1. Training rural doctors: is there a formula for (Swedish) success? The theoretical part of the equation Dean Carson Glesbygdsmedicinbskt Centrum (Visiting Professor) Northern Institute, Charles Darwin University, Australia. 1 August 2015

2. Why rural training? To improve the recruitment and retention of rural doctors – a global challenge 2

3. But not a new challenge! Mesopotamia 3000bc Hard to get physicians to work outside the city walls Donkeys, goats, wives, housing, holidays... 3

4. Many solutions have been tried Wilson, N. W., I. D. Couper, E. De Vries, S. Reid, T. Fish and B. J. Marais (2009). "A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas." Rural and Remote Health Coercion Financial incentives Personal and social support Limited evidence of success – successful cases, but no universal indicators 4

5. The best evidence ‘Rural background’ –Family home –Schooling ‘Rural Exposure’ –Clinical training –Maybe other rural based activities like research or community projects The ‘Rural Pipeline’ 5

6. Does it work here? Aaraas, Ivar J., Peder A. Halvorsen, and Olaf G. Aasland. "Supply of doctors to a rural region: Occupations of Tromsø medical graduates 1979-2012." Medical Teacher Carson, Dean B., Adrian Schoo, and Peter Berggren. “The ‘rural pipeline and retention of rural health professionals in Europe’s northern peripheries.” Health Policy Recruit and Retain project and survey Scotland, Ireland, Norway, Greenland, Iceland, Sweden, Canada Sweden – 80% with rural training want to stay rural (vs. 70%) Rest of European participants – 70% vs 60% Canada – 90% vs 80% 6

7. When does rural training ‘work’? When the quality of education and exposure to ‘real practice’ is high When training is ‘immersive’ (students live the rural doctor life, not just visit it) When the community is involved When it happens at the right scale (usually one or two students per supervising doctor) 7

8. Will rural training solve everything? Geographic limitations – 70% go where they were trained (or where they grew up) –So need to have ‘exposure’ to as many places as possible Time limitations – when do people ‘go rural’? What ‘markets’ are there (early career, mid life changers, pre-retirement)? –We might need different rural training systems for different ‘markets’ Scale limitations – can we train enough in enough places? Competition with Umeå… 8

9. International lessons QA - Rural training is higher quality in every case – personalised and practical learning. Partnerships between small and larger hospitals address curriculum issues. Host Hospitals – Local doctors enthusiastic about becoming teachers. Many hospitals well equipped in medical and communications technology (and used to using it). Student Selection – works best if community involved in process, and students visit the community first. Student Costs – participating communities often cover costs of travel and accommodation. Social Satisfaction – students offered opportunities for sport, culture, volunteering… and students WANT this. Community Demand – Unis in Australia and Canada have developed proven process for community engagement and ensuring community participation in the program. 9

10. What could be done here? QA – Partnerships with regional hospitals (Lycksele, Kiruna etc). Oversight from Umeå - Umeå remains the ‘home base’ for students, allowing continuous monitoring. Borrow evaluation processes from Australia and Canada. Host Hospitals – Storuman (for example) has 3 qualified GP educators. Many sjukstuga equipped with distance bridging technologies. Rural hosts can form a network to share experience. Student Selection – participating communities can host student visits prior to selection. Community representative can help interview students. Student Costs – formal contract with Kommuns can secure housing (and internet and transport to Umeå) at no cost to student. Social Satisfaction – students can have a local ‘buddy’ from the community to help them get involved in community life (it works for my students!). Community Demand – Demonstrated in many communities here already who host student research and other visits. Community engagement process can be implemented here. 10

11. How GMC can help Offer advice on which pilot communities –Liaise with communities, run the engagement process Help train and mentor rural educators Assist with QA and evaluation – especially impacts on communities –And connect with our international partners Support other ‘rural exposure’ options like ‘training doctors for towns without doctors’ (research and community projects etc.) Be an advocate for rural training models in Sweden 11

12. Quick Summary ‘Rural training’ works to improve recruitment and retention (Canada, Australia, South Africa, USA…) Some evidence it already works in Sweden, even though we don’t do much of it It is not easy and it does not solve everything, so we need to research how to do it here in the context of other things we need to do A good opportunity to start moving forward with Umeå Uni pilot GMC is a critical part of the equation 12