Education , training and support needs of Australian trained doctors and international medical graduates in rural Australia : a case of special needs ?

Introduction: Little attention has been paid to issues relating to the education, training and support needs of Australian medical graduates and international medical graduates (IMGs) in rural practices. The focus continues to be on recruiting to rural areas. The aim of this article was to document the education, training and support needs of rural GPs. Methods: Cross-sectional surveys were made of rural GPs working in rural north-west New South Wales, Australia. The main outcome measures were the key factors influencing rural GPs to stay in rural practice. Results: Australian medical graduates and IMGs largely agree on key education, training and professional support needs. Continuing professional development, training opportunities, professional support and networking, as well as financial support are the doctors’ shared top priority issues. Rural GPs satisfied with their current medical practice, intend to remain in rural practice for 40% longer than those who are not satisfied (11.5 years compared with 8.2 years). Rural GPs contented with their life as a rural doctor intend to remain in rural practice for 51% longer than those who are discontented (11.8 years compared with 7.8 years).


Introduction
The current shortage of 340 full-time equivalent rural GPs (more than 10% of the current rural doctor workforce) in Australia cannot be addressed in the short term by policy and program initiatives aimed at bolstering national selfsufficiency.The major reasons for this relate to the globalization and feminization of the medical workforce, changing work practices of GPs, as well as the rising level of care demanded by an increasingly ageing population 1,2 .
Faced with this situation, key stakeholders, including local, state and federal governments, professional organizations and support agencies developed and implemented a range of educational, funding and regulatory programs aimed at recruiting GPs to rural areas.
Seen from this perspective, the recruitment of international medical graduates (IMGs) to Australia to fill this shortage will continue.They will form an integral and essential part of medical workforce planning with, for example, the number of visas issued to temporary resident doctors, who do not require Australian Medical Council (AMC) accreditation, having increased from 664 in 1993/1994 to 2496 in 200220/03 3 .Currently, IMGs constitute 21% of the Australian medical workforce and over 30% of the remote area medical workforce 4,5 .The proportion of IMGs practising in Australia is similar to that found in the USA (27%), Canada (23%) and the United Kingdom's National Health Service (24%) [5][6][7]  doctors are really different 5,[9][10][11][12][13] , this project aimed to document the current education, training and support needs of IMGs, as well as all other registrars and GPs who currently train and/or practise in our region.For the purposes of discerning differences in these needs, this project also aimed to identify such needs on the basis of gender.This will allow an analysis of relevant responses according to the following three pairs of groups which can be compared: • IMGs and doctors whose primary medical qualification was obtained from an Australian medical school • GPs and registrars • Male and female doctors.

