eMJA: Kamien, Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions

Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions

Max Kamien

MJA 1998; 169: 318-321
For editorial comment, see Cameron

→ Other articles have cited this article

Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details
Make a comment - Register to be notified of new articles by e-mail - Current contents list - ©MJA1998

Abstract
Objective: To examine the 1996 outcomes of a sample of Western Australian rural doctors who in 1986 had indicated their intentions to stay in or leave rural practice.
Design: Postal questionnaire survey in December 1996, semi-structured interview and feedback by doctors on a draft of this article.
Participants: 91 respondents from the 101 doctors who in 1986 had filled in a questionnaire on their intentions to stay in or leave rural practice.
Main outcome measures: Proportion of doctors whose actions by 1996 were at variance with their intentions in 1986, and the reasons for their change of direction.
Results: 49% (22/45) of doctors who intended to leave had stayed ("stayers") and 24% (11/46) who intended to stay had left ("leavers"). Doctors' main concerns in 1986 were overwork, lack of locum relief, professional contact with colleagues, specialist backup in emergencies, downsizing of hospital facilities, continuing medical education, and income. By 1996 stayers had solved most of these professional problems and felt they were doing a special job which made a difference to their community. Conversely, more than half the leavers were unable to solve these problems and felt disempowered and dispirited. Their most potentially solvable problems were overwork, forced deskilling and conflict with other healthcare professionals.
Conclusion: Professional satisfaction was the main reason for doctors staying in or leaving rural practice. Professionally dissatisfied rural doctors reach a critical phase which they have to surmount if they are going to stay. An examination of the positive experiences of the stayers points the way to retaining at least half the potential future leavers.
Introduction
Much is known about recruiting doctors to rural practice, but less on how to retain them.^1-3 A difficulty in researching retention of doctors in rural practice is a lack of baseline data on the intentions of the doctors. In 1986, the Western Australian Minister for Health commissioned an inquiry into the recruitment and retention of rural doctors.¹ Those doctors who did not make written or oral submissions to the 1986 inquiry were then sent a questionnaire which included an item on how long they intended to stay in rural practice. The focus of my study is on those doctors whose subsequent actions by the end of 1996 were at variance with their stated intentions in 1986.
Methods
In 1986, 121 doctors answered questions on their intention to leave or stay in rural practice and on factors which would influence their decision. At the end of 1996, various local and national databases were used to find these doctors. Twenty were either retired, overseas or not on any Australian medical register. The remaining 101 doctors were sent a questionnaire and 91 returned a completed reply. The 1986 responses of those doctors were used to classify these doctors in 1996. If, in 1986, the doctors stated they would stay another five years and were still there in 1996, they were classified as "stayers". If, on the other hand, they said they would still be in rural practice for 10 or more years but left before 1996, they were classified as "leavers" (Figure). The 1996 questionnaires to leavers and stayers contained similar questions but were worded according to the doctors' intentions in 1986 and their actions by 1996. For example, leavers were asked if a lack of locum relief had influenced their decision to leave, while stayers were asked if the availability of locum relief had influenced their decision to stay.
Data were analysed with SAS for Windows,⁴ using Fisher's exact test.

To improve depth of understanding of the questionnaire responses, five randomly chosen leavers and 10 stayers were interviewed by one research officer using a semi-structured questionnaire. A further random sample of 15 respondents were asked for comment on whether the findings of my study conformed with their experiences and those of their rural practice colleagues.
Results
Eleven (24%) of those who intended to stay in rural practice in 1986 had left by 1996 and 22 (49%) of those who intended to leave had stayed (Figure). Six of the stayers had moved from one rural area to another: two from one regional centre to another; one from one rural practice to another; one from one remote practice to another; one from a rural practice to a salaried position in a regional hospital; and one from a remote to a rural practice. This last doctor was the only one to mention medicolegal concern as a contributory reason for changing from a single-doctor practice to a rural group practice. The main reasons for relocating rural practices were to prevent deskilling, especially in anaesthetics, and to reduce workload.
There was little difference in demographic characteristics between the leavers and the stayers (Box 1). The only statistically significant variable was the unexpected finding that the leavers were more likely to have completed a rural internship (P < 0.05). Other unexpected findings were that the leavers were more likely to be practising in the medical discipline of their first choice and stated, in 1986, that they would choose the same discipline given their life over again. Although both groups had equivalent postgraduate qualifications in 1986, all but two of the leavers had acquired further qualifications before leaving rural practice. The most commonly held qualifications were a Diploma of Obstetrics and Fellowship of the Royal Australian College of General Practitioners.
Box 1

