Rural student entry into a medical course : a South Australian rural high school perspective

Introduction: Rural background is an acknowledged predictor of later rural medical practice. This study aimed to explore why only small numbers of high school students from rural South Australia seek entry to the University of Adelaide Medical School. Method: Questionnaires were designed to explore the interest in, knowledge of and attitudes about studying medicine of rural high school students, their parents and their careers counsellors. A stratified sample of 15 high schools in rural South Australia was selected. Data were collected from all participants on perceptions and knowledge of the entry processes and subject requirements for studying medicine. Student participants were also asked about their interest in studying medicine and becoming a doctor. Results: Four hundred and sixty-one rural year 11 and 12 students, 512 parents of rural year 11 and 12 students, and 12 rural high school careers advisors returned useable data. Students, parents and career advisors were found to hold inaccurate perceptions of the minimum Tertiary Entrance Rank, and they incorrectly believed prerequisite subjects were required in order to study medicine at the University of Adelaide. Analysis identified a group of students interested in a career as a doctor but who had never considered studying medicine. The majority of students who had seriously considered studying medicine reported a lack of knowledge of admission processes and the requirements for studying medicine. Among students who found becoming a doctor © B Hoggan, G Laven, JW Newbury, C Laurence, V Ryan, S Baillie, F Baker, 2009. A licence to publish this material has been given to ARHEN http://www.rrh.org.au Published 12 November 2009; modified 24 November 2009. A correction and modification was made to Table 5 2 appealing, those who had never considered medicine had less confidence regarding and knowledge of requirements and entry processes into medical courses than those who had. Conclusions: Some keen rural students have inadequate or inaccurate information about medical courses and admissions processes, which will deter them from applying to study medicine. Another group of students were identified who were attracted to a medical career but had not sought information on entry to a university undergraduate medical course. Both groups might be encouraged to progress their application to a medical school through ‘academic detailing visits’ to rural high schools, targeting medical careers promotion and provision of accurate and timely information on applying for and studying medicine.


Introduction
Research suggests that Australia's rural medical workforce issues would be positively influenced by supporting and encouraging rural students to study medicine [1][2][3][4][5] .Currently Australian Government incentives require medical schools to admit at least 25% of their students from those who have a rural background 6 .However, many medical schools have difficulty recruiting enough rural students; in 2003 only 20% of first-year medical students nationwide had a rural background, with Queensland the only state over 25% 7 .
Attempts have been made to assist rural students by medical selection procedures but recruitment has been hampered by the general barriers to tertiary education faced by rural students.Geographic distance and isolation 8,9 , financial costs 2,3,9,10 , and dislocation from family and friends 3 all act as deterrents to further study.Added to these determinants are a perceived lower level of academic achievement 2 and support for tertiary education from students, parents, and teachers in rural communities 8,11 , leaving rural students underrepresented in Australian tertiary institutions 12 .Lack of access to information on medical careers and courses is a further barrier to rural students' academic and career decision-making 2,3,5 .The availability of accurate information and exposure to professional role models are among the most successful means of supporting a rural student's desire to study medicine 3,5 .

Studying medicine at the University of Adelaide
There is a sequential process for applying to study medicine at the University of Adelaide: • school students sit the written Undergraduate Medicine and Health Sciences Admissions Test (UMAT) • students with a score above a threshold are invited to a structured oral assessment • subsequently, the Tertiary Entrance Rank (TER; a standardisation of end of school exam results), determines if assessed students are offered a place.
Poor or inadequate information on this complex admissions procedure has been found to deter potential students from considering studying medicine 2,4,9,13 .

Study aims
The present study sought data on rural students' attitudes to medicine and knowledge of the admissions processes.The study aimed to determine the accuracy and availability of medical course information, as well as the perceptions, knowledge and interest in applying for and studying medicine held by rural students, their parents and careers advisors.

Method
All rural South Australian secondary schools were stratified by Rural, Remote, and Metropolitan Area (RRMA)
The proportion of year 11 and 12 student respondents was relatively even, slightly more females responded than males, and over half of the student respondents had a family member who had attended university (Table 1).The majority of parent respondents were female and aged between 40 and 49 years.
Careers advisors, students and parents were found to hold inaccurate perceptions of the minimum TER required to study medicine at the University of Adelaide; half of careers advisors, 48.8% of students and 59.8% of parents believed the required score to be 95 or greater (Fig1), whereas the actual requirement was a score of 90.Although there are currently no prerequisite subject requirements at the University of Adelaide, 425 students (92.2%) and 477 parents (93.2%) reported that at least one prerequisite subject was required to 'get into' (gain entrance to) medicine.2).

Students' opinions
Not surprisingly there were a number of significant differences between students who had seriously considered studying medicine and those who had not.They were significantly more likely to understand the purpose of the medical admission interview and UMAT, believe they could achieve the required TER, know that no specific subjects were required to get into medicine at the University of Adelaide, and know medical students are not required to study in the city for the entirety of the course (Table 2).
As a measure of potential interest in a medical career, students were asked whether they found the career of a doctor appealing (Table 3).A total of 96 students (20.8%) reported that being a doctor appealed to them; however, 34 (35.4%) of these students had never seriously considered studying medicine.Analysis of these two subgroups is presented (Table 4).Students who had not seriously considered medicine had less confidence in and knowledge of the requirements and processes for entry into medicine than those who had.No significant difference was found between the groups' perceptions of the minimum TER required for medicine at the University of Adelaide (93.3 ± 8.2 vs 93.1 ± 6.0, p = 0.432).

