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Aims: This commentary uses the Tasmanian Palliative and End of Life Care Policy Framework (2022; the TPE Framework) to reflect upon palliative care services delivered by a rural Tasmanian general practice. Context: Rural populations have challenges in accessing many healthcare services, including palliative care. General practitioners (GPs) and other primary healthcare workers are frequently relied upon to deliver palliative care in rural Australia. Palliative care is often needed before the end‐of‐life phase and patients prefer this to be delivered in the community or at home. GPs face challenges and barriers in continuing to deliver home‐based palliative care services. Approach: All Medical Benefit Scheme billings for after‐hours or home‐based palliative care provided by the practice, between September 2021 and August 2022, were identified and patient demographic and clinical details collated. To further understand this data, nine GPs were surveyed to explore their attitudes to provision of palliative care service to the local rural communities they serve. These data highlighted several priority areas of the TPE Framework. The TPE Framework is used here to add to the shared understanding of palliative care service delivery in a rural community, and to see if GP's responses align with the priorities of the TPE Framework. Of the 258 after‐hours and home‐visits delivered over a 12‐month period, almost 58% (n = 150) were for palliative care. Patients receiving palliative care were generally older than non‐palliative patients visited (79.9 years vs. 72.0 years respectively; p = 0.004). Patients not at imminent risk of death (64.0%) were more frequently recipients of home‐visits. Of the nine GPs responding to the survey, most intended to continue home visits for palliative patients. Disincentives to providing palliative care during home visits included a lack of time during the day (or after hours), low levels of interdisciplinary coordination or role‐definition, and inadequate remuneration. Conclusion: Existing frameworks can be used as an implementation and evaluation guide to help understand local palliative care services. Using a Framework, a rural general practice in Tasmania reflected on their provision of palliative care services. Providing holistic palliative care services from a rural general practice is desirable and achievable with a coordinated, team‐based approach. Access to and integration with specialist services remains a key component of community‐based palliative care pathways. [ABSTRACT FROM AUTHOR]

Introduction: Dementias a prevalent chronic healthcare condition affecting 46 million people worldwide and projected to grow in the coming years. Australians living in rural and regional areas often lack access to specialist dementia care, despite greater prevalence relative to metropolitan areas. Objective: This study aimed to explore general practitioners (GP) understanding, confidence and attitudes towards dementia management in the rural context, and design and pilot a dementia‐specific training program. Design: A two‐stage, mixed methods design, using qualitative and quantitative methods. Sixteen regional GPs from across Victoria participated in scoping semi‐structured interviews. Fourteen separate GPs in the St Anthony Family Medical Practice group in the regional Loddon–Mallee area of Victoria completed the pilot training intervention. Pre‐ and post‐training surveys (n = 10), as well as post‐training interviews (n = 10), assessed attitude and knowledge changes. Findings: Analysis of semi‐structured scoping interviews indicated three themes regarding experience of dementia management, including: (1) attitudes to and experiences of dementia; (2) supporting people living with dementia; and (3) knowledge, education and training of dementia. The pilot dementia‐specific training was found to improve attitudes (agreement across 24 best‐practice indicators improved from 30% to 79%), knowledge (median increase of 2.5/10) and confidence in managing dementia and disclosing dementia diagnoses (median increase 3/10 and 2.75/10, respectively). Discussion: General practitioners in this study lacked initial confidence in detecting and managing dementia in a rural primary care setting. A targeted training program showed improvements in these areas. Conclusion: Accessible, locally delivered, dementia education has the potential to improve confidence in early detection and management of people with dementia and thereby may address gaps in access to care for people living with dementia in rural settings. [ABSTRACT FROM AUTHOR]

Objective: Over 34% of New Zealand (NZ) adults are classed as obese, which reduces quality of life for many individuals. Those living in rural areas, high‐deprivation communities, and indigenous Māori populations are more likely to experience obesity and related co‐morbidities than other cohorts. General practice is positioned as most suitable to deliver effective weight management health care; however, little is understood about the rural general practitioner (GP) experience in NZ, despite having the majority of patients at high risk of developing obesity. The aim of this study was to investigate rural GP perspectives on barriers to delivering weight management. Design: Qualitative descriptive design guided by Braun and Clarke (2006) using semi‐structured interviews and analysed using deductive reflexive thematic approach. Setting: Rural Waikato general practice which has significant rural, Māori and high‐deprivation communities. Participants: Six rural Waikato GPs. Results: Three significant themes were identified: communication barriers, rural health care barriers, and social and cultural barriers. GPs reported not wanting to jeopardise the doctor‐patient relationship by discussing weight. GPs felt unsupported by the health system through lack of rurally appropriate obesity intervention options, funding and resources. The unique rural lifestyle and health needs were reportedly not understood at the wider health system level, making the role of a rural GP working in high‐deprivation communities more difficult. Additional barriers to delivering effective weight management included factors outside the clinical practice such as obesity stigma, an obesogenic environment and sociocultural factors shaping rural patients' lives. Conclusion: Rural GPs have a lack of weight management referral options that are considered effective for their patients, as the options available reportedly do not cater for their patients' unique rural health needs. GPs position addressing the individualised and complex weight management health issue as challenging. Navigating stigma, wider sociocultural issues, and limited intervention options were difficult and found to be questionable to achieve in a short 15‐min consult. There is a need for rural health support in the form of funding, staff (indigenous and non‐indigenous), and rurally feasible resources to improve health outcomes and reduce inequity. Effective primary care weight management strategies need to be appropriate for high‐deprivation rural communities, including tailored, affordable and reliable interventions that GPs can offer patients if future weight management efforts are to be successful in this space. [ABSTRACT FROM AUTHOR]

Introduction. The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim. This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods. This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results. In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion. Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice. [ABSTRACT FROM AUTHOR]

Purpose The global health workforce suffers long-term understaffing in remote and underserved areas. To attract young doctors for rural work, it is necessary to identify the main motivating factors.Materials and methods The pilot survey with 201 general practitioner trainees in the Czech Republic was conducted using a structured questionnaire. The response rate was 67%.Results Not only financial support motivates general practitioner trainees for rural work. A combination of incentives from sources other than medical would greatly increase the chance for general practitioner trainees to work in rural regions.Conclusions To what extent can the survey outcomes relate with other European regions needs to be investigated further.

