Building general practice training capacity in rural and remote Australia with underserved primary care services: a qualitative investigation

Abstract

Background
Australians living in rural and remote areas have access to considerably fewer doctors compared with populations in major cities. Despite plentiful, descriptive data about what attracts and retains doctors to rural practice, more evidence is needed which informs actions to address these issues, particularly in remote areas. This study aimed to explore the factors influencing General Practitioners (GPs), primary care doctors, and those training to become GPs (registrars) to work and train in remote underserved towns to inform the building of primary care training capacity in areas needing more primary care services (and GP training opportunities) to support their population’s health needs.

Methods
A qualitative approach was adopted involving a series of 39 semi-structured interviews of a purposeful sample of 14 registrars, 12 supervisors, and 13 practice managers. Fifteen Australian Medical Graduates (AMG) and eleven International Medical Graduates (IMG), who did their basic medical training in another country, were among the interviewees. Data underwent thematic analysis.

Results
Four main themes were identified including 1) supervised learning in underserved communities, 2) impact of working in small, remote contexts, 3) work-life balance, and 4) fostering sustainable remote practice. Overall, the findings suggested that remote GP training provides extensive and safe registrar learning opportunities and supervision is generally of high quality. Supervisors also expressed a desire for more upskilling and professional development to support their retention in the community as they reach mid-career. Registrars enjoyed the challenge of remote medical practice with opportunities to work at the top of their scope of practice with excellent clinical role models, and in a setting where they can make a difference. Remote underserved communities contribute to attracting and retaining their GP workforce by integrating registrars and supervisors into the local community and ensuring sustainable work-life practice models for their doctors.

Conclusions
This study provides important new evidence to support development of high-quality GP training and supervision in remote contexts where there is a need for more GPs to provide primary care services for the population.

Full text

R E S E A R C H A R T I C L E Open Access
Building general practice training capacity
in rural and remote Australia with
underserved primary care services: a
qualitative investigation
Louise Young
1*
, Raquel Peel
1
, Belinda O’Sullivan
2
and Carole Reeve
1
Abstract
Background: Australians living in rural and remote areas have access to considerably fewer doctors compared with
populations in major cities. Despite plentiful, descriptive data about what attracts and retains doctors to rural
practice, more evidence is needed which informs actions to address these issues, particularly in remote areas. This
study aimed to explore the factors influencing General Practitioners (GPs), primary care doctors, and those training
to become GPs (registrars) to work and train in remote underserved towns to inform the building of primary care
training capacity in areas needing more primary care services (and GP training opportunities) to support their
population’s health needs.
Methods: A qualitative approach was adopted involving a series of 39 semi-structured interviews of a purposeful
sample of 14 registrars, 12 supervisors, and 13 practice managers. Fifteen Australian Medical Graduates (AMG) and
eleven International Medical Graduates (IMG), who did their basic medical training in another country, were among
the interviewees. Data underwent thematic analysis.
Results: Four main themes were identifiedincluding1)supervisedlearningin underserved communities, 2) impact of
working in small, remote contexts, 3) work-life balance, and 4) fostering sustainable remote practice. Overall, the findings
suggested that remote GP training provides extensive and safe registrar learning opportunities and supervision is
generally of high quality. Supervisors also expressed a desire for more upskilling and professional development to support
their retention in the community as they reach mid-career. Registrars enjoyed the challenge of remote medical practice
with opportunities to work at the top of their scope of practice with excellent clinical role models, and in a setting where
they can make a difference. Remote underserved communities contribute to attracting and retaining their GP workforce
by integrating registrars and supervisors into the local community and ensuring sustainable work-life practice models for
their doctors.
Conclusions: This study provides important new evidence to support development of high-quality GP training and
supervision in remote contexts where there is a need for more GPs to provide primary care services for the population.