In 1986, the two main professional satisfactions of both the leavers and stayers were providing full and continuous patient care and the ability to practise procedural medicine. A third professional satisfaction was the feeling of doing a special job for their community, and this was reported by 11 stayers but by only one leaver (P < 0.05). Seventeen stayers also reported the social enjoyment and esteem of being involved with the community, compared with only five of the leavers. This involvement was distinct from simply enjoying the quality of life from living in a rural area. In the words of one stayer: "I enjoy the feeling of being a big fish in a small pond." This was not a statement of arrogance but of self- efficacy.
In 1996, five of the leavers reported their spouses' desire to move as a contributory factor, but only one as a definitive factor, in their decision to leave, while two stayers reported their spouse's view as a major influence in their decision to stay. However, there was little difference between the spouses (all were female) of the leavers and stayers with respect to rural background, work situation, attitudes to a rural lifestyle and 1986 intentions to stay in a rural area beyond 1996 (Box 2). Of those spouses with a professional qualification, all were nurses, except for two who were primary school teachers and who left before 1996. There was no statistical difference between families in which one or both partners were professionals with regard to staying or leaving rural practice.
Box 2

Box 3 shows the importance of various retention issues in doctors' decisions to leave or stay in rural practice. In 1986, the stayers were more concerned with being overworked, unable to find locums, the lack of specialist backup when managing emergencies, the adequacy of hospital facilities, and income. By 1996, the stayers had solved most of these problems, and this was important in their decision to stay. Conversely, the leavers had been influenced to leave because of these problems, and had left before 1994, by which time many of the problems were being addressed by the Western Australian Centre for Remote and Rural Medicine (WACRRM), the Rural Doctors' Association of Australia (RDAA), the Australian Medical Association (WA) Locum Services and the Federal Government's General Practice Rural Incentives Program.
Box 3
The leavers' mean age at leaving was 42 years and the mean time for leaving was 4.6 years from when they were surveyed in 1986 (range, 1-8 years). The final decision to leave rural practice was made after periods of deliberation ranging from two months to three years (mean, 10 months). The main reasons why leavers left rural practice were a desire to change professional direction through specialisation or to pursue a special interest (eg, medical education), burn-out, and disillusionment from the downgrading of hospital facilities resulting in an inability to fully use their skills (Box 4). The main social reasons for leaving were children's education and difficulties with marital relationships. Overwork, deskilling, conflict with other healthcare professionals, lack of privacy, poor income and inadequate housing (all potentially solvable) accounted for 60% of the problems and involved six of the leavers.
Box 4
Box 5 shows the main reasons why those who intended to leave stayed in rural practice. More than 60% of reasons for staying were related to job satisfaction, with the remaining reasons divided between social and financial issues.
Box 5
However, 12 stayers reported that interference with factors which contributed to their job satisfaction would make them seriously consider leaving rural practice. This included bureaucratic interference from State or Federal government (6 doctors), downgrading of local services (3), and overwork (3). The next-most-common reasons which could cause doctors to leave rural practice were personal and family difficulties (5).
Discussion
The number of doctors who were stayers was twice the number who were leavers. In agreement with a recent Queensland study, the main reasons for staying were the professional satisfaction of the variety of work, autonomy of practice and the social and personal satisfaction of rural life.⁵ Also important was the feeling of doing an important job. Conversely, some leavers felt disempowered and unable to regain control over their own life. Although both groups had comparable qualifications in 1986, the leavers had acquired more postgraduate qualifications by 1996. This gave them greater options and possibly greater confidence to change their professional direction.
In 1986, the eventual stayers reported a much higher prevalence of problems than did the eventual leavers. By 1996, the stayers had solved most of these problems, including the provision of those hospital facilities which enabled the full use of their clinical and procedural skills. This indicates that professionally dissatisfied rural doctors have reached a critical phase which has to be negotiated if they are going to stay. The most common profile for such a doctor is a man aged 42 years, discouraged by deskilling from downgrading of hospital facilities or clinical privileges, with children aged 13 to 15 years (when the hard decisions about schooling and matriculation opportunities have to be made). Much effort is required to discover and assist these doctors; this is an important task for organisations such as WACRRM, RDAA and rural divisions of general practice.
For Queensland rural doctors, the triggers to leaving were difficulties in coping with change, perceived problems with secondary education for children, poor housing, and personality clashes with colleagues. The ultimate pressures to leave were constancy of after-hours work, difficulty in obtaining locum relief, access to continuing medical education, bureaucratic requirements and family pressures.⁵ These factors also apply in Western Australia. But also important were professional isolation and the downgrading of hospital facilities, preventing the full use of the doctor's procedural skills. These two factors would also influence many stayers to leave rural practice. This is illustrated by the statements of a stayer who relocated in order to maintain his clinical skills, and by a leaver:
"I am self-reliant, and have become disillusioned by interference from outside agencies like the Health Insurance Commission, Medicare, government, the Australian Medical Association, the Royal Australian College of General Practitioners, Divisions etc. I am waiting for the day when I will be asked to relinquish my duties in accident and emergency because I do not hold a fellowship in emergency medicine -- it just seems to be the way things are moving. I also wonder if the day will come when I can auction my provider number like a crayfisherman with a crayfish licence."

