Recruiting and retaining

Thursday, August 27th, 2020 | Rory | No Comments

Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects                                                                     

Ogden J, Preston S, Partanen RL, Ostini R, Coxeter P. Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects. Med J Aust. 2020;1–9.

Why is this paper important? 

It brings together the evidence in a formal systematic review and meta-analysis. It only includes papers that look at place of work after completion of postgraduate training. It does not include softer outcomes like intention to practice rurally, undertaking an intern or early PGY/registrar job in a rural area. 

Does is provide any new information? 

Not really. It just reinforces what we know about the 3 proven strategies.

That is:

1) taking students from a rural background,

2) prolonged (and ideally repeated) undergraduate attachments in rural areas and

3) targeted postgraduate training in rural communities.

All these increase the uptake of rural careers – and combining the strategies works even better.

Are there any surprises? 

Not really. There were not a lot of eligible studies, and none from NZ (someone needs to do one).

Many thanks to Associate Professor Garry Nixon and Katelyn Costello for their comments.


Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas.

Study design: Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas.

Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature.

Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies).

Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce.
Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).

Broken? Postgraduate medical education

Tuesday, January 21st, 2020 | Rory | No Comments

Hutten-Czapski P. The ‘Brokenness’ of postgraduate medical education. Can J Rural Med [serial online] 2020 [cited 2020 Jan 21];25:3–4. Available (open access) from:

Seem familiar?

“There is a disconnection in all Canadian postgraduate programmes, from both the medical school mission and community needs’ standpoint.”

A nice editorial that outlines issues familiar to us in NZ. The lack of a coordinated pathway (? is there a better term ?) to rural generalist practice. We eagerly await the results of the survey into the first 10 years of the rural hospital medicine training programme, but this programme only addresses one aspect of rural practice – what about rural general practice? what about rurally based academics?

“Not surprisingly, a longitudinal residency that takes place entirely, or mostly, in rural generalist settings (typically between 4000 and 30,000 population and 150–1000 km distant from a city of over 100,000) is associated with rural practice at an odds ratio of 3.9.”

Rural Simulation Faculty Development Plan

Monday, January 20th, 2020 | Rory | No Comments

The simulation team that put on the rural inter professional simulation course have developed a Rural Simulation Faculty Development Plan.

This useful document provides a pathway that those that are interested can follow to up-skill in simulation and debriefing.

Look forward to more simulation resources being made available – and perhaps a repository of NZ rural cases and scenarios that we can contribute to and access.

Check out the Rural Health Academic Centre, Ashburton (RHACA)  (permanent link in the side bar) and I know Marc and Sampsa will welcome any correspondence. Drop them a line!

click here to access the document in full (PDF)



The Rural Simulation Faculty vision is of a pool of inter-professional faculty with expertise around simulation-based education (SBE) and debriefing who can all contribute to all rural simulation courses as needed. The group of rural courses should be strategically planned each year by the whole group to maximise value and demand. Each course will have designated course directors or leaders but can expect assistance from all faculty group members as available.




  • Establish a broad interprofessional rural group of SBE faculty across NZ.
  • Describe a common pathway for rural faculty to be credentialled as course providers through a shared understanding and experience of SBE
  • Maintenance and development of simulation expertise through feedback, mentoring and sharing of learning resources
  • Develop opportunities for learning, developing and collaborating using simulation-based education.
  • Design interprofessional educational courses for rural health care workers.
  • Research and evaluation of rural SBE



Rural simulation faculty development stream:


  1. Open for all doctors, GP’s, nurses, paramedics, allied health and midwives involved in rural health care at all levels of training.
  2. Faculty development stream comprises 7 components within three tiers, with stepwise progression through.
  3. Participation is purely voluntary and is expected to be self directed

The best not quite there yet…

Tuesday, November 19th, 2019 | Rory | No Comments

Hutten‐Czapski P. Is Northern Ontario School of Medicine there yet? Can J Rural Med 2019;24:103‐4.

Full text available at the CJRM website

This editorial is in the latest edition of the Canadian Journal of Rural Medicine. The Northern Ontario School of Medicine is considered the gold standard in rural medical education. But it appears that rural communities in Northern Ontario are still more likely to see medical students than the finished product, and most of the graduates are still headed to the cities; albeit the provincial cities in Northern Ontario.

This tells us what we already know. It’s not easy, and it’s important not to confuse workforce success in provincial centres with success in rural areas.

I am however sure we still have much to learn from NOSM.

Thanks to Assoc. Prof Nixon for the commentary

Tracking the students

Friday, May 24th, 2019 | Rory | No Comments

Poole P, Wilkinson TJ, Bagg W, Freegard J, Hyland F, Jo E, et al. Developing New Zealand’s medical workforce: realising the potential of longitudinal career tracking. New Zealand Medical Journal. 2019;132(1495):9.

“Some of the key findings to date are:

  • Most New Zealand graduates wish to work in New Zealand.
  • Rural background is very important in rural career intention, justifying the rural preferential entry pathways to New Zealand medical schools.
  • Over time, fewer New Zealand students have an urban career intention, while rural and remote medicine is emerging as a career path.
  • Student perception places the major influence on career intention as ‘atmosphere/work culture typical of the discipline’. The importance of a range of positive undergraduate and early postgraduate experiences cannot be overstated, especially since most students are undecided at graduation. Specialties finding it difficult to attract sufficient numbers of trainees need to address factors that affect student choices“.