Keywords: General practice training, Family Physician Training, Primary Care Services, Rural Health, Remote Underserved
Communities, Medical Workforce Shortage, Health Care Equity, Qualitative Research, Thematic Analysis
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: louise.young1@jcu.edu.au
1
College of Medicine and Dentistry, James Cook University, 1 James Cook
Drive, Townsville, QLD 4811, Australia
Full list of author information is available at the end of the article
Young et al. BMC Health Services Research (2019) 19:338
https://doi.org/10.1186/s12913-019-4078-1
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Background
Approximately 29% percent of the Australian population
lives in rural and remote areas [1] where their health status
is worse than those living in major centres, with higher
mortality rates for chronic disease, injury and poorer access
to and use of health services [2]. Australians living in rural
and remote areas have access to 274 doctors per 100,000 in
remote/very remote areas compared with 433 doctors per
100,000 in major cities [3]. The health sector employs more
people than any other industry in Australia, but the maldis-
tribution of health workers continues to be problematic
and undermines the capacity to achieve health improve-
ments for rural and remote people whose cultures, lives,
and livelihoods are based in these towns [4,5].
Access to primary care services is particularly concern-
ing for ensuring early intervention, continuity of care, and
managing important health needs. However, in terms of
more nuanced targeting of primary care workforce devel-
opment, it is critical to identify communities where
primary care training and primary care services need to be
built up to adequately address population health needs.
This includes understanding how to increase General
Practice (GP), or family physician training posts in these
specific communities. This paper describes the culmin-
ation of such work, undertaken in the context of
north-western remote Queensland, Australia.
McGrail et al. [6] undertook a quantitative analysis in
2017 to explore the distribution of GP supervisors and reg-
istrars (doctors training in non-hospital community-based
training posts to become GPs) relative to general practice
(GP) workforce supply measures (GP billing data) and
population needs according to defined rural and remote
sub-regionsandtownsofnorth-westernQueensland.Mul-
tiple standardised workforce indicators: supply, rurality, and
other indicators, including population size, Australian
Standard Geographical Classification –Remoteness Areas
(ASGCRA; [7]), Modified Monash Model (MMM; [8]),
Registrar count [6], aggregated Districts of Workforce
Shortage (DWS) ratings [8–10], Index of Access (IA; [11–
14]), Socio-Economic Indexes for Areas (SEIFA; [15]), and
Indigenous population were applied to this evaluation.
A range of communities (n= 11), pre-identified from
the McGrail et al. [6] study, were purposively sampled for
the current study with the aim of more in-depth explor-
ation of these contexts to understand the nature of work,
supervision, and how to build general practice (GP) train-
ing capacity in these specific communities.
Building GP training capacity in these communities has
enormous potential to provide additional primary health
care services for populations in need of more services. GP
registrars increase the available pool of local doctors see-
ing patients. Providing training in these settings is essen-
tial to develop GP registrars with relevant skills for the
scope of practice required by remote communities. There
is also the potential that registrars may stay in these com-
munities after they complete their vocational training [16].
Rural-based GP training has been shown to increase the
likelihood of GPs practising in these areas for at least five
years [17]. Other research has shown that both rural back-
ground [18–20] and extended rural placements during
medical school [21,22] positively influence rural practice
in early career. However, there is very little contextual in-
formation about the rich range of background factors re-
lated to working and undertaking supervised postgraduate
medical training in such communities, making it hard to
implement solutions.
This project was led by James Cook University’s(JCU)
GP training program, Generalist Medical Training
(GMT), which operates as one of nine decentralised re-
gional GP training organisations across Australia. It pro-
vides GP training across over 90% of the large state of
Queensland, much of it in rural and remote locations. In
Australia, GP training can be commenced as early as the
second year of postgraduate medical practice (after in-
ternship to achieve full registration). JCU’sgoalisto
provide training to build a distributed medical workforce
with the skills to meet the population health needs of
the large rural and remote catchment population. Hence,
this project had high practical application to JCU and it
was done in an academically rigorous way to inform the
international evidence-based literature.
