impact of undergraduate and postgraduate rural training, and medical school entry criteria on rural...

Impact of undergraduate and postgraduate rural training, andmedical school entry criteria on rural practice among Australiangeneral practitioners: national study of 2414 doctors

David Wilkinson, Gillian Laven, Nicole Pratt & Justin Beilby

Objective To determine the association between rural

undergraduate training, rural postgraduate training and

medical school entry criteria favouring rural students, on

likelihood of working in rural Australian general practice.

Methods National case–control study of 2414 rural and

urban general practitioners (GPs) sampled from the

Health Insurance Commission database. Participants

completed a questionnaire providing information on

demographics, current practice location and rural

undergraduate and postgraduate experience.

Results Rural GPs were more likely to report having

had any rural undergraduate training [odds ratio (OR)

1Æ61, 95% confidence interval (CI) 1Æ32–1Æ95] than

were urban GPs. Rural GPs were much more likely to

report having had rural postgraduate training (OR 3Æ14,

95% CI 2Æ57–3Æ83). As the duration of rural postgra-

duate training increased so did the likelihood of

working as a rural GP: those reporting that more than

half their postgraduate training was rural were most

likely to be rural GPs (OR 10Æ52, 95% CI 5Æ39–20Æ51).

South Australians whose final high school year was

rural were more likely to be rural GPs (OR 3Æ18, 95%

CI 0Æ99–10Æ22).

Conclusions Undergraduate rural training, postgraduate

training and medical school entry criteria favouring

rural students, all are associated with an increased

likelihood of being a rural GP. Longer rural postgra-

duate training is more strongly associated with rural

practice. These findings argue for continuation of rural

undergraduate training opportunities and rural entry

schemes, and an expansion in postgraduate training

opportunities for GPs.

Keywords Education, Medical/*organisation/standards,

Rural health services/*supply and distribution, Family

Practice/*organisation/education, School Admission

Criteria, Schools, Medical, Career Choice,

Questionnaires, Case Control Studies, Australia/

*epidemiology.

Medical Education 2003;37:809–814

Introduction

The difficulty in recruiting general practitioners (GPs)

to work in rural and remote areas is well documented in

Australia and other developing countries.1–3 Numerous

policy initiatives aimed at increasing the number of

rural doctors have been implemented. These range

from financial incentives and the recruitment of over-

seas trained doctors to ease acute shortages, to estab-

lishment of a rural academic network4 and to enhanced

opportunities for rural GP training.5

Although widely supported, there is limited high

quality, quantitative evidence to support these major

initiatives.6 It is important to increase the evidence base

that can support policy development in order to confirm

that current policy is appropriate, that new opportunities

are not missed and to ensure that resources are directed

towards areas likely to have the greatest impact in terms

of the number of doctors that work in the country.

We have previously shown that it is possible to do

large-scale, quality, quantitative research into these

issues, thereby adding to the existing evidence base.8

We have now completed a national study of Australian

GPs that aims to determine the impact of rural

background, educational experience at school and

university and postgraduate training on where GPs

work. This paper reports on three key aspects: the

association between rural practice and undergraduate

Division of Health Science, University of South Australia, Adelaide,

South Australia, Australia

Correspondence: David Wilkinson, Division of Health Sciences, City

East Campus, North Terrace, University of South Australia, Adelaide

SA 5000. Tel.: + 61 88302 2028; Fax: + 61 88302 2030, E-mail:

[email protected]

Curriculum matters

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:809–814 809

rural training, postgraduate rural training and prefer-

ential entry to medical school for rural students.

While the findings of our research will have imme-

diate relevance to Australian policy, as many of the

factors influencing physician location seem to be

common internationally, our findings may also be of

international relevance and interest.

Methods

Design and participants

We did a national case–control study using a self-

administered questionnaire distributed by mail. Cases

were defined as GPs in rural practice and controls were

defined as GPs in urban practice, at the time of the

mailout. A national sample, stratified by state and

territory [excluding the Australian Capital Territory

(ACT)] was developed. The ACT was excluded, as there

are no rural parts of the territory in which doctors work.

We also excluded GPs working in the armed forces.

