Selecting for a sustainable workforce to meet the future healthcare needs of rural communities in Australia

Abstract

An undersupply of generalists doctors in rural communities globally led to widening participation (WP) initiatives to increase the proportion of rural origin medical students. In 2002 the Australian Government mandated that 25% of commencing Australian medical students be of rural origin. Meeting this target has largely been achieved through reduced standards of entry for rural relative to urban applicants. This initiative is based on the assumption that rural origin students will succeed during training, and return to practice in rural locations. One aim of this study was to determine the relationships between student geographical origin (rural or urban), selection scores, and future practice intentions of medical students at course entry and course exit. Two multicentre databases containing selection and future practice preferences (location and specialisation) were combined (5862), representing 54% of undergraduate medical students commencing from 2006 to 2013 across nine Australian medical schools. A second aim was to determine course performance of rural origin students selected on lower scores than their urban peers. Selection and course performance data for rural (461) and urban (1431) origin students commencing 2006-2014 from one medical school was used. For Aim 1, a third (33.7%) of rural origin students indicated a preference for future rural practice at course exit, and even fewer (6.7%) urban origin students made this preference. Results from logistic regression analyses showed significant independent predictors were rural origin (OR 4.0), lower Australian Tertiary Admissions Rank (ATAR) (OR 2.1), or lower Undergraduate Medical and Health Sciences Admissions Test Section 3 (non-verbal reasoning) (OR 1.3). Less than a fifth (17.6%) of rural origin students indicated a preference for future generalist practice at course exit. Significant predictors were female gender (OR 1.7) or lower ATAR (OR 1.2), but not rural origin. Fewer (10.5%) urban origin students indicated a preference for generalist practice at course exit. For Aim 2, results of Mann-Whitney U tests confirmed that slightly reducing selection scores does not result in increased failure, or meaningfully impaired performance during training relative to urban origin students. Our multicentre analysis supports success of the rural origin WP pathway to increase rural student participation in medical training. However, our findings confirm that current selection initiatives are insufficient to address the continuing problem of doctor maldistribution in Australia. We argue for further reform to current medical student selection, which remains largely determined by academic meritocracy. Our findings have relevance to the selection of students into health professions globally.

Selection methods in healthcare professions: where are we now and where next?

“…Conversely, Hay et al (2016) found that rural origin of students predicted intention to return to practice in rural settings, although not as a general practitioner (family physician) which is a specialty where greater numbers are needed in rural areas. As such, they conclude that rural origin widening participation initiative is only a part of the required solution to address rural health force undersupply.…”

“…On the contrary, they suggest that those students who manage to reach the qualifying standard for medical school despite the quality of the school they attended will, if anything, tend to perform better in medical school than students from high-performing schools due to their motivation and capacity to achieve ''against the odds''. Hay et al's (2016) paper also provides evidence that reducing selection cut points (academic achievement, UMAT, and interview) for rural applicants to Australian medical schools does not result in increased failure, or significantly impaired clinical performance during training.…”

“…Both Griffin et al (2016) and Hay et al (2016) in this issue focus on the practice intention of 'non-traditional' students to return to their location of origin (whether areas of low socioeconomic status [SES], or rural settings, respectively). Such investigations are timely, as global calls to widen access are often driven by healthcare provision needs in underserved areas, and are underpinned by the assumption that individuals recruited into medical school from such areas will then return to practice there once qualified.…”

“…However, there are many intervening factors between early intention and later behaviour, including clinical experience, career and location choices of role models and peers, discovering one's own personality and skills ''fit'' with a particular specialty, and so on, which may affect the relationship between intention and outcome in career decision making. Nicholson and Cleland (2016), Stringer et al (2016) and to some extent Hay et al (2016) in this special issue focus on widening access with the lens of ''getting in'' to and subsequently ''getting on'' in medical school (Milburn 2012). One significant concern, both from a research standpoint but also (and perhaps more significantly) from the perspective of higher education institutions, is whether encouraging and facilitating entry of nontraditional students to highly competitive healthcare degrees such as medicine, should be accompanied by ongoing support.…”

The efficacy of medical student selection tools in Australia and New Zealand

“…This binary approach may be increasingly important as schools seek to further diversify their student intake to better meet health and community needs. Schools may need to focus more on improving the accuracy and validity of selection tools close to the selection threshold mark rather than at the upper end of the scale 25 …”