Methods
Participants
Eleven purposively selected towns were chosen for this
study. They had been delineated as underserved for gen-
eral practitioners as well as GP supervisor and registrars,
relative to their assessed population need as per the
McGrail et al. [6] study. These included towns with pop-
ulations of < 15,000 people or were more than 10 km
from the nearest regional centre with a population of
15,000 or more. Most had a district hospital (small rural
hospital with selected generalist services) as a major re-
ferral site for surrounding communities and at least one
general practice clinic in the town. Queensland remote
areas has a higher than average proportion of Indigenous
population and this was notable in several of the
communities studied. The characteristics of the towns
sampled are outlined in Table 1.
Within these towns all GP supervisors, GP registrars,
and practice managers were invited to participate in a
semi-structured interview face to face or remotely by
phone, about supervising or receiving GP training in the
context of their town. The basis for selecting these
participants was to understand the factors from different
perspectives as these can vary between GPs-in-training,
longer term GPs, and those working in a business context.
Interviews were conducted from mid-November 2017 to
Young et al. BMC Health Services Research (2019) 19:338 Page 2 of 10
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mid-February 2018, digitally recorded, transcribed verba-
tim, and entered into NVivo 11 Plus (QSR International
Pty) for analysis. All transcripts were sent to participants
for checking and confirmation prior to analysis.
Data analysis
Qualitative data from semi-structured interviews under-
went thematic analysis using a three-level qualitative ap-
proach [24]. Transcripts were read in full and coding of
identified themes was confirmed using shared coding ses-
sions and theme generation by two researchers (LY, RP)
with consensus used to resolve discrepancies. Inter-coder
reliability was undertaken by three researchers (LY, RP,
BO’S) on half of a random selection of the transcripts to
ensure consensus of themes and integrity of coding. Au-
thors discussed and reached consensus about the final
main themes and sub-themes (level 1 and level 2) as they
emerged, further analysing and discussing the data over a
period of six months. In addition to thematic coding,
quantitisation as a mixed methods approach that allows
the numerical translation, transformation or conversion of
qualitative data, was applied to determine the importance
and occurrence of each theme [25]. For this, qualitative
verbal comments in sentence units were transferred into
numerical form to show commonality of themes and to
aid interpretation as to the weight of the data in each
theme. Some verbatim illustrative quotes were selected
from these sentence units and were included in the textual
presentation of results (in italics).
Results
Overall 39 participants (19 males, 20 females) were inter-
viewed including 14 GP registrars, 12 GP supervisors, and
13 practice managers. All participants were aged from 20
to 50 years. There were 15 Australian Medical Graduates
(AMG) and 11 International Medical Graduates (IMG).
See Table 2.
Insight from all participants interviewed is presented
across four key themes: 1) supervision in underserved
communities, 2) impact of working in small, underserved,
remote contexts, 3) work-life balance, and 4) fostering
sustainable remote practice. (See Table 3).
Theme 1 - supervision in pre-identified underserved
communities
Most comments related to perceptions of supervision and
emphasised the impact of supervision for providing men-
torship and support during registrar training. One registrar
commented they chose to train in the location for the qual-
ity of supervision available across the community –“It is
the reason I came out”. Another registrar noted, however,
that supervisors were busy in the remote practice context
though they found ways to stay in touch with registrars
during busy daily routines, including methods to stay in
touch through a “quick text”. For trainees needing more
support and to develop the resilience for remote practice,
supervisors recognised the need to be available “on the
ground”,and“on the run”including the middle of the night
for on-call work. Over a quarter of responses raised the
issue of sufficient supervision through “being able to have
access to good supervision in the general practice and at the
hospital”. To a lesser extent, some raised issues of remote
areas having inexperienced supervisors who are “not much
more experienced than you are - junior people”. Although
most participants discussed the supervision schedule at an
operational level, there was no clear consensus about an
optimal model of supervision, including the best arrange-
ments for scheduled versus unscheduled “teaching-learn-
ing”time outside of delivering the much-needed clinical
services in these communities. Additionally, options of
using remote supervision and co-supervision models were
only raised by a couple of participants, rather than being
noted as a possible option for building capacity in different
communities. Table 4exemplifies a range of other com-
ments by various participants.
