Abstract
Introduction: This longitudinal tracking project by the University of Queensland Rural Clinical School (UQRCS) provides data on the early career pathways of alumni since its inception in 2002. Specifically we report on; (1) perceptions of the UQRCS regarding its influence on current career choice, (2) current speciality choices, and (3) factors that influenced these choices.
Methods: A retrospective web-based survey of all graduates who undertook clinical Year 3, Year 4 or Years 3 & 4 at UQRCS from 2002 to 2006. Associations with demographics, Year(s) at UQRCS, current workplace and speciality choice were assessed.
Results: Response rate was 69%, (N = 180). Alumni who spent two years (Years 3 & 4) at UQRCS reported significantly higher degrees of encouragement to pursue a rural career. Alumni currently working in a non-urban location had spent two years at UQRCS and were significantly higher in desire to remain rural. ‘Time spent at the UQRCS’ contributed most to interest in a rural career. General practice and emergency medicine were most preferred specialities.
Conclusions: Findings confirm that a longer rural clinical experience is more effective in eventual choice of workplace location and future interest in a rural career. This corroborates the positive impact of Australian rural clinical schools toward rural medical workforce improvement.
Introduction
The Rural Clinical Schools initiative established by the Australian government in 2000–2001 have provided an opportunity for medical students to undertake their clinical training across a network of hospitals, general practice surgeries and community medical centres in rural/regional locations throughout Australia. The primary goal of this national program is to improve rural medical practitioner workforce recruitment and retention.
Rural Clinical Schools (RCS) are now established in 14 medical schools throughout Australia (Australian Government Department of Health and Ageing 2002). Definitive evidence for an impact of the RCS on the shortage of rural doctors is dependent on the longitudinal nature of this initiative. Cross sectional studies assessing short term factors such as internship choices and attitudes towards future rural practice have been reported with encouraging results (Eley & Baker Citation2007; Playford et al. Citation2008; Worley et al. Citation2008).
The RCS at the University of Queensland (UQ), is part of the School of Medicine's 4-year graduate MBBS (Bachelor of Medicine Bachelor of Surgery) program. Year 3 and Year 4 students may elect to train for one or 2 years in the UQRCS, which provides four clinical training sites throughout regional/rural Central and Southwest Queensland. The first UQRCS cohort of 2002 is now 5 years in the workforce.
The aim and objectives of our longitudinal study are twofold. The first stage was a retrospective cohort study to track RCS alumni workforce participation patterns since graduation. The second stage entails a prospective longitudinal study to establish and maintain a UQRCS alumni to track their career pathways and vocational choices. This longitudinal design will monitor changes and trends in their workforce participation patterns and allow comparison of succeeding cohorts regarding their reasons behind career choice and factors predictive of those choices.
It is acknowledged that career choice depends on a myriad of individual differences and is governed by internal attributes which develop over time. Four sources of individual differences are recognised that influence this choice; personality traits, career interests, values and attachments styles (Ng et al. Citation2007). An exploration of these sources of individual difference alongside our tracking project would provide a deeper understanding of reasons behind career choice but is beyond the scope of this study.
This paper reports on results of the first stage of this project. Specifically we address the following questions of the UQRCS alumni; (1) what are their perceptions of the UQRCS regarding its influence on their current career choices, (2) what are their current speciality choices and (3) what factors impact on these choices after graduation?
Methods
In September 2007, contact details (primarily email addresses) for all UQ MBBS graduates who spent either, Year 3 only, Year 4 only or Year 3 and 4 at the UQRCS from 2002 to 2006 were collated. The total eligible alumni were 277. Exhaustive attempts provided contact details for 180 (65%) and all were invited to participate via email which gave immediate access to the survey.
A survey was developed incorporating long standing items from internal UQRCS evaluations (Eley & Baker Citation2006) and previous studies (DeWitt et al. Citation2005). A core set of demographic questions (age, sex, marital status, children, education, rural background, rural experience and current job title) along with details of their internship and current workplace location choices since graduation were asked. Location throughout this study uses the Rural Remote Metropolitan Classification (RRMA) system (AIHW Citation2005) based on population numbers and an index of remoteness. Seven categories are included in this classification: two urban RRMA1–2; three rural RRMA3–5 and two remote RRMA6–7.
Data were analysed with SPSS 14 (SPSS Inc, Chicago, IL USA). Descriptive statistics summarised the data. Associations with current workplace, internship location and speciality preference were assessed by univariate analysis using Chi square for categorical variables and ANOVA for continuous variables.
Ethics approval was obtained from the UQ Behavioural & Social Sciences Ethical Review Committee.
Results
Response rate
A total of 180 former UQRCS students were invited to participate and 124 replies were received resulting in an overall response rate of 69%. There were 56 (50%) respondents who reported attending Year 3 only, 14 (12%) who attended Year 4 only and 43 (38%) who spent both Years 3&4 at the UQRCS.
