Building a sustainable rural physician workforce.

CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants. MAIN OUTCOME MEASURES: Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians. RESULTS: Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8). CONCLUSION: Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas. DESIGN, SETTING AND PARTICIPANTS: In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19. MAIN OUTCOME MEASURES: Individual and collective descriptors of professional identity. RESULTS: We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation. CONCLUSION: Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters. MAIN OUTCOME MEASURES: Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location. RESULTS: Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors. CONCLUSION: Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action. DESIGN: We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles. RESULTS: Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles. CONCLUSION: These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce.

The Northern Territory Medical Program - growing our own in the NT.

CONTEXT: The Northern Territory (NT) is characterised by major health inequalities. A high proportion of the population is Indigenous, with poor socioeconomic conditions and a high burden of disease. The small NT population - 1% of the total Australian population - is dispersed over one-sixth of Australia's land mass. Given this very low population density and the geographical isolation of many small communities, access to services is often difficult. Medical workforce recruitment and retention have been persistent problems. Prior to 2011, NT residents who aspired to study medicine had to leave the NT. This was the only Australian state or territory that did not have the capacity for students to complete an entire medical degree within the jurisdiction. This article describes the development, implementation and outcomes of the Northern Territory Medical Program (NTMP), which commenced in Darwin in 2011. This was a major development of the Flinders University distributed program, which aimed to develop the medical workforce for the challenging NT environment. ISSUES: Based on evidence regarding the importance of selection in achieving rural workforce outcomes, and a national priority to graduate more Indigenous Australian doctors, NT residents and Indigenous applicants to the NTMP were prioritised in the selection process. Aspiring doctors would not now have to move interstate to study. The curriculum of Flinders University, based in Adelaide, South Australia, would be contextualised to the NT. The NTMP was developed and implemented in collaboration with Charles Darwin University, the major university in the NT. LESSONS LEARNED: Some of the lessons learned may be useful to others contemplating the delivery of a distributed program that includes a full medical program in a remote area. These include: Leadership at the highest levels of the university is crucial. Expect faculty turnover and avoid single person vulnerabilities. Actively engage local clinicians. Ensure a strong focus on new or alternative selection processes that are able to predict progression. Provide preparatory skills and support for students, especially Indigenous students, with non-science backgrounds. Appreciate and accommodate the community and family pressures experienced by some Indigenous students. Anticipate that the first pioneering cohort of students will not be typical of future cohorts, and work with them to adapt the curriculum, teaching and selection methods. Whilst exemplary telecommunications are needed, some elements of the curriculum will be able to be delivered far better locally than at the larger campus. Do not underestimate the level of student and staff support required both locally and centrally. Develop a 'network' rather than a 'hub and spoke' model. The network may include multiple dispersed placement sites, requiring infrastructure, staffing and ongoing support. The 'new kid' will mean the 'older sibling' will change for the better and use the small size and agility to explore innovations. Focus on the goals. We wanted to contribute to improved economic, social and health outcomes for NT residents by developing an appropriately prepared medical workforce, thereby eliminating the need to recruit doctors from interstate and overseas, and by graduating more Indigenous doctors - potential medical leaders for Australia. Build your expectation for success based on past successes in innovation. Flinders University was able to build on its experience in developing the first 4-year medical program in Australia.

Challenges in transformation of the "traditional block rotation" medical student clinical education into a longitudinal integrated clerkship model.

BACKGROUND: Longitudinal integrated clerkships (LIC) in the first major clinical year in medical student training have been demonstrated to be at least equivalent to and in some areas superior to the "traditional block rotation" (TBR). Flinders University School of Medicine is starting a pilot changing the traditional teaching at the major Academic Medical Centre from TBR to LIC (50% of students in other locations in the medical school already have a partial or full LIC programme). METHODS: This paper summarises the expected challenges presented at the "Rendez-Vous" Conference in October 2012: (a) creating urgency, (b) training to be a clinician rather than imparting knowledge, (c) resistance to change. RESULTS: We discuss the unexpected challenges that have evolved since then: (a) difficulty finalising the precise schedule, (b) underestimating time requirements, (c) managing the change process inclusively. DISCUSSION: Transformation of a "block rotation" to "LIC" medical student education in a tertiary academic teaching hospital has many challenges, many of which can be anticipated, but some are unexpected.

Glutamate decarboxylase 67 is expressed in hippocampal mossy fibers of temporal lobe epilepsy patients.