Theme 2 - impact of working in small, underserved, and
remote context
The impact of working in small, underserved, and re-
mote communities was discussed in relation to the
Table 1 Selected Regions and Towns relative to population needs*
* Individual towns, registrar count, and indigenous population are not identified in this table for the purposes of adhering with ethical requirements and to keep
towns and participants unidentified
** Population of 2011 as per the Australian Bureau of Statistics 2011 Census [23]
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community, its health service quality, and the unique
learning experiences it offered for registrars. The presence
of registrars in these communities was perceived by both
registrars and supervisors to contribute to health out-
comes and continuity of practice to “make a difference”.
One practice manager also noted the centrality of medical
care to the community “if we didn’t have a doctor, we
wouldn’t have a community”. Community trust and to a
lesser extent community engagement emerged as import-
ant. Registrars who started a community triathlon club in
their community are an example community participation.
From the health service perspective, having registrars
training in the town facilitated patient-centred care, a
positive medical teaching and learning environment,
“quality of service”, and reputation for good healthcare,
improving the perception of the community having skilled
doctors, and facilitated inter-professional team-focussed
care. The substantial skill demands required were ob-
served by a practice manager who stated that “some of
them [/registrars/] come out –they think it’s a small sleepy
town…don’t realise the emergency experience that they
need”. Undertaking supervised practice in these communi-
ties, registrars were noted to work across an increased
scope of practice, develop professional and personal resili-
ence and increase their professional confidence. A regis-
trar noted “you’ve got real ability to just practice at the top
of your level”. Additionally, a supervisor noted that exten-
sive team work is an important lesson for GP registrars -
“the team is everything”.Overall,remoteunderserved
communities could focus on engaging registrars and su-
pervisors and promote sustainable work-life practice
models for their doctors. Table 5exemplifies a range of
other comments on this theme.
Theme 3 - work-life balance
The importance of work life balance in these under-
served communities was strongly emphasised. Issues
which came up for both supervisors and registrars were
Table 3 Summary of Themes and Sub-themes
Table 2 Demographic Profile of Interviewed Participants
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trying to balance workload, time for family and friends,
sporting and other leisure activities, and community in-
volvement. Supervisors perceived that they were role
models of these factors for registrars. Challenges to
achieving a work life balance were mainly mentioned by
registrars and supervisors and included the problem of
work spill-over into time off and boundaries with pa-
tients seen in the community, as well as workload,
on-call, study load and a shortage of clinical staff. A few
participants also mentioned burnout as having the po-
tential to impact their retention and registrars recog-
nised the importance of maintaining and role-modelling
the balance of work for sustainability. Some of the key
factors driving work life balance in these communities
were the amount of quality time with family, doing other
activities in the community and workload expectations
including on-call requirements. Table 6exemplifies a
range of other comments on this theme.
Theme 4 - fostering sustainable practice
Sustainable practice was a strong theme noted by regis-
trars, supervisors, and practice managers impacting the
attraction, training, and retention of GPs. Developing
the overall local and visiting workforce capacity, en-
gaging community involvement in recruitment and
orientation and promoting sustainable workforce prac-
tices were all thought to enhance sustainability. Early
and repeated exposure of medical students and junior
doctors to these communities and fostering the positive
aspects of a remote lifestyle were thought to contribute
to building a local critical mass and attract more GPs to
remote practice. Other ways to potentially increase
registrar supply are to foster the quality of supervision in
remote medical practice by retaining and supporting su-
pervisors who have remote experience, provide support-
ive mentors and enhance supervision through
co-supervision models. To maintain the current remote
GP supervisor workforce, many who were reaching
mid-career considered it important to ensure opportun-
ities to upskill and maintain existing skills.
