Issue 48 / 16 December 2013

MORE intern and postgraduate training places are needed in regional and rural areas to build on the success of rural clinical schools in securing a sustainable rural medical workforce, says Australian College of Rural and Remote Medicine president, Professor Richard Murray.

Professor Murray, who is also dean and head of the School of Medicine and Dentistry at James Cook University in Townsville, told MJA InSight rural medical placement was one of several predictors of a rural medical career, but subsequent training opportunities were also essential.

“If [junior doctors] do not have the opportunity to pursue their subsequent training into a medical specialty from a base in a regional or rural area, then we have defeated ourselves”, he said.

Professor Murray was commenting on research published in the MJA that found rural clinical training through extended placements in rural clinical schools was more strongly associated with preference for and acceptance of a rural internship than rural background. (1)

The longitudinal study of three successive cohorts from the Sydney Medical Program at the University of Sydney found that students who had an extended rural placement were more than three times as likely as those with rural backgrounds to express a preference for a rural internship (23.9% v 7.7%), and more than twice as likely to accept a rural internship (21.3% v 9.9%).

Professor Murray said extended rural placements and rural background were single factors in what should be considered a complex set of interventions that interact to shape students’ later choice of a rural medical career.

“For instance, the fact that the proportion of Sydney Medical Program students with an interest in a rural career dropped from 20.7% on entry to the school to 12.5% on exit suggested that there were other factors at play — and room for all medical schools to do better”, he told MJA InSight.

Professor Murray said competition to secure city-based specialist training posts was leading to more subspecialisation in medicine and potentially driving even those medical students with a rural inclination to settle in the city.

To reverse this further, a focus on rurally based medical education was needed, he said, noting a recent call in the House of Representatives to increase intern and postgraduate training places in rural locations. (2)

“Unless active efforts are made to divert a reasonable proportion of [these graduates] to rural and regional areas, they will simply be shoehorned into big city teaching hospitals and we will end up with exactly the medical workforce we didn’t want and don’t need”, Professor Murray said.

Ben Veness, Australian Medical Students Association president, said the research supported anecdotal reports from many students — including those with initial reservations about rural living — who found rural placements very valuable.

A systematic review by James Cook University researchers, in the same issue of the MJA, found there was evidence of advantages for junior doctors doing rural and regional general practice placements to gain advanced skills in communication and professionalism, and autonomy in clinical management and decision making. However, there was less evidence of the development of clinical skills. (3)

The reviewers wrote that rural and regional general practice was likely to comply with the requirements of the Australian Curriculum Framework for Junior Doctors and provide “excellent learning opportunities in several domains of the curriculum”.

Mr Veness said there were many infrastructure hurdles to overcome in preparing rural general practice to fulfil this training role, but it could provide valuable rural-based training for junior doctors.

“We will see an increase in the diversity of training experiences right from medical school through to specialty training. Done well, this should increase exposure to the different types of patient presentations and treatment options, and assist providers in different settings to work as part of one team”, he said.

Professor Murray said rural general practice could provide an effective and flexible alternative to the traditional curriculum by rotation.

“This notion of a integrated clerkship and having a generalist experience where it depends on what comes through the door or what you are looking after in the hospital, probably is not only adequate in terms of covering the same competencies that you might have had on a traditional rotation, but probably better in that they are more engaged with their patients as human beings”, he said.

In an MJA editorial, Professor John Hamilton, emeritus professor of the University of Newcastle’s school of medicine and population health, wrote of the need for social accountability to also be included in medical education, and the role of rural placements in teaching aspects of social accountability. (4)

1. MJA 2013; 199: 779-782
2. Parliament of Australia Hansard 2013; Rural Clinical Schools, 2 Dec
3. MJA 2013; 199: 787-790
4. MJA 2013; 199: 722-723


Would you encourage medical students and junior doctors to undertake training in the bush?
  • Yes - if there is good support (65%, 71 Votes)
  • Yes - it's likely to be superior (22%, 24 Votes)
  • No - it's still too not good enough (13%, 14 Votes)

Total Voters: 109

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6 thoughts on “Nurture beats nature for rural career

  1. Genevieve Freer says:

    Students from a rural background were more likely to undertake extended rural placements (30%) acceptance) than  students from an urban background (21%)  in the  study at Sydney Uni. 

    9.9% of  all rural background students accepted a rural internship versus 7.3% of all urban background students . The study shows the highest rate of acceptance of rural internships was by rural background students who undertook ERP.

