Medical education

Evidence showing the importance of education as a determinant of individuals’ health and wellbeing is among the most agreed by scholars and practitioners.1 Quality and equity of education have strong associations with individuals’ life expectancy, morbidity and health behaviour, and educational attainment is important to people's health as it shapes their further education, employment and success in life.2 Therefore, high quality education and health for all children and young people is at the heart of employment pathways for societal progress that reaps profound intergenerational benefits. It is one of seven domains considered in the MJA supplement on the Future Healthy Countdown 2030. Australia is struggling to provide the foundations for learning and wellbeing for many young Australians that would enable them to live a good life in adulthood. We can turn this around by broadening the approaches to and outcomes of schooling from academic grades to whole child development, including better wellbeing and health for all. Much effort, little progress In international light, Australia has an advanced education system. In many ways it offers world‐class learning opportunities to children and youth, but unfortunately not for everyone. While having mostly well educated teachers and many innovative schools, Australian education is rated as unequal when compared with education systems of other advanced wealthy nations.3 This is not a problem caused by schools or teachers; it is because the education system has been designed in a way that leaves many children behind in both learning and health outcomes.4,5 But it does not have to be this way. Education and health in modern societies are not cheap — anywhere. On average, Organisation for Economic Co‐operation and Development (OECD) countries invested about 3.5% of their national wealth (or gross domestic product [GDP]) in primary and secondary education and 9.7% in health in 2020.6,7 Australia spends more than other OECD countries on school education — 4.1% of GDP. Where that money to finance schools comes from varies from country to country. In European Union countries and the United States, for example, private share of total education expenditure is about 8%, while in Australia it is 18%.8 Another way to say this is that Australian governments spend about the same amount of GDP on school education as OECD countries on average, and that the rest comes from parents and other private sources. So, most Australian parents who can afford to pay have access to world‐class schooling for their children. Another difference between Australian schools and those of the OECD countries is that Australian children spend more time in school receiving compulsory instruction than their peers in other OECD countries.8 In OECD countries, on average, students have 4600 hours of primary education and 3000 hours of lower secondary education. Australian children have about 11000 hours of primary and lower secondary education in total, as shown in Box 1. This is considerably more than in OECD countries on average, and yet these long hours of formal instruction do not turn into high quality learning outcomes or positive wellbeing as measured by current student assessments and health surveys. Another peculiar feature of Australian education today is persistent reliance on parental choice in the education marketplace as the preferred way to maintain and enhance learning outcomes for all. Free and only loosely managed school choice has been a defining part of federal and state public policies in the past, even when international advice has warned about adverse consequences of market models in education.9,10 As increasing amounts of government funds have been channelled into private and religious schools, chronic underfunding of most public schools has exacerbated inequities and contributed to higher concentration of disadvantaged students in the public system and declining equity of outcomes in Australia. The problem of socio‐educational segregation in Australia is widespread — more than 12% of all students are enrolled in a school where most children are socio‐educationally disadvantaged, and almost all students who are in schools with high concentrations of socio‐educational disadvantage are in public schools.11 It is not surprising that student learning and wellbeing does not flourish in this unequal and unfair educational environment. More data are being collected from schools and more money is being spent on schools than ever before, but educational performance (in terms of quality and equity) has not improved.12 This suggests that there is a need for different thinking about policies and strategies that would change these inconvenient trends for the better. The Alice Springs (Mparntwe) Education Declaration provides a useful framework for doing so.13 Snapshots of current student learning trends Pressing educational issues for Australian children and young people are well researched and reported.14,15,16 The challenge is more about how all that knowledge and understanding could be turned into better operational policies and investments that would make a positive difference. Moreover, trends in student learning and prevalent achievement gaps between various equity groups are nothing new (Box 2, Box 3); policy makers have been aware of these issues for a decade or more. Data from the National Assessment Program – Literacy and Numeracy (NAPLAN) that have been collected across the nation since the year 2008 provide another window to understanding educational progress, or lack of it, in Australian states and territories. NAPLAN tests students’ knowledge in reading and mathematics in Years 3, 5, 7 and 9. Overall, there has been no progress in literacy and numeracy since 2008, although the reason for introducing NAPLAN was to improve educational performance across the nation. For example, Australian students’ achievements in mathematics as measured by NAPLAN in Year 3 and Year 9 have not improved since 2008 (Box 2). It has been frustrating that despite numerous reforms, reviews and growing financial spending, Australian students’ performance in basic school subjects has not improved during the past two decades. Educational performance in Australia as a whole and within its different jurisdictions has systematically been measured since the 2000s. The OECD Programme for International Student Assessment surveys show that, in comparison to international benchmarks, Australian students’ academic achievements have declined since 2000.17 These data also show that large achievement gaps between different socio‐economic and other equity groups have persisted since 2000 (Box 3). There are notable differences in average student outcomes between different schools in Australia, beyond what could be explained by students’ backgrounds. The Productivity Commission analysis of NAPLAN data collected between 2013 and 2021 for mathematics revealed that Aboriginal and Torres Strait Islander students enrolled in schools with high concentrations of socio‐educational disadvantage (that are mostly government schools) were about half a year of learning behind other Aboriginal and Torres Strait Islander students in Year 3.11 This learning gap grew to 1.3 years by Year 9. Learning gaps between children from different equity groups that are substantial at the beginning of formal education are often magnified rather than narrowed during school years. This means that the time it would take for a typical student from a disadvantaged equity group to catch up with other students increases while students are in school. For example, learning gaps in mathematics continue to grow when the same cohort of students is followed from Year 3 to Year 9 (Box 4). New foundations for learning Not so long ago, for most children, school was the only place to learn sufficient basic knowledge and skills needed to have a job and live a good life. School then held the monopoly of learning. Now that monopoly is gone — children can learn anywhere, any time. Schools still play a significant role in teaching complex skills and competencies that are needed in work and the increasingly uncertain world. Critically, school should be the environment in which all children need to learn new skills for life and contemporary work, not just the basic knowledge and skills. School is also a place where they can develop attitudes and mindsets that equip them to participate confidently in a complex world. These new foundations — such as ability to think flexibly, manage impulsivity, use imagination in new situations, seek opportunities in complex situations, identify and use necessary resources, regulate one's own thinking, understand and improve one's own wellbeing, and take responsible risks — enable self‐regulated behaviour plus critical and creative thinking.18,19,20 As children and young people continue to learn through a variety of experiences in and out of school, it is becoming more important to address their personal interests and individual learning needs properly in school. Children's self‐directed, informal learning at home and in communities is taking an increasingly important role as digital technologies have become a natural way to communicate and process information. This was recently recognised by the Nest framework, developed by the Australian Research Alliance for Children and Youth in 2021, in which a new generation of child and youth voices defined the learning and employment pathways they require. Their definition emphasised the importance of having opportunities to participate “in a breadth of experiences where their learning is valued and supported by their family and in the wider community”.21 Student agency, in appropriate ways, in building these new foundations is critically important. Continuing to do more of the same to transform education makes no sense. We have all the necessary knowledge and practical wisdom to change the course towards a better and fairer education for all Australian children. But we need to do different things, and do them differently enough, to get there. For instance, improving education experiences for Indigenous children requires recognising the importance of First Nations’ knowledge and knowing, and this would benefit all children in Australia. National education policies have recognised that schools need to educate students for a world yet to be realised, meeting the needs of all students, and equipping them with transversal skills and general capabilities for future work and lifelong learning. International evidence suggests that there should be multiple pathways from school to the world of work if we want to meet the needs and interests of all young people.22 Furthermore, as we have suggested elsewhere, new foundations for learning should be built on whole child and whole school approaches that establish closer connections between learning and wellbeing in schools.23 Education attainment is a strong predictor of steady employment and better physical and mental health.24 The Australian Institute of Health and Welfare has identified the need for reporting to link health and welfare data to better understand the effects of