"I would have stayed except that I was forced to be deskilled. Prior to commencing rural practice I spent three years training in emergency medicine, anaesthetics, surgery, caesarean sections etc. There were no medical mishaps, yet these procedures were stopped in the two country towns I worked in."

It is therefore important not to create unnecessary problems and, where problems exist, to counter them. Health departments, in particular, need to be clear about their aims and should value rural doctors as a scarce resource and include them in deliberations about change. The ultimate criteria for decisions on rural workforce and hospital facilities should be the maintenance of essential services sufficient to provide safe medical care to rural and remote Australia and to use the full skills of doctors already resident in those areas.
In turn, rural doctors need to be more innovative and flexible in devising methods to reduce their professional isolation, practise procedural medicine, and gain some relief from being constantly on call.
Flexibility is also essential from medical organisations and statutory bodies. The doctor in this study who left for financial reasons had a recognisable qualification in psychiatry and wished to practise it on a 40% time basis. National Specialist Qualification Advisory Committee regulations did not allow him to be classified as a consultant psychiatrist, making his practice financially unviable and depriving 80 000 people of resident psychiatric expertise. He commented:
"I had a specialist qualification and was happy to use it but got no cooperation from the Commonwealth Government to come to some accommodation to pay for consultant psychiatric services. So I could only charge the same fee as a dermatologist for prolonged consultations and this simply wasn't financially viable. I was sad to leave after 10 years, but the more of my speciality I did, the less I earned, and we were simply getting deeper into debt."

The increasing accent on rural issues in undergraduate medical education, the rising proportion of women doctors and the decreasing migration of doctors trained outside Australia make it difficult to estimate the needs for the rural workforce in the next decade. A 1997 study of Australian rural doctors predicts that only 50% will be in their current practice in 2007 and, for Western Australia, only 20%.⁶ Western Australia will therefore have to recruit 250 doctors over the next decade simply to keep pace with anticipated loss. Attention to factors shown to be important in retaining doctors would have an appreciable effect on reducing this loss.
In this study more than half the doctors who intended to stay left for professional and, to a lesser extent, for social reasons which were potentially preventable. Reducing this avoidable loss is therefore an important factor in maintaining the rural workforce. The other main factor in retention is to understand and facilitate the conditions which reinforce the autonomy, efficacy and self-esteem of rural doctors.
Acknowledgements
Thanks are due to Mrs Rosalind Woodcock, who was a Research Officer on this project, and to all the doctors whose participation and insights made the project possible. This project was funded by the Australian Rural Health Research Institute.
References

Western Australian Health Department (M Kamien, Chairman). Report of the Ministerial Inquiry into the Recruitment and Retention of Country Doctors in Western Australia. Perth: Western Australian Health Department, 1987.
South Australian Health Commission, Royal Australian College of General Practitioners (SA), Australian Medical Association (SA). Review of general medical practice in South Australia. Third report: country general practice. Adelaide: South Australian Health Commission, 1992.
Strasser R. Rural general practice in Victoria: the report from a study of the attitudes of Victorian rural general practitioners to country practice and training. Moe: Monash University Centre for Rural Health, 1992.
SAS for Windows [computer program]. Version 6.11. Cary, North Carolina: SAS Institute, 1995.
Hays RB, Veitch PC, Cheers B, Crossland L. Why doctors leave rural practice. Aust J Rural Health 1997; 5: 198-203.
Strasser R, Hays R, Kamien M, Carson D. National rural general practice study. Draft report. Moe: Monash University Centre for Rural Health, 1997.

