Intention mutability and translation of rural intention into actual rural medical practice.

BACKGROUND: Rural intention and experience during medical school have been related to subsequent rural work. However, their relative contributions and the timing of their effects are not known. These data are critical to effective educational interventions able to improve rural medical workforce numbers, an international priority. METHODS: Participants were graduates of an Australian MBBS degree between 2006 and 2016, who completed both entry and exit surveys approved by the Medical Deans of Australia, including workplace intention data. Rural/urban workplace intention changes from entry to exit were analysed using multinomial logistic regression. Binary logistic regression was used to assess actual rural versus urban work, obtained from a public practitioner registration website. RESULTS: Of 547 eligible undergraduates, 169 completed a year-long rural clinical school (RCS). A subset of 93 of the 547 graduates practiced rurally, of whom 42 had completed RCS. Both rural background and RCS predicted rural practice intention; both were also significantly related to actual rural work. Enduring rural intention was associated with nearly sevenfold odds of actually practicing rurally, compared with an enduring urban intention. Those who changed practice intention from entry to exit were more likely to practice in the region of their exit intention. Of special note: Rural Clinical School of Western Australia (RCSWA) exposure particularly affects urban origin students such that the odds of changing from an urban to a rural orientation immediately after their rural experience were more than fourfold higher than those not so participating. DISCUSSION: Both intention and RCSWA experience are associated with subsequent rural work. The impacts of RCSWA were able to be localised after the rural educational experience. Amongst those with mutable intention, exit intention was that most strongly related to actual work, suggesting this as the most reliable point to select for further rural training.

Publisher Correction: Survival analysis of Rural Clinical School of Western Australia graduates: the long-term work of building a long-term rural medical workforce.

In the original publication of this article [1], an error occurred during the publication of this article in Table 2.

Alcohol and Hypertension-New Insights and Lingering Controversies.

PURPOSE OF REVIEW: To examine outstanding issues in the relationship of alcohol to hypertension. These include whether the increase in BP with alcohol is causally related, the nature of the relationship in women, the contribution of alcohol-related increases in BP to cardiovascular disease and the aetiology of alcohol-related hypertension. RECENT FINDINGS: Intervention studies and Mendelian randomisation analyses confirm the alcohol-BP relationship is causal. The concept that low-level alcohol intake reduces BP in women is increasingly unsustainable. Alcohol-related hypertension is in the causal pathway between alcohol use and increased risk for several cardiovascular outcomes. The aetiology of alcohol-related hypertension is multifactorial with recent data highlighting the effects of alcohol on the vasoconstrictor 20-HETE and oxidative stress. The high prevalence of both alcohol use and hypertension mandates a careful alcohol history in every patient with elevated BP. Early intervention for excessive alcohol use offers the promise of lower levels of BP and reduced risk of adverse cardiovascular outcomes.

Relationship between pulse pressure and inflammation with left ventricular diastolic dysfunction in chronic kidney disease patients.

BACKGROUND: Diastolic dysfunction (DD) is an important cause of cardiovascular disease (CVD) mortality in chronic kidney disease (CKD) patients. Non-traditional risk factors, such as arterial stiffness and inflammation, are implicated in the pathogenesis of DD in CKD patients. AIM: To determine the association between inflammatory markers (interleukin (IL)-12, IL-18, highly sensitive C-reactive protein (hsCRP)) and non-invasive markers of arterial stiffness (24-h pulse pressure (PP)) with DD in stages 3-4 CKD patients. METHODS: We performed a sub-analysis of 78 non-diabetic stages 3-4 CKD subjects to determine the relationship between 24-h PP, IL-12, IL-18 and hsCRP with DD. RESULTS: DD was present in 38 subjects (49%). Subjects with DD were significantly older (61.0 ± 1.9 vs 50.2 ± 2.0 years; P < 0.001) and had higher 24-h PP (48(95% confidence interval 45, 52) vs 43(95% confidence interval 41, 45) mmHg; P < 0.005); 24-h PP was associated with DD (P = 0.02), but this was no longer significant after adjustment for age (P = 0.31). Serum IL-12, IL-18 and hsCRP levels were not significantly different between subjects with or without DD. CONCLUSION: Asymptomatic subclinical DD was present in 50% of a cohort of stages 3-4 CKD patients but was not associated with IL-12, IL-18 or hsCRP. The association between 24-h PP and DD was no longer apparent following adjustment for age, but given the small sample size, our findings will need to be explored in larger-sized cohorts of individuals with moderate-stage CKD.

Survival analysis of Rural Clinical School of Western Australia graduates: the long-term work of building a long-term rural medical workforce.

