Introduction
Background
…[a] broad generalist set of skills, knowledge and attitudes…practiced at a distance from comprehensive specialist medical and surgical services and investigations. [17]
Rural medical staff
Australia as an example: the expenditure–evidence gap
New rural medical schools
Medical programmes in rural locations
A polarised debate
Methods
Defining the research question
Identifying relevant studies
Population and course | Location and training | Time | Practice |
---|---|---|---|
Medic* AND (Student OR Preregistration OR Undergraduate OR University) | (Rural* OR Regional OR Remote) AND (Preceptorship OR clinical placement OR Rotation OR clinical training) | Whole OR Part | Rural practice OR Actual practice OR Practice location |
Inclusion | Exclusion |
---|---|
Peer reviewed articles published in English from any country | Articles not published in English and non-peer reviewed |
Focus medical education | Other health professionals/cohort not defined |
Published—post-1990 | Published—pre-1990 |
Professional entry medical education | Postgraduate courses for qualified doctors |
Continuing professional education | |
Continuing professional development | |
Specialisation | |
Quantified amount of medical education in rural location | Amount of medical education in rural location could not be quantified |
Study selection
Data charting and collation
Category | Typology |
---|---|
1 | Studies comparing rural work outcomes for rural versus urban campuses of the same university |
2 | Studies examining rural work destination of graduates of rural medical schools (i.e. medical education provided completely in a rural place) |
3 | Studies of the impact of partial rural medical education |
4 | Studies of impact of various durations of rural medical education on rural postgraduate internship |
5 | Studies that identify rural practitioners and investigate an association with rural medical education |
Authorship and location | Sample and method | Major findings | Discussion points/limitations |
---|---|---|---|
Brokaw et al. [42] USA: Indiana University School of Medicine (IUSM) | 2 487 IUSM graduates matched to American Medical Association Physician Masterfile to determine practice site. Students with first 2 years at eight regional campuses (n = 1 211) were compared with main city campus (n = 1 200). Multivariate logistic regression used. | Compared to city students, those who attended five of the regional campuses were more likely to practise in the region. Overall, attendance at any regional campus was a significant predictor of practice outside the city. | Regional campus students spent only first 2 years at regional campus. |
Crump et al. [41] USA: University of Louisville School of Medicine, Kentucky | 1 391 graduates (60 from rural Trover campus) matched to American Medical Association Masterfile to determine practice site. Compares students of rural Trover campus with main city campus students. Descriptive frequencies, percentages, means and standard deviations calculated. | Trover graduates were six times more likely to choose a non-metro area as a practice site (p = 0.001). | Students self-selected and were then interviewed. 68% of Trover students were from a rural hometown. |
Authorship and location | Sample and method | Major findings | Discussion points/limitations |
---|---|---|---|
Inoue et al. [43] Japan: Jichi Medical School (JMS) | 1 871 JMS graduates. Postal survey. | ‘Almost 100%’ response. 792 (42%) graduates working in rural prefectures. | Cannot compare with other Japanese medical schools as data not collected. Entrance exam focused on students intending to return to home prefecture. |
Magnus and Tollan [44] Norway: Tromso School of Medicine Northern Norway | 417 Tromso graduates. Postal survey. | 84.2% response. 56.1% were working in ‘remote areas’/Northern Norway. | 43.3% were reportedly raised in Northern Norway. |
Sen Gupta et al. [32] Australia: James Cook University | 530 JCU graduates. Longitudinal cohort study of graduates. | 1–7 years following graduation. 59% worked rural at some point compared with 40% metro. | Approximately 14% had a bonded scholarship. Those with rural hometown and rural internship were most likely to work rural. |
Stratton et al. [45] USA: University of North Dakota School of Medicine (UNDSM) | 2230 UNDSM graduates postal survey. | 41% response. 29.5% work in communities of 25 000 or fewer people. | Study focused on impact of curriculum expansion on retention of North Dakotan students in North Dakota practice following graduation. |
Author and location | Sample and method | Major findings | Discussion points/limitations |
---|---|---|---|
Forster et al. [61] Australia, University of New South Wales (UNSW) | n = 315. Retrospective online survey of graduates who spent 1–3 years of undergraduate training in UNSW Rural Clinical School. | 214 respondents (68%); 26% are currently working in rural. Incremental effect of 1–3 years of rural exposure. | Self-reported on type (e.g. rural) of current work location. |
