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15 Aug 2019



This month I have invited Ms Jacoba van Wees, Chair of AMSA Rural Health, to write a guest column on rural health from the medical student perspective. It is time to quietly listen to our new generation of junior doctors, as they can help us solve our workforce issues – Dr Sandra Hirowatari, Chair, AMA Council of Rural Doctors.


Internship. It’s the word that makes medical students quiver in fear of responsibility and expectations. It’s also the word that makes students excited, and hopeful. It marks the epitome of everything they’ve worked towards during the last four to six years of study. It is also one of the most terrifying aspects of medical students’ professional lives thus far, and marks the beginning of their careers.

The above feelings are not unique – every medical student has contemplated the day they make the fated transition from student to intern. It becomes a much more complex, muddled emotional experience when you add rurality into the mix.

Through my role within AMSA Rural Health, I have had the privilege to hear many unique perspectives on rural internships, particularly students who have just endured the internship application process themselves, and the emotional journey that accompanied it. As a part of my role, I am often asked: “What makes someone want to practise rurally when they graduate?”

There is no simple answer, unfortunately. While there is evidence that positive rural experiences as a student and rural origin both increase the likelihood of someone practising in a rural area as a junior doctor, real and perceived barriers can dissuade even the most passionate of would-be rural doctors.

There is a stigma surrounding rural internships, and fear amongst medical graduates that spending your intern year in rural or regional hospital decreases your chances of being accepted into a number of colleges.

Medical students are constantly being bombarded with the idea that you will never make it onto certain training programs unless you do your internship in a metropolitan hospital. There are ongoing concerns that a lack of exposure to certain specialties as a PGY1 and 2 will hinder your chances of training in that field.

Some aspects of these fears are based on legitimate concerns for interns, such as lack of access to consultants in certain fields in order to gain appropriate references. However, many of these concerns are persistent despite there being little evidence that a rural internship will exclude you from any specialty training program. In fact, some colleges are now rewarding rural practice, such as RANZCOG, which awards two points to applicants for completing a minimum of one-year full time as a non-bonded trainee in a rural area.

The stigma runs even deeper than that – with a fear among students that if you ‘end up’ rural, you won’t ever be able to obtain a position at any metropolitan hospital. In Victoria, final year medical students are provided with a ‘Z-score’, which is a standardised score comparing students from the different Victorian Medical Schools that indicates how far below or above the mean a student is.

This system of internship allocations further exacerbates negative perceptions towards rural internship programs as the more competitive metropolitan hospitals end up with a cohort of students with a higher average Z-score, implying that students who receive rural internship placements performed worse academically than their peers who receive metropolitan internship allocations.

Many of my peers often talk about how awful it would be to ‘end up’ rural, and cannot fathom that I would actively choose to do rural terms as both a student and, hopefully, junior doctor. In my clinical placements as a student so far, the experiences I’ve had in a rural area have been far superior to those I’ve experienced in metropolitan tertiary hospitals. I attribute this to the cumulative effect of increased exposure and experience, smaller teams with more access to supervision, and strong support from peers and mentors. But for my peers who haven’t had the opportunity for positive rural experiences, there is no incentive drawing them to rural internship programs.

In my eyes, the fear of missed opportunities is the biggest deterrent from rural internship programs – fear of missing out on relationships, support, mentors, training programs, friendship and so much more. Those of us who are passionate about rural health know that this isn’t always the case, but the onus shouldn’t fall on the students and interns to educate themselves to decipher fact from fiction.

We need greater visibility of the many positive aspects of rural internship, especially from current rural interns and junior doctors. We need the good stories to outweigh the myths and misinformation. We need to publicise and reward the health services that provide junior doctors with support, and show junior doctors that they will be welcomed into rural communities. We need to hear the specialty colleges and health services actively dispelling falsities and promoting rural specialty training. I certainly do not have the panacea to our rural workforce shortage, but what I do know is this – a perceived barrier can still hinder our rural workforce. Together we must strive to eliminate these barriers.

Published: 15 Aug 2019