Aust. J. Rural Health (2014) 22, 63–67

Original Research Rural experience for junior doctors: Is it time to make it mandatory? Casey Jane Rowe, BSc, MBBS,1 Ian S. Campbell, MBBS, MPH&TM, PGDipSurgAnat,2 and Lynton Ashley Hargrave, MBBS3 1

School of Medicine, University of Queensland, Brisbane, Queensland, Australia, and 2Royal Brisbane and Women’s Hospital, Butterfield St, Herston, QLD 4006, and 3Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD 4215

Abstract Objective: To determine whether rural practice terms for junior doctors result in increased interest in rural practice and whether these terms improve learning experiences, clinical skills and insight into difficulties of rural practice. Design: Semistructured, self-administered survey with questions on respondent demographics, clinical experience during rural practice terms, post-rural experience and personal opinion. Setting: South East Queensland. Participants: Thirty junior doctors from three tertiary hospitals were approached. The response rate was 100%. Main outcome measures: Exploration of junior doctors’ rural term experience. Results: Two thirds (67%) of the respondents reported feeling uncomfortable with respect to clinical practice requirements during their rural terms. Half (47%) performed procedures they had only previously performed in simulation environments, and the majority (87%) relied on textbooks or other resources on a daily basis. Two thirds (67%) changed aspects of their usual clinical practice while practising in a rural setting, and 80% reported a change in attitude towards the hardships faced by rural practitioners. The majority of the Correspondence: Dr Casey Rowe, University of Queensland Centre for Clinical Research, Building 71/918, Royal Brisbane and Women’s Hospital Campus, Herston, QLD, 4029. Email: [email protected] Institutions involved: Gold Coast Hospital, 108 Nerang St, Southport, Queensland 4215 Princess Alexandra Hospital, Ipswich Rd, Woolloongabba, Queensland 4102 Royal Brisbane and Women’s Hospital, Cnr Butterfield St and Bowen Bridge Rd, Herston, Queensland 4029 Accepted for publication 4 November 2013. © 2014 National Rural Health Alliance Inc.

respondents (87%) enjoyed their rural term, gaining confidence as a result of it, and more than half (53%) reported considering working in rural areas in the future. Conclusions: The results of this survey suggest that junior doctors on rural rotations are required to perform at a clinical level higher than that required of them in metropolitan hospitals. While their clinical experience appears to result in a greater interest in future rural career possibilities for junior doctors, this survey highlights the requirement to improve support for junior doctors undertaking terms in rural areas. KEY WORDS: Australia, education, health service accessibility, Queensland, rural health service.

Introduction Rural and remote areas in Australia and also worldwide are faced with the major problem of health worker shortages. This maldistribution of health professionals as well as lack of health services in these rural areas, combined with other factors including socioeconomic status and level of education, poses a significant impact on health outcomes.2 As evidence of this, life expectancy is shorter in rural and remote areas of Australia compared with major cities.3 Also, morbidity is increased, with a higher level of illness and health risk factors among people living in rural and remote areas.4 While the cause of these discrepancies is multifactorial, it is clear that there is a requirement for improvement in health care provision in these areas, including through the attraction and retainment of health workers. It is widely published in the literature that having a rural background, as well as being exposed to rural health issues during medical training, have a strong positive influence on junior doctors’ future willingness to work in a rural area.5,6 This concept is described as the ‘rural pipeline’.5 Australia currently has compulsory 4-week minimum rural placement requirements for doi: 10.1111/ajr.12082



What is already known on this subject: • Only one small study to date has examined attitudes of junior doctors on rural practice terms, with this study focusing on multiple key stakeholders including medical administrators, medical educators and directors of clinical training, as well as junior doctors.1 • No study has examined what skills junior doctors are performing on their rural practice terms. • No study has asked junior doctors if rural practice terms should be compulsory.

What this study adds: • This survey highlights that junior doctors find rural practice terms to be challenging, although beneficial to their training. It also reveals that rural practice terms result in a change in junior doctors’ care of rural patients in metropolitan hospitals and can help to foster a desire to practice rural medicine.

questioned if rural terms should become a core compulsory term for junior doctors. medical students.7 One study has explored the opinion of senior medical students on their rural placements completed when they were junior medical students, finding that the majority of those senior medical students surveyed accepted the importance of rural placements.8 A review article from 2000 outlined a multitude of benefits of rural practice placements for medical students, including the significant educational advantages as well as the increased exposure to both community and hospital caseloads, relevant medical conditions and procedures when compared with students remaining at urban hospitals.9 Our paper, with the use of a selfadministered survey, focuses on the impact of rural exposure for junior doctors through rural practice terms completed during their residency years. The Rural and Remote Area Placement Program was established in 2000 with the objective of providing junior doctors the opportunity of training in rural community practice in their first three years following graduation.10 While not a compulsory term, it is now accepted that in metropolitan hospitals in South East Queensland, junior doctors from their second postgraduate year (PGY) and above can undertake a term in rural practice for 5–12 weeks, in both community and hospital settings. It has been noted that at times, junior doctors complete their rural practice terms as relievers in solo doctor towns.1 While there have been studies evaluating the influence of rural exposure (particularly during medical school training) on junior doctors’ decision making about future training and careers,5,6,10 to date, only a single small study has examined the overall impact this experience has on the junior doctors involved.1 In particular, no paper has focused on examining the actual experiences and difficulties faced by junior doctors during their rural practice terms, or the resultant change of clinical practice and opinions upon their return to metropolitan hospitals following these terms. No paper has