We defined a GP as a non-specialist, vocationally

registered GP, using Health Insurance Commission

(HIC) criteria. Specifically, we included non-specialist

vocationally registered medical practitioners, who in the

last or most recently available quarter had at least half

the schedule fee value of their Medicare billing from

non-referred attendance items. Medicare billing is

income generated from rebates provided by the Com-

monwealth government and accounts for the large

majority of income for Australian GPs. HIC adminis-

ters Medicare. At the time of the study, the Health

Information Section of the HIC defined rurality using

the Rural and Remote Metropolitan Areas classification

(RRMA).8 The seven RRMA zones were collapsed into

two groups, that we called urban1,2 and rural3–6

because there are insufficient numbers of GPs in each

of the seven RRMA zones, in each state and the

Northern Territory, to allow meaningful comparisons.

Sample size and selection

With alpha set at 5% and power at 80%, assuming that

5% of urban GPs are of rural background we sought to

have the power to show that 13% or more of rural GPs

are of rural origin, in each state and territory. The

required sample size for each state and territory to

achieve this was calculated at 400 rural GPs (or as

many as possible in states and territories with fewer

than 400) and 400 urban GPs.

The number of eligible GPs in 2000 using the study

definition was 17 182. The HIC randomly selected 400

GPs from urban areas and 400 from rural areas (or as

many as possible in jurisdictions with fewer than 400)

for each state and territory (excluding ACT). Eligible

GPs were randomly selected from the HIC DB2-

derived Major Specialty table during quarter 2 ⁄2000.

Questionnaire design and survey methods

Our questionnaire was based on previously used

surveys7–10 and we tested and refined it by piloting it

with 10 rural and urban GPs in South Australia. HIC

did all mailouts. All correspondence used HIC station-

ary and a letter from HIC explained how GPs had been

selected for inclusion. The research team had access to

de-identified data only. The questionnaire was first

mailed in December 2000 and was re-sent three times

to non-responders.

The University of South Australia Ethics Committee

provided ethical approval for this study.

Statistical analysis

We limited our analysis to graduates of Australian

medical schools because the undergraduate and post-

graduate training experiences, and medical school entry

criteria and processes are very different in overseas

medical schools.

As our survey was stratified by state and territory and

had a fixed sample size in each jurisdiction, our analyses

took account of this design. Stata 7Æ0 (StataCorp. 2001,

Stata Statistical Software: Release 7Æ0. College Station,

TX, USA) was used for all survey design-based

analyses. Survey logistic regression11 was used to

examine associations between current place of work

Key learning points

There is a world wide shortage of rural doctors.

We studied the association between rural under-

graduate and postgraduate training, rural high

student special access, on likelihood of working in

rural Australian general practice, through

a national case–control study of 2414 GPs.

Rural GPs were more likely to report having rural

undergraduate and postgraduate training than

urban GPs. As the duration of rural postgraduate

training increased so did the likelihood of working

as a rural GP. Rural high school students were

more likely to be rural GPs.

These findings argue for rural undergraduate and

postgraduate training and rural entry schemes.

Rural under- and postgraduate training for rural practice • D Wilkinson et al.810

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:809–814

(rural or urban) and other categorical variables, with

current state as the strata variable, the GP as the

primary sampling unit and weights as the reciprocal of

the probability of a particular GP participating in the

study (the number of GPs in the HIC population ⁄ the

number responding to our survey). Post-stratification

adjustment was not applied to weight age and sex

groups within each state, as the distribution of our

sample reflected the overall population. Survey-based

linear regression was used to compare mean age

between rural and urban GPs. Design-based propor-

tions were estimated using Stata’s �–svytab–� command.

