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Aim: To develop theory about how contexts and mechanisms interact to contribute to openness to future rural practice by medical students undertaking immersive rural training. Methods: A realist evaluation based on RAMESES II protocol. We interviewed 23 students exploring Contexts (C) which were external (place-based) and internal (the student’s characteristics), Mechanisms (M) (that drive a response) and Outcomes (O) (openness to rural work). Results: ‘Openness to rural work’ related to: a desire to live rurally, work in rural medicine, or consider this as a possibility. This was triggered by responses to experience in rural places of an aspirational, intellectual and emotional nature (mechanisms). Students most affected were those with a strong motivation to help others and who value teamwork. Students with clearly envisaged career paths suited to metropolitan areas, or those retaining/prioritising strong social and community ties in metropolitan areas were less likely to commit to future rural work. Conclusion: Our theory indicates multi-level stimuli activates openness. Implications are that rural immersion programs could select students with an orientation towards teamwork, without pre-set professional ideation, and with a strong commitment to helping others. Experiencing rural immersion will trigger aspirational, intellectual and emotional responses leading to rural work openness for such students.

Evaluation of patient reported outcome measures post urethroplasty: Piloting a “Trifecta” approach

Context The implementation of rural undergraduate medical education can be improved by collecting national evidence about the aspects of these programmes that work well and the value of investing in national policies. Objectives This study aimed to explore how different durations, degree of remoteness and number of rural undergraduate medical training placements relate to working rurally, and to investigate differences after the introduction of formal national training policies that fund short- and long-term rural training experiences for medical students. Methods A cohort of 6510 Australian-trained doctors who completed the Medicine in Australia: Balancing Employment and Life survey recalled their participation in rural undergraduate medical training. Responses were categorised by duration, remoteness as defined by the Modified Monash Model levels 3-4 and 4-7 compared with 1, and total number of placements. Multivariate regression was used to test associations with working rurally in 2017, and differences between cohorts of students who graduated pre- and post-2000, of which the latter were exposed to formal national training policies. Results Any rural undergraduate training was associated with working rurally (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.3-1.9) with incrementally stronger associations for longer duration (>1 year: OR 3.0, 95% CI 2.3-4.0), greater remoteness (OR 1.8, 95% CI 1.5-2.1) and three placements (OR 2.4, 95% CI 1.9-3.0) compared with none. Rural background (OR 2.6, 95% CI 2.3-3.0) and general practice (OR 2.6, 95% CI 2.2-2.9) were independently associated with working rurally; being female was negatively associated with rural work (OR 0.7, 95% CI 0.6-0.8). The cohort of doctors who trained in a period when national rural training policies had been implemented included more graduates with a rural background and experience of undergraduate rural training but returned equivalent proportions of rural doctors to pre-policy cohorts, and included proportionally more women and fewer general practitioners. Conclusions Rural undergraduate training should focus on multiple dimensions of duration, remoteness and number of rural undergraduate training experiences to grow the rural medical workforce. Formal national rural training policies may be an important part of the broader system for rural workforce development, but they rely on the uptake of general practice and the participation of female doctors in rural medicine.

Ensuring that specialty trainees are professionally satisfied is not only important from the point of view of trainee well-being, but is also critical if health systems are to retain doctors. Despite this, little systematic research in specialist trainees has identified policy-amenable factors correlated with professional satisfaction. This study examined factors associated with trainee professional satisfaction in a national Australian cohort.This study used 2008-2015 data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, a national study of doctor demographics, characteristics and professional and personal satisfaction. Our study examined specialist trainees using a repeat cross-sectional method pooling first responses across all waves. A multivariate logistic regression analysis was used to assess correlates with professional satisfaction.The three factors most strongly correlated with professional satisfaction were feeling well supported and supervised by consultants (odds ratio [OR] 2.59, 95% confidence interval [CI] 2.42-2.77), having sufficient study time (OR 1.54, 95% CI 1.40-1.70) and self-rated health status (OR 1.65, 95% CI 1.53-1.80). Those working56 hours per week were significantly less professionally satisfied (OR 0.76, 95% CI 0.70-0.84) compared with those working the median work hours (45-50 hours per week). Those earning in the lower quintiles, those earlier in their training and those who had studied at overseas universities were also significantly less likely to be satisfied.Our study suggests that good clinical supervision and support, appropriate working hours and supported study time directly impact trainee satisfaction, potentially affecting the quality of clinical care delivered by trainees. Furthermore, the needs of junior trainees, overseas graduates and those working56 hours per week should be given particular consideration when developing well-being and training programmes.

Globally there is an urban/rural divide in relation to health and healthcare access. A key strategy for addressing general practitioner shortages in rural areas is GP vocational training in rural places, as this may aid in developing practitioners' scope, values and community orientation, and increase propensity for rural practice. This creates a need for deeper understanding of the nature and quality of this training. Rural GPs are well-positioned to reflect on vocational learning in 'place'. We aimed to explore rural GPs' perceptions and experiences of GP vocational learning in relation to rural places. Semi-structured interviews were conducted with 25 GPs based in smaller rural communities in Tasmania. Inductive and theoretical thematic analysis was undertaken. Rural places provide learning opportunities for GP registrars, which shape the relationships between GPs and registrars and their communities. Rural GPs are committed to developing the next generation and improving access to primary care for their communities. Rural places provide unique learning environments for general practice, including rich learning, relationships and community commitment.

Producing enough doctors working in general practice or rural locations, or both, remains a key global policy focus. However, there is a lack of evidence about doctors’ emerging commitment to these decisions. This study aimed to explore changes in the level of certainty about career interest in working in general practice and working rurally, as doctors pass through various early career stages. The participants were 775 eligible respondents to a 2019 survey of medical graduates of The University of Queensland from 2002–2018. Certainty levels of specialty choice were similar between GPs and specialists up until the beginning of registrar training. At that point, 65% of GPs compared with 80% of other specialists had strong certainty of their specialty field. Consistently (and significantly) less of those working rurally had strong certainty of the location where they wanted to practice medicine at each career time point. At the start of registrar training, a similar gap remained (strong certainty: 51% rural versus 63% metropolitan). This study provides new evidence that career intent certainty is more delayed for the cohort choosing general practice and rural practice than the other options. The low level of certainty in early career highlights the importance of regular positive experiences that help to promote the uptake of general practice and rural practice.

Background ‘Grow your own’ strategies are considered important for developing rural workforce capacity. They involve selecting health students from specific rural regions and training them for extended periods in the same regions, to improve local retention. However, most research about these strategies is limited to single institution studies that lack granularity as to whether the specific regions of origin, training and work are related. This national study aims to explore whether doctors working in specific rural regions also entered medicine from that region and/or trained in the same region, compared with those without these connections to the region. A secondary aim is to explore these associations with duration of rural training. Methods Utilising a cross-sectional survey of Australian doctors in 2017 (n = 6627), rural region of work was defined as the doctor’s main work location geocoded to one of 42 rural regions. This was matched to both (1) Rural region of undergraduate training ( 1 university year) and (2) Rural region of childhood origin (6+ years), to test association with returning to work in communities of the same rural region. Results Multinomial logistic regression, which adjusted for specialty, career stage and gender, showed those with > 1 year (RRR 5.2, 4.0–6.9) and 3–12 month rural training (RRR 1.4, 1.1–1.9) were more likely to work in the same rural region compared with 1-year rural training there related to 17.4 times increased chance of working in the same rural region compared with Conclusion This study provides the first national-scale empirical evidence supporting that ‘grow your own’ may be a key workforce capacity building strategy. It supports underserviced rural areas selecting and training more doctors, which may be preferable over policies that select from or train doctors in ‘any’ rural location. Longer training in the same region enhances these outcomes. Reorienting medical training to selecting and training in specific rural regions where doctors are needed is likely to be an efficient means to correcting healthcare access inequalities.