BACKGROUND: Deficits in the rural medical workforce is an international issue. In Australia, The Rural Clinical School intervention is effective for initial recruitment of rural doctors. However, the extent of survival is not yet established. This paper summarises rural survival over a 10-year period. METHODS: Rural Clinical School graduates of Western Australia were surveyed annually, 2006-2015, and post Graduate Years (PGY) 3-12 included. Survival was described as "tours of service", where a tour was either a period of ≥1 year, or a period of ≥2 weeks, working rurally. A tour ended with a rural work gap of ≥52 weeks. Considering each exit from urban as an event, semi-parametric repeated measures survival models were fitted. RESULTS: Of 468 graduates, using the ≥2 weeks definition, 239 PGY3-12 graduates spent at least one tour rurally (average 61.1, CI 52.5-69.7 weeks), and a total length of 14,607 weeks. Based on the tour definition of ≥1 year, 120 graduates completed at least one tour (average 1.89, 1.69-2.10 years), and a total of 227 years' rural work. For both definitions, the number of tours increased from one to four by PGY10/11, giving 17,786 total weeks (342 years) across all PGYs for the ≥2 weeks tour definition, and 256 years total for ≥1 year. Significantly more graduates exited from urban work for the 2007-09 middle cohort compared with 2010-11 (HR 1.876, p = 0.022), but no significant difference between 2002 and 06 and 2010-11. Rural origin, age and gender were not statistically significant. CONCLUSIONS: PGY3-12 RCS graduates contributed substantially to the rural workforce: 51% did so by short rotations, while 26% contributed whole years of service. There was an apparent peak in entry and survival for the middle cohort and decline thereafter, likely attributable to lack of advanced/specialist vocational training. These data indicate a real commitment to rural practice by RCS graduates, and the need for rural vocational training as a key element of a successful rural survival strategy.

The Effects of OMEGA-3 Fatty Acid Supplementation Upon Interleukin-12 and Interleukin-18 in Chronic Kidney Disease Patients.

OBJECTIVE(S): Cardiovascular disease (CVD) remains a leading cause of mortality in chronic kidney disease (CKD) patients. Interventions targeting traditional risk factors have largely proven ineffective in CKD patients in part because of the increased role of nontraditional risk factors such as chronic inflammation. Omega-3 fatty acids (ω3FA) are inexpensive and safe natural agents, which target inflammation and have potential cardioprotective benefits. The aim of the study was to determine the effects of ω3FA supplementation upon serum interleukin (IL)-12, IL-18, and highly sensitive C-reactive protein (hsCRP) in patients with Stage 3-4 CKD. METHODS: We performed a post-hoc analysis of a randomized placebo-controlled trial in 73 nondiabetic CKD patients to determine the effects of ω3FA supplementation (4 g daily for 8 weeks) upon serum levels of IL-12, IL-18, and hsCRP. RESULTS: There were no preintervention differences in IL-12, IL-18, or hsCRP between treatment groups. Postintervention levels of IL-12, IL-18, and hsCRP were similar between the treatment groups. However, IL-12 and IL-18 increased in both treatment groups over the intervention period, whereas hsCRP remained unchanged. The magnitude of increase in serum IL-18 (ΔIL-18) was significantly less in participants in the ω3FA treatment group compared to placebo (P = .047). CONCLUSION(S): This study has shown that 4 g daily ω3FA supplementation may lower serum IL-18 levels in patients with moderate CKD. Although there were no apparent effects on several other markers of inflammation, this study provides evidence for a specific effect of ω3FA on inflammatory pathways.

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.

Graduate doctors' rural work increases over time.

Background: The contribution of rural clinical school (RCS) and rural origin to developing a long-term rural medical workforce was examined. Methods: Longitudinal cohort study, after undergraduate location in either rural or urban setting, for all medical graduates 2004-2010, identified in the Australian Health Practitioner Regulation Agency, in the following groups: Urban origin/no RCS; Rural origin/no RCS; Urban origin/RCS; and Rural origin/RCS. Results: Proportions of all graduates working rurally increased from 2013 to 2018, including amongst urban origin/nonRCS graduates. Rural origin/RCS participants worked rurally at the highest rates across all time points, with an endpoint of 47%, and an odds ratio of 9.70 (5.41, 17.40) relative to the urban reference group. They had a cumulative duration of rural practice over 5 times higher than the urban reference group. RCS graduates were more likely to be working in remote areas than nonRCS graduates. Conclusion: All graduates' contribution to rural and remote workforce is dynamic and increasing. Both RCS participation and rural student recruitment make synergistic and increasing contributions to rural work. RCS effects workforce distribution to more remote areas. Single cross-sectional studies do not capture this dynamic growth in the rural workforce.

