POLICY DOCUMENT –
Rural Medical Training

BACKGROUND
The New South Wales Medical Students’ Council (NSWMSC) is the peak
representative body for medical students in New South Wales (NSW).
In 2013, the Australian Government Department of Health issued a
projection of the status of Australia’s medical workforce in 2025. Key
features of the report were a declaration of the inevitable shortage and
maldistribution of rural doctors and allied health staff, and the conclusion
that this fate could not be remedied unless concurrent models of funding,
distribution, and clinical training were to change [1]. The underlying aim, as
outlined in the 2004 National Health Workforce Strategic Framework, is to
achieve a state self-sufficiency, whereby Australia’s workforce will no
longer require internationally trained medical graduates to address
workforce maldistribution [2].
Despite 31% of Australians residing outside major urban centres, they have
access to less than half the number of medical practitioners when compared
to Australians living in metropolitan and urban areas [3,4,5]. Whilst
progress has been made towards resolving the fundamental issues (i.e.
federal health funding shortages) that underpin this shortfall, we are
increasingly left with the ever-worsening consequences of workforce
shortages, particularly in rural areas. The specific causative agents for the
worsening maldistribution are numerous, though many can be associated
with the component parts of the medical training pathway, from medical
education through to specialist consultancy. In order to address these causes,
many process have been reconsidered over time. Recruitment policies have
been adapted to ensure that a proportion of commencing students are from
rural areas, and placement policies to ensure that a proportion of students
attend a minimum period of time on rural attachments have also been
implemented [6,7]. However, it should be noted that these rural attachments
in Rural Clinical Schools (RCS) are currently inaccessible by international
students.
Current government funding is structured so as not to support RCS taking
on international students [6]. Despite a recent NSWMSC survey indicating
that 81% of international students training in NSW express the willingness
to practice rurally, the opportunity for international students to develop rural
clinical experience prior to graduation is small. The disparity that exists
between the willingness of international students and the availability of
RCSs placements for international students is one which may potentially be
addressed as a means to combat the maldistribution of rural doctors.
The shortage of rural doctors has generated a significant amount of research
into the factors contributing to the recruitment and retention of medical
students to rural areas. It has been found that the highest predictors of
students developing into rural doctors are:
a. Rural origin [8];
b. Positive rural experiences in late training [8]; or
c. A partner from a rural area [8]
  

Evidence for these predictors is extensive [8,9,10], and has given rise to the
current body of entry and placement policy used by medical schools across
NSW. In 2009, Jones et. al found that, “The strongest predictors of rural
practice intention were generalist intentions, length of rural residence and
holding a scholarship (but not a bonded arrangement)[8].” The sentiment of
their conclusion is echoed in last year’s change to a single-year bonded
contract for entry medical students – the large proportion of students buying
out of the previous five-year bonded contract was doing little for rural
practice’s image – and is a strong support for the positive effect of elective
(and, therefore, competitive) scholarship programs such as the John Flynn
Placement Program, the GP Synergy Scholarship, and the Rural Resident
Cadetship, amongst others, all of which involve some period of time in a
rural area.
While it has been demonstrated that rural and remote placements contribute
to increased retention in these areas it should be noted that these figures fall
post-graduation. This can be attributed to the fact that it is difficult for a
doctor to complete vocational training without doing so in a metropolitan or
urban centre [9]. Thus, in order to significantly address the issue of rural
workforce maldistribution there must be increased support from specialty
colleges to complete vocational training in rural and remote centres.
While both domestic and international medical students express a
willingness to undertake their clinical training at RCSs, there are many
perceived barriers that lead to apprehension when considering undertaking
these placements. Some of these include:
1. Consideration of family/partners [10];
2. Financial issues [10];
3. Prior housing, social, sporting or other commitments [10];
4. Internship and specialty training opportunities [10,11].
Though internship and specialty training opportunities is surely an imposing
barrier, as highlighted above, its treatment would be better addressed by a
policy dedicated to the breadth of the underlying issue of specialty training
locations. The other barriers, however, all lie within the bounds of influence
of the state government, rural hospitals, and medical schools. The latter two,
in particular, are well placed to make changes and policies focused on the
specific issues that compose each of these barriers. General financial
barriers could be mitigated through the provision of additional funding for
the expenses of a placement that requires students to commute or relocate –
a stipend, which may be limited to the reimbursement of costs documented
in advance or in receipt, would allay monetary concerns. This would
particularly be the case for those whose rural medical education might
otherwise be restrained by the need to fulfil concurrent rental contracts.
Ventures into social, sport, and other pastoral commitments are more
difficult to quantify; students may not be able to provide a receipt for
enjoyment lost from missing such commitments, yet the issue is
nevertheless paramount to ensuring positive rural experiences. Currently,
rural placements are often painted with the assurance of smaller, tight-knit
communities – still, there is always room for improvement. More, and
continued efforts by rural clinical schools to involve their medical students
are needed.
  

This policy will focus on the role that positive rural experiences in late
training can play in the recruitment and retention of rural doctors by:
1. Supporting students undertaking rural placements academically,
financially, and socially as community members;
2. Providing possible financial incentives, in the form of scholarship
and subsidies, for undertaking placement rurally;
3. Providing international students with the opportunity to undertake
rural clinical placements.
 

