who at some time were inpatients of a public hospital. The sampling frame was patients admitted to an Australian regional public hospital 1996–2010. Those with known mental disorder were compared with an equal number of randomly selected patients without known mental disorder, matched for age, sex, and year of admission. Mortality outcomes were determined by linkage of hospital data and the National Death Index. We identified 15,356 patients with mental disorder and 15,356 without known mental disorder, 25.2% of the former and 17.3% of the latter died during the study period. The odds ratio (OR) for death in those with mental disorder was 2.20 (95% confidence interval: 2.01–2.41) after adjusting for confounders, and their mean age at death was 4.6 years younger (p < 0.001). Other independent risk factors for mortality were being Indigenous (OR 1.72, 1.32–2.24), not partnered (OR 1.55, 1.36–1.76) or having multiple comorbidities (OR 1.65, 1.43–1.90). In the model that included multiple interactions, the ORs for death in Indigenous patients with mental disorder were markedly higher (6.6–9.5), regardless of other risk factors. Among patients with a history of public hospital admission, those with mental disorders have higher mortality than those without mental disorders. This gap in life expectancy mandates increased attention, by clinicians and health services alike, to preventable causes of death in people with mental illness. [ABSTRACT FROM AUTHOR]

Abstract 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. Highlights • Difference-in-differences design is used to study GP rural financial incentives. • Overall rural-urban distribution of GPs is unaffected by financial incentives. • New GPs are more likely to respond to financial incentives than existing GPs. • The findings suggest a targeted approach in incentive design. [ABSTRACT FROM AUTHOR]

Abstract: 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 &y& Elsevier]

