Rural medical education has developed as a workforce-driven strategy in response to early evidence that most graduates pursued sub-specialty-focused careers in urban communities, not necessarily where they were needed most. In retrospect, this should be no surprise. Nearly all medical schools were in larger metropolitan centres, most medical students came from those large centres and clinical learning took place almost exclusively in large metropolitan teaching hospitals. Furthermore, most clinical teachers and role models were in metropolitan teaching hospitals and most PGY1 positions and postgraduate training positions were based in the same hospitals. While the academic ability, contribution to society and career success of graduates from this model was sound, it could be argued that the workforce needs of the 20%–30% of the population residing outside of metropolitan Australia have benefited less. Making a case for change was challenging. Concerns were raised about the potential to reduce the academic quality of applicants, the breadth and depth of clinical learning and the potential for imposing constraints on career choice. There were no formal barriers to rural careers—indeed many graduates entered rural practice because of interesting work opportunities that arose 1. However, there were less visible barriers—rural background students were less likely to be competitive in State-wide academic rankings and less likely to move to city-based medical schools immediately after completing secondary school 2. Those making the move were immersed in a large city culture that influenced the personal and social network development during the formative early adulthood stage of life. Furthermore, the surrounding professional culture often regarded non-metropolitan health care as inferior and a less desirable career option. Early rural medical education pioneers sought evidence to support change. Rural background medical students were shown to be much more likely to work after graduation outside of metropolitan centres 3. Clinical placements in both district hospitals and rural general practice were shown to be popular and of high quality 4, supporting the expansion of the healthcare system in outer suburbs and regional centres, where workplace cultures were different to the previous highly centralised model. The results have been truly amazing. Targets for rural background student selection have produced a more diverse medical student population. Several new medical schools and rural clinical schools (RCS) have been established in regional, rural and remote communities. Many students live and study in regional, rural and remote communities for substantial proportions, sometimes all, of their medical programs 5, 6. Prevocational and postgraduate training opportunities have also been expanded in regional centres, although this varies considerably by specialty 7. Rural generalism has been promoted and recognised as a specialty within general practice and has an improved career structure 8; a national pathway has been developed and is popular with recent graduates. The impact of workforce development is varied, with overall increases in the numbers of doctors in regional, rural and remote communities, but with some persistent substantial shortages 9. Has rural medical education now emerged as a coherent discipline or is it seen as a bunch of poorly defined initiatives that are applied inconsistently and achieve variable outcomes? Rural programs may look similar from the outside but, as with minestrone, vary considerably in both the ingredients and how and when they are added. These variations may produce differences in scope, location, duration and impact. Is there a single recipe that ensures success? If so, is there a single powerful ingredient or is success due to consistent application of a combination of initiatives, both national and local? To what extent do some initiatives overlap, resulting in co-linearity that may distort analyses? Are some of these initiatives proxies for ‘community connectedness’, a consistent thread that may support other initiatives that foster development of a rural community of practice 10? The literature reflects analyses that claim that single factors may be predictive, proving their value. One example is rural clinical school attendance, but is this an independent variable? It may be that rural community-connected students attend rural clinical schools for longer placements, so any predictive value reflects more than just RCS attendance. A key issue is the motivation for, timing and duration of the placements, which may be voluntary or ‘conscripted’, vary from a few weeks to three years and may be either early or late, probably with differing degrees of associations with later rural career choice. In summary, voluntary and longer placements have stronger associations 11. Rural background is another difficult to unravel concept—how long and at what period of life is living in rural communities supportive of rural career choice? Rural background in medical students can also be ‘watered down’ unless supported by rural placements 11. Behind all these factors is the variation in defining ‘rural’, which often includes (but probably should not) MMM2 communities 7. Regional cities with populations of around 200 000, while qualitatively different to larger cities, are also quite different to smaller rural and remote communities, so initiatives in MMM2 communities may have less influence on MMM3-7 workforce development. A stronger approach may be to recognise that combining several factors that alone may be weak predictors can produce much stronger influence. The first medical school that did this comprehensively was James Cook University, founded in 2000, based on the available evidence for all potential predictors—rural background students with academic scores adjusted based on evidence, ruralised curriculum and assessment, rural teachers, mentors and role models and clinical learning entirely within non-metropolitan facilities 12. All students have substantial exposure to high quality learning in smaller hospitals and primary care facilities. This program consistently produces the highest proportions of graduates entering general practice and rural medical careers and living/working in all specialties in non-metropolitan communities 13-15. The model was extended to varying degrees to dentistry, allied health and nursing programs, resulting in a rural health professional milieu that supports regional, rural and remote career development. More recently the range and depth of postgraduate specialty training opportunities have been increased within the region as part of the national development of regional training hubs through the Rural Health Multidisciplinary Training program 16. This allows graduates to undertake substantial proportions (if not all) of postgraduate specialty training in regional and rural communities while drawing on and contributing to the local social fabric. An even stronger approach is that of the Queensland Rural Generalist program, which combines undergraduate and postgraduate education initiatives with a well-defined career structure 17. It may therefore be time to stop looking for a single, powerful predictive factor that supports rural medical workforce development. Instead, medical programs should be encouraged to combine even weakly predictive initiatives to foster a pipeline of consistent rural community-connectedness throughout medical career development. An early example of this may be the ‘end-to-end’ programs being established by several medical schools in some locations, but these may work better for rural background rather than metropolitan background or international students. Graduate entry programs should be linked to regional university pre-cursor programs so that rural community-connectedness is maintained. Specialty Colleges should be encouraged to expand as much as possible learning opportunities in district and regional centres. This predictor ‘stacking’ may not be practical in all programs, so funding may be better spent strengthening non-metropolitan pathways where this is more likely to be effective—in rural medical schools and rural clinical schools. No two minestrones are identical but all recipes have some things in common. They benefit from local ingredients that cater for local tastes, but it is the mix of ingredients and expert care and attention that pleases the palate. Perhaps the thicker the mix, the better? Lucie Walters: writing – review and editing. T. K. Sen Gupta: writing – review and editing. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Hays et al. (Wed,) studied this question.