20th February 2015, Volume 128 Number 1409

Christina Matthews, Warwick Bagg, Jill Yielder, Vernon Mogol, Phillippa Poole

There is a mal-distribution of doctors in New Zealand (NZ) with too few doctors working in regional and rural areas. The shortage of rural health professionals in NZ contributes to disadvantage and disparity in health status, health infrastructure and economic vitality.1,2

The 2012 New Zealand Medical Council workforce survey identified that rural areas, as defined by less than 20 people per square kilometre, have less doctors and general practitioners per population and the doctors’ average age is higher at 48.3 years compared to 44.8 years in urban areas.3 To meet their social contract, medical programmes are introducing measures designed specifically to enhance student interest in practising in regional or rural areas.

Several factors are known to predict which students will eventually practice rurally. The strongest of these is the impact of place of birth on future practice.4–7 Students who have lived and worked in regional / rural areas are more likely to practice in rural areas.4,8–16 This finding underpins the presence of dedicated entry pathways for rural students into medicine in NZ for over a decade. In terms of curriculum, there is an effect of rural exposure, with this shown to be stronger with prolonged attachments and within clinical years of training.13

A systematic review by Laven and Wilkinson found four out of five studies showed rural undergraduate training to be associated with rural practice, with a typical odds ratio of approximately 2.0. 17 However, the relative contributors to long-term rural work place choice remain unclear, largely due to the failure to adjust for critical independent predictors of rural practice.16

Northland forms the most northern part of NZ. It has a population of 151,68918 and, based on the deprivation index, 35% of the population are in the lowest quintile compared with 20% of the total population of NZ.19 The Pūkawakawa programme is a partnership between the University of Auckland, Northland District Health Board and Hokianga Health. Up to 24 Year 5 medical students live and learn in Northland for most of their penultimate year of study. The majority of clinical placements are undertaken at Whangarei Hospital, with one 7-week general practice and integrated care placement in Kawakawa, Kaitaia, Rawene or Dargaville.

To be selected for the Pūkawakawa programme, students must have sound academic standing, submit a written application and go through an interview process. There are four entry pathways into the medical programme: general admission; international admission; the Māori and Pacific Admission Scheme (MAPAS) and the Rural Origin Medical Preferential Entry (ROMPE). Students in the two latter categories receive preference for Pūkawakawa.

The aim of the study was to evaluate the early outcomes of the University of Auckland rural-regional placement, Pūkawakawa, on location of practice and future career intentions. Additionally, we explored the reasons for career choices and whether or not Pūkawakawa has had an effect on students’ choices and consequently New Zealand’s workforce.

Methods

Participants—Between 2008 and 2011, a total of 78 students participated in Pūkawakawa. Of these 27 were ROMPE, 27 MAPAS, 23 general entry students and one international. Six students had not yet graduated, or started work after graduation. One student’s contact information was marked confidential on the Medical Council’s database. A survey link was sent by mail using the address on the Medical Council of New Zealand database and followed up through the University of Auckland database, by email and letter. 72 graduates were sent questionnaires.

The Survey—Survey questions (n = 36) examined a range of factors that are known predictors of future entry into the rural medical workforce,4-14 as well as questions regarding graduates’ workforce journey, the reasons for workforce choices and future intentions. The anonymous survey was conducted using Survey Gizmo. Free text responses to three questions were gathered to explore the reasons for choices made and to explore future intentions. Ethics approval was granted by the University of Auckland Human Participants Ethics Committee.

Definitions—Participants self-identified whether they had a rural or regional origin, or an urban origin. The place of work was defined by hospital or practice location within the DHB regions of New Zealand. Regional or rural areas are defined in this paper according to the parameters of the recent Regional Rural Admission Scheme at the University of Auckland. Thus, any DHBs largely outside of Auckland, Hamilton, Tauranga, Wellington, Porirua, Hutt, Upper Hutt, Christchurch or Dunedin City Councils are considered rural or regional.

The first year since graduation from the medical programme is denoted PGY1, the second, PGY2 and so on.

Analysis—Quantitative data were collected and analysed for summary statistics using Excel. A chi-square test was used for datasets with over 80% of the variables being over 5. The level of significance was set at a p < 0.05. We analysed whether there was an effect by entry pathway into the medical programme.

A dichotomous variable was created to classify the respondents’ preference for working at either an urban (0) or rural/regional hospital (DHB) (1). Phi correlation was computed to examine which of the possible 22 factors influencing intended future place of work have a relationship with preference for working in a rural/regional hospital versus an urban hospital. Similarly, respondents who selected regional and rural medicine or GP as one of their first three choices were assigned (1), whereas those who did not were assigned (0). Phi correlation was computed to examine the 25 possible factors affecting choice for future specialty training in regional and rural medicine or general practice versus all other specialties.

