Social network analysis of rural medical networks after medical school immersion in a rural clinical school.

BACKGROUND: The impact of new medical graduates on the social dimensions of the rural medical workforce is yet to be examined. Social Network Analysis (SNA) is able to visualize and measure these dimensions. We apply this method to examine the workforce characteristics of graduates from a representative Australian Rural Clinical School. METHODS: Participants were medical graduates of the Rural Clinical School of Western Australia (RCSWA) from the 2001-2014 cohorts, identified as being in rural work in 2017 by the Australian Health Practitioner Regulation Agency. SNA was used to examine the relationships between site of origin and of work destination. Data were entered into UCInet 6 as tied pairs, and visualized using Netdraw. UCINet statistics relating to node centrality were obtained from the node editor. RESULTS: SNA measures showed that the 124 of 709 graduates in rural practice were distributed around Australia, and that their practice was strongly focused on the North, with a clear centre in the remote Western Australian town of Broome. Women were strongly recruited, and were widely distributed. CONCLUSIONS: RCSWA appears to be a "weak tie" according to SNA theory: the School attracts graduates to rural nodes where they had only passing prior contact. The multiple activities that comprise the social capital of the most attractive, remote, node demonstrate the clear workforce effects of being a "bridge, broker and boundary spanner" in SNA terms, and add new understanding about recruiting to the rural workforce.

Likelihood of rural practice in medical school entrants with prior tertiary experience.

Background: Workforce decisions of medical students with prior tertiary education, relative to those without, are not known. Methods: Rural workforce outcomes for three separate streams of medical students were compared: school leaver entry (SLE) entered medical school direct (N = 682), non-standard entry (NSE) had some prior tertiary education (N = 123), and graduate entry (GE) (N = 317), had a prior completed degree. All students were at least in postgraduate year 3 in 2018, when current urban or rural medical workforce participation was ascertained. Results: Multivariate logistic regression allowing for the influences of rural background, rural clinical school participation, gender, being born overseas, socioeconomic status, and being a bonded rural scholar, showed that NSE students and GE students had increased odds of being in rural practice relative to SLE students. This increase was more than three-fold for NSE students (OR = 3.41, 95% CI 1.94, 5.99, p < 0.001) and greater than two-fold for GE students (OR = 2.54, 95% CI 1.57, 4.10, p < 0.001). Conclusion: Graduates with prior tertiary education were more likely to enter the rural medical workforce than direct school entrants. This suggests that increasing graduate entry programs may augment the rural medical workforce and that undergraduate programs allowing non-standard entry may have the same benefit.

Feedback learning opportunities from medical student logs of paediatric patients.

BACKGROUND: Feedback can alter medical student logging practices, although most learners feel feedback is inadequate. A varied case mix in rural and urban contexts offers diverse clinical encounters. Logs are an indicator of these clinical experiences, and contain opportunities for feedback, which can greatly influence learning: we labelled these 'feedback learning opportunities' (FLOs). We asked: How often do FLOs occur? What are the case complexities of rural compared to urban paediatric logs? Do more complex cases result in more FLOs? METHODS: In Western Australia, 25% of medical students are dispersed in a Rural Clinical School (RCSWA) up to 2175 miles (3500 km) from the city. Urban students logged 20 written cases; rural students logged a minimum of 25 paediatric cases electronically. These were reviewed to identify FLOs, using a coding convention. FLO categories provided a structure for feedback: medical, professionalism, insufficient, clinical reasoning, student wellbeing, quality and safety, and sociocultural. Each log was assigned an overall primary, secondary or tertiary case complexity. RESULTS: There were 76 consenting students in each urban and rural group, providing 3034 logs for analysis after exclusions. FLOs occurred in more than half the logs, with significantly more rural (OR 1.35 95% CI 1.17, 1.56; p < 0.0001). Major FLOs occurred in over a third of logs, but with no significant difference between rural and urban (OR 1.10 95% CI 0.94, 1.28; p = 0.24). Medical FLOs were the most common, accounting for 64.0% of rural and 75.2% of urban FLOs (OR 1.71 95% CI 1.37, 2.12; p < 0.0001). Students logged cases with a variety of complexities. Most cases logged by urban students in a tertiary healthcare setting were of primary and secondary complexity. Major medical FLOs increased with increasing patient complexity, occurring in 32.1% of tertiary complexity cases logged by urban students (p < 0.001). CONCLUSIONS: Case logs are a valuable resource for medical educators to enhance students' learning by providing meaningful feedback. FLOs occurred often, particularly in paediatric cases with multiple medical problems. This study strengthens recommendations for regular review and timely feedback on student logs. We recommend the FLOs categories as a framework for medical educators to identify FLOs.

