Journal Search

Journal Search - issue 4, 2007


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Paul Worley1
PhD, Editor in Chief *


* Paul Worley


1 Rural and Remote Health


21 December 2007 Volume 7 Issue 4


RECEIVED: 13 December 2007

ACCEPTED: 21 December 2007


Worley P.  Journal Search - issue 4, 2007. Rural and Remote Health 2007; 7: 922. Available: www.rrh.org.au/journal/article/922


© Paul Worley 2007 A licence to publish this material has been given to ARHEN, arhen.org.au

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Journal Search brings Rural and Remote Health users information about relevant recent publications. This issue includes recent publications in North American and Australian rural health journals.


Journal Canadien de la M├ędecine Rural/Canadian Journal of Rural Medicine
[in French and English]
Contents, 2007; 12: (4) Fall 2007 / Automne 2007
Issue includes:

Nurse-Physician Collaborative Partnership: a rural model for the chronically ill
Craig Mitton, David O'Neil, Liz Simpson, Yvonne Hoppins, Sue Harcus

Introduction: Accessibility and quality of primary health care services in rural areas are challenging issues, particularly for the elderly and those with chronic or complex medical conditions. The objective of the Nurse-Physician Collaborative Partnership was to implement and evaluate a collaborative partnership between homecare nurses and family physicians in the rural Trochu-Delburne-Elnora area of Alberta.
Methods: Overall, 37 patients were enrolled in a shared care plan, which included comprehensive biopsychosocial assessment, early intervention, health education and self-management. Patient and provider outcomes were assessed using quantitative and qualitative data collected at baseline, 6 months and 12 months.
Results: Results showed that patients made improvements in activities of daily living and robust cognitive status. In interviews, patients reported improvements in psychological well-being, knowledge of disease processes and confidence to manage health issues. Patients' use of acute health care services decreased, showing a 51% reduction in the number of days in hospital, a 32% reduction in emergency department visits and a 25% reduction in hospital admissions. Total acute service costs, excluding program costs, decreased by 40% from an average of $15 485 to $9313 per person (p ≤ 0.05).
Conclusion: Based on these results, policy initiatives that incorporate the shared care model developed in this project may be considered. To our knowledge, this type of evaluation has not previously been conducted in a rural Canadian setting.

Factors associated with career satisfaction among general practitioners in Canada
Rein Lepnurm, Roy Dobson, Allen Backman, David Keegan

Introduction: There are important differences in rural, regional and urban general practice environments. The purpose of this study was to articulate models that explain career satisfaction among general practitioners (GPs) in these practice environments.
Methods: Of 4958 eligible physicians across Canada, 2810 (56.7%) completed a 12-page survey between January and March 2004, from whom a total of 256 GPs in rural, regional and urban communities were selected. Response bias was checked and found to be negligible. We used hierarchical regression analysis to record cumulative R2, standardized beta and significance levels as each predictor was entered. We applied weighting factors to reflect the actual physician population in Canada.
Results: The models explained 88.5% of the variance in career satisfaction for GPs in small towns, 88.9% for GPs in regional communities and 86.3% for GPs in urban cities. The explanatory variables consisted of distress and coping, role in community activities, the quality of health care services and access to them, intrinsic and extrinsic rewards, workload and organizational structure.
Conclusion: Career satisfaction for small-town doctors is associated with being able to cope with stress in handling a wide variety of clinical conditions, largely on their own, but with effective collaboration from physicians in larger centres. Rural GPs also enjoy academic responsibilities. Satisfaction for GPs in regional communities also depends on coping with stress and the ability to maintain an efficiently operating set of secondary-level health services in their community. Satisfaction for urban GPs is associated with collegiality, which dampens stress, and access to a full range of health services, including community, hospital, mental health and rehabilitation services. Career satisfaction for all GPs is associated with equity, manageable workloads and effective practice management; however, all of these professional issues contribute, in small increments, to satisfaction.