The qualitative data were analysed by two of the researchers independently, using a process of cross-sectional thematic analysis. 20 Themes were established for each of the three open-ended questions:

1.How did Pūkawakawa affect views about regional/rural practice?

2.How do you think the participation in the Pūkawakawa scheme affected your career choices?

3.What were your best experiences of Pūkawakawa?

The themes have been included in the results and comments integrated into the discussion section of this article.

Results

The response rate was 62.5% (45/72). The respondents were representative of the whole cohort and similar across cohorts and entry pathways (Table 1). Over two-thirds of Pūkawakawa participants had entered the medical programme by the Rural Origin Medical Preferential Entry (ROMPE) or Māori and Pacific Admission Scheme (MAPAS) pathways.

 

Table 1. Participants in Pūkawakawa by year and entry route into the medical programme. The numbers of responders are brackets

Variables

2008

2009

2010

2011

Total

General

6 (1)

6 (5)

4 (3)

7 (5)

23 (14)

MAPAS

5 (3)

7 (5)

8 (4)

7 (3)

27 (15)

ROMPE

8 (3)

7 (4)

7 (4)

5 (5)

27 (16)

International

1 (0)

0 (0)

0 (0)

0 (0)

1 (0)

Total

20 (7)

20 (14)

19 (11)

19 (13)

78 (45)

 

In 2013, 62% of the Pūkawakawa graduates were working in regional or rural hospitals compared to urban DHBs (Table 2). Of the respondents, 31% were working in Northland DHB, 16% Counties Manukau DHB and 18% in Lakes DHB at the time of the study.

Since graduation, the highest proportion of Pūkawakawa graduates have been working in the Northland DHB; PGY1 (45 responses), PGY2 (33 responses) or PGY3 (22 responses). These figures are followed closely by Counties Manukau DHB and Lakes DHB (Table 3).

Of those working in Northland DHB, 93% reported their experience there as a Pūkawakawa medical student affected their choice of current place of work; 79% cited the opportunity to do more hands on work at that site; and 71% identified that hobbies in the area and the atmosphere/work culture affected their current place of work.

 

Table 2. Place of work in 2013 and intention to work for the 45 study participants, by entry pathway

Variables

Current place of work

Intention to work

Entry pathway

Urban

Regional/Rural

Urban

Regional/rural

General (n=14)

5

9

5

9

MAPAS (n=15)

9

6

3

12

ROMPE (n=16)

3

13

1

15

Total

17 (38%)

28 (62%)

9 (20%)

36 (80%)

 

Table 3. Employment history by DHB in the early postgraduate (PG) years

DHB

PGY1

n (%)

PGY2

n (%)

PGY3

n (%)

PGY4

n (%)

Northland

13 (28.9%)

9 (27.3%)

5 (22.7%)

0 (0%)

Waitemata

3 (6.7%)

1 (3.0%)

0 (0%)

0 (0%)

Auckland

3 (6.7%)

4 (12.1%)

1 (4.6%)

1 (10%)

Counties Manukau

7 (15.6%)

5 (15.2%)

5 (22.7%)

3 (30%)

Waikato

5 (11.1%)

4 (12.1%)

3 (13.6%)

0 (0%)

Lakes

6 (13.3%)

5 (15.2%)

4 (18.2%)

2 (20%)

Bay of Plenty

2 (4.4%)

1 (3.0%)

0 (0%)

0 (0%)

Taranaki

0 (0%)

0 (0%)

1 (4.6%)

0 (0%)

Tairawhiti

5 (11.1%)

2 (6.1%)

2 (9.1%)

1 (10%)

Whanganui

0 (0%)

1 (3.0%)

0 (0%)

0 (0%)

Capital and Coast

0 (0%)

0 (0%)

0 (0%)

1 (10%)

Nelson Marlborough

1 (2.2%)

1 (3.0%)

0 (0%)

0 (0%)

Canterbury

0 (0%)

0 (0%)

0 (0%)

2 (20%)

Overseas

0 (0%)

0 (0%)

1 (4.6%)

0 (0%)

 

The Pūkawakawa graduates were asked to identify their intentions for future work and career choice. When they identified in which DHB they would most like to work, 35.6% identified Northland DHB, with Lakes DHB identified by a further 20% of participants (Table 4).

Within DHB regions, graduates were asked to specify which hospital they intended to work in; overall 80% of the graduates intend to work in a rural or regional hospital (Table 4).

