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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 22-October-2004, Vol 117 No 1204

What evidence-based undergraduate interventions promote rural health?
Wayne Hsueh, Tim Wilkinson, Janne Bills
Abstract
Aims This article identifies published reports of medical undergraduate rural programmes from international medical schools and investigates the features making these programmes successful in recruiting and retaining rural physicians.
Method Literature review.
Results Ten successful programmes were identified. Common features included selective admission, curricular focus on primary care/family medicine, community-based teaching, and community/rural preceptorship. A strong association exists between rural background of the student and choice of both a rural career and a career in primary care. Medical students of rural origin with an initial interest in a generalist career are significantly more likely to enter rural practice. Community preceptorship with its high staff:student ratio has been effective in influencing students’ career choices.
Conclusions The effectiveness of a medical undergraduate rural programme in preparing and recruiting physicians for rural practice does not occur with one isolated strategy but with a chronological sequence of interventions. The most effective programmes consider both pre-medical school and medical school educational factors. Medical schools would need to implement a combination of these strategies when designing a programme to maximise success.

New Zealand’s economy depends largely on agricultural industries; it has been stated that rural New Zealand is the barometer of our economy and rural health care is an indicator and predictor of the future health care in New Zealand.1 Furthermore, rural health care is difficult and expensive to provide. New Zealand Government rural and primary care health policy documents released in the last three years have recommended changes2,3 and initiatives in an attempt to address this difficulty.4
New Zealand has a rural doctor shortage crisis that is not unique to this country.5–7 The problem has existed for years and the future does not look promising with only 1% of medical students at the Christchurch School of Medicine indicating they would practise rurally.8,9
General practitioners (GPs) constitute the main medical workforce in rural New Zealand, and some of the reasons given for rural practice being unattractive have been identified:10–14
  • Lack of locum relief for both holidays and continuing medical education (CME),
  • Lack of quality CME opportunities,
  • Heavy on-call and usual workload,
  • Non-clinical administrative responsibilities,
  • Professional isolation from specialised medical and other health professional support, and
  • Social and cultural isolation for medical families and lack of ideal educational opportunities for school-aged children
Significantly, the current shortage of rural GPs has made conditions more difficult for the rural GPs remaining.12
The New Zealand general practice workforce is maldistributed in terms of geographic location and specialty choice. Only 4.2% of New Zealand-trained GPs’ main work location at 17 years post-graduation was in minor urban, rural, and coastal areas (0–9,999 population)15 where 23% of New Zealanders lived (according to the 2001 Census). On the other hand, over 95% of New Zealand-trained GPs worked mainly in main urban and secondary urban areas (10,000+ population)15 where only 77% of New Zealanders resided.
New Zealand relies heavily on foreign-trained GPs12,16,17 to service its rural population, but it has to compete hard with the international market for the diminishing supply16 of rural doctors. It is essential for New Zealand to produce a healthy supply of rural doctors domestically.
The literature describes three main factors related to rural recruitment and retention:
  • Pre-medical school factors, such as rural upbringing and initial specialty preference,
  • Medical undergraduate education, and
  • Postgraduate residency training.18
Recruitment is defined as ‘enrolment of primary care physicians into rural practice’ and retention relates to the ‘length of time in either the original rural community or any other subsequent rural location’.18
Undergraduate medical education plays a significant role in recruiting and retaining rural physicians,18 and the New Zealand Ministry of Health has requested that New Zealand medical schools assist with the recruitment of more young doctors to practise in under-served rural areas of New Zealand.
If the medical schools in New Zealand are to develop programmes that will encourage an interest in rural practice and subsequent recruitment, then it is important to evaluate present successful programmes. Effectiveness of any such programme must be determined by an unbiased, evidence-based examination of the interventions that work and those that do not. The main question to answer is ‘what can medical schools do to increase the supply of rural physicians?’ The Medical Council of New Zealand commissioned the answer to this question through its summer studentship sponsorship programme. The full report is available from the Medical Council of New Zealand on request, and the following is a summary of the findings.