Around the world, the supply of rural health services to address population health needs continues to be a wicked problem. Adding to this, an increasing proportion of female doctors is graduating from medical courses but gender is not accounted for within rural workforce policy and planning. This threatens the future capacity of rural medical services. This perspective draws together the latest evidence, to make the case for industry and government action on responsive policy and planning to attract females to rural medicine. We find that the factors that attract female doctors to rural practice are not the same as males. We identify female-tailored policies require a re-visioning of rural recruitment, use of employment arrangements that attract females and re-thinking issues of rural training and specialty choice. We conceptualise a roadmap that includes co-designing rural jobs within supportive teams, allowing for capped hours which align with childcare along with boosting of female peer support and mentorship. There is also a need to enhance flexible rural postgraduate training options in a range of specialties (at a time when many women are establishing families) and to consider viable partner employment (including for female doctors with university trained partners) and advertising specific rural attractors to women, including the chance to connect with communities and make a difference.

Objective: Junior doctors, in their first four years of medical work, are an important part of the health care team. Attracting and retaining these doctors to rural areas underpins the development of the future rural workforce. This is the first national-scale study about satisfaction of junior doctors, based on their work location, to inform recruitment and retention. Design: Repeat cross-sectional data 2008 and 2015, pooled for analysis. Setting: Medicine in Australia: Balancing Employment and Life survey. Participants: First responses of 4581 pre-vocational doctors working as interns up to their fourth postgraduate year. Main outcome measures: Differences between metropolitan and rural respondents in satisfaction and positivity on two inventories. Results: Overall work satisfaction was approximately 85% amongst rural and metropolitan junior doctors, but controlling for other factors rural junior doctors had significantly higher overall satisfaction. Rural junior doctors were significantly more satisfied with their work-life balance, ability to obtain desired leave and leave at short notice, personal study time and access to leisure interests compared with metropolitan junior doctors. Metropolitan junior doctors were more satisfied with the network of doctors supporting them and the opportunities for family. Conclusion: While both metropolitan and rural junior doctors are generally satisfied, many professional and personal aspects of satisfaction differ considerably by work location. In order to attract early career doctors, the benefits of rural work should be emphasised and perceived weaknesses mitigated.

In the general population, people with mental disorders have increased mortality. This association, however, has not been explored in a population who at some time were inpatients of a public hospital.The sampling frame was patients admitted to an Australian regional public hospital 1996-2010. Those with known mental disorder were compared with an equal number of randomly selected patients without known mental disorder, matched for age, sex, and year of admission. Mortality outcomes were determined by linkage of hospital data and the National Death Index.We identified 15,356 patients with mental disorder and 15,356 without known mental disorder, 25.2% of the former and 17.3% of the latter died during the study period. The odds ratio (OR) for death in those with mental disorder was 2.20 (95% confidence interval: 2.01-2.41) after adjusting for confounders, and their mean age at death was 4.6 years younger (p 0.001). Other independent risk factors for mortality were being Indigenous (OR 1.72, 1.32-2.24), not partnered (OR 1.55, 1.36-1.76) or having multiple comorbidities (OR 1.65, 1.43-1.90). In the model that included multiple interactions, the ORs for death in Indigenous patients with mental disorder were markedly higher (6.6-9.5), regardless of other risk factors.Among patients with a history of public hospital admission, those with mental disorders have higher mortality than those without mental disorders. This gap in life expectancy mandates increased attention, by clinicians and health services alike, to preventable causes of death in people with mental illness.

Purpose To investigate whether publishing research is an important aspect of medical careers, and how it varies by specialty and rural or metropolitan location. Methods Annual national panel survey (postal or online) of Australian doctors between 2008 and 2016, with aggregated participants including 11 263 junior doctors not enrolled in a specialty (‘pre-registrars’), 9745 junior doctors enrolled as specialist trainees, non-general practitioner (GP) (‘registrars’) and 35 983 qualified as specialist consultants, non-GP (‘consultants’). Main outcome was in agreement that ‘research publications are important to progress my training’ (junior doctors) or ‘research publications are important to my career’ (consultants). Results Overall, the highest proportion agreeing were registrars (65%) and pre-registrars (60%), compared with consultants (36%). After accounting for key covariates, rural location was significantly associated with lower importance of publishing research for pre-registrars (OR 0.69, 95% CI 0.61 to 0.78) and consultants (OR 0.69, 95% CI 0.63 to 0.76), but not for registrars. Compared with anaesthetics, research importance was significantly higher for pre-registrars pursuing surgery (OR 4.46, 95% CI 3.57 to 5.57) and obstetrics/gynaecology careers, for registrars enrolled in surgery (OR 2.97, 95% CI 2.34 to 3.75) and internal medicine training, and consultants of internal medicine (OR 1.84, 95% CI 1.63 to 2.08), pathology, radiology and paediatrics. Conclusions This study provides new quantitative evidence showing that the importance of publishing research is related to medical career stages, and is most important to junior doctors seeking and undertaking different specialty training options. Embedding research requirements more evenly into specialty college selection criteria may stimulate uptake of research. Expansion of rural training pathways should consider capacity building to support increased access to research opportunities in these locations.

This paper evaluates rural work location outcomes of an Extended Rural Cohort (ERC) program in medical school. Students nominate a preference and are contracted to the program at entry to the medical course, involving 2-3 years continuous rural training. Data included 2412 graduates from a large university medical school cohort study. Regression modeling compared 2017 work location of ERC participants, by their level of preference for the ERC and students who had other (similar or shorter duration) rural training with a metropolitan-only trained group. Students who entered medicine with ERC as their first preference commonly had rural background (95.5%) compared with second or lower preferences (61.5% and 40.4%, respectively). Multivariate regression modeling identified ERC participants were more likely to work rurally (OR: 2.69-3.27, compared with metropolitan-trained), though higher odds were associated with lower preference for ERC. However, non-ERC students undertaking a similar duration rural training by opting for this "year by year" after course entry, had the strongest odds of rural work (OR: 4.62, 95%CI: 3.00-7.13) and work in smaller rural towns (RRR: 4.08, 95%CI: 2.36-7.06). The ERC attracts rural background students and increases rural work outcomes. However, students choosing a rural training path of equivalent duration after course entry may be more effective and improve rural workforce distribution.

Background Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment. Methods An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access –spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning. Results 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion. Conclusions Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.

Background Medical training is a long process that is not complete until doctors finish specialty training. Getting into specialty training is challenging because of strong competition for limited places, depending on doctors’ chosen field. This may have a negative impact on doctor well-being and reduce the efficiency of the medical training system. This study explored the barriers of pre-registrar (junior) doctors getting into specialty training programs to inform tailored support and re-design of speciality entry systems. Methods From March to October 2019, we conducted 32 semi-structured interviews with early-career doctors in Australia, who had chosen their specialty field, and were either seeking entry, currently undertaking or had recently completed various fields of specialty training. We sought reflections about barriers and major influences to getting into specialty training. In comparing and contrasting generated themes, different patterns emerged from doctors targeting traditionally non-competitive specialty fields like General Practice (GP) and other specialties (typically more competitive fields). As a result we explored the data in this dichotomy. Results Doctors targeting entry to GP specialties had relatively seamless training entry and few specific barriers. In contrast, those pursuing other specialties, regardless of which ones, relayed multiple barriers of: Navigating an unpredictable and complex system with informal support/guidance; Connecting to the right people/networks for relevant experience; Pro-actively planning and differentiating skills with recurrent failure of applications. Conclusions Our exploratory study suggests that doctors wanting to get into non-GP specialty training may experience strong barriers, potentially over multiple years, with the capacity to threaten their morale and resilience. These could be addressed by a clearinghouse of information about different speciality programs, broader selection criteria, feedback on applications and more formal guidance and professional supports. The absence of challenges identified for doctors seeking entry to GP could be used to promote increased uptake of GP careers.