We therefore report here summary odds ratios (OR)

and associated 95% confidence intervals (CIs) adjusted

for state and territory and weighted for sampling, for

Australia as a whole. We also provide individual state

and territory ORs where appropriate. Rural undergra-

duate training was defined as any �rural placement taken

during medical school�, either elective or required, and

irrespective of type, location and duration. Rural

postgraduate training was defined as �postgraduate

training in a rural location, after internship�.To examine the association between medical school

entry criteria and rural practice we analysed a subset of

the data relating to GPs whose final year in high school

was in South Australia. The Fairway Scheme is a

special access scheme conducted by the University of

Adelaide. The scheme provides an additional oppor-

tunity for rural students to be selected for undergradu-

ate programmes at the university and it applies to all

undergraduate programmes. The scheme is directed at

designated �under-represented� schools according to the

schools student participation rate in higher education at

the three universities in South Australia. Students do

not have to opt-in to the scheme. Designated schools

are those with a postcode of 5200 or higher within

South Australia (which equates with rurality), selected

�under-represented� schools from the Adelaide metro-

politan area, Northern Territory schools and some

schools near the borders with other states. Students

who spend their final year in designated schools have

6 bonus points added to their TER (university

admissions) score.13 We compared practice location

of students who were or would have been eligible for

the Fairways scheme with those who were not or would

not have been eligible for it.

Results

Of 4513 surveys mailed out, 137 were excluded as they

were �returned to sender ⁄ left address ⁄ incomplete

address�, the doctor had retired, was deceased or not

currently in Australia. Thirty doctors declined to

participate and the rest (1263) did not respond, leaving

3083 useable responses (response rate 71%). Of the

3083, 2414 (78%) are graduates of Australian medical

schools and are analysed here.

Characteristics

Rural GPs were on average 2Æ0 years (95% CI 0Æ9–3Æ0)

younger than urban GPs. Rural doctors were rather

more likely to be male than were urban GPs (OR 1Æ42,

95% CI 1Æ17–1Æ73). Rural doctors were more likely to

have a spouse or partner (OR 1Æ55, 95% CI 1Æ14–2Æ11)

and to have children aged under 18 years (OR 1Æ55,

95% CI 1Æ29–1Æ87).

Undergraduate training

Rural GPs were more likely to report having had rural

undergraduate training at medical school (OR 1Æ61,

95% CI 1Æ32–1Æ95) than were urban GPs. A similar

association was measured for each state, except

Tasmania and the Northern Territory (Table 1). How-

ever, for Tasmania and the Northern Territory, the

confidence intervals are wide and include 1Æ0.

Postgraduate training

Rural GPs were much more likely to report having had

some rural postgraduate training than were urban GPs

(OR 3Æ14, 95% CI 2Æ57–3Æ83). As the duration of

postgraduate training in the country increased so did

the likelihood of working as a rural GP (Table 2): GPs

who reported that more than half their postgraduate

training was rural were most likely to be rural GPs (OR

10Æ52, 95% CI 5Æ39–20Æ51).

Most GPs reported having no rural postgraduate

training (Fig. 1). However, urban GPs were much

more likely to report no rural postgraduate training

(75%) than were rural GPs (50%). While only 3% of

Table 1 Odds ratios (and 95% confidence intervals) for associ-

ation between rural undergraduate training and rural practice for

individual states and the Northern Territory

State ⁄ territory Odds ratio 95% confidence interval

New South Wales 1Æ59 1Æ06–2Æ39

Northern Territory 0Æ75 0Æ26–2Æ12

Queensland 1Æ96 1Æ31–2Æ93

South Australia 1Æ78 1Æ17–2Æ69

Tasmania 0Æ86 0Æ49–1Æ50

Victoria 1Æ40 0Æ97–2Æ04

Western Australia 1Æ97 1Æ21–3Æ20

Rural under- and postgraduate training for rural practice • D Wilkinson et al. 811


urban GPs reported having more than half of their

postgraduate training in the country, this was true of

17% of rural GPs (Fig. 1).

The association between rural postgraduate training

and rural practice was similar in all states, with

confidence intervals overlapping, indicating no statisti-

cally significant difference (Table 3). The only excep-

tion was in the Northern Territory where there was no

association observed, however, the confidence interval

is wide.

Combination of rural and postgraduate training

GPs reporting rural undergraduate training but no rural

postgraduate training were more likely than those

receiving neither to be rural GPs (OR 1Æ39, 95% CI

1Æ09–1Æ77). Those reporting rural postgraduate training

only were much more likely to be rural GPs (OR 3Æ42,

95% CI 2Æ39–4Æ89). Those reporting both undergradu-

ate and postgraduate training were also more likely to

be rural GPs (OR 3Æ73, 95% CI 2Æ88–4Æ83).

