Journal of the New Zealand Medical Association, 03-April-2009, Vol 122 No 1292
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.
Graduating 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.
The 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)
This 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: email@example.com
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.
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