To review the selection policies and models used by speciality colleges to select candidates for entry to vocational training, exploring whether these processes are rural-focused. A systematic desktop audit of college selection processes and criteria was done via college websites (Australian Medical Council (AMC) requires selection information to be publicly available). Material was extracted into a structured template, in 2020. Information extracted related to (i) training entry and selection steps; (ii) selection criteria and elements; (iii) rural-focused components; and (iv) rural outcomes. Findings were critically reviewed to explore their degree of rural focus. Of 14 specialist colleges included, rural-focused selection mostly related to college-led selection models rather than employer-led. Six colleges had rural-focused selection criteria (four college-led), with the Australian College of Rural and Remote Medicine strongest, utilising a 'suitability assessment' for rural practice. Of the remaining five, childhood background or rural work experience contributed between 5% and 20% of the curriculum vitae assessment. Of eight specialist colleges without rural-focused selection, six used employer-led selection models. The majority of specialty colleges have no rural-focused selection criteria and colleges using employer-led models are weakest. Given that the colleges are required to adhere to the AMC's accreditation standards, it follows that the best way to mobilise change is by including rural selection policies within the AMC standards and requiring reporting of selection outcomes, regardless of the selection models used. This will substantially strengthen ongoing rural pathways in medicine.

There is a lack of theory about what drives choice to be a generalist or specialist doctor, an important issue in many countries for increasing primary/preventative care. We did a realist evaluation to develop a theory to inform what works for whom, when and in what contexts, to yield doctors&rsquo, choice to be a generalist or specialist. We interviewed 32 Australian doctors (graduates of a large university medical school) who had decided on a generalist (GP/public health) or specialist (all other specialties) career. They reflected on their personal responses to experiences at different times to stimulate their choice. Theory was refined and confirmed by testing it with 17 additional doctors of various specialties/career stages and by referring to wider literature. Our final theory showed the decision involved multi-level contextual factors intersecting with eight triggers to produce either a specialist or generalist choice. Both clinical and place-based exposures, as well as attributes, skills, norms and status of different fields affected choice. This occurred relative to the interests and expectations of different doctors, including their values for professional, socio-economic and lifestyle rewards, often intersecting with issues like gender and life stage. Applying this theory, it is possible to tailor selection and ongoing exposures to yield more generalists.

Background Improved medical care access for rural populations continues to be a major concern. There remains little published evidence about postgraduate rural pathways of junior doctors, which may have strong implications for a long-term skilled rural workforce. This exploratory study describes and compares preferences for, and uptake of, rural internships by new domestic and international graduates of Victorian medical schools during a period of rural internship position expansion. Methods We used administrative data of all new Victorian medical graduates’ location preference and accepted location of internship positions for 2013–16. Associations between preferred internship location and accepted internship position were explored including by rurality and year. Moreover, data were stratified between ‘domestic graduates’ (Australian and New Zealand citizens or permanent residents) and ‘international graduates’ (temporary residents who graduated from an Australian university). Results Across 2013–16, there were 4562 applicants who filled 3130 internship positions (46% oversubscribed). Domestic graduates filled most (69.7%, 457/656) rural internship positions, but significantly less than metropolitan positions (92.2%, p p Conclusions The preferences for, and uptake of, rural internship positions by domestic graduates is sub-optimal for growing a rural workforce from local graduates. Current actions that have increased the number of rural positions are unlikely to be sufficient as a stand-alone intervention, thus regional areas must rely on international graduates. Strategies are needed to increase the attractiveness of rural internships for domestic students so that more graduates from rural undergraduate medical training are retained rurally. Further research could explore whether the uptake of rural internships is facilitated by aligning these positions with protected opportunities to continue vocational training in regionally-based or metropolitan fellowships. Increased understanding is needed of the factors impacting work location decisions of junior doctors, particularly those with some rural career intent.

Background In Australia registrar training to become a general practitioner (GP) involves three to four years of supervised learning with at least 50% of GP registrars training wholly in rural areas. In particular rural over regional GP placements are important for developing future GPs with broader skills because the rural scope of practice is wider. Having enough GP supervisors in smaller rural communities is essential such training. We aimed to explore what makes rural GPs’ based outside of major regional centres, participate in supervising or not, their experiences of supervising, and impact of their practice context. Methods Semi-structured interviews were undertaken with 25 GPs based in rural Tasmania (outside of major regions - Hobart and Launceston), in towns of Results Supervising was perceived to positively impact on quality of clinical care, reduce busy-ness and improve patient access to primary care. It was energising for GPs working in rural contexts. Rural GPs noted business factors impacted the decision to participate in supervision and the experience of participating: including uncertainty and discontinuity of registrar supply (rotational training systems), registrar competence and generating income. Conclusions Supervising is strongly positive for rural GPs and related to job satisfaction but increasing supervision capacity in rural areas may depend on better policies to assure continuity of rural registrars as well as policies and systems that enable viable supervision models tailored to the context.

Almost 500 international students graduate from Australian medical schools annually, with around 70% commencing medical work in Australia. If these Foreign Graduates of Accredited Medical Schools (FGAMS) wish to access Medicare benefits, they must initially work in Distribution Priority Areas (mainly rural). This study describes and compares the geographic and specialty distribution of FGAMS. Participants were 18,093 doctors responding to Medicine in Australia: Balancing Employment and Life national annual surveys, 2012&ndash, 2017. Multiple logistic regression models explored location and specialty outcomes for three training groups (FGAMS, other Australian-trained (domestic) medical graduates (DMGs), and overseas-trained doctors (OTDs)). Only 19% of FGAMS worked rurally, whereas 29% of Australia&rsquo, s population lives rurally. FGAMS had similar odds of working rurally as DMGs (OR 0.93, 0.77&ndash, 1.13) and about half the odds of OTDs (OR 0.48, 0.39&ndash, 0.59). FGAMS were more likely than DMGs to work as general practitioners (GPs) (OR 1.27, 1.03&ndash, 1.57), but less likely than OTDs (OR 0.74, 0.59&ndash, 0.92). The distribution of FGAMS, particularly geographically, is sub-optimal for improving Australia&rsquo, s national medical workforce goals of adequate rural and generalist distribution. Opportunities remain for policy makers to expand current policies and develop a more comprehensive set of levers to promote rural and GP distribution from this group.

Background A key strategy for increasing the supply of rural doctors is rurally located medical education. In 2000, Australia introduced a national policy to increase rural immersion for undergraduate medical students. This study aims to describe the characteristics and outcomes of the rural immersion programs that were implemented in Australian medical schools. Methods Information about 19 immersion programs was sourced in 2016 via the grey and published literature. A scoping review of the published peer-reviewed studies via Ovid MEDLINE and Informit (2000–2016) and direct journal searching included studies that focused on outcomes of undergraduate rural immersion in Australian medical schools from 2000 to 2016. Results Programs varied widely by selection criteria and program design, offering between 1- and 6-year immersion. Based on 26 studies from 10 medical schools, rural immersion was positively associated with rural practice in the first postgraduate year (internship) and early career (first 10 years post-qualifying). Having a rural background increased the effects of rural immersion. Evidence suggested that longer duration of immersion also increases the uptake of rural work, including by metropolitan-background students, though overall there was limited evidence about the influence of different program designs. Most evidence was based on relatively weak, predominantly cross-sectional research designs and single-institution studies. Many had flaws including small sample sizes, studying internship outcomes only, inadequately controlling for confounding variables, not using metropolitan-trained controls and providing limited justification as to the postgraduate stage at which rural practice outcomes were measured. Conclusions Australia’s immersion programs are moderately associated with an increased rural supply of early career doctors although metropolitan-trained students contribute equal numbers to overall rural workforce capacity. More research is needed about the influence of student interest in rural practice and the duration and setting of immersion on rural work uptake and working more remotely. Research needs to be more nationally balanced and scaled-up to inform national policy development. Critically, the quality of research could be strengthened through longer-term follow-up studies, adjusting for known confounders, accounting for postgraduate stages and using appropriate controls to test the relative effects of student characteristics and program designs. Electronic supplementary material The online version of this article (10.1186/s12960-018-0271-2) contains supplementary material, which is available to authorized users.