Context: Ireland has one of the most rural populations in Europe. Rurality presents challenges when accessing health services but should not be perceived as problematic and in need of a structural fix. Structural urbanism where health care is viewed as a commodity for individuals, rather than an infrastructure for populations, innately favours larger urban populations and has detrimental outcomes for rural health. In this article we present a brief account of advocacy led by rural GPs, their communities, and the political and policy implications of their efforts., Issues: In the period 2010-2016, Irish rural general practices were struggling for viability. Two key financial supports, distance coding and the Rural Practice Allowance, were withdrawn. This directly contributed to the founding of the 'No Doctor No Village' public campaign, following which the Rural Practice Allowance took shape as the Rural Support Practice Framework and was expanded to cover a larger number of rural practices. The World Rural Health Conference in June 2022 at the University of Limerick invited over 600 expert delegates who contributed to the authorship of the Limerick Declaration, a blueprint for advancing rural health in Ireland and internationally. This created a new momentum in advocacy for Irish rural general practice, which has drawn financial investments, sparked research interest building capacity for a pipeline to train rural general practitioners., Lessons Learned: Local voices have driven monumental change in the Irish healthcare context. For these communities, the policy and politics of rural health are mere tools to maintaining or restoring their way of life. The biggest lesson to be learned is that unrelenting community commitment, when supported by the capacity to advocate, can influence politics and policy to generate sustainable outcomes and thriving communities.

Introduction: Declining house-call rates have been documented worldwide; however, up-to-date data on current rates are lacking, particularly in rural settings. Systematic reviews in this area are inconsistent; however, other work, principally qualitative research, demonstrates benefits for both doctors and patients. The aim of this study was to establish the current rate of, and reasons for, home visits in a rural general practice setting. Methods: This was a descriptive observational study in the north- west of Ireland. Fourteen general practice training practices with approximately 30 000 patients were recruited. Data on house calls done in each practice were collected during May and June 2019. Anonymised data were analysed using Microsoft Excel and GraphPad. Results: Data were received on 547 house calls. The rate of house calls done within normal working hours (443) was calculated at 87 house calls/1000 patients/year (raw proportion 1.44%). Using the N-1 χ² test, this rate was compared to that calculated in a similar 2009 study (143/1000/year; raw proportion 2.43%), giving a difference of 0.991% (95% confidence interval 0.759-1.22%; p<0.001). This is a statistically significant reduction of 40% over 10 years. Most (86.2%) house calls were to patients aged over 65 years. House calls were commonly done for respiratory infection (17%), other infections (12%), palliative care (11%) and pain (11%). Most patients were managed solely within the community (88.3%), with 45.8% of those requiring a prescription, and only 11.7% of house calls being referred to hospital. Conclusion: There are documented benefits to home visits and yet the rate of house calls has been declining worldwide. With no recent literature on the rate or reasons for home visits in rural general practice, this research has demonstrated that the house call rate in the north-west of Ireland is falling, mirroring the decline seen in other parts of Europe, Australia and the USA. These house calls are mainly for elderly patients to address infection or palliative care, and the majority can be managed successfully by general practitioners in the community. With an ageing population with increasing multi-morbidity, planning for care delivery to these patients is important for clinicians going forward. We now need to decide if house calls are a service worth saving. [ABSTRACT FROM AUTHOR]

Objective: This study investigates whether General Practice placement experience or locations (urban/metropolitan vs non‐metropolitan) promote student interest in pursuing general practice. Design: SurveyMonkey was used in the design of the survey. Setting: The study was conducted online. Participants: A total of 520 and 705 clinical‐year students were surveyed in 2009 and 2019, respectively. The study was conducted online, using SurveyMonkey, and the participants were mostly non‐indigenous Australian medical students, between the ages of 18 and 30. Interventions: Students were recruited from the General Practice Students' Network membership database to complete the survey online. Chi‐squared testing, Pearson's correlation and a multivariate logistic regression analysis were used to investigate the correlation between general practice placements and intention to become a general practice. Main outcome measures: The association and causation between general practice placement location, student experience and students' intended career outcomes. Results: In 2009, majority of students rated their general practice experience 'mostly positive' while most metropolitan participants and majority of non‐metropolitan placement participants in the 2019 survey responded with 'mostly positive' in 2019. Based on 2009 and 2019 data, general practice placement location had no association with the likelihood of pursuing general practice as a career, while student experience had a stronger positive correlation with the likelihood of pursuing general practice as a career. Conclusion: Our study shows that students' overall experience with their general practice placements significantly encourages medical students to pursue the general practice pathway. As such, increasing both metropolitan and non‐metropolitan placement experiences can potentially overcome general practice shortage. [ABSTRACT FROM AUTHOR]