Demographics
Demographics of the respondents are shown in and are not significantly different from the full UQ MBBS cohort. Overall, the younger age group (25–29 years) are the majority and 52% were males. There were significantly (X2 = 19.7, df = 6, p < 0.003) more younger students (25–29 years) who attended Year 3 only compared to Year 4 only and Years 3&4. All respondents did their undergraduate degree in Australia and 85% were Australian born. Rural background was determined by two questions; one asked if they were from a rural background (yes/no). The other, rural experience, asked more specifically when and for how long they lived rural (Somers et al. Citation2007). This was reported most frequently (21%) as 10 years or more in combination as a child (5–18 years) and as an adult (over 18 years). Current job title is distributed nearly equal across intern, junior house officer (JHO) and registrar positions. The majority (41%) of UQRCS respondents are currently working/training in a RRMA1 location, with 28% in RRMA2, 22% in RRMA3 and 7% in RRMAs4–7. Collectively, UQRCS alumni currently in non-urban locations (RRMAs3–7) comprise 29% of all respondents.
Table 1. Demographics of sample by MBBS year
Impact of the UQRCS
Four questions required participants to recall how the UQRCS influenced alumnus degree of interest in pursuing a rural career. All questions used a Likert scale of 1–5. The overall mean response (1 = greatly discouraged to 5 = greatly encouraged) to the question; ‘how did your time at the UQRCS alter your desire to pursue a medical career in a rural or remote location?’ is 3.75 (n = 113; SD = 0.81). There was no difference by age or sex but a significant difference (F = 13.839, df = 1; p < 0.000) between rural background and non-rural background alumni was detected. A two-way ANOVA also showed a significant main effect for rural background and no interaction (F = 7.18, p < 0.009; η2 = 0.062). Levene's Test showed equal variance. Comparison of this question by internship choice showed that the responses of UQRCS students who choose a RRMA1 internship were higher (F = 4.826; df = 2; p < 0.010) than those who chose RRMA2 or 3 internships in their feeling that the UQRCS altered their desire to go rural. Comparison by MBBS year showed that alumni who spent 2 years at the UQRCS rated this question significantly higher (F = 6.044, df = 2, p < 0.003) in comparison to those spending only 1 year ().
Table 2. Influence of the UQRCS on desire to pursue a rural medicine career
Overall mean response (1 = no interest to 5 = definitely interested) to the question; ‘what degree of interest do you have in practicing in a rural or remote area in the future?’ is 3.56 (n = 91; SD = 1.30) with 11 respondents (10%) reporting they already practice rural. The only difference in this response detected between other variables was for ‘current workplace location’. UQRCS alumni who are currently working in RRMA3 locations have a stronger interest in working in a rural/remote location in the future (F = 2.281; df = 8; p < 0.05) compared to those working in other RRMA locations. shows respondents’ reported degree of interest by MBBS year. Year 3 alumni (21%) are most undecided about going rural, followed by Year 4 (14%) with Years 3&4 reporting the least indecision (10%). It is noteworthy that the majority of those alumni already practising in rural areas spent 2 years (Years 3&4) rather than one at the UQRCS.
Table 3. Degree of interest in practicing rural medicine in the future
The mean response (1 = strongly disagree to 5 = strongly agree) for the statement; ‘in retrospect, I would still choose to study at the UQRCS’ is 4.51 (SD = 0.62) with 96% (n = 111) in agreement (agree or strongly agree) that given the opportunity they would still choose to study at the UQRCS. There was no difference between any other groupings. A clear majority of alumni (n = 94, 94%), reported that ‘based on their experiences to date, they would recommend attending the RCS to other students’. One ‘no’ response was reported and five (5%) reported they would recommend the UQRCS ‘only if the student already had an interest in rural medicine’.
The factors that contributed to alumni interest in rural medicine are listed in order of priority in . The most frequent response (n = 57, 23%) was ‘time spent at the RCS’, followed by ‘having a rural background’ (n = 56, 22%) and ‘rural lifestyle’ (n = 56, 22%). There was no difference in this ranking by age, sex or MBBS year. Highest ranking response by males was ‘time spent at UQRCS’ and by females ‘rural background’. Among Year 3 and Year 4 respondents, ‘time at the UQRCS’ ranked highest but ‘lifestyle’ and ‘rural background’ were reported as the most important by Years 3&4 alumni. Other factors cited included scholarship, generalist/procedural aspect, rural medicine rotation, rural health club, diverse patient range, challenge and rewarding work.
Table 4. Factors that contributed to interest in rural medicine
Speciality choice
shows the most preferred specialties across all respondents were General Practice (18%) and Emergency Medicine (13%). There was no significant difference between groups. Of note is that these specialities were also most preferred across all MBBS groups and General Practice was most often chosen by both sexes. Rural Medicine (an emerging area of specialisation) was chosen by 6% of all respondents.
