A new model to understand the career choice and practice location decisions of medical graduates

Introduction: Australian medical education is increasingly influenced by rural workforce policy. Therefore, understanding the influences on medical graduates’ practice location and specialty choice is crucial for medical educators and medical workforce planners. The South Australian Flinders University Parallel Rural Community Curriculum (PRCC) was funded by the Australian Government to help address the rural doctor workforce shortage. The PRCC was the first community based medical education program in Australia to teach a full academic year of medicine in South Australian rural general practices. The aim of this research was to identify what factors influence the career choices of PRCC graduates. Methods: A retrospective survey of all contactable graduates of the PRCC was undertaken. Quantitative data were analysed using SPSS 14.0 for Windows. Qualitative data were entered into NVIVO 7 software for coding, and analysed using content analysis. Results: Usable data were collected from 46 of the 86 contactable graduates (53%). More than half of the respondents (54%) reported being on a rural career path. A significant relationship exists between being on a rural career pathway and making the decision prior to or during medical school (p = 0.027), and between graduates in vocational training who are on an urban career path and making a decision on career specialty after graduation from medical school (p = .004). Graduates in a general practice vocational training program are more likely to be on a rural career pathway than graduates in a specialty other than general practice (p = .003). A key influence on graduates’ practice location is geographic location prior to entering medical school. Key influences on graduates choosing a rural career pathway are: having a spouse/partner with a rural background; clinical teachers and mentors; the extended rural based undergraduate learning experience; and a specialty preference for general practice. A lack of rural based


Introduction
There is a critical shortage of doctors in rural Australia 1,2 .In response to this, the Australian Government supported South Australia's Flinders University to develop the Flinders University Parallel Rural Community Curriculum (PRCC).
The PRCC was the first community based medical education program in Australia to teach a full academic year of medicine based in rural general practice, and was constructed on the hypothesis that increased rural practice exposure during undergraduate medical education would influence students to pursue a rural career path [3][4][5][6][7][8][9][10][11] .
The PRCC is undertaken by medical students for the entire third year of their four-year graduate entry medical program at Flinders University.The first cohort of eight students commenced in 1997 in the Riverland region of South Australia.At the time this was a radical departure from the standard medical curricula in Australia, where accepted practice was for medical students to undertake only short 2-6 week rural clinical placements.
The PRCC places are open to rural and urban applicants.In order to gain a PRCC place, students apply voluntarily and are selected by interview.Between 50% and 60% of PRCC places are filled by rural background students annually.
The PRCC has been considered an outstanding academic and workforce success [12][13][14][15][16] .However, there is no data on how the PRCC exerts this workforce effect.The success of the initial program has resulted in replication of this approach to other rural regions of South Australia.In 2008 there were 30 medical students participating annually in PRCCs across four rural regions of South Australia.
The graduates in the present research undertook their PRCC placements in the Riverland and the Greater Green Triangle regions of South Australia.This research explores how the PRCC has influenced their career choices as graduates of the program.

Methods
Between 1997 and 2005 a total of 98 students had participated in the PRCC.By 2007, all these students had graduated and were working as doctors.
A comprehensive search for current contact details of all graduates was undertaken.This included searches of alumni data bases, websites and telephone directories, rural doctor workforce agencies, medical registration boards and local contacts.This resulted in 86 graduates being contacted with an invitation to participate in this research.
A retrospective survey of all contactable graduates of the PRCC was undertaken in 2007.Those surveyed were between one and 9 years post-graduation.

Ethics approval was granted by the Flinders University
Social and Behavioural Research Ethics Committee.

Definition of rurality
Within Australia there is no agreed definition of 'rural'.In this study, the Rural, Remote and Metropolitan Areas (RRMA) classification system was used, as is used by the Australian Medical Workforce Advisory Committee (AMWAC) in its national medical careers longitudinal studies 17 .In this research 'rural' was defined as 'a regional city or large town, a smaller town or a small community' 17 , which included the RRMA 3-7 classifications.This definition of rural was used to determine the study participants' current training or practice location, identification of self and spouse as having a rural background, and self-identification as being on a 'rural career pathway'.