Background: The shortage of professional workers in rural and regional Australia continues as a major policy challenge. There has been substantially more strategy investment for the medical general practitioner (GP) profession than for other professions, particularly at the start of their careers. Aims: To examine differences between domestic migration patterns of GPs and other professionals to rural and regional zones in Australia for younger, mid-life and older workers. Data and methods: Data from the Australian Bureau of Statistics (ABS) 2011 Census were used to examine five-year migration rates for professionals in five ABS occupational classifications: generalist medical practitioners (GPs); engineering professionals; legal professionals; education professionals; and other health professionals. Migration volumes were benchmarked for GPs and compared both for other professions and career stage. Results: GPs were less likely than other professionals to migrate from major urban to rural zones, regional to rural zones, or rural to regional zones. Younger GPs had the highest rural migration rates, while mid-life and older GPs were least likely to migrate to rural and regional zones. In contrast, increasingly age was associated positively with migration to rural zones for those in the other four professions. Conclusions: Despite concerted policy efforts to encourage more GPs to move to rural areas, overall rural migration rates for GPs are lower than for other professionals, especially for older workers. Further investigation of the links between GP migration patterns and workforce policies needs to be undertaken to inform the application or otherwise of workforce strategies used by other professions.

Background Reduced opportunities for children’s schooling and spouse’s/partner’s employment are identified internationally as key barriers to general practitioners (GPs) working rurally. This paper aims to measure longitudinal associations between the rurality of GP work location and having (i) school-aged children and (ii) a spouse/partner in the workforce. Methods Participants included 4377 GPs responding to at least two consecutive annual surveys of the Medicine in Australia: Balancing Employment and Life (MABEL) national longitudinal study between 2008 and 2014. The main outcome, GP work location, was categorised by remoteness and population size. Five sequential binary school-age groupings were defined according to whether a GP had no children, only preschool children (aged 0–4 years), at least one primary-school child (aged 5–11 years), at least one child in secondary school (aged 12–18 years), and all children older than secondary school (aged ≥ 19). Partner in the workforce was defined by whether a GP had a partner who was either currently working or looking for work, or not. Separate generalised estimating equation models, which aggregated consecutive annual observations per GP, tested associations between work location and (i) educational stages and (ii) partner employment, after adjusting for key covariates. Results Male GPs with children in secondary school were significantly less likely to work rurally (inclusive of > 50 000 regional centres through to the smallest rural towns of

The purpose of this arm of the study was to investigate the impact of medication on healing times of the various wound types, including acute wounds and leg ulcers. A prospective longitudinal study design was used, with de-identified data collected using an electronic mobile wound care database system. Three main categories of data were collected, including patients' demographics, wounds types and treatment characteristics. For acute wounds, there was a total of 1732 patients with 2089 acute wounds. The average healing time was about 35 days. The only significant association was with chemotherapy, which increased healing time by 21 days (P = 0·048). There were non-significant trends towards reduced healing times with antibiotics (0·5 days; P = 0·853), anticoagulants (1·7 days, P = 0·673) and corticosteroids (4·98 days, P = 0·303). Non-steroidal anti-inflammatory drugs (NSAIDs) were associated with a non-significant increase in healing time (2·17 days, P = 0·707). For leg ulcers, there was a total of 264 patients with 370 leg ulcers. We only examined the impact of antibiotics, anticoagulants, corticosteroids and NSAIDs on healing times as they had an adequate number of wounds to analyse. The average healing times of leg ulcers were found to be 73 days. None of the classes of medications had any significant impact on healing time. Both anticoagulants and NSAIDs increased healing time by (22·5 days, P = 0·08) and (12·5 days, P = 0·03), respectively. On the other hand, antibiotics and corticosteroids decreased healing times non-significantly by (9·1 days, P = 0·33) and (21·6 days, P = 0·84), respectively.

PURPOSE Despite considerable investment in increasing the number of primary care physicians in rural shortage areas, little is known about their movement rates and factors influencing their mobility. We aimed to characterize geographic mobility among rural primary care physicians, and to identify location and individual factors that influence such mobility. METHODS Using data from the American Medical Association Physician Masterfile for each clinically active US physician, we created seven 2-year (biennial) mobility periods during 2000–2014. These periods were merged with county-level “rurality,” physician supply, economic characteristics, key demographic measures, and individual physician characteristics. We computed (1) mobility rates of physicians by rurality; (2) linear regression models of county-level rural nonretention (departure); and (3) logit models of physicians leaving rural practice. RESULTS Biennial turnover was about 17% among physicians aged 45 and younger, compared with 9% among physicians aged 46 to 65, with little difference between rural and metropolitan groups. County-level physician mobility was higher for counties that lacked a hospital (absolute increase = 5.7%), had a smaller population size, and had lower primary care physician supply, but area-level economic and demographic factors had little impact. Female physicians (odds ratios = 1.24 and 1.46 for those aged 45 or younger and those aged 46 to 65, respectively) and physicians born in a metropolitan area (odds ratios = 1.75 and 1.56 for those aged 45 or younger and those aged 46 to 65, respectively) were more likely to leave rural practice. CONCLUSIONS These flndings provide national-level evidence of rural physician mobility rates and factors associated with both county-level retention and individual-level departures. Outcomes were notably poorer in the most remote locations and those already having poorer physician supply and professional support. Rural health workforce planners and policymakers must be cognizant of these key factors to more effectively target retention policies and to take into account the additional support needed by these more vulnerable communities.

Objective Systematically describe the characteristics of rural specialists, their work and job satisfaction by geographical location of work. Design Cross-sectional. Setting and participants Three thousand, four hundred and seventy-nine medical specialists participating in the 2014 Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors. Main outcome measure Location of practise, whether metropolitan, large (>50 000 population) or small regional centres (

Background and objectiveGeneral practice training in Australia is uniquely structured to allow half of all registrars to train in rural areas, in order to increase rural workforce development and access to rural primary care. There is, however, limited national-scale information about rural general practice supervisors who underpin the capacity for rural general practice training. The objective of this research was to explore the factors related to rural general practitioners (GPs) supervising general practice registrars.MethodsResults were obtained using multivariate analysis of the 2016 Medicine in Australia: Balancing Employment and Life survey data.ResultsOverall, 57.8% of rural GPs were supervising registrars. Supervising was strongly related to being Australian-trained, working in a larger practice, and supervising medical students and interns.DiscussionRural supervising capacity could be increased through supporting GPs in smaller practices to engage in supervision and maintaining the strong involvement of GPs in larger practices. Other important factors may include a greater number of Australian-trained graduates working in rural general practice and increased support for international medical graduates to Fellow and feel confident to supervise.

