Perceived stakeholder benefits of continuously training general practitioners in the same rural or remote practice: interviews exploring the Remote Vocational Training Scheme.

OBJECTIVE: Explore stakeholder perspectives of the benefits of continuously training general practitioners in the same rural or remote practice in distributed locations via the Remote Vocational Training Scheme (RVTS). DESIGN, SETTING, PARTICIPANTS: Online one-hour semi-structured interviews were conducted with 27 RVTS staff, participants and supervisors from all states and territories between 16 October and 24 November 2023. Data were deductively and inductively coded by stakeholder type and the range of benefits, and the findings were informed by insights from a project reference group and a stakeholder advisory group. Questions explored the benefits of the RVTS - a program which supports doctors already working in rural, remote and First Nations communities to train towards general practice or rural generalist fellowship while remaining in the same practice. MAIN OUTCOMES MEASURES: Perspectives on the nature and spread of benefits. RESULTS: Broad benefits were perceived to flow to four system-level stakeholders: communities, health services, participants and policy makers. Perceived participant and community benefits were doctors staying longer in distributed locations with tailored place-based supports and training, doctors building relationships with patients, and doctors learning through longitudinal care. Health service benefits included reduced reliance on locums, improved continuity of accessible and appropriate services in areas otherwise facing major recruitment and retention issues, and the doctors having more time to contribute to improving service quality and upskilling local staff. Policy-maker benefits were sustaining safe and high quality services for distributed populations with high needs. CONCLUSION: The RVTS model was perceived to offer diverse benefits for different system stakeholders which could improve quality of learning, service delivery and community care. It also aligned with key policy directions for a distributed and sustainable generalist workforce under the goals of the National Medical Workforce Strategy 2021-2031 and the directions set by the independent review of overseas health practitioner regulatory settings led by Robyn Kruk. However, models like the RVTS largely rely on distribution levers to recruit more doctors to the locations it supports.

Continuity of service and longer term retention of doctors training as general practitioners in the Remote Vocational Training Scheme.

OBJECTIVE: To explore continuity of service and longer term retention outcomes of participants of the Remote Vocational Training Scheme (RVTS). DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study of all doctors who participated in the RVTS from 2000 to 2023, many of whom are international medical graduates and are expected to work in the same community for three to four years in remote (Modified Monash Model [MMM] categories 4-7) or rural Aboriginal Medical Services (AMS) streams while undertaking training towards general practice fellowship. MAIN OUTCOME MEASURES: Continuity of service was measured in the pre-program period (period working in same practice before commencing) and during-program period (period completing the RVTS program in same practice as worked in before commencing the program). Retention was measured firstly within two years, and secondly beyond two years (up to 20 post-completion years) based on: working in the same community (relevant to both streams); working in the same region (Remote Stream only); working in any MMM4-7 community (Remote Stream only); or working anywhere rurally (both streams). RESULTS: From 506 enrolled participants, 373 (73.7%) were international medical graduates. The approximate mean service continuity in the same practice was 1.6 years (standard deviation [SD], 2.2 years) for the pre-program period and 3.6 years (SD, 1.4 years) for the during-program period (mean total, 5.2 years). Two years after completion, 21 out of 43 Remote Stream doctors (49%) and four out of five AMS Stream doctors (80%) remained in the same community. Over the long term, retention in the same community stabilised to 44 out of 242 Remote Stream doctors (18.2%) and seven out of 27 AMS Stream doctors (26%); 72 Remote Stream doctors (29.8%) remained in the same region, 70 Remote Stream doctors (28.9%) were in an MMM4-7 community, and 11 AMS Stream doctors (41%) were in a rural (MMM2-7) community. CONCLUSION: Strong service continuity outcomes have been achieved by the RVTS, which supports mostly international medical graduates in locations typified by the highest workforce turnover. This suggests that continuity of service could be improved for remote and First Nations communities through place-based retention-focused programs like the RVTS.

Recruitment and retention of new doctors in remote and Aboriginal medical services through the Remote Vocational Training Scheme's Targeted Recruitment Strategy: a focus group study.