Relative progress and academic performance of graduate vs undergraduate entrants to an Australian medical school.

BACKGROUND: Whether graduate entrants to medical school perform better academically than undergraduate entrants remains controversial. Differences in the discipline backgrounds of graduates may, at least in part, have accounted for differences in the results of comparative studies reported to date. This study aimed to address the dual issues of whether academic performance and progression rates were different between GE and UG students and the extent to which the discipline background of GE students may underpin any differences observed. METHODS: Relative academic performance as well as indicators of student progression (supplementary examinations, repeat years, leave of absence, withdrawal from the programme) were compared between graduate entrants (GE) (N = 410) and both school leaver entrants (SLE) (N = 865) and non-standard entrants (some prior tertiary education) (NSE) (N = 148) who combined for the final 4 yr. of a 6 yr. MBBS undergraduate programme in 8 consecutive cohorts from 2006 to 2013 in Western Australia. RESULTS: Examination scores were generally at or very close to a distinction grade or higher across all groups. Higher mean examination scores were seen for GE versus both SLE and NSE in the first 2 years with no significant differences in the final 2 years. GE from biological science / science backgrounds (N = 241) or physical science backgrounds (N = 26) performed the same as SLE and NSE throughout the programme. GE with a health / allied health background (N = 91), however, performed better throughout. They also performed better when compared to their GE counterparts from a humanities (N = 32) or a biological science / science background. GE had increased odds of withdrawing when compared to SLE (OR 2.50, 95% CI 1.30, 4.79, P = 0.006), but not compared to NSE. NSE had increased odds of repeating at least one level when compared to either GE (OR 2.74, 95% CI 1.21, 6.21, P = 0.016) or SLE (OR 4.10, 95% CI 1.93, 8.70, P < 0.001). There were no differences by entry category in the odds of sitting at least one supplementary examination during the programme. There was an increase in the odds of taking at least one leave of absence in both SLE (OR 2.55, 95% CI 1.79, 3.63, P < 0.001) and NSE (OR 2.47, 95% CI 1.50, 4.07, P < 0.001) compared to GE. CONCLUSIONS: Better academic performance by GE compared to SLE and NSE was predominantly due to higher scores for GE with a health / allied health background. GE were also less likely to have impeded progress during the course.

The effect of n-3 fatty acids and coenzyme Q10 supplementation on neutrophil leukotrienes, mediators of inflammation resolution and myeloperoxidase in chronic kidney disease.

BACKGROUND: Neutrophils release leukotriene (LT)B4 and myeloperoxidase (MPO) that may be important mediators of chronic inflammation in chronic kidney disease (CKD). The n-3 fatty acids (n-3 FA) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have the potential to attenuate inflammation through production of LTB5 and the Specialized Proresolving Lipid Mediators (SPM) that promote the resolution of inflammation. In animal models, coenzyme Q10 (CoQ) also attenuates inflammation by reducing MPO and LTB4. OBJECTIVE: This study evaluated the independent and combined effects of n-3 FA and CoQ supplementation on neutrophil leukotrienes, the pro-inflammatory eicosanoid 5-hydroxyeicosatetraenoic acid (5-HETE), SPM, and plasma MPO, in patients with CKD. DESIGN: In a double-blind, placebo-controlled intervention of factorial design, 85 patients with CKD were randomized to either n-3 FA (4 g), CoQ (200 mg), both supplements, or control (4 g olive oil), daily for 8 weeks. Plasma MPO and calcium ionophore-stimulated neutrophil release of LTs, 5-HETE and SPM were measured at baseline and after 8 weeks. RESULTS: Seventy four patients completed the intervention. n-3 FA, but not CoQ, significantly increased neutrophil LTB5 (P < 0.0001) and the SPM 18-hydroxyeicosapentaenoic acid (18-HEPE), resolvin E1 (RvE1), resolvin E2 (RvE2) and resolvin E3 (RvE3) that derive from EPA, as well as 17-hydroxydocosahexaenoic acid (17-HDHA) and resolvin D5 (RvD5) that derive from DHA (all P < 0.01). Neutrophil LTB4 and its metabolites, and 5-HETE were not significantly altered by n-3 FA or CoQ. Plasma MPO was significantly reduced with n-3 FA alone (P = 0.013) but not when given in combination with CoQ. CONCLUSION: n-3 FA supplementation in patients with CKD leads to increased neutrophil release of LTB5 and several SPM, as well as a reduction in plasma MPO that may have important implications for limiting chronic inflammation.