Studies which report outcomes of continuing medical education (CME) interventions for rural general practitioners (GPs) are limited. This mixed methods study recruited GPs from four CME small group learning (SGL) tutor groups based in different rural locations in the Republic of Ireland. A two-hour teaching module on deprescribing in older patients was devised and implemented. Assessment of educational outcomes was via questionnaires, prescribing audits and qualitative focus groups. All GPs (n = 43) in these CME-SGL groups agreed to participate, 27 of whom (63%) self-identified as being in rural practice. Rural GPs were more likely to be male (56%), in practice for longer (19 years), and attending CME for longer (13 years). The questionnaires indicated learning outcomes were achieved knowledge increased immediately after the education, and was maintained 6 months later. Twenty-four GPs completed audits involving 191 patients. Of these, 152 (79.6%) were de-prescribed medication. In the qualitative focus groups, GPs reported sharing experiences with their peers during CME-SGL helped them to improve patient care and ensured that clinical practice is more consistent across the group. For rural GPs, CME-SGL involving discussion of cases and the practical implementation of guidelines, associated with audit, can lead to changes in patient care. [ABSTRACT FROM AUTHOR]

Background: The diverse rural medical education initiatives that have been developed in Australia to address the medical workforce maldistribution have been less successful in many smaller and remote communities. This study explored the factors that attract and retain GP registrars and supervisors and the impact that localised training (i.e., rural and remote workplace-based training and support) has on both GP registrars and supervisors, and the GP workforce in rural and remote underserved areas. Methods: A purposive sample of 79 GP registrars, supervisors, practice managers, health services staff and community representatives living and working in areas of low GP workforce in rural and remote Australia were invited to participate in semi-structured interviews and one focus group divided over two phases. Thematic analysis was used to explore themes within the data. Findings: Attractors and barriers to rural and remote practice were identified as the main themes. Attractors include family and community lifestyle factors, individual intrinsic motivators, and remote medicine experiences. In contrast, barriers include work related, location, or family factors. Further, localised GP training was reported to specifically influence GP registrars and supervisors through education, social and financial factors. Conclusion: The current study has provided a contemporary overview of the issues encountered in expanding GP training capacity in rural and remote communities to improve the alignment of training opportunities with community and workforce needs. Strategies including matching scope of practice to registrar interests have been implemented to promote the attractors and lessen the barriers associated with rural and remote practice. [ABSTRACT FROM AUTHOR]

The World Health Organisation policy of improving retention of rural health care practitioners recommended that continuing medical education (CME) programmes addressing their needs should be accessible and delivered where they live and work. This cross-sectional study involved a self-administered anonymous questionnaire completed by GPs attending CME small groups (CME-SGL) in Ireland. All GPs attending CME-SGL in a one-month period were invited to complete the questionnaire which examined demographic details, distance to travel to educational meetings/nearest regional hospital, barriers to accessing continuing education, whether CME-SGL met their educational needs, morale and professional isolation. A total of 1,686 responses were collected, of which 332 (19.6%) were from rural GPs. Of these, 289 (87%) reported that their educational needs were fully or mostly met by attending CME-SGL. Compared to urban doctors, rural GPs had further to travel to CME-SGL meetings, were further from the nearest regional hospital, and reported increased barriers to accessing continuing education. Rural GPs reported lower morale and greater levels of professional isolation. Despite considerable barriers to accessing continuing education, rural GPs reported that CME-SGL meets their educational needs. Future research should focus on the potential positive impact this may have on professional isolation and morale. [ABSTRACT FROM AUTHOR]

Objective: To propose a framework for examining both the spatial equity and sustainability of GP services. Design: A conceptual discussion based on a systematic literature review of spatial equity definitions and methods. Setting: Improving the spatial equity of health services is a key step in achieving health equity. Health systems should contribute to achieving health equity and maintain equitable services into the future. The GP services are a key component of primary health care, which often aims to promote health equity. Despite the importance of spatially equitable and sustainable GP services, a framework for analysis has not yet been established. Main outcome measure: Examples of how the proposed framework could be implemented are provided from the New Zealand health care context. Result: The framework entails three steps: (i) defining spatial equity and sustainability; (ii) estimating current and future distributions of health services and needs; and (iii) quantifying spatial equity and sustainability. In step (i), a needs‐based distribution is the most common definition of spatial equity, while sustainability is the ability to provide ongoing equitable access. Step (ii) depends on current and future estimates of access and need within a well‐defined geographical area. In step (iii), spatial equity and sustainability should be quantified through measures, such as the Gini coefficient. Current and future levels of spatial equity should then be compared to assess the sustainability of equitable GP services. Conclusion: This article outlines a novel conceptual framework for examining the spatial equitability and sustainability of GP services. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To examine clinical service activity amongst patients of the Royal Flying Doctor Service South Eastern Section in Far West New South Wales and to evaluate the management of chronic disease among frequent users of evacuation services. Design: A retrospective audit of the Royal Flying Doctor Service South Eastern Section patient database inclusive of patients within the geographical study area who accessed a clinical or remote consultation, or evacuation service at least once between 1 July 2008 and 30 June 2013. Frequent users of evacuation services (≥3 evacuations per year) were investigated through RFDS patient files for determinants of chronic disease management. Main outcome measures: Category of service accessed, clinical consultation amongst frequent evacuees, determinants of chronic disease management. Results: Total number of evacuees increased by 5.4%; number of remote and clinical consultation patients increased by 5.4%. Of the 47 frequent users of evacuation services, 19 (40%) were infrequent or non‐users of clinics (≤3 attendances per year) and 32 (70%) did not have a general practice management plan. Frequent evacuees averaged 2.7 chronic conditions per patient and had seen an average of 16.8 primary care physicians over the 5‐year evaluation. Conclusion: Most frequent evacuees had several chronic conditions, multiple primary care providers, did not have a general practice management plan and had infrequent clinic reviews. This evidence highlights the challenge of remote primary care and the need to improve systems of chronic disease management. It underlines the importance of current local efforts to improve electronic records, follow‐up and team care and to explore further telehealth implementation. [ABSTRACT FROM AUTHOR]

