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| Journal of the New Zealand Medical Association,
03-April-2009, Vol 122 No 1292
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Characteristics
of University of Auckland medical students intending to work in the
regional/rural setting
Thomas Pasley, Phillippa Poole
There is a significant shortage of doctors in regional and
rural areas around the world and this is particularly evident in New Zealand
(NZ). Currently in NZ there is a particular shortage of rural general
practitioners (GPs) and in this sector an ongoing loss of doctors exists. This
exodus is evidenced by a recent workforce survey, which showed that 34% of rural
GPs were intending to leave their rural practice within 5
years.1
Currently, 38 rural GPs in NZ are working with
doctor/patient ratios of over 1:2000, which is above the ‘alert’
level set by the Ministry of Health.2 It is
also expected that with the aging rural population and the feminisation of the
medical workforce, a significantly larger number of doctors will be needed to
replace the full-time (mainly male) doctors that are leaving rural practice. In
NZ, female doctors work, on average, 8 hours fewer per week than their male
counterparts.3
At present only 43% of rural GPs are NZ
trained1 emphasising the strong reliance on
overseas-trained doctors and the lack of NZ graduates choosing rural medicine.
As global medical workforce shortages increase, it is difficult to see this
situation improving in the absence of targeted action.
There are limited data on the number of specialists working
in rural hospitals but Nixon et al4 stated that
of the 120 doctors working in rural hospitals around NZ, almost all were either
general practitioners or Medical Officers of Special Scale
(MOSSs—experienced doctors who are not members of a specialist
college),with only a very small number being surgeons, physicians, or emergency
medicine physicians. Regional base hospitals are also particularly vulnerable to
staffing changes and workforce shortages.
To address the shortage of rural doctors, the NZ Ministry of
Health recommended changes in their Primary Health Care
Strategy,2 including:
Medical schools around the world have tried to
tackle the rural workforce shortage by introducing rural-orientated curricula
including rural attachments, and/or admitting students from a rural background.
In 2000, the University of Otago’s Dunedin School of Medicine introduced a
7-week rural placement for their 5th year
students. In the same year, the University of Auckland Medical School introduced
a rural attachment in each of Year 4 and Year 6 of their general practice
rotations.
In 2004, the Rural Origin Medical Preferential Entry (ROMPE)
scheme was introduced. This scheme allocated 20 undergraduate places to each of
the two medical schools, Auckland and Otago, for students who meet one of three
criteria:
For the purposes of the ROMPE programme,
‘rural’ includes towns with populations of less then 20,000.
Statistics New Zealand defines a city as an urban centre of a region where the
population exceeds 50,000.5
We planned a study with the aim of identifying a group of
graduating Auckland medical students interested in working in RR settings. We
evaluated the characteristics of this group and compared them with graduating
medical students who were intending to work in a city.
MethodsGraduating medical students were invited to take part
in the FMHS Tracking Health Professional Students and Graduates Project. This is
a longitudinal investigation of the characteristics and career patterns of
students studying to become health professionals through the MBChB, BNurs,
BPharm, and BHSc programmes at The University of Auckland.
The Tracking Project will continue to survey
participants at 2, 5, 12, and 20 years post graduation. The aim of the project
is to evaluate the effect of curriculum and selection policies on the shape of
the future health workforce in New Zealand.
Ethics approval was granted by the University Of
Auckland’s Human Subjects Ethics Committee.
This study involved data from the exit questionnaires
from the classes of 2006 and 2007 with this being collected around the time of
completion of the final year of the programme. Questions were focused on career
intentions, factors influencing career choice and intended region of practice
following graduation. Students were asked whether they intended to practice in
either a ‘city’ or ‘regional/rural’ community. Students
who were ‘undecided’ were not included in the analysis. The
questionnaire also asked about a student’s ethnicity, relationship status
and if they had dependent children. The characteristics of students intending to
work in RR areas were compared to those wanting to work in a city setting. As
the first students entering under the ROMPE scheme will complete their final
year at the end of 2009, they were not yet eligible for the study.