Method

A literature search was the sole methodology of this research project. Articles most suitable for this research were selected from a wide range of sources based on the title, content, nature (editorial, letter, opinion, original study, and review article), year published, and country of publication. The search initially selected publications from Australia, Canada, and the United States because, similar to New Zealand, they were English-speaking countries that had comparable medical education systems and areas of remote geography. However any other countries with long-standing, well-evaluated programmes were considered as well. Email communication with international organisations, medical schools, and local and international rural medicine academics was used to inquire about updates of the programme or to request further information on imminent publications describing more recent evaluation data.
Inclusion criteria used to rate success included:
  • The duration of the programme (greater than or equal to 12 months),
  • Number of years of operation (greater than or equal to 10 years),
  • The extensiveness of evaluation of the programme,
  • Frequency of citation by other studies, and
  • Programme features and statistical analysis of the original studies by personnel involved in the programme.
Information was collected from the following databases:
  • Ovid MEDLINE and EMBASE
Rural health, rural medicine, undergraduate medical education, curriculum and rural medical school were used as key words in searches.
  • General GOOGLE internet search engine
GOOGLE was used to search for both international and New Zealand information, including websites for specific undergraduate rural programmes.
  • Email communication with international organisations, medical schools, and local and international rural medicine personnel.
  • A manual search of the New Zealand Medical Journal website, and previous paper-based issues
New Zealand rural healthcare information was retrieved from the New Zealand Medical Journal, from both paper-based (before 7/7/2002) and electronic issues 7/7/2002 and after).
  • Email communication with New Zealand organisations
Statistics New Zealand and the Medical Council of New Zealand were contacted for the New Zealand workforce information.
  • References from relevant articles
Further articles were obtained from the reference sections of relevant articles.

Results

A total of 107 references, published between 1961 and 2001, were collected relevant to the topic. Of the 32 email contacts made, 20 replies were received and, of these 20 replies, 15 produced useful information and/or further links to requested information.
A total of 22 original articles were published on 10 successful medical undergraduate courses/programmes (five programmes had more than one articles published on them) to demonstrate the favourable outcomes of the strategies implemented by individual programmes. These programmes are listed in Table 1.19–40 The specific features of each programme and the key findings are found in Table 2.
Measures used by the authors (of the 22 original articles) to assess outcomes of success in these 10 programmes included practice location, specialty selection, rural practice and under-served area locations, doctor:population ratio, residency choice, gender differences, physician distribution according to area of upbringing, physician intention of settlement, contract completion, influence of clinical campus location on practice location, population of hometown, and influence on practice location.
Eight of the 10 programmes are based in the United States, one in Japan, and one in Norway. Many of these programmes have been in operation for two to three decades and have all been well evaluated. While the United States has contributed the most evidence on this topic, not all interventions within an American setting can be directly transferable to a New Zealand setting. Evidence of the effectiveness of Australian and Canadian programmes is presently not available, as the introduction of educational strategies to redress the physician maldistribution has only occurred in the last decade.
(Click here to see Table 1 and Table 2)