In terms of the learning model in these remote
towns, the practice managers specifically suggested
building a flexible and balanced workload for both
registrars and supervisors to allow for teaching time.
Teaching opportunities could be facilitated in the
busy environment by more dedicated “educational
resource”. The health service leadership in the town
was also considered important for supporting sus-
tainable practice by the local GPs, thereby enabling
their active engagement in supervision and leader-
ship roles. One registrar explained that it “makes a
bigdifferenceinacountryhospitalhavinganestab-
lished administration staff with strong leadership”.
Further, a supervisor explained that “trying to build
leadership and executive structure within our rural
medical workforce is something that is needed”.Hav-
ing time off and becoming part of the community
were also important elements for sustainable prac-
tice, and therefore for attracting registrars and
retaining supervisors and registrars.
Table 4 Theme 1 - Supervision in pre-identified underserved communities
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Inherent to registrar learning in the remote setting
were developing self-care strategies, enabling oppor-
tunities for professional development and career pro-
gression relative to personal career interests, and
exploring strategies for managing the workload.
More registrar orientation to the clinical practice en-
vironmentwasthoughttobehelpfulbyapractice
manager who explained that “it would be really
beneficial if people came out before and had a look”.
Alternatively, having peer support from other regis-
trars working in a similar role and supervisors en-
gaging with them prior to and throughout their
training. It was also important that registrars had
mechanisms to receive support and comradery from
family, friends, and a broader social network. A
supervisor stated “we have got two guys who have
moved there, and the wives are friends and the two
boys are great friends from university years. It’sa
thumping success”. The remote underserved commu-
nities could focus on engaging registrars and
supervisors and promote sustainable work-life prac-
tice models for their doctors. Table 7exemplifies a
range of other comments on this theme.
Discussion
This study provides important new insights into the fac-
tors that relate to developing GP training capacity in re-
mote areas that need more primary care services for
their population’s needs. Four main themes provide
guidance as to the direction of investment needed to
build general practice workforce and training opportun-
ities in this context. Firstly, supervision is of high quality
in this context and supervisors are important role
models and mentors, but supervisors are busy working
across the community. It was apparent that there was no
consistent framework for supervision across the various
remote communities. It is important to tailor supervi-
sion models to the needs of individual communities in-
cluding considering options such as remote and
co-supervision models, as a means of enabling regular
Table 5 Theme 2 - Impact of Working in small, underserved, and remote context
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access to supervisors, particularly in this setting where
registrars work at the top of their skills and supervisors
are time pressured due to clinical demands [26,27]. To
some extent, registrar selection for remote placements
may overcome this issue. The registrars in this study
were functioning at high levels and knew when to ask
for help, however, this may not lead to consistent super-
vision, depending on the registrar and their willingness
to ask for help.
Remote towns provide a unique teaching and learning
context for registrars to learn about GP practice through
the lens of a community connection seeing the impact
of their work on the quality of health care services and
on people who really need their services. Providing GP
training in remote communities who need more primary
care services is good for the community and provides a
“richness”of experience for the learners with remote ex-
posure enhancing their scope of practice, feeling of ac-
complishment, and resilience.
Having a critical mass of doctors was a key issue enab-
ling balanced and flexible work schedules to be modelled
by supervisors resulting in attracting and retaining regis-
trars and a sustainable remote supervision model. Crit-
ical mass could be developed encouraging groups of
medical students and registrars to train together, includ-
ing early and repeated training opportunities in remote
communities as multiple placements throughout medical
school, in the early postgraduate years, and during voca-
tional training [22]. Retaining remote supervisors
through their careers requires upskilling provisions and
innovative work and supervision models to promote car-
eer diversification whilst sustaining work in the same re-
mote community [28]. The quality of remote
supervision and registrar learning opportunities is poten-
tially a key attractor for medical students and registrars.
However, equally important is enhancing this quality by
investing in supervisor up-skilling and supporting sus-
tainable working conditions.