Introduction: Rural recruitment and retention of physicians is a global issue. The Faculty of Medicine at Memorial University of Newfoundland, Canada, was established as a rural-focused medical school with a social accountability mandate that aimed to meet the healthcare needs of a sparse population distributed over a large landmass as well as the needs of other rural and remote areas of Canada. This study aimed to assess whether Memorial medical degree (MD) and postgraduate (PG) programs were effective at producing physicians for their province and rural physicians for Canada compared with other Canadian medical schools. Methods: This retrospective cohort study included medical school graduates who completed their PG training between 2004 and 2013 in Canada. Practice locations of study subjects were georeferenced and assigned to three geographic classes: Large Urban; Small City/Town; and Rural. Analyses were performed at two levels. (1) Provincial level analysis compared Memorial PG graduates practicing where they received their MD and/or PG training with other medical schools who are the only medical school in their province (n=4). (2) National-level analysis compared Memorial PG graduates practicing in rural Canada with all other Canadian medical schools (n=16). Descriptive and bivariate analyses were performed. Results: Overall, 18 766 physicians practicing in Canada completed Canadian PG training (2004–2013), and of those, 8091 (43%) completed Family Medicine (FM) training. Of all physicians completing Canadian PG training, 1254 (7%) physicians were practicing rurally and of those, 1076 were family physicians. There were 379 Memorial PG graduates and of those, 208 (55%) completed FM training and 72 (19%) were practicing rurally, and of those practicing rurally, 56 were family physicians. At the national level, the percentage of all Memorial PG graduates (19.0%) and FM PG graduates (26.9%) practicing rurally was significantly better than the national average for PG (6.4%, p<0.000) and FM (12.9%, p<0.000). Among 391 physicians practicing in Newfoundland and Labrador (NL), 257 (65.7%) were Memorial PG graduates and 247 (63.2%) were Memorial MD graduates. Of the 163 FM graduates, 148 (90.8%) were Memorial FM graduates and 118 (72.4%) were Memorial MD graduates. Of the 68 in rural practice, 51 (75.0%) were Memorial PG graduates and 31 (45.6%) were Memorial MD graduates. Of the 41 FM graduates in rural practice, 39 (95.1%) were Memorial FM graduates and 22 (53.7%) were Memorial MD graduates. Two-sample proportion tests demonstrated Memorial University provided a larger proportion of its provincial physician resource supply than the other four single provincial medical schools, by medical school MD for FM (72.4% vs 44.3%, p<0.000) and for overall (63.2% vs 43.5% p<0.000), and by medical school PG for FM (90.8 % vs 72.0%, p<0.000). Conclusion: This study found Memorial University graduates were more likely to establish practice in rural areas compared with the national average for most program types as well as more likely to establish practice in NL compared with other single medical schools’ graduates in their provinces. This study highlights the impact a comprehensive rural-focused social accountability approach can have at supplying the needs of a population both at the regional and rural national levels. [ABSTRACT FROM AUTHOR]

Context: This report describes the community context, concept and mission of The Faculty of Medicine at Memorial University of Newfoundland (Memorial), Canada, and its ‘pathways to rural practice’ approach, which includes influences at the pre-medical school, medical school experience, postgraduate residency training, and physician practice levels. Memorial’s pathways to practice helped Memorial to fulfill its social accountability mandate to populate the province with highly skilled rural generalist practitioners. Programs/interventions/initiatives: The ‘pathways to rural practice’ include initiatives in four stages: (1) before admission to medical school; (2) during undergraduate medical training (medical degree (MD) program); (3) during postgraduate vocational residency training; and (4) after postgraduate vocational residency training. Memorial’s Learners & Locations (L&L) database tracks students through these stages. The Aboriginal initiative – the MedQuest program and the admissions process that considers geographic or minority representation in terms of those selecting candidates and the candidates themselves – occurs before the student is admitted. Once a student starts Memorial’s MD program, the student has ample opportunities to have rural-based experiences through pre-clerkship and clerkship, of which some take place exclusively outside of St. John’s tertiary hospitals. Memorial’s postgraduate (PG) Family Medicine (FM) residency (vocational) training program allows for deeper community integration and longer periods of training within the same community, which increases the likelihood of a physician choosing rural family medicine. After postgraduate training, rural physicians were given many opportunities for professional development as well as faculty development opportunities. Each of the programs and initiatives were assessed through geospatial rurality analysis of administrative data collected upon entry into and during the MD program and PG training (L&L). Among Memorial MD-graduating classes of 2011–2020, 56% spent the majority of their lives before their 18th birthday in a rural location and 44% in an urban location. As of September 2016, 23 Memorial MD students self-identified as Aboriginal, of which 2 (9%) were from an urban location and 20 (91%) were from rural locations. For Year 3 Family Medicine, graduating classes 2011 to 2019, 89% of placement weeks took place in rural communities and 8% took place in rural towns. For Memorial MD graduating classes 2011–2013 who completed Memorial Family Medicine vocational training residencies, (N=49), 100% completed some rural training. For these 49 residents (vocational trainees), the average amount of time spent in rural areas was 52 weeks out of a total average FM training time of 95 weeks. For Family Medicine residencies from July 2011 to October 2016, 29% of all placement weeks took place in rural communities and 21% of all placement weeks took place in rural towns. For 2016–2017 first-year residents, 53% of the first year training is completed in rural locations, reflecting an even greater rural experiential learning focus. Lessons learned: Memorial’s pathways approach has allowed for the comprehensive training of rural generalists for Newfoundland and Labrador and the rest of Canada and may be applicable to other settings. More challenges remain, requiring ongoing collaboration with governments, medical associations, health authorities, communities, and their physicians to help achieve reliable and feasible healthcare delivery for those living in rural and remote areas. [ABSTRACT FROM AUTHOR]