OBJECTIVE: To explore the results of a targeted recruitment strategy designed to attract and retain new doctors in remote and Aboriginal medical services where they can access Remote Vocational Training Scheme (RVTS) training and support to qualify as general practitioners. STUDY DESIGN: Two 2-hour purposeful online focus groups on the RVTS' Targeted Recruitment Strategy. SETTING AND PARTICIPANTS: Five participants and nine stakeholders with knowledge and experience of the strategy. Data were transcribed and deductively and inductively coded for themes including insights from separate project reference and stakeholder advisory groups. MAIN OUTCOMES MEASURES: Perspectives of the strategy. RESULTS: The overarching theme was that the strategy is useful for attracting and retaining new general practitioners in areas of high need and is potentially scalable. Since 2018, 20 new doctors were recruited via the Targeted Recruitment Strategy and six of them completed the RVTS program. The strategy could better differentiate target locations because increasing communities are experiencing major general practice workforce shortages. The package of employment and training could also be more clearly defined for participants, nationally marketed and collaboratively implemented. Further, more site accreditation and ongoing risk and quality review is needed, along with intense early supports for participants who are new to both the community and general practice work. CONCLUSION: The Targeted Recruitment Strategy is still maturing but the early results suggest it is a unique and proactive model for attracting and improving access to general practitioners in places with high needs. It could be strengthened through formal agreements between communities and agencies, ensuring coordinated implementation, clarifying roles and responsibilities, and developing clear pathways for risk and quality management.

Holistic support framework for doctors training as rural and remote general practitioners: a realist evaluation of the RVTS model.

OBJECTIVE: To develop theory about how and why the supervision and support model used by the Remote Vocational Training Scheme (RVTS) addresses the professional and non-professional needs of doctors (including many international medical graduates) who are training towards general practice or rural generalist fellowship while based in the same rural or remote practice. DESIGN, SETTING, PARTICIPANTS: We conducted a realist evaluation based on the RAMESES II protocol. The initial theory was based on situated learning theory, networked ecological systems theory, cultural theory and geographical narcissism theory. The theory was developed by collecting empirical data through interviews with 27 RVTS stakeholders, including supervisors, participants and RVTS staff. The theory was refined using a project reference and a stakeholder advisory group and confirmed using individual meetings with experts. MAIN OUTCOMES MEASURES: Theory about how the contexts of person, place and program interacted to address professional and non-professional needs. RESULTS: The RVTS program offers remote access to knowledgeable and caring supervisors, real-time tailored advice, quality resources and regular professional networking opportunities, including breaks from the community. It worked well because it triggered five mechanisms: comfort, confidence, competence, belonging and bonding. These mechanisms collectively fostered resilience, skills, professional identity and improved status; they effectively counteracted the potential effects of complex and relatively isolated work settings. CONCLUSION: This theory depicts how a remotely delivered supervision and support model addresses the place and practice challenges faced by different doctors, meeting their professional and non-professional needs. The participants felt valued as part of a special professional group delivering essential primary health care services in challenging locations. The theory could be adapted and applied to support other rural and remote doctors.

Rural community-centred co-planning for sustainable rural health systems.

OBJECTIVE: Sustaining rural healthcare services is challenging because of numerous systemic factors. Rural communities can inform the design of sustainable rural health models; however, further evidence of effective co-design is needed to guide implementation. The study aim was to co-design a series of place-based and evidence-informed rural health models, to improve local health system sustainability. SETTING: A rural region (categorised as Modified Monash Model 5) defined by three adjoining Shires in Central and Northwest Victoria, Australia. PARTICIPANTS: A health executive co-planning network led the co-design, with input and oversight from a broader cross-sector group. Healthcare professionals (n = 44) and consumers and carers (n = 21) participated in interviews, and an online survey was completed by healthcare professionals (n = 11) and consumers and carers (n = 7) to provide feedback on the preliminary results. DESIGN: Community-based participatory action research was applied incorporating co-design methods and systems thinking. Data were collected through qualitative interviews followed by an online feedback survey. Mixed method data analysis (QUAL-quant) was conducted with qualitative directed content analysis of interview transcripts and quantitative descriptive analyses of survey responses to aid prioritisation. RESULTS: Healthcare priorities, strengths and challenges, and proposed rural health models are described. A rural health system sustainability strategy was developed with three integrated pillars: 1. Workforce strengthening, 2. Integrated health services and 3. Innovative models of care. CONCLUSION: Community-centred co-design with rural health stakeholders was effective for generating locally tailored ideas and potential health models that emulate community strengths and resources, and provide a foundation for further planning, implementation and evaluation.

Exploring learning characteristics and progression of GP trainees based in regional, rural and remote settings: A qualitative study.

OBJECTIVE: Globally, most doctors train and work in metropolitan areas but a key strategy for developing the rural health workforce is expanding rural training. The aim of this study was to describe the scope and quality of learning along with skill acquisition of GP trainees based in regional, rural, and remote settings. SETTING: Regional, rural and remote settings in Queensland Australia excluding Brisbane. PARTICIPANTS: Thirty-seven general practice trainees who had undertaken their first community placement were recruited from regional, rural and remote learning settings within Queensland. DESIGN: Qualitative descriptive methodology based on constructionist epistemology was employed which allowed for the exploration of current GP trainees' experiences. Trainees were interviewed and data were thematically analysed as to the scope and quality of learning by the setting of training. Learning experiences were then mapped against the Dreyfus and Dreyfus model to explore skill acquisition. RESULTS: In terms of the scope and quality of learning, rural and remote trainees mainly focused on the diverse and unique (sometimes challenging) experiences their setting offered compared with regionally based trainees. Mapping of the trainee comments to the Dreyfus model of skill acquisition demonstrated that regardless of setting, equivalent learning occurred by GP trainees. CONCLUSIONS: This exploratory study provides evidence that rural and remote learning may provide a more diverse and challenging experience. It suggests an equivalence of quality of education and skill acquisition across settings rural, regional and remote. This suggests that the training distribution policies may not disadvantage GP trainees and the scope and quality of more remote learning may increase uptake of remote placements.

Tools, frameworks and resources to guide global action on strengthening rural health systems: a mapping review.

BACKGROUND: Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action. OBJECTIVE: This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building. METHODS: This study collected peer-reviewed materials published in 15-year period (2005-2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems). RESULTS: The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%). CONCLUSION: This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening.

A comparative evaluation of quality and depth of learning by trainee doctors in regional, rural, and remote locations.

BACKGROUND: An equitable supply and distribution of medical practitioners for all the population is an important issue, especially in Australia where 28% of the population live in rural and remote areas. Research identified that training in rural/remote locations is a predictor for the uptake of rural practice, but training must provide comparable learning and clinical experiences, irrespective of location. Evidence shows GPs in rural and remote areas are more likely to be engaged in complex care. However, the quality of GP registrar education has not been systematically evaluated. This timely study evaluates GP registrar learning and clinical training experiences in regional, rural, and remote locations in Australia using assessment items and independent evaluation. METHODS: The research team retrospectively analysed GP trainee formative clinical assessment reports compiled by experienced medical educators during real-time patient consultations. Written reports were assessed using Bloom's taxonomy classified into low and high cognitive level thinking. Regional, rural, and remotely located trainees were compared using Pearson chi-squared test and Fisher's exact test (for 2 × 2 comparisons) to calculate associations between categorical proportions of learning setting and 'complexity'. RESULTS: 1650 reports (57% regional, 15% rural and 29% remote) were analysed, revealing a statistically significant association between learner setting and complexity of clinical reasoning. Remote trainees were required to use a high level of clinical reasoning in managing a higher proportion of their patient visits. Remotely trained GPs managed significantly more cases with high clinical complexity and saw a higher proportion of chronic and complex cases and fewer simple cases. CONCLUSIONS: This retrospective study showed GP trainees in all locations experienced comparable learning experiences and depth of training. However, learning in rural and remote locations had equal or more opportunities for seeing higher complexity patients and the necessity to apply greater levels of clinical reasoning to manage each case. This evidence supports learning in rural and remote locations is of a similar standard of learning as for regional trainees and in several areas required a superior level of thinking. Training needs to seriously consider utilising rural and remote clinical placements as exceptional locations for developing and honing medical expertise.

Understanding the non-professional needs of early career doctors: An interview-based study.

Speciality colleges and health services are often well attuned to professional factors, but non-professional needs are less acknowledged and are the focus of this study. This likely relates to limited research about the non-professional needs of early career doctors. This study aimed to describe the non-professional needs of doctors in their early postgraduate career, including how they intersect with career and training experiences. Semi-structured interviews were conducted with 32 male and female medical graduates working across all Australian states and territories, spanning a variety of speciality areas and early career stages. Participants were asked about their career journey to date including non-professional factors related to their experiences. This study identified important non-professional needs, that strongly interplayed with career and training experiences, including: children's education; partner's career needs; family stability; major life stages; proximity to the extended family; and spending time with immediate family. Results suggested clear gender differences, with female doctor's needs orientated to partner work and carer responsibilities, while male doctor's needs were oriented to spending time with family and meeting the family's needs. Non-professional needs should be considered as legitimate needs within health service employment and speciality training arrangements enabling early career doctors to realise their full potential.

Rural general surgeon confidence with managing vascular emergencies: A national survey.

OBJECTIVE(S): Life and limb threatening vascular emergencies often present to rural hospitals where only general surgery services are available. It is known that Australian rural general surgical centres encounter 10-20 emergency vascular surgery procedures annually. This study aimed to assess rural general surgeons' confidence managing emergent vascular procedures. SETTING, PARTICIPANTS AND DESIGN: A survey was distributed to Australian rural general surgeons to determine their confidence (Yes/No) in performing emergent vascular procedures including limb revascularisation, revising arterio-venous (AV) fistulas, open repair of ruptured abdominal aortic aneurysm (AAA), superior mesenteric artery (SMA)/coeliac embolectomy, limb embolectomy, vascular access catheter insertion and limb amputation (digit, forefoot, below knee and above knee). Confidence level was compared with surgeon demographics and training. Variables were compared using univariate logistic regression. RESULTS: Sixteen per cent (67/410) of all Australian rural general surgeons responded to the survey. Increased age, years since fellowship and training prior to 1995 (when separation of Australian vascular and general surgery occurred) were associated with greater confidence in limb revascularisation, revising AV fistulas, open repair of ruptured AAA, SMA/coeliac embolectomy, and limb embolectomy (p < 0.05). Surgeons who completed >6 months of vascular surgery training were more comfortable with SMA/coeliac embolectomy (49% vs. 17%, p = 0.01) and limb embolectomy (59% vs. 28%, p = 0.02). Confidence in performing limb amputation was similar across surgeon demographics and training (p > 0.05). CONCLUSION: Recently graduated rural general surgeons do not feel confident in managing vascular emergencies. Additional vascular surgery training should be considered as part of general surgical training and rural general surgical fellowships.

Outcomes of rural generalist internship training in Victoria, Australia.

INTRODUCTION: Victoria, Australia commenced its first Rural Community Internship Training program in 2012 to support the development of rural generalist (RG) doctors. These general practitioners have additional skills to work at a broad scope to deliver the range of primary care and additional specialist services that communities need. Unlike most internships, which are wholly hospital-based and delivered mostly within larger metropolitan and regional centres, this RG internship training model involves completing general practice experience in smaller rural communities working with RGs and visiting specialists. This study aimed to explore the characteristics and satisfaction of doctors who participate in RG internship training in Victoria and their workforce outcomes. METHODS: Between October and November 2021, a retrospective 10-minute anonymous survey invitation was sent to all contactable interns (n=222) who had completed/were completing the RG internship training (2012-2021). The survey was co-designed with RG internship managers and other stakeholders of a statewide evaluation advisory group, informed by the latest evidence regarding RG medicine and rural training predictors, and outcomes of interest. Participants completed the survey using Microsoft Forms, with three invitations circulated to an up-to-date email address maintained by the internship program. Collected data were analysed descriptively, by subgroup, to explore training pathway outcomes by region, training stage and specialty choice. Workforce distribution outcomes were defined in line with objectives of the program and predetermined indicators of RG scope. Results were compared with the benchmarks of rural workforce training outcomes in Australia using recent research. RESULTS: There were 59 participants (27% response rate); 81% were in postgraduate years 3-7. Respondents included 54% male, 17% rurally bonded, 39% of rural origin, 34% having had more than 3 months rural undergraduate training and 48% doing RG training where they previously did undergraduate training. All were satisfied/very satisfied with the RG training and 61% were working in general practice (excluding the prevocational group). Overall, 40% were currently working in the same rural region as their internship (including three who were currently interns), 56% continued to complete some prevocational training in the same region as their RG internship, while 20% had gone on to be currently based in smaller rural communities (Modified Monash Model locations 4-7) and 44% to be working part-time in smaller rural communities. Overall, 42% self-identified as working as an RG and nearly all (97%) met at least one of the key indicators of extended (RG) scope. In all areas the RG internship outcomes were better than the national benchmarks from published evidence about rural training. CONCLUSION: This study provides evidence from doctors up to 9 years after completing their RG internship. Compared with industry benchmarks, the RG internships attract rurally intentioned and rurally experienced doctors who may be likely to remain in the same rural region as their undergraduate rural medical training and continue their postgraduate training in the same region. They were all satisfied with RG internship training, had high propensity to follow a general practice career and work at broad scope in smaller communities. Importantly, they intended to stay in the region where they trained. This suggests RG internship programs are a positive intervention for promoting an RG workforce.

A critical review of definitions of rural areas in Indonesia and implications for health workforce policy and research.

BACKGROUND: Choosing the appropriate definition of rural area is critical to ensuring health resources are carefully targeted to support the communities needing them most. This study aimed at reviewing various definitions and demonstrating how the application of different rural area definitions implies geographic doctor distribution to inform the development of a more fit-for-purpose rural area definition for health workforce research and policies. METHODS: We reviewed policy documents and literature to identify the rural area definitions in Indonesian health research and policies. First, we used the health policy triangle to critically summarize the contexts, contents, actors and process of developing the rural area definitions. Then, we compared each definition's strengths and weaknesses according to the norms of appropriate rural area definitions (i.e. explicit, meaningful, replicable, quantifiable and objective, derived from high-quality data and not frequently changed; had on-the-ground validity and clear boundaries). Finally, we validated the application of each definition to describe geographic distribution of doctors by estimating doctor-to-population ratios and the Theil-L decomposition indices using each definition as the unit of analysis. RESULTS: Three definitions were identified, all applied at different levels of geographic areas: "urban/rural" villages (Central Bureau of Statistics [CBS] definition), "remote/non-remote" health facilities (Ministry of Health [MoH] definition) and "less/more developed" districts (presidential/regulated definition). The CBS and presidential definitions are objective and derived from nationwide standardized calculations on high-quality data, whereas the MoH definition is more subjective, as it allows local government to self-nominate the facilities to be classified as remote. The CBS and presidential definition criteria considered key population determinants for doctor availability, such as population density and economic capacity, as well as geographic accessibility. Analysis of national doctor data showed that remote, less developed and rural areas (according to the respective definitions) had lower doctor-to-population ratios than their counterparts. In all definitions, the Theil-L-within ranged from 76 to 98%, indicating that inequality of doctor density between these districts was attributed mainly to within-group rather than between-group differences. Between 2011 and 2018, Theil-L-within decreased when calculated using the MoH and presidential definitions, but increased when the CBS definition was used. CONCLUSION: Comparing the content of off-the-shelf rural area definitions critically and how the distribution of health resource differs when analysed using different definitions is invaluable to inform the development of fit-for-purpose rural area definitions for future health policy.

