Australia’s medical workforce is distributed unevenly — in rural and remote areas, where people have the highest morbidity and mortality rates, there is reduced access to medical services. 1,2 Not only is there a maldistribution adversely affecting rural and remote areas, but the work of rural and remote general practitioners is more complex than that in metropolitan areas.3 Thus, we need to provide appropriate medical training for these environments, and strategies to increase the rural workforce.

In recent years a suite of initiatives has been introduced to encourage more doctors to choose careers in the bush.4 These range from visits to rural high schools promoting medicine as a career, to undergraduate scholarship schemes, through to regionalised general practice training. Rural Australian Medical Undergraduate Scholarships are offered to students from rural areas, and the John Flynn Scholarships are open to all students who express an interest in future rural practice. Both of these foster relationships with rural areas and practitioners. All general practice registrars are now required to work for at least 6 months in a rural area, and there are financial incentives to train in rural areas. Finally, substantial academic infrastructure, in the form of university departments of rural health and rural clinical schools, has been funded.5

Will these initiatives have an impact on rural and remote workforce shortages?

Current evidence suggests that rural doctors are more likely to have come from a rural background, to have a partner or spouse with a rural background, to have wanted a career as a general practitioner, and to have undertaken undergraduate and postgraduate training in rural areas. 6-8 Doctors who spend more than half their postgraduate training period in rural areas are over 10 times more likely to practise in a rural area.9

Most of the initiatives to encourage rural practice have been aimed at medical students, or at doctors after rather than before registration. Historically, most internships have been completed in metropolitan hospitals. The health system needs high technology centres, but are they an appropriate place to apprentice practitioners in their pre-differentiated stage?

In this issue of the Journal, Peach et al (page 106)10 present the results of a study on the eventual place of work of doctors who completed their internships in a regional hospital in Victoria. These doctors were more likely to work as general practitioners in regional Victoria than their contemporaries who completed internships in metropolitan hospitals. Peach et al argue that more internships should be available in regional areas.

This retrospective, case–controlled study shows an association between regional internships and regional careers, but, as the authors acknowledge, this does not prove causation. Were those who worked in regional Ballarat a self-selected group, already with an interest in life outside the city? Only a prospective study can explore why choices were made, and what aspect of the internship promoted the choice of a career in rural medicine. Was it the social network the doctor made? or the content of medicine in rural areas, with common acute presentations to hospital rather than rare conditions (providing confidence in diagnosis and reducing the “fear” factor of on-call in comparative isolation)? or was it the context, with close relationships with a community making the doctor feel involved and included?

There has always been a tension in postgraduate medical education between providing workforce and furthering the education of doctors in training. Studies have shown that sending general practice registrars to areas of workforce need does not always guarantee a good learning experience, and may generate a desire to rush back to the city at the earliest opportunity. A study in central Australia suggests that, without adequate supervision, the significant learning opportunities available in rural areas are not fully utilised.11 Moreover, the National Female Rural General Practitioners Research Project12 noted that, while increasing numbers of women are choosing rural general practice, many female general practice registrars in rural areas planned to return to metropolitan areas once they had completed their training.

To solve the rural and remote workforce shortages, we need to provide appropriate, high-quality training in rural areas and specifically for rural areas. The absolute numbers of medical students with a rural background are still low, so any mechanisms that encourage students from urban backgrounds to work in rural and remote areas are important. However, the intern year needs to provide, in a protected environment, the practical knowledge and skills necessary for a safe standard of medical practice. We need to be sure that regional areas can provide this environment — accredited education, support, assessment, and suitable working conditions.13-15

Do we need further evaluative research, as suggested by Peach et al? Yes, we need a prospective cohort study, taking into account the planned Committee of Deans of Australian Medical Schools (CDAMS) Rural Programs Evaluation Project, to examine the impact of both undergraduate and postgraduate rural initiatives on career directions.16 Should we wait for another 5 or 10 years for the results of this research? No, Australians in rural and remote areas cannot wait. We now have sufficient evidence to be confident that rural and remote training has an impact on subsequent choice of rural practice, and we know what constitutes an effective training post. Armed with these two pieces of information, we can proceed with increasing the numbers of regional internships. The distribution of internships should better reflect the health needs across Australia.