Introduction: The ongoing rural doctor workforce shortage continues to stimulate interest in new strategies to alleviate the situation. Alongside increasingly promising approaches is the notion that attracting and nurturing the ‘right’ individuals may be paramount to achieving long-term success in recruitment and retention. This study compares the patterns of demographic and temperament and character trait profiles of general practice registrars in training across three Australian vocational training pathways: the Australian College of Rural and Remote Medicine independent rural pathway, and the rural and general pathways of Australian general practice training. The aim is to describe the predominant personalities of existing trainees. At its foundation, this study strives to obtain more information about those individuals choosing rural practice, which may inform ways to enhance future recruitment and training into rural medicine. This rationale has been explored with medical students using intention as the dependent variable, but registrars are that much closer to their final career choice, and therefore may provide more practical and reliable indicators of the notion of who attracts whom into rural practice. Methods: A cross-sectional design sampled four registrar training groups: one from the Australian College of Rural and Remote Medicine, one Australian general practice training rural only, and two Australian general practice training rural and general pathway regional training providers. Registrars (451) completed a questionnaire that gathered basic demographics and a personality trait profile using the Temperament and Character Inventory plus a measure of resilience. Statistical analysis explored the relationships between variables (multivariate analyses of variance) and compared levels of traits between registrar groups (analyses of variance). Results: Registrars training via the Australian College of Rural and Remote Medicine pathway were more likely to be male, older, have a definite interest in or already practising in a rural area and were significantly (with moderate effect sizes) lower in levels of harm avoidance and higher in persistence, self-directedness and resilience compared to the other training pathways. Conclusions: The implications of the data to the recruitment and training of general practice registrars goes further than identifying groups of individuals with similar temperament and character trait patterns. This sample is portrayed as relatively homogenous in light of their overall trait levels as compared to population norms. However, it is the combination of the levels of individual traits that suggests a profile that differs between registrars on a rural or general training path. Importantly the combination of trait levels that tend to differentiate registrars (low harm avoidance, high self-directedness and persistence) correlates strongly with high levels of resilience. Doctors and medical students benefit from a high level of resilience to cope with and manage the challenges of the profession and arguably more so in rural practice. Along with certain demographic characteristics, the combination and levels of temperament (stable) and character (developmental) traits support the notion of a mixture of personal traits that may be indicative of individuals best suited to rural and remote medicine. Further investigation is needed to determine whether individuals with a certain pattern of personal traits are attracted to rural practice training or whether the training itself, in part by exposure to rural life and rural medical practice, selects for those who are most suited to and will eventually choose to practice in a rural location. [ABSTRACT FROM AUTHOR]

Background Continuing Professional Development (CPD) implementation and accreditation for General Practitioners (GPs)/Family Medicine (FM) in rural and urban practices. Various situations exist in Europe regarding CPD, and there is no regulation or mutual recognition of the cursus, this can induce disruption and inequities between GPs/FM, and subsequently impact on the quality of care to the patients. Aim of the workshop Respecting national obligations, the objective of the workshop is to run a pre-statement to organise a specific accreditation for European GPs. Participants A face to face and virtual panel consisting of rural and urban GPs/FM. Methodology Attendees will be invited to discuss their experiences and issues, after a short presentation of a tool dedicated to CPD • mains ethics and qualities criteria for CPD. • mains barriers to implement • opportunities allowed by new technologies and skills • urban/rural inequities in CPD. Expected Outcomes Workshop. Participants will propose a pre-statement which will be sent to all the potential stakeholders. [ABSTRACT FROM AUTHOR]

Objective There is a need for emerging Australian data on emergency peripartum hysterectomy ( EPH) especially in rural areas due to the associated high maternal morbidity and mortality. The aim of this study is to review the incidence and complications of EPH in the northern region of Tasmania. Design A retrospective cohort study at a single health care institution during a 10 year period. Setting Launceston General Hospital, the main maternity referral centre for the northern region of Tasmania. Participants Case notes of women coded with hysterectomy during childbirth were included and analysed. Main outcome measures Primary outcomes were maternal and neonatal morbidity and mortality. Results Eighteen women were identified, giving an incidence of 1.01 per 1000 births. Indications for surgery were abnormal placentation, uterine atony and uterine rupture. Maternal morbidity was high, and included intensive care admissions (55%), disseminated intravascular coagulopathy (50%), hypovolemic shock (38%), febrile illness (27%) and urinary tract injuries (22%). The mean estimated total blood loss was 4091.6 mL, and 88% of women received blood transfusions. All women received prophylactic antibiotics. Women with morbidly adherent placenta were likely to experience more complications and transfusions. There were no maternal or neonatal deaths identified. Conclusion The rate of peripartum hysterectomy in rural Tasmania is higher compared with other Australian tertiary-level hospitals, suggesting that Australian women birthing in rural and regional areas might be at greater risk. Maternal morbidity associated with abnormal placentation is high; hence, better diagnostic modalities and multidisciplinary antenatal management are required to improve maternal outcomes. [ABSTRACT FROM AUTHOR]

Background: General practices vary in the provision of training and education. Some practices have training as a major focus with the presence of multi-level learners and others host single learner groups or none at all. This study investigates the educational benefits and challenges associated with 'multi-level learner' practices. Methods: This paper comprised three case studies of rural general practices with multiple levels of learners. Qualitative data were collected from 29 interviews with learners (n = 12), staff (n = 12) and patients (n = 5). Interviews were initially analyzed using open and axial coding and thematic analysis. Results: Thematic analysis showed 'multi-level learning' in general practices has benefits and challenges to learners and the practice. Learner benefits included knowledge exchange, the opportunity for vertical peer learning, a positive learning environment and the development of a supportive network. The presence of multi-level learners promoted sharing of knowledge with all staff, a sense of community, an increase in patient services and enthused supervisors. Challenges for learners included perception of decreased access to supervisors, anxiety with peer observation, reduced access to patient presentations and patient reluctance to be seen by a learner. Practice challenges were administration requirements, high learner turnover, infrastructure requirements and the requirement for supervisors to cater to a range of learner level needs. Conclusions: The presence of medical students, interns and registrars in general practice has educational benefits to the learners extending to the other stakeholders (staff and patients). Multi-level learners present challenges to the learners and the practice by increasing pressures on resources, staff (administrative and supervisors) and infrastructure. [ABSTRACT FROM AUTHOR]