 

Table 4. Intended future DHB region

DHB region

n (%)

Northland

16 (35.6)

Auckland

2 (4.4)

Counties Manukau

3 (6.7)

Waikato

3 (6.7)*

Lakes

9 (20)

Bay of Plenty

3 (6.7)

Taranaki

2 (4.4)

Tairawhiti

2 (4.4)

Hawke’s Bay

1 (2.2)

Hutt Valley

2 (4.4)

Nelson Marlborough

1 (2.2)

Southern

1 (2.2)

*Waikato DHB included Waikato Hospital (1), considered urban; and Thames hospital (1) and rural general practices (1), considered rural/regional.

 

In terms of place of work, there were significant subgroup differences in the rating of 22 influencing factors. Those who intend to work at a rural/regional hospital cited the hours of work (phi = 0.34, p<0.05) and the types of patients (phi = 0.36, p<0.05) as important. On the other hand, those who intend to work at an urban hospital indicated that prestige (phi = -0.47, p<0.1), teaching at the hospital (phi = -0.4, p<0.1), and the ability to do research (phi = -0.32, p<0.05) influenced their choice.

Students ranked their top three areas of future specialisation (Table 5). Surgery was the most popular first choice, with General Practice the most popular overall, with 68% of respondents listing it as one of their top three choices.

There were significant differences in responses to the 26 potential reasons for intended specialty between those planning to work in rural and remote medicine or general practice and those who are not. We combined these two pathways, as they are both areas of workforce need in New Zealand.

Hours of work (phi = 0.33, p<0.05), ability for flexible hours (phi 0.3, p<0.5), location (phi = 0.5, p<0.001) and hobbies in the area (phi = 0.34, p<0.05) were important to the former, and experience in that specialty (phi = -0.33, p<0.05), and ability to do future research (phi = -42, p<0.01) important to the latter.

Qualitative results—Respondent comments about how their Pūkawakawa experience affected their views about regional/rural practice focused on five primary themes, shown below in order of decreasing frequency:

  • Confirmed and consolidated their views on desire to work in a regional/rural setting (20).
  • Demonstrated the positive aspects of work-life balance and lifestyle (17).
  • Changed their views to a positive consideration of future regional/rural work (15).
  • Demonstrated the positive aspects of teamwork in a collegial and supportive work environment (9).
  • Helped them to appreciate sociological determinants of health (3).
Comments about whether participation in the Pūkawakawa programme affected career choices focused on four themes:
  • Working in a rural hospital (14).
  • Working as a rural GP (8).
  • Didn’t have an influence (5).
  • Two individual comments indicated influencing a decision to work in ED, and to general rather than sub-specialty work.

Finally, five themes emerged regarding the best experiences in the Pūkawakawa programme:

  • Being part of the hospital team with collegial relationships (21).
  • The social aspects experienced with peers, the hospital and community (18).
  • Lifestyle factors (15).
  • The learning experience (14).
  • Involvement in community and sense of belonging (9).

Discussion

The results of this study have indicated that there is a benefit to the health system with possible changes to workforce distribution of graduating medical students. There is a change in the Pūkawakawa students’ views of regional/rural practice and future career choice.

A large proportion of the medical graduates who participated in Pūkawakawa in the years 2008–2011 are currently working or intend to work in rural or regional areas in New Zealand. The response rate at 62.5% is adequate to be confident that the data collected is valid and representative of the student population who were part of Pūkawakawa.

In the literature, the link of future rural practice to rural origin is clear4–7,17 and further is highlighted in this study, with ROMPE students most strongly associated with current and intended work in rural/regional areas. However, we noted a high retention in rural and regional DHBs throughout all entry pathways.

It is encouraging that the general entry students have also chosen to work in rural/regional areas; with 64% currently employed and 64.3% intending to in the future, compared to the 80% intention of all of the total Pūkawakawa graduates. This suggests a different pattern to where clinicians are working in New Zealand.21

Students confirm the beneficial aspects of their experience in Pūkawakawa. The most obvious theme to come out of our analysis was the consolidation of views of rural and regional practice, but some also commented that it changed their view positively to working outside urban areas.

The positive experiences relate to the work-life balance, collegial relationships and communal living that encompass the Pūkawakawa experience. Students see Pūkawakawa as a unique experience and “enjoyed the atmosphere and support of a smaller hospital.” These points need to guide the development of future medical student placements in rural/regional areas to maximise the positive experience. Interestingly none of the open answers resulted in negative viewpoints on the programme.

There is clear evidence from the analysis of the data that the Northland DHB is a popular workforce choice for graduates of Pūkawakawa. Of these currently working in Northland DHB, the most cited reason was experience there as a medical student. Majority of the respondents intend to work in a rural or regional area. These findings add to the literature that living and working in a rural area increases future intention to work in a rural area.4,8–15

An interesting theme that came out of the analysis was the appreciation of sociological determinants of health which links to the types of patients with whom graduates will work. Some comments from students about Pūkawakawa included: “It showed me the personal rewards of serving a population with poorer access to health services than other New Zealanders” and it “made me more committed to the health of rural and indigenous populations.”