The ARTS of risk management in rural and remote medicine
Frederic B. McConnel, Dennis Pashen

Introduction: This paper describes an action research process (in which the researchers are active participants throughout the process of development, testing and refinement) to develop a framework for clinical risk assessment and management in the context of rural and remote medicine. The framework is needed to support educational, medicolegal and quality improvement processes in rural and remote medical practice.
Methods: The research process included identifying a problem and gradually developing a research question, developing a potential model for application in a specific context, refining the tool and piloting the tool in a limited context. The research question and framework were developed during a series of teleconferences under the aegis of the Censorial Panel of the Australian College of Rural and Remote Medicine (ACRRM). After the framework was developed and refined, it was tested at a workshop in conjunction with the ACRRM Scientific Forum in Alice Springs, Australia, in July 2004. Workshop participants were principally but not exclusively rural medical practitioners from across Australia. The main outcome measure was a working framework for risk management broadly applicable in rural and remote medicine.
Results: The process clarified differences between safety and quality approaches in metropolitan and rural and remote medical practice, culminating in an appropriate clinical risk management framework.
Conclusion: The action research as undertaken resulted in a workable risk management framework that is worthy of further development and that may be a valuable educational tool, both for existing practitioners and for future rural doctors. Further, it has potential as a means of providing legal protection to rural practitioners when actual rural practice is at odds with "best practice" as defined by a metropolitan group of experts.

A large splenic epidermoid cyst in rural Labrador
Colin Clarkson, Narsing Pradhan

Splenic cysts are rare clinical entities, reportedly occurring in only 0.5%-2.0% of the population.1 The first splenic cyst was reported in 1829 by Andral,2 and with the increasing use of diagnostic imaging, splenic cysts are now more commonly being diagnosed incidentally.3 We report the case of a splenic cyst in an 18-year-old man who initially presented to a remote nursing station in Labrador with non-specific abdominal complaints. After being transferred to a community hospital, the patient was found to have a very large splenic cyst and he subsequently underwent a total splenectomy with the removal of an associated epidermoid cyst.


Journal of Rural Health

Contents: 2007; 23: (2)
Issue includes:

Physical Health, Illicit Drug Use, and Demographic Characteristics in Rural Stimulant Users
Thomas F. Garrity, Carl G. Leukefeld, Robert G. Carlson, Russel S. Falck, Jichuan Wang, and Brenda M. Booth

Context: There is growing concern about illicit rural stimulant use, especially regarding methamphetamine use and its health consequences.
Purpose: The present study describes associations between aspects of stimulant use and illness experience in rural areas, with additional focus on the role of demographic characteristics in these associations.
Methods: The research participants were 710 stimulant drug users who were recruited from rural areas of Arkansas, Kentucky, and Ohio using Heckathorn's respondent-driven sampling method. Health was measured by self-reports of perceived health and extent of current, recent, and lifelong health problems. Drug use was measured with self-reports of type and frequency of use.
Findings: Several associations were found between drug use and illness, controlling for demographics. Stimulant use pattern related significantly with the sum of health problems in the previous 6 months and the sum of lifetime illness diagnoses, after adjustment for demographic factors. Extent of illicit drug use in the past month and self-perceived drug and alcohol problems were associated with several measures of health.
Conclusions: In this sample of stimulant users, methamphetamine use was associated with fewer recent medical problems than crack cocaine, combined crack and powder cocaine use, and use of all 3 of these stimulants. These results, across the 3 sites, suggest that prevalent assumptions about the methamphetamine "plague" and its negative health consequences must be viewed cautiously and examined with additional research.

Use of Critical Access Hospital Emergency Rooms by Patients With Mental Health Symptoms
David Hartley, Erika C. Ziller, Stephenie L. Loux, John A. Gale, David Lambert, and Anush E. Yousefian

Context: National data demonstrate that mental health (MH) visits to the emergency room (ER) comprise a small, but not inconsequential, proportion of all visits; however, we lack a rural picture of this issue.
Purpose: This study investigates the use of critical access hospital (CAH) ERs by patients with MH problems to understand the role these facilities play in rural MH needs and the challenges they face.
Methods: Primary data were collected through the combination of a telephone survey and ER visit logs. Our sampling frame was the universe of CAHs at the time the survey was fielded.
Key Findings: About 43% of CAHs surveyed operate in communities with no MH services, while 9.4% of all logged visits were by patients identified as having some type of MH problem. The most common problems identified were affective disorders, substance abuse, anxiety, and psychotic disorders. Only 32% of CAHs have access to on-site detoxification and 2% have inpatient psychiatric services, meaning that patients in need of these services typically must leave their communities to gain treatment.
Conclusions: The lack of community resources may impact CAHs' ability to assist patients with MH problems. Among those with a primary MH condition, 21% left the ER with no or unknown treatment, as did 51% of patients whose MH condition was secondary to their emergent problem. Patients in need of detoxification or inpatient psychiatric services often must travel over an hour to obtain these services, potentially creating significant issues for themselves and their families.