Methods Ethics approval for this study was gained through Gold Coast Hospital Ethics Committee. A semistructured, self-administered survey was used, comprising closed questions, aimed at exploring junior doctors’ rural clinical experiences (Table S1). In November 2011, 30 junior doctors, 10 each from three tertiary hospitals in South East Queensland (Gold Coast Hospital, Princess Alexandra Hospital and Royal Brisbane and Women’s Hospital) were approached by local representatives to complete the survey. These 30 doctors were selected for participation based on having completed a rural practice term within the prior 12 months. Doctors that agreed to participate were provided with the survey papers to complete independently, with the opportunity to ask questions if required. Survey answers were quantified and analysed.

Results Demographics In November 2011, a total of 30 junior doctors responded to the survey, with a response rate of 100%. The majority (77%) of the respondents were PGY2, 7% were interns, 3% were PGY3 and the remainder were PGY4 or above. Fourty-seven per cent of the respondents were in the 27–29 year age bracket. Sixty per cent (60%) of the respondents were men. The majority (80%) of junior doctors surveyed spent at least 4 weeks working in a rural setting, and 70% of the respondents reported relieving a regular medical practitioner from the area during their term. One third (33%) of the respondents were placed as the sole practitioner for the area during their term, and only one third (33%) had prior rural clinical experience. © 2014 National Rural Health Alliance Inc.



Rural practice term experience Of the respondents, 87% had relied on textbooks daily to assist in clinical decision making during their rural practice term. Almost all (97%) of those surveyed had contacted retrieval services or doctors at other hospitals during their rural term to assist in clinical decisions, with half (50%) of the respondents requiring assistance on more than five occasions during their term. Two thirds (67%) of those surveyed admitted to feeling outside of their comfort zone at least once during their rural term, and almost two thirds (63%) performed procedures that they had only previously witnessed being performed. Almost half (47%) of the respondents were required to perform procedures that they had only previously performed on a mannequin or during a clinical simulation scenario, including the skills shown in Figure 1. A minority of the respondents (13%) reported performing procedures during their term that they had neither previously performed nor seen performed before. Two thirds (67%) of those surveyed reported having varied their usual patient management plans during their rural practice term because of the difficulties and limitations of practicing in a rural setting.

Post rural experience and personal opinion The majority (87%) of those surveyed enjoyed their rural practice term. However, one third (30%) reported


feeling that their level of training had not adequately prepared them for their rural term. Almost all (97%) reported that their confidence had improved in terms of patient management upon return to their metropolitan hospital, as a result of their rural clinical experience. Also, following their rural terms, almost two thirds (60%) of those surveyed reported a change in their discharge planning of rural patients seen at their metropolitan hospitals, and over 80% reported a change in attitude towards the difficulties faced by rural practitioners. More than half (53%) of the respondents reported considering pursuing a career as a medical practitioner in a rural area following their rural term. The majority (80%) of the respondents considered that rural terms should become a core requirement during residency, highlighted in Figure 2.

Discussion While the results of this study highlight some of the benefits of rural practice terms for junior doctors, it also becomes apparent from the results that there are a number of controversial aspects of placing junior doctors in these rural positions. Firstly, of particular note, a surprisingly large proportion (33%) of the junior doctors surveyed were sole practitioners in the areas they were placed. Secondly, junior doctors on rural terms were required to perform clinical duties (Fig. 1) with less supervision compared with their prior

Graph showing procedures reported to have been performed by respondents during their rural rotations.

© 2014 National Rural Health Alliance Inc.


FIGURE 2: Survey response to question ‘Do you think that a rural term should be a core requirement?’ (( ) yes; ( ) no.)

experiences from working in metropolitan hospitals, placing them outside of their comfort zone. While orientation courses aimed at refreshing procedural skills have been implemented at the three hospitals involved in this survey, and are compulsory for junior doctors to attend prior to their rural practice terms, a large proportion of the respondents (33%) still felt inadequately prepared for their experience. The possible negative implications for patients in these rural settings need to be considered in light of these findings. It has been previously reported that trauma patients have a better outcome when seen by consultant emergency physicians when compared with junior doctors, and a stepwise improvement in patient outcome with increasing grade of doctor is observed in one study from the United Kingdom.11 Similarly, Bhonagiri et al. showed that there was increased mortality associated with admission to intensive care units in times where senior staff are not present.12 The discrepancies in patient outcome described in these studies should be acknowledged when considering placement of junior doctors in areas where there lacks the support of more senior practitioners. It is interesting that despite the potential professional isolation and the requirement to perform with less or no supervision, the majority of the respondents found the overall experience of their rural term enjoyable. Rural terms provide a valuable learning opportunity for junior doctors, reflected by respondents reporting an increase in confidence in clinical management and procedural skills upon returning to their usual workplace. As seen by the results, rural rotations provide junior doctors with a valuable insight into the difficulties of rural practice, and their rural experience can lead to a change in the management and discharge planning of rural patients admitted to metropolitan hospitals. A hypothesis might be that this change may be due to the recognition of possible consequences associated with premature discharge of a rural patient,