Glasser et al. [51] USA: Illinois | n = 159. Effect of Rural Medical Education (RMED) Program and add-on curriculum of monthly sessions during the first 3 years of medical school and a capstone in the fourth year. Database on RMED students, graduation, location and specialty of residency. | Of the 103 grads in practice, 69 (67%) are in towns ≤20 000 or rural communities. | Does not compare with non-RMED or national data for rural practice. The RMED recruiter makes yearly trips to feeder schools to meet with sophomore, junior and senior students who have an interest in rural medicine. |
Halaas [54] USA Minnesota | n = 1 063. Rural Physician Associate Program (RPAP) graduates. RPAP is a 36-week community-based elective placing students in rural communities of 3 000–20 000. Method not specified. | 521 (62%) of RPAP students in practice at time of measurement were physicians in rural communities. | Does not specify where the data come from. |
Halaas et al. [54] USA: Minnesota | n = 1 175. Rural RPAP graduates. Used RPAP database and descriptive statistics. | 448/901 (49.7%) of currently practising graduates are in rural settings. 44% have practised in a rural setting all of the time. Proportion of RPAP graduates in rural settings is higher than 9% USA figure. | |
Jamar et al. [59] Flinders University Australia | n = 124. Retrospective study of graduates who completed a rural fifth year. | Response rate 74 out of 124 (58.2%). Eight years after graduation, 20.8%–34.1% were located rurally; average of 21.8% per year over this time. | Voluntary programme—those interested in rural practice may have biased results. Does not compare percentage working rurally with a non-rural cohort or with a national figure. |
Kane et al. [49] USA: University of Missouri School of Medicine | n = 168. Questionnaire of Summer Community Program graduates: second year medical students working with rural physician preceptors (4–8 weeks). | n = 78 (46%) were in rural practice for their first work location. Compared with non-participants, summer participants were more likely to work in rural locations for their first practice. 46% compared with 11% nationally that practise rurally. | Unable to compare participants with non-participants due to lack of full data set. |
Lang et al. [50] USA: Dept. of Family Medicine at East Tennessee State University | n = 134. Effect of 4-week summer elective clinical preceptorships in southern Appalachia. Database of practice locations linked with databases from medical schools and other sites. | Of the 134 former students whose practice locations were identified, 44 (33%) are in rural areas compared with 9% of all physicians. | Small numbers over an 18-year period. |
MacDowell et al. [52] USA: Illinois College of Medicine at Rockford | n = 160 RMED and 2 663 non-RMED graduates. Compared data on Rural Medical Education (RMED) Program and non-RMED students. RMED is add-on programme in years 1–4 plus 16 weeks in a rural practice in year 4. | 56.3% RMED graduates are working in small towns or rural communities. RMED graduates reported more than 17.2 times more likely to be currently practising in a rural location (excluded those in residency), compared with all other U. Illinois medical graduates. | |
Orzanco et al. [46] Canada: Universite de Sherbrooke (UdeS) and University of British Columbia (UBC) medical schools | n = 180 (UdeS), n = 194 (UBC). Linked students’ personal data and undergraduate MD programme to practice location data from the Canadian Post-MD Education Registry. Retrospective analysis with multiple regression analysis. | Significant difference in no. of weeks family practitioners practising in non-metro had spent in non-metro clerkships (p < 0.000 1). Median time 7.7 weeks compared with 3.9 weeks for those practising in other types of areas (UdeS). For UBC, none of those doing non-metro clerkship were likely to establish non-metro practice. | Length of clerkship in non-metro areas was the strongest predictor of location of practice for UdeS and ‘some’ relationship for UBC but small sample size. Noted lack of quality data. |
Playford et al. [60] University of Western Australia | n = 1 017 (258 from rural clinical school; 79 urban) Cohort study comparing those in a rural clinical school (fifth-year rural placement) and those not. | Of 258 rural clinical school graduates, 42 (16.3%) were working rurally compared with 36 of 759 (4.7%) in the non-rural clinical school control group. | Voluntary programme—those interested in rural practice may have biased results. Rural background did not have an independent significant effect. |
Quinn et al. [19] USA: University of Missouri School of Medicine | n = 48 rural programme graduates with n = 506 non-participants. MU-RTPP = summer community programme pre-second year, rural clerkship in third year and rural elective in fourth year. Tracked all participants of MU-RTPP, using database of postgraduate specialty training, practice locations and professional and public sources such as Board of Medical Specialties databases. | 57.4% of graduates from MU-RTPP cohorts chose to practise rural or mixed rural county. Over 57% chose a rural location for their first practice. Compares 57.4% with 9% it states work in rural nationally. | Unable to make comparisons with non-participants because data incomplete. |