Table 5. Speciality preference across all respondents
Discussion
These findings are part of a longitudinal tracking study that has presented self-reported perceptions of impact of the UQRCS on former graduates’ reasons for their early career choices. Important factors to consider and compare among our sample of respondents include the amount of time spent at the UQRCS (i.e. MBBS Years 3, 4 or 3&4) and current workplace/training location.
Our findings indicate that overall the UQRCS had a positive impact on UQRCS graduates’ interest and desire to pursue a rural career, which is supported by the 29% of all respondents currently working/training in non-urban (RRMA3–7) locations. Significantly higher encouragement was reported by graduates who spent 2 years (Years 3&4) at the UQRCS or have a rural background. Unexpectedly, those who chose a RRMA1 internship were also significantly encouraged to go rural. There could be a myriad of reasons for this result but it might be important to consider that this is a reflective account and as such is likely to be independent of choices made at an earlier time. Irrespective of the reason, this finding is positive and achieves the objective of providing rural clinical exposure and promoting informed choice for students regarding early careers.
The current degree of interest in practicing rural medicine sometime in the future was rated moderately high across all respondents and groupings. The only difference was detected among graduates currently working in a non-urban location who were significantly higher in their degree of interest to remain in a rural area, compared to those currently working in urban locations. It was also noteworthy that the majority of those graduates already practicing in a rural location had spent two years at the UQRCS.
The most frequent response regarding the factors that contributed to an interest in rural medicine was ‘time spent at the UQRCS’. This is a clear indication of the positive influence of the Australian rural clinical schools initiative. Speciality choice among all respondents showed a preference for general practice followed by emergency medicine. These results are also encouraging and in line with the relevance of these two speciality areas to rural medical practice.
Our results are in agreement with reports of intended future career choices by students in other rural clinical schools, although we saw no significant differences due to the age of our respondents (Worely et al. Citation2008). Our findings suggest that the most important factors regarding positive perceptions of and interest in rural medicine are spending two as opposed to 1 year at the UQRCS, a non-urban current workplace location and rural background. These results confirm what has been consistently reported in the literature regarding the influence of a rural background (AMWAC Citation2005; Laven et al. Citation2003; Laven & Wilkinson Citation2003; Somers et al. Citation2007; Woloschuk & Tarrant Citation2004) and what is increasingly being provided by recent studies, that is, more rural experience and clinical exposure (Wilkinson et al. Citation2003; Nichols et al. Citation2004; Peach et al. Citation2004; Tolhurst et al. Citation2006; Critchley et al. Citation2007; Eley & Baker Citation2007; McDonnel Smedts & Lowe Citation2007; Playford et al. Citation2008).
A limitation to the study is that we could not contact all former UQRCS students. Irrespective of this, we obtained a 69% response rate. In addition to the possible bias of self-report data, there may be a self-selection bias regarding those who responded although the demographics of non-responders were not different than responders in our sample. It is possible that the response rate reflects in part, a lower interest in the rural focus of the project and confirms a bias of the study. The time to complete a questionnaire by busy doctors may exacerbate this (VanGeest et al. Citation2007). Further follow-up and contact with our alumni continues and in time a more complete sample and picture of the vocational career paths of our students will be evident.
Conclusion
Our study has tracked and surveyed former graduates in their current vocations post graduation. Determining what variables are predictive of choosing a rural workplace location will only be evident through longitudinal studies extending over many years – of which ours is at a very early stage. In particular we confirm that the length of time spent at our rural clinical school is related to eventual rural practice and increased interest in a rural career.
This finding is important in light of the increasing intake of students facing medical schools in next few years which is already putting a strain on resources and teaching capacity. In particular rural clinical schools must find ways of maintaining their level of quality rural clinical teaching in the face of ever increasing students but a static teaching supply (Eley et al. Citation2008). Decisions regarding the length of rural clinical exposure offered to students will be heavily influenced by this situation and if compromised, pose a threat to the quality of rural clinical education on offer and the overall effectiveness of the rural clinical schools initiative.
This is another dilemma facing rural clinical schools and one which further threatens the shortage of the rural medical workforce in Australia.
Acknowledgement
The authors wish to thank Mrs Erin Bowly and Mrs Beverly Hadfield for their assistance with the data collection for this project.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
Additional information
Notes on contributors
Diann Eley
DIANN ELEY, MSc, PhD, is the Director of Research, Rural Clinical School, School of Medicine, The University of Queensland, Locked Bag 9009, Toowoomba, QLD, Australia.
Peter Baker
PETER BAKER, ChB, MD, MEd, FRCP, FRACGP, FACRRM, is the Head of Rural Clinical School, School of Medicine, The University of Queensland, Locked Bag 9009, Toowoomba, QLD, Australia.
Bruce Chater
BRUCE CHATER, MBBS, [Hons UQ], FACRRM, FRACGP, DRANZGOG [ADV] is an Associate Professor and Head of the Discipline – Rural and Remote Medicine, Rural Clinical School, School of Medicine, The University of Queensland, Rockhampton, QLD, Australia.
Related Research Data
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