Objective: To evaluate the importance of rural internships to observed medical workforce distribution outcomes up to 8 years post-medical school., Design and Setting: Cohort study of medical graduates of The University of Queensland (UQ), Australia., Participants: UQ graduates who were medical interns in Queensland's public health system between 2014 and 2021 and observed working in Australia in 2022. Internship location was defined as being metropolitan or rural, along with other key rural exposures of whether they are of rural origin (childhood) and whether at least 1 year of clinical training at medical school was in a rural location., Primary Outcome Measure: Current work location was collected from the Australian Health Practitioner Regulation Agency (AHPRA) in 2022, classified as either rural or metropolitan and measured in association with their internship location., Results: From 1930 eligible graduates, 21.5% took up a rural internship, which was associated with rural origin (OR 1.5, 95% CI 1.2 to 2.0) and medical school rural immersions of either 1 year (OR 2.8, 95% CI 2.1 to 3.7) or 2 years (OR 5.8, 95% CI 4.4 to 7.7). Completing a rural internship was associated with currently working rural (47% vs 14%, OR 4.6, 95% CI 3.5 to 5.9), which weakened the observed (adjusted) effect of rural origin (OR 1.5, 95% CI 1.2 to 2.0) or medical school rural immersions (1 year: OR 1.4, 95% CI 1.0 to 1.9; 2 years: OR 1.7, 95% CI 1.2 to 2.3). All combinations of the key rural exposures that included rural internship had the highest proportions currently working rurally (range 32-69%) compared with the combinations with a metropolitan internship (range 12-22%)., Conclusions: Internship location appears to be a critical factor in shaping medical workforce distribution decisions. This evidence supports the need for strengthened and expanded rural training pathways after medical school. In particular, clearer pathways into specialty programmes via rural internships are likely to support increased numbers choosing (with confidence) to preference rural internship first and subsequently more working in rural areas long term., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Explore stakeholder perspectives of the benefits of continuously training general practitioners in the same rural or remote practice in distributed locations via the Remote Vocational Training Scheme (RVTS)., Design, Setting, Participants: Online one-hour semi-structured interviews were conducted with 27 RVTS staff, participants and supervisors from all states and territories between 16 October and 24 November 2023. Data were deductively and inductively coded by stakeholder type and the range of benefits, and the findings were informed by insights from a project reference group and a stakeholder advisory group. Questions explored the benefits of the RVTS - a program which supports doctors already working in rural, remote and First Nations communities to train towards general practice or rural generalist fellowship while remaining in the same practice., Main Outcomes Measures: Perspectives on the nature and spread of benefits., Results: Broad benefits were perceived to flow to four system-level stakeholders: communities, health services, participants and policy makers. Perceived participant and community benefits were doctors staying longer in distributed locations with tailored place-based supports and training, doctors building relationships with patients, and doctors learning through longitudinal care. Health service benefits included reduced reliance on locums, improved continuity of accessible and appropriate services in areas otherwise facing major recruitment and retention issues, and the doctors having more time to contribute to improving service quality and upskilling local staff. Policy-maker benefits were sustaining safe and high quality services for distributed populations with high needs., Conclusion: The RVTS model was perceived to offer diverse benefits for different system stakeholders which could improve quality of learning, service delivery and community care. It also aligned with key policy directions for a distributed and sustainable generalist workforce under the goals of the National Medical Workforce Strategy 2021-2031 and the directions set by the independent review of overseas health practitioner regulatory settings led by Robyn Kruk. However, models like the RVTS largely rely on distribution levers to recruit more doctors to the locations it supports., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Objective: To develop theory about how and why the supervision and support model used by the Remote Vocational Training Scheme (RVTS) addresses the professional and non-professional needs of doctors (including many international medical graduates) who are training towards general practice or rural generalist fellowship while based in the same rural or remote practice., Design, Setting, Participants: We conducted a realist evaluation based on the RAMESES II protocol. The initial theory was based on situated learning theory, networked ecological systems theory, cultural theory and geographical narcissism theory. The theory was developed by collecting empirical data through interviews with 27 RVTS stakeholders, including supervisors, participants and RVTS staff. The theory was refined using a project reference and a stakeholder advisory group and confirmed using individual meetings with experts., Main Outcomes Measures: Theory about how the contexts