Purpose: The global health workforce suffers long-term understaffing in remote and underserved areas. To attract young doctors for rural work, it is necessary to identify the main motivating factors., Materials and Methods: The pilot survey with 201 general practitioner trainees in the Czech Republic was conducted using a structured questionnaire. The response rate was 67%., Results: Not only financial support motivates general practitioner trainees for rural work. A combination of incentives from sources other than medical would greatly increase the chance for general practitioner trainees to work in rural regions., Conclusions: To what extent can the survey outcomes relate with other European regions needs to be investigated further.

Objective: Evidence indicates that medical graduates with a rural background are more likely to become rural doctors than those with an urban background (the rural background effect (RBE)). Exactly why this is so has rarely been studied. This study sought to identify the role of social, environmental and economic factors in addition to isolation characterising rural environments that either explain or modify the association between rural background and becoming a rural doctorrural practice intention. Design and setting: Secondary analysis of linked databases from the Medical Schools Outcomes Database (MSOD), Australian Bureau of Statistics and other government sources. Participants: Seven thousand four hundred twenty-two commencing medical students who took part in the MSOD survey and for whom external data could be linked. Results: No social, environmental or economic factor studied or isolation significantly contributed to explaining the RBE, although there is some evidence that areas of more attractive climate strengthen the RBE. However, even when the RBE is at its weakest, it remains a strong, positive predictor of attraction to rural practice. Conclusion: Why the RBE occurs remains unexplained. Evidence was found of a reduced RBE under certain climatic conditions and personal circumstances, but further work is required to better understand why rural background is so strongly related with rural medical intention and practice. [ABSTRACT FROM AUTHOR]

Despite significant efforts at a primary care level, at least 35% of people with diabetes fail to meet health targets. It is assumed that these poor results are a consequence of the patient not understanding their disease or not caring. This study seeks to understand what really lies behind poor control. A qualitative study using semistructured interviews was conducted in a primary care setting in rural Western Australia. People living with diabetes for at least two years were specifically selected on the basis of whether they had either 'good' (HbA1c < 7%) or 'poor' (HbA1c > 8%) control. Interviews revealed that people understood only too well their disease and their responsibilities. Frequently, either they did not choose to make diabetes a priority in their lives or were unable to make appropriate lifestyle changes which were demanded for good blood sugar control. Their life/social stresses often influenced their glucose control. Poor control in our study was not related to lack of knowledge but more to how diabetes was prioritised in their lives. Attention to the patients' priorities is required to accomplish improved glycaemic control. [ABSTRACT FROM AUTHOR]

Objective: The practice of rural and remote medicine in Australia entails many challenges, including a broad casemix and the remoteness of specialist support. Many rural practitioners employ advanced procedural skills in anaesthetics, surgery, obstetrics and emergency medicine, but the use of these skills has been declining over the last 20 years. This study explored the perceptions of rural general practitioners (GPs) on the current and future situation of procedural medicine. Design: The qualitative results of data from a mixed-method design are reported. Free-response survey comments and semistructured interview transcripts were analysed by a framework analysis for major themes. Setting: General practices in rural and remote Queensland. Participants: Rural GPs in Rural and Remote Metropolitan Classification 4–7 areas of Queensland. Main outcome measure: The perceptions of rural GPs on the current and future situation of rural procedural medicine. Results: Major concerns from the survey focused on closure of facilities and downgrading of services, cost and time to keep up skills, increasing litigation issues and changing attitudes of the public. Interviews designed to draw out solutions to help rectify the perceived circumstances highlighted two major themes: ‘synergy’ between the support from medical teams and community in ensuring ‘sustainability’ of services. Conclusions: This article presents a model of rural procedural practice where synergy between staff, resources and support networks represents the optimal way to deliver a non-metropolitan procedural service. The findings serve to remind educators and policy-makers that future planning for sustainability of rural procedural services must be broad-based and comprehensive. [ABSTRACT FROM AUTHOR]

Objective: To identify and compare the roles of urban, rural and remote general practitioners (GPs) in colorectal cancer (CRC) management. Design: Semistructured interviews exploring GP views of their role in CRC management. Setting: Urban, rural and remote general practices in north Queensland. Participants: Fifteen GPs in urban, rural and remote practice. Main outcome measures: Self-reported roles in the management of CRC patients and factors influencing these roles. Results: All GPs, regardless of location of practice, played a role in diagnosis, referral, postoperative care, psychosocial counselling, follow up and palliative care. Involvement in treatment of CRC patients was only performed by remote GPs. In general, rural and remote GPs played greater roles in care coordination, clinical and psychosocial care. Rural and remote GPs were more heavily involved throughout the entire illness progression when compared with their urban counterparts. Conclusions: The results of this study indicate that rural and remote GPs in north Queensland play a greater role than urban GPs in the management of CRC. In order to maintain and enhance the roles of rural and remote GPs in CRC care, appropriate guidelines and remuneration should be provided. Palliative care support might also be useful to rural and remote GPs. [ABSTRACT FROM AUTHOR]

Objective: This study describes the extent to which general practitioners in the Kimberley region are available for doctor-provided primary care and relates primary care availability to need and standardised population. Design: Data collection and analysis was based on government statistics and interviews with general practitioners, local managers and regional employers and organisations. Results: A shortfall of 20.6 full time general practitioner positions was identified and this was aggravated by a significant number of unfilled positions in the areas of greatest need. Overall the region had only half the primary care general practitioners needed. The Shire of Halls Creek at the time of survey had less than a quarter of the doctors required based on this analysis. Conclusion: Steps to increase the Australian medical workforce have begun but resources to recruit, support and sustain this workforce are required. Aboriginal health workers and locally trained nurses competently provide much of the primary care but need greater resources to support the available medical care. [ABSTRACT FROM AUTHOR]