Practice managers, in particular, recommended ensur-
ing flexible and balanced workloads for both registrars
and supervisors to mitigate the local GP medical work-
force shortage. Maintaining doctor’s well-being is an im-
portant consideration [29,30]. Also, it is important that
educators and supervisors foster leadership skills in their
registrars due to its importance in rural and remote
communities [30].
Registrars benefit from the challenge of remote practice
and become resilient through optimising opportunities to
increase their scope of practice and accelerate their ca-
reers [28]. Preparing registrars for their role as rural GPs
by engaging with and exploring the community prior to
re-locating and having support from other registrars and
supervisors prior to and throughout their training is also
important as is the support of family and friends.
Encouraging local communities to participate in induct-
ing and integrating registrars and supervisors into the
local lifestyle through community inductions, community
integration, non-monetary incentives, and cultural train-
ing is a critical strategy for success. Overall, the findings
from this study, although extracted from interviews in
Table 6 Theme 3 - Work-life balance
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Australian rural and remote communities, may apply to
the needs of rural areas worldwide as a way of developing
GP training capacity and increasing the workforce in
underserved areas.
Limitations
The scope of the present study is restricted to the com-
munities and stakeholders where the interviews were
undertaken. However, these communities were all
pre-identified as needing more GP services to address
population health needs, and so this paper contributes
to the literature on this topic. Towns were sampled in
different geographic areas to overcome this potential
weakness and the characteristics of these towns is pre-
sented. Themes were triangulated by using a range of
supervisor-registrar-practice stakeholders until satur-
ation was reached.
Conclusion
This study provides the first empirical data exploring
how supervised general practice training capacity in
communities that are underserved may be enhanced.
Key factors are: building tailored supervision systems/
frameworks across the remote community which include
supervisor training, engaging registrars in the unique
learning experience of working in these locations, man-
aging work-life balance, and building registrar resilience
while ensuring sustainable practice models. This study
provides evidence for building capacity in general prac-
tice training settings in remote areas which require more
primary care services for their population.
Abbreviations
Australian Medical Graduates (AMG): Doctors who completed basic medical
training in an Australian medical school.; Australian Standard Geographical
Classification –Remoteness Areas (ASGC-RA): A geographical classification
system which defines locations on a scale with respect to their remoteness
(physical distance to nearest service centre with 1 classified as Major City, 2
as Inner Regional, 3 as Outer Regional, and 4-5 as Very Remote.; Districts of
Workforce Shortage (DWS): Areas classified as having less general practice
services than the population average, based on Medicare data.; General
Practitioners (GPs): Doctors or physicians who are qualified (fellowed with a
specialist medical college following specific post-graduate training) to work
in primary care and/or hospitals.; Generalist Medical Training (GMT): A GP
training organisation which operates as one of nine decentralised regional
Table 7 Theme 4 - Fostering Sustainable Practice
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organisations across Australia. It provides GP training across over 90% of the
large state of Queensland, much of it in rural and remote locations.; Index of
Access (IA): A score which delineates level of access to services based on the
volume of GP services and population characteristics within floating
catchments.; International Medical Graduates (IMG): Doctors completed their
basic medical training in another country and now working in Australia.;
Modified Monash Model (MMM): A more recent geographical classification
system adopted in Australian policy in 2015. This classification defines
locations according to their population size and remoteness with 1 being
Major City, 2 being >50,000 Population, 3 being 15-50,000 population, 4 be-
ing 5-15,000 population, and 6-7 Remote or Very Remote.; Socio-Economic
Indexes for Areas (SEIFA): A classification system used nationally as the
relative score of socio-economic advantage or disadvantage, based on five-
yearly census data.
Acknowledgements
The authors thank Ms. Lee Gasser for assisting with data collection.
Funding
This project was supported by the Australian College of Rural and Remote
Medicine Education Research Grant (ACRRM –ERG) but the authors had full
autonomy over the study design, data collection, analysis and interpretation
as well as the contents of the final manuscript.