social determinants of health and wellbeing through life: “Across all key determinants, evaluation of programs and interventions to identify successes in reducing inequalities is important.”25 The evidence is clear that education and health are positively connected — healthier students are better learners — and vice versa.26,27,28 If we are to turn things around by 2030, indicators need to focus attention on the range of current inequities in education outcomes in Australian education.29 These indicators also need to report publicly on policy approaches to reducing these inequities and progress made in terms of learning a broader range future skills and competencies at federal, state and territory levels throughout schooling from early learning to higher education and beyond. The National Report on Schooling in Australia as an annual review should provide the benchmarks for policy targets and new outcomes that address and reduce inequities. Key indicators relating to equity of education that are available are: proportion of students at or below proficiency levels in reading and mathematics; proportion of students enrolled in schools with high concentrations of socio‐educational disadvantage; achievement gaps in reading and mathematics between disadvantaged students in different equity groups in Years 3, 5, 7 and 9; and reading and mathematics achievement by the level of socio‐economic and educational disadvantage. In addition, beginning to track progress on the following indicators could help turn things around: clear and shared definition of what equity of education outcomes means across different education systems and sectors; data on broader outcomes of schooling (eg, transversal skills, psychosocial health and wellbeing, happiness, life satisfaction); student agency and engagement in school; and safety and belonging in school (for both children and adults). The evidence (summarised in Box 5) is clear and the road ahead should be too — educational and health inequities need to be addressed now before it is too late. Box 1 – Total number of compulsory instruction hours in OECD countries in primary and lower secondary education in 2019* OECD = Organisation for Economic Co‐operation and Development.* Source: OECD Programme for International Student Assessment database. Number after country indicates duration of primary and lower secondary education in years. Box 2 – Australian students’ national average achievements in mathematics in Year 3 and Year 9, 2008–2022* NAPLAN = National Assessment Program – Literacy and Numeracy.* Source: Australian Curriculum, Assessment and Reporting Authority database. Box 3 – Australian 15‐year‐old students’ average reading literacy scores in the OECD Programme for International Student Assessment (PISA), 2000–2018* SES = socio‐economic status.* Source: OECD Programme for International Student Assessment database. Box 4 – Australian students’ average mathematics scores in NAPLAN in the same cohort from 2015 to 2021* NAPLAN = National Assessment Program – Literacy and Numeracy.* Source: Productivity Commission estimates of de‐identified student‐level NAPLAN data. Box 5 – New foundations for learning in Australia What are the most pressing issues where change could make a real difference by 2030 and why? Academic outcomes are stagnant or declining while per‐student spending is going up. Student engagement in school weakens during schooling and fewer students think they benefit from schooling. Equity of education outcomes is weak and has worsened over time. More and more data are being collected — using data for transforming schools has become a problem. What are some of the key indicator measures available and what are we lacking? Key indicators ‣ regular census‐based data on literacy and numeracy proficiencies by year level (Years 3, 5, 7 and 9); and ‣ school completion rates for Year 12 (or equivalent). What is lacking? ‣ data on broader skills and competencies learned across Australian curricula in school, including creative problem solving, complex communication, self‐regulation and lifelong learning; and ‣ better data on student agency and engagement, wellbeing, and sense of belonging in school. What are the key baseline data on these indicator measures that are available? More than 20% of Australian 15‐year‐olds were low performing students in reading and mathematics in the Organisation for Economic Co‐operation and Development's Programme for International Student Assessment survey conducted in 2018. More than 12% of Australian students are enrolled in a school with high concentrations of socio‐educational disadvantage and that trend is worsening over time according to the MySchool database. For reading, the measured achievement gap between socio‐educationally disadvantaged and advantaged students grows almost threefold from Year 3 to Year 9 according to the Australian Curriculum, Assessments and Reporting Authority (ACARA) database.

Pasi Sahlberg · Sharon R Goldfeld

Emily Squires · Stephen Bacchi · John Maddison

The shortage of doctors in remote, rural and regional Australian communities is a longstanding health policy challenge. It is the main reason why almost 3000 overseas‐trained doctors enter the labour force annually1 — a similar number to the domestic graduate output of Australian medical schools.2 Most overseas‐trained doctors end up practising in major cities; 75% of all registered overseas‐trained doctors in clinical practice in 2021 were metropolitan based, with major cities also accounting for 76% of the growth in overseas‐trained doctors over the 2015–2021 period.3 In effect, rurally targeted recruitment of overseas‐trained doctors compounds the problem of geographic maldistribution that it is meant to solve. Achieving a substantial pipeline of Australian‐trained graduates who will willingly pursue regional careers as general practitioners, rural generalists and non‐GP specialists is therefore a first order policy priority. What it takes The evidence on what influences medical graduates to pursue non‐metropolitan careers has been accumulating over several decades.4 The best understanding is that a systems approach is required — an alchemy that combines the various factors known to enhance rural career choice.5 Putting aside remuneration and other incentives, a systems design in medical training must consider the full pathway from medical school applications through to GP and non‐GP specialist careers.4,6 Medical students who have a rural background are more likely to pursue rural careers than their metropolitan counterparts.4 However, not all students with a rural background will practise in rural areas, nor should they be expected to. Likewise, we cannot assume that all students with a city background are not keen to practise rurally. Strategies that can influence medical graduates to practise rurally include locating medical programs outside of major cities and aligning pathways for graduates with rurally based general practice training.6 While teasing out individual contributions of other elements of rural program design is difficult, interventions that are common to the programs that have the most success include substantial rural clinical exposure, longitudinal integrated clerkships, a rurally rich curriculum, rural health student clubs, rural teachers, rural clinical mentors, and rural social networks.4,6 Quality rural experience is also vital, as positive learner experiences are fundamental to driving rural interest.7 Australia has a strong record of investment in rural training, which has both applied and contributed to the evidence. This includes long term funding for regional health professional training through rural clinical schools and university departments of rural health.8 Under current arrangements, a quarter of all domestic medical students undertake at least one year of clinical training in rural and regional locations, with other students having access to shorter rural terms. Participating universities are required to admit at least 25% of their students from rural backgrounds and support rural health student clubs. The positive impacts of programs run by rural clinical schools and university departments of rural health are well documented.8 Encouragingly, domestic graduates accounted for 72% of the 4645 net growth in regionally practising clinician numbers over the period 2015 to 2021.3 Rural career interest among medical graduates is substantial, with 39% indicating a preference to work outside of a capital city.2 While it would seem evident that those graduates should be supported into regional postgraduate training, there are few resources in place to facilitate this. It is largely left to the wit of individuals to navigate the complex, city‐centric and large hospital‐oriented graduate training system. Much of the rural interest among graduates therefore goes unrealised. To bridge this continuity gap in regional training, various programs have been devised, albeit on a somewhat piecemeal basis. These include: Australian Government funding for supplementary specialist training posts in regional and private hospitals9; a stipulation that half the trainees in the Australian General Practice Training Program undertake their training outside of major cities10; and opportunities for a subset of junior doctors to gain rural general practice experience in addition to hospital rotations.11 In addition, the need for a more comprehensive approach to the regional medical training continuum is increasingly being recognised. Since 2017, the capacity of rural clinical schools to support medical training beyond graduation has been supplemented via the Regional Training Hubs program, with the aims of understanding and responding to regional needs, building regional capacity, and supporting students and graduates to do regional training and pursue regional careers.8 Despite modest resources and it being early days, this approach appears sound.8 A key challenge, however, is that while Regional Training Hubs are an Australian Government initiative, it is the state and territory governments that are primarily responsible for junior doctor training, non‐GP specialist training and hospital‐based components of general practice training through the public hospital system.8 A stronger collaborative model is therefore needed. Priority actions Australia must deliver a domestic medical workforce for the regions. This requires a reform of the medical training continuum, with buy‐in from universities, specialist medical colleges, public and private hospitals, and the primary and community care sectors. The Australian National Medical Workforce Strategy sets out overarching priorities for medical workforce reform, including better collaboration on planning and design of Australia's medical workforce, rebalancing supply and distribution, reform of training pathways and building generalist capability, and flexibility and responsiveness of the medical workforce.12 In terms of early reforms, and with unanimous support from its members, Medical Deans Australia and New Zealand is advocating four interrelated actions. Expand professional entry medical training in regional Australia Our current heavy