To the Editor: I would like to report the results of a recent survey showing that junior doctors who undertook undergraduate training in a rural clinical school (RCS) felt better prepared for their new role as a doctor than those who did not.

In Australia, the potential threat to the quality of clinical training because of increasing numbers of medical graduates justifies an interest in junior doctors’ perceptions of their learning environment and their level of preparedness for hospital work. Factors affecting this potential threat were investigated.

In 2008, 428 junior doctors employed in Queensland training hospitals were asked to complete an online survey. Ethics approval was obtained from the Behavioural and Social Science Ethical Review Committee of the University of Queensland. During their undergraduate training, the majority of respondents had not studied at an RCS. The remaining respondents had attended a large university RCS (of about 1600 enrolled students) or a small university RCS (of about 650 enrolled students) in Queensland, or had attended an RCS of unknown size in another state (n = 9).

A mixed methods cross-sectional design, based on two validated scales, was used:

• The Preparation for Hospital Practice Questionnaire (PHPQ) assessed respondents’ perceptions of the adequacy of undergraduate medical training to prepare them for hospital work;1 and

• The Postgraduate Hospital Educational Environment Measure (PHEEM) measured respondents’ hospital clinical teaching and learning environment.2

Of 167 responses received (a 39% response rate), 33 were incomplete, leaving 134 usable responses. The majority of respondents were women (60%), aged 26–29 years (53%) and graduates of the large university (79%). Forty-eight per cent had chosen to spend a portion of their undergraduate training at an RCS.

A univariate analysis (using analysis of variance and analysis of covariance) made comparisons by age, sex, undergraduate university medical program (large or small Queensland university, university in another state) and attendance at an RCS.

Overall responses to the PHEEM indicated that there was “room for improvement” in the autonomy, teaching and social support of the hospital learning environment. No significant differences were detected in either the PHEEM or PHPQ subscale scores by age, sex, postgraduate year or undergraduate university. Junior doctors who attended any RCS as part of their undergraduate education scored significantly higher on three out of eight scales of preparedness for hospital work (based on the PHPQ) (Box). A caveat is that confidence and feelings of preparedness do not equate to “competence”, but the study was not designed to assess competence. Confidence is also strongly related to temperament, which could influence self-selection choices such as factors associated with the size of medical school.

These findings are congruent with other studies showing that students perceive undergraduate training outside a traditional metropolitan-based program to be of higher quality3 and that the performance of students trained in RCSs is comparable to that of their urban-based peers.4,5 Dispersing smaller cohorts of students to individual clinical schools (similar to the RCS model) may prove a successful strategy to cope with escalating numbers of undergraduate students. In theory, better prepared junior doctors should require less intensive supervision, contribute more to the hospital workload and alleviate the strain on already stretched educational resources in hospitals.

In summary, given the imminent increase in medical graduates entering training hospitals, considerable work needs to be done to improve the quality of education provided for junior doctors in order to maintain a high-quality, supportive educational atmosphere.