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

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

Predicting future performance in medical students. A longitudinal study examining the effects of resilience on low and higher performing students.

Introduction: Medical students have high rates of distress and burnout, exacerbated by a high academic workload. Resilience is stated to mitigate such stress, and even allow positive adaptations in the face of such challenges. Despite this, no research has examined the relationship of resilience on the academic performance of medical students. Methods: The goal of our study was to investigate the association between resilience on academic performance. We surveyed all year 2, 3, and 4 medical students (n = 160), and combined this with data on past and future course performance. We conducted an analysis of the internal consistency and validity of the RS-14, suggesting two factors: which we represent as self-assuredness and drive. We then analyzed future course performance using multiple regression. Results: Models utilizing the combined RS-14 score suggested past-performance as the only significant predictor of future course performance. Considering self-assuredness and drive as separate predictors demonstrated self-assuredness to be a predictor of improved performance in lower-than-average students, whilst drive was a predictor of improvement in higher-than-average students. Conclusions: We suggest that the conceptualization of resilience needs greater nuance, and consideration in tandem with broader psychosocial concepts, as it may exert different effects for different students.

Social and community networks influence dietary attitudes in regional New South Wales, Australia.

INTRODUCTION: Rural populations in Australia have a higher prevalence of obesity, cardiovascular disease, type II diabetes and some cancers. The purpose of the present study was to determine associations between socioeconomic characteristics (socioeconomic position, income, wealth, debt, occupation, social network diversity), dietary attitudes, and fruit and vegetable intake for people living rurally in Australia. METHOD: A community based cross-sectional survey between February and July 2018 of 326 adults (median age 57 years, range 20-90 years, 64.4% female) who attended rural shows in four rural towns in south-eastern New South Wales, supplemented with data from patients attending general practices in two additional towns. Participants completed a questionnaire that recorded self-reported daily consumption of fruit and vegetables, a dietary attitude score, and items measuring social and economic circumstances. RESULTS: Using multivariable regression analysis, the odds of meeting Australian fruit intake guidelines was 13% higher for each unit increase in dietary attitude score (odds ratio (OR)=1.13, 95% confidence interval (CI)=1.03-1.23). The odds of meeting vegetable intake guidelines were 19% higher for each unit increase in score (OR=1.19, 95%CI=1.09-1.31). Social and economic factors were not independently associated with fruit or vegetable intake. Dietary attitude score, in turn, increased on average by 0.07 points (95%CI=0.01-0.12) for each additional occupation type among the participants' social networks. For women who socialised regularly in small towns the score was 1.97 points higher (95%CI=0.93-3.00). Men in outer regional areas were more likely to meet vegetable intake guidelines than men in inner regional areas, whereas women in outer regional areas were more likely to meet fruit intake guidelines than women in inner regional areas. CONCLUSIONS: Greater fruit and vegetable intake was predicted by healthier dietary attitudes which in turn were related to social and community connections, rather than economic factors.

How does studying rurally affect peer networks and resilience? A social network analysis of rural- and urban-based students.

OBJECTIVE: To examine differences in peer networks between urban-based students and rural-stream students in an Australian medical school and to examine how characteristics of networks relate to resilience. DESIGN: Cross-sectional survey asking students to signify social, academic and support relationships with students in the same year and to complete a survey on their resilience. SETTING AND PARTICIPANTS: All second-, third- and fourth-year students at the Australian National University Medical School. MAIN OUTCOME MEASURES: Social network analysis comparing peer networks, t-test comparing mean resilience of urban and rural students. RESULTS: A visual analysis of the peer networks of year 2, 3 and 4 medical students suggests greater integration of rural-stream students within the year 2 and 4 urban cohorts. Resilience is similar between year 2 and 3 students in both urban and rural streams, but is significantly higher in year 4 rural-stream students, compared to their urban-based peers. Networks of rural-stream students suggest key differences between their period spent rurally and on their return and integration within the larger student cohort. Furthermore, rural students, once reintegrated, had larger and stronger social networks than their urban counterparts. CONCLUSION: The results of the study suggest that the rural experience can instruct support systems in urban settings. However, whether the rural placement creates a more resilient student or resilient students are selected for rural placement is unclear.

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

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

Managing national and international priorities: a framework for low-income countries.

CONTEXT: Capacity-building programmes in low-income countries (LICs) are subject to a tension between the requirement to best train workers to fulfil national needs and the requirement to meet international expectations of their students, academics and institutions. This paper presents a theoretical framework developed from a case study of an undergraduate degree programme in Malawi and explores how national needs and international expectations can be managed in health profession settings in LICs to ensure successful curriculum development. METHODS: An inductive qualitative methodology, grounded theory, combined with open-ended interviews with students, graduates, tutors and external stakeholders in the programme, was used to develop a theoretical framework. RESULTS: A total of 22 interviews were performed; their analysis conceptualised the tension between national needs and international expectations, and resulted in 12 codes, in four categories: competing and advancing agendas; processes of collaboration; developing a programme or professional identity, and perceptions of programme change. CONCLUSIONS: This study describes a conceptual framework highlighting three particular areas for analysis to aid in understanding how to best manage competing agendas. These areas refer to, respectively, the significance of international expectations, the organisational climate, and the development of a professional identity.

Rural clinical school students do come back: But it may take time

BACKGROUND AND OBJECTIVES: Rural clinical schools (RCSs) help address Australia's rural workforce shortfall, but they require an investment by rural clinicians and communities. Our objective was to determine the location of RCS graduates as one measure of the effectiveness of RCSs. METHOD: This cross-sectional study obtained work location data for Australian National University Medical School (ANUMS) graduates and analysed both RCS and non-RCS data. RESULTS: The percentage of graduates working in rural areas after their fifth postgraduate year (PGY6­11: 34.7%) was significantly greater than that of graduates in PGY1­5 (15.2%, P <0.001). DISCUSSION: Many graduates who trained in rural sites spend time in cities before returning to work in rural areas. This is encouraging for rural clinicians and communities, but it can take time for graduates to return.