Availability of data and materials
The datasets produced and/or analysed during the current study are
available from the corresponding author on reasonable request.
Authors’contributions
LY designed the study, participated in shared coding sessions to confirm
initial themes, and drafted the manuscript. RP collected the data, conducted
all analyses, and drafted the manuscript. BO participated in shared coding
sessions to confirm initial themes and drafted the manuscript. CR assisted
with study design and interpretation of results. All authors contributed to
writing, reading, and approved the final manuscript.
Ethics approval and consent to participate
The authors assert that all procedures contributing to this work comply with
the ethical standards of the relevant national and institutional commitments
on human experimentation and with Helsinki Declaration of 1975, as revised
in 2008. This study was approved by the James Cook University Human
Research Ethics Committee (Project H7132) and the Monash University
Human Research Ethics Committee (Project 11,026). All participants provided
written consent to participate in interviews, which were recorded and
transcribed verbatim. Interview transcripts were sent back to each participant
for member checking.
Consent for publication
Participants gave consent for using direct quotes in this publication.
Competing interests
LY, RP, and CR were employed by James Cook University and its affiliate
Generalist Medical Education in Queensland. BO’S was employed by Monash
University School of Rural Health.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
College of Medicine and Dentistry, James Cook University, 1 James Cook
Drive, Townsville, QLD 4811, Australia.
2
Monash University School of Rural
Health, Bendigo, Victoria, Australia.
Received: 22 November 2018 Accepted: 8 April 2019
References
1. Australian Bureau of Statistics. Causes of death, Australia, 2013 (No. 3303.0)
2015. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/
by%20Subject/3303.0~2013~Main%20Features~Suicides~10004. Accessed
23 Nov 2018.
2. Australian Institute of Health and Welfare. Australia’s health 2016. Australia’s
health series no. 15. Cat. no. AUS 199. Canberra: AIHW.; 2016. Available from:
https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-
f4d1c3d6a727/19787-AH16.pdf.aspx. Accessed 23 Nov 2018.
3. Australian Institute of Health and Welfare. Australia’s welfare 2013. Australia’s
welfare series no.11. Cat. no. AUS 174. Canberra: AIHW; 2013. Available from:
https://www.aihw.gov.au/reports/australias-welfare/australias-welfare-2013/
contents/table-of-contents. Accessed 23 Nov 2018.
4. Fraser S. Putting doctors under a data microscope. An examination of
doctors’working lives is raising questions about their efficiency and
effectiveness. Pursuit. 2017. https://pursuit.unimelb.edu.au/articles/putting-
doctors-under-a-data-microscope. Accessed 16 Apr 2019.
5. Murray R, Sen Gupta TK. Assessment in rural medicine: how to measure and
motivate achievement of abilities. In: Chater AB, Rourke J, Strasser R, Couper
I, Reid S, editors. WONCA rural medical education guidebook. Bangkok:
WONCA; 2014. p. 1–12.
6. McGrail M, Russell D, O’Sullivan B, Reeve C, Gasser L, Campbell D.
Demonstrating a new approach to planning rural medical training
distribution around population need in north West Queensland.
Unpublished report. Australia: James Cook University; 2019.
7. Australian Government Department of Health. Australian Standard
Geographical Classification - Remoteness Area (ASGC-RA 2006) 2018.
Available from: http://www.doctorconnect.gov.au/internet/otd/publishing.
nsf/content/ra-intro. Accessed 23 Nov 2018.
8. Australian Government Department of Health. Modified Monash Model.
2018. Available from: http://www.health.gov.au/internet/main/publishing.
nsf/content/modified-monash-model. Accessed 16 Apr 2019.
9. Commonwealth Department of Health. District of workforce shortage Canberra:
Australian Government 2018. Available from: http://doctorconnect.gov.au/
internet/otd/publishing.nsf/Content/dwsFactsheet. Accessed 23 Nov 2018.