reliance on overseas recruitment and hospital service demand for junior doctors suggest that a substantial increase in medical school places is required. Although we acknowledge that universities have an economic interest in medical school places, rural medical workforce is an urgent priority. Additional medical school places should therefore be deployed regionally into programs that apply the best evidence for delivering rural and primary care workforce outcomes. This should involve admissions policies, program design, and clinical training experience that emphasises learning in and for the following settings: rural and primary care, Aboriginal community‐controlled health services, rural hospitals, aged care services, disability care services, community mental health services and other community‐based services. The evidence on entirely regionally based programs vis‐a‐vis substantial rural placements is still emerging. However, improving access to medical programs for students and graduates wishing to be rurally based during their training offers additional benefits, and both models should be supported. In addition, to attract junior doctors and stem the loss from regional locations, rural practice must be fulfilling and sustainable throughout doctors’ training and careers. This requires funding reforms that enable: flexible business and clinical models; support for rural doctors to flourish in research, teaching and leadership; career paths that recognise fluidity in doctors’ vocations; and a flexible, needs‐focused approach to skills credentialling. Invest in the primary care sector as a quality teaching, training and research system If Australia is to build a stronger primary care system and achieve an equitable distribution of doctors, a greater emphasis on teaching, training and research (TTR) in primary care and rural settings is required. The Australian Government invested $2.2 billion in TTR in public hospitals in the financial year 2022–23,13 while support for teaching in primary care is limited to payments for GPs to supervise medical students, GP trainees and some junior doctors.11 Funding reforms must better embed TTR in primary care clinical and business practices; this is essential if the aspiration to “make primary care a first choice career”, noted in the Strengthening Medicare Taskforce report, is to be realised.14 Investment in primary care teaching infrastructure (such as additional consulting rooms, learning spaces and learning technologies) is sorely needed. Other community‐based settings need to be included too — Aboriginal community‐controlled health services that seek the opportunity, aged care services, disability care services, and community mental health services. A strong primary care teaching system can create an environment that strengthens vital primary care research and scholarship. It drives primary care‐based innovation and attracts and retains the next generation of primary care professionals. To deliver this, we need more equitable funding of TTR between hospitals and primary care or community‐based settings, and we need to grow the primary care TTR workforce. We also need: universities and research institutes to champion rural and primary care academics and researchers; medical colleges to preference rural pathways and experiences; hospitals to partner with primary care; and primary care and community‐based settings to embed TTR in their practice. This requires leadership, a funded strategy and key performance indicators for primary care TTR, plus more connected pathways into teaching and research for early career clinicians. Scale up intern and junior doctor posts in primary care settings and rural locations, aligned with the boost to graduate supply Medical graduates need high quality experiences in rural locations, primary care and other community settings in their junior doctor years, but achieving this is challenging because hospitals rely on trainee doctors to meet service demands.12 Reducing the reliance of hospitals on trainee doctors is important, as is progressing an outcomes‐focused approach to graduate training rather than conventional rotations through specialty units.12 The new national framework for prevocational medical training, set out by the Australian Medical Council, provides an impetus to take such an approach.15 That said, the main practical opportunity for growth of intern and junior doctor training in primary care settings and regional locations is aligning this with a substantial boost in graduate supply through medical schools. To ensure that these rural positions attract graduates and interns, we need to address the “hidden curriculum” that elevates city‐based subspecialisation within the training system and the profession. Selection into specialty training programs needs to preference rural experience and ensure strong rural trainee support and professional networks. Trainees need to know that going rural does not mean going it alone. Establish integrated regionally based postgraduate training capacity via regional training collaboratives Medical Deans Australia and New Zealand is advocating for the establishment of regional training collaboratives to draw the various currently discontinuous elements of medical training into functional alignment and deliver critical mass. Building on the Regional Training Hub initiative, regional training collaboratives would leverage two decades of investment in regional medical training. They would also enable stronger connections with regional hospital medical education units and with GP and non‐GP specialty training. Such place‐based approaches would support local strategies to grow training capacity that are based on local needs, local networks and local opportunities.16,17 Moving to integrated, collaborative models would coordinate regional training pathways, and provide consistent support for doctors in training, particularly across transition points and for those needing additional support. While a key challenge is connecting federal‐ and state‐funded elements, a principle of the 2020–25 National Health Reform Agreement is “joint planning and funding at a local level”.18 This provides both direction and a mechanism to progress the required collaborative funding, governance and accountability. Action is needed now Greater self‐sufficiency for Australia's medical workforce has never been more important. A boost to regional graduate supply that is aligned with rural, primary care and community‐based training and capacity building will be a key reform in producing medical graduates more aligned to future community need. Leadership, collaboration and a focus on outcomes will be key to delivering on the intent of this investment in Australia's future health care.

Richard B Murray · Helen Craig

Rural communities across Australia face an ongoing shortage of doctors, which reduces access to care and leads to poorer health outcomes for people living in rural areas. Significant undersupply exists, particularly in rural general practice, priority-need generalist specialties and rural generalism.1,2 The coronavirus disease 2019 (COVID-19) pandemic exacerbated vacancies as immigration of international medical graduates came to a standstill and interstate movement of rural locum doctors reduced. The recently released National Medical Workforce Strategy emphasises the need to grow a workforce of our own that is fit for purpose, to deliver culturally safe and context-specific medical services to all Australian people.1 Over the past 20 years, there have been significant political and educational initiatives to increase the rural workforce, with accompanying research investigating their outcomes.3 Eminent rural researcher Denese Playford wrote: These data collectively build a portrait of candidates who are more likely to work rurally. The portrait suggests that a very convincing set of known factors are at play: rural background, lower socio‐economic status, locally‐born, quarantined rural pathway … entering with rural intent, Medical Rural Bonded Scholarship holders.4 Selection and support of rural students, rural placement immersions and development of comprehensive rural medical programs are within the control of medical schools and supported by Australian evidence. The pathways to rural practice are rich and varied. Successful approaches tailor these elements to local resources, needs and priorities (Box 1). In this article, we describe the elements of a comprehensive approach for medical schools. The Aristotelian notion that “the whole is greater than the sum of its parts” is important and medical schools need to apply a comprehensive approach to deliver more graduates who will work rurally. Enact a social mission statement for rural service Social accountability obliges medical schools to focus their own research, service and education undertakings specifically on addressing the health needs of their local community, region and/or nation. Priority health needs are to be identified jointly by local communities, health care organisations, health professionals and the government.5 As the majority of medical schools remain centred in large metropolitan areas, it is essential that these medical schools adopt a rural social mission statement as a way of expressing their commitment. Overt commitment enables the medical schools to put in place the strategies outlined below to produce more rural doctors, and build a supportive environment to fulfil this mission.6 Select for rural workforce outcomes Increase rural background cohort numbers Graduates from rural backgrounds are more likely to work in rural practice (odds ratio, 2.6 to 3.9).7,8,9,10,11 This “rural background effect” is independent of rural clinical training, but is augmented by it.7,8,9,12 The effect endures throughout postgraduate career stages,8,13 and has been found in some studies to increase over time.14 Rural background graduates are more likely to commence in rural practice, move to rural practice and remain in rural practice.13 Since 1995, in an effort to meet equity‐of‐access goals, the Commonwealth Government has mandated that 25% of medical student Commonwealth‐supported places are allocated to students with a rural background.15 With 28% of Australians living in rural areas,16 more recently funded rural programs, such as the Murray–Darling Medical Schools Network, have higher mandated proportions of rural background places (up to 100%).17 Medical school selections traditionally use university entrance examinations, which are expensive and less easily accessed from rural areas.18 Admitting more students from a rural background has been achieved in different ways across Australia. Equity adjustments have been used by many universities, such as adjusting academic and entrance exam scores, or keeping selection methods consistent and creating specific rural quotas. Other medical programs have adopted specific rural selection tools, including written personal statements and interviews, using community members to understand candidates’ rural interests.19,20,21,22 Despite these adjustments to admissions, rural background students demonstrate the same academic outcomes in medical school