Medical school entry criteria: Fairways scheme

Those whose final year of high school was spent in a

rural school and hence who would have been included

in the Fairways scheme were more likely to become

rural GPs (OR 3Æ18, 95% CI 0Æ99–10Æ22) than those

not eligible for the Fairways scheme.

Discussion

Our data provide evidence that medical students who

have undergraduate rural training, and that GPs who

have rural postgraduate training, are more likely to

become rural GPs. We also provide supportive evidence

that students whose final year is spent in a rural high

school are also more likely to become rural GPs. Our

data suggests that of these factors, rural postgraduate

training is the factor more strongly associated with rural

practice than is undergraduate rural training. Those

doctors with more than half their postgraduate training

in the country are about 10 times more likely to become

rural GPs than those with no rural postgraduate training.

Our findings do not necessarily apply to all Australian

doctors. We analysed data for graduates of Australian

medical schools only as we wish to provide evidence to

inform medical education policy in Australia. Also,

while overseas trained doctors make up about 25% of

the GP workforce and their recruitment remains an

important component of a workforce strategy, we are

unable to influence their background and training

experience. Our main findings were similar in all

jurisdictions but with some variation for the Northern

Table 2 Association between proportion of postgraduate training

undertaken in the country and current practice location for Aus-

tralian-trained general practitioners

Proportion of

postgraduate

training

in rural settings

Current location, number and %

Urban Rural Total OR 95% CI

0 844 598 1442 1Æ0 1Æ49–2Æ46

75Æ0 50Æ5

0Æ1–25Æ0 192 246 438 1Æ92 2Æ76–5Æ98

17Æ7 20Æ8

25Æ1–50Æ0 55 150 205 4Æ07 5Æ39–20Æ51

4Æ6 11Æ9

50Æ1–99Æ9 16 80 96 10Æ52 4Æ49–15Æ20

1Æ0 7Æ4

100 15 96 111 8Æ26

1Æ7 9Æ5

Total 1122 1170 2292

Proportion of postgraduate training in rural settings

0

10

20

30

40

50

60

70

80

0 0-25.0 25.1-50.0 50.1-99.9 100Proportion of postgraduate training

Per

cent

of G

Ps

Urban GPs

Rural GPs

Figure 1 Proportion of postgraduate training in rural settings.

Table 3 Odds ratios (and 95% confidence intervals) for associ-

ation between rural postgraduate training and rural practice for

individual states and the Northern Territory

State ⁄ territory Odds ratio 95% confidence interval

New South Wales 4Æ23 2Æ72–6Æ56

Northern Territory 1Æ65 0Æ66–4Æ14

Queensland 3Æ73 2Æ40–5Æ78

South Australia 3Æ21 2Æ13–4Æ85

Tasmania 2Æ00 1Æ18–3Æ41

Victoria 2Æ05 1Æ40–2Æ99

Western Australia 3Æ22 2Æ02–5Æ13



Territory and Tasmania. We studied a sample drawn

from the HIC database, comprising doctors who earn

income from Medicare. This excludes salaried doctors

who otherwise provide general practice-type services in

a primary care setting, including those working in

Aboriginal Medical Services and regional hospitals for

example. This may help explain the slightly different

results for the Northern Territory and Tasmania,

however, due to the small sample size, confidence

intervals are wide, differences may not be real and firm

conclusions cannot be drawn. Thus it seems reasonable

to provide Australia-wide estimates and it seems

reasonable to apply our findings to the broad group of

Australian private practice GPs, who make up the large

majority of the primary care medical workforce.

There is limited Australian evidence to indicate that

rural undergraduate training increases the likelihood of

subsequent rural practice. Rolfe et al.9 showed that

students who chose a rural general practice attachment

in their final year of medical school were more likely

(relative risk 3Æ02) to become rural GPs. Our data, from

a much larger and national sample supports these

findings but suggests that the probability may be smaller.

The evidence around the impact of undergraduate

training from North America is generally supportive.

Carter et al.13 reported an OR of 2Æ03, while Easterbrook

et al.14 reported no association between rural undergra-

duate training and rural practice. Rabinowitz et al.10 also

showed an association (OR 2Æ30) between rural under-

graduate training and rural practice.