Rabinowitz [55] USA Philadelphia Jefferson Medical College | n = 148. Data of current practice locations of graduates in the Physician Shortage Area Program (PSAP). PSAP required third-year clerkship at one of two non-metro locations. | PSAP graduates were around four times more likely than non-PSAP to practise in rural areas 39% vs 11%. | |
n = 206. PSAP graduates. Retrospective cohort study 1978–1991. Using data from JMC Alumni Association to tracked PSAP and non PSAP graduates at Jefferson Medical College. | PSAP graduates were 32/150 (21%) of family physicians practising in rural Pennsylvania who graduated from one of the state’s seven medical schools although they are only 1% of graduates from those schools. 68 (34%) of PSAP grads were practising rurally anywhere in USA compared with 303 (11%) of non PSAP. | ||
Rabinowitz et al. [57] USA: Pennsylvania Jefferson Medical College | n = 38 PSAP graduates and 54 non-PSAP graduates, 11–16 years after graduation. Longitudinal follow-up of PSAP graduates. | After 11–16 years, 26/38 (68%) PSAP graduates were practising in the same rural area, compared with 25/54 (46%) non-PSAP (p = 0.03). Survival analysis showed PSAP graduates practise in the same rural locality for longer than non PSAP (p = 0.04). | |
Smucny et al. [58] USA: New York State | n = 132. Rural Medical Education (RMED) Program graduates. RMED is 36-week clinical experience in rural communities in year 3. Physician masterfiles of American medical Association to compare practice locations for RMED with non-RMED used. | 76 RMED graduates (58%) completed the questionnaire. 56/69 (81%) had completed postgraduate training. 26 % of RMED practised in rural areas (22/86), compared with non-RMED 95/1307 (7%). | 59% RMED respondents considered their home town to be rural. |
Strasser et al. [22] Australia: Monash University Bachelor of Medicine/Bachelor of Surgery Programme | Number of questionnaires distributed is not given. Retrospective cohort mail survey of four groups of students with different rural/urban background and experiences in rural medical education. | n = 243 responding higher mean in total number of weeks of rural placement was associated with a current practice location in a rural community rather than an urban community (p = 0.05), but not with first practice location (once vocationally qualified) (p = 0.16). | Author reports that rural/urban background had a significant interaction with all of the main outcomes except current place of practice. |
Williamson et al. [19] New Zealand: Otago University Faculty of Medicine | n = 367; 293 after exclusions. fifth-year medical students from 2000–2001 were identified by the enrolment and alumni records. Study cohorts from three campuses (one of which has a 7-week undergraduate ‘rural health course’) were posted a questionnaire. Non-responders were followed up. | 177 (63%) returned, of which 30 were ‘Gone, no address’, leaving 147 (50%). There was no significant difference among schools in the proportion of students working in rural areas. | Small numbers and 50% response. Content of the 7-week course is not described, although described as a ‘rural rotation’. |
Author and location | Sample and method | Major findings | Discussion points/limitations |
---|---|---|---|
Clark et al. [22], Australia, University of Sydney | n = 448 (98 had completed 32 weeks rural placement). Questionnaire on entry and exit from medical school. | 8.1 % accepted rural internship. Those that completed 32 weeks rural placement were twice as likely to accept rural internship (21.3% vs 9.9 %). | Those undertaking the long rural placement did so because they already intended to go rural. Students undertaking extended rural placement were more than three times as likely as those with rural backgrounds to express preference for a rural internship. (23.9% vs 7.7%; p = 0.008). |
Eley and Baker [63] Australia, University of Queensland | n = 28 completed questionnaire (in aggregate). Year 4 exit questionnaire of rural clinical school (RCS) programme and data on internship choice. Statistical tests compared answers to questions about experience of rural clinical school with internship choice. | Six out of 27 chose to return to their undergraduate placement hospital for internship. | No. of participants was too small to detect differences between sites. Lack of information about the hospital sites. |
Eley and Baker [64] Australia, University of Queensland | n = 27 Undergraduates exiting RCS programme. Questionnaire and data on internship choices. | 14/27 went to internships in large rural centres with 25 000-100 000 population in 2006. | |
Eley et al. [65] Australia: University of Queensland (UQ) | n = 180. A retrospective web-based survey of all graduates who undertook clinical year 3, year 4 or years 3 and 4 at UQ rural clinical school 2002–2006. | 124 replies (69% response). 29% working in rural places with population ≤100 000. Most important factor affecting rural workplace choice was spending 2, as opposed to 1, year at a rural clinical school. | 69 % response rate so maybe selection bias possible in that rural workers respond to a rural focused research project. Only 7% of interns were in places with ≤25 000 population. |
