To the Editor: The editorial by Wearne and Wakerman on the subject of rural training and its relationship to rural practice is timely.1

There is widespread belief that the rural problem lies in small country centres, and it is generally not realised that most of the regional centres, in New South Wales at least, are seriously short of both general practitioners and specialists. The statistics are highly unreliable, as many people, such as me, are listed as GPs even though we do not practise.

It seems likely that improved selection processes and the undergraduate rural training initiatives will increase student interest in rural practice. Many students express intent to practice in a rural or regional centre, but are later deflected from this by the necessity for training after graduation. Several large centres are not primary allocation centres, so a student who trained there may never get back. (The Australian Medical Students’ Association study puts the figure for rural internships as 9% of the total.)2 All too often, regional centres are understaffed, and junior staff lack adequate supervision and educational possibilities. Their negative experience is highly visible to students.

The allocation of registrars and senior resident medical officers, who supervise or make time for consultants to supervise, rests between the major hospitals and the various colleges. Regional hospitals are often low on their priority list when shortages occur. Yet there are regional hospitals that rate very highly in the quality of the training experience they provide. Regional hospitals that do not enjoy this reputation need to take active steps to improve their training and supervision or their plight will worsen.

Training packages also need to be developed for those who express an interest in rural practice so they can plan their future. This must be a collaborative process between the different seconding agencies: without such a process, much of the impetus of the undergraduate initiatives will be lost.

To the Editor: I recently had the opportunity to analyse the home postcodes of medical students at the University of Adelaide over five recent consecutive years. Although this analysis is rather simplistic, its findings are quite startling (see Box).

Between 50 and 60 students per year were from the Adelaide metropolitan area. My colleagues in the Department of Human Services tell me that we struggle every year to fill the junior posts at our metropolitan public hospitals.

A considerable number of students (25–41) were from outside South Australia. It is only natural that these students would want to go home after completing their degree, and I believe that considerable effort is made every year to encourage these students to stay and staff junior positions in our hospitals.

There has been much discussion about students from outside Australia and I will not add to the debate on this complex issue.

The most alarming feature is the small number of students from rural South Australia. This ranged from zero to three or four. Moreover, I have included in this category students whose home address was in the Adelaide Hills, which is between 5 and 20 km from the Adelaide metropolitan area.

We spend a lot of time encouraging students who grew up and were educated in cities to come to rural settings, using various schemes of bonding and financial inducement, with limited success.

After 18 years’ practice in a rural area, I am firmly of the belief that we should be starting much earlier. If a person is born and reared in the country, and has their secondary schooling in the country, it is much easier to transplant that person back to the country after tertiary eduction.

If these figures of students’ home residence are representative, we will always be fighting an uphill battle to attract doctors to rural areas.This is not the fault of our universities, as they are constrained by federal regulations. I believe the solution lies in Canberra.

In our parliaments, we have proportional representation. As far as medical students are concerned, I think South Australia has disproportionate representation.

Comment: Data collected by the Committee of Deans of Australian Medical Schools (CDAMS) would appear to broadly support the pattern of medical student origins reported by McCusker from the University of Adelaide. CDAMS has been collecting medical student statistics annually for the past few years. Box 1 sets out the basic enrolment figures for Australian and international students across all years in 2003.

In 2003, CDAMS also commenced collecting data on interstate mobility (ie, students attending medical school in another state) among first-year medical students at the 12 medical schools. As a general principle, some level of interstate mobility brings positive benefits by fostering diversity in the medical student body and broadening educational and social opportunities for individual students. However, as McCusker rightly points out, this can create problems when interstate medical graduates choose to return to their home states (or move to other states) when they enter their intern training years.

In this regard, South Australia faces particular problems, as it has the highest proportion of students entering medicine from interstate. Box 2 shows that just under half of all commencing medical students at Adelaide and Flinders medical schools in 2003 were from other states. This may well have an impact when these students come to choose their intern training locations.

Box 3 sets out state averages for first-year students with a rural background. The figure for South Australia as a state suggests that it is reasonably comparable with other states. However, there is a sizeable gap between the rural student cohorts at Flinders and Adelaide medical schools: in 2003, 26% compared with 12%, respectively, were from a rural background. All medical schools in Australia have committed their energies to a range of collaborative programs, together with the Australian Department of Health and Ageing, aimed at ensuring a sustainable medical workforce that is equitably distributed across the nation.