The relative predictive value of undergraduate versus graduate selection tools in two Australian medical schools.

Context: Monash University and the University of Western Australia admit both school-leavers and graduates into their Bachelor of Medicine and Bachelor of Surgery (MBBS) courses. The Undergraduate Medicine and Health Sciences Admission Test (UMAT) and the Graduate Medical Schools Admissions Test (GAMSAT) are used for selection, along with an academic score and an interview score. The aim of this study was to compare the relative predictive validity of the selected components in the two entry streams, particularly UMAT versus GAMSAT. Methods: Aggregated scores for course outcomes were calculated in the categories of knowledge, clinical and total scores, at four-time points. A path analysis was conducted based on multivariate regressions with model constraint parameters defined across the outcome variables to investigate change over time. Results: Academic scores were the strongest predictors of knowledge scores and end of course results. Interview scores had a small positive increasing effect, being stronger for clinical than knowledge outcomes. The effect size for GAMSAT was greater than for UMAT. Conclusions: Aptitude tests and interview scores added small but significant incremental predictive value to previous academic achievement. GAMSAT showed larger predictive value on outcomes than UMAT, for which one section (UMAT 3) had a negative effect.

Predicting performance of junior doctors: Association of workplace based assessment with demographic characteristics, emotional intelligence, selection scores, and undergraduate academic performance.

INTRODUCTION: Predicting workplace performance of junior doctors from before entry or during medical school is difficult and has limited available evidence. This study explored the association between selected predictor variables and workplace based performance in junior doctors during their first postgraduate year. METHODS: Two cohorts of medical students (n = 200) from one university in Western Australia participated in the longitudinal study. Pearson correlation coefficients and multivariate analyses utilizing linear regression were used to assess the relationships between performance on the Junior Doctor Assessment Tool (JDAT) and its sub-components with demographic characteristics, selection scores for medical school entry, emotional intelligence, and undergraduate academic performance. RESULTS: Grade Point Average (GPA) at the completion of undergraduate studies had the most significant association with better performance on the overall JDAT and each subscale. Increased age was a negative predictor for junior doctor performance on the Clinical management subscale and understanding emotion was a predictor for the JDAT Communication subscale. Secondary school performance measured by Tertiary Entry Rank on entry to medical school score predicted GPA but not junior doctor performance. DISCUSSION: The GPA as a composite measure of ability and performance in medical school is associated with junior doctor assessment scores. Using this variable to identify students at risk of difficulty could assist planning for appropriate supervision, support, and training for medical graduates transitioning to the workplace.

A Randomized Trial of Effects of Alcohol on Cytochrome P450 Eicosanoids, Mediators of Inflammation Resolution, and Blood Pressure in Men.

BACKGROUND: Cardiovascular effects of alcohol consumption may be influenced by both pro- and anti-inflammatory mechanisms. We previously showed that chronic alcohol consumption increased blood pressure (BP), oxidative stress, and 20-hydroxyeicosatetraenoic acid (20-HETE), a vasoconstrictor and pro-inflammatory eicosanoid synthesized by cytochrome P450 (CYP450) enzymes from arachidonic acid. This study in men examined the effect of consuming red wine (RW) on BP in relation to changes in 20-HETE, oxidative stress (F2 -isoprostanes), markers of inflammation, anti-inflammatory CYP450 epoxyeicosatrienoic acids (EETs), and specialized pro-resolving mediators of inflammation (SPMs) derived from eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). METHODS: Normotensive men (n = 22) were randomly allocated to drink RW (375 ml/d) or the equivalent volume of dealcoholized red wine (DRW) or water for 4 weeks in a 12-week, 3-period crossover trial. BP, heart rate, 20-HETE, F2 -isoprostanes, and SPM were measured at baseline, 4, 8, and 12 weeks. RESULTS: Drinking RW increased BP (p < 0.05), plasma and urinary 20-HETE (p < 0.05), plasma F2 -isoprostanes (p < 0.0001), and the SPMs 18-hydroxyeicosapentaenoic acid (18-HEPE) from EPA, and resolvin D1 (RvD1) and 17R-resolvin D1 (17R-RvD1) from DHA (all p < 0.05) compared with DRW and water. EETs and high-sensitivity C-reactive protein were unaffected by RW. Plasma 18-HEPE was positively related to urinary 20-HETE (p < 0.008) only after RW. CONCLUSIONS: This study has shown that men consuming moderate-to-high alcohol as RW for 4 weeks had increased BP, 20-HETE, and oxidative stress, as well as specific SPM that resolve inflammation. These paradoxical findings require further studies to determine whether alcohol stimulates different CYP450 enzymes and whether the findings can be replicated in females.

Opting for rural practice: the influence of medical student origin, intention and immersion experience.

OBJECTIVE: To compare the influence of rural background, rural intent at medical school entry, and Rural Clinical School (RCS) participation on the likelihood of later participation in rural practice. DESIGN: Analysis of linked data from the Medical School Outcomes Database Commencing Medical Students Questionnaire (CMSQ), routinely collected demographic information, and the Australian Health Practitioner Regulation Agency database on practice location. SETTING AND PARTICIPANTS: University of Western Australia medical students who completed the CMSQ during 2006-2010 and were practising medicine in 2016. MAIN OUTCOME MEASURES: Medical practice in rural areas (ASGC-RAs 2-5) during postgraduate years 2-5. RESULTS: Full data were available for 508 eligible medical graduates. Rural background (OR, 3.91; 95% CI, 2.12-7.21; P < 0.001) and experience in an RCS (OR, 1.93; 95% CI, 1.05-3.54; P = 0.034) were significant predictors of rural practice in the multivariate analysis of all potential factors. When interactions between intention, origin, and RCS experience were included, RCS participation significantly increased the likelihood of graduates with an initial rural intention practising in a rural location (OR, 3.57; 95% CI, 1.25-10.2; P = 0.017). The effect of RCS participation was not significant if there was no pre-existing intention to practise rurally (OR, 1.38; 95% CI, 0.61-3.16; P = 0.44). CONCLUSION: For students who entered medical school with the intention to later work in a rural location, RCS experience was the deciding factor for realising this intention. Background, intent and RCS participation should all be considered if medical schools are to increase the proportion of graduates working rurally.

On the validity of repeated assessments in the UMAT, a high-stakes admissions test.

The possibility that the validity of assessment is compromised by repeated sittings of highly competitive and high profile selection tests has been documented and is of concern to stake-holders. An illustrative example is the Undergraduate Medicine and Health Sciences Admission Test (UMAT) used by some medical and dental courses in Australia and New Zealand. The proficiencies of all applicants who sat the UMAT from one to four sittings between 2006 and 2012 were estimated on the same metric using the probabilistic Rasch model. A fit index characterising each profile's degree of conformity to the model was also calculated. Confirming expectations, mean proficiencies increased with repeated sittings on all three UMAT scales with the greatest difference (which was nevertheless relatively small) between the first two sittings. The fit index showed that the increases in proficiency estimates arose from additional easier items being answered correctly on repeated sittings rather than additional more difficult ones, suggesting that improvements are not on the substantive construct of the variable of assessment but in skills in answering the questions. Although strategies for dealing with the increase in proficiency estimates on repeated sittings could be canvassed, these results suggest that the validity of results on repeated sittings was not compromised. Accordingly, it might be concluded that although particular individuals might improve substantially between sittings, any validity is not likely to be compromised with the possibility that for some applicants, the second sitting might be the most valid.

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.

Interest in rural clinical school is not enough: Participation is necessary to predict an ultimate rural practice location.

OBJECTIVE: Rural exposure during medical school is associated with increased rural work after graduation. How much of the increase in rural workforce by these graduates is due to pre-existing interest and plans to work rurally and how much is related to the extended clinical placement is not known. DESIGN: This cohort study compared the employment location of medical graduates who professed no rural interest as undergraduates (negative control), with those who applied but did not participate in Rural Clinical School of Western Australia (RCSWA) (positive control), and those who applied and participated in RCSWA (participants). PARTICIPANTS: All 1026 University of Western Australia students who had an opportunity to apply for a year-long rotation in RCSWA from 2004 to 2010, and who had subsequently graduated by the end of 2011, were included. MAIN OUTCOME MEASURE: Graduates' principal workplace location (AHPRA, Feb 2014). RESULT: The three groups differed significantly in their graduate work locations (χ2 = 39.2, P < 0.001). In multivariate analysis, only being of older age at graduation (OR 2.28 (95% CI 1.40, 3.72), P = 0.001), being from a rural background (OR 2.99 (95% CI 1.85, 4.85), P < 0.001), being a recipient of a Medical Rural Bonded Scholarship (OR 3.36 (95% CI 1.68, 6.73, P = 0.001) and actually participating in the RCSWA remained significantly related to rural work (OR 3.10 (95% CI 1.95, 4.93), P < 0.001). CONCLUSION: After accounting for other factors relating to rural work, RCSWA graduates were three times more likely to work rurally than either control group. These data suggest that RCSWA has a significant independent effect on rural workforce.

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 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.