of person, place and program interacted to address professional and non-professional needs., Results: The RVTS program offers remote access to knowledgeable and caring supervisors, real-time tailored advice, quality resources and regular professional networking opportunities, including breaks from the community. It worked well because it triggered five mechanisms: comfort, confidence, competence, belonging and bonding. These mechanisms collectively fostered resilience, skills, professional identity and improved status; they effectively counteracted the potential effects of complex and relatively isolated work settings., Conclusion: This theory depicts how a remotely delivered supervision and support model addresses the place and practice challenges faced by different doctors, meeting their professional and non-professional needs. The participants felt valued as part of a special professional group delivering essential primary health care services in challenging locations. The theory could be adapted and applied to support other rural and remote doctors., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Objective: To explore continuity of service and longer term retention outcomes of participants of the Remote Vocational Training Scheme (RVTS)., Design, Setting, Participants: Retrospective cohort study of all doctors who participated in the RVTS from 2000 to 2023, many of whom are international medical graduates and are expected to work in the same community for three to four years in remote (Modified Monash Model [MMM] categories 4-7) or rural Aboriginal Medical Services (AMS) streams while undertaking training towards general practice fellowship., Main Outcome Measures: Continuity of service was measured in the pre-program period (period working in same practice before commencing) and during-program period (period completing the RVTS program in same practice as worked in before commencing the program). Retention was measured firstly within two years, and secondly beyond two years (up to 20 post-completion years) based on: working in the same community (relevant to both streams); working in the same region (Remote Stream only); working in any MMM4-7 community (Remote Stream only); or working anywhere rurally (both streams)., Results: From 506 enrolled participants, 373 (73.7%) were international medical graduates. The approximate mean service continuity in the same practice was 1.6 years (standard deviation [SD], 2.2 years) for the pre-program period and 3.6 years (SD, 1.4 years) for the during-program period (mean total, 5.2 years). Two years after completion, 21 out of 43 Remote Stream doctors (49%) and four out of five AMS Stream doctors (80%) remained in the same community. Over the long term, retention in the same community stabilised to 44 out of 242 Remote Stream doctors (18.2%) and seven out of 27 AMS Stream doctors (26%); 72 Remote Stream doctors (29.8%) remained in the same region, 70 Remote Stream doctors (28.9%) were in an MMM4-7 community, and 11 AMS Stream doctors (41%) were in a rural (MMM2-7) community., Conclusion: Strong service continuity outcomes have been achieved by the RVTS, which supports mostly international medical graduates in locations typified by the highest workforce turnover. This suggests that continuity of service could be improved for remote and First Nations communities through place-based retention-focused programs like the RVTS., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Background: Central venous access devices (CVADs) allow intravenous therapy, haemodynamic monitoring and blood sampling but many fail before therapy completion., Objective: To quantify CVAD failure and complications; and identify risk factors., Designs, Settings, and Participants: Secondary analysis of multicentre randomised controlled trial including patients aged ≥16 years with a non-tunnelled CVAD (NTCVAD), peripherally-inserted central catheter (PICC) or tunnelled CVAD (TCVAD). Primary outcome was incidence of all-cause CVAD failure (central line-associated bloodstream infection [CLABSI], occlusion, accidental dislodgement, catheter fracture, thrombosis, pain). Secondary outcomes were CLABSI, occlusion and dislodgement. Cox regression was used to report time-to-event associations., Results: In 1892 CVADs, all-cause failure occurred in 10.2% of devices: 49 NTCVADs (6.1%); 100 PICCs (13.2%); 44 TCVADs (13.4%). Failure rates for CLABSI, occlusion and dislodgement were 5.3%, 1.8%, and 1.7%, respectively. Independent CLABSI predictors were blood product administration through PICCs (hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.24-5.55); and in TCVADs, one or two lumens, compared with three to four (HR 3.36, 95%CI 1.68-6.71), intravenous chemotherapy (HR 2.96, 95%CI 1.31-6.68), and diabetes (HR 3.25, 95%CI 1.40-7.57). Independent factors protective for CLABSI include antimicrobial NTCVADs (HR 0.23, 95%CI 0.08-0.63) and lipids in TCVADs (HR 0.32, 95%CI 0.14-0.72). NTCVADs inserted at another hospital (HR 7.06, 95%CI 1.48-33.7) and baseline infection in patients with PICCs (HR 2.72, 95%CI 1.08-6.83) were predictors for dislodgement. No independent occlusion predictors were found. Modifiable risk factors were identified for CVAD failure, which occurred for 1-in-10 catheters. Strict infection prevention measures and improved CVAD securement could reduce CLABSI and dislodgement risk., (© 2024 The Author(s). Journal of Hospital Medicine published by Wiley Periodicals LLC on behalf of Society of Hospital Medicine.)