Title-blended supervision models for post-graduate rural generalist medical training in Australia: an interview study.

BACKGROUND: Expanding rural training is a priority for growing the rural medical workforce, but this relies on building supervision capacity in small towns where workforce shortages are common. This study explored factors which support the use of blended supervision models (consisting of on- and offsite components) for postgraduate rural generalist medical training (broad scope of work) in small rural communities. METHODS: Data were collected between June and August 2021 through semi-structured, in-depth interviews with medical training stakeholders experienced in blended supervision models for rural generalist training. Interviews were audio-recorded, transcribed verbatim and analysed using an inductive thematic analysis process. RESULTS: Fifteen participant interviews provided almost 13 h of audio-recorded data. Four themes were developed: governance, setting, the right supervisor and the right supervisee. Blended supervision models may be effective if selectively applied including where the model is well-planned, the setting has local team supports and supervisor and supervisee characteristics are appropriate. CONCLUSIONS: Understanding factors involved in the application of blended supervision models can help with expanding rural generalist training places in distributed communities. Blended supervision models can be effective for rural generalist training if the model is planned, and the context is suitable.

Challenges and innovations in access to community-based rural primary care services during the Covid-19 pandemic in Australia.

BACKGROUND: Access to primary care is a significant issue for rural populations. The Covid-19 pandemic imposed a unique operating environment for rural General Practice enabling accessible services. This study aimed to explore the challenges and innovations rural General Practices experienced in promoting accessible primary care during a year of the pandemic. METHODS: Longitudinal semi-structured interviews were done with key informants (General Practitioners or Practice Managers) from purposefully selected General Practices from different rural towns in different subregions. Interviews occurred at three stages of the pandemic, June 2020-June 2021. They explored participant perspectives of the emerging challenges and innovatinos as they sought to support accessible primary care services during the pandemic. The data were thematically coded using a deductive framework of access challenges and innovations over time. RESULTS: Of 12 practices approached, 11 key informants responded, providing around 30 h of interview data. The challenges and innovations related to access, changed over time as the pandemic evolved. A common theme concerned reflexive action. Practices had been on a journey during the pandemic to embed new planning processes, digital health options and to innovate to protect and support patients and staff to sustain access. CONCLUSION: This study provides useful insights into the challenges and innovations experienced in rural general practice during the Covid-19 pandemic to reflect on models, strategies and approaches that can apply to promote access to rural primary care services going forward.

Responsive policies needed to secure rural supply from increasing female doctors: A perspective.

Around the world, the supply of rural health services to address population health needs continues to be a wicked problem. Adding to this, an increasing proportion of female doctors is graduating from medical courses but gender is not accounted for within rural workforce policy and planning. This threatens the future capacity of rural medical services. This perspective draws together the latest evidence, to make the case for industry and government action on responsive policy and planning to attract females to rural medicine. We find that the factors that attract female doctors to rural practice are not the same as males. We identify female-tailored policies require a re-visioning of rural recruitment, use of employment arrangements that attract females and re-thinking issues of rural training and specialty choice. We conceptualise a roadmap that includes co-designing rural jobs within supportive teams, allowing for capped hours which align with childcare along with boosting of female peer support and mentorship. There is also a need to enhance flexible rural postgraduate training options in a range of specialties (at a time when many women are establishing families) and to consider viable partner employment (including for female doctors with university trained partners) and advertising specific rural attractors to women, including the chance to connect with communities and make a difference.

Functional outcomes following an in-hospital cardiac arrest: A retrospective cohort study.