(Received 16 Feb, accepted 1 Jun, 1998)

Authors' details

University of Western Australia, Perth, WA.
Max Kamien, MD, FRACGP, Professor and Head of General Practice.

Reprints: Professor M Kamien, Professor of General Practice, University of Western Australia, 328 Stirling Highway, Claremont, WA 6010.
E-mail: mkamienATcyllene.uwa.edu.au


Abstract	*Objective:* To examine the 1996 outcomes of a sample of Western Australian rural doctors who in 1986 had indicated their intentions to stay in or leave rural practice. Design: Postal questionnaire survey in December 1996, semi-structured interview and feedback by doctors on a draft of this article. Participants: 91 respondents from the 101 doctors who in 1986 had filled in a questionnaire on their intentions to stay in or leave rural practice. Main outcome measures: Proportion of doctors whose actions by 1996 were at variance with their intentions in 1986, and the reasons for their change of direction. Results: 49% (22/45) of doctors who intended to leave had stayed ("stayers") and 24% (11/46) who intended to stay had left ("leavers"). Doctors' main concerns in 1986 were overwork, lack of locum relief, professional contact with colleagues, specialist backup in emergencies, downsizing of hospital facilities, continuing medical education, and income. By 1996 stayers had solved most of these professional problems and felt they were doing a special job which made a difference to their community. Conversely, more than half the leavers were unable to solve these problems and felt disempowered and dispirited. Their most potentially solvable problems were overwork, forced deskilling and conflict with other healthcare professionals. Conclusion: Professional satisfaction was the main reason for doctors staying in or leaving rural practice. Professionally dissatisfied rural doctors reach a critical phase which they have to surmount if they are going to stay. An examination of the positive experiences of the stayers points the way to retaining at least half the potential future leavers.
Introduction	Much is known about recruiting doctors to rural practice, but less on how to retain them.^1-3 A difficulty in researching retention of doctors in rural practice is a lack of baseline data on the intentions of the doctors. In 1986, the Western Australian Minister for Health commissioned an inquiry into the recruitment and retention of rural doctors.¹ Those doctors who did not make written or oral submissions to the 1986 inquiry were then sent a questionnaire which included an item on how long they intended to stay in rural practice. The focus of my study is on those doctors whose subsequent actions by the end of 1996 were at variance with their stated intentions in 1986.
Methods	In 1986, 121 doctors answered questions on their intention to leave or stay in rural practice and on factors which would influence their decision. At the end of 1996, various local and national databases were used to find these doctors. Twenty were either retired, overseas or not on any Australian medical register. The remaining 101 doctors were sent a questionnaire and 91 returned a completed reply. The 1986 responses of those doctors were used to classify these doctors in 1996. If, in 1986, the doctors stated they would stay another five years and were still there in 1996, they were classified as "stayers". If, on the other hand, they said they would still be in rural practice for 10 or more years but left before 1996, they were classified as "leavers" (Figure). The 1996 questionnaires to leavers and stayers contained similar questions but were worded according to the doctors' intentions in 1986 and their actions by 1996. For example, leavers were asked if a lack of locum relief had influenced their decision to leave, while stayers were asked if the availability of locum relief had influenced their decision to stay. Data were analysed with SAS for Windows,⁴ using Fisher's exact test. To improve depth of understanding of the questionnaire responses, five randomly chosen leavers and 10 stayers were interviewed by one research officer using a semi-structured questionnaire. A further random sample of 15 respondents were asked for comment on whether the findings of my study conformed with their experiences and those of their rural practice colleagues.
Results	Eleven (24%) of those who intended to stay in rural practice in 1986 had left by 1996 and 22 (49%) of those who intended to leave had stayed (Figure). Six of the stayers had moved from one rural area to another: two from one regional centre to another; one from one rural practice to another; one from one remote practice to another; one from a rural practice to a salaried position in a regional hospital; and one from a remote to a rural practice. This last doctor was the only one to mention medicolegal concern as a contributory reason for changing from a single-doctor practice to a rural group practice. The main reasons for relocating rural practices were to prevent deskilling, especially in anaesthetics, and to reduce workload. There was little difference in demographic characteristics between the leavers and the stayers (Box 1). The only statistically significant variable was the unexpected finding that the leavers were more likely to have completed a rural internship (P < 0.05). Other unexpected findings were that the leavers were more likely to be practising in the medical discipline of their first choice and stated, in 1986, that they would choose the same discipline given their life over again. Although both groups had equivalent postgraduate qualifications in 1986, all but two of the leavers had acquired further qualifications before leaving rural practice. The most commonly held qualifications were a Diploma of Obstetrics and Fellowship of the Royal Australian College of General Practitioners. In 1986, the two main professional satisfactions of both the leavers and stayers were providing full and continuous patient care and the ability to practise procedural medicine. A third professional satisfaction was the feeling of doing a special job for their community, and this was reported by 11 stayers but by only one leaver (P < 0.05). Seventeen stayers also reported the social enjoyment and esteem of being involved with the community, compared with only five of the leavers. This involvement was distinct from simply enjoying the quality of life from living in a rural area. In the words of one stayer: "I enjoy the feeling of being a big fish in a small pond." This was not a statement of arrogance but of self- efficacy. In 1996, five of the leavers reported their spouses' desire to move as a contributory factor, but only one as a definitive factor, in their decision to leave, while two stayers reported their spouse's view as a major influence in their decision to stay. However, there was little difference between the spouses (all were female) of the leavers and stayers with respect to rural background, work situation, attitudes to a rural lifestyle and 1986 intentions to stay in a rural area beyond 1996 (Box 2). Of those spouses with a professional qualification, all were nurses, except for two who were primary school teachers and who left before 1996. There was no statistical difference between families in which one or both partners were professionals with regard to staying or leaving rural practice. Box 3 shows the importance of various retention issues in doctors' decisions to leave or stay in rural practice. In 1986, the stayers were more concerned with being overworked, unable to find locums, the lack of specialist backup when managing emergencies, the adequacy of hospital facilities, and income. By 1996, the stayers had solved most of these problems, and this was important in their decision to stay. Conversely, the leavers had been influenced to leave because of these problems, and had left before 1994, by which time many of the problems were being addressed by the Western Australian Centre for Remote and Rural Medicine (WACRRM), the Rural Doctors' Association of Australia (RDAA), the Australian Medical Association (WA) Locum Services and the Federal Government's General Practice Rural Incentives Program.