Overall the receptivity of the community and health workforce allowed a positive experience of Northland and encouraged them to return. They were also able to gain a deeper understanding of cultural aspects that play a part in a patient’s health and wellbeing.

The communities they are working in is important to the graduates and developing a relationship and understanding of what faces Northland may encourage them to return: “Encounters with patients from the Hokianga in Whangarei Hospital were a highlight—as these were profoundly more rewarding because I could identify with places the patients were connected to.”

A connection with a place and community developed in medical school may be a factor for DHBs and universities to consider for the future.

Limitations—Students self-select to participate in the programme. In addition the University positively selects for ROMPE and MAPAS students to participate in the Pūkawakawa programme, thus there is a risk of selection bias. The selection process also includes an evaluation of a student’s likelihood of continuing in rural/regional medicine.

Moreover, some of the MAPAS students could be classed under the ROMPE criteria as well. We did not compare our findings to a control group of medical students—i.e. students of all entry pathways who did not complete rural undergraduate training. This may have helped to establish if there is a link of entry pathway to career and workplace choices.

Our study did not intend to split intentions for graduates to work in rural general practice versus urban general practice given the limited numbers that have come through the programme. We have no prior data on the cohort groups before exposure to the Pūkawakawa, therefore cannot accurately comment on change of intentions. At the very least, Pūkawakawa seem to be consolidating and maintaining rural and regional career intentions in these students, which might not be the case if they remained in urban settings.

Further areas of work are to evaluate the effect of rural placements on medical students with no intent to work rurally/regionally in the future, as well as to compare these results from those of students who did not have the opportunity to take Pūkawakawa. Longer-term follow-up, plus multivariate analysis may improve precision estimates of the important student characteristics that predict eventual practice in rural and regional areas.

Further research might include a comparison of academic performance over time between Pūkawakawa and other students to quantify whether there may be discernible differences in learning in this environment. This information will help to refine iteratively selection and educational policy for this programme.

At this stage no major changes are planned for the Pūkawakawa experience and we are seeking ways to replicate aspects in other regions.

Conclusion

In conclusion, this study demonstrates that in the short-mid term, Pūkawakawa’s workforce aims are being achieved. A large proportion of graduates are choosing to work in rural/regional areas. Encouragingly, the future career intention in general practice, and rural and remote medicine bode well for meeting the workforce need in New Zealand. 

Summary

University of Auckland medical students spending a year in Northland greatly value the experience. In the early years after graduation they are likely to work in regional and rural areas of New Zealand. In addition, these graduates show an intention to work in general practice. Together these outcomes may help to address workforce shortages and misdistribution in New Zealand. Funding of regional and rural medical student learning opportunities ought to be a high priority.

Abstract

Aim

Relative shortages of rural doctors persist. In 2008 the University of Auckland medical programme introduced a Year 5 regional and rural immersion programme, Pūkawakawa, based in Northland, New Zealand (NZ). This study evaluates the early workforce outcomes of graduates of this programme.

Method

During 2013 we surveyed Auckland medical graduates who were in the 2008–2011 Pūkawakawa cohorts. Questions were asked regarding recent and current place of work, future intentions for place of work, and career preference with reasons why. Qualitative analysis was undertaken to analyse free text responses about experiences of Pūkawakawa on this choice.

Results

Of the 72 Pūkawakawa participants, 45 completed the survey, for a response rate of 63%. In 2013, 62% were working in rural or regional areas, with 31% in the Northland DHB. The great majority intend to work rurally or regionally, with 35.6% intending to return to Northland DHB. Of the respondents, 68% listed general practice in their top three future career intentions

Conclusion

In the early postgraduate years, medical graduates who participated in Pūkawakawa are very likely to be working in rural and regional areas. These graduates also show an intention to work in general practice and rural medicine.

Author Information

Christina Matthews, Medical Student; Warwick Bagg, Head of Medical Programme; Jill Yielder, Senior Lecturer, Medical Programme Directorate; Vernon Mogol, Psychometrician, Medical Programme Directorate; Phillippa Poole, Head Department of Medicine. Faculty of Medical and Health Sciences, University of Auckland

Acknowledgements

Christina Matthews was funded through the University of Auckland Summer Scholarship. We also thank Kimberley Buckley and Ian Wood (University of Auckland) for their assistance with data collection and analysis. 

Correspondence

Associate Professor Warwick Bagg, Medical Programme Directorate, University of Auckland, Park Rd, Auckland 1142, New Zealand.

Correspondence Email

w.bagg@auckland.ac.nz

Competing Interests

Nil.

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