    So it appears to me that there are 2  positive predictors of accepting rural internships- (a) rural background and (b) extended rural placement.

    The alarming statistic, which has failed to attract any comment,  is that more than 92% of Sydney Uni medical students in the study do not accept rural internship.

    If rural medical schools are more able to supply interns to rural areas, should rural medical schools receive more funding than Sydney Uni and other urban medical schools?


  2. Ashraf Saleh says:

    Previous well-put comments notwithstanding, the greatest influence in the impetus for a medical practitioner to live and work in the bush is a combination of work-life sustainability, a positive team environment and career satisfaction. Birthplace, medical school rural placements, rural relieving terms and PGPPP are but a tip of the iceberg for actually being planted in the bush and establishing a rural medical career.

    Even with the finest initial experiences to inspire a young practitioner to uproot from the bigger centres to the smaller towns, a job entailing a large proportion of being on-call in a busy district hospital, or being unsupported in the workplace, creates an environment not conducive to long term tenure.

    Whilst these issues are chiefly determined by each medical practice and regional health service, they are important issues that will determine the overall appeal for a doctor to move from a city to a smaller town.

  3. Genevieve Freer says:

    Box 6 of the study shows the highest acceptance of rural placements was by students from rural backgrounds who also undertook extended rural placements .

    So I would suggest a better title for the article is “nurture plus nature beats no nurture of nature for rural career at the University of Sydney.”


  4. Scott Kitchener says:

    A interesting paper however the most interesting fact in my opinion was the translation rate from the rural program appeared to be down around 20%. Rural programs transplanting tertiary hospital term based approaches incidentally into regional areas are not really rural programs and probably cannot be expected to translate into rural careers.  Nevertheless, the authors did show that this was more effective than taking young rural people and indoctrinating them to the city to dampen their interest in returning to the country.

  5. Q402026@amamember says:

    in reply to the previous correspondent, I would contend that the statement “little action and leadership”could not be further from the truth in rural training. I am a rural gp of 25 years and I have witenessed a renaissance in interest in rural practice and rural training.

    I believe that strong leadership from a rural college (ACRRM), coupled with the efforts of rural clinical schools and regional training consortia in supporting students into longitudinal placements has created the right mix for an interest in rural practice.

    The Rural Generalist Program ,auspiced by Queensland health, recently doubled its intake with Minister Springborg’s announcement at the recent Rural Medicine Austrlaia conference. This program is a shining light in models to reinvigorate and revalue rural practice – General and specilaists alike.

    Sadly it is perhaps leaders in the Specialist  Colleges and their narrow protectionist world view coupled with stubborness to look at flexible training and innovative career paths that tie young clinicians to long years of competitive training for more restricted practices.

    It is these restricted practices that drive up the cost of health delivery, and they need to be challenged. Let our students tell us what they want they’re careers to look like, let them have more varied and diverse career paths, and let them not fall foul of the rhetorhic that Rural training is Inferior, nor that seeing a rare case makes you somehow a better diagnostician or clinician.

    The leadership and the action is there, its just many choose not to see or hear it…

  6. Joe Li says:

    Postgraduate training is a major issue if we are serious about rural workforce shortage.  Unfortunately I see almost nil action.

    We all know what getting specialist training is all about.  It’s about knowing everyone on the selection panel, having done research papers with them, do unpaid volunteer clinical/admin/research work, suck up to the big professors who push their weights around when it comes down to choosing 3 candidates from 300.  It’s not about your qualities, knowledge, etc.  It’s all about who you know.

    Unfortunately the tsunami of medical graduates has hit the registrar selection level now and many well-qualified senior residents have no registrar jobs to look forward to.  Going bush is a dead end to your medical career unless your aim is rural GP.  I used to be very enthusiastic about rural training, but I have been advising every medical student to avoid it like fire unless they want to be GPs.

    After getting into specialist training, one quickly finds that rural training is inferior because there are not enough rare cases which the various colleges require one to see.  Often one cannot fulfill all the modules/requirements in one major city hospital, let alone going out to little country hospitals.

    With the lengthiest training programs int he world, junior doctors then find themselves spending 15 years in the city trying to get their FRAC***.  We marry city partners, buy houses, etc.  It’s too hard to move.

    Then once one sub-sub-sub-specialises, one can not keep up skill base seeing rural general patients.

    Lots of issues to sort and little action and leadership.

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