Discussion

Selective admission, curricular emphasis on primary care/family medicine, decentralised/community-based teaching, and preceptorship have been found to be the four common features that seem to have made the ten identified undergraduate rural programmes successful.
Selective/preferential admission or affirmative action for students of rural origin is a strategy developed as a consequence of extensive research evidence demonstrating a strong association between rural background and graduates’ choice of rural careers. The strongest relationship with non-urban practice is a non-urban background of doctors (and their spouses)31,41–44,45 and a career in primary care.31,43,44,46,47 Because of these observations, successful schools have developed selection policies specifically to admit students with rural ties and an interest in family practice.
Students of rural origins have also demonstrated more positive attitudes towards postgraduate training and careers in rural regions48-50,51 which may explain the strong association between rural origin and rural practice location. One follow-up study, of Jefferson Medical College graduates, showed that graduates with rural backgrounds who did not have a special curriculum were still more likely than other graduates to enter rural practice.34 As expected however, those graduates with rural backgrounds, an interest in family medicine, and a special curriculum were the most likely to enter rural practice.34
Rabinowitz has evaluated the differential effect of rural background, admission policy and curriculum on subsequent choice of rural career.34 Admission policies were found to be more powerful than curriculum characteristics. From the data provided in this study, we found that the numbers needed to ‘teach’ in a special curriculum to result in one extra rural practitioner is 17. In contrast, the number needed to ‘admit’ (under revised admission criteria to result in one extra rural practitioner) is six. Clearly therefore, there are powerful factors acting outside the control of medical schools that influence a choice of rural practice.
Currently, rural students are under-represented at the Otago Medical School.52 If society and the government are seriously committed to increasing the rural supply of doctors, then the discussions to change admission policies and curriculum should involve ideas on how to increase the number of rural students studying medicine.
An emphasis on primary care throughout all years of the curriculum is believed to contribute significantly towards producing primary care physicians for rural areas. It has also been found that a programme that offers longitudinal primary care experiences is associated with more students choosing primary care careers.53 Even though undergraduate rural rotations do not prepare for rural living, they can prepare for rural practice if they are of three months or longer in duration.51
Medical schools in Australia and Canada have been moving towards offering decentralised and community-based teaching5,6 after such strategies have demonstrated success in the United States,20–25,28–36,39,40 Japan,27 and Norway.26 It has been found that the rural location of a medical school is strongly associated with the number of rural physicians it produces and that the more rural a medical school’s location, the more graduates of that school would enter rural practice.47
Delivering undergraduate medical education in a rural area provides more benefit than just the production of rural physicians. Students are exposed to more patients and hands-on experiences, and they gain a holistic education in a primary care-based environment where they can integrate the impact of an illness or condition on the patient, their family, and the community.36,54–57,58
In 2000, the Dunedin School of Medicine through Te Waipounamu Rural Health Unit established a 7-week rural attachment as part of its 5th year undergraduate programme. The students were exposed to patients in the community practice and rural hospitals. Findings from a survey of the students, before and after the attachment, resulted in more students considering rural general practice as a career choice, increased the stated likelihood of students entering rural general practice, increased the number of students viewing rural general practice positively, and increased the students’ awareness of rural general practice as a distinct discipline. And confirming overseas findings, students of rural origin also indicated a higher likelihood of entering rural general practice than their urban colleagues.59
The University of Auckland School of Medicine, and the other schools within the University of Otago, have now established similar initiatives where students spend at least 4 weeks in rural areas as part of their general practice teaching. Currently no data have been published on the outcomes of these initiatives.
Preceptorship or mentorship in primary care during rural clerkships is another strategy shared by several model programmes. Teaching in the rural setting is generally achieved at the primary care doctor’s office and having the doctor act as the student’s educational facilitator. Students develop clinical and communication skills under the guidance of the preceptor. It is under this informal, friendly, and high staff-student contact environment57 that the medical student matures. Preceptors have also been found to be influential in students’ career choices and this, combined with the excellent preceptorship teaching,37,57 is likely to have contributed to the success of the rural programmes. Herein lies a paradox—success requires a high teacher:student ratio—something that any student in any setting might benefit from. However, the rural setting is now characterised by overworked practitioners. Would they have the spare capacity to provide this high quality contact if the numbers of students were increased?
‘Effectiveness (of a programme) is not with one isolated strategy but a chronological sequence of interventions’. (Personal communication: Whiteside C, University of British Columbia.) This review of the literature has demonstrated one important lesson: any new model implemented as a solution to the rural doctor shortage requires long-term planning by university institutions with a commitment to the vision and a recognition that numerous interventions at various stages of the educational process are required. An integration of different strategies will maximise success. Special admission policies combined with a customised curriculum and a preceptorship at a decentralised teaching post are certainly features that should be taken into consideration when designing a programme to help redistribute doctors into rural areas.
All these interventions however come at a cost. Brooks and colleagues have said it well—‘policies for staffing rural areas with primary care physicians should be aimed at both selecting the right students and giving them during their formal training the curriculum and then experiences that are needed to succeed in primary care in rural settings’.53 Therefore, the recent initiative to increase places for rural medical students is an important step in the right direction. As well as strategies at the undergraduate level, medicine should be promoted as a career to high school rural students at the pre-medical school level, and rural training should be implemented to prepare graduates for small-town living at the postgraduate level.
While beyond the scope of this review, these coordinated strategies also need to examine incentives to retain doctors already working within rural settings. Introducing reform to construct a sustainable New Zealand rural medical workforce is not easy and it requires time and patience, though tempered with a sense of urgency. With careful planning and a long-term vision, the end result, long overdue, should be successful.
Author information: Wayne Hsueh, Trainee Intern; Tim J Wilkinson, Associate Dean (Medical Education); Janne Bills, Senior Lecturer, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch
Acknowledgements: This research was funded by the Medical Council of New Zealand as a summer studentship for Wayne Hsueh. The authors thank Dr Howard Rabinowitz of Thomas Jefferson University Jefferson Medical College in Pennsylvania, USA for his timely response to requested information and helpful expert advice in the preparation of this report.
Correspondence: Wayne Hsueh, Trainee Intern, University of Otago Christchurch School of Medicine and Health Sciences, PO Box 4345, Christchurch. Fax: (03) 366-3783; email: whsueh@paradise.net.nz
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