as other student cohorts admitted with higher entry scores.23 Select students from higher rurality locations The Modified Monash Model (MMM) categorises the rurality of Australian communities using a scale from 1 for metropolitan to 7 for very remote.24 Including MMM2 communities (regional, population>50000) in selection targets risks displacing students from more isolated locations. Applying a sub‐quota to MMM3–MMM7 communities ensures that students from smaller communities and remote Australia enter medical school. This focus is an important step forward in rural selection. Targeting selection of MMM3–MMM7 students from a specific geographic region within a university's regional footprint is a promising emerging strategy — it is informed by evidence that rural students are more likely to return to their own or a similar rural community.12,25 Many students in rural schools, particularly those from higher rurality areas, do not see medicine as an achievable career. Geographical, financial, social and self‐efficacy barriers prevent many potential rural applicants from considering medicine. Medical schools can play a key role in leading community‐engaged recruitment and support programs for high school students and other people living in rural areas who are eligible to access graduate‐entry medical schools. The impact of these recruitment programs can increase applications from students in rural areas.26 Provide early support, not constraints Strongly coercive interventions, such as bonded medical places, are associated with comparatively lower rural retention than interventions that involve less coercion.27 Currently about 25% of all Commonwealth‐supported medical students are bonded to areas of workforce need (including rural areas) for 3 years.28 Medical student bonding arrangements have reduced over time, due to limited evidence of long term success. Bonding conveys messages at the start of medical school that rural is less attractive, and it perpetuates inappropriate deficit discourse around rural practice. The current policy initiative of reducing Higher Education Loan Program debt for rural doctors is likely to have a much more positive impact.29 Promoting this financial support to students will assist with their choices to move to and stay in rural areas, but more needs to be done to overcome financial pressures for students from disadvantaged backgrounds during medical school. Rural students are a heterogeneous group, with potentially vast differences in rurality of background, socio‐economic status, and personal agency. When available, generous scholarships targeting rural students enable those experiencing financial hardship to participate in medical training. Access to safe, student‐friendly and affordable accommodation is invaluable for student success and rural retention. University‐owned and subsidised housing allows students to transition into medical school and access clinical placements in a range of locations. Make medical training locations more accessible for rural people Few medical courses are wholly based outside of capital cities in Australia.21 In 2019, the Commonwealth Government recognised the value of comprehensive rurally based programs that are more accessible for rural students by introducing legislation to reallocate 2% of medical school Commonwealth‐supported places from urban medical schools to rural end‐to‐end programs every 3 years. This redistribution of medical school training places, which commenced in 2020, facilitated the recent establishment of medical programs in regional areas of New South Wales and Victoria.17 Before the COVID‐19 pandemic began, this redistribution of medical places to rural programs may have been enough to provide an adequate rural medical workforce. Recent significantly reduced inward immigration of international medical graduates means that this policy needs to be reviewed. An expansion of Commonwealth‐supported medical student places is required in rurally located end‐to‐end medical school programs, rather than a reliance solely on redistribution, to ensure that each state has at least one rural medical school program that provides remote or rural training from the start to the completion of the medical degree. A national collaboration could share medical education and remote teaching resources to support this initiative, with the Federation of Rural Australian Medical Educators well placed to facilitate this (https://ausframe.org/). Highlight rural medicine in medical school curricula Showcase diverse rural contexts Medical curricula and assessments shape students’ views of rural career options.30 Traditional medical school teaching is predominantly metropolitan focused and specialist led. Medical students report that denigration of both rural doctors and general practice is still commonplace in Australia.31 Attitudes which fail to recognise the expertise of generalists influence students’ career choices away from rural practice. Medical schools with strong academic engagement by rural clinicians illustrate the value of rural doctors. Integrating rural clinical cases and management plans for rural practice within the formal curriculum can reinforce positive and realistic messages about rural medicine in Australia.30 Australian medical schools with MD programs require students to undertake research, providing an opportunity for students to undertake rural projects that contribute to rural communities, which in turn can draw students to rural careers. Teach generalist ways of working As generalists, rural doctors deal with high levels of complexity and uncertainty in clinical practice. Students who are ill prepared for clinical complexity can avoid specialties that have high loads of uncertainty. Modern curricula need to prepare students explicitly for uncertainty, multimorbidity, shared decision making and communication across clinical settings. Clinical cases set in rural contexts provide opportunities to build medical students’ generalist approaches to clinical care. Having rural doctors teach core medical content will encourage a broader scope of practice for all students. In addition, medical students need to learn to work in multidisciplinary teams. Ensuring that a broad range of rural health practitioners teach medical students alongside nursing and allied health students will promote good foundations for future work practices. These changes in the curriculum will ensure all medical students have the skills for 21st century health care. Invest in rural training pathways Immerse students in a rural place Immersive rural training remains a cornerstone for producing more rural doctors. Australian rural clinical schools have provided a generation of medical students with a year or more of rural clinical experience.32 Placement types vary from traditional hospital rotations in regional centres, with arguably less rural context, to placements based in general practices in small rural communities where students interleave general practice and hospital experience, often supervised by rural generalists.33 Rural placements enable students to build connections with rural clinicians and communities. Their influence can range from cementing intent for students already interested in rural practice to changing intent of students primarily interested in metropolitan practice.9,34 Longitudinal integrated rural clinical placements demonstrate consistently excellent academic outcomes and increased rural medical workforce outcomes by up to seven times those of metropolitan medical student clinical training.8,35 These programs, when situated in small rural towns, result in graduates who are up to five times more likely to work in small rural towns.36 This workforce outcome takes time, particularly in communities that are not big enough to provide prevocational training. Many rural clinical school graduates who have to leave rural areas for their postgraduate training come back 5–10 years after graduation.37 Students who become rural doctors often spend longer than their peers being undecided about their specialty intentions, highlighting the importance of regular positive rural experiences to promote the uptake of general practice and rural practice.38 Longer duration (18–24 versus 12 months) of rural training is associated with a threefold increase in returning to practise in the same rural region after training.7,39 Incrementally stronger associations exist for longer duration, a combination of regional hospital and general practice experience, greater remoteness and multiple placements.7,10,32 Apart from duration, there may be specific place‐based effects. For example, the Rural Clinical School of Western Australia distributes rural medical workforce in a clearly geographically patterned way, with Broome acting as a bridge to the remote north of Australia.40 In Victoria, those selected from a specific region and having greater than one year of rural training in that region had a 17.4 times increased chance of working in that same rural region compared with urban background students who had completed fewer than 12 weeks of training in the region.25 In rural communities, students make an authentic contribution to the clinical care of patients.41 They are seen by local people as contributing members of the community, and these meaningful relationships shape their learning and professional identity.41 As students on full year rural placements engage in community social activities, such as participation in sport, choir or church, they develop individual informal relationships with community members. Adopting a community‐engaged approach to training also includes facilitating rural communities to engage in the selection and education of students as patient‐experts and simulated patients. Prolonged rural placement experiences trigger aspirational, intellectual and emotional responses, particularly in students who have a strong motivation to help others and who value teamwork.42 Accordingly, students are drawn in and bound to their “own” town.43 Develop medical students’ rural identity For many students choosing a rural career, this requires simultaneous choices of rural location and specialty discipline, while urban medical careers tend to be shaped first by chosen specialty and later by location of practice.38 A medical school's social and cultural context shapes who students become (eg, rural community member), not solely what they practise (ie, discipline interest).33,44 This highlights the importance of fostering rural self‐identity during medical school. Rural practice self‐efficacy is an individual's sense of self‐confidence to thrive working in rural practice.45 It correlates with medical student rural practice intent and increased remoteness of location of practice after graduation.45,46,47 Rural doctors describe their practice as involving connection with their communities, comfort with clinical uncertainties and preparedness to undertake clinical activities at the edge of their scope.48 Students on rural placements are immersed in this culture of rural medicine, see others like them in rural practice, and thereby develop rural practice self‐efficacy.45 Students’ aspirations and