Introduction: Access to medical services for rural communities is poorer than for metropolitan communities in many parts of the world. One of the strategies to improve rural medical workforce has been rural clinical placements for undergraduate medical students. This study explores the workforce outcomes of one model of such placements – the longitudinal integrated clerkship (LIC) – delivered in year 4, the penultimate year of the medical course, as part of the rural programs delivered by a medical school in Victoria, Australia. The LIC involved student supervision under a parallel consulting model with experienced rural generalist doctors for a whole year in small community rural general practices. Methods: This study aimed to compare the work locations (regional or more rural), following registration as a medical practitioner, of medical students who had completed 1 year of the LIC, with, first, students who had other types of rural training of comparable duration elsewhere, and second, students who had no rural training. Study participants commenced their medical degree after 2004 and had graduated between 2008 and 2016 and thus were in postgraduate year 1–9 in 2017 when evaluated. Information about the student training location(s), and duration, type and timing of training, was prospectively collected from university administrative systems. The outcome of interest was the main work location in 2017, obtained from the Australian Health Practitioner Regulation Agency’s public website. Results: Students who had undertaken the year 4 LIC along with additional rural training in years 3 and/or 5 were more likely than all other groups to be working in smaller regional or rural towns, where workforce need is greatest (relative risk ratio (RRR) 5.62, 95% confidence interval (CI) 2.81–11.20, compared with those having metropolitan training only). Non-LIC training of similar duration in rural areas was also significantly associated, but more weakly, with smaller regional work location (RRR 2.99, 95%CI 1.87–4.77). Students whose only rural training was the year 4 LIC were not significantly associated with smaller regional work location (RRR 1.72, 95%CI 0.59–5.04). Overall, after accounting for both LIC and non-LIC rural training exposure, rural work after graduation was also consistently positively associated with rural background, being an international student and having a return of service obligation under a bonded program as a student. Conclusion: This study demonstrates the value of rural LICs, coupled with additional rural training, in contributing to improving Australia’s medical workforce distribution. Whilst other evidence has already demonstrated positive educational outcomes for doctors who participate in rural LIC placements, this is the first known study of work location outcomes. The study provides evidence that expanding this model of rural undergraduate education may lead to a better geographically distributed medical workforce.

INTRODUCTION: In Australia, about one in five medical specialist doctors travel away from their main practice to provide regular outreach services in rural communities. A consistent policy question is whether video consultations (VC) are used as part of rural outreach service provision and the degree to which they partly or wholly substitute outreach visits. This study aimed to explore how commonly specialists providing rural outreach services also use VC to provide clinical service at the outreach site, the aspects of outreach clinical services they consider suitable for VC delivery, whether VC use reduces outreach travel frequency and, if used, has the potential to improve the sustainability of outreach. METHODS: The study involved 390 specialists in Victoria being invited to participate in an online survey between December 2016 and March 2017. Invited specialists were those travelling to provide rural outreach services in areas of need, already subsidised by the Australian government's outreach policy. Analysis included basic frequency counts and proportions and Pearson χ2 tests for associations. Qualitative free text responses were analysed and grouped thematically. RESULTS: Of 65 respondents, who were travelling to provide rural outreach services on average 11 times per year, 57% (95% confidence interval (CI) 44-69%) used VC to provide aspects of clinical services to the outreach site. They used VC for a median of 12 sessions per year, mainly for one patient per session. VC was used for non-complicated health care, to support rural GPs, undertake clinical reviews or see urgent new patients expediently. Key restrictions were the inability to conduct physical examinations and complex assessments. VC reduced the frequency of outreach travel for 50% of those using it (95%CI 29-63%) although 43% (95%CI 27-61%) reported that providing outreach clinical services via VC took more time than providing face-to-face consultations. Use was not associated with increased intention to continue rural outreach services for 5 or more years (56% v 62%; p=0.70) Conclusion: More than half of specialist doctors complemented their rural outreach services with VC. However, VC was used infrequently, mainly for one patient per session, for restricted clinical scenarios. Although VC use reduced outreach travel frequency for half of providers, 43% responded that VC takes more time than face-to-face clinical service provision. In conclusion, VC is a potentially useful adjunct to outreach service models, but it is unlikely to replace the utility of face-to-face rural specialist services, particularly for complex care, and may not influence outreach service sustainability in the manner in which it is currently used.

Background The capacity for high-income countries to supply enough locally trained doctors to minimise their reliance on overseas-trained doctors (OTDs) is important for equitable global workforce distribution. However, the ability to achieve self-sufficiency of individual countries is poorly evaluated. This review draws on a decade of research evidence and applies additional stratified analyses from a unique longitudinal medical workforce research program (the Medicine in Australia: Balancing Employment and Life survey (MABEL)) to explore Australia’s rural medical workforce self-sufficiency and inform rural workforce planning. Australia is a country with a strong medical education system and extensive rural workforce policies, including a requirement that newly arrived OTDs work up to 10 years in underserved, mostly rural, communities to access reimbursement for clinical services through Australia’s universal health insurance scheme, called Medicare. Findings Despite increases in the number of Australian-trained doctors, more than doubling since the late 1990s, recent locally trained graduates are less likely to work either as general practitioners (GPs) or in rural communities compared to local graduates of the 1970s–1980s. The proportion of OTDs among rural GPs and other medical specialists increases for each cohort of doctors entering the medical workforce since the 1970, peaking for entrants in 2005–2009. Rural self-sufficiency will be enhanced with policies of selecting rural-origin students, increasing the balance of generalist doctors, enhancing opportunities for remaining in rural areas for training, ensuring sustainable rural working conditions and using innovative service models. However, these policies need to be strongly integrated across the long medical workforce training pathway for successful rural workforce supply and distribution outcomes by locally trained doctors. Meanwhile, OTDs substantially continue to underpin Australia’s rural medical service capacity. The training pathways and social support for OTDs in rural areas is critical given their ongoing contribution to Australia’s rural medical workforce. Conclusion It is essential for Australia to monitor its ongoing reliance on OTDs in rural areas and be considerate of the potential impact on global workforce distribution.

Objective The aim of this study was to explore the association between career stage and rural medical workforce supply among Australian-trained medical graduates. Design and Setting Descriptive analysis using the national Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal study. Participants Australian-trained GPs and other specialists who participated in the MABEL study, 2008-2013. Main outcome measure(s) Proportions of GPs and specialists working in rural locations, according to career stage (establishing, early, mid and late), gender and childhood-origin type (rural versus metropolitan). Results Logistic regression models revealed that establishing- and early-career GPs had significantly higher likelihood (OR 1.67 and 1.38, respectively) of working rurally, but establishing and early-career doctors were significantly less likely (OR 0.34 and 0.43, respectively) to choose general practice, contributing proportionally fewer rural GPs overall (OR 0.77 and 0.75, respectively) compared to late-career doctors. For specialists, there were no significant associations between career cohorts and rural practice. Overall, there was a significantly lower likelihood (OR 0.83) of establishing-career doctors practising rurally. Women were similarly likely to be rural GPs but less likely to be rural specialists, while rural-origin was consistently associated with higher odds of rural practice. Conclusions The supply of Australia's rural medical workforce from its medical schools continues to be challenging, with these data highlighting both their source and associations with doctors at different career stages. Despite large investments through rural medical training and rural workforce recruitment and retention policies, these data confirm continued reliance on internationally trained medical graduates for large proportions of rural supply is likely.