Note that rural is defined as ‘rural-regional’ (from location <100 000 population)


For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected survey information from medical students and junior doctors in Australia and New Zealand to look at social, demographic and training effects on career intentions. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results, and future directions.


For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected data from medical students in Australia and New Zealand. This project aims to explore how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results and future directions.

Reflections on rural medical schools

Thursday, April 11th, 2019 | Rory | No Comments

Two articles in the latest edition of the Journal of Primary Care on rural medical schools for New Zealand. Dr. John Burton writes a piece on his time at the Northern Ontario Medical School and reflects what that experience means in the NZ context.

Burton John (2019) Experiencing a rural medical school. Journal of Primary Health Care 11, 6-11.

Open access

The other is a guest editorial by Dr. Garry Nixon and Dr. Ross Lawrenson contextualising this in the current political climate. Hopefully the health minister has a read (and he might of given the comments at the National Rural Health Conference). Fingers crossed

Nixon Garry, Lawrenson Ross (2019) Failing to thrive: academic rural health in New Zealand. Journal of Primary Health Care 11, 4-5.

Open access

More sense from Australia?

Tuesday, March 5th, 2019 | Rory | No Comments

Benefits of a rural clinical school: An Australian experience

McGirr J, Seal A, Barnard A, Cheek C, Garne D, Greenhill J, Kondalsamy-Chennakesavan S, Luscombe GM, May J, Mc Leod J, O’Sullivan B, Playford D, Wright J. The Australian Rural Clinical School (RCS) program supports rural medical workforce: evidence from a cross-sectional study of 12 RCSs. Rural and Remote Health 2019; 19: 4971.

Open access link

An important paper on rural clinical school outcomes in Australia. What we need to aim for in NZ.

The MMM (modified monash model) is a better indicator of what we would consider ‘rural’ in NZ and that analysis is more relevant.

The take home message – rural origin programmes, yearlong placements in rural communities for undergraduates (the RMIP model) work. There is less evidence for short term rural placements. Rurally focused postgrad training may be at least, if not more important.

Overall 29% of Australian med students in this study undertook a year long RMIP type programme. RMIP is only 6% of the Uni Otago class. We need a more realistic target.



Introduction: Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs’ 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background.

Methods: All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2–5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a ‘rural’ area (ASGC categories RA2–5 or MMM categories 3–7) or ‘metropolitan’ area. Pearson’s χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated.

Results: Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3–76.6% and the proportion who had participated in extended RCS placement had a range of 13.7–74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8–55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3–7), range 4.5–29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2–2.1, p=0.004) using ASGC criteria. Using the MMM 3–7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8–3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system (ASGC, MMM) used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally.

Conclusion: Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.

Development of the Rural Inter-professional Simulation Course

Monday, February 18th, 2019 | Rory | No Comments


Gutenstein M, Kiuru S, Withington S. Development of a Rural Inter-professional Simulation Course: an initiative to improve trauma and emergency team management in New Zealand rural hospitals. Journal of Primary Health Care [Internet]. 2019 [cited 2019 Feb 17]; Available from (Open Access):

Fresh publication from three conveners from the Rural Postgraduate Programme and founders of the RISC. A very topical publication especially given two papers recently published (by the same author) in two Australian Journals detailing that rural doctors want and need more training in emergency and trauma.(1,2) Perhaps NZ is ahead of the game on this one!

Information about RISC


BACKGROUND AND CONTEXT: New Zealand is a largely rural nation. Despite the regionalisation of trauma services, rural hospitals continue to provide trauma and emergency care. A dedicated rural inter-professional team-based simulation course was designed, as part of a wider strat- egy of using simulation-based education to address the disparity in experience and training for rural hospital teams providing emergency and trauma care.

ASSESSMENT: A pre-course questionnaire identified learning needs. Post-course evaluationand a follow-up survey assessed participants’ perception of the course, and whether lasting changes in clinical or organisational practice occurred.

RESULTS: Three courses were provided over 2 years to 60 interprofessional participants from eight rural hospitals. The course employed an interprofessional faculty and used skill work-shops and high-fidelity trauma simulations to address learning needs identified in pre-courseresearch. Evaluation showed the course to be an effective learning experience for partici- pants. The post-course survey indicated possible lasting changes in team performance and rural hospital protocols. This educational strategy also allowed the collection of research data for investigating rural team dynamics and interprofessional learning.

STRATEGIES FOR IMPROVEMENT: Further development of rural interprofessional simulation courses should include more diverse clinical content, including paediatric and medical sce-narios. Participant access was sometimes limited by typical rural challenges such as hospital staffing and locum availability.

LESSONS: Rural simulation-based education is both effective for rural trauma team training and a vehicle for rural research; however, there are challenges to participant access and course sustainability, which echo the rural–urban disparity.


1. Pandit T, Ray R, Sabesan S. Review article: Managing medical emergencies in rural Australia: A systematic review of the training needs. Emergency Medicine Australasia. 2019;31(1):20–8.

2. Pandit T, Sabesan S, Ray RA. Medical emergencies in rural North Queensland: Doctors perceptions of the training needs. Australian Journal of Rural Health. 2018;26(6):422–8.