in light of a more thorough understanding of the limited resources available in rural areas as well as the isolation faced by these patients. There was a change in attitude towards the difficulties faced by rural practitioners reported by many respondents, and this may be partly explained by the fact that only a minority (33%) of the respondents had any previous rural experience. One of the most interesting results from this study was that the majority (80%) of the respondents considered that rural terms should become a core requirement during residency. Currently, through the Australian General Practice (GP) training program, registrars must complete a minimum of six months training in a rural area.13 One study has explored the opinion of GP registrars following their compulsory rural term and found that while many of those surveyed reported an overall positive opinion of this compulsory term in terms of acquisition of clinical skills and knowledge, a small portion found the isolation of rural practice to be detrimental in terms of both professional development and also psychological wellbeing.14 It was also noted by this study that the compulsory nature of these rotations generated feelings of resentment among some of the GP registrars surveyed,14 which might also occur in junior doctors if rural practice terms were made compulsory. The results of this survey reinforce the concept of the ‘rural pipeline’, with more than half of those surveyed reporting consideration of a rural career following their rural term. Creating a compulsory rural practice term for junior doctors may aid in attracting them to pursue rural careers. As well as possibly helping to address the shortage of doctors in rural areas, compulsory rural practice terms would also provide a valuable educational advantage with greater exposure to relevant medical conditions and procedures, as supported by existing evidence.9 However, issues including provision of adequate supervision for junior doctors on rural terms must first be addressed. General consensus would remain that doctors PGY2 and below should not be located in a setting where they are the sole practitioner for that area. While this study is limited by a small sample size, it explores novel and unique aspects of rural experience among junior doctors. This small sample size of this study limits the ability to draw conclusions from the results in terms of whether rural practice terms should become compulsory for junior doctors. A further limitation is that the participants were recruited from only two closely located geographical areas (Brisbane City and Gold Coast City). Lastly, this survey was limited by the inclusion of only closed-ended questions and therefore did not permit the respondents to elaborate further on their rural term experiences. © 2014 National Rural Health Alliance Inc.



References 1 Smith DM. Barriers facing junior doctors in rural practice. Rural and Remote Health 2005; 5: 348 (Online). 2 Smith KB, Humphreys JS, Wilson MG. Addressing the health disadvantage of rural populations: how does epidemiological evidence inform rural health policies and research? The Australian Journal of Rural Health 2008; 16: 56–66. 3 Australian Institute of Health and Welfare. Life Expectancy 2002. [Cited 2013]. Available from URL: http:// 4 Australian Institute of Health and Welfare. Australia’s Health 2012. Australia’s health series no.13 [Internet] 2012. [Cited 2013], Cat. no. AUS 156. Available from URL: .aspx?id=10737422169 5 Henry JA, Edwards BJ, Crotty B. Why do medical graduates choose rural careers? Rural and Remote Health 2009; 9: 1083 (Online). 6 Rogers ME, Searle J, Creed PA. Why do junior doctors not want to work in a rural location, and what would induce them to do so? The Australian Journal of Rural Health 2010; 18: 181–186. 7 Australian Government Department of Health and Ageing. Evaluation of the University Departments of Rural Health Program and the Rural Clinical Schools Program. Canberra: Commonwealth of Australia, 2008. 8 D’Amore A, Mitchell EK, Robinson CA, Chesters JE. Compulsory medical rural placements: senior student opinions of early-year experiential learning. The Australian Journal of Rural Health 2011; 19: 259–266.

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9 Worley PS, Prideaux DJ, Strasser RP, Silagy CA, Magarey JA. Why we should teach undergraduate medical students in rural communities. Medical Journal of Australia 2000; 172: 615–617. 10 Nichols A, Worley PS, Toms L, Johnston-Smith PR. Change of place, change of pace, change of status: rural community training for junior doctors, does it influence choices of training and career? Rural and Remote Health 2004; 4: 259 (Online). 11 Wyatt JP, Henry J, Beard D. The association between seniority of accident and emergency doctor and outcome following trauma. Injury 1999; 30: 165–168. 12 Bhonagiri D, Pilcher DV, Bailey MJ. Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis. Medical Journal of Australia 2011; 194: 287–292. 13 General Practice Education and Training Limited. Australian General Practice Training Handbook 2014. Canberra: ACT, 2013. 14 Bayley SA, Magin PJ, Sweatman JM, Regan CM. Effects of compulsory rural vocational training for Australian general practitioners: a qualitative study. Australian Health Review: A Publication of the Australian Hospital Association 2011; 35: 81–85.

Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Table S1. Copy of: Rural Experience Survey for Junior Medical Officers in Queensland.

Rural experience for junior doctors: is it time to make it mandatory?

To determine whether rural practice terms for junior doctors result in increased interest in rural practice and whether these terms improve learning e...
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