3. Background - before RCSs
Decades before RCSs started, a number of programmes in North
America were doing similar things
•Rural Physician Associate Program (RPAP) Minnesota –1971 – entry
by interview - 9 months immersion in primary care practices:
- 448/901 – 49.7% - working in rural settings
•Physician Shortage Area Program(PSAP) Pennsylvania - 1975
- growing up in a rural area, planning to practice in a rural area, and
planning to practice the specialty of family medicine.
- With all 3 factors – 45 / 99 - 45% rural
•But internationally, there’s still a rural workforce shortage
– we’re not there yet
4. RCSWA versus non RCSWA
• AHPRA - national registratio database
• No bias in identifying graduates
• Principal work location
• Census at the end of each year – collected data beginning of
next year
5. Accuracy of AHPRA
• There was 94% agreement for principal state between
RCSWA personal-contact and the AHPRA registry.
• AHPRA identified nearly two times as many graduate
locations.
• For year-long rural placement, personal contact was 88%
concordant with AHPRA
AHPRA accurately identifies full time work location
6. AHPRA identified rural workforce
% working RURAL
No RCSWA RCSWA
Urban Rural Urban Rural
Student Background
7. RCSWA dramatically increases the odds of rural work
RCSWA Cohort Odds Ratio
Rural Background 7.5 (CI 3.5 – 15.8)
Urban Background 5.1 (CI 1.8 – 9.2)
Other significant factors for working rurally
Rural background without RCSWA participation: OR, 4.2; CI, 1.8–9.2
Older age: >=40 years: OR, 6.6; 95% CI, 2.8–15 vs
30– 39 years: OR, 2.2; 95% CI, 1.3–3.7
.
8. Our first conclusion:
After RCSWA
graduates not expected to be interested in rural work
in fact enter rural workforce at relatively high rates
RCSWA is having a transformative effect
9. What are the workforce patterns of these graduates?
• Looking at all graduates annually
• Ask more questions
• Follow in time
• 317 contacted graduates in PGY3 and beyond
15. Conclusion 1
Graduates not expected to be interested in rural work
in fact enter rural workforce at relatively high rates
Conclusion 2 ,
RCSWA is producing a mobile rural workforce.
But how well is it distributing this workforce?
21. Conclusion 1
Graduates not expected to be interested in rural work
in fact enter rural workforce at relatively high rates
Conclusion 2 ,
RCSWA is producing a mobile rural workforce.
Conclusion 3
This workforce is distributed to remote areas
where it is most needed
22. As a model of Rural Clinical Schools,
RCSWA demonstrates that a single-year
Longitudinal Integrate Clerkship
effectively
transforms graduates’ workforce choices
23.
24. • There was no difference in interest between those who applied
and were unsuccessful and those who were successful
• Those from a rural background were 3 times more likely to
apply to RCSWA (OR 2.98, 1.98 - 4.82)
25. Argument against
• RCSs could just be recruiting the students who
were always interested in rural work, and
would have gone on to rural work even
without RCS participation –
• It’s not RCS that matters, its student’s original
intentions
26. How many students enter RCS with a pre-existing
interest in rural medicine?
• Dataset of all UWA graduates from 1988 – present
MSOD data from 2006. All students complete on entry.
• MSOD question:
20. If in Australia, please indicate in which geographical location you would
most like to practise.
• Capital city ie Adelaide, Brisbane, Canberra, Darwin, Hobart, Melbourne, Perth, Sydney
• Major urban centre (>100,000) eg Cairns, Geelong, Gold Coast-Tweed Heads, Gosford,
Newcastle, Townsville, Wollongong, Wyong
• Regional city or large town (25,000 – 100,000) eg Alice Springs, Ballarat, Bunbury, Dubbo,
Launceston, Mount Gambier
• Smaller town (10,000 – 24,999)
• Small community (<10,000)
• Not applicable, not intending to work in Australia
28. Interest in rural medicine and RCSWA
Application to RCSWA Interested rural Interested urban
Yes 97 / 328 (29.6 %) 231 / 328 (70.4% )
No 53 /400 (13.2 %) 347 / 400 (86.8%)
OR 2.75
29. Rationale
• As well as their educational value, LICs are of interest because
they may also have long-term workforce impact.
• In Australia, the LIC model has been adopted as a strategy to
redress rural workforce shortages via The Rural Clinical
Schools, embedding medical students for a year in the country.
• The Rural Clinical School of Western Australia (RCSWA)
LIC has been operating since 2002, allowing a 10-year
evaluation of Rural Clinical School workforce impact in
Australia.
• We take RCSWA as a model for RCSs as a whole
30. Methods
• The success of RCSWA LIC in developing rural doctors was
calculated by comparing workforce locations of RCSWA with
matching urban graduates from the same university. The
national practitioner registration database was used to identify
graduates’ rural or urban location. Univariate comparisons
were made between the two groups for known correlates of
rural practice. Logistic regression was used to predict the
relative importance of each factor.