Definition of rural career pathway
In this research, rural career pathway is defined as the intention or actual practice in a rural area as described in the definition of rurality.The PRCC graduates in intern training were asked to self-identify as being on a rural or urban career pathway, that is the intention to undertake further training or practice in an urban or rural area.Graduates in vocational training or vocationally qualified were assumed to be on a rural career pathway if they were practising in a regional city or large town, a smaller town or a small community, which included RRMA 3-7.

Survey design and administration
Survey questions were based on known factors that may be associated with rural medical career choice 1,[3][4][5][6][7][8][9][10][17][18][19][20][21][22][23][24] . All qustions relating to geographic location were based on previously validated questions used in the AMWAC national medical careers longitudinal studies 17 .The survey was conducted either by telephone interview or on-line completion using Perseus Software Solutions, according to the preference of the participant.Telephone interviews were recorded and transcribed, and the transcript was returned to the interviewee for verification.The survey instrument was piloted with the 2007 cohort of PRCC students who were not included in the research sample.The pilot resulted in changes to one question.
Anonymity was maintained because each responder was given a unique identifier at the point of submission of the survey at the central IT repository of the Flinders University Rural Clinical School.
Statistical data were analysed using t-tests with Fisher's exact test.Content analysis was used to identify themes that emerged from the qualitative data, and to construct conclusions about the meanings in the text.

Results
Responses were received from 49 of the 86 graduates invited to participate.Three respondents did not identify a definite career choice.These responses were removed from the analysis, resulting in useable data from 46 respondents, which represented a 53% response rate.The representativeness of the responders to the whole cohort is strengthened because the gender balance of responders and non-responders was similar, and a search of records identified a comparable rural/urban background ratio of responders and non-responders.The age profile of responders and non-responders was between 19 and 53 years.
Analysis found that 54% of respondents indicated they were on a rural career pathway.These respondents were equally divided between those with a rural background and those with an urban background.A further 24% of survey respondents identified as having a rural background reported being on an urban career path.These respondents reported that limited rural options influenced them to practise in a non-rural location.The remaining 22% of respondents identified as having an urban background and being on an urban career path.
Data on the specialty choice of graduates were analysed by career stage (internship, vocational training, fully qualified) and career pathway (Table 1).In Australia, medical graduates intending to pursue a career in any specialty, Data were analysed to identify when graduates made their definitive career choice (Table 2).A positive relationship existed between being on a rural career pathway and making the decision prior to or during medical school (p = 0.027).There were no significant associations for graduates on an urban career pathway and making the decision prior to or during medical school.A positive relationship existed between graduates in vocational training on an urban career path and making their decision on career specialty after graduation from medical school (p = .004).There were no significant associations for graduates in internship or those who were fully qualified and when they made their career choice.
The literature identifies rural background as the predominant variable influencing a rural career choice, along with undergraduate rural exposure [18][19][20]24 . Furher analysis of graduates' career pathway choice (rural/urban) and geographic background (rural/urban) was conducted to construct a four quadrant (Q) model (Fig1).The distribution of survey respondents among the quadrants was similar.This was unexpected.Therefore, further analysis of the data was undertaken to explore the characteristics of graduates in each quadrant (Table 3).

Analysis of data in each quadrant
Quadrant 1. Rural background and rural career pathway: Respondents in Q1 were predominantly female (n = 8/13; 62%) and nine (69%) were either married or in a partnership.A positive relationship was found between these respondents (all rural origin) and having a rural spouse (p = 0.002), with 100% of partners identified as rural origin.
The Q1 respondents had lived in small communities for a long period of time (mean years = 15) prior to admission to medical school.The Q1 respondents reported family relationships (returning to family, children and partner needs) as influencing their career location choice.Eight had chosen general practice as their specialty choice (62%).The Q1 respondents were more likely to make a career decision either prior to or during medical school than were non-Q1 respondents (p = 0.034).Twelve respondents (92%) reported that the PRCC experience confirmed their existing career decision.Reported PRCC program positive influences were rural clinical mentors and the rural general practice experience.The Q1 respondents said:  There is no rural pathway but there is the opportunity to do rural rotations.There will be rural aspects to it as there will be future opportunities for rural rehab as it is an expanding field both in the city and country.R55 Quadrant 4. Urban background and urban career pathway: This is the only quadrant in which the gender split was biased towards males (6 vs 4, respectively).All respondents in this quadrant lived in a capital city for all of their life prior to medical school.The majority (80%) were undertaking a specialist career other than general practice, and the majority (80%) made their career specialty decision after graduation from medical school.Influences affecting career decision-making in this quadrant were more likely to be family, such as children's schooling and spouse employment, rather than personal preferences.The concordance of these data with previously published data on career choice [3][4][5][6][7][8][9][10][11] is encouraging, given the small sample size.The literature supports the findings that medical graduates with a rural background and a spouse with rural background are more likely to choose rural general practice (The True Believers) 3,7,8,16 .
New information is contained in the analysis of The Convertibles who report the extended rural undergraduate experience as influencing them to undertake a rural career path, despite a city based upbringing.This is important for curriculum planners to understand, and further research is recommended in this area.
Of concern is the number of rural background graduates identified as The Frustrated who report barriers to undertake training to follow a rural career pathway.This requires further investigation on a larger scale because it has implications for postgraduate training providers and rural scholarship holders.
The Metro Docs appear to be influenced by the PRCC experience differently from the other PRCC graduates, choosing different specialties and making this decision later in their careers.This may still be seen as a positive outcome of the rural based program because these city doctors may have more empathy with rural patients and referrals from rural doctors as a result of their rural experiences.

