Exploring recent trends (2014–21) in preferencing and accepting Queensland medical internships in rural hospitals

Geographic maldistribution of metropolitan and rural doctors persists world-wide. There are many underlying factors, including few medical schools producing rural doctors as central to their organisational mission, inadequate selection of students with rural backgrounds and/or rural interest, the growth and incompatibility with rural practice of some medical sub-specialisations, and many doctors remaining near to where they complete their training in larger cities, particularly beyond medical school [1, 2].

In most countries an internship immediately after graduation from medical school is required for gaining general registration, either before entry to specialty college training (as in Australia and the UK) or embedded within residency programs (as in the USA). Medical internship is the key transition point in the training pathway from medical student to independent (junior) doctor [3], with interns closely supervised by senior doctors whilst both finding their feet in the workplace and ‘sightseeing’ as they determine where they best fit in the healthcare system [4]. It is a key stage for solidifying career decisions, both of place and specialty, for many [5]. Medical graduates’ choice of internship hospital and their predominant junior doctor work location has been strongly associated with their longer-term career outcomes [6, 7]. Moreover, previous studies of rurally-based medical internships in Australia have demonstrated these to be positive and professionally satisfying experiences [8, 9]. It follows that encouraging and enabling more graduates to choose a rural internship could play a role in producing more rural doctors and partly addressing maldistribution.

Evidence supports the benefit of rural training interventions and policies for improving rural workforce supply and retention [10‐12]. This evidence reinforces the positive impact of rural medical school training (the longer the better) and selecting students more likely to practice rurally because of their rural childhood origin or interest in rural work [12‐17]. Rural training pathways, particularly in the early career stages, are critical interventions for producing a skilled, well-distributed and stable rural workforce. In contrast, offering financial incentives to shift the established medical workforce into relatively underserved areas have limited effect [18], and are costly [19].

Australia’s Rural Health Multidisciplinary Training program aims to improve the recruitment and retention of doctors to the rural workforce through several key initiatives, including Rural Clinical Schools (RCSs, began 2000) and Regional Training Hubs (RTHs, began late 2017) [20]. RCSs and RTHs build partnerships with medical schools, hospitals and other health services to increase clinical training and supervision capacity in rural areas, thus strengthening rural professional and social networks and career interest. Whilst RCSs have long delivered rural immersion placements for students, the newer RTHs aim to support expanded rural medical training pathways beyond medical school and starting at internship, including career guidance for rurally-interested students and junior doctors. Of note, the RCS program generally cannot support rural placements for international students within Australian medical schools whereas RTHs can support all junior doctors [21].

Outside of one Victorian study [22], there has been little published on internship preferences and acceptances, and none since the establishment of RTHs. This collaborative study focused on graduates from Queensland’s four medical schools, with James Cook University and The University of Queensland having both RCSs and RTHs, Griffith University having an RCS in partnership with Rural Medical Education Australia, and Bond University which does not have its own RCS or RTH. Queensland Health (QH) coordinates an annual internship campaign for Hospitals and Health Services (HHS) across Queensland. Similar to other States, Queensland has fewer intern positions on offer compared to the total number of eligible graduates, with an online portal used to assess applicants’ merit, compare preferences with available positions and allocate a position [23]. Eligible candidates are categorised into four groups which are in priority order from A to D, with most going through the general campaign and a small proportion through the Queensland Rural Generalist Pathway (QRGP) [24] (see Table 1). This study aims to explore preferencing and acceptance trends for rural medical internship positions in Queensland, Australia. Moreover, it focuses on internship preference and acceptance outcomes prior to and following the establishment of RTHs, and their association with key covariates such as rural training immersions offered by medical schools. A secondary aim explores factors associated with short-term rural retention in post-graduate years (PGY) 2 and 3.

This study is the first to investigate possible impacts of the RTH initiative on short-term increase of the rural workforce. These results suggest a positive increase from the largest and primary target group of medical graduates (Group A, Queensland trained domestic students) choosing to both highly preference and accept an intern position in Queensland rural hospitals since RTH establishment, equating to an average 17 additions to the rural workforce each year. Findings from Group A confirm the importance of factors relating to rural connections with take-up of rural internships. Both moderate (11–74 weeks) and long-stay (75 + weeks) rural clinical training immersions were associated with preferencing rural internships, even after factoring in those who were already in a rural location during their final undergraduate year. Unsurprisingly, those entering QRGP were more likely to choose a rural intern position. These results align with previously reported Queensland medical school intention data [26, 27].

Outcomes of Group C (Australian-trained international graduates), the next largest cohort, were somewhat mixed. Proportionally, they were less likely to preference or accept a rural intern position post-RTHs; this was counterbalanced by the size of this cohort which meant the number of Group Cs working in a rural hospital also increased. Consistent with previous evidence [22], Group C applicants remained substantially more likely to both preference and accept internships in rural hospitals, which is strongly driven by the allocation process, whereby Group A and B applicant’s preferences are prioritised first. However, a common characteristic of the international students who continue working in Australia is their lack of rural connections at their time of medical school graduation, being largely excluded from government-supported rural immersions during medical school and being ineligible for the QRGP. Retention of Group C interns in rural hospitals in PGY2/3 was significantly less than Group A interns, suggesting that local integration of this group may be problematic and that the longer-term effectiveness of their current preference allocations to the rural workforce supply is weakened [21, 28]. These findings suggest longer-term rural workforce benefits from potentially expanding Australia’s Rural Health Multidisciplinary Training program to be inclusive of these students, offering QRGP beyond Group A, and preferentially selecting applicants.

Of those who completed a metropolitan internship, only a small proportion changed to a rural location within the next two years; already having a rural interest, being enrolled in the QRGP, and first preferencing a rural internship (but accepting a metropolitan internship) were the main predictors. Most notably, time spent training in a rural area and being in a rural location immediately prior to internship were not associated with returning to a rural location after their internship. This evidence confirms that the choice of internship location is a strong indication of where graduates will be in the 1–2 prevocational years that immediately follow, and thus internship is a critical point for determining workforce distribution within the early junior doctor period.

The proportion of Queensland interns experiencing extended (75 + weeks) undergraduate rural training increased greatly post-RTH and was confirmed as a significant predictor of choosing a rural internship in this study. However, the observed 33% expansion of rural placements has not led to more applicants choosing rural internships post-RTH. This suggests that even though the rural clinical training places in Queensland medical schools has significantly expanded in synergy with RTHs, more time is required to show its impact on the Queensland rural workforce.

A strength of this study was the analysis of 5956 records over 8 years representing all QH hospitals offering intern positions. However, the design of this study precludes confirming a positive impact on regional Queensland medical workforce from the establishment of RTHs, though these results are encouraging. Also, as the RTHs were operational only from late 2017 and their key activities continue to be refined, its effect may not be shown in this short study period.

The analysis did not include rural origin, a widely demonstrated factor associated with working rurally, as this measure was not wholly available for matching by all participating universities. In addition, the outbreak of the Covid-19 pandemic may have impacted relocation/immigration rates of interstate and international graduates due to travel restrictions. Finally, the quantitative nature of the study does not allow conclusions to be drawn regarding intent and drivers for accepting or staying rurally. Thus, further research using qualitative methodologies is required to investigate why medical graduates choose their internship year to be in a rural hospital and why they choose to stay or leave in PGY2 and PGY3, including hospital specific factors versus individual career interests.

This study reports first evidence on the rate and trend of preferencing and uptake of rural intern positions at a whole-of-state level since establishment of RTHs. The findings show a positive association between the RTH initiative and higher preferencing of rural intern positions. However, because of the nature of the study design, it was not possible to determine if a causal relationship exists. Pleasingly, an expansion of graduates undertaking longer periods of undergraduate rural training in the same period did not diminish the proportion choosing a rural internship, suggesting there remains an appetite for more rural training opportunities. The study findings fit with existing evidence that the sustainability of rural medical workforce remains challenging, and while possibly not generalisable to other states and countries due to their context-specific features, can be used as a baseline for future research at national level to understand the impact of RTHs on addressing medical workforce distribution concerns.