BACKGROUND/PURPOSE: Whilst much is known about the survival outcomes of patients that suffer an in-hospital cardiac arrest (IHCA) in Australia very little is known about the functional outcomes of survivors. This study aimed to describe the functional outcomes of a cohort of patients that suffered an in-hospital cardiac arrest (IHCA) and survived to hospital discharge in a regional Australian hospital. METHODS: This is a single-centre retrospective observational cohort study conducted in a regional Australian hospital. All adult patients that had an IHCA in the study hospital between 1 Jan 2017 and 31 Dec 2019 and survived to hospital discharge were included in the study. Functional outcomes were reported using the Modified Rankin Scale (mRS), a six-point scale for which increasing scores represent increasing disability. Scores were assigned through a retrospective review of medical notes. RESULTS: Overall, 102 adult patients had an IHCA during the study period, of whom 50 survived to hospital discharge. The median age of survivors was 68 years, and a third had a shockable initial arrest rhythm. Of survivors, 47 were able to be assigned both mRS scores. At discharge, 81% of patients achieved a favourable functional outcome (mRS 0-3 or equivalent function at discharge equal to admission). CONCLUSIONS: Most survivors to hospital discharge following an IHCA have a favourable functional outcome and are discharged home. Although these results are promising, larger studies across multiple hospitals are required to further inform what is known about functional outcomes in Australian IHCA survivors.

Mandatory bulk billing policies may have differential rural effects: an exploration of Australian data.

INTRODUCTION: Over the course of the COVID-19 pandemic, Australian general practices have rapidly pivoted to telephone and video call consultations for infection control and prevention. Initially these telehealth consultations were required to be bulk billed (doctors could only charge fees equivalent to the national Medicare Benefits Schedule (MBS)). The potential impact of this policy on general practices − and particularly rural general practices - has been difficult to assess because there is limited published data about which practices are less likely to bulk bill and therefore more impacted by mandatory bulk billing policies. There was concern that bulk billing only policies could have a broader impact on rural practices, which may rely on mixed or private billing for viability in small communities where complex care is often needed. This study aimed to understand the patterns of bulk billing nationally and explore the characteristics of practices more or less likely to bulk bill patients, to identify the potential impact of a rapid shift to bulk billing only policies. METHODS: General practice bulk billing patterns were described using aggregate statistics from Australian Department of Health public MBS datasets. Bulk billing rates were explored over time by rurality, and state or territory. Next, questions about bulk billing were included in a cross-sectional survey of practices conducted in 2019 by General Practice Supervisors Australia (GPSA). Practice bulk billing patterns were explored by rurality, state or territory and practice size at univariate level before a multivariate logistic regression model was done, including the statistically significant variables. RESULTS: Nationally, bulk billing rates for general practice non-referred attendances increased over 2012-2019 from 82% to 86% but declined slightly in Modified Monash Model (MMM)2−7 (rural areas) at the end of this period. Further, bulk billing rates varied by rurality, and were highest in very remote (MMM7) (89-91%) and metropolitan areas (MMM1) (83-87%) and lowest in regional centres (MMM2) (76-82%) over this period. The results from the GPSA survey concurred with national data, showing that the proportion of practices bulk billing all patients was highest in metropolitan locations (28%) and lowest in regional centres and large rural towns (MMM2−3) (16%). Smaller practices (five or fewer general practitioners) were more likely to bulk bill all patients than were larger ones (six or more general practitioners). Multivariate modelling showed that bulk billing all patients was statistically significantly (p<0.05) less likely for larger practices compared with smaller ones, and for rural practices (MMM2−7) compared with those in metropolitan areas. CONCLUSION: Mandatory bulk billing policies should accommodate the fact that bulk billing varies by context, including rurality and the size of a practice, and has been decreasing in rural areas over recent years. Rapidly pivoting to bulk billing only service models may put pressure on rural and large practices unless they have time to adjust their business models and have ways to offset the loss of billings. Policies that allow for a range of billing arrangements may be important for practices to fit billings to their local context of care, including in rural settings, thereby supporting business viability and the availability of sustainable primary care services.

What recently graduated podiatrists think of rural work, and how services are responding: a qualitative study.