Eley et al. [65] Australia: Queensland | n = 631 internships. Analysis of number, source and location of interns by rural classification from university and health department records (2003–2008). Compared University of Queensland (UQ), UQ Rural Clinical School (UQRS) and James Cook University (JCU), which it implies is defined as equivalent to UQRS. | Rural clinical schools (JCU/UQRCS) were more likely to supply interns to hospitals in places with ≤100 000 than to major city hospitals.(OR, 8.8; 95% CI, 4.6–16.7; p < 0.000 1; OR, 6.5; 95% CI, 3.5–12.2; p < 0.000 1) | Study focus is on producing interns for Queensland from Queensland Universities. |
McDonnel Smedts and Lowe [67] Australia: Flinders University Northern Territory (NT). | n = 452. Statistical analysis of de-identified data from a database of place of internship and medical registration of Flinders medical graduates 1999–2005. | Those doing final year in at NT clinical school were more than 10 times more likely to complete their residency in NT (54 % did so). | If students were from NT and attended NT clinical school, 70% completed residency in NT. |
McDonnel Smedts and Lowe [68] Australia: Northern Territory Clinical School of Flinders University | n = 683. Retrospective analysis of medical school and hospital data on all medical students who completed a placement with the Northern Territory Clinical School (NTCS) between 1998 and 2007. | Placement length was a significant predictor of an NT internship (p < 0.05; OR, 1.08; 95% CI, 1.07–1.09). | Did not identify whether medical students had a rural background. |
Playford and Cheong (2012) [27] Australia: University of Western Australia | n = 490. Undergraduate data were linked with postgraduate placements to provide dataset on rural exposure history of junior medical practitioners. | Participation in a longer rural placement at RCSWA was associated with significantly more postgraduate year 1 rural work compared with a short placement alone (OR = 1.5, CI 0.97–2.38). | Interns are classified as working in rural if they do 4 weeks in rural out of the year. This is a very short amount of time to classify as rural. Rural-origin practitioners were more likely to take rural rotations in postgraduate years. |
Sen Gupta et al. [66] Australia: James Cook University (JCU) Queensland and other Australian medical schools. | n = 292. Exit survey of JCU graduates compared with Medical Students Outcomes Database data for eight other, largely metropolitan, schools. | 67% of JCU graduates undertook their internship outside a metropolitan centre compared with 17% of others (OR: 10.0), and 47% in outer regional centres compared with 5% of others (OR: 16.6). | 46% of JCU graduates intend to practise in outer-regional, remote or very remote areas, compared with 15% for other Australian universities. |
Author and location | Sample and method | Major findings | Discussion points/limitations |
---|---|---|---|
Pathman et al. [71] USA | n = 456. Two postal surveys of primary care physicians who had moved to rural practices 1991 and 1996–1997. Considered where and when attended medical school and number of months in rural as a medical student. | 456 responded to both surveys (69%). More than half of those working rurally had participated in rural rotations as students. | Included only those who were working in rural areas. |
Rourke et al. [70] Canada | 507 rural family practitioners in Ontario Medical Association, compared with 505 randomly selected from practising in places with population >50 000. Postal survey. | Response of 484 (47.8%); 264 rural, 179 urban. Rural were 1.8× more likely to have spent ≥8 weeks in a rural setting during undergraduate medical training compared with urban. | |
Rosenblatt et al. [72] USA | 1 991 practice locations of USA medical graduates 1976–1985. Practice location determined using American Medical Association masterfile, includes year and place of medical school and current practice location. | 12.6% were practising in rural areas. Much variation between medical schools: University of North Dakota highest (41.2%). 12 medical schools produced over 25% of graduates working rurally. Strongest association was between % of graduates working rurally and rurality of state where medical school is located. | Study focused on all medical graduates and then clustered programmes by rural state. No specific focus on location of education within the states. |
Rolfe et al. [73] Australia: University of Newcastle Medical School | n = 217. Linked graduate data from a survey with Faculty of Medicine admissions database. Cross-sectional survey of University of Newcastle medical graduates. | 226 (68.3%) response. After exclusions 162/217 (75%). 22% of post-interns working in rural. Those who chose a rural location for the general practice attachment were 3.02 (95% CI: 1.25–7.32) times more likely to be working in a rural area than those who chose an urban location. | Limitation students chose year 5 attachment. There was a significant relationship between a rural background and currently practising there. |