	The leavers' mean age at leaving was 42 years and the mean time for leaving was 4.6 years from when they were surveyed in 1986 (range, 1-8 years). The final decision to leave rural practice was made after periods of deliberation ranging from two months to three years (mean, 10 months). The main reasons why leavers left rural practice were a desire to change professional direction through specialisation or to pursue a special interest (eg, medical education), burn-out, and disillusionment from the downgrading of hospital facilities resulting in an inability to fully use their skills (Box 4). The main social reasons for leaving were children's education and difficulties with marital relationships. Overwork, deskilling, conflict with other healthcare professionals, lack of privacy, poor income and inadequate housing (all potentially solvable) accounted for 60% of the problems and involved six of the leavers. Box 5 shows the main reasons why those who intended to leave stayed in rural practice. More than 60% of reasons for staying were related to job satisfaction, with the remaining reasons divided between social and financial issues. However, 12 stayers reported that interference with factors which contributed to their job satisfaction would make them seriously consider leaving rural practice. This included bureaucratic interference from State or Federal government (6 doctors), downgrading of local services (3), and overwork (3). The next-most-common reasons which could cause doctors to leave rural practice were personal and family difficulties (5).
Discussion	The number of doctors who were stayers was twice the number who were leavers. In agreement with a recent Queensland study, the main reasons for staying were the professional satisfaction of the variety of work, autonomy of practice and the social and personal satisfaction of rural life.⁵ Also important was the feeling of doing an important job. Conversely, some leavers felt disempowered and unable to regain control over their own life. Although both groups had comparable qualifications in 1986, the leavers had acquired more postgraduate qualifications by 1996. This gave them greater options and possibly greater confidence to change their professional direction. In 1986, the eventual stayers reported a much higher prevalence of problems than did the eventual leavers. By 1996, the stayers had solved most of these problems, including the provision of those hospital facilities which enabled the full use of their clinical and procedural skills. This indicates that professionally dissatisfied rural doctors have reached a critical phase which has to be negotiated if they are going to stay. The most common profile for such a doctor is a man aged 42 years, discouraged by deskilling from downgrading of hospital facilities or clinical privileges, with children aged 13 to 15 years (when the hard decisions about schooling and matriculation opportunities have to be made). Much effort is required to discover and assist these doctors; this is an important task for organisations such as WACRRM, RDAA and rural divisions of general practice. For Queensland rural doctors, the triggers to leaving were difficulties in coping with change, perceived problems with secondary education for children, poor housing, and personality clashes with colleagues. The ultimate pressures to leave were constancy of after-hours work, difficulty in obtaining locum relief, access to continuing medical education, bureaucratic requirements and family pressures.⁵ These factors also apply in Western Australia. But also important were professional isolation and the downgrading of hospital facilities, preventing the full use of the doctor's procedural skills. These two factors would also influence many stayers to leave rural practice. This is illustrated by the statements of a stayer who relocated in order to maintain his clinical skills, and by a leaver: "I am self-reliant, and have become disillusioned by interference from outside agencies like the Health Insurance Commission, Medicare, government, the Australian Medical Association, the Royal Australian College of General Practitioners, Divisions etc. I am waiting for the day when I will be asked to relinquish my duties in accident and emergency because I do not hold a fellowship in emergency medicine -- it just seems to be the way things are moving. I also wonder if the day will come when I can auction my provider number like a crayfisherman with a crayfish licence." "I would have stayed except that I was forced to be