Every student involved in the survey was given a unique
number, with analysis being conducted blinded to student identity. Data were
entered into a Microsoft Excel spreadsheet and p values were calculated using
the Chi squared test or Fisher’s exact test. Data was recorded as a
percentage to the nearest significant figure.
ResultsThe response rate was 88% (n=115) in the 2006 exit survey
and 53% (n=71) in the 2007 exit survey. The overall response rate was 71%
(n=186).
Long-term intentions—Overall, 58%
(n=108) of graduating students (2006/2007) indicated an intention to work in a
city, 15% (n=27) wanted to work in a RR setting and 27% (n=51) were undecided
(Figure 1).
Figure 1. Intended career setting of graduating
students 2006/2007 (n=186)
 The majority (55%) of all graduating students intend to work
in the greater Auckland region for their first postgraduate year (Table 1).
Table 1. Destination of graduating students
2006/2007
Gender—59% (n=16) of respondents
intending to work in RR setting were female and 41% (n=11) were male. There was
no significant difference between the gender make up of RR group compared with
those intending to work in the city (p=0.5).
Ethnicity—Participants were given
five choices for reporting ethnicity: European, Māori, Asian, Pacific
Island, and Other. Ethnicity was recorded by 26 of the 27 respondents intending
to work in a RR setting and by 92 of the 108 respondents intending to work in a
city (Table 1).
There was a significant difference (p = 0.02) between the
numbers of Asian students wanting to work in a city (n=47) compared with a RR
environment (n=5). There was also a significant difference (p < 0.05) between
numbers of Māori students who wanted to work in the city (n=2) versus those
intended to work rurally (n=6). There were no significant differences among the
other three ethnic groups (p=0.5).
Dependent children/relationships—Only
small numbers of graduating students had children. Five of those intending to
work in the RR setting had dependent children compared with three of students
intending to work in the city (Fisher’s exact test, p=0.10). Of the 27
students intending to work in a RR setting, 40% (n=11) were married or in a
de-facto relationship compared to 20% (n=22) of students intending to go to a
city (p=0.12).
Figure 2. Ethnicity (RR intentions versus city
intentions)
 Career intentions—From a list of 18
careers, participants were asked to state whether they had ‘strong
interest’, ‘some interest’, or ‘no interest’ in
each career.
Those intending to practise in RR settings were
significantly more likely to have strong interest in general practice
(p<0.05) when compared to students intending to work in the city. While not
significant, RR students also tended to show increase interest in paediatrics
and obstetrics and gynaecology (O&G) and decreased interest in specialty and
general surgery (Figure 3). None of those interested in a RR setting expressed a
strong interest in pathology or radiology. Only one RR student expressed an
interest in psychiatry.
Factors influencing career
choice—Participants rated eight factors as to whether they had a
‘significantly positive effect’, ‘little/no effect’, or
‘significantly no effect’ on their career choice. There was no
significant difference between the RR and the city-intending groups as to how
students rated these factors. Overall, the most significantly positive factors
for all students were clinical attachments (rated by 97%) and medical role
models (89%) (Table 2).
Figure 3. Careers in which graduating students
have strong interest (n=186)
 Table 2. Factors affecting career choice
(n=186)
DiscussionThis is the first study from The University of Auckland
School of Medicine specifically looking at the proportion of students intending
to work in the RR community, their demographic characteristics, and their
specialty intentions. The study does not include ROMPE students, who will not be
graduating until the end of 2009, nor does it include the 20 Auckland students
who have undertaken the Year 5 Pūkawakawa regional/rural immersion scheme
in Northland, introduced in 2008. Consequently, this study will serve as a
baseline to evaluate any additional effects of these new initiatives.
A study from the Christchurch School of Medicine found that
only 1% of students were definitely intending to practice rurally, while another
10% were likely to.6 A survey of just under
2000 medical students in Canada (which has a higher proportion of people living
rurally) found that 11% of students intend working in the rural
community.7
All of the students in the survey will have completed at
least two rural GP placements and a significant number will have had hospital
attachments in North lsland cities and towns outside the greater Auckland
metropolitan area. The investigators did not know who the subjects were, hence
it was impossible to use other information to investigate the extent to which a
rural upbringing might have led to a stated intention to work in a RR setting.