Paediatric case mix in a rural clinical school is relevant to future practice.

BACKGROUND: Exposure to a representative case mix is essential for clinical learning, with logbooks established as a way of demonstrating patient contacts. Few studies have reported the paediatric case mix available to geographically distributed students within the same medical school. Given international interest in expanding medical teaching locations to rural contexts, equitable case exposure in rural relative to urban settings is topical. The Rural Clinical School of Western Australia locates students up to 3500 km from the urban university for an academic year. There is particular need to examine paediatric case mix as a study reported Australian graduates felt unprepared for paediatric rotations. We asked: Does a rural clinical school provide a paediatric case mix relevant to future practice? How does the paediatric case mix as logged by rural students compare with that by urban students? METHODS: The 3745 logs of 76 urban and 76 rural consenting medical students were categorised by presenting symptoms and compared to the Australian Institute of Health and Welfare (AIHW) database Major Diagnostic Categories (MDCs). RESULTS: Rural and urban students logged core paediatric cases, in similar order, despite the striking difference in geographic locations. The pattern of overall presenting problems closely corresponded to Australian paediatric hospital admissions. Rural students logged 91% of cases in secondary healthcare settings; urban students logged 90% of cases in tertiary settings. The top four presenting problems were ENT/respiratory, gastrointestinal/urogenital, neurodevelopmental and musculoskeletal; these made up 60% of all cases. Rural and urban students logged similar proportions of infants, children and adolescents, with a variety of case morbidity. CONCLUSIONS: Rural clinical school students logged a mix of core paediatric cases relevant to illnesses of Australian children admitted to public hospitals, with similar order and pattern by age group to urban students, despite major differences in clinical settings. Logged cases met the curriculum learning outcomes of graduates. Minor variations were readily addressed via recommendations about logging. This paper provides evidence of the legitimacy of student logs as useful tools in affirming appropriate paediatric case mix. It validates the rural clinical school context as appropriate for medical students to prepare for future clinical paediatric practice.

Impact of medical student origins on the likelihood of ultimately practicing in areas of low vs high socio-economic status.

INTRODUCTION: Medical schools are in general over-represented by students from high socio-economic status backgrounds. The University of Western Australia Medical School has been progressively widening the participation of students from a broader spectrum of the community both through expanded selection criteria and quota-based approaches for students of rural, indigenous and other socio-educationally disadvantaged backgrounds. We proposed that medical students entering medical school from such backgrounds would ultimately be more likely to practice in areas of increased socio-economic disadvantage. METHODS: The current practice address of 2829 medical students who commenced practice from 1980 to 2011 was ascertained from the Australian Health Practitioner Regulation Agency (AHPRA) Database. Logistic regression was utilised to determine the predictors of the likelihood of the current practice address being in the lower 8 socio-economic deciles versus the top 2 socio-economic deciles. RESULTS: Those who were categorised in the lower 8 socio-economic deciles at entry to medical school had increased odds of a current practice address in the lower 8 socio-economic deciles 5 or more years after graduation (OR 2.05, 95% CI 1.72, 2.45, P < 0.001). Other positive univariate predictors included age at medical degree completion (for those 25 years or older vs those 24 years or younger OR 1.53, 95% CI 1.27, 1.84, P < 0.001), being female (OR 1.26, 95% CI 1.07, 1.48, P = 0.005) and having a general practice versus specialist qualification (OR 4.16, 95% CI 3.33, 5.19, P < 0.001). Negative predictors included having attended an independent school vs a government school (OR 0.77, 95% CI 0.64, 0.92, P < 0.001) or being originally from overseas vs being born in Oceania (OR 0.80, 95% CI 0.67, 0.96, P = 0.017). After adjustment for potential confounders in multivariate logistic regression, those in the lower 8 socio-economic deciles at entry to medical school still had increased odds of having a current practice address in the lower 8 socio-economic deciles (OR 1.63, 95% CI 1.34, 1.99, P < 0.001). CONCLUSION: Widening participation in medical school to students from more diverse socio-educational backgrounds is likely to increase the distribution of the medical workforce to ultimate service across areas representative of a broader socio-economic spectrum.

Creation of a mobile rural workforce following undergraduate longitudinal rural immersion.