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., (© 2024. The Author(s).)

Context: There is growing evidence supporting a shift towards 'grow your own' approaches to recruiting, training and retaining health professionals from and for rural communities. To achieve this, there is a need for sound methodologies by which universities can describe their area of geographic focus in a precise way that can be utilised to recruit students from their region and evaluate workforce outcomes for partner communities. In Australia, Deakin University operates a Rural Health Multidisciplinary Training (RHMT) program funded Rural Clinical School and University Department of Rural Health, with the purpose of producing a graduate health workforce through the provision of rural clinical placements in western and south-western Victoria. The desire to establish a dedicated Rural Training Stream within Deakin's Doctor of Medicine course acted as a catalyst for us to describe our 'rural footprint' in a way that could be used to prioritise local student recruitment as well as evaluate graduate workforce outcomes specifically for this region., Issue: In Australia, selection of rural students has relied on the Australian Statistical Geography Standard Remoteness Areas (ASGS-RA) or Modified Monash Model (MMM) to assign rural background status to medical course applicants, based on a standard definition provided by the RHMT program. Applicants meeting rural background criteria may be preferentially admitted to any medical school according to admission quotas or dedicated rural streams across the country. Until recently, evaluations of graduate workforce outcomes have also used these rurality classifications, but often without reference to particular geographic areas. Growing international evidence supports the importance of place-based connection and training, with medical graduates more likely to work in a region that they are from or in which they have trained. For universities to align rural student recruitment more strategically with training in specific geographic areas, there is a need to develop precise geographical definitions of areas of rural focus that can be applied during admissions processes., Lessons Learned: As we strived to describe our rural activity area precisely, we modelled the application of several geographical and other frameworks, including the MMM, ASGS-RA, Primary Healthcare Networks (PHN), Local Government Areas (LGAs), postcodes and Statistical Areas. It became evident that there was no single geographical or rural framework that (1) accurately described our area of activity, (2) accurately described our desired workforce focus, (3) was practical to apply during the admissions process. We ultimately settled on a bespoke approach using a combination of the PHN and MMM to achieve the specificity required. This report provides an example of how a rural activity footprint can be accurately described and successfully employed to prioritise students from a geographical area for course admission. Lessons learned about the strengths and limitations of available geographical measures are shared. Applications of a precise footprint definition are described including student recruitment, evaluation of workforce outcomes for a geographic region, benefits to stakeholder relationships and an opportunity for more nuanced RHMT reporting.

Introduction: Digital technology is increasingly being adopted within primary healthcare services to improve service delivery and health outcomes; however, the scope for digital innovation within primary care services in rural areas is currently unknown. This systematic review aims to synthesise existing research on the use and integration of digital health technology within primary care services for rural populations across the world., Methods and Analysis: A systematic approach to the search strategy will be conducted. Relevant medical and healthcare-focused electronic databases will be searched using key search terms between January 2013 and December 2023. Searches will be conducted using specific inclusion and exclusion criteria. A systematic study selection and data extraction process will be implemented, using standardised templates. Outcomes will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses- Protocol statement guidelines. Quality assessment and risk of bias appraisal will be conducted using the Mixed Methods Appraisal Tool., Ethics and Dissemination: Ethical approval will not be required because there is no individual patient data collected or reviewed. The finding of this review will be disseminated through peer-reviewed publications and conference presentations. Outcomes will help to understand existing knowledge and identify gaps in delivering digital healthcare services, while also providing potential future practice and policy recommendations., Prospero Registration Number: CRD42023477233., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aims to determine the associations between specialty type and practice location at postgraduate year 10 (PGY10), matched with PGY5 and PGY8 work locations, and earlier rural exposure/experience., Design and Setting: A cohort study of medicine graduates from nine Australian universities., Participants: 1220 domestic medicine graduates from the class of 2011., Outcome Measures: Practice location recorded by the Australian Health Practitioner Regulation Agency in PGY10; matched graduate movement between PGYs 5, 8 and 10 as classified by the Modified Monash Model, stratified by specialty type (predominantly grouped as general practitioner (GP) or non-GP)., Results: At PGY10, two-thirds (820/1220) had achieved fellowship. GPs were 2.8 times more likely to be in non-metropolitan practice (28% vs 12%; 95% CI 2.0 to 4.0, p<0.001) than graduates with non-GP (all other) specialist qualifications. More than 70% (71.4%) of GPs who were in non-metropolitan practice in PGY5 remained there in both PGY8 and PGY10 versus 29.0% of non-GP specialists and 36.4% of non-fellowed graduates (p<0.001). The proportion of fellowed graduates observed in non-metropolitan practice was 14.9% at PGY5, 16.1% at PGY8 and 19.0% at PGY10, with this growth predominantly from non-GP specialists moving into non-metropolitan locations, following completion of metropolitan-based vocational training., Conclusions: There are strong differences in practice location patterns between specialty types, with few non-GP specialists remaining in non-metropolitan practice between PGY5 and PGY10. Our study reinforces the importance of rural training pathways to longer-term work location outcomes and the need to expand specialist vocational training which supports more rural training opportunities for trainees outside general practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (© 2024. Crown.)