Objectives To investigate patterns of Australian GP procedural activity and associations with: geographical remoteness and population size hours worked in hospitals and in total; and availability for on-call Design and participants National annual panel survey (Medicine in Australia: Balancing Employment and Life) of Australian GPs, 2011–2013. Main outcome measures Self-reported geographical work location, hours worked in different settings, and on-call availability per usual week, were analysed against GP procedural activity in anaesthetics, obstetrics, surgery or emergency medicine. Results Analysis of 9301 survey responses from 4638 individual GPs revealed significantly increased odds of GP procedural activity in anaesthetics, obstetrics or emergency medicine as geographical remoteness increased and community population size decreased, albeit with plateauing of the effect-size from medium-sized (population 5000–15 000) rural communities. After adjusting for confounders, procedural GPs work more hospital and more total hours each week than non-procedural GPs. In 2011 this equated to GPs practising anaesthetics, obstetrics, surgery, and emergency medicine providing 8% (95%CI 0, 16), 13% (95%CI 8, 19), 8% (95%CI 2, 15) and 18% (95%CI 13, 23) more total hours each week, respectively. The extra hours are attributable to longer hours worked in hospital settings, with no reduction in private consultation hours. Procedural GPs also carry a significantly higher burden of on-call. Conclusions The longer working hours and higher on-call demands experienced by rural and remote procedural GPs demand improved solutions, such as changes to service delivery models, so that long-term procedural GP careers are increasingly attractive to current and aspiring rural GPs.

Objective: To synthesise key Australian empirical rural retention evidence and outline implications and potential applications for policymaking. Design: A comprehensive search of Medline, PsychINFO, CINAHL plus, Scopus and EMBASE revealed eight peer-reviewed empirical studies published since 2000 quantifying factors associated with actual retention. Setting and participants: Rural and remote Australian primary health care workers. Main outcome measures: Hazard ratios (hazard of leaving rural), mean length of stay in current rural position and odds ratios (odds of leaving rural). Results: A broad range of geographical, professional, financial, educational, regulatory and personal factors are strongly and significantly associated with the rural retention of Australian primary health care workers. Important factors included geographical remoteness and population size, profession, providing hospital services, practising procedural skills, taking annual leave, employment grade, employment and payment structures, restricted access to provider numbers, country of training, vocational training, practitioner age group and cognitive behavioural coaching. These findings suggest that retention strategies should be multifaceted and ‘bundled’, addressing the combination of modifiable factors most important for specific groups of Australian rural and remote primary health care workers, and compensating health professionals for hardships they face that are linked to less modifiable factors. Conclusions: The short retention of many Australian rural and remote Allied Health Professionals and GPs, particularly in small, outer regional and remote communities, requires ongoing policy support. The important retention patterns highlighted in this review provide policymakers with direction about where to best target retention initiatives, as well as an indication of what they can do to improve retention.

Background One of the most common and potentially fatal complications in critically ill burns patients is catheter related bloodstream infection (CR-BSI). Lack of in situ diagnostic techniques requires device removal if CR-BSI is suspected with 75–85% of catheters withdrawn unnecessarily. Aims To assess the sensitivity, specificity and accuracy of two in situ diagnostic methods for CR-BSI in an adult ICU burns population: Differential Time to Positivity (DTP) and Semi-Quantitative Superficial Cultures (SQSC). Methods Both arterial (AC) and central venous (CVC) catheters were studied. On clinicians’ suspicion of CR-BSI, the CVC and AC were removed. Superficial semi-quantitative cultures were taken by removing the dressings and swabbing within a 3 cm radius of the CVC and AC insertion sites, as well as inside each hub of the CVC and AC. Peripheral blood was taken for qualitative culture and the catheter tip sent for semi-quantitative culture. DTP was considered positive if culture of lumen blood became positive at least 120 min before peripheral blood with an identical pathogen. Superficial and tip cultures were identified as positive if ≥15 CFUs were grown. CR-BSI was confirmed when both catheter tip culture and peripheral blood culture were positive with the same micro-organism. Results Sixteen patients (88% male) with an APACHE II score of 22.0 (7.3) were enrolled. The mean age was 45.7 (16.9) years with mean total burn surface area 32.9 (19.4)%. Fifty percent had airway burns. ICU stay was 19.9 (11.1) days. All 16 survived ICU discharge with a hospital survival of 93%. There were 20 episodes of CR-BSI in these 16 patients. For these 20 episodes the exposure time (line days) was 113.15. The CR-BSI rate was 15.6 per 1000 catheter days (95% CI 1.9–56.4). For diagnosis of CR-BSI in either AC and CVC, SQSC had a sensitivity of 50% [95% CI 3–97], specificity 83.3% [95% CI 67–93], PPV 14.3 [95% CI 1–58], NPV 96.8 [95% CI 81–100], accuracy of 81.6% [95%CI 65–92] and diagnostic odds ratio 5.0 [95% CI 0.3–91.5]. To diagnose tip colonisation (>15CFU), sensitivity of SQSC was 75% [95% CI 22–99], specificity 88.2% [95%CI 72–96], PPV 42.7 [95% CI 12–80], NPV96.8% [95% CI 81–100], accuracy 86.8% [95% CI 71–95] and diagnostic odds ratio 22.5 [95% CI 1.9–271.9]. For combined DTP blood cultures, sensitivity for CR-BSI was 50% [95% CI 3–97], with specificity 97% [95% CI 82–100], PPV 50% [5% CI 3–97%], NPV 97% [95% CI 82–100], accuracy 94.3% 95% CI 79–99] and diagnostic odds ratio 32 [95% CI 1.1–970.8]. Conclusion Both DTP and SQSC displayed high specificity, NPV and accuracy in a population of adult burns patients. These features may make these tests useful for ruling out CR-BSI in this patient group. This study was limited by a low number of events and further research is required.

Strategies are urgently needed to foster rural general practitioners (GPs) with the skills and professional support required to adequately address healthcare needs in smaller, often isolated communities. Australia has uniquely developed two national-scale faculties that target rural practice: the Fellowship in Advanced Rural General Practice (FARGP) and the Fellowship of the Australian College of Rural and Remote Medicine (FACRRM). This study evaluates the benefit of rural faculties for supporting GPs practicing rurally and at a broader scope. Data came from an annual national survey of Australian doctors from 2008 and 2017, providing a cross-sectional design. Work location (rurality) and scope of practice were compared between FACRRM and FARGP members, as well as standard non-members. FACRRMs mostly worked rurally (75&ndash, 84%, odds ratio (OR) 8.7, 5.8&ndash, 13.1), including in smaller rural communities (&lt, 15,000 population) (41&ndash, 54%, OR 3.5, 2.3&ndash, 5.3). FARGPs also mostly worked in rural communities (56&ndash, 67%, OR 4.2, 2.2&ndash, 7.8), but fewer in smaller communities (25&ndash, 41%, OR 1.1, 0.5&ndash, 2.5). Both FACRRMs and FARGPs were more likely to use advanced skills, especially procedural skills. GPs with fellowship of a rural faculty were associated with significantly improved geographic distribution and expanded scope, compared with standard GPs. Given their strong outcomes, expanding rural faculties is likely to be a critical strategy to building and sustaining a general practice workforce that meets the needs of rural communities.

Background Limited evidence exists about the extent to which doctors are returning to rural region(s) where they had previously trained. This study aims to investigate the rate at which medical students who have trained for 12 months or more in a rural region return to practice in that same region in their early medical career. A secondary aim is to investigate whether there is an independent or additional association with the effect of longer duration of rural exposure in a region (18–24 months) and for those completing both schooling and training in the same rural region. Methods The outcome was rural region of work, based on postcode of work location in 2017 for graduates spanning 1–9 years post-graduation, for one large medical program in Victoria, Australia. Region of rural training, combined with region of secondary schooling and duration of rural training, was explored for its association with region of practice. A multinomial logistic regression model, accounting for other covariates, measured the strength of association with practising in the same rural region as where they had trained. Results Overall, 357/2451 (15%) graduates were working rurally, with 90/357 (25%) working in the same rural region as where they did rural training. Similarly, 41/170 (24%) were working in the same region as where they completed schooling. Longer duration (18–24 vs 12 months) of rural training (relative risk ratio, RRR, 3.37, 1.89–5.98) and completing both schooling and training in the same rural region (RRR: 4.47, 2.14–9.36) were associated with returning to practice in the same rural region after training. Conclusions Medical graduates practising rurally in their early career (1–9 years post-graduation) are likely to have previous connections to the region, through either their basic medical training, their secondary schooling, or both. Social accountability of medical schools and rural medical workforce outcomes could be improved by policies that enable preferential selection and training of prospective medical students from rural regions that need more doctors, and further enhanced by longer duration of within-region training.