BACKGROUND: This study followed the workforce choices of 10-years of graduates from a longitudinal rural immersion programme, which involved living for one academic year in a rural location as a medical student. The Rural Clinical School of Western Australia is a whole-of-state Rural Clinical School partnership involving two medical schools and fourteen rural/remote towns. METHOD: For this longitudinal cohort study, all consenting graduates were contacted annually after graduation, with the outcome measure being rural work location (defined by the Australian Standard Geographical Classification -Remoteness Area) of any duration. RESULTS: There were 417 consenting graduates. Between 16 and 50% of contacted alumni worked rurally for a period of each post-graduate year. Aggregated over time, the majority took up to 30% of their postgraduate training rurally. There was considerable movement in and out of rural work. About 17% of contacted and practicing graduates were working full time rurally at the 2013 contact point. The majority remained in their state of training. The majority identified with GP and other rural-related colleges, and College-affiliation predicted amount of rural training time. Entry into rural work was equivalent for urban-origin and rural origin alumni, suggesting one year of RCS is sufficient to convert commitment to rural work. CONCLUSION: Undergraduate rural immersion is sufficient to create a graduate rural workforce that is far more mobile that was previously appreciated.

Medical student selection criteria and socio-demographic factors as predictors of ultimately working rurally after graduation.

BACKGROUND: We have previously demonstrated that both coming from a rural background and spending a year-long clinical rotation in our Rural Clinical School (RCS) have independent and additive effects to increase the likelihood of medical students practicing rurally following graduation. The current study assesses the extent to which medical school selection criteria and/or the socio-demographic profile of medical students may further facilitate or hamper the selection of students ultimately destined for the rural medical workforce. METHODS: The study comprised 729 students, admitted from secondary school since 1999 and having graduated by 2011, whose actual workplace location in 2014 was classified as either urban or rural using the Australian Health Practitioner Regulation Agency database. Selection factors on entry (score from a standardised interview, percentile scores for the 3 components of the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and prior academic performance as assessed by the Australian Tertiary Admissions Rank) together with socio-demographic factors (age, gender, decile for the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD)), were examined in relation to ultimate rural destination of practice. RESULTS: In logistic regression, those practicing in a rural location in 2014 were more likely to have come from the lower 6 IRSAD deciles (OR 2.75, 95% CI 1.44, 5.23, P = 0.002), to be older (OR 1.86, 95% CI 1.09, 3.18, p = 0.023) and to have a lower UMAT-3 (Non-verbal communication) score (OR 0.98, 95% CI 0.97, 0.99, P = 0.005). After further controlling for either rural background or RCS participation, only age and UMAT-3 remained as independent predictors of current rural practice. CONCLUSIONS: In terms of the socio-demographic profiles of those selected for medical school entry from secondary school, only older age weakly augmented the selection of graduates likely to ultimately work in a rural destination. Among the selection factors, having achieved higher scores in UMAT-3 tended to mitigate this outcome. The major focus in attempts to grow the rural medical workforce should therefore remain on recruiting medical students from a rural background together with providing maximal opportunity for prolonged immersion in rural clinical environments during their training.

Longitudinal rural clerkships: increased likelihood of more remote rural medical practice following graduation.

BACKGROUND: Extended rural clerkships clearly increase the likelihood of rural practice post-graduation. What has not been determined is whether such rural interventions increase the likelihood of graduates practicing in more remote, versus inner regional, locations. METHODS: The Australian Health Practitioner Regulation Agency database was used to identify the current workplace of every graduate of the Medical School of Western Australia, 1980 to 2011. There were 324 graduates working in a primary practice location defined by the Australian Standard Geographical Classification as inner regional to very remote. They were divided into 3 groups - 200 graduates who entered medical school before commencement of the Rural Clinical School of Western Australia (RCSWA), 63 who entered after the RCSWA had started, but not participated in RCSWA, and 61 who participated in the RCSWA. The RCSWA offers a longitudinal rural clinical clerkship throughout level 5 of the MBBS course. RESULTS: The two groups not participating in the RCSWA had 45.5% and 52.4% of subjects in outer regional/very remote locations, respectively. In comparison, 78.7% of those who had participated in the RCSWA were currently practicing in outer regional/very remote locations. When the 3 groups were compared, the significant predictors of working in a more remote practice compared to working in an inner regional area were being female (OR 1.75 95% CI 1.13, 2.72, P = 0.013) and participating in the RCSWA (OR 4.42, 95% CI 2.26, 8.67, P < 0.001). In multivariate logistic regression that corrected for gender and remoteness of rural address before entry to medical school, participation in the RCSWA still predicted a more than 4-fold increase in the odds of practicing in a more remote area (OR 4.11, 95% CI 2.04, 8.30, P < 0.001). CONCLUSION: Extended rural clinical clerkship during an undergraduate MBBS course is related to a much greater likelihood of practicing in more remote, under-serviced rural locations.

