Developing interconnectedness is critical in retaining rural general practitioners: A qualitative thematic analysis of recently recruited general practitioners to South East New South Wales, Australia.

Australia, in common with many countries globally, has a shortage of doctors working rurally. Whilst strategies and current research focus on recruitment, attrition from rural practice is a significant determinant of such shortages. Understanding doctors' decisions to stay or leave, once recruited, may provide further insights on how to address this rural differential. This study comprises a qualitative study of 21 recently recruited nationally-trained doctors and international medical graduates to a rural area of New South Wales, Australia. Interviews focused on their experiences prior to and within rural practice, and how these influenced their future career intentions. We used reflexive thematic analysis with each interview coded by two researchers to build an explanatory framework. Our findings comprise five themes which applied differentially to nationally-trained doctors and international medical graduates: connectedness across professional, personal and geographic domains, how multi-faceted connectedness was, and dissonance between participants' expectations and experiences. Amongst nationally-trained doctors, connectedness stemmed from prior rural experiences which engendered expectations founded upon their ability to develop community-level relationships. Experiences were mixed; some described difficulties maintaining a boundary between their personal and professional lives, which encroached upon their ability to embed within the community. International medical graduates' expectations were cultivated by their pre-conceptions of Australian postgraduate training but they lamented a lack of professional opportunities once in practice. Moreover, they described a lack of professional relationships with local, nationally-trained, doctors that could help them embed into rural practice. This study highlighted that when connectedness occurs across professional, geographic and personal domains doctors are more likely to continue rural practice, whilst illustrating how the importance of each domain may differ amongst different cadres of doctor. Supporting such cadres develop supportive interrelationships may be a low hanging fruit to maximise retention.

How the training pathways and capacity of rural physicians inform their scope of practice: A qualitative study examining the experiences of Australian and international medical graduates in South-East New South Wales, Australia.

INTRODUCTION: Current strategies to address shortages of rural doctors focus on developing a pipeline for rural generalist practice. Limited research has explored how doctors' professional journey engenders the skills required to practice rurally. OBJECTIVE: This paper analyses how rural general practitioners' clinical pathway informs their scope of practice and future retention. DESIGN: Qualitative thematic analysis using semi-structured telephone interviews. Twenty-one general practitioners appointed in their local health district of Murrumbidgee and Southern New South Wales, Australia, within the past 10 years. Participants comprised 10 Australian medical graduates (AMG) and 11 international medical graduates (IMG). FINDINGS: AMGs and IMGs contrasted how their pathway into rural practice, and capacity to work rurally, informed their scope of practice. Australian medical graduates' familiarity with rural areas was consolidated through congruous experiences, including at rural clinical schools. Paradoxically, the fluency of their training limited the amount of unsupervised experience and confidence AMGs gained. Together with a focus on work-life balance, this limited many to providing mainstream general practice, precluding extending their scope of practice. International medical graduates described disseminated experiences, often unsupervised in high-volume contexts. However, a lack of professional opportunities prevented them from extending their scope of practice. DISCUSSION: IMG and AMG motivation and pathway for working rurally differ. Respective cohorts have concerns regarding requisite skills and knowledge for rural practice, which incorporates opportunity and recognition. Entry points for training should be variable to allow consideration of life stage, prior skill development and extension of scope of practice. CONCLUSION: Doctors' scope of practice is informed by their pathways into rural practice. Australian medical graduates may not gain adequate competence during expedited training programs to confidently undertake extended clinical activities. International medical graduates, however lacked the opportunities and support, to utilise their expertise in rural practice. Complementarily utilising the expertise and commitment of both AMGs and IMGs may synergistically address workforce shortages.