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., (© 2024. The Author(s).)

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., (© 2023. The Author(s).)

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.

Introduction: Victoria, Australia commenced its first Rural Community Internship Training program in 2012 to support the development of rural generalist (RG) doctors. These general practitioners have additional skills to work at a broad scope to deliver the range of primary care and additional specialist services that communities need. Unlike most internships, which are wholly hospital-based and delivered mostly within larger metropolitan and regional centres, this RG internship training model involves completing general practice experience in smaller rural communities working with RGs and visiting specialists. This study aimed to explore the characteristics and satisfaction of doctors who participate in RG internship training in Victoria and their workforce outcomes., Methods: Between October and November 2021, a retrospective 10-minute anonymous survey invitation was sent to all contactable interns (n=222) who had completed/were completing the RG internship training (2012-2021). The survey was co-designed with RG internship managers and other stakeholders of a statewide evaluation advisory group, informed by the latest evidence regarding RG medicine and rural training predictors, and outcomes of interest. Participants completed the survey using Microsoft Forms, with three invitations circulated to an up-to-date email address maintained by the internship program. Collected data were analysed descriptively, by subgroup, to explore training pathway outcomes by region, training stage and specialty choice. Workforce distribution outcomes were defined in line with objectives of the program and predetermined indicators of RG scope. Results were compared with the benchmarks of rural workforce training outcomes in Australia using recent research., Results: There were 59 participants (27% response rate); 81% were in postgraduate years 3-7. Respondents included 54% male, 17% rurally bonded, 39% of rural origin, 34% having had more than 3 months rural undergraduate training and 48% doing RG training where they previously did undergraduate training. All were satisfied/very satisfied with the RG training and 61% were working in general practice (excluding the prevocational group). Overall, 40% were currently working in the same rural region as their internship (including three who were currently interns), 56% continued to complete some prevocational training in the same region as their RG internship, while 20% had gone on to be currently based in smaller rural communities (Modified Monash Model locations 4-7) and 44% to be working part-time in smaller rural communities. Overall, 42% self-identified as working as an RG and nearly all (97%) met at least one of the key indicators of extended (RG) scope. In all areas the RG internship outcomes were better than the national benchmarks from published evidence about rural training., Conclusion: This study provides evidence from doctors up to 9 years after completing their RG internship. Compared with industry benchmarks, the RG internships attract rurally intentioned and rurally experienced doctors who may be likely to remain in the same rural region as their undergraduate rural medical training and continue their postgraduate training in the same region. They were all satisfied with RG internship training, had high propensity to follow a general practice career and work at broad scope in smaller communities. Importantly, they intended to stay in the region where they trained. This suggests RG internship programs are a positive intervention for promoting an RG workforce.