The Health Trade-off of Rural Residence for Impaired Older Adults: Longer Life, More Impairment
James N. Laditka, Sarah B. Laditka, Bankole Olatosi, and Keith T. Elder

Context: Years lived with and without physical impairment are central measures of public health.
Purpose: We sought to determine whether these measures differed between rural and urban residents who were impaired at the time of a baseline measurement. We examined 16 subgroups defined by rural/urban residence, gender, race, and education.
Methods: This is a 20-year retrospective cohort study, following 2,939 Americans who were aged 65-69 in 1982 and physically impaired at the time of the baseline measurement, with data from the National Long-Term Care Survey. Interpolated Markov chain analysis and microsimulation estimated life expectancy at age 65 and expected number of years with physical impairment. Impairment was defined as requiring help in 1 or more activities of daily living.
Findings: Among older individuals with physical impairments at baseline, rural residents lived notably longer than urban residents. In all but 1 group, rural residents lived more years with physical impairment, and they also had a notably larger proportion of remaining life impaired.
Conclusions: Results suggest a notable public health impact of rural residence for impaired individuals, a longer expected period of impairment. Needs for services for people with impairments may be greater in rural areas.

Predicting Rural Practice Using Different Definitions to Classify Medical School Applicants as Having a Rural Upbringing
John A. Owen, Mark R. Conaway, Beth A. Bailey, and Gregory F. Hayden

Purpose: This study determines the relationship between a medical school applicant's rural background and the likelihood of rural practice using different definitions of rural background.
Methods: Cohort study of 599 physicians who entered the University of Virginia School of Medicine in 1990-1995 and graduated in 1994-1999. The "rurality" of the applicants' backgrounds was assessed by coding applicants' high school, college, and permanent addresses using 4 definitions of rural. In addition, most physicians responded to a survey question "Did you grow up in a rural area?" The same 4 definitions of rural were used to assess the rurality of practice locations. Logistic regression models were used to predict the simultaneous effect of different definitions of rural background, gender, and applicants' career preference at matriculation on the probability of practicing in rural areas.
Findings: In univariate analyses, the high school, college, and permanent addresses were all predictive of rural practice using 1 or more definitions of rural. In the multivariate analysis, only the "grew up rural" self-description was predictive of rural practice location using 3 of the definitions of rural. In a secondary analysis, the grew up rural self-description and applicants' career preferences at matriculation were predictors of rural practice.
Conclusions: Readily available addresses were predictive of rural practice. In a multivariate analysis, physicians' self-description about having grown up in a rural area was the best predictor of rural practice. Recruiting more applicants who match this definition of rural background should increase the number of rural physicians.

Recruitment of Physicians To Rural America: A View Through the Lens of Transaction Cost Theory
J. Matthew Fannin, and James N. Barnes

Context: Many rural hospitals in the United States continue to have difficulties recruiting physicians. While several studies have examined some of the factors affecting the nature of this problem, we know far less about the role of economic incentives between rural providers and physicians.
Purpose: This conceptual article describes an economic theory of organization called Transaction Cost Theory (TCT) and applies it to rural hospital-physician relationships to highlight how transaction costs affect the type of contractual arrangement used by rural hospitals when recruiting physicians.
Methods: The literature is reviewed to introduce TCT, describe current trends in hospital contracting with physicians, and develop a TCT contracting model for analysis of rural hospital-physician recruitment.
Findings: The TCT model predicts that hospitals tend to favor contractual arrangements in which physicians are full-time employees if investments in physical or other assets made by hospitals cannot be easily redeployed for other services in the health care system. Transaction costs related to motivation and coordination of physician services are the key factors in understanding the unique contractual difficulties faced by rural providers.
Conclusions: The TCT model can be used by rural hospital administrators to assess economic incentives for physician recruitment.