Objective: We analysed community participation in organising rural general medical practice in order to suggest ways to extend and sustain it. Design: A multisite, embedded case-study design collecting data through semistructured interviews, non-participation observation and a document analysis. Setting: One remote and two rural communities in Australia. Participants: Community members, GPs, health professionals, government officers and rural medical workforce consultants. Results: High levels of community participation in recruiting and retaining GPs, organising the business model, and contributing to practice infrastructure were evident. Community participation in designing health care was uncommon. Participation was primarily to ensure viable general practice services necessary to strengthen the social and economic fabric of the community. There were factors about the decision-making and partnership processes in each of the communities that threatened the viability of community participation. Conclusions: We recommend that a concept of community development and explicit facilitation of the processes involved is necessary to strengthen participation, create effective partnerships and ensure inclusive decision-making. [ABSTRACT FROM AUTHOR]

Objective: To describe palliative care services as they exist in the hinterlands (towns away from regional centres) of Midwest New South Wales, including an estimation of the numbers of cases treated by local doctors, and the service they provide to their patients. Generalist doctors’ attitudes to palliative care are also explored, as this information is lacking in the literature but is important for service provision. Design: Descriptive survey. Setting: Rural primary care and district hospitals. Participants: Generalist doctors in hinterland areas. Results: In total, 38% (19/50) of surveys were returned. ‘Visiting rights’ to the district hospital were held by 78.9% of local doctors, and patients are admitted under the care of their own doctor for symptom control and terminal care, 94.1% and 76.5% of the time, respectively. All doctors surveyed perform home visits for terminally ill patients, and 68.4% make themselves routinely available after hours. Doctors surveyed estimated that they managed a mean of 8.4 deaths due to chronic illness in the past 12 months. Most (78.9%) said that they would continue to manage dying patients even if they had a choice, and they feel between moderately and very satisfied that they provide quality care. However, only 21.1% considered their undergraduate training in palliative medicine to be adequate, and all said that they would refer to a specialist service if it were available. Conclusions: Generalist rural doctors not only treat many dying patients, but also provide a continuity of care that is rarely seen in other settings. Proposals of models for ‘rural’ palliative care should, therefore, take this unique setting into account. One such suggestion is given in this article. [ABSTRACT FROM AUTHOR]

Retention of rural GPs is an increasing area of concern and is receiving considerable attention from the government, medical authorities and the media. This study aimed to examine the potential for psychological interventions to assist in the retention of rural GPs through targeting their psychological well-being.GPs completed a questionnaire, including questions about their level of support in rural practice, psychological health (work-related morale and distress, distress related specifically to working in rural general practice, quality of work life) and intentions to leave rural practice.Rural general practices in South Australia.One hundred and eighty-seven rural GPs.Results indicated that rural GPs who were seriously considering leaving rural practice had higher work-related distress, higher distress related specifically to working in a rural general practice and lower quality of work life. GPs who considered leaving rural practice also reported having fewer colleagues with whom to discuss professional issues.Results indicated that psychological interventions (such as cognitive behavioural training), assistance with stress reduction and coping mechanisms (such as more interaction with colleagues) may be of benefit to GPs who are considering leaving rural practice. Such training may increase the number of GPs who ultimately stay in rural practice. [ABSTRACT FROM AUTHOR]

Abstract: The Royal Australian College of General Practitioners’ (RACGP) 1998 Rural Quality Assurance and Continuing Education (QA & CE) Needs Assessment Project was designed to generate sufficient data to inform strategic planning for rural and remote GPs participating in the College’s QA & CE Program. Results indicated that the demand for QA & CE activities has changed over the past 12 years. Three distinct streams of continuing education emerged, where once only one was researched. This reflected a move towards continuing professional development (CPD) rather than purely continuing medical education (CME). However, differences between the CME needs identified suggested that national data could not be reduced to the local level. Data on CME in which rural and remote GPs felt underserviced, proved more useful in relation to other workforce variables such as age, length of service and gender. A broad ‘rural set’ of CPD topics was established, and the survey yielded information on learning format preferences that will be of use to providers of QA & CE activities for rural GPs across Australia. [ABSTRACT FROM AUTHOR]

Abstract: The GP Links program aims to promote the amalgamation of smaller general practices into larger group practices and is one of several strategies being used to modernise Australian family practice. GP Links provides financial incentives to practices willing to amalgamate. The focus of the program has been on urban practices to date and indeed some of the requirements of the program mean that rural practices are less likely to access the scheme. We report our positive and negative experiences of practice amalgamation through the GP Links program in a regional setting of South Australia. From our experience we suggest that for rural practices, a staged approach of increasing collaboration that may lead to amalgamation, which focuses on rural practices developing a supportive network and alliances with others such as Divisions and University Departments of Rural Health might be a positive way ahead. [ABSTRACT FROM AUTHOR]

ABSTRACT In 1998, the Department of General Practice (Faculty of Medicine and Dentistry, University of Western Australia) ran a pilot project to use computers in a sixth year rural general practice term. Students were provided with a laptop computer to take into rural and remote areas throughout Western Australia during their 4-week clinical attachment. An email mailing list was set up for course participants to share experiences and complete set learning activities specifically related to rural general practice. An evaluation of this pilot project found that students felt less isolated on rural attachments, course outcomes were improved and rural preceptors were more involved in the programme. The development of a teaching and learning programme that involves the use of computers in rural general practice for undergraduate students has the potential to improve the quality of their medical education. [ABSTRACT FROM AUTHOR]