POSITION STATEMENT

NSWMSC acknowledges the important role that RCSs play in both our
state-wide and nationwide health services. In light of ongoing workforce
maldistribution and shortage, we urge consideration of how these
inefficiencies might be corrected, and place particular focus on increasing
the availability and quality of rural clinical school placements to both
domestic and international students. Furthermore, we encourage both
government and medical schools to ensure rural placement are positive
experiences via ensuring adequate support services - both monetary and
social - are available to all students.
  

POLICY

NSWMSC calls upon:

1. The NSW Government to:

1.1. Increase the availability of rural clinical placements;

1.2. Allow international students to access to rural clinical placements;
1.3. Acknowledge the role of Australian trained international students
in addressing the rural workforce shortage;
1.4. Provide financial support, in the form of rural clinical school
funding, for international students to undertake rural placements;
1.5. Widen the footprint of specialist training programs to include rural
centres.

2. NSW Medical Schools to:

2.1. Encourage all students to undertake placements at rural clinical

schools;
2.2. Ensure transparency in dealings with international students, so that
they are made aware of their career prospects after graduation;
2.3. Provide adequate support for students undertaking placements at
rural clinical schools, in the form of:
2.3.1. Funding for accommodation and travel expenses;
2.3.2. Guaranteed access to computer and internet services;
2.3.3. Availability of education resources to an extent that they are
treated equally to their counterparts undertaking
metropolitan placements,
2.3.4. Established staff members and/or methods of contact, to
provide personal support for transitions into rural
communities;
2.4. Provide support for international students to undertake placements
at rural clinical sites by:
2.4.1. Allowing access to rural clinical school placements
2.4.2. Ensuring support, as outlined in 2.3.1, 2.3.2, 2.3.3 and 2.3.4.
2.5. Provide adequate support for clinicians at rural sites to appropriately
teach students at rural clinical schools.
  

REFERENCES:
[1] Australian Department of Health. (2013). Appendix ii: Health
Workforce 2025 - summary. Retrieved from
http://www.health.gov.au/internet/publications/publishing.nsf/Cont
ent/work-review-australian-government-health-workforce-
programs-toc~appendices~appendix-ii-health-workforce-2025-
summary
[2] Australian Health Ministers’ Conference (2004), National Health
Workforce Strategic Framework, Sydney.
[3] Australian Bureau of Statistics. 3235.0 Population by age and sex,
regions of Australia, 2013. Canberra: Australian Government;
2013.
[4] Australian Institute Health and Welfare: Medical Workforce 2012.
National Health Workforce Series no. 8. Cat. no HWL
54.Canberra: AIHW; 2014.
[5] National Rural Health Alliance. Measuring the metropolitan rural
inequity: Fact Sheet 23. Canberra: National Rural Health Alliance;
2010.
[6] Department of Health (2016a) Rural Health Multidisciplinary
Training (RHMT) 2016-2018 – Programme Framework. Retrieved
from
http://www.health.gov.au/internet/main/publishing.nsf/Content/rura
l-health-multidisciplinarytraining-programme-framework.
[7] Mason J. 4.1 Health education strategies for rural distribution.
Review of Australian Government Health Workforce Programs.
Canberra: Australian Government Department of Health and
Aging; 2013.
[8] Jones M, Humphreys J, Prideaux D 2009. Predicting medical
students’ rural practice intentions using data from the Medical
Schools’ Outcome Database. National Rural Health Conference.
2009 [cited 2017 Aug 17]. Available from:
https://ruralhealth.org.au/10thNRHC/10thnrhc.ruralhealth.org.au/pa
pers/docs/Jones_Michael_B7.pdf
[9] Woolley, T., Sen Gupta, T., Murray, R., & Hays, R. (2014).
Predictors of rural practice location for James Cook University
MBBS graduates at postgraduate year 5. Aust J Rural Health,
22(4), 165-171.
[10] Jones GI, DeWitt DE, Cross M. Medical Students’ perceptions of
barriers to training at a rural clinical school. Rural and Remote
Health. 2007 [cited 2013 Sep 3]; 7:685. Available via Wiley Online
Library.
[11] Eley D, Baker P 2005. Does recruitment lead to retention? – Rural
Clinical School training experiences and subsequent intern choices.
Rural and Remote Health. 2005 [cited 2013 Sep 3]; 6(1):511-522.
Available via the Directory of Open Access Journals.
  

This policy was ratified at the NSWMSC Council 3 meeting on October 15th
2017.
_____________________________________________________________
Authored by:

Kirsty Fuller Bal Dhital

The University of Notre Dame, Sydney The University of Newcastle
   

Under the supervision of:

Liam Mason
NSWMSC Advocacy Officer 2017
_____________________________________________________________
Media Contacts:

Liam Mason Ashna Basu

Advocacy Officer 2017 President 2017
NSWMSC NSWMSC
M: +61 432 949 086 M: +61 452 568 694
E: advocacy@nswmsc.org.au E: president@nswmsc.org.au
 

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