expectations are strongly influenced by peers. Rural health clubs at universities celebrate and support students’ interests and facilitate contact with like‐minded peers. Students who undertake a rural stream in medical school develop strong ties, before and during rural placements, with each other and with mentors.49 Extended rural placements help students build firm friendships in the student group on location and between students in other similar rural sites. In rural areas, a strong community of practice is essential for developing and sustaining clinicians who thrive.50 An apprenticeship‐style mentoring model between rural medical practitioners and rural students enables students to feel supported and trained appropriately for rural and remote practice.51 Close working relationships between learners and their rural clinical supervisors enable rural professional identity formation over time.41,52 Mentors have a key influence on graduates’ career choices and practice locations.53 The John Flynn Placement Program, which previously supported medical students to undertake extracurricular rural placements (2 weeks annually for 4 years), demonstrated positive effects of mentorship on rural practice intent.11 Value rural practitioners and rural academics The rural medical workforce is under stress. Maintaining and developing training capacity is vital for all rural programs and Australia's future rural medical workforce. Junior doctors, registrars and international medical graduates compete for limited supervisor time and clinical space. Rural clinical schools play an important role in developing educationally supportive communities of practice for rural doctors. Schools also advocate for increased resources for rural areas, including financial remuneration for teaching and research, and clinical training infrastructure in rural general practices and hospitals. With proposed expansion of rural medical training pathways at all levels, the importance of appropriate support for rural clinical teachers, to ensure high quality clinical supervision, cannot be underestimated. Rural academic positions provide career diversity in rural Australia. Rural medical programs develop and support rural doctors to have blended roles, including clinician–teacher and clinical academic. Medical schools that include rural academics in curriculum design and delivery, assessment, research projects and wider opportunities within the university can improve advancement and longevity of engagement of rural staff.54 Having rural academics in senior medical school management teams secures rural oversight of rural missions. Rural clinical schools can provide academic skills for general practitioner and specialist registrars, enabling them to complete their training rurally. Many of these registrars will stay on or come back to the rural centre that provided this academic environment.32 Facilitate rural prevocational and specialist training Developing and sustaining rural and regional postgraduate training pathways is critical for supporting doctors to stay in rural areas.55 The Commonwealth Government's regional training hubs initiative funds rural clinical schools to develop, promote and sustain intern and vocational training opportunities in rural and remote Australia. Importantly, rural clinical schools connect students and junior doctors to vertically integrated training opportunities. Through regional training hubs, medical schools are increasingly engaging with other stakeholders contributing to workforce outcomes to maximise return on government investment and collaborate to address Australia's rural workforce needs. Several specialist training programs have now adopted a rural health equity strategy which sees rural background graduates privileged in college selection processes, particularly for rural training positions.56 The Australian College of Rural and Remote Medicine has recognised the value of rural connection and has incorporated a demonstrated connection with rural communities into its selection process for all candidates.57 Evaluate and recommit to the social mission Ongoing research into medical school influences on rural career choice will continue to influence medical school policy. Small changes in admissions policies can effect significant changes in terms of rural students entering medical school. Reporting on outcomes of rural pathways within the medical course must hold medical schools to account, ensure appropriate participation of students from under‐represented rural communities, and enable continuous quality improvement of rural training pathways. Tracking rural student progress throughout the course can facilitate access to social and academic supports when required to retain these students. Finally, the Australian Health Practitioner Regulation Agency collects data on location of practice, which enables universities to track their graduates to understand the impact on the end goal — more rural doctors. The rural workforce outcomes of medical school interventions can take many years to eventuate and will remain dependent on other factors such as specialty choice, rural postgraduate training opportunities, and individual, family and partner commitments. Conclusion Rural clinical schools in Australia have demonstrated the compounding effect of rural background, generalist intent, rural immersion, rural curricula, rural practice self‐efficacy and rural identity on rural practice outcomes (Box 2). Medical schools have an obligation to direct their activities to addressing priority health needs in rural areas. Incorporating a comprehensive approach to all the elements of selection, rural immersion and rural curriculum, based on a defined social mission and geographic binding to the communities they serve, will enable students to develop their skills and careers in rural areas across Australia. Box 1 – A comprehensive approach for medical schools to develop more rural doctors Enact a social mission statement for rural service Select for rural workforce outcomes ‣ Increase rural background cohort numbers ‣ Select students from higher rurality locations ‣ Provide early support, not constraints Make medical training locations more accessible for rural people Highlight rural medicine in medical school curricula ‣ Showcase diverse rural contexts ‣ Teach generalist ways of working Invest in rural training pathways ‣ Immerse students in a rural place ‣ Develop medical students’ rural identity ‣ Value rural practitioners and rural academics Facilitate rural prevocational and specialist training Evaluate and recommit to the social mission Box 2 – University pathway to more rural doctors PG = postgraduate.

Matthew R McGrail · Zelda Doyle · Lara Fuller · Tarun Sen Gupta · Lizzi Shires · Lucie Walters

Inequities in the distribution of human resources in health around the world have long been a topic of concern and discussion. There is an absolute shortage of health care providers in many parts of the world, notably in sub‐Saharan Africa and parts of the Asia–Pacific region.1 However, here and in other areas the problem is that the available health care workforce is maldistributed, both geographically and in terms of specialty.2,3 Understanding these issues and their drivers is an important step in developing, implementing and evaluating potential solutions, but both the understanding and the solutions need to be contextualised to region and circumstance.3 Health professional educational institutions can be important engines in driving social and educational change and innovation to ensure that their products (medical, nursing and other health professional graduates) are fit for purpose in terms of meeting the needs of the populations that they serve.4 Recognition of this potential has led the World Health Organization to focus on its agenda of transformative health professional education, to consciously improve access to health services by distributing the health workforce and aligning its competencies with evolving health needs on the way to addressing the broader social determinants of health.5 Importantly, to deliver socially accountable health professional education, educational institutions must hold themselves accountable for delivering appropriate health professionals, and for working in partnership to strengthen the health system and the quality of care that it delivers. Investment in training of the health workforce and strong primary health care delivers real economic value.6 The Training for Health Equity Network: learning from each other The Training for Health Equity Network (THEnet; thenetcommunity.org), which was founded in 2008, is a community of practice that now includes 13 medical and health professional schools, selected on the basis of their commitment to social accountability. Located primarily in rural and underserved areas of nine countries (low and high income), they share a commitment to producing and supporting health workforces that will meet the needs of the communities they serve (Box 1). These schools share the aims of: recruiting students from underserved and under‐represented populations; providing primary care‐focused curricula; delivering medical programs mainly in underserved areas and within communities; and providing postgraduate training to address local health workforce needs.7,8 THEnet is a collaborative learning network, where members share challenges across sectors and countries, and partner schools learn from and share with other innovative schools worldwide. Research and evaluation using a self‐critical lens helps members to understand how best to improve health equity and how to maintain accountability for outcomes.7,8 Collaboration and commitment: building an evidence base As a learning network that aims to influence health systems and share lessons between partners, THEnet considered how best to measure progress towards, and outcomes of, social accountability in its early work. Collaborative creation of THEnet's Evaluation Framework for Socially Accountable Health Professional Education was its foundational work, which involved careful attention to the use of plain language and definitions that can be used and adapted across many contexts.8,9 This work has since been adapted and expanded to create other widely used frameworks, such as the Indicators for Social Accountability Tool, and has been incorporated into medical accreditation standards worldwide.10,11 THEnet partner schools share a commitment to finding out where graduates work and the difference that they make. Measuring impact is important. The THEnet evidence group conducts a program of research, including the THEnet Graduate Outcome Study — a prospective cohort study of more than 6000 learners enrolled across partner schools, from which data have been received from nine schools in seven countries.12 The THEnet Evidence Group designed the study to correlate learner characteristics and practice intentions at entry to and exit from medical school, and then follow these graduates into postgraduate practice for up to 10 years, to determine the location and discipline of their actual practice. In recognition of our work in this area, THEnet has contributed to