ABSTRACT The aim of the present study was to compare selected characteristics of the Australian general medical practitioner workforce in capital cities and regional areas. Data were derived from the 1996 Census of Population and Housing. Characteristics included age, sex, full- or part-time work, place of birth and change in residential address. Analyses were performed for each state and territory in Australia, the statistical division containing each capital city and all other statistical divisions in each state and territory. Of the 26 359 general medical practitioners identified, 68% were male. More female than male general medical practitioners were aged < 45 years (74 vs 52%, respectively; P < 0.0001). The proportion of general medical practitioners aged < 35 years was higher in capital cities (30%) than regional areas (24%; P < 0.0001). Overall, 32% of the general medical practitioner workforce was female and almost 50% of those aged < 35 years were female. The proportion of female general medical practitioners was higher in capital cities than regional areas, by up to 30%. While 13% of male general medical practitioners reported part-time work, 42% of females also reported part-time work and these figures were similar in capital cities and regional areas. Approximately 40% of the Australian general medical practitioner workforce was born outside Australia and while fewer migrants have entered in recent years they were more likely to be living in regional areas than the capitals. The census provides useful medical workforce data. The regional workforce tends to be made up of more males and is older than in capital cities. Monitoring trends in these characteristics could help to evaluate initiatives aimed at addressing regional workforce issues. [ABSTRACT FROM AUTHOR]

ABSTRACT The results of a study that sought to investigate the utility of and satisfaction with telephone consultations from the perspective of general practitioners and specialists are reported. Semi-structured interviews with rural general practitioners and specialists were used to elicit information about their most recent telephone consultations. The telephone was found to be an important means of communication for rural practitioners, primarily in terms of organising referrals. General practitioners tended to called specialists who they knew and appeared to have fairly well-formed networks of specialists who they called for most of their concerns. Trust is an important element of interpractitioner communication as it increases understanding and confidence in the reliability of the information exchanged. Good working relationships ensure that rural general practitioners have an accessible source of acceptable specialist support. [ABSTRACT FROM AUTHOR]

ABSTRACTThe West Vic Division of General Practice, working with the Department of General Practice, The University of Queensland conducted a qualitative study of GPs who had left western Victoria over the previous 10 years to examine issues relating to the decision to leave rural practice. This study was conducted as part of a project to explore the role of rural Divisions in assisting with general practitioner recruitment and retention. The study supported the conclusions of a similar study in North Queensland and proposed a model that regards rural retention as an interplay of influences both positive and negative with acute trigger factors that can precipitate the decision to leave. Conflict and dissatisfaction with aspects of rural GP hospital work appeared to be a relatively frequent trigger factor that is immediately amenable to intervention from Divisions of general practice and through improvement in negotiation and conflict resolution skills for rural general practitioners. [ABSTRACT FROM AUTHOR]

ABSTRACTThe objective of this study was to describe the distribution of general practitioners in each State and Territory, stratified by statistical division and adjusted for estimated community need. The location of general practitioners was obtained from the 1996 Census of Population and Housing. Community need was estimated from crude death rates supplied by the Australian Bureau of Statistics. On average there are 920 people per full-time general practitioner in Australia. Three States are relatively oversupplied by up to 5% (Australian Capital Territory) and the rest are relatively undersupplied by up to 12% (Western Australia). Adjusted for estimated need, the Australian Capital Territory is oversupplied by 71% compared with all of Australia, while Western Australia is undersupplied by 15%. More marked differences occur within the States, with the statistical division containing each capital city in each State that is relatively overserved. The greatest oversupply is in Sydney, where 33% fewer people share a full-time general practitioner than the whole of New South Wales (adjusted for need, oversupply in Sydney is 63%). Relative undersupply is greatest in Queensland, with 133% more people sharing each general practitioner in the north-west statistical division compared with the whole State. The distribution of general practitioners between and within States and Territories is unequal and inequitable. In each State, capital cities tend to be relatively oversupplied compared with more rural areas. While these data do not inform the absolute level of service needed in a community, they do suggest that strategies to redress the inequitable distribution are required. [ABSTRACT FROM AUTHOR]

Health economists often use discrete choice experiments (DCEs) to predict behavior, as actual market data is often unavailable. Manski (1990) argues that due to the incompleteness of the hypothetical scenarios used in DCEs, substantial uncertainty surrounds stated choice. Uncertainty can be decomposed into "resolvable" and "unresolvable"; the former is expected to become resolved in actual choice, as individuals collect further information. To enable its identification, Manski suggests eliciting subjective choice probabilities (ECPs) rather than discrete choices. We introduce the ECP approach in health economics and explore its convergent validity. The context is future physicians' stated choices of job in rural general practice in Denmark. Our results are mixed, but show remarkable similarities in forecasting abilities, despite the ECP models being less econometrically demanding and relying on different preference distributional assumptions. • The elicited choice probability (ECP) approach is introduced to health economics. • The validity of the ECP approach is tested against the discrete choice approach. • Results are mixed. • However, we find remarkable similarities in forecasting abilities for the two approaches. • The ECP approach is less econometrically demanding. [ABSTRACT FROM AUTHOR]

The author, a family practice specialist from Minnesota in the United States, worked as a locum in rural New South Wales for 6 months. This provided him with the opportunity to reflect on the differences between the specialty of family practice in his home state of Minnesota and general practice in New South Wales; and to recognise that general practice in New South Wales is at a crossroads. This paper highlights the need for general practitioners (GPs) to work together and support each other, to provide quality care and to lobby both State and Commonwealth governments on the importance of broadly trained GP specialists in rural communities. To influence the future of their profession, GPs in New South Wales need to focus on quality of care and on educating themselves, their colleagues and the communities in which they work. [ABSTRACT FROM AUTHOR]