Nature or nurture: the effect of undergraduate rural clinical rotations on pre-existent rural career choice likelihood as measured by the SOMERS Index.

OBJECTIVE: Do undergraduate rural clinical rotations increase the likelihood of medical students to choose a rural career once pre-existent likelihood is accounted for? DESIGN: A prospective, controlled quasi-experiment using self-paired scores on the SOMERS Index of rural career choice likelihood, before and after 3 years of clinical rotations in either mainly rural or mainly urban locations. SETTING: Monash University medical school, Australia. PARTICIPANTS: Fifty-eight undergraduate-entry medical students (35% of the 2002 entry class). MAIN OUTCOME MEASURES: The SOMERS Index of rural career choice likelihood and its component indicators. RESULTS: There was an overall decline in SOMERS Index score (22%) and in each of its components (12-41%). Graduating students who attended rural rotations were more likely to choose a rural career on graduation (difference in SOMERS score: 24.1 (95% CI, 15.0-33.3) P<0.0001); however, at entry, students choosing rural rotations had an even greater SOMERS score (difference: 27.1 (95% CI, 18.2-36.1) P<0.0001). Self-paired pre-post reductions in likelihood were not affected by attending mainly rural or urban rotations, nor were there differences based on rural background alone or sex. CONCLUSIONS: While rural rotations are an important component of undergraduate medical training, it is the nature of the students choosing to study in rural locations rather than experiences during the course that is the greater influence on rural career choice. In order to improve the rural medical workforce crisis, medical schools should attract more students with pre-existent likelihood to choose a rural career. The SOMERS Index was found to be a useful tool for this quantitative analysis.

The SOMERS Index: a simple instrument designed to predict the likelihood of rural career choice.

OBJECTIVE: The World Health Organization has drawn up a set of strategies to encourage health workers to live and work in remote and rural areas. A comprehensive instrument designed to evaluate the effectiveness of such programs has not yet been tested. Factors such as Stated rural intention, Optional rural training, Medical sub-specialization, Ease (or self-efficacy) and Rural Status have been used individually or in limited combinations. This paper examines the development, validity, structure and reliability of the easily-administered SOMERS Index. DESIGN: Limited literature review and cross-sectional cohort study. SETTING: Australian medical school. PARTICIPANTS: A total of 345 Australian undergraduate-entry medical students in years 1 to 4 of the 5-year course. MAIN OUTCOME MEASURES: Validity of the factors as predictors of rural career choice was sought in the international literature. Structure of the index was investigated through Principal Components Analysis and regression modelling. Cronbach's alpha was the test for reliability. RESULTS: The international literature strongly supported the validity of the components of the index. Factor analysis revealed a single, strong factor (eigenvalue: 2.78) explaining 56% of the variance. Multiple regression modelling revealed that each of the other variables contributed independently and strongly to Stated Rural Intent (semi-partial correlation coefficients range: 0.20-0.25). Cronbach's alpha was high at 0.78. CONCLUSIONS: This paper presents the reliability and validity of an index, which seeks to estimate the likelihood of rural career choice. The index might be useful in student selection, the allocation of rural undergraduate and postgraduate resources and the evaluation of programs designed to increase rural career choice.

Influences on medical students' decisions to study at a rural clinical school.

OBJECTIVE: To identify factors that influenced medical students at Monash University to undertake their first year of clinical training (third year of the medical course) at a rural clinical school (RCS). DESIGN: Third-year Monash University medical students undertaking clinical placements at a RCS were surveyed in 2005. A semistructured questionnaire was used to ask students to rate the influence of a list of factors on their decision to undertake their year-long placement at a RCS. RESULTS: Under half (48%) of students studying at an RCS reported that they were of rural background. All surveyed items were identified as having had a positive influence. Greater clinical experience, learning opportunities and patient access were identified as having the greatest positive influence followed closely by free accommodation and other financial and supportive incentives. Future rural career intention was eight times more likely to be a positive influence in rural compared with urban background students. CONCLUSION: The most important positive influence on Monash third-year medical students' decision to study at an RCS is the perception of high-quality clinical experiences and education. This perception arises from rural exposure during pre-clinical years.

What does it take? The influence of rural upbringing and sense of rural background on medical students' intention to work in a rural environment.

INTRODUCTION: There is abundant evidence that rural origin is an influence on rural career choice. Rural origin is widely used to select students to be supported into programs designed to address the rural medical workforce shortage. What is not as clear is how many years of rural upbringing are required to have a maximal effect on rural career choice. Neither is the place of having a sense of rural background well understood. METHODS: A cross-sectional self-completed paper-based survey of all students in years one through four of the Monash University medical course was undertaken in 2003. The survey included a scale to measure stated rural career intention as well as questions about the number of years of rural upbringing and whether students had a sense of rural background. The Rural Intention score was divided into three categories: strong urban intent, strong rural intent, and an intermediate, less certain intent. RESULTS: There was an 88% (n = 399) response rate from students holding Commonwealth Supported Places. Approximately 30% of these claimed a sense of rural background, and 28% had more than 8 years of rural upbringing. Twenty-five percent stated a strong intention to choose a rural career and 34.5% had strong urban intent. The remaining 40.5% were in the intermediate group. Almost all students (97.5%) with over 5 years of rural upbringing had developed a sense of rural background, and almost all (97.5%) with less than 5 years' rural upbringing denied a sense of rural background. Rural intent was high for those with a sense of rural background and those with more than 8 years of rural upbringing, but the students who had had from 4 to 8 years of rural upbringing mainly fell into the 'uncertain' category. DISCUSSION: In this cohort of almost 400 Australian medical students, a sense of rural background developed at a clear point, around 5 years of rural upbringing. Students with a sense of rural background were likely to develop a strong rural intent several years before similar students who had failed to make this connection with a rural community. This latter group displayed uncertainty toward a rural career choice, possibly due to unfamiliarity. Unlike those with strong urban intent, these students have not excluded a rural career and should be supported. The inclusion of a measure of the intention of students to work in a rural environment is likely to increase the reliability and validity of selection procedures.