white papers for the Pan American Health Organization and a recent WHO handbook on the rationale and strategies for graduate tracking.13 These data have highlighted that, relative to other medical schools, THEnet partner schools deliberately use diverse selection processes to ensure that their learner cohort has sociodemographic characteristics that are much more similar to the population they serve.12 Data have confirmed the association between rural or low socio‐economic background and intention to practise in rural and remote areas, and that this is maintained from entry to exit from medical school.14,15 Importantly, for learners in low and middle income schools in South Africa, Sudan and the Philippines, these demographic determinants are significantly associated with lower desire to emigrate after graduation, and thus contribute to a desire to meet the health needs of their home country.15 In response to local need, THEnet members have also designed and collaborated on studies of work readiness of graduates, perceptions of social accountability among faculty and students, impact on the health system, impact on health outcomes, and social return on investment.16,17,18,19,20,21 The evidence base produced by THEnet collectively, from studies involving partnerships between two or more partner schools from different contexts, is summarised in Box 2. Our research shows promising outcomes from THEnet partner schools in terms of: intending to practise and actually practising in rural, remote and underserved areas; practice in generalist disciplines rather than subspecialties; broadening health teams to include community‐based health workers and other mid‐level providers; and health professionals remaining in low and middle income countries rather than emigrating.15,18 Longer term data from some schools suggest that practice intentions translate well into actual practice.25 Global lessons: building a rural and remote health workforce By summarising and integrating evidence from our collective work and the experience of partner schools in diverse locations, we identified consistent findings that may help produce a fit‐for‐purpose global health workforce (Box 2). Locating health professional education institutions in remote, rural and regional areas is a key factor in terms of producing a fit‐for‐practice rural and remote health workforce. In addition, providing a contextualised primary care‐focused curriculum to a diverse body of students who are largely from remote, rural and regional areas themselves is important. Using these approaches has become known as training health professionals “from, in, with and for” the rural and remote communities that we would like them to serve.4 However, lessons from pioneering schools suggest that these approaches are necessary but not sufficient — that the building blocks necessary for success are broader still.26 A vital common factor is a clearly expressed and widely understood mission for each school, which is linked to meeting the health needs of the population served. Also, committed and charismatic leadership that conveys each school's mission to its faculty and students is essential. Likewise, schools need diversity among the staff and the teaching body, including a wide variety of inspiring community‐based and primary care practitioners or generalists, to mitigate against the hidden hospital‐centric curriculum that often deters students from pursuing careers in primary care.27 In addition, exposing learners to a wide variety of inspirational rural and remote service providers provides motivation and encouragement to both mentors and mentees. Two further critical elements for producing a fit‐for‐purpose global health workforce are: learning in and with rural communities; and recognising the role of community members as teachers, particularly with respect to the social and cultural determinants of health. Working alongside community extension officers, Aboriginal or Torres Strait Islander health workers and practitioners, community nurses, or other mid‐level health professionals is critical for these aspects of learning.28 In all of these areas, increasing skills in telehealth and digitally assisted education — accelerated by the coronavirus disease 2019 (COVID‐19) pandemic — can help build a rural and remote health workforce.7 However, we believe that nothing can replace the impact of a rural longitudinal placement. Future priorities: measuring impacts and outcomes of school activities THEnet's partner schools have cooperated to produce a significant collective contribution to the evidence base on approaches to education that can help build a rural and remote health workforce. They have highlighted important factors which can help ensure that we deliver on our collective social accountability mandate. However, there is still much work to do as we strive to measure and critically reflect on the impact of our activities on the health of individuals, communities and populations, and on strengthening the health system. We have started to develop and apply novel approaches to measure social return on investment — in settings within Australia, the Philippines and Canada — with a view to extending this to a broader range of schools. It is important to measure the economic and social impact of school activities and outcomes for communities. Current work is also focused on measuring the impact of a learning health system and is looking at how we can build a chain of association from health professional education activities to accessibility of health services (and other markers of quality of care) through to improved health outcomes. Despite marked differences in the settings where THEnet's partner schools operate, similarities in approach provide lessons that may support more equitable distribution of the health and medical workforce into the future. Box 1 – Health professional schools in the Training for Health Equity Network (THEnet)* Ateneo de Zamboanga University School of Medicine, The Philippines Ghent University, Belgium Flinders University, Australia† Imperial College, United Kingdom James Cook University, Australia Latin American School of Medicine (ELAM), Cuba Northern Ontario School of Medicine, Canada Patan Academy of Health Sciences, Nepal Walter Sisulu University, South Africa University of Gezira, Sudan University of New Mexico, USA University of the Philippines Manila, School of Health Sciences, Leyte, the Philippines University of Sherbrooke, Canada University of Texas, El Paso, USA * Reproduced from Murray et al7 under a CC BY 4.0 license. † Founding school; recently withdrew from THEnet. Box 2 – Summary of evidence collaboratively produced by Training for Health Equity Network (THEnet) partner schools, from studies on building a rural and remote health workforce that involved partnerships between two or more partner schools from different contexts Publication (schools involved) Methods and main findings Implications THEnet's evaluation framework Larkins SL, et al (2013)8 (JCU, ELAM, Ghent U, UPM‐SHS, ADZU, WSU, FU, NOSM U) THEnet's Evaluation Framework for Socially Accountable Health Professional Education was developed as a tool to assist schools in assessing progress towards social accountability. The framework considers three questions: ‣ How does our school work? ‣ What do we do? ‣ What difference do we make? The evaluation framework proceeded to pilot testing, and is now widely used and cited. Ross SJ, et al (2014)9 (JCU, FU, NOSM U, ADZU, UPM‐SHS) THEnet's evaluation framework was piloted at five THEnet partner schools. It was found to be relevant, acceptable and feasible across the schools. The evaluation framework can be used by health professional education schools as a tool to facilitate critical evaluation of school performance, progress and capacity towards social accountability, and to identify and inform improvements. THEnet Graduate Outcome Study Larkins S, et al (2015)12 (JCU, Ghent U, WSU, Gezira U, ADZU, NOSM U) An analysis of 944 first year learners from five THEnet partner schools was conducted. THEnet partner schools used various selection strategies: quota‐based approaches, use of selection criteria, involvement of community, and marketing the school to attract learners. The demographic profiles of first year learners were reflective of their respective populations (eg, in terms of socio‐economic status and population group). A high proportion of learners intended to practise in underserved communities, and there were associations between rural origin and intent to practise in rural populations. Diversity of the learner cohort is influenced by wider policy and school selection strategies. THEnet partner schools used broad selection strategies that selected a diverse and representative learner cohort. A high proportion of these learners were from underserved backgrounds and expressed higher intention to practise in rural populations, potentially addressing workforce maldistribution. Larkins S, et al (2018)14 (JCU, NOSM U, Ghent U, Gezira U, WSU, ADZU, FU, UPM‐SHS) Entry and exit data for 3346 learners from eight THEnet partner schools were analysed. A positive association between rural background and intention to practise in a rural location was found in entry and exit cohorts. Positive associations were found between intention to practise in rural locations and the following: rural background, low parental income and attending medical school in a regional location. Positive associations were also found between intention to work abroad and the following: urban background and high parental income. A higher proportion of learners intended to practise in family medicine or general practice at exit than at entry. Strategies focusing on social accountability in health professional education have positive impacts on intention to practise in rural populations and in family medicine, and are likely to help address workforce maldistribution. Johnston K, et al (2020)15 (JCU, ADZU, Gezira, WSU, UPM‐SHS, PAHS, NOSM U, FU) Data were analysed for 5078 learners from eight THEnet partner schools participating in the Graduate Outcome Study, including: 3849 learners at entry; 1229 learners at exit; 149 learners for whom entry and exit data were available; and 2041 learners from five schools in LMICs (Sudan, South Africa, the Philippines, Nepal). Differences were found between schools in high income countries and LMICs, in terms of wider policy support for general practice or family medicine postgraduate programs in high income countries. Intention to practise in rural areas was associated with: rural background at entry and exit, attending medical school in a LMIC (AOR at exit, 2.01), and being female (AOR at exit, 1.80). Intention to practise in general practice or family medicine was lower for learners in schools in LMICs than for those in schools in high income countries. Intention to work abroad for learners in schools in LMICs reduced over medical schooling. In LMICs, strengthening the rural health workforce involves: locating schools in rural and regional areas; active recruitment of learners with rural backgrounds; and a curriculum with a focus on primary health care, and which is