There is even less Australian evidence for the impact

of rural postgraduate training. Strasser15 reported that

33Æ8% of rural GPs reported rural postgraduate training

compared to 13Æ8% of urban GPs. In North America,

Potter17 has shown that rural GPs had longer duration

of rural postgraduate training and Rabinowitz et al.

have shown that a special programme focused on

developing rural physicians is effective.10,17

There is more evidence that students with a rural

background are more likely to become rural GPs. Rolfe

et al.9 have shown an association (RR 2Æ49) for New-

castle University students, and similar evidence has

been provided by other studies in South Australia,7

Victoria15 and nationally.18 Most studies from North

America also show similar strengths of association.19,20

Our findings suggest that rural postgraduate training

has a greater effect than does undergraduate training,

and that the two experiences may not be additive.

It is important to note that rural undergraduate

exposure has only become widespread in recent years in

Australian medical schools, and most students only

have about 8 weeks rural training. With new rural

clinical schools large numbers of students will be

spending many months in the country. Rural postgra-

duate training opportunities are limited, although this is

changing with new training arrangements. Our study

was an observational epidemiological study, not a

randomized trial, and as such it is impossible to control

for self-selection. Specifically, it is quite likely that

students and doctors who already favour rural practice

(perhaps because of rural background) choose rural

undergraduate and postgraduate opportunities. That

this is so is supported by our findings for the Fairway

scheme that shows students with a rural background are

more likely to become rural GPs and is also supported

by previous research.9,10 We are analysing our dataset

to explore the impact of rural background.

Australian medical schools have over recent years

increased the proportion of medical students with a

rural background. The proportion at the University of

Adelaide medical school has increased from 9% in 1994

to 22% in 2000,21 partly through the Fairway Scheme.

Our data provide support for this and similar schemes,

suggesting that students whose final high school year is

rural, are about three times more likely to become rural

GPs. Due to the modest sample size available to us to

explore this specific issue our estimate of the strength of

the association has a wide confidence interval. Never-

theless, these findings support those from other studies

that have measured rural background in other ways9,10

and support the increased recruitment of students with

a rural background into medical school.

In the last 5–10 years in Australia, more medical

schools have increased exposure to rural practice during

their courses. Starting out as small pilot programmes,

rural placements have now become mainstreamed and

are financially supported by the Commonwealth gov-

ernment. The Rural Undergraduate Support and

Coordination (RUSC) committee programmes man-

date 8 weeks rural placement for all Australian stu-

dents.5 The University Department of Rural Health

programme4 has further increased rural opportunities

and placements, and more recently the Rural Clinical

School programme aims to deliver half the clinical

training for 25% of all Australian medical students in

rural settings. Finally, the regionalization of GP training

should increase opportunities for rural GP training.

Our findings give strong support to the notion that, as

much postgraduate training as possible – including

hospital terms – should be available in the country.

The shortage of rural doctors is a global problem, it is

multifactorial in its causation, and at times seems

intractable. However, there is increasing, high quality,

quantitative evidence about which interventions should

increase the number of GPs choosing to work in rural

areas, and by how much. These include enrolling more

Rural under- and postgraduate training for rural practice • D Wilkinson et al. 813


students with a rural background into medical school,

continuing to expand rural undergraduate training

opportunities, and expanding opportunities for rural

postgraduate training.

Contributions

DW conceived and designed the study, supervised the

survey and analysis and drafted the paper. GL contri-

buted to study design, conducted the survey and

supported the analysis and revised the paper. NP

contributed to design, conducted the analysis and

reviewed the paper. JB contributed to design, helped

supervise the analysis, and helped draft the paper.

Acknowledgements

This study was funded through the Rural Health

Support, Education and Training (RHSET) Program

of the Commonwealth Department of Health &

Ageing. Heather McElroy, BSc(Hons), Statistician,

Department of General Practice and Department of

Public Health, The University of Adelaide, for addi-

tional statistical input.

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Received 10 June 2002; editorial comments to authors 5 August 2002

and 18 December 2002; accepted for publication 5 March 2003



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