Parental opinions
A comparison of parents whose child had seriously considered studying medicine and those whose child had not showed significant differences in perceptions and knowledge of medical course entry requirements and processes.Parents whose child had seriously considered studying medicine were significantly more likely to understand the purpose of the medical admission interview and UMAT, and to believe their child could obtain the required TER for medicine, and to be aware that no prerequisite subjects are required for entry to medicine at the University of Adelaide (Table 5).
They also perceived the minimum TER required to study medicine at the University of Adelaide to be significantly lower than their counterparts (93.8 ± 5.1 vs 95.8 ± 4.2, p = 0.001).

Career advisor opinions
Half of the careers advisors reported understanding the purpose of the medical admissions interview, and 58.3% reported understanding the purpose of the UMAT.While most were confident in their knowledge and access to information on medical courses in Adelaide, only 50% believed they had adequate access to information on interstate medical courses, which is reflected in fewer careers advisors being confident in their knowledge of interstate medical entry requirements.Only 25% of careers advisors stated their school had accessed medical career promotion activities, or knew that students are not required to study in the city for the length of the medical degree course.Career advisor responses to all questions are provided (Table 6).

Discussion
The present study revealed misconceptions and deficiencies in knowledge about school leavers applying to study medicine at the University of Adelaide.
A key finding of the present study was the identification of a group of students who found the idea of being a doctor appealing but who had never considered studying medicine (n = 34, Table 3).These students reported less confidence and knowledge of requirements and processes for entry into the medical course than students who had seriously considered studying medicine.However, even among those who had seriously considered studying medicine, the majority still did not understand the purpose of the medical admission interview and UMAT, and believed that at least one prerequisite subject was required for entry to medicine at the University of Adelaide.Thus, poor information or inadequate knowledge may act as a barrier to these students gaining entry.Students, parents, and careers advisors held inaccurate perceptions of TER scores and prerequisite subject for studying medicine at the University of Adelaide, with a large proportion believing the required TER to be 95 or greater (actually threshold = 90) with rural students also eligible for 6 bonus University Aggregate points to be added under the University of Adelaide's 'Fairway' scheme 15 .This may explain respondents' pessimism about obtaining the necessary score and their reluctance to apply, believing they could not obtain the necessary TER.That over 90% of students and parents believed at least one subject is necessary for entry to medicine is also a potential barrier.
Many smaller rural schools cannot offer a comprehensive senior school curriculum 16,17 and students may believe they cannot study and achieve in the prerequisite subjects.
The finding that many students and parents were unaware that medical students are not required to study in the city for the entire course would be of interest to all Rural Clinical Schools.As dislocation from family and friends is a recognised barrier to tertiary study 3 , an increased knowledge of rural medical education options may act as an incentive for rural high school students.
Some careers advisors reported deficiencies in their knowledge of processes for entry into a medical course, while their confidence generally corresponded with having accessed medical course information.Their knowledge and confidence was greater with the only local undergraduate entry medical school (Adelaide), and less so with interstate medical courses.Only a small number of careers advisors reported having accessed medical promotional resources, implying these deficiencies may be due to a lack of a 'critical mass' of students interested in medicine.
One limitation of the present study is that the response rate was relatively low, but this may be due to participants only responding if they had a particular interest in medical issues or university study.However, the raw number of responses was good, and the results are consistent with both the University of Adelaide's experience of rural student entry and the anecdotal opinions expressed by rural South Australians.A second limitation is that only year 11 and 12 students were surveyed.It has been shown that many students make study choices in earlier school years, and it is recommended that health careers promotion occurs with students in year 10 and earlier 2 .While the present study only collected data from a rural South Australian sample, it is believed that the findings are generalisable to rural schools throughout Australia.

Conclusion
In summary, this study indicates that a lack of accurate knowledge of the admissions processes, and the difficulty of obtaining this complex information, may be key impediments to rural students entering a medical course.
Additionally, there appears to be a substantial group of students who find a medical career appealing but have not sought information on how to enter a medical course, or see it as unattainable.These barriers can be addressed through targeted medical careers promotion, including the provision of accurate, timely information about applying for and studying medicine to assist in educating students, parents and careers advisors.This may result in an increase in the number of rural background students in medical courses and so achieve a worthwhile goal for all medical schools.

Figure 1 :
Figure 1: Perceived minimum tertiary entrance rank required for entry to medical course at the University of Adelaide, by respondent group 14

Table 1 : Student demographics
† Numbers may not total due to missing information.

Table 2 : Students' perceptions and knowledge on applying for and studying medicine
TER, Tertiary entrance rank; UMAT, undergraduate medicine and health sciences admissions test.†Students n = 461; ¶numbers and percentages represent collapsed 'agree/strongly' and 'agree/don't know' responses.

Table 3 : Students' interest in studying and practicing medicine †Students
n = 461; ¶does not total due to missing information.

Table 4 : Perceptions and knowledge on applying for and studying medicine in students who find being a doctor appealing
NA, Not applicable; TER, Tertiary entrance rank; UMAT, undergraduate medicine and health sciences admissions test.†Studentswhofind being a doctor appealing (in Table3; N = 96); ¶numbers and percentages represent collapsed 'agree/strongly' and 'agree/don't know' responses.

Table 5 : Parents' perceptions and knowledge on applying for and studying medicine Parents † n (%) Perceptions/ knowledge Child has seriously considered studying medicine n = 96 Child has not seriously considered studying medicine n = 416 Odds ratio CI (95%)
TER, Tertiary entrance rank; UMAT, undergraduate medicine and health sciences admissions test.†Parentsn = 512; ¶Numbers and percentages represent collapsed 'agree/strongly' and 'agree/don't now' responses.