Rural/Urban Differences in Barriers to and Burden of Care for Children With Special Health Care Needs
Asheley Cockrell Skinner, and Rebecca T. Slifkin

Purpose: To examine the barriers and difficulties experienced by rural families of children with special health care needs (CSHCN) in caring for their children.
Methods: The National Survey of Children with Special Health Care Needs was used to examine rural-urban differences in types of providers used, reasons CSHCN had unmet health care needs, insurance and financial difficulties encountered, and the family burden of providing the child's medical care. We present both unadjusted and adjusted results to allow consideration of the causes of rural-urban differences.
Findings: Rural CSHCN are less likely to be seen by a pediatrician than urban children. They are more likely to have unmet health care needs due to transportation difficulties or because care was not available in the area; there were minimal other differences in barriers to care. Families of rural CSHCN are more likely to report financial difficulties associated with their children's medical needs and more likely to provide care at home for their children.
Conclusions: Examining results from both unadjusted and adjusted odds ratios shows that the burden of care for families of rural CSHCN stems both from socioeconomic differences and health system differences. Policies aimed at achieving equity for rural children will require focusing on both individual factors and the health care infrastructure, including increasing insurance coverage to lessen financial difficulties and addressing the availability of providers in rural areas.

Fatal Passenger Vehicle Crashes With At Least 1 Driver Younger Than 15 Years: A Fatality Analysis Reporting System Study
Larry Frisch, and Alexander Plessinger

Context: A small number of fatalities continue to occur due to motor vehicle crashes on highways in which at least 1 passenger vehicle (automobile, van, or small truck) is driven by a child younger than 15 years.
Purpose: The purpose of this study was to extend previous work suggesting that such crashes occur frequently in the Southern states and have relatively high rates in rural areas in the South and Great Plains.
Methods: This study utilizes data for the 5-year period 1999-2003 from the National Highway Transportation Safety Administration's online Fatality Analysis Reporting System. All cases were identified in which at least 1 conventional passenger vehicle in a fatal crash was being driven by a child younger than 15 years.
Findings: During the 5-year period, 350 fatal crashes occurred with at least 1 driver younger than 15 years involved. Twenty-one of these drivers were licensed (11) or driving with a learner's permit (10). A total of 987 individuals in 419 vehicles were involved in these crashes, and 402 deaths resulted (1.16 deaths/crash). These crashes occurred primarily in Texas, Florida, Arkansas, and Arizona, but the highest rates per 100,000 children were found in North and South Dakota and predominantly in a band of Intermountain and Plains states. There was a strong correlation between crash rates and several measures of rurality.
Conclusions: Crashes involving young, largely unlicensed, drivers account for about 70 deaths yearly.

Rural Versus Suburban Primary Care Needs, Utilization, and Satisfaction With Telepsychiatric Consultation
Donald M. Hilty, Thomas S. Nesbitt, Christina A. Kuenneth, Grace M. Cruz, and Robert E. Hales

Context and Purpose: Rural and suburban populations remain underserved in terms of psychiatric services but have not been compared directly in terms of using telepsychiatry.
Methods: Patient demographics, reasons for consultation, diagnosis, and alternatives to telepsychiatric consultation were collected for 200 consecutive, first-time telepsychiatric consultations at rural and suburban clinics.
Findings: Rural patients were more likely than suburban patients to be younger than 18 years, using Medicaid, and needing treatment planning (lest they be referred out of the community). Rural patient and primary care physician satisfaction was higher than that of suburban counterparts.
Conclusion: Telepsychiatry programs may enhance access, satisfaction, and quality of rural care.

Information Seeking and Intentions to Have Genetic Testing for Hereditary Cancers in Rural and Appalachian Kentuckians
Kimberly M. Kelly, James E. Andrews, Donald O. Case, Suzanne L. Allard, and J. David Johnson

Context: Research is limited regarding the potential of genetic testing for cancer risk in rural Appalachia.
Purpose: This study examined perceptions of genetic testing in a population sample of Kentuckians, with a focus on Appalachian and rural differences. The goals were to examine cultural and psychosocial factors that may predict intentions to test for hereditary cancer, need for help with information seeking for decision making about genetic testing for hereditary cancer, and amount of help needed with information seeking for decision making about genetic testing for hereditary cancer in this population.
Methods: Analysis of data from a general social survey of adults using random-digit dialing in Kentucky (N = 882).
Findings: An ordinal regression found that younger age, having a family history of cancer, and greater worry predicted greater intentions to seek genetic testing. A logistic regression found that having more education, excellent subjective knowledge of genetics, and less worry about cancer predicted less need for help in seeking information about testing. An ordinal regression found that less subjective knowledge of genetics and greater worry predicted greater amount of help needed.
Conclusions: Additional counseling to explain limitations of genetic testing may be needed. Further, those with less knowledge about genetics and more worry about hereditary cancer may have greater need for help with information seeking for decision making, a need that may be further exacerbated by the lack of medical professionals, particularly genetic counselors, who may provide information about genetic testing in rural, Appalachian Kentucky.

Prioritizing Threats to Patient Safety in Rural Primary Care
Ranjit Singh, Ashok Singh, Timothy J. Servoss, and Gurdev Singh

Context: Rural primary care is a complex environment in which multiple patient safety challenges can arise. To make progress in improving safety with limited resources, each practice needs to identify those safety problems that pose the greatest threat to patients and focus efforts on these.
Purpose: To describe and field-test a novel approach to prioritizing safety problems in rural primary care based on the method of Failure Modes and Effects Analysis.
Methods: A survey instrument designed to assess perceptions of medical error frequency, severity, and cause was administered anonymously to staff of 2 rural primary care practices in New York State. Responses were converted to quantitative hazard scores, which were used to make priority rankings of safety problems. Concordance analysis was conducted.
Results: Response rate was 94% at each site. Analysis yielded a list of priorities for each site. Comparison between staff groups (provider vs nursing vs administration), based on the top 10 priorities perceived by staff, showed 53% concordance at one site and 30% at the other. Concordance between sites was lower, at 20%.
Conclusions: Initial field-testing of a Failure Modes and Effects Analysis approach in rural primary care suggests that it is feasible and can be used to estimate, based on staff perceptions, the greatest threats to patient safety in an individual practice so that limited resources can be focused appropriately. Higher concordance between staff within a practice than between practices lends preliminary support to the validity of the approach.

Improving Work Environment Perceptions for Nurses Employed in a Rural Setting
Susan L. Teasley, Kathleen A. Sexton, Cathryn A. Carroll, Karen S. Cox, Michele Riley, Kathleen Ferriell

Context: Effective recruitment and retention of professional nurses is a survival strategy for health care facilities, especially in rural areas.
Purpose: This study examines the use of the Individual Workload Perception Scale to measure nurse satisfaction by a small rural hospital in order to make positive changes in the work environment for nurses.
Methods: Baseline work environment perceptions of nurses employed in a rural Kentucky hospital were assessed using the Individual Workload Perception Scale, a validated 38-item instrument. Nurses reviewed the results and brainstormed on potential interventions to address areas of concern. The 4 interventions selected for implementation by the nursing staff included (1) implementation of a shared decision making or governance model; (2) enhanced role of licensed practical nurses within the organization; (3) augmentation of administrative support on night and weekend shifts; and (4) utilization of wireless communication devices. After implementation of the interventions, staff nurse perceptions were reassessed using the same tool.
Findings: The follow-up survey revealed improvements in all areas measured by the Individual Workload Perception Scale, with the greatest improvement in the perception of the work environment noted among night nurses. The increase in positive work environment perception among these nurses, with greater than or equal to 11 years of professional experience, was statistically significant.
Conclusions: Tools exist to support the development and evaluation of interventions to improve the work environment for nurses practicing in rural health care settings. By addressing issues of specific concern, both job satisfaction and retention of this talented pool of professionals can be enhanced.

Evaluation of a Medical School for Rural Doctors
Kazuo Inoue, MD, PhD;1 Masatoshi Matsumoto, and Tsutomu Sawada

Context: Jichi Medical School (JMS) is the first and only medical school in Japan that was founded exclusively to graduate/prepare rural doctors.
Purpose: To evaluate the long-term effect of JMS on the nationwide distribution of doctors.
Methods: Data from the Japanese population census of 1995 and from the Japanese physician census of 1994 were combined for use in this study. We extracted the JMS graduates from the physician census and compared the distribution of JMS graduates to that of non-JMS graduates. JMS graduates have an obligation to work in rural areas for 9 years after graduation. Therefore, we divided them into those doctors who were either "under rural duty" or "after rural duty."
Findings: JMS graduates were more likely than non-JMS physicians to practice in rural municipalities. The percentage of JMS graduates practicing under rural duty in communities meeting at least 1 of 4 possible criteria for being considered rural was 2.7 times greater than the percentage of non-JMS graduates in such communities. The percentage of JMS graduates practicing after rural duty in communities meeting at least 1 rural criterion was 2 times that of non-JMS graduates. The JMS graduates accounted for only 0.7% of all the physicians in Japan. However, they accounted for 4.2%, 1.5%, 1.8%, and 3.0% of the physicians in small population, remote, mountain, and medically underserved municipalities, respectively.
Conclusions: The goal of JMS to produce rural doctors in Japan has made an impact on doctor distribution nationwide.


Australian Journal of Rural Health

2007; 15: (6)
issue includes:

Extending rural and remote medicine with a new type of health worker: Physician assistants
Teresa M. O'Connor and Roderick S. Hooker

The purpose of this paper was to demonstrate that the medical workforce shortage is an international phenomenon and to review one of the strategies developed in the USA in the late 1960s: the physician assistant model of health service provision. The authors consider whether this model could provide one strategy to help address the medical workforce shortage in Australia. A systematic review of the literature about medical workforce shortages, strategies used to address the medical workforce shortage, and the physician assistant role was undertaken. Literature used for the review covered the period 1967-2006. Physician assistants provide safe, high-quality and cost-effective primary care services under the direction of a doctor and respond to workforce shortages in rural and remote areas, family practice medicine and hospital settings. This model of health care provision has been adopted in several other developed countries, including England, Scotland, the Netherlands and Canada. The physician assistant concept might provide Australia with a novel strategy for addressing its medical workforce shortage, particularly in rural and remote settings.

Evaluating the effectiveness of a university health sciences experience program for regional Year 10 students
Joy Penman, Bronwyn Ellis, Frances White and Gary Misan

Objective: The main aim of this pilot program was to raise secondary students' awareness of university studies and careers in the health sciences through a three-day program. Further aims of the program were to increase the participants' knowledge of health issues through group activities, and provide an opportunity to interact with university staff and health professionals.
Design: The participants were surveyed at the conclusion of the program using an online questionnaire (30 items) consisting of both open and closed questions.
Setting: The program and evaluation were carried out at a regional campus of a metropolitan-based university during the mid-year vacation.
Participants: Fourteen Year 10 students (11 female, 3 male; 5 from government schools, 9 from a non-government school) from a regional city completed the evaluation.
Main outcome measures: Satisfaction with the program, increased awareness of pathways into university, and changes in attitude about university as a career option.
Results: The evaluation revealed that the participants had had a pleasant learning experience, which had led them to feel positive about university studies in general and as an option for themselves. They made useful suggestions for improvements.
Conclusion: The evaluation of the effectiveness of the program showed that it had achieved its objectives. It also provided the program organisers with insights regarding timing and activities, which will be useful in improving future programs targeting secondary students.

Recruitment and retention of rural general practitioners: A marketing approach reveals new possibilities
Elizabeth Hemphill, Steve Dunn, Hayley Barich1and Rebecca Infante

Objective: This paper repositions the challenge of attracting and retaining rural GPs in a marketing context as a new focus for future research and policy development.
Design: Case study with mixed design of surveys of GPs and medical students and depth interviews with GPs, medical students, regional-division administrators and GP recruitment agents.
Setting: GP recruitment and retention in the Limestone Coast region of South Australia.
Participants: Twenty-seven Limestone Coast (LC) GPs; random sample of medical students from Adelaide University, Adelaide University Rural Health Society and Flinders University; snowball sampling two adjacent rural regions (20 GPs); and administrators from LC and adjacent regions and GP recruitment agencies in Adelaide.
Main outcome measures: Drawing from marketing theory, creative suggestion of 'promotion of the practice and not the region' offers a means of GP recruitment and retention for structured succession planning for rural general practices.
Results: Structural attempts to broaden the GP market with overseas recruitment have done little for improving full-time equivalent GP levels. Market segmentation and market orientation offer a new emphasis on value exchange between the corporation (the practice), customer (GPs) and competition (all practices) to influence future mobility.
Conclusion: A marketing orientation to the GP challenge emphasises individual's perceptions of value, GP expectations and practice offerings. Failure to acknowledge benefits of this marketing approach means that solutions such as those developed in the Limestone Coast region are unlikely. Research is now required to define GP satisfaction and value for long-term viability of general practices.