Method
Subsequent to a review of published and relevant literature, two questionnaires were designed; one to be completed by IMGs and the other by GPs whose primary medical qualification was obtained from an Australian medical school.As there is no systematic record that identifies where (in Australia or overseas) a GP's or registrar's primary medical degree was obtained, in August 2004 all GPs and registrars were sent both questionnaires, a cover letter and a reply-paid envelope.A second mail-out, targeting all those GPs who had not returned a completed survey form by the due date, was administered in late 2004.Participants were asked to self-select the appropriate survey form.Both questionnaires contained two main sections: one focusing on demographic and practice issues and the other dealing with information and support programs.The IMG questionnaire incorporated all the 21 questions asked for respondents whose primary medical degree was from an Australian medical school, and also contained additional questions which related to visa and registration matters and ease of commencing medical work in Australia.The draft survey forms were piloted on a sample of GPs who were not included in the study's population.
Names and addresses of the region's practicing GPs were obtained from the three local Divisions of General Practice.
The list of the region's registrars, consisting of GP registrars and junior medical officers working in the region's hospitals, was held by the Hunter New England Area Rural Training Unit.
All data were entered and analysed using the SPSS v12.0.1 statistical software package (SPSS Inc, Chicago, IL, USA).Differences between, for example, IMGs and Australiantrained doctors were calculated in respect of selected variables by way of non-parametric χ 2 and, in all cases where the expected frequency count in one or more cells was less than five, Fisher's exact tests.
Approval to carry out each project was given by the Hunter New England Health Ethics Committee in 2004.
The study's full results and some of the project's major findings are published elsewhere 14,15 .
Participants were asked to indicate whether they would welcome additional information in relation to eight separate issues.The top three issues identified related to the Australian healthcare system, Indigenous health and key rural health issues (Fig 1).Comparing the responses of the relevant target groups, the following statistically significant differences were found in relation to further information requested concerning: • the Australian health care system: • proportionately more registrars than GPs would welcome such additional information (χ 2 = 21.9, df = 1, p <0.01) • proportionately more IMGs than Australian-trained doctors requested further information (χ 2 = 7.1, df = 1, p <0.01).
All participants were asked whether any of the six programs  Overall, the vast majority (86%) of all respondents were either very satisfied/satisfied with their current medical practice.The highest proportion (95%) are IMGs and the lowest proportion (84%) were Australian-trained and male doctors.
There were no statistically significant differences between the following groups of doctors in terms of being either satisfied or dissatisfied: • GPs and registrars (Fisher's exact, two sided: p = 1) • Australian trained doctors and IMGs (Fisher's exact, two sided: p = 0.3) • male and female doctors (χ 2 = 0.4, df = 1, p = 0.53).The average intended length of remaining in rural practice is 40% longer for those doctors who are satisfied with their current medical practice than for doctors who are not satisfied (11.5 years compared to 8.2 years).Figure 5 illustrates that, at every time interval for which comparable data is available, proportionately more doctors who were satisfied with their current medical practice intend to stay in rural areas than doctors who were dissatisfied.There were no statistically significant differences between the following groups of GPs in terms of being either contented or discontented: • GPs and registrars (χ 2 = 0.17, df = 1, p = 0.68) • Australian-trained doctors and IMGs (Fisher's exact, two sided: p = 0.52) • male and female doctors (χ 2 = 0.06, df = 1, p = 0.81).
The average intended length of remaining in rural practice was 51% longer for doctors contented with their life as a rural doctor than for those doctors who were discontented (11.8 years compared with 7.8 years).Figure 7 illustrates that, at each time period for which comparable data was available, proportionately more doctors who were contented, intended to remain in rural practice.

Discussion
Retaining rural doctors in rural practice depends on satisfactorily addressing a range of professional and nonprofessional items 16,17 .In a recent article, systematic and organized professional support mechanisms, as well as good educational facilities for their children and work opportunities for their partners, were identified as significant factors contributing to IMGs remaining in rural practice 18 .
Our results highlight that the most important education, training and support needs identified by all the participants relate to: • more detailed information in the areas of Indigenous health and key rural health issues being made available • programs in respect of advanced business practices, clinical skills and consultation skills being provided by appropriate professional organizations • continuing professional development, training opportunities and professional support being offered.
These results do not concur with other research findings which suggest that, 'interventions not affecting on-call and related professional issues will not solve the key problem' 19 .
An explanation for this may be found in the fact that a very high proportion of the doctors responding to our survey indicated that they were either satisfied/very satisfied (86%) with their current medical practice or contented/very contented (83%) with their life as a rural doctor.These high proportions hold true for male and female doctors as well as registrars, and are well in excess of the 75% of GPs and 65% of registrars expressing being either satisfied/very satisfied and the 77% of GPs and 60% of registrars indicating being contented/very contented in a recent survey of rural doctors 20 .Furthermore, our respondents also expressed a very high level of satisfaction (rating of 3 or higher on a four-point Likert scale) with professional support organizations, especially the Australian College for Rural and Remote Medicine, the NSW Rural Doctors' Network,

Figure 4
Figure 4 illustrates the proportion of doctors according to their level of satisfaction with their current medical practice.
The four Likert scale categories(1 = very discontented, 2 = discontented, 3 = contented, 4 = very contented) available to participants in terms of expressing their level of contentment with life as a rural doctor were collapsed into two categories.The new category 'discontented' combined the total percentage of respondents who expressed being either very discontented or discontented.The new category 'contented' combined the total percentage of respondents who expressed being either contented or very contented.

Figure 6
Figure 6 illustrates the proportion of doctors who were either contented or discontented with life as a rural doctor.Overall, the vast majority (83%) of all respondents were satisfied with their current medical practice.The highest proportion (89%) were IMGs and the lowest proportion (81%) were registrars.