Recently, expression of glutamate decarboxylase-67 (GAD67), a key enzyme of GABA synthesis, was detected in the otherwise glutamatergic mossy fibers of the rat hippocampus. Synthesis of the enzyme was markedly enhanced after experimentally induced status epilepticus. Here, we investigated the expression of GAD67 protein and mRNA in 44 hippocampal specimens from patients with mesial temporal lobe epilepsy (TLE) using double immunofluorescence histochemistry, immunoblotting, and in situ hybridization. Both in specimens with (n = 37) and without (n = 7) hippocampal sclerosis, GAD67 was highly coexpressed with dynorphin in terminal areas of mossy fibers, including the dentate hilus and the stratum lucidum of sector CA3. In the cases with Ammon's horn sclerosis, also the inner molecular layer of the dentate gyrus contained strong staining for GAD67 immunoreactivity, indicating labeling of mossy fiber terminals that specifically sprout into this area. Double immunofluorescence revealed the colocalization of GAD67 immunoreactivity with the mossy fiber marker dynorphin. The extent of colabeling correlated with the number of seizures experienced by the patients. Furthermore, GAD67 mRNA was found in granule cells of the dentate gyrus. Levels, both of GAD67 mRNA and of GAD67 immunoreactivity were similar in sclerotic and nonsclerotic specimens and appeared to be increased compared to post mortem controls. Provided that the strong expression of GAD67 results in synthesis of GABA in hippocampal mossy fibers this may represent a self-protecting mechanism in TLE. In addition GAD67 expression also may result in conversion of excessive intracellular glutamate to nontoxic GABA within mossy fiber terminals.

Survey of sex/gender diversity in the GEDA 2019/2020-EHIS study - objectives, procedure and experiences.

Sex/gender diversity is increasingly recognised by society and should be taken into account more in population-representative studies, as they are important data sources for targeting health promotion, prevention and care. In 2019, the Robert Koch Institute started a population-representative health survey with the study Health in Germany Update (GEDA 2019/2020-EHIS) with a modified, two-stage measures of sex/gender. The survey covered sex registered at birth and gender identity with an open response option. This article describes the aims, the procedure and the experiences with the operationalisation of sex/gender and the results. Out of 23,001 respondents, 22,826 persons are classified as cisgender, 113 persons as transgender and 29 persons as gender-diverse. 33 respondents were counted as having missing values. A survey of interviewers showed that the two-stage measures of sex/gender had a high level of acceptance overall and that there were only a few interview drop-outs. On the basis of previous experience, the modified query can be used for further surveys, but should also be adapted in perspective. For this purpose, participatory studies are desirable that focus on how the acceptance of measures of sex/gender can be further improved and how hurtful experiences in the context of the questions asked can be avoided.

Civil society stakeholders' participation in national health reporting on sex/gender issues: a study protocol for an intersectionality-informed and sex/gender-sensitive approach to focus group research.

INTRODUCTION: Health reporting is one of the foundations on which public health interventions and policies as well as prevention measures are developed. However, it faces the challenge of adequately reflecting social and sex/gender-related heterogeneity. The German Federal Ministry of Education and Research-funded joint project, AdvanceGender, aims to develop guidelines for sex/gender-sensitive and intersectional approach to population-based studies and health reporting. In its subproject, AdvanceHealthReport, four focus groups will be conducted to provide essential information on possible ways of participation of civil society stakeholders and on communication of health information for the further development of the guidelines (research period: from January 2019 to March 2020). METHODS AND ANALYSIS: The civil society stakeholders provide valuable information which health topics are relevant in regard to specific populations and how health information should be communicated in a non-stigmatising way. The groups will also discuss how civil society stakeholders should participate in health reporting. The starting point for intersections will be sex/gender. The intersection of sex/gender and migration and sex/gender and sexual orientation is particularly taken into account. The focus groups will be recorded, transcribed, anonymised and then analysed according to the qualitative content analysis. RESULTS: The results will show the pathways as well as benefits and possible limitations of civil society stakeholder involvement in national health reporting and will contribute in developing guidelines for sex/gender-sensitive and intersectional health reporting. ETHICS AND DISSEMINATION: The results of the focus groups will be published in scientific journals and presented at various national and international conferences. Furthermore, the findings will be incorporated into guidelines for research and health reporting. The study was approved by the Ethics Commission of Brandenburg Medical School Theodor Fontane (AZ: E-01-20180529).

A Checklist for Implementing Rural Pathways to Train, Develop and Support Health Workers in Low and Middle-Income Countries.

Background: There is an urgent need to scale up global action on rural workforce development. This World Health Organization-sponsored research aimed to develop a Rural Pathways Checklist. Its purpose was to guide the practical implementation of rural workforce training, development, and support strategies in low and middle-income countries (LMICs). It was intended for any LMICs, stakeholder, health worker, context, or health problem. Method: Multi-methods involved: (1) focus group concept testing; (2) a policy analysis; (3) a scoping review of LMIC literature; (4) consultation with a global Expert Reference Group and; (5) field-testing over an 18-month period. Results: The Checklist included eight actions for implementing rural pathways in LMICs: establishing community needs; policies and partners; exploring existing workers and scope; selecting health workers; education and training; working conditions for recruitment and retention; accreditation and recognition of workers; professional support/up-skilling and; monitoring and evaluation. For each action, a summary of LMICs-specific evidence and prompts was developed to stimulate reflection and learning. To support implementation, rural pathways exemplars from different WHO regions were also compiled. Field-testing showed the Checklist is fit for purpose to guide holistic planning and benchmarking of rural pathways, irrespective of LMICs, stakeholder, or health worker type. Conclusion: The Rural Pathways Checklist provides an agreed global conceptual framework for the practical implementation of "grow your own" strategies in LMICs. It can be applied to scale-up activity for rural workforce training and development in LMICs, where health workers are most limited and health needs are greatest.

The Northern Ontario School of Medicine: a long-term strategy to enhance the rural medical workforce.

Like many rural and remote regions around the world, Canada's Northern Ontario has a chronic shortage of doctors and other health care providers. Recognizing that doctors who have grown up in a rural area are more likely to practise in the rural setting, the Government of Ontario decided to establish a new medical school with a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario. The Northern Ontario School of Medicine (NOSM), a joint initiative of Laurentian University in Sudbury and Lakehead University in Thunder Bay, was established as a rural, community-based medical school. NOSM is a long-term sustainable 'strategy that is expected to lead not only to more skilled doctors and enhanced health care with improved health outcomes, but also to broader academic developments for the universities and substantial economic developments for Northern Ontario communities.

The proposal for a third medical school in New Zealand: a community-engaged graduate entry medical program.

New Zealand has a maldistributed workforce that is heavily dependent on recruiting international medical graduates. Shortages are particularly apparent in high needs communities and in general scope specialties in provincial regions. The University of Waikato in partnership with the Waikato District Health Board has proposed a third medical school for New Zealand which will concentrate on addressing the workforce needs of disadvantaged rural and provincial communities. The proposed program is a community engaged, graduate entry medical course.

Putting communities in the driver's seat: the realities of community-engaged medical education.

"Community" has featured in the discourse about medical education for over half a century. This discourse has explored relationships between medical education programs and communities in community-oriented medical education and community-based medical education and, in recent years, has extended to community-engaged medical education (CEME). This Perspective explores the developing focus on "community" in medical education, describes CEME as a concept, and presents examples of CEME in action at Flinders University School of Medicine (Australia), the Northern Ontario School of Medicine (Canada), and Ateneo de Zamboanga University School of Medicine (Philippines).The authors describe the ways in which CEME, which features active community participation, can improve medical education while meeting community needs and advancing national and international health equity agendas. They suggest that CEME can redefine student learning as taking place at the center of the partnership between communities and medical schools. They also consider the challenges of CEME and caution that criteria for community engagement must be sensitive to cultural variations and to the nature of the social contract in different sociocultural settings.The authors argue that CEME is effective in producing physicians who choose to practice in rural and underserved areas. Further research is required to demonstrate that CEME contributes to improved health, and ultimately health equity, for the populations served by the medical school.

Making the 2007-2010 Action Plan work for women in family medicine in the Asia Pacific.

The Wonca Working Party for Women and Family Medicine (WWPWFM) was organized in 2001 with the following objectives: to identify the key issues for women doctors; to review Wonca policies and procedures for equity and transparency; to provide opportunities to network at meetings and through the group's listserve and website; and to promote women doctors' participation in Wonca initiatives.In October 2008, at the Asia Pacific Regional conference, the Wonca Working Party on Women in Family Medicine (WWPWFM) held a preconference day and conference workshops, building on the success and commitment to initiatives which enhance women's participation in Wonca developed in Ontario, Canada (2006) and at the Singapore World Congress (2007). At this meeting fifty women workshopped issues for women in Family Medicine in the Asia Pacific. Using the Action Plan formulated in Singapore (2007) the participants identified key regional issues and worked towards a solution.Key issues identified were professional issues, training in family medicine and women's health. Solutions were to extend the understanding of women's contributions to family medicine, improved career pathways for women in family medicine and improving women's participation in practices, family medicine organizations and academic meetings.