Limitations
The small sample size combined with the low response rate exerts a limiting effect on the validity of the results.
Limitations could result from a self-selection bias of students because the researcher was known to the study participants who were volunteers in this research.In addition, because this research was undertaken in one medical school, caution should be used in generalising findings to other institutions.

Conclusions
The PRCC was established in 1997 as an intervention to help address the rural doctor workforce shortage.That over half responding PRCC graduates in this study were on a rural career path supports the results of previous PRCC outcome studies that found the PRCC is helping to address the rural medical workforce shortage.Equally important are the urban background respondents who selected a rural career path.These respondents (named The Convertibles) provide valuable insights into the experiences that 'converted' them into rural practitioners.
The Four Qs Model provides a potentially useful model that demonstrates consistent themes in the characteristics of graduates of the PRCC and why they choose a rural medical career.The model could be usefully applied to the selection of medical students into rural medical education programs, and it could assist in the construction of rural curricula.The model also offers a useful framework for further research in this field.
including general practice, must undertake further formal training (known as vocational training) in an accredited training program.The PRCC graduates in intern training were asked to selfidentify as being on a rural or urban career pathway.Only two graduates (12%) in internship reported choosing general practice and being on a rural career pathway, while eight graduates (50%) reported choosing a career specialty other than general practice and being on a rural career pathway.Conversely, in vocational training (the next stage of training) graduates in a general practice vocational training program were more likely to be on a rural career pathway than graduates in any other specialty training program (p = .003).
Importantly, many graduates in this research reported being frustrated in their endeavours to undertake rural-based postgraduate training programs.This emphasizes the need to establish more rural career pathways for current graduates, and for the planned increase in medical graduates in 3 years time.Additional rural postgraduate training places, including rural internships, coordinated by Rural Clinical Schools, would build on the successful undergraduate community based educational programs, such as the PRCC, to significantly reduce the Australian rural doctor workforce shortage.

Table 1 : Specialty choice of graduates by career stage and career pathway General practice Other specialty Combined GP and other specialty Not in a program Career stage Rural career path Urban career path Rural career path Urban career path Rural career path Urban career path Rural career path
NA, Not applicable.

The four combinations of graduate background and career pathway choice.
There were no single males in this quadrant.Eleven (92%) of Q2 respondents had an almost entirely city based background prior to entry to medical school, with a median of 21 years lived in a capital city.Seven (58%) had chosen general practice as their specialty choice and 8 (67%) made their career specialty decision during medical school.It [the PRCC] showed me the benefits of general practice and the ability to practise obstetrics in a meaningful way, rather than 'shared care' in the city.R57 I wanted to work in a smaller friendly hospital.I decided rural GP was for me.R42

Quadrant 3. Rural background and urban career pathway: The
There isn't a rural pathway for psychiatry; there are various rural options when I finish.R10 A rural tract in the geriatric psychiatry program didn't exist.I have created one as part of my fellowship.R19 Currently have no choice of location as in rotational training program which sets my roster and training locations.No opportunity for rural anaesthetics training in South Australia.R37