This study was undertaken to calculate the incidence of 8 signs and symptoms used for the diagnosis of phlebitis with peripheral intravenous catheters, or short peripheral catheters, and the level of correlation between them. A total of 22 789 daily observations of 6 signs (swelling, erythema, leakage, palpable venous cord, purulent discharge, and warmth) and 2 symptoms (pain and tenderness) were analyzed of 5907 catheter insertion sites. Most signs and symptoms of phlebitis occurred only occasionally or rarely; the incidence of tenderness was highest (5.7%). Correlations were mostly low; warmth correlated strongly with tenderness, swelling, and erythema.

Many countries use financial incentive programs to attract physicians to work in rural areas. This paper examines the effectiveness of a policy reform in Australia that made some locations newly eligible for financial incentives and increased incentives for locations already eligible. The analysis uses panel data (2008-2014) on all Australian general practitioners (GPs) aggregated to small areas. We use a difference-in-differences approach to examine if the policy change affected GP entry or exit to the 755 newly eligible locations and the 787 always eligible locations relative to 2249 locations which were never eligible. The policy change increased the entry of newly-qualified GPs to newly eligible locations but had no effect on the entry and exit of other GPs. Our results suggest that location incentives should be targeted at newly qualified GPs.

Summary Background Two billion peripheral intravenous catheters (PIVCs) are used globally each year, but optimal dressing and securement methods are not well established. We aimed to compare the efficacy and costs of three alternative approaches to standard non-bordered polyurethane dressings. Methods We did a pragmatic, randomised controlled, parallel-group superiority trial at two hospitals in Queensland, Australia. Eligible patients were aged 18 years or older and required PIVC insertion for clinical treatment, which was expected to be required for longer than 24 h. Patients were randomly assigned (1:1:1:1) via a centralised web-based randomisation service using random block sizes, stratified by hospital, to receive tissue adhesive with polyurethane dressing, bordered polyurethane dressing, a securement device with polyurethane dressing, or polyurethane dressing (control). Randomisation was concealed before allocation. Patients, clinicians, and research staff were not masked because of the nature of the intervention, but infections were adjudicated by a physician who was masked to treatment allocation. The primary outcome was all-cause PIVC failure (as a composite of complete dislodgement, occlusion, phlebitis, and infection [primary bloodstream infection or local infection]). Analysis was by modified intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000769987. Findings Between March 18, 2013, and Sept 9, 2014, we randomly assigned 1807 patients to receive tissue adhesive with polyurethane (n=446), bordered polyurethane (n=454), securement device with polyurethane (n=453), or polyurethane (n=454); 1697 patients comprised the modified intention-to-treat population. 163 (38%) of 427 patients in the tissue adhesive with polyurethane group (absolute risk difference −4·5% [95% CI −11·1 to 2·1%], p=0·19), 169 (40%) of 423 of patients in the bordered polyurethane group (–2·7% [–9·3 to 3·9%] p=0·44), 176 (41%) of 425 patients in the securement device with poplyurethane group (–1·2% [–7·9% to 5·4%], p=0·73), and 180 (43%) of 422 patients in the polyurethane group had PIVC failure. 17 patients in the tissue adhesive with polyurethane group, two patients in the bordered polyurethane group, eight patients in the securement device with polyurethane group, and seven patients in the polyurethane group had skin adverse events. Total costs of the trial interventions did not differ significantly between groups. Interpretation Current dressing and securement methods are commonly associated with PIVC failure and poor durability, with simultaneous use of multiple products commonly required. Cost is currently the main factor that determines product choice. Innovations to achieve effective, durable dressings and securements, and randomised controlled trials assessing their effectiveness are urgently needed. Funding Australian National Health and Medical Research Council.

Objective: To describe the geographical mobility of general practitioners in Australia, both within rural areas and between rural and metropolitan areas. Design and participants: Annual panel survey of GPs between 2008 and 2012. Main outcome measures: Work location, categorised by a typology based on geographical location and community size; frequency of mobility (change of location category); and characteristics of those who moved. Results: There were 3906 participants in 2008 (representative cohort, 19% of Australia’s GP workforce) and 3502, 3514, 3287 and 3361 in subsequent years. 1810 GPs participated in all 5 years, and 10 900 origin–destination pairs were observed after removing GP registrars from the dataset. A total of 133 GPs moved from rural to metropolitan locations, 103 moved from metropolitan to rural locations, and 271 observed location changes were within rural areas. Annual location retention rates were 95% in regional centres, 90% in small rural towns and 82% in very remote areas. GPs in small towns of < 5000 residents had the highest risk of leaving rural practice. Mobility rates were significantly higher for GPs who had worked in a location for under 3 years and those working as either contracted or salaried employees, and somewhat higher for international medical graduates. Younger age was a small predictor of increased mobility, while sex and family status had no association with mobility. Conclusion: GPs working in small communities and those in a rural location for less than 3 years are most at risk of leaving rural practice.

Objective: To test predictors of practice location of fully qualified Monash University Bachelor of Medicine, Bachelor of Surgery (MBBS) graduates. Design: Cohort survey, 2011. Setting: Australia. Participants: Rural (n=67/129) and urban (n=86/191) background doctors starting at Monash University 1992-1999. Approximately 60% female, 77% married/partnered, 79% Australian-born, mean age 34 years, 31% general practitioners, 72% fully qualified and 80% training/practising in major cities. Main outcome measures: First and current practice location once fully qualified. Intended practice location in 5-10 years. Results: Logistic regression found that rural versus urban background was a significant predictor of rural (outside major city) first practice location (odds ratio (OR) 5.0, 95% confidence interval (CI) 1.3-19.2) and rural current practice location (OR 5.6, 95% CI 1.5-21.2) for fully qualified doctors. General practitioner versus other medical specialists significantly predicted first (OR 7.2, 95% CI 2.1-25.2) or current (OR 3.6, 95% CI 1.1-11.9) rural practice location. Preference for a rural practice location in 5-10 years was predicted by rural background (OR 4.4, 95% CI 1.6-11.8) and positive intention towards rural practice upon completing MBBS (OR 4.6, 95% CI 1.7-12.6). Surveyed in 2011, 28% of those who also responded to the 2006 survey shifted their preferred future practice location from rural to urban communities versus 13% shifting from urban to rural (McNemar-Bowker test, P=0.02). Conclusion: The majority of fully qualified Monash MBBS graduates practicing in rural communities have rural backgrounds. The rural-background effect diminished over time and may need continued support during training and full practice.

