Persistent medical workforce shortages in rural Australia continue to undermine equitable access to health care. This commentary explores key barriers and enablers to rural medical graduate retention, focusing on the role of rural immersion programs, systemic training constraints, and evolving models of end-to-end rural medical education. While initiatives such as rural clinical schools, the John Flynn Placement Program, and Murray-Darling Medical Schools Network have enhanced rural exposure, the lack of accessible specialty training pathways and professional support in rural areas continues to disrupt continuity. The mismatch between medical graduate output and vocational training availability compounds the issue. A coordinated effort involving universities, specialist colleges, government, and communities is essential to establish integrated training pipelines. End-to-end rural training, expanded regional training hubs, cultural competence, and community integration are critical components of a sustainable solution. Addressing these multifactorial challenges offers an opportunity to build a resilient and regionally distributed rural medical workforce.

Australia faces an entrenched and worsening maldistribution of general practitioners, leaving rural and remote communities with chronic workforce shortages and unacceptable barriers to accessing primary care in a timely manner. The apprenticeship-style model that underpins general practice training relies fundamentally on supervisors to provide clinical oversight, teaching, assessment and mentorship. This supervisory capacity, central to shaping registrar competence, professional identity and long-term rural practice is now one of the key rate-limiting factors in rural workforce development. That capacity is steadily eroding. An ageing workforce, post-pandemic attrition and escalating clinical demand are shrinking the pool of experienced supervisors, while growing dependence on international medical graduates and locums (less likely to supervise) further weakens the supervisory pipeline. Compounding this are persistent system-level failures: variable supervision standards, the late introduction of formal supervisor training, limited financial and structural incentives, and limited professional recognition. Together, these pressures constrain the ability of rural practices to train registrars at the scale required to address workforce shortages. Strengthening supervision is therefore not an adjunct consideration but a strategic necessity. Building a resilient supervisory workforce will require coordinated reform that embeds protected teaching time into routine practice, recognizes and remunerates supervisory work appropriately, expands dedicated educator roles, develops tiered and flexible supervision models and provides targeted support for women and international medical graduate clinicians. Without decisive investment in supervision, efforts to expand rural training pathways will exceed the system’s capacity to sustain them.

Australia faces a persistent shortage of doctors in rural and regional areas, exacerbating health disparities between urban and rural communities. Traditional medical education models, which have been largely centralized in metropolitan areas, often result in rural-origin students needing to relocate to cities for training, thus disrupting community connections and reducing the likelihood of their return to rural practice. To address this challenge, the University of Melbourne and La Trobe University have collaborated to establish Victoria’s first end-to-end rural medical pathway, an innovative model that enables students to complete both their undergraduate [“Bachelor of Biomedical Science (Medical)”] and Doctor of Medicine (MD) entirely within regional and rural settings. This paper explores the implementation, practical considerations, and evaluation mechanisms of the end-to-end rural medical pathway, highlighting its place-based curriculum, and fully distributed medical education model. Although this program is yet to be evaluated, it is intended that by embedding students in primary care clinics and regional hospitals throughout their training, the program will foster long-term professional and personal ties to rural communities. This initiative represents a scalable and evidence-based model for addressing rural medical workforce shortages, offering insights that could inform national and international medical education policy.

The health disparities between rural and urban populations in Australia, driven by socioeconomic, environmental, and healthcare access factors, highlight the urgent need for rural-focused medical education. The Melbourne Medical School’s Rural Health Discovery program addresses this need by integrating adult learning principles within a redesigned curriculum that includes the Rural Health Foundations and Integrating Rural Health topics. These Discovery topics engage medical students from diverse backgrounds through a blend of self-directed learning, problem-solving, and immersive clinical placements in rural settings. By aligning with andragogical principles—such as fostering autonomy, practical relevance, and experiential learning—the program prepares students for the unique demands of rural healthcare practice. Students are introduced to the complexities of rural health, including the social determinants affecting rural communities, through asynchronous modules, case studies, and team-based learning. This innovative curriculum, which is flexible and inclusive of rural and metropolitan students, represents a strategic model for promoting rural healthcare careers, addressing workforce shortages, and ensuring equitable health outcomes for underserved communities.

