Table 6 Typology category 3: studies of the impact of partial rural medical education

Forster et al. [61] Australia, University of New South Wales (UNSW)

n = 315. Retrospective online survey of graduates who spent 1–3 years of undergraduate training in UNSW Rural Clinical School.

214 respondents (68%); 26% are currently working in rural. Incremental effect of 1–3 years of rural exposure.

Self-reported on type (e.g. rural) of current work location.

Glasser et al. [51] USA: Illinois

n = 159. Effect of Rural Medical Education (RMED) Program and add-on curriculum of monthly sessions during the first 3 years of medical school and a capstone in the fourth year. Database on RMED students, graduation, location and specialty of residency.

Of the 103 grads in practice, 69 (67%) are in towns ≤20 000 or rural communities.

Does not compare with non-RMED or national data for rural practice. The RMED recruiter makes yearly trips to feeder schools to meet with sophomore, junior and senior students who have an interest in rural medicine.

Halaas [54] USA Minnesota

n = 1 063. Rural Physician Associate Program (RPAP) graduates. RPAP is a 36-week community-based elective placing students in rural communities of 3 000–20 000. Method not specified.

521 (62%) of RPAP students in practice at time of measurement were physicians in rural communities.

Does not specify where the data come from.

Halaas et al. [54] USA: Minnesota

n = 1 175. Rural RPAP graduates. Used RPAP database and descriptive statistics.

448/901 (49.7%) of currently practising graduates are in rural settings. 44% have practised in a rural setting all of the time. Proportion of RPAP graduates in rural settings is higher than 9% USA figure.

Jamar et al. [59] Flinders University Australia

n = 124. Retrospective study of graduates who completed a rural fifth year.

Response rate 74 out of 124 (58.2%). Eight years after graduation, 20.8%–34.1% were located rurally; average of 21.8% per year over this time.

Voluntary programme—those interested in rural practice may have biased results. Does not compare percentage working rurally with a non-rural cohort or with a national figure.

Kane et al. [49] USA: University of Missouri School of Medicine

n = 168. Questionnaire of Summer Community Program graduates: second year medical students working with rural physician preceptors (4–8 weeks).

n = 78 (46%) were in rural practice for their first work location. Compared with non-participants, summer participants were more likely to work in rural locations for their first practice. 46% compared with 11% nationally that practise rurally.

Unable to compare participants with non-participants due to lack of full data set.

Lang et al. [50] USA: Dept. of Family Medicine at East Tennessee State University

n = 134. Effect of 4-week summer elective clinical preceptorships in southern Appalachia. Database of practice locations linked with databases from medical schools and other sites.

Of the 134 former students whose practice locations were identified, 44 (33%) are in rural areas compared with 9% of all physicians.

Small numbers over an 18-year period.

MacDowell et al. [52] USA: Illinois College of Medicine at Rockford

n = 160 RMED and 2 663 non-RMED graduates. Compared data on Rural Medical Education (RMED) Program and non-RMED students. RMED is add-on programme in years 1–4 plus 16 weeks in a rural practice in year 4.

56.3% RMED graduates are working in small towns or rural communities. RMED graduates reported more than 17.2 times more likely to be currently practising in a rural location (excluded those in residency), compared with all other U. Illinois medical graduates.

Orzanco et al. [46] Canada: Universite de Sherbrooke (UdeS) and University of British Columbia (UBC) medical schools

n = 180 (UdeS), n = 194 (UBC). Linked students’ personal data and undergraduate MD programme to practice location data from the Canadian Post-MD Education Registry. Retrospective analysis with multiple regression analysis.

Significant difference in no. of weeks family practitioners practising in non-metro had spent in non-metro clerkships (p < 0.000 1). Median time 7.7 weeks compared with 3.9 weeks for those practising in other types of areas (UdeS). For UBC, none of those doing non-metro clerkship were likely to establish non-metro practice.

Length of clerkship in non-metro areas was the strongest predictor of location of practice for UdeS and ‘some’ relationship for UBC but small sample size. Noted lack of quality data.