As the majority of respondents indicated that clinical
attachments and role models have significantly positive effects on future career
choice, it could be argued that curriculum policies in place during the early
2000s had a positive effect, even in the absence of specific selection policies
aimed at rural students. By providing all students with rural experiences, they
are given the opportunity to make an informed decision about rural practice as a
career. This assumption will be able to be tested once paired data from students
completing questionnaires at entry and exit from the programme is available;
that is, after 2010. The entry surveys include questions on student background
and entry pathway.
Another NZ study has confirmed the benefits of rural health
experiences. Williamson et al8 found that
participating in a rural attachment had a ‘strongly positive’ effect
on the attitudes of students towards a career in rural general practice.
A systematic review of 12
studies9 showed that the likelihood of working
rurally is around twice as much in doctors coming from a rural background then
an urban one. Rural background students are relatively under-represented in
medical schools.10 As a way of addressing this
shortfall in NZ, the ROMPE admission programme was devised and successfully
introduced into both medical schools in 2005. Long-term tracking will be
necessary to ensure it meets its stated aim of increasing the number of rural
practitioners. A secondary aim of the ROMPE scheme was to increase the numbers
of students considering psychiatry as a career, however there is little evidence
as to how this might be achieved. It is concerning that only one of the students
interested in RR practice reported a significant interest in this discipline.
Recruitment of female doctors to the rural environment is
not a problem unique to NZ; countries such as the United States and Australia
are experiencing shortages of rural female
doctors.11,12 Approximately 30% of NZ’s
rural GPs are female. This study found that the percentage of female students
intending to work in a rural community (59%) was similar to the proportion of
females in the classes as a whole (62%). This increasing female interest in
rural medicine has been mirrored in a recent survey of NZ’s rural
workforce, which showed an increasing proportion of females entering rural
medicine.1
An increasing proportion of rural doctors being female may
help alleviate problems with access to healthcare for the rural female
population; however this potentially has a negative impact on the workforce with
female doctors being more likely to work fewer days and hours than their male
counterparts.3,13
Māori in New Zealand have lower life expectancies on
average than non Māori.14 Additionally,
Malcolm15 found that Māori rates of GP
utilisation are significantly lower then the rest of NZ suggesting that
geographical and cultural issues were significant barriers to access. These
issues might be addressed with an increase in rural Māori GPs—at this
stage, Māori make up 16% of the total rural
population,16 yet only 3% of rural
doctors.1
Even though numbers are small, the percentage of graduating
Māori students interested in RR practice is significantly higher than the
number of Māori students interested in working in a city setting, although
is not possible to determine the reasons for this difference. It will be
particularly important to track these graduates through the next few years to
determine final location of practice.
In this study, 7% of students identified themselves as
Māori; well above the current proportion of Māori doctors in NZ (2.5
%).17 While this appears encouraging, unless
there is a significant jump in the numbers of young Māori with both the
passion and educational preparation for medical study, the proportion of doctors
that is Māori will never approximate the current population percentage
(15%). A necessary corollary will be a decrease in NZ’s heavy reliance on
overseas trained doctors to reduce the denominator.
One the other hand, a low proportion of Asian students
expressed intentions to work rurally. This is consistent with The Rural
Workforce Survey of 2005 which showed low numbers of Asian doctors in NZ rural
practice.1 A rural health tracking survey from
Australia also found that medical students of Asian descent are more likely to
want to work in a city and less likely to want to work rurally then any other
ethnicity.18
In 2008, Asian students comprised 35% of the Auckland
medical student population (P Poole, personal communication, 2009). It is a
relatively urgent task to investigate these observations further so that
strategies may be devised to encourage a wider geographical scope of practice in
this group.
The major limitation of this study is that it can only
assess graduating students’ intentions. In the near future, paired
comparisons will be able to be made between entry intentions and exit
intentions, and also with longer term Medical Council of New Zealand data on
eventual location and vocational scope of practice. Not all of the students who
state an intention to work in RR environment will actually end up there. On the
other hand, there is the potential that at least some of the 47 students
undecided on where they will work, will also end up working in RR practice.