Context. The COVID-19 pandemic added to demand and diversification in specialist palliative care, including unprecedented need to deliver supportive respiratory therapies. Objective. To understand training needs and ongoing models of care, including delivery of chronic disease management and supportive respiratory therapies, post-pandemic for palliative care clinicians. Methods. Mixed-methods study of specialist palliative care physicians and nurses, recruited through Australian palliative care organizations and snowballing sampling between November 2022 and March 2023. Online survey captured training required and acquired in chronic disease management, respiratory therapies, and ongoing barriers to quality care delivery. Structured follow-up interviews explored adjustments in models of care and key areas of need. Quantitative data were described, free-text and interview data analyzed through content and thematic analyses respectively. Results. Of 71 palliative care responding clinicians (47 physicians, 23 nurses), most were female (79%) and many were rurally-based (38%). Completion of any chronic disease-specific training was infrequent (21% physicians, 30% nurses), compared with informal organ-specific training (61%-83%) and age-related decline training (44%-60%) through generalized palliative care qualifications. Respondents commonly managed chronic breathlessness (55%) and respiratory therapies (24%-42%), yet targeted training was atypical. Content analysis (n = 64) confirmed ongoing training gaps broadly in coping with daily operational demands and workforce fluctuations and specifically in respiratory skills. Interviews (n = 7) reported challenges in care delivery post-pandemic; absence of pathways and policies for chronic disease management; and patient misconceptions about palliative care. Conclusion. Clinicians are frequently required to support varied chronic conditions, including the use of respiratory therapies and breathlessness management, but report lack of specific training. Future endeavors should address workforce training and models of care to support increased demand. J Pain Symptom Manage 2025;69:569-580. (c) 2025 Published by Elsevier Inc.

Background:Addressing rural healthcare workforce shortages requires evidence-based strategies in medical education. Extended rural immersion programs offer a potential solution, but the optimal duration for fostering long-term regional and rural practice remains unclear. Methods:This retrospective study evaluates the impact of one-year versus three-year rural immersion experiences at the University of Melbourne's Rural Clinical School (RCS) on graduate clinical practice locations of the 2016-2023 graduating cohorts. Using logistic regression analysis, we assessed key predictors of regional and rural practice, including rural immersion duration and intent to practice regionally or rurally. Results:Graduates who completed the three-year rural immersion program were significantly more likely to practice in Modified Monash Model (MMM) 2-7 areas than those with only one year of rural immersion. Intent to practice regionally or rurally and completing a regional/rural internship emerged as strong predictors of regional/rural practice. However, regional/rural intent did not appear to be a strong indicator for students who only completed 1-year of rural immersion. This highlights the importance of the duration of immersion. Conclusion:The study demonstrates the effectiveness of extended rural immersion in increasing regional and rural workforce retention. Findings support further investment in rural medical education, including end-to-end rural training models, which integrates rural exposure across the entire medical education journey. Future research should examine long-term workforce retention and strategies for sustaining rural career pathways.

A parallel, multi-campus anatomy curriculum was developed that could be delivered with or without body donor cadaveric teaching resources. This blended program includes asynchronous lectures, e-Learning modules, formative self-assessment, independent study, and synchronous hands-on practical sessions. Practical sessions at the metropolitan campus utilise professionally prepared body donor cadaveric teaching resources, whereas rural campus practical sessions use a combination of non-cadaveric resources such as 3D models (physical and digital) and interactive multimedia to achieve identical learning outcomes. Here, we discuss the specific features of the practical sessions delivered in this novel cross-campus curriculum, with a focus on the non-cadaveric teaching resources deployed.