Editor's Notes
RCSWA embeds 25% of one medical year in a rural or remote location.
The reason for doing so is not just to provide an excellent educational experience – though talks at this conference will demonstrate this. The rationale for Rural Clinical Schools is to so transform students’ perceptions that they WANT to work rural. So this makes rural work the index of choice for our success.
Therefore this presentation looks at graduates’ rural workforce choices over the 10 year period since we began.
I have no conflicts of interest in reporting these data
Clearly we are not working in a vacuum. Some great programmes have preceded us, and are having significant workforce impacts.
But rural workforce shortfall is still a significant issue. In australia, up to 50% of our rural workforce is trained internationally. So we desperately need to keep on looking at local solutions.
In Australia, we have an fantastic way of tracking our graduates through the National Health Professional registration database – known as AHPRA.
AHPRA asks all practioners to specify their primary work location.
In this way it provides an unbiassed set of locational information for all graduates. It is renewed each your as health professionals are required to annually re-register.
The only problem with AHPRA is that the principal location is not mandatory. But we had a way of checking its accuracy, since every year we contact our graduates and ask where they are working. So we compared datasets and found that AHPRA was concordant with our database for graduates working full time in a rural location. Having thus triangulated our data, we confrimed that AHPRA accurately identifies full time work location
If you take one message home, I hope you take this one.
Here is the location data for urban controls and RCSWA graduates, Post graduate year 3 and beyond.
We have known for a long time that urban background graduates are not likely to work rural – we found less than 5% in rural work. We have also known that coming from a rural background is associated with rural work – we found 15% working rurally.
BUT look at the rural clinical school data. After one year of experience, here are URBAN background students looking like rural background peers. This was entirely unexpected, and hasn’t been describe before. Clearly there was some kind of transformative experience happening through RCSWA. Rural background students also had increased likelihood of working rurally.
1:5 vs 1:7
1:7 vs 1:25
Effect of the RCSWA is stronger on urban background than rural background students.
In logistic regression, both rural and urban background were significant, as was age of the participant, with older age predicting rural work.
We wanted to know more about these rural-working graduates, so we turned to our personal contact data, which has collected data each year.
We asked about vocational college registration and got these numbers in our 2013 snapshot.
The vast majority of graduates are working as general practitioners, then as general physicians, both adult and paediatric, followed not far behind by anaesthetists and emergency medicine physicians.
All these are rural appropriate disciplines. They are also generalist in nature.
If they work rural, the majority stay within their stat of training – Western Australia. Although since rural training positions are limited, these graduates also seek out rural work in other states.
Many of these graduates chose rural work as a fraction of the year. Of our 317 graduates PGY3 and beyond, 17% were in fulltime rural work in 2013, but a further 20 % had spent some time working rurally.
Because we are collecting data every year, graduate location data can be aggregated over time. In this way, we found out that almost none of our graduates spent all their time training rurally. This is largely because Australian vocational colleges only allow part of their fellowships to be done rurally. This might be seen as an indictment of our training pathway. But there is more to the data than that.
When we partitioned amount of rural work by college, we could see that even colleges where all training can be done rurally, not all graduates do so.
So it looks like this is an intentionally mobile workforce, moving in and out of rural training by choice.
This is a MOBILE workforce
This is a map of Western Australia, with a grey scale showing remoteness. Dark is easy urban, easy access, pale is remote, limited access to services.
Youll see that there is a small concentration of urban and inner regional, but that most of the state is outer regional and remote
RCSWA sites are scattered in all, with 50% in remote locations.
What is the effect of one year in regional and remote settiong?
Here we look at data on doctors who AHPRA has classified as working rural.
These data are from the whole medical school – before RCSWA existed, for those who didn’t do RCS, and RCS.
Both non-RCSWA cohorts were the same. 50% of graduates worked in the dare inner regional areas with easy access to capital city tertiary hospital services.
However RCSWA graduates had a strikingly different pattern. Only 20% worked inner regional. 80% worked outer regional and remote.
This figure looks at how remote graduates worked.
As we saw before, most graduates who did not do RCSWA, but who chose rural work, stayed close to the city, with relatively fewer in outer regional locations.
BUT RCSWA graduates moved to outer regional and remote.
Inner Regional – Bunbury, Busselton
Outer regional – Albany, Geraldton, Narrogin
Remote – Esperance, Kalgoorlie, Port Hedland, Broome.
Very remote – Derby, Kununura
Even rural and remote background did not have an effect relative to RCSWA.
Being a woman who participated in RCSWA was the biggest predictor of remote work
In Australia, we have an fantastic way of tracking our graduates through the National Health Professional registration database – known as AHPRA.
AHPRA asks all practioners to specify their primary work location.
In this way it provides an unbiassed set of locational information for all graduates. It is renewed each your as health professionals are required to annually re-register.