In the University of Auckland School of Medicine there is a
focus on growing the ‘regional/rural’ medical workforce rather than
on ‘rural’ alone as regional hospitals also need a steady supply of
New Zealand graduates. The survey relied on the students’ own
interpretations of ‘city’ and ‘regional/rural’ - no
definitions were used. While this may be regarded as a limitation, it could be
argued that as all Auckland students are exposed to rural general practice and
many to regional hospitals during their medical training, they might have a good
working understanding of these categories.
Most who indicated a ‘city’ preference will be
working in Auckland in PGY1, suggesting that students in the study linked
‘city’ with metropolitan or major centre. By default, any thing
outside this would be ‘regional/rural’. Therefore while our results
are similar when compared to previous studies, the 15% of students intending to
work in the RR setting is below the current proportion of people living in RR
areas.
In future surveys, definitions will be more clearly defined
and examples given. This is being largely driven by a need to standardise
definitions with those being used in an Australasia-wide tracking project
(details available from http://www.medicaldeans.org.au/msod.html)
with similar goals.
Another limitation of this study is the lower response rate
for the 2007 exit survey which occurred for administrative reasons. Despite this
oversight, the overall response was 71%. The 2007 findings were very similar to
the 2006 findings; as there had been no recent major changes in selection or
curriculum we felt that data from these years could reasonably be combined.
There is the possibility of both Type 1 and Type 2 errors because of the small
numbers in some categories, however the power to draw accurate conclusions will
increase as data from more cohorts are included. A range of interventions will
be employed in order to increase the overall response rates in 2008.
There was internal consistency in the responses given in
this study - the majority of graduating students intending to work in RR setting
are interested in general practice with this proportion higher than their
‘city’ intending colleagues. Reassuringly the proportions interested
in general surgery and general medicine were similar between the two groups.
Prior to the introduction of a specific rural origin
selection scheme, graduating University of Auckland medical students show a
comparable level of interest in RR practice when compared to similar studies.
However the proportion of students interested in working in a RR setting is
still below the population percentage living in RR areas.
New rural schemes (ROMPE and Pūkawakawa) have been
introduced to increase interest in regional/rural health and this study provides
a baseline for ongoing evaluation of these programmes. The relatively large
proportion of students undecided on career setting at graduation suggests there
may be room to increase the proportion through formative early postgraduate
experiences, or other incentives. Medical students rate positive experiences on
clinical attachments and role models as important factors in future career
choice. There is no reason to think this would be any different for junior
doctors if more rural attachments were to become available.
Effective educational supervision away from traditional
tertiary teaching hospitals places further demands on a workforce that is
already under threat. It is also relatively expensive. Care needs to be taken to
ensure that RR placements are used optimally, and learners and supervisors are
well-supported by the various stakeholders in medical student and junior doctor
training.
The effects of the introduction of the ROMPE scheme and the
Northland regional/rural programme on RR intentions will be able to be
quantified in the next few years. The aim of these programmes will be to
increase interest in RR health in an attempt to address the shortages that
currently exist. Long-term data from tracking projects will help to unravel the
complex interplay of curriculum and selection policies in order to better inform
educators interested in providing the requisite range of doctors for New
Zealand’s health needs.
Competing interests: None known.
Author information: Thomas Pasley, Clinical
Medical Education Fellow, Faculty of Medical and Health Sciences, University of
Auckland; Phillippa Poole, Associate Dean (Medical Programme), Faculty of
Medical and Health Sciences, University of Auckland
Correspondence: Associate Professor
Phillippa Poole, University of Auckland, Faculty of Medical and Health Sciences,
Private Bag 92019, Auckland, New Zealand. Email: p.poole@auckland.ac.nz
Acknowledgements: The authors acknowledge
the assistance of the following University of Auckland staff: Greg Gamble with
statistical analysis, and Ian Wood and Suani Nasoordeen with accessing the FMHS
Tracking Project data.
References:
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