David Campbell,1 Irwyn Shepherd,2 Matthew McGrail,3 Lisa Kassell,4 Marnie Connolly,1,5 Brett Williams,6 Debra Nestel7 1East Gippsland Regional Clinical School, School of Rural Health, Monash University, Melbourne, VIC, 2Simconhealth Healthcare Simulation Consultancy Group, Linsfield, NSW, 3School of Rural Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, 4Southern General Practice Training, Churchill, 5Central Gippsland Health Service, Sale, 6Department of Community Emergency Health and Paramedic Practice, Faculty of Medicine, Nursing and Health Sciences, 7School of Rural Health and HealthPEER, Monash University, Melbourne, VIC, Australia Introduction: Procedural skills are a significant component of clinical practice. Doctors, nurses, midwives and paramedics are trained to use a variety of procedural skills. Rural clinicians in particular are often required to maintain competence in some procedural skills that are used infrequently, and which may require regular and repeated rehearsal. This paper reports on a research project conducted in Gippsland, Victoria, to ascertain the frequency of use, and relevance to clinical practice, of a range of skills in the fields of medicine, nursing, midwifery, and paramedic practice. The project also gathered data on the attitudes of clinicians regarding how frequently and by what means they thought they needed to practice these skills with a particular focus on the use of simulation as an educational method. Methods: The research was conducted following identification of a specific set of procedural skills for each professional group. Skills were identified by an expert steering committee. We developed online questionnaires that consisted of two parts: 1) demographic and professional characteristics, and 2) experience of procedural skills and perceived training needs. We sought to invite all practicing clinicians (doctors, nurses, midwives, paramedics) working in Gippsland. Online surveys were distributed between November 2011 and April 2012 with three follow-up attempts. The Monash University Human Research Ethics Committee approved the study. Results: Valid responses were received from 58 doctors, 94 nurses, 46 midwives, and 30 paramedics, whom we estimate to represent not more than 20% of current clinicians within these professions. This response rate reflected some of the difficulties experienced in the conduct of the research. Results were tabulated for each professional group across the range of skills. There was significant correlation between the frequency of certain skills and confidence with maintenance of these skills. This did not necessarily correlate with perceptions of respondents as to how often they need to practice each skill to maintain mastery. The more complex the skill, the more likely the respondents were to report a need for frequent rehearsal of the skill. There was variation between the professional groups as to how to retain mastery; for some skills, professional groups reported skill maintenance through clinical observation and clinical practice; for other skills, simulation was seen to be more appropriate. Conclusion: This project provided insight into the clinical application of procedural skills for clinicians comprising a relatively large professional population within a defined geographical region in rural Victoria, as well as attitudes to skills maintenance and competency. Although not the focus of the study, an unexpected outcome was the design of questionnaires on procedural skills. We believe that the questionnaires may have value in other rural settings. We acknowledge the limitations of the study in the text. The project provides some information on which to base planning for procedural skills education, including simulation-based training, and directions for further research. Keywords: procedural skills, simulation, rural health education, skills maintenance

Context: Providing year-long rural immersion as part of the medical degree is commonly used to increase the number of doctors with an interest in rural practice. However, the optimal duration and setting of immersion has not been fully established. This paper explores associations between various durations and settings of rural immersion during the medical degree and whether doctors work in rural areas after graduation. Methods: Eligible participants were medical graduates of Monash University between 2008 and 2016 in postgraduate years 1-9, whose characteristics, rural immersion information and work location had been prospectively collected. Separate multiple logistic regression and multinomial logit regression models tested associations between the duration and setting of any rural immersion they did during the medical degree and (i) working in a rural area and (ii) working in large or smaller rural towns, in 2017. Results: The adjusted odds of working in a rural area were significantly increased if students were immersed for one full year (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.15–2.79), for between 1 and 2 years (OR, 2.26; 95% CI, 1.54–3.32) and for 2 or more years (OR, 4.43; 95% CI, 3.03–6.47) relative to no rural immersion. The strongest association was for immersion in a mix of both regional hospitals and rural general practice (OR, 3.26; 95% CI, 2.31–4.61), followed by immersion in regional hospitals only (OR, 1.94; 95% CI, 1.39–2.70) and rural general practice only (OR, 1.91; 95% CI, 1.06–3.45). More than 1 year's immersion in a mix of regional hospitals and rural general practices was associated with working in smaller regional or rural towns (

Introduction: Many rural communities continue to experience an undersupply of primary care doctor services. While key professional factors relating to difficulties of recruitment and retention of rural primary care doctors are widely identified, less attention has been given to the role of community and place aspects on supply. Place-related attributes contribute to a community's overall amenity or attractiveness, which arguably influence both rural recruitment and retention relocation decisions of doctors. This bi-national study of Australia and the USA, two developed nations with similar geographic and rural access profiles, investigates the extent to which variations in community amenity indicators are associated with spatial variations in the supply of rural primary care doctors. Methods: Measures from two dimensions of community amenity: geographic location, specifically isolation/proximity; and economics and sociodemographics were included in this study, along with a proxy measure (jurisdiction) of a third dimension, environmental amenity. Data were chiefly collated from the American Community Survey and the Australian Census of Population and Housing, with additional calculated proximity measures. Rural primary care supply was measured using provider-to-population ratios in 1949 US rural counties and in 370 Australian rural local government areas. Additionally, the more sophisticated two-step floating catchment area method was used to measure Australian rural primary care supply in 1116 rural towns, with population sizes ranging from 500 to 50 000. Associations between supply and community amenity indicators were examined using Pearson's correlation coefficients and ordinary least squares multiple linear regression models. Results: It was found that increased population size, having a hospital in the county, increased house prices and affluence, and a more educated and older population were all significantly associated with increased workforce supply across rural areas of both countries. While remote areas were strongly linked with poorer supply in Australia, geographical remoteness was not significant after accounting for other indicators of amenity such as the positive association between workforce supply and coastal location. Workforce supply in the USA was negatively associated with fringe rural area locations adjacent to larger metropolitan areas and characterised by long work commutes. The US model captured 49% of the variation of workforce supply between rural counties, while the Australian models captured 35-39% of rural supply variation. Conclusions: These data support the idea that the rural medical workforce is maldistributed with a skew towards locating in more affluent and educated areas, and against locating in smaller, poorer and more isolated rural towns, which struggle to attract an adequate supply of primary care services. This evidence is important in understanding the role of place characteristics and rural population dynamics in the recruitment and retention of rural doctors. Future primary care workforce policies need to place a greater focus on rural communities that, for a variety of reasons, may be less attractive to doctors looking to begin or remain working there.

[Extract] Australia is in a critical period of rural workforce policy reform. The Australian government is responding to a surge of domestic and international doctors, while addressing the pervasive problem of geographic and specialty maldistribution. There is renewed commitment to strengthen rural health policy and further develop a well skilled, adaptable rural general practitioner workforce. GPs underpin resilient, healthy rural and remote communities and are essential for a coordinated and efficient health system. This article seeks to inform future directions and research priorities by reflecting on 20 years of policy activity and outcomes.

Background The purpose of the study is to explore the reasons why specialist doctors travel to provide regular rural outreach services, and whether reasons relate to (1) salaried or private fee-for-service practice and (2) providing rural outreach services in more remote locations. Methods A national cross-sectional study of specialist doctors from the Medicine in Australia: Balancing Employment and Life (MABEL) survey in 2014 was implemented. Specialists providing rural outreach services self-reported on a 5-point scale their level of agreement with five reasons for participating. Chi-squared analysis tested association between agreement and variables of interest. Results Of 567 specialists undertaking rural outreach services, reasons for participating include to grow the practice (54%), maintain a regional connection (26%), provide complex healthcare (18%), healthcare for disadvantaged people (12%) and support rural staff (6%). Salaried specialists more commonly participated to grow the practice compared with specialists in fee-for-service practice (68 vs 49%). This reason was also related to travelling further and providing outreach services in outer regional/remote locations. Private fee-for-service specialists more commonly undertook outreach services to provide complex healthcare (22 vs 14%). Conclusions Specialist doctors undertake rural outreach services for a range of reasons, mainly to complement the growth and diversity of their main practice or maintain a regional connection. Structuring rural outreach around the specialist’s main practice is likely to support participation and improve service distribution.