supported by postgraduate training programs. Levers in health professional education for building a rural health workforce (rural background, low income background, medical school located in a regional area) may be more powerful in LMICs and could encourage learners to serve in rural areas and in their country. Understandings of social accountability Preston R, et al (2016)22 (FU, JCU, ADZU, UPM‐SHS) Interviews were conducted with 75 stakeholders (staff, faculty, students, health workers, members of the community) at four THEnet partner schools. Social accountability was perceived to be meeting workforce, community and health needs through learning and service in underserved communities by students and graduates. The concept may be explicit in a mission statement and/or seen as a moral obligation shown through service and beginning with values. The nature and content of school programs shaped social accountability, including student selection, involvement of communities in decision making and use of a curriculum that addresses the needs of underserved populations. Social accountability as a concept is not universal and should continue to be challenged and debated. Understanding of social accountability may be limited, even when enacted in school programs. Differences in understanding affect the ability of a school to work towards social accountability. Values‐based understanding of social accountability may not be shared at an institutional level, and an explicit mission could isolate those who do not share it. A mixture of both is needed. Ellaway RH, et al (2018)17 (NOSM U, Ghent U, JCU, FU, UNM, Gezira U, UPM‐SHS, WSU) Mission statements were analysed, and interviews were conducted with 72 senior learners at eight THEnet schools. Social mission was expressed explicitly and was central to identity at some schools. Social mission was reflected in: various modes of compulsory community service activities; optional community components; role modelling by faculty; and admission processes. Learners understood their school's social mission in terms of community, social justice in medicine and particular communities, and workforce distribution. Learners internalised the social mission through sensitisation (via institutional culture and curriculum), through personal experiences and by exposure to influential role models. Translation of the social mission to students’ perceptions is variable and affected by how explicit the school social mission is, how it is reflected in the education program, other institutional drivers and the processes that students use to internalise the social mission. Impact and outcomes Reeve C, et al (2017)23 (FU, JCU, ADZU, UPM‐SHS) A systematic review on the impact of health professional schools with a social accountability mandate was conducted. Socially accountable education included: selection processes that admit learners from local rural areas; partnerships between communities, health services and schools; and positive rural experiences through educational activities and clinical placements. Positive impacts of rural placement and training in communities were seen, including effects on competencies, learning experiences, and attitudes to general practice and/or community service. Longer rural placements were associated with increased likelihood of rural practice. Having learners based in rural communities was shown to have positive impacts for rural communities. Overall, there is a lack of studies about the impact of socially accountable medical education. Learning and attitudes towards communities are positively influenced through longitudinal placements in rural areas. Other relevant inputs are: selection strategies aimed at recruiting learners from underserved populations; mandatory placement in rural communities; and undertaking health projects in communities. Halili S Jr, et al (2017)18 (ADZU, JCU, FU) Graduate outcomes of a socially accountable THEnet partner school in the Philippines were compared with those for a conventional medical school in the Philippines. ADZU learners had lower family incomes, were more likely to become doctors to help others, were more likely to have attended ADZU due to the curriculum, and were more likely to intend to practise in family medicine at graduation than learners at the conventional school. ADZU graduates were less likely to be practising in family medicine and more likely to be practising in paediatrics. They were more likely to be working as a rural or municipal health officer or as a generalist medical officer than graduates of the conventional school. ADZU graduates were likely to have positive attitudes towards practice in communities. The socially accountable, community‐engaged medical education model at ADZU has produced graduates who have positive attitudes to communities and health equity, and who practise in areas and fields of need in the Philippines. Siega‐Sur JL, et al (2017)19 (UPM‐SHS, JCU, FU) The motivation for community‐based service, preparedness to address local health issues, career choices and practice location of graduates from a THEnet partner school were compared with those for graduates from a conventional school. UPM‐SHS graduates had more positive attitudes to community service and were more likely to work in rural areas and at rural government health services than graduates from the conventional school. The UPM‐SHS social accountability philosophy drives student selection strategies that include community nominations, social contracts with communities to support students, and extended community‐based training. This approach is successful in developing a fit‐for‐purpose, professional workforce that is committed to working with rural communities. Woolley T, et al (2018)20 (JCU, ADZU, UPM‐SHS, FU) The population and socio‐economic profiles of practice locations for graduates of two THEnet partner schools and two conventional schools were compared. ADZU and UPM‐SHS graduates were more likely to practise in communities with populations of less than 100000 and low income communities compared with those from conventional schools. Two THEnet partner schools have increased medical coverage in rural and economically disadvantaged areas in two regions of the Philippines. Policies that support rurally bonded places were filling workforce gaps. Woolley T, et al (2018)21 (JCU, ADZU, UPM‐SHS, FU) A non‐randomised controlled study was conducted to compare child and maternal health outcomes in five communities served by graduates and student interns who had been trained at THEnet partner schools and conventionally trained graduates. A total of 494 mothers were surveyed. Mothers in communities served by ADZU and UPM‐SHS graduates and interns were more likely than mothers in communities served by conventionally trained graduates to report: discussing results of prenatal samples; having their first prenatal check‐up before 4 months’ gestation; doctor‐assisted birth of their youngest child; receiving timely newborn and postnatal care across all USAID‐recommended core elements; their youngest child being in the normal birthweight range; and still breastfeeding their youngest child when they were 6 months of age. Graduates and student interns of ADZU and UPM‐SHS are: strengthening child and maternal health services in some communities served by these two schools, increasing access to child and maternal health services for economically disadvantaged mothers; and producing positive child health outcomes. This study added to evidence showing that socially accountable education helps address health workforce maldistribution and benefits underserved populations. Woolley T, et al (2019)16 (JCU, UNM, Gezira U) A total of 184 hospital and community facility staff were surveyed; they rated key competencies of graduates from three THEnet partner schools and those of graduates from conventional schools. Graduates (postgraduate year 1) of three THEnet partner schools were rated above average for overall performance, work readiness, overall clinical skills, teamwork, professional attitudes and commitment to health equity. Workplace‐based training in community and local hospital settings and a socially accountable curriculum that focuses on health equity produces work‐ready graduates with locally relevant competencies. Woolley T, et al (2020)24 (JCU, NOSM U) The impact of postgraduate training location on practice in the service area of the medical school was examined by surveying 149 JCU graduates (specialist doctors and fellows) and 400 fully licensed NOSMU‐trained doctors. 38% of JCU graduates were practising in the school's service area. For family practitioners, general specialists and subspecialists, regional training was positively associated with practice in the service area. Family practitioners were more likely to practise in the service area than general specialists and subspecialists. 92% of family practitioners who completed undergraduate and postgraduate training at NOSMU were practising in the school's service area compared with 54% who completed only postgraduate training at NOSM U. 30% of general speciality graduates were practising in the service area. Location of postgraduate training is positively associated with later practice location — two socially accountable medical schools found that a training pathway for family practitioners in the school's service area was associated with later practice location in the school's service area. The findings support specialty training programs based in rural and regional centres, with rotations for trainees into city locations when required. Murray R, et al (2022)7 (JCU, ADZU, PAHS, UPM‐SHS, NOSM U, Ghent U, UNM) In a perspective piece, the authors reflected on the implications of COVID‐19 in terms of speeding up uptake of equity‐promoting initiatives, such as distributed education and telehealth. Interruptions to medical education during the COVID‐19 pandemic have highlighted inequities across the health and health education systems, and prompted new and increased use of online learning (including for clinical skills), use of online examinations, and deployment of students to aid in the health response to COVID‐19. The COVID‐19 pandemic presents an opportunity to disrupt conventional approaches to medical education and consider how necessary adaptations can drive change that is beneficial for medical education and health equity. Lessons from THEnet partner schools provide guidance on successful innovations to achieve these aims. ADZU = School of Medicine, Ateneo de Zamboanga University; AOR = adjusted odds ratio; COVID‐19 = coronavirus disease 2019; ELAM = Latin American School of Medicine; FU = Flinders University; Gezira U = Faculty of Medicine, Gezira University; Ghent U = Ghent University; JCU = College of Medicine and Dentistry, James Cook University; LMICs = low and middle income countries; NOSM U = NOSM University (formerly known as Northern Ontario School of Medicine); PAHS = Patan Academy of Health Sciences; UNM = University of New Mexico; UPM‐SHS = School of Health Sciences, University of the Philippines Manila, Leyte; USAID = United States Agency for International Development; WSU = Walter Sisulu University.