10. McGrail MR, Humphreys JS. Measuring spatial accessibility to primary care in
rural areas: improving the effectiveness of the two-step floating catchment
area method. Appl Geogr. 2009;29(4):533–41.
11. McGrail MR, Humphreys JS. The index of rural access: an innovative
integrated approach for measuring primary care access. BMC Health Serv
Res. 2009;9(1):124.
12. McGrail MR, Humphreys JS. Spatial access disparities to primary health care
in rural and remote Australia. Geospat Health. 2015;10(2):138–43.
13. McGrail MR, Humphreys JS. Geographical classifications to guide rural health
policy in Australia. Aust N Z Health Policy. 2009;6:28.
14. McGrail MR, Russell DJ, Humphreys JS. Index of access: a new innovative
and dynamic tool for rural health service and workforce planning. Aust
Health Rev. 2017;41(5):492–8.
15. Socio-Economic Indexes for Areas [Internet]. 2018. Available from:
http://www.abs.gov.au/websitedbs/censushome.nsf/home/seifa.Accessed
23 Nov 2018.
16. Wearne S, Patrick G, Jeanette ML, Catherine G. Where are they now? The
career paths of the Remote Vocational Training Scheme registrars. Aust
Family Physician. 2010;39:53–6.
17. McGrail M, Russell D, Campbell D. Vocational training of general
practitioners in rural locations is critical for Australian rural medical
workforce supply. Med J Aust. 2016;205(5):216–21.
18. Hays R. Interpreting rural career intention in medical workforce research.
Educ Prim Care. 2017;28(1):7–9.
19. Hudson JN, May JA. What influences doctors to work in rural locations?
Med J Aust. 2015;202(1):5–6.
20. Wearne S. General practice supervision at a distance. Aust Fam Physician.
2005;34(12):31–3.
21. O'Sullivan B, McGrail M, Russell D, Walker J, Chambers H, Major L, et al.
Duration and setting of rural immersion during the medical degree relates
to rural work outcomes. Med Educ. 2018;52(8):803–15.
22. Sen Gupta T, Johnson P, Rasalam R, Hays R. Growth of the James Cook
University medical program: maintaining quality, continuing the vision,
developing postgraduate pathways. Med Teach. 2018;40(5):495–500.
23. Australian Bureau of Statistics. 2011 Census Data 2017. Available from: http://
www.abs.gov.au/websitedbs/censushome.nsf/home/
historicaldata2011?opendocument&navpos=280. Accessed 23 Nov 2018.
24. Fossey E, Harvey C, Mcdermott F, Davidson L. Understanding and
evaluating qualitative research. Aust N Z J Psychiatry. 2002;36(6):717–32.
Young et al. BMC Health Services Research (2019) 19:338 Page 9 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

25. Sandelowski M, Voils CI, Knafl G. On Quantitizing. J Mixed Methods Res.
2009;3(3):208–22.
26. Martin P, Sen Gupta T, Douyere J. Clinical supervision in rural Australia:
challenges and opportunities. Med J Aust. 2018;209(9):382–3.
27. Thomson JS, Anderson KJ, Mara PR, Stevenson AD. Supervision—growing
and building a sustainable general practice supervisor system. Med J Aust.
2011;194(11):S101.
28. Young L, Malau-Aduli B, Peel R, Sen Gupta T, Reeve C, Hays R. Factors
impacting GP training in rural and remote locations: Current perspectives
from GP registrars, supervisors, and practice staff. Unpublished report.
Australia: James Cook University; 2019.
29. Cooke GPE, Doust JA, Steele MC. A survey of resilience, burnout, and
tolerance of uncertainty in Australian general practice registrars. BMC Med
Educ. 2013;13(1):2.
30. Walters L, Laurence CO, Dollard J, Elliott T, Eley DS. Exploring resilience in
rural GP registrars - implications for training. BMC Med Educ. 2015;15(1):110.
Young et al. BMC Health Services Research (2019) 19:338 Page 10 of 10
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