Playford et al. [60] University of Western Australia

n = 1 017 (258 from rural clinical school; 79 urban) Cohort study comparing those in a rural clinical school (fifth-year rural placement) and those not.

Of 258 rural clinical school graduates, 42 (16.3%) were working rurally compared with 36 of 759 (4.7%) in the non-rural clinical school control group.

Voluntary programme—those interested in rural practice may have biased results. Rural background did not have an independent significant effect.

Quinn et al. [19] USA: University of Missouri School of Medicine

n = 48 rural programme graduates with n = 506 non-participants. MU-RTPP = summer community programme pre-second year, rural clerkship in third year and rural elective in fourth year. Tracked all participants of MU-RTPP, using database of postgraduate specialty training, practice locations and professional and public sources such as Board of Medical Specialties databases.

57.4% of graduates from MU-RTPP cohorts chose to practise rural or mixed rural county. Over 57% chose a rural location for their first practice. Compares 57.4% with 9% it states work in rural nationally.

Unable to make comparisons with non-participants because data incomplete.

Rabinowitz [55] USA Philadelphia Jefferson Medical College

n = 148. Data of current practice locations of graduates in the Physician Shortage Area Program (PSAP). PSAP required third-year clerkship at one of two non-metro locations.

PSAP graduates were around four times more likely than non-PSAP to practise in rural areas 39% vs 11%.

Rabinowitz et al.* [56] USA Philadelphia Jefferson Medical College *Rabinowitz and Paynter (2000) [75] provides the same data but with a different focus.

n = 206. PSAP graduates. Retrospective cohort study 1978–1991. Using data from JMC Alumni Association to tracked PSAP and non PSAP graduates at Jefferson Medical College.

PSAP graduates were 32/150 (21%) of family physicians practising in rural Pennsylvania who graduated from one of the state’s seven medical schools although they are only 1% of graduates from those schools. 68 (34%) of PSAP grads were practising rurally anywhere in USA compared with 303 (11%) of non PSAP.

Rabinowitz et al. [57] USA: Pennsylvania Jefferson Medical College

n = 38 PSAP graduates and 54 non-PSAP graduates, 11–16 years after graduation. Longitudinal follow-up of PSAP graduates.

After 11–16 years, 26/38 (68%) PSAP graduates were practising in the same rural area, compared with 25/54 (46%) non-PSAP (p = 0.03). Survival analysis showed PSAP graduates practise in the same rural locality for longer than non PSAP (p = 0.04).

Smucny et al. [58] USA: New York State

n = 132. Rural Medical Education (RMED) Program graduates. RMED is 36-week clinical experience in rural communities in year 3. Physician masterfiles of American medical Association to compare practice locations for RMED with non-RMED used.

76 RMED graduates (58%) completed the questionnaire. 56/69 (81%) had completed postgraduate training. 26 % of RMED practised in rural areas (22/86), compared with non-RMED 95/1307 (7%).

59% RMED respondents considered their home town to be rural.

Strasser et al. [22] Australia: Monash University Bachelor of Medicine/Bachelor of Surgery Programme

Number of questionnaires distributed is not given. Retrospective cohort mail survey of four groups of students with different rural/urban background and experiences in rural medical education.

n = 243 responding higher mean in total number of weeks of rural placement was associated with a current practice location in a rural community rather than an urban community (p = 0.05), but not with first practice location (once vocationally qualified) (p = 0.16).

Author reports that rural/urban background had a significant interaction with all of the main outcomes except current place of practice.

Williamson et al. [19] New Zealand: Otago University Faculty of Medicine

n = 367; 293 after exclusions. fifth-year medical students from 2000–2001 were identified by the enrolment and alumni records. Study cohorts from three campuses (one of which has a 7-week undergraduate ‘rural health course’) were posted a questionnaire. Non-responders were followed up.

177 (63%) returned, of which 30 were ‘Gone, no address’, leaving 147 (50%). There was no significant difference among schools in the proportion of students working in rural areas.

Small numbers and 50% response. Content of the 7-week course is not described, although described as a ‘rural rotation’.