Medical student selection criteria as predictors of intended rural practice following graduation.

BACKGROUND: Recruiting medical students from a rural background, together with offering them opportunities for prolonged immersion in rural clinical training environments, both lead to increased participation in the rural workforce after graduation. We have now assessed the extent to which medical students' intentions to practice rurally may also be predicted by either medical school selection criteria and/or student socio-demographic profiles. METHODS: The study cohort included 538 secondary school-leaver entrants to The University of Western Australia Medical School from 2006 to 2011. On entry they completed a questionnaire indicating intention for either urban or rural practice following graduation. Selection factors (standardised interview score, percentile score from the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and prior academic performance (Australian Tertiary Admissions Rank), together with socio-demographic factors (age, gender, decile for the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) and an index of rurality) were examined in relation to intended rural or urban destination of practice. RESULTS: In multivariate logistic regression, students from a rural background had a nearly 8-fold increase in the odds of intention to practice rurally after graduation compared to those from urban backgrounds (OR 7.84, 95% CI 4.10, 14.99, P < 0.001). Those intending to be generalists rather than specialists had a more than 4-fold increase in the odds of intention to practice rurally (OR 4.36, 95% CI 1.69, 11.22, P < 0.001). After controlling for these 2 factors, those with rural intent had significantly lower academic entry scores (P = 0.002) and marginally lower interview scores (P = 0.045). UMAT percentile scores were no different. Those intending to work in a rural location were also more likely to be female (OR 1.93, 95% CI 1.08, 3.48, P = 0.027), to come from the lower eight IRSAD deciles (OR 2.52, 95% CI 1.47, 4.32, P = 0.001) and to come from Government vs independent schools (OR 2.02, 95% CI 1.15, 3.55, P = 0.015). CONCLUSIONS: Very high academic scores generally required for medical school entry may have the unintended consequence of selecting fewer graduates interested in a rural practice destination. Increased efforts to recruit students from lower socioeconomic backgrounds may be beneficial in terms of an ultimate intended rural practice destination.

Impact of the Rural Clinical School of Western Australia on work location of medical graduates.

OBJECTIVE: To determine whether completing a year of the Rural Clinical School of Western Australia (RCSWA) program is associated with entering the rural medical workforce. DESIGN AND SETTING: Cohort study of graduates from the University of Western Australia who completed Year 5 of medical school between 2002 and 2009, comparing work location (identified from the Australian Health Practitioner Regulation Agency database in March-June 2013) between those who participated in the RCSWA (RCSWA graduates) and those who did not (controls). MAIN OUTCOME MEASURE: Rural or urban work location of graduates. RESULTS: Of 1116 eligible graduates, 1017 (91.1%) could be traced and were included in the study. Of 258 RCSWA graduates, 42 (16.3%) were working rurally compared with 36 of 759 controls (4.7%). Of 195 RCSWA graduates from urban backgrounds, 29 (14.9%) were working rurally compared with 26 of 691 urban-background controls (3.8%). Of 63 rural-background RCSWA graduates, 13 (20.6%) were working rurally, compared with 10 of 68 rural-background controls (14.7%). Using logistic regression, RCSWA participation had a strong relationship with working rurally (rural-background RCSWA graduates: odds ratio [OR], 7.5; 95% CI, 3.5-15.8; urban-background RCSWA graduates: OR, 5.1; 95% CI, 2.9-9.1). Rural background without RCSWA participation (OR, 4.2; 95% CI, 1.8-9.2) and older age (age in 2012, 30-39 years: OR, 2.2; 95% CI, 1.3-3.7 v ≥ 40 years: OR, 6.6; 95% CI, 2.8-15.0) were also significant factors for working rurally. CONCLUSIONS: Participation in the RCSWA is strongly associated with greater likelihood of working rurally. Graduates from urban backgrounds who participated in the RCSWA were much more likely to work in rural areas than those who did not. These data substantiate the RCSWA as an effective rural workforce strategy.

Women in the rural medical academic workforce.