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: Little is known about how medical school placements in rural areas impact key stakeholders such as patients, host organisations and the wider rural community. With engagement from rural communities crucial to the success of rural medical training, this case study sought to demonstrate the benefit that rural clinical placements can have on rural general practices (systems) and likely impacts on communities (health outcomes). Specifically, we describe how a series of consecutive short-term student placements in a single rural practice were the drivers of a series of clinical audits and interventions resulting in improved management of chronic disease., Methods: Data for this project were obtained from student research reports completed as part of a rural and remote medicine rotation at an Australian medical school. For this series of projects, eight consecutive students were based at the same rural medical centre, with each attending for 6 weeks across a 15-month period, completing a report for a quality improvement activity and evaluating the outcomes. Each project related to chronic kidney disease (CKD), with CKD chosen based on the needs of the medical centre and the higher burden of this disease in rural areas. Each project was developed and delivered in consultation with the practice, taking into account student interest and skills, and related projects completed prior or concurrently. Projects were related to database management (n=2), alignment between CKD management and best-practice guidelines (n=3), patient health literacy (n=3), and a summary and staff perceptions of the preceding quality improvement activities (n=1)., Results: The combination of student projects led to tangible improvements in CKD management at a rural general practice. All doctors at the medical centre (n=4) reported using the database management tools implemented by the students and felt the interventions were sustainable, long-term solutions for ensuring clinical investigations are not being delayed or missed. Following the various interventions completed by the students, clinician knowledge and implementation of best-practice CKD management increased, and some patients became more aware of their condition and how to manage it., Conclusion: This case study provides evidence that short-term rural clinical placements for medical students have the potential to greatly improve health care and clinical practice in rural and remote communities, when designed around a consistent topic within a medical practice. Outcomes of the student projects in combination demonstrate that addressing CKD management longitudinally led to improvements in administrative processes, clinical practices, and patient awareness and accountability, despite each student only being at the medical centre for a short period of time. Similar approaches to structuring rural clinical placements and defining community projects for medical students should be considered more broadly.

Speciality colleges and health services are often well attuned to professional factors, but non-professional needs are less acknowledged and are the focus of this study. This likely relates to limited research about the non-professional needs of early career doctors. This study aimed to describe the non-professional needs of doctors in their early postgraduate career, including how they intersect with career and training experiences. Semi-structured interviews were conducted with 32 male and female medical graduates working across all Australian states and territories, spanning a variety of speciality areas and early career stages. Participants were asked about their career journey to date including non-professional factors related to their experiences. This study identified important non-professional needs, that strongly interplayed with career and training experiences, including: children's education; partner's career needs; family stability; major life stages; proximity to the extended family; and spending time with immediate family. Results suggested clear gender differences, with female doctor's needs orientated to partner work and carer responsibilities, while male doctor's needs were oriented to spending time with family and meeting the family's needs. Non-professional needs should be considered as legitimate needs within health service employment and speciality training arrangements enabling early career doctors to realise their full potential., (© 2022 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

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.

Objectives: To investigate the effects of extended short-term medical training placements in small rural and remote communities on postgraduate work location., Design and Setting: Cohort study of medical graduates of The University of Queensland, Australia., Participants: Graduating medical students from 2012 to 2021 who undertook a minimum of 6 weeks training in a small rural or remote location. Some participants additionally undertook either or both an extended short-term (12-week) placement in a small rural or remote location and a long-term (1 or 2 years) placement in a large regional centre., Primary Outcome Measure: Work location was collected from the Australian Health Practitioner Regulation Agency in 2022, classified as either rural, regional or metropolitan and measured in association with rural placement type(s)., Results: From 2806 eligible graduates, those participating in extended small rural placements (n=106, 3.8%) were associated with practising rurally or regionally postgraduation (42.5% vs 19.9%; OR: 2.2, 95% CI: 1.1 to 4.6), for both those of rural origin (50% vs 30%; OR: 4.9, 95% CI: 2.6 to 9.2) or metropolitan origin (36% vs 17%; OR: 2.8, 95% CI: 1.7 to 4.8). Those undertaking both an extended small rural placement and 2 years regional training were most likely to be practising in a rural or regional location (61% vs 16%; OR: 8.6, 95% CI: 4.5 to 16.3). Extended small rural placements were associated with practising in smaller rural or remote locations in later years (15% vs 6%, OR: 2.7, 95% CI: 1.3 to 5.3)., Conclusion: This work location outcome evidence supports investment in rural medical training that is both located in smaller rural and remote settings and enables extended exposure with rural generalists. The evaluated 12-week programme positively related to rural workforce outcomes when applied alone. Outcomes greatly strengthened when the 12-week programme was combined with a 2-year regional centre training programme, compared with either alone. These effects were independent of rural origin., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (© 2022. The Author(s).)

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., (© 2022 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

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., (© 2022 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)