Objective This study aims to determine the associations between specialty type and practice location at postgraduate year 10 (PGY10), matched with PGY5 and PGY8 work locations, and earlier rural exposure/experience.Design and setting A cohort study of medicine graduates from nine Australian universities.Participants 1220 domestic medicine graduates from the class of 2011.Outcome measures Practice location recorded by the Australian Health Practitioner Regulation Agency in PGY10; matched graduate movement between PGYs 5, 8 and 10 as classified by the Modified Monash Model, stratified by specialty type (predominantly grouped as general practitioner (GP) or non-GP).Results At PGY10, two-thirds (820/1220) had achieved fellowship. GPs were 2.8 times more likely to be in non-metropolitan practice (28% vs 12%; 95% CI 2.0 to 4.0, p<0.001) than graduates with non-GP (all other) specialist qualifications. More than 70% (71.4%) of GPs who were in non-metropolitan practice in PGY5 remained there in both PGY8 and PGY10 versus 29.0% of non-GP specialists and 36.4% of non-fellowed graduates (p<0.001). The proportion of fellowed graduates observed in non-metropolitan practice was 14.9% at PGY5, 16.1% at PGY8 and 19.0% at PGY10, with this growth predominantly from non-GP specialists moving into non-metropolitan locations, following completion of metropolitan-based vocational training.Conclusions There are strong differences in practice location patterns between specialty types, with few non-GP specialists remaining in non-metropolitan practice between PGY5 and PGY10. Our study reinforces the importance of rural training pathways to longer-term work location outcomes and the need to expand specialist vocational training which supports more rural training opportunities for trainees outside general practice.

Introduction/AimDespite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission.MethodsMultisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019.ResultsOf 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. “Not-for-resuscitation” orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001).ConclusionsEnd-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.

INTRODUCTION:Australia has a doctor shortage in rural settings, and rural placements for medical students have an important role in increasing the likelihood of students staying in rural settings throughout their careers. However, to date there is limited research regarding medical student perceptions of rural placement quality.OBJECTIVE:We aimed to determine factors that impact the overall medical student experience during rural placements.DESIGN:Cross-sectional survey.SETTING:Rural/remote clinical schools across Australia.PARTICIPANTS:Medical students on rural/remote clinical placements for at least 6 months.MAIN OUTCOME MEASURES:To assess factors impacting student experience on rural placements, we conducted a cross-sectional survey, known as the Australian Rural Clinical School Support Survey (ARCSSS) which was completed online by medical students across Australia. Demographic data were collected in addition to responses regarding academic teaching, extracurricular activities, and support services. Multiple choice and Likert scale questions were utilised.RESULTS:A total of 107 responses to our survey were analysed. The majority of participants were female (66.4%), and in their middle years of clinical education (55.1%). Overall, respondents showed high levels of satisfaction with clinical school supervisors, and clinical education. A high proportion of respondents indicated minimal accessibility of health and other support services. While a large proportion of participants indicated satisfaction with the rural placements, it was demonstrated that students were generally dissatisfied with school wellness activities and extracurricular activities. Financial insecurity was noted.CONCLUSION:The findings from our survey indicate there are numerous areas in which rural placements have been effective for medical students, and others in which improvement is needed. Furthermore, more research is required to better develop well-being initiatives that are effective in improving overall experience.

Context. Despite clear benefit from palliative care in end-stage chronic, non-malignant disease, access for rural patients is often limited due to workforce gaps and geographical barriers.Objectives. This study aimed to understand existing rural service structures regarding the availability and provision of palliative care for people with chronic conditions.Methods. A cross-sectional online survey was distributed by email to rural health service leaders. Nominal and categorical data were analyzed descriptively, with free-text questions on barriers and facilitators in chronic disease analyzed using qualitative content analysis.Results. Of 42 (61.7%) health services, most were public (88.1%) and operated in acute (19, 45.2%) or community (16, 38.1%) settings. A total of 17 (41.5%) reported an on-site specialist palliative care team, primarily nurses (19, 59.5%). Nearly all services (41, 95.3%) reported off-site specialist palliative care access, including: established external relationships (38, 92.7%); visiting consultancy (26, 63.4%); and telehealth (18, 43.9%). Perceived barriers in chronic disease included: lack of specific referral pathways (18; 62.1%); negative patient expectations (18; 62.1%); and availability of trained staff (17; 58.6%). Structures identified to support palliative care in chronic disease included: increased staff/funding (20, 75.0%); formalized referral pathways (n = 18, 64.3%); professional development (16, 57.1%); and community health promotion (14, 50%).Conclusion. Palliative care service structure and capacity varies across rural areas, and relies on a complex, at times ad hoc, network of onsite and external supports. Services for people with chronic, non-malignant disease are sparse and largely unknown, with a call for the development of specific referral pathways to improve patient care. J Pain Symptom Manage 2023;66:301-309. (c) 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Objective: To examine associations between extended medical graduates' rural clinical school (RCS) experience and geographic origins with practising in rural communities five and eight years after graduation. Design, participants: Cohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools. Main outcome measures: Practice location types eight years after graduation (2019/ 2020) as recorded by the Australian Health Practitioner Regulation Agency, classified as rural or metropolitan according to the 2015 Modified Monash Model; changes in practice location type between postgraduate years 5 (2016/2017) and 8 (2019/2020). Results: Data were available for 1321 graduates from ten universities; 696 were women (52.7%), 259 had rural backgrounds (19.6%), and 413 had extended RCS experience (31.3%). Eight years after graduation, rural origin graduates with extended RCS experience were more likely than metropolitan origin graduates without this experience to practise in regional (relative risk [RR], 3.6; 95% CI, 1.8-7.1) or rural communities (RR, 4.8; 95% CI, 3.1-7.5). Concordance of location type five and eight years after graduation was 92.6% for metropolitan practice (84 of 1136 graduates had moved to regional/rural practice, 7.4%), 26% for regional practice (56 of 95 had moved to metropolitan practice, 59%), and 73% for rural practice (20 of 100 had moved to metropolitan practice, 20%). Metropolitan origin graduates with extended RCS experience were more likely than those without it to remain in rural practice (RR, 2.0; 95% CI, 1.3-2.9) or to move to rural practice (RR, 1.9; 95% CI, 1.2-3.1). Conclusion: The distribution of graduates by practice location type was similar five and eight years after graduation. Recruitment to and retention in rural practice were higher among graduates with extended RCS experience. Our findings reinforce the importance of longitudinal rural and regional training pathways, and the role of RCSs, regional training hubs, and the rural generalist training program in coordinating these initiatives.