INTRODUCTION: This study assessed the role of women as fractional full-time equivalent (FTE) rural academics in the context of significant workforce shortage and increasing academic demand. METHODS: The design was a cross-sectional cohort study conducted from June 2002 to June 2012. All Rural Clinical School teaching sites in Western Australia were included, numbering from 3 (at inception in 2002) to 13 in 2012. Participants were all clinicians employed as academic staff of The University of Western Australia since its inception. Teaching staff employed elsewhere were not included. Main outcome measures were the proportion of women employed in the Rural Clinical School and work characteristics including appointment fraction, duration and site leadership. RESULTS: Relative to the workforce at large, female academics were disproportionately employed in the Rural Clinical School with a relative risk of 1.28 (CI 1.0-1.64), χ²=2.0 p=0.46. Their likelihood of being Australian trained was 1.62 (CI 1.3-2.0), χ²=19.3, p=0.000 relative to the rural female GP workforce. Their FTE (t=1.0 p=0.295), time of tenure (t=1.19, p=0.24) and site leadership was indistinguishable from male Rural Clinical School academics. CONCLUSION: Female doctors who are willing to take on part-time work are supporting the rural medical teaching workforce.

Rural Undergraduate Support and Coordination, Rural Clinical School, and Rural Australian Medical Undergraduate Scholarship: rural undergraduate initiatives and subsequent rural medical workforce.

BACKGROUND: This study examined postgraduate work after an undergraduate clinical year spent in the Rural Clinical School of Western Australia (RCSWA), compared with 6 weeks Rural Undergraduate Support and Coordination (RUSC)-funded rural experience in a 6-year undergraduate medical course. Rural background, sex and Rural Australian Medical Undergraduate Scholarship (RAMUS)-holding were taken into account. Methods. University of Western Australia undergraduate data were linked by hand with postgraduate placements to provide a comprehensive dataset on the rural exposure history of junior medical practitioners working in Western Australia between 2004 and 2007. RESULTS: Participation in the RCSWA program was associated with significantly more postgraduate year one rural work than RUSC placement alone (OR=1.5, CI 0.97-2.38). The RCSWA workforce effect increased at postgraduate year two (OR=3.0, CI 1.6484 to 5.5935 relative to RUSC). Rural-origin practitioners who chose the RCSWA program were more likely than other rural-origin practitioners to take rural rotations in both postgraduate years. RAMUS holders' choice in relation to the RCSWA program predicted later rural work. There were no effects of sex. CONCLUSIONS: Rural initiatives, in particular the Rural Clinical School program, are associated with postgraduate rural choices. The real impact of these data rely on the translation of early postgraduate choices into long-term work commitments.

Growing rural doctors as teachers: a rural community of medical education practice.

This reflective work considered the journey of rural doctors from diverse backgrounds as teachers and academics during the establishment and rapid expansion of an Australian rural clinical school. The observed social and academic processes are analysed in the context of social learning theory. The extent to which the theoretical social processes match observations during a period of transformational change indicates how social learning processes contributed to the outcome. Ten areas of thematic teacher concerns were identified during teachers' professional development and the strategies used to address these declared. Despite the concurrent evolution of both the overall organisation (teacher environment) and teachers' task (curriculum approach), a community of rural educational practice (CREP) formed and thrived. It adopted a culture of sharing experiences which enabled ongoing knowledge brokering, engaged experts and transformed members. Critical reflection resulting from engagement in mutual activity and a supporting culture of enablement driven by senior leadership was central to success. A generic framework for building a successful CREP includes, leadership that 'enables' its members to flourish, a rural academic identity with a 'Community of Practice' governance, internal benchmarking by members to measure and refine practice, critical reflection 'in' and 'on' academic practice, vertical and horizontal mentoring.

Medical teaching in rural Australia: should we be concerned about the international medical graduate connection?

The two rural workforce strategies of rural clinical schools and deployment of international medical graduates (IMGs) geographically overlap in Australia's large expanse of under-served rural and remote areas. We used the Rural Clinical School of Western Australia (RCSWA) as a model to examine the relative numbers of IMG clinical academics, and the contribution of IMGs to rural clinical school development and education. IMGs have established six of 10 rural clinical school sites, maintained an academic presence, and continue to staff the RCSWA in high proportions. In a fragile rural work ecology, WA's IMGs are contributing to both meeting current workforce needs and the education of future rural doctors. The "double debt" Australia owes to IMGs, stemming from the rich cross-fertilisation of these two workforce strategies, should be acknowledged.