INTRODUCTION: Access to healthcare services should be equitable no matter where you live. However, the podiatry needs of rural populations are poorly addressed, partly because of workforce maldistribution. Encouraging emerging podiatrists to work in rural areas is a key solution. The aims were to explore (1) recently graduated podiatrists' perceptions regarding working rurally and (2) broader industry views of the factors likely to be successful for rural recruitment and retention. METHODS: Recruitment for interviews pertaining to podiatrist recruitment and retention was conducted during 2017. Recruitment was through social media, podiatry professional association newsletters, public health podiatry emails. Graduate perceptions were explored via two focus groups of Australian podiatrists enrolled in the Podiatrists in Australia: Investigating Graduate Employment longitudinal survey. Industry views were explored through semistructured interviews with podiatry profession stakeholders. Inductive thematic analysis was used to analyse data about the perceptions of recently graduated podiatrists and stakeholders and the themes were triangulated between the two groups. RESULTS: Overall, 11 recent graduate podiatrists and 15 stakeholders participated. The overarching themes among the two groups were the importance of 'growing me' and 'growing the profession'. Three superordinate themes were generated through analysis of both datasets, including (i) building a career, (ii) why I stay, and (iii) it cannot be done alone. CONCLUSION: This study identified that recently graduated podiatrists are likely to be attracted to rural work and retained in rural areas if they foresee opportunities for career progression in stable jobs, have a background of training and living in rural areas, like the lifestyle, and are able to access appropriate professional and personal supports. Building employment that spans public and private sector opportunities might be attractive to new graduate podiatrists seeking a breadth of career options. It is also important to recognise rural generalist podiatrists for any extended scope of services they provide along with raising public awareness of the role of rural podiatrist as a core part of multidisciplinary rural healthcare teams. Future training and workforce planning in podiatry must promote podiatrists taking up rural training and work so that maldistribution is reduced.

Developing supervision capacity for training rural generalist doctors in small towns in Victoria.

INTRODUCTION: Rural generalist (RG) doctors are broadly skilled to provide comprehensive primary care, emergency and other specialist services in small, distributed communities where access is otherwise limited because of distance, transport and cost limitations. In Victoria, Australia, the Victorian Rural Generalist Pathway (VRGP) represents a significant state-wide investment in training and growing the next generation of RGs. The first step of the VRGP is well established through the Rural Community Internship Training program, which commenced in Victoria in 2012-2015; however, the second step (RG2) requires expansion by growing supervised learning in small rural communities where RGs will eventually work. This project aimed to explore enablers and barriers to the supervision of RG2 learners across a core generalist curriculum in distributed towns in three rural Victorian regions. METHODS: Data were collected between June and August 2021 through semistructured, in-depth interviews conducted via Zoom or telephone with general practitioners (GPs) and health service executives from small and big health services in the Hume, Loddon Mallee and Barwon South West regions. Interview questions were shared prior to the interview to support reflective responses. Interviews were an hour in length and data were transcribed verbatim and analysed using an inductive thematic analysis process. The research team met regularly throughout the analysis process to refine theme development, test assumptions, and reduce any subjective biases. This study had ethical approval from Monash University. RESULTS: Thirty-one participants, including 13 GPs working at RG scope in MMM 4-7 and 18 health service executives, engaged with RGs consented and participated. The supervision of RG2s was affected by multilayer enablers and barriers. Enablers that emerged were having a critical mass of fellowed doctors using viable models to supervise RG2s, funding for the supervision of RG2s, generalist learning opportunities, and coordination and case management. Barriers included insufficient doctors to supervise, the cost and risk of supervising RG2s, developing rural training but finding it was unattractive to trainees, and a reliance on rotational staff, which limited supervision on the ground. Different regions experienced enablers and barriers to different degrees. CONCLUSION: Building supervised training for RG2 learners across a generalist scope in distributed rural communities is a complex undertaking, with multilayered enablers and barriers at play. A range of issues are beyond the control of the VRGP and rely on advocacy and collaboration with stakeholders. The major themes suggest that supervised learning should be addressed at multiple levels of the system, the community, clinical settings, and clinicians. Expanding supervision of RG2s across core generalist curriculum in small rural communities will also require a regionally guided long-term vision and stepwise planning. With ongoing commitment to RG-led care, it is possible to achieve high-quality supervision at the RG2 stage, retain RGs on the pathway, and produce skilled RG trainees to serve Victoria into the future.

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.