The critical importance of primary health care in maintaining a healthy population is well established internationally. Nevertheless, general practitioner care is not always easily accessible for some patients in Australia, particularly in rural regions. This is partly due to an insufficient number of medical graduates entering and being retained in the rural general practitioner workforce. Key elements of international and national programs designed to address this shortfall are discussed and include the use of entry requirements that preferentially select for applicants from a rural residence background, and immersion of medical students for a large share, or entire duration, of their training in rural communities. In addition, other factors that can influence decisions to enter and stay in rural practice are discussed.

BACKGROUND:People living in rural and remote communities commonly experience significant health disadvantages. Geographical barriers and reduced specialist and generalist services impact access to care when compared with metropolitan context. Innovative models of care have been developed for people living with chronic diseases in rural areas with the goal of overcoming these inequities. The aim of this paper was to describe the characteristics and outcomes of studies investigating innovative models of care for people living with chronic disease in rural areas of developed countries where a metropolitan comparator was included.METHODS:An integrative systematic review was undertaken. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to understand the empirical and theoretical data on clinical outcomes for people living with chronic disease in rural compared with metropolitan contexts and their models of care in Australia, New Zealand, United States, Canada and the United Kingdom.RESULTS:Literature searching revealed 620 articles published in English between 1st January 2000 and 31st March 2019. One hundred sixty were included in the review including 68 from the United States, 59 from Australia and New Zealand (5), 21 from Canada and 11 from the United Kingdom and Ireland. 53% (84) focused on cardiovascular disease; 27% (43) diabetes mellitus; 8% (12) chronic obstructive pulmonary disease; and 13% (27) chronic kidney disease. Mortality was only reported in 10% (16) of studies and only 18% (29) reported data on Indigenous populations.CONCLUSIONS:This integrated review reveals that the published literature on common chronic health issues pertaining to rural and remote populations is largely descriptive. Only a small number of publications focus on mortality and comparative health outcomes from health care models in both urban and non-urban populations. Innovative service models and telehealth are together well represented in the published literature but data on health outcomes is relatively sparse. There is significant scope for further directly comparative studies detailing the effect of service delivery models on the health outcomes of urban and rural populations. We believe that such data would further knowledge in this field and help to break the deadly synergy between increased rurality and poorer outcomes for people with chronic disease.