Sarah L Larkins · Fortunato Cristobal · John Hogenbirk · Filedito Tandinco · Abu‐Bakr Othman · Jabu Mbokazi · Kaatje Van Roy · Shambhu Upadhyay · Karen Johnston · Andre‐Jacques Neusy

In this article, I share my journey of being a medical student, in which I seized rural health student opportunities to develop both personally and professionally. This culminated in my being elected as chair of the National Rural Health Student Network (NRHSN) for 2022. The NRHSN (https://nrhsn.org.au/) is a grassroots movement that started as a single university‐based rural health club (RHC) for rural medical students. It is now a federally funded network of 29 RHCs, the peak multidisciplinary body for 12000 health students, and one of Australia's largest student organisations. I never imagined that I would be a rural medical officer cadet studying in the New South Wales city of Bathurst. Before this, I spent years wandering and searching for a community; I grew up on Reunion Island off the coast of Africa, experienced a chikungunya epidemic and its impact on under‐resourced remote health care,1 moved to Western Australia as an international student to study English, and worked in roles such as breakfast chef and tour guide, taking international students on tours of the outback. At 29, I decided to become a factor for change for those who need it most and moved to Sydney to study medicine. At orientation week, I met an executive member of the local RHC who mentioned that the club is required to engage rural high schools as part of their funding requirements. This sparked my interest, and we discussed my previous experience working with students from low socio‐economic backgrounds. This simple conversation took me on an unexpected path of national leadership and advocacy. My journey included a detour to Central Australia, as I completed six weeks of life‐changing placement in Northern Territory communities during the summer holidays of my pre‐clinical years. I realised that the social determinants of health have a crucial impact in remote Australia. Some of my fondest memories are of the first day of rain after 18 months in Tennant Creek, helping a nurse change a LandCruiser tyre in a remote community with no mobile reception, and being taught how to eat honey ants in Yuendumu. My early and repeated exposures to rural and remote health have been the most memorable parts of my medical journey, and this is reflected in publications on future rural practice intent.2 As I started my clinical years, I felt that I needed to be a part of the solution to the problems I witnessed during my placements, and the only way I could enact change was through grassroots movements. This led to my role as chair of the NRHSN in 2022. The council of the NRHSN is formed by the presidents of the 29 RHCs and 11 executives, who are led by the chair; it gathers biannually for a national in‐person forum. My purpose became ensuring the post‐pandemic sustainability of this organisation which, through my local RHC, had put me on my path. As chair of the NRHSN, I was a member of the Advisory Network to the National Rural Health Commissioner. I was also a council member for the National Rural Health Alliance and the Royal Australian College of General Practitioners Rural Council. The NRHSN is a key rural stakeholder — for example, it was invited to participate in a budget meeting with the Minister for Regional Health. Also, it is the only student delegation to the Ngayubah Gadan Summit, a national rural health meeting held in Cairns which led to the development of a consensus statement on multidisciplinary rural teams (as yet unpublished). As a fourth‐year medical student, finding myself in crucial discussions on the future of rural health care was daunting but incredibly rewarding. The ability to advocate on behalf of students, and to take information and lessons back to the student body, was invaluable. As research is also a crucial part of the NRHSN's role, I was able to present the work of the NRHSN at the 16th National Rural Health Conference and at RMA22 (the Rural Medicine Australia 2022 conference). At these meetings, I advocated for further investment in short term rural placements for allied health, nursing and midwifery students, as it is well documented that non‐medical students are consistently underexposed to rural settings, and longer placements are not an option in many shorter degrees.3,4 I also presented this work at the 14th National Rural and Remote Allied Health Conference, where I won the Best Student Presenter award. The predictors of rural practice are varied and conflicting. Rural origin is a major factor, but regardless of origin, repeated exposure to rural communities throughout training is paramount in producing future rural practitioners.5,6,7 Another significant influence is student‐led movements by engaged and passionate leaders. Their many individual stories are reflected in my journey, which started with a simple discussion at my local medical school orientation and led to my role as chair of a national organisation. I finally found the community of like‐minded individuals I had been seeking and I look forward to a lifetime of future involvement.

Jean‐Baptiste H Philibert

As Australia's first regional education commissioner, I want all people in regional, rural and remote Australia, regardless of where they live, to be able to access the education and career opportunities they need to reach their full potential. Having spent most of my life in country Australia, I know that some challenges can be greater in the regions compared with the cities, such as going to school or university or moving your family for work. Much is made of offering financial and other incentives or subsidies to encourage students to relocate to, or eventually practise in, the country, and there is certainly a place for that. But I like to think that rural living offers its own rewards. Regional towns have a strong sense of community, where you know and support your neighbours, and they know and support you. Unfortunately, not enough people are asking themselves “is a career in rural health a great option for me?”. This needs to change, because health professionals are central to rural communities — by providing essential services, they are valued and indispensable parts of the regional fabric. We know that there are challenges for health professionals who practise in the regions, such as vast distances from peers and colleagues. But there may not be enough focus on the many opportunities for health professionals in the regions. Practising in the regions can help health professionals develop broad skills, self‐reliance and confidence earlier in their career than they might otherwise. It also offers them the chance to provide health and wellbeing services to their own community, and to become respected leaders and trusted mentors. Unsurprisingly, the National Skills Commission identified care sector occupations as some of the most important in terms of future skill needs for Australia. To give a sense of the scale of future demand, the National Skills Commission has projected that an additional 100000 health professionals, at least, will be needed across Australia over the next 5 years.1 So, what can be done to attract students to a career in rural health? In discussions with stakeholders across the education sector and industry groups, a recurring theme is the importance of information for young students who are making decisions about the careers and pathways that suit them. The role of locally informed career advisers is critically important. Equally important is exposing regional students to industries and potential career pathways throughout their education, in a relatable way. As the adage goes, you cannot be what you cannot see. Industries like health should inspire the next generation of skilled workers by getting involved at the school level and letting students know about the opportunities to work in health care. Industry ambassadors — such as rural dentists or pharmacists who travelled away from home to learn before returning to regional Australia — can share their experiences at schools, making the pathway feel more attainable and lifting aspiration in regional students. Flying doctors and speech pathologists who practise by telehealth can demonstrate the potential for exciting careers that apply technology to make a difference in communities. Attending university can be a daunting experience. For a young person who needs to leave their home and community to study, it brings additional challenges and expense. Indeed, some of our future health professionals may well be the first in their family to go to university. Successive reviews prepared for the federal government — such as the Review of Australian Higher Education (Bradley review)2 and the National Regional, Rural and Remote Tertiary Education Strategy (Napthine review)3 — have shown that financial barriers for regional and remote students, particularly those relating to relocation, are a persistent problem. When regional students have no choice but to leave home to study, because local training options are not available, they need support to do so. More broadly, universities should consider the support they provide to regional students, to help them achieve their educational goals. Support services need to be visible and accessible; universities need to ensure that students are aware of the support available, and they should establish proactive methods to identify and support students who require assistance. When a student has the opportunity to study closer to home, this benefits their community. We know that health students from regional areas, and those who undertake extensive training in a rural setting, are more likely to take up practice in the regions.4,5 I remember talking to a high school principal in Albury not long after the announcement that there would be university medical schools in regional areas, where students would be able to do their entire degree. He had been speaking to three of his students, who were all very excited because they would not have to leave home and move to a city to study medicine. The smile on his face said it all. It is also important to offer health students the opportunity to train in rural and remote communities. One example is the Rural Health Multidisciplinary Training program, which aims to improve the recruitment and retention of medical, nursing, dental and allied health professionals in rural and remote Australia. Many years ago, when I was visiting the University Centre for Rural Health in Lismore, I spoke to a young student from Sydney who was studying there. She said that being in Lismore had completely changed her view of where she wanted to be. From the experience, she was sure that her future was not going to be in the city — it was going to be living and working in a regional community. Sharing the opportunities of working in health industries in regional, rural and remote Australia with young people, and making these professions attainable and relevant to them, will go a long way towards creating aspiration and vision for future career pathways. Balancing inspiration with investment will equip our future health professionals to meet the needs of their patients for decades to come. And if we get that inspiration and investment right, many more people will answer “yes” when they consider whether a career in rural health is a great option for them.

Fiona Nash