deskilled. Prior to commencing rural practice I spent three years training in emergency medicine, anaesthetics, surgery, caesarean sections etc. There were no medical mishaps, yet these procedures were stopped in the two country towns I worked in." It is therefore important not to create unnecessary problems and, where problems exist, to counter them. Health departments, in particular, need to be clear about their aims and should value rural doctors as a scarce resource and include them in deliberations about change. The ultimate criteria for decisions on rural workforce and hospital facilities should be the maintenance of essential services sufficient to provide safe medical care to rural and remote Australia and to use the full skills of doctors already resident in those areas. In turn, rural doctors need to be more innovative and flexible in devising methods to reduce their professional isolation, practise procedural medicine, and gain some relief from being constantly on call. Flexibility is also essential from medical organisations and statutory bodies. The doctor in this study who left for financial reasons had a recognisable qualification in psychiatry and wished to practise it on a 40% time basis. National Specialist Qualification Advisory Committee regulations did not allow him to be classified as a consultant psychiatrist, making his practice financially unviable and depriving 80 000 people of resident psychiatric expertise. He commented: "I had a specialist qualification and was happy to use it but got no cooperation from the Commonwealth Government to come to some accommodation to pay for consultant psychiatric services. So I could only charge the same fee as a dermatologist for prolonged consultations and this simply wasn't financially viable. I was sad to leave after 10 years, but the more of my speciality I did, the less I earned, and we were simply getting deeper into debt." The increasing accent on rural issues in undergraduate medical education, the rising proportion of women doctors and the decreasing migration of doctors trained outside Australia make it difficult to estimate the needs for the rural workforce in the next decade. A 1997 study of Australian rural doctors predicts that only 50% will be in their current practice in 2007 and, for Western Australia, only 20%.⁶ Western Australia will therefore have to recruit 250 doctors over the next decade simply to keep pace with anticipated loss. Attention to factors shown to be important in retaining doctors would have an appreciable effect on reducing this loss. In this study more than half the doctors who intended to stay left for professional and, to a lesser extent, for social reasons which were potentially preventable. Reducing this avoidable loss is therefore an important factor in maintaining the rural workforce. The other main factor in retention is to understand and facilitate the conditions which reinforce the autonomy, efficacy and self-esteem of rural doctors.
Acknowledgements	Thanks are due to Mrs Rosalind Woodcock, who was a Research Officer on this project, and to all the doctors whose participation and insights made the project possible. This project was funded by the Australian Rural Health Research Institute.
References	Western Australian Health Department (M Kamien, Chairman). Report of the Ministerial Inquiry into the Recruitment and Retention of Country Doctors in Western Australia. Perth: Western Australian Health Department, 1987. South Australian Health Commission, Royal Australian College of General Practitioners (SA), Australian Medical Association (SA). Review of general medical practice in South Australia. Third report: country general practice. Adelaide: South Australian Health Commission, 1992. Strasser R. Rural general practice in Victoria: the report from a study of the attitudes of Victorian rural general practitioners to country practice and training. Moe: Monash University Centre for Rural Health, 1992. SAS for Windows [computer program]. Version 6.11. Cary, North Carolina: SAS Institute, 1995. Hays RB, Veitch PC, Cheers B, Crossland L. Why doctors leave rural practice. Aust J Rural Health 1997; 5: 198-203. Strasser R, Hays R, Kamien M, Carson D. National rural general practice study. Draft report. Moe: Monash University Centre for Rural Health, 1997. (Received 16 Feb, accepted 1 Jun, 1998)

Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions

Abstract

Introduction

Methods

Results

Discussion

Acknowledgements

References

Authors' details

Other articles have cited this article: