Rural: Overview

Abstract
Introduction: The James Cook University (JCU) medical school in Australia has a mission to produce graduates committed and competent to practise in local regional, rural and remote areas. As positive rural placement experiences are known to enhance interest in a rural career and generalist medicine, this study explores key factors contributing to JCU medical students having a 'high quality' rural clinical learning experience during their final-year rural placement.

Methods: This sequential, explanatory mixed-methods study included four focus groups (n=17) and a one-on-one interview followed by a cross-sectional survey (n=71; response rate=45%) of final-year JCU medical students in 2023. The main outcome variable for the survey was a visual analogue scale question asking students to rate the clinical learning environment on their rural placement, while an open-ended question asked if and how clinical learning received on placement differed depending upon the background training of their supervising doctor. In the focus groups, students were asked to identify on a circle diagram all key components that impacted on having a good or bad clinical learning experience on their placement, and then to explain individually and discuss as a group the contexts around each component.

Results: Overall, 46% of students completing the survey reported their rural placement was of high clinical learning value (≥85/100 on the visual analogue scale). Quantitative analysis identified 'high value' clinical learning placements were predicted by students spending >50% of their placement learning in EDs (p=0.005; prevalence odds ratio (POR) 9.4), having 'very high' confidence in knowing how to manage the common presentations of North Queensland patients (p=0.006; POR 8.5) and being placed in small towns more than 100 km from the populated North Queensland coast. Student focus group participants consistently reported they received the best teaching from local doctors who were more permanently based in that community, had significant experience in rural medicine, and were familiar with their competency level as a sixth-year student and their learning objectives on rural placement. Overall, the key areas impacting students' clinical learning on rural placement can be summarized as 'quality teaching/supervision', 'appropriate levels of autonomy', 'appropriate clinical variety and workload' and 'student factors'.

Conclusion: The study findings suggest the key to JCU medical students having 'high quality' clinical learning on rural placements is by developing supportive learning relationships with senior, permanently based rural doctors who are willing to teach and know their scope of practice and specific placement learning requirements; and experiencing a diverse roster across hospital, GP and outreach clinics but with significant placement time in the ED. Potentially, these findings may assist rural placement programs coordinators to better plan, develop and support training sites and thus improve future placement experiences for student and junior doctor trainees. These improved learning experiences may in turn lead to more positive rural experiences that may further increase trainees' interest in rural and/or generalist medicine careers.

Abstract
Background: In response to rural medical workforce shortages in Western and Southwestern Victoria, Australia, Deakin University's School of Medicine established a dedicated Rural Training Stream (RTS) within its graduate entry Doctor of Medicine course in 2022. Consistent with the school's intention to promote social accountability, the RTS embodies a place-based approach, aiming to recruit 30 local applicants annually and train them in situ, thereby maximising opportunities for deeper connections with their communities and enhancing the likelihood of future local workforce retention. To underpin and facilitate collaborative program evaluation and research conceptually, a Program Logic Model (PLM) was developed. A PLM was chosen as the basis of this evaluation framework due to its foundations in systems and complexity theory and its amenity to collaborative development.

Methods: The PLM was developed using a stepwise, participatory approach, incorporating the contributions of a broad range of educators involved in the RTS program. Over a period of three months, participant input was provided through individual submissions and group workshops, sequentially developing each component of the model. Data gathered were summarised, reviewed and validated by the group periodically.

Results: The development of the PLM brought together a diverse group of academic and professional educators during the early stages of delivery of a new program, providing an opportunity for consensus building and the development of a shared understanding of the goals and objectives of the program. The developed PLM provides three clear objectives related to recruitment, training and professional identity formation. Short, medium and long-term outcomes aligned with each of these areas provide key reference points for the design of a comprehensive program of evaluation and research that is clearly linked to the program's goals.

Conclusion: The development of a PLM for Deakin's new RTS has provided an accessible roadmap that transparently communicates the design of the program to enhance local workforce outcomes for the rural communities that Deakin serves. The PLM provides a shared foundation for program-related evaluation and research, that is aligned with the strategic goals and desired outcomes.

Trial registration: Clinical trial number: not applicable.

Abstract
The value of distributed training of the medical workforce is well documented. Australia's Remote Vocational Training Scheme (RVTS) provides a scalable approach to specialist training in general practice that utilizes distance education and remote supervision. RVTS enables trainees to stay in their rural, remote and First Nations communities while working toward specialist certification as a general practitioner. The program, which supports both international and domestically trained graduates through tailored supervision and education, has operated across Australia for 25 years. Trainees are supported both professionally and socially over 4 years. An independent evaluation (2023-24) demonstrated a 78% completion rate among participants who remained in the same rural or remote practice for an average of 5.2 years. Two years after completing the program, 49% were still working in the community where their training commenced, well above documented retention benchmarks for these settings. High levels of participant satisfaction were reported, ranging from 88 to 100% across various indicators. The evaluation found that the program supports retention by eliciting five participant responses: comfort, confidence, competence, belonging, and bonding. Engagement and connection between participants are maintained through accessible technology, real-time support, virtual small-group learning, and twice-yearly in-person workshops. Despite the program's focus on high-need areas, it is cost-effective compared to similar rural training schemes. The experience of RVTS can inform other countries seeking to enhance rural workforce retention, particularly for underserved populations and migrant healthcare workers. The adaptable structure of the program aligns with the global development goals of the World Health Organization.