The ASTRAL trial showed no difference in clinical outcomes between medical therapy and revascularization for atherosclerotic renal vascular disease (ARVD). Here we report a sub-study using echocardiography to assess differences in cardiac structure and function at 12 months. ASTRAL patients from 7 participating centres underwent echocardiography at baseline and 12 months after randomisation. Changes in left ventricular ejection fraction (LVEF), left ventricular mass (LVM), left atrial diameter (LAD), aortic root diameter (AoRD), E:A, and E deceleration time (EDT) were compared between study arms. Analyses were performed using t-tests and multivariate linear regression. Ninety two patients were included (50 medical versus 42 revascularization). There was no difference between arms in any baseline echocardiographic parameter. Comparisons of longitudinal changes in echocardiographic measurements were: δLVEF medical 0.8 ± 8.7% versus revascularization − 2.8 ± 6.8% (p = 0.05), δLVM − 2.9 ± 33 versus − 1.7 ± 39 g (p = 0.9), δLAD 0.1 ± 0.4 versus 0.01 ± 0.5 cm (p = 0.3), δAoRD 0.002 ± 0.3 versus 0.06 ± 0.3 cm (p = 0.4), δE:A − 0.0005 ± 0.6 versus 0.03 ± 0.7 (p = 0.8), δEDT − 1.1 ± 55.5 versus − 9.0 ± 70.2 ms (p = 0.6). In multivariate models, there were no differences between treatment groups for any parameter at 12 months. Likewise, change in blood pressure did not differ between arms (mean δsystolic blood pressure medical 0 mmHg [range − 56 to + 54], revascularization − 3 mmHg [− 61 to + 59], p = 0.60). This sub-study did not show any significant differences in cardiac structure and function accompanying renal revascularization in ASTRAL. Limitations include the small sample size, the relative insensitivity of echocardiography, and the fact that a large proportion of ASTRAL patient population had only modest renal artery stenosis as described in the main study.

The Single Ventricle Group (SVG) was developed to provide a standardised approach to monitoring infants with single ventricle and shunt dependent physiology who had undergone Stage 1 palliation with either a Norwood or an aortopulmonary shunt prior to their Stage 2 procedure. The SVG was introduced in January 2017 with the aim of reducing Stage 1 and interstage mortality at our centre. We conducted a retrospective review over a 6 year period of patients who had undergone single ventricle palliation from January 2013 to March 2019. Our primary endpoint was mortality. There were a total of 95 patients; 63 patients were pre-SVG group (35% Norwood) and 32 patients were managed as part of the SVG (63% Norwood). In the pre-SVG group, there were 14 interstage deaths (22%) compared to 0 deaths in the SVG group (p = 0.004) acknowledging that 6 patients in the SVG are currently interstage and awaiting Stage 2 palliation. Of the 14 pre-SVG deaths, 7 (64%) were Norwood and 10 (71%) occurred in hospital. In this institution, the implementation of a multidisciplinary group with a standardised approach to managing and monitoring high risk infants through Stage 1 to Stage 2 palliation coincided with a significant reduction in mortality. The cause of this is likely multifactorial, however we hypothesise that this is largely a result of standardising the management for these children to a specialised single group.

Aims: To determine the impact of the implementation of a single ventricle group (SVG) in management of infants between stage 1 and stage 2. Methods: A SVG commenced January 2017 at our hospital and consisted of cardiologists and senior nursing staff. Data from infants enrolled on the Home Monitoring Programme (HMP) was reviewed each week to inform clinical decisions. Criteria for inclusion were infants with single ventricle physiology who had a Norwood or aorto-pulmonary shunt in 2017–2018 and had completed stage 2. An infant admitted to hospital for a breach of the HMP was defined as a “save”. A breach in criteria included hypoxemia, poor growth (<150 g/week) or weight loss (>50 g in one day). Breaches were escalated to the Nurse Specialists who facilitated their admission to the local hospital or cardiac centre for further assessment. Results: A total of 25 infants have completed stage 2 with no mortality. Inter-stage discharge criteria were not met in 5/25 (20%). Of the remaining, 3/20 (15%) followed their expected trajectory. The remaining 17/20 (85%) breached criteria requiring hospital admission. Hypoxaemia was the commonest breach 13/17 (76%) with the remaining 4/17 (24%) admitted for poor growth/weight loss. Early CT scan was required for 13/17 (76%), 6 had re-intervention and 5 had early Bi-Directional Glenn. Conclusion: Close surveillance and uniformity of practice by a specified group of clinicians can result in excellent outcomes for this vulnerable population.