Rural and remote health research: Key issues for health providers in southern Queensland
Rob M. Eley, Peter G Baker

Objective: To determine what community health service providers in rural southern Queensland considered were major issues affecting their efficacy. Results will inform the future research strategy of the Centre for Rural and Remote Area Health with the aim of addressing specific regional needs.
Design: Interactive research workshops.
Setting: Health providers and other key stakeholders.
Subjects: Participants from organisations directly involved with health care were complemented by representatives from local government, the police service and church groups.
Main outcome measures: The workshops used the nominal group technique to identify what participants considered were key health issues in their locations. These issues were then prioritised by the participants. Thematic analysis of the issues generated a ranking of themes by importance. Results were compared with a similar exercise undertaken in 2003.
Results: Seventeen themes were identified, with workforce by far the major concern of health providers. Recruitment and retention of health workers were the principal issues of concern. The other four highest ranked themes across all workshops were mental health care, access to health services, perceptions and expectations of consumers, and interagency cooperation. The workshops provided important information to the Centre for Rural and Remote Area Health for developing research strategy. Additionally, new alliances among health providers were developed which will support sharing of information and resources.
Conclusion: The workshops enabled organisations to meet and identify the key health issues and supported research planning. New alliances among health providers were forged, and collaborative research avenues are being explored. The workshop forum is an excellent means of information exchange.

Primary health care in the Kimberley: Is the doctor shortage much bigger than we think?
Sally Roach, David Atkinson, Andrew Waters and Felicity Jefferies

Objective: This study describes the extent to which general practitioners in the Kimberley region are available for doctor-provided primary care and relates primary care availability to need and standardised population.
Design: Data collection and analysis was based on government statistics and interviews with general practitioners, local managers and regional employers and organisations.
Results: A shortfall of 20.6 full time general practitioner positions was identified and this was aggravated by a significant number of unfilled positions in the areas of greatest need. Overall the region had only half the primary care general practitioners needed. The Shire of Halls Creek at the time of survey had less than a quarter of the doctors required based on this analysis.
Conclusion: Steps to increase the Australian medical workforce have begun but resources to recruit, support and sustain this workforce are required. Aboriginal health workers and locally trained nurses competently provide much of the primary care but need greater resources to support the available medical care.

Physiotherapy in rural and regional Australia
Elizabeth Williams, Wendy D'Amore and Joan McMeeken

Objective: To inform rural physiotherapy recruitment and retention strategies by describing physiotherapists in the Shepparton region: reasons for career choice, education and physiotherapy professional issues.
Design: Survey.
Setting: Health service providers.
Participants: Practising and non-practising physiotherapists.
Main outcome measure: Survey responses.
Results: Survey response rate 79%. Eighty four physiotherapists (79 practicing and 5 non-practicing; 80% female) clustered in main regional centres responded. Two-thirds worked part-time with most in the public sector (70%), with one third holding more than one position. One-third considered themselves generalists and one-third specialists. Physiotherapy was first career choice for 83% who made this decision between 14 and 19 years old (16.8-2.5 years) because of contact with a physiotherapist. Professional issues challenging physiotherapists in a rural location are compounded by lack of career path, professional support, access to professional development and postgraduate education. Additional issues are the costs and time to attend courses and conferences, travel/distance, and inadequate resources. Positive elements of rural practice were part-time employment opportunities, independence as primary health providers, practice variety and community recognition.
Conclusion: Rural physiotherapy recruitment and retention strategies must address resource shortcomings by developing career paths, access to postgraduate education and support. Enhancing workforce capacity could enable more students to have meaningful rural experience to assist recruitment. Strategies highlighting existing positive features of rural practice, reinforced with tangible rewards and recognition of physiotherapists' contribution to the health care of Australians are recommended.