A Post-Fellowship Support Framework for Rural Doctors: the Queensland experience

Background International workforce shortages have prompted many initiatives to recruit, train and retain rural doctors, including Australia’s emerging National Rural Generalist Pathway. This project explored an important component of retention, rural doctors' post-Fellowship support needs, to develop and validate a post-Fellowship support framework. There has been considerable international attention on social accountability in medical education and how medical schools and other institutions can address the needs of the communities they serve. The recognition that rural and remote communities globally are underserved has prompted numerous educational approaches including rurally focused recruitment, selection, and training. Less attention has been paid to the support needs of rural doctors and how they can be retained in rural practice once recruited. Methods The project team reviewed international and Australian rural workforce and medical education literature and relevant policy documents to develop a set of guiding principles for a post-Fellowship support framework. This project utilised a mixed methods approach involving quantitative and qualitative methodologies. A range of rural doctors, administrators, and clinicians, working in primary and secondary care, across multiple rural locations in Queensland were invited to participate in interviews. Thematic analysis was undertaken. Results The interviews validated ten interconnected guiding principles which enabled development of a grounded, contextually relevant approach to post-Fellowship support. This framework provides a blueprint for a retention strategy aiming to build a strong, skilled, and sustainable medical workforce capable of meeting community needs. Conclusions The ten principles were designed in the real-world context of a mature Queensland Rural Generalist Pathway. Four themes emerged from the inductive thematic analysis: connecting primary and secondary care; valuing a rural career; supporting training and education; and valuing rural general practice. These themes will be used as a basis for engagement and consultation with rural stakeholders to develop appropriate retention and support strategies.


Introduction
Virtually every country worldwide is experiencing shortages of rural doctors and other health providers with consequent effects on service delivery and community health outcomes.The recognition of rural generalist doctors skilled in primary care, public health and advanced specialised care is one approach to addressing this global deficit.
In 2007, Queensland was the first Australian state to establish a Rural Generalist Pathway -an effective, sustainable training pathway leading to a vocationally registered career in Rural Generalist Medicine 1 .A Rural Generalist needs to be competent in a scope of practice able to meet the needs of their community which typically will have limited access to services available in larger centres and be influenced by geographic and demographic factors.The scope of practice is broad, providing medical services capable of responding to the health needs of an entire community, i.e., a 'generalist' scope of practice which integrates primary and secondary care 2 .The Queensland pathway is well-developed having produced a critical mass of 234 graduates who have achieved vocational recognition via College Fellowship.There are currently over 384 trainees, many filling critical vacancies in rural hospitals, i.e. providing a significant component of the clinical service whilst undertaking supervised training 3 .
In Queensland, the state government funds hospitals and primary care clinics in many rural locations while the Commonwealth supports private General Practitioners (GPs) through Medicare funding.Rural communities may have one or both models, with many Queensland rural doctors working in both sectors 3 .

National rural generalist pathway
Australia has a strong commitment to a national framework for rural generalism, the National Rural Generalist Pathway (NRGP), which will build a skilled workforce like the established program in Queensland 4 .While there are clear demographic differences between 'rural' and 'remote' communities the national pathway does not make this distinction, so the term 'rural' will be used throughout this paper.
Australia has two General Practice colleges, the Australian College of Rural and Remote Medicine (ACRRM) and the Royal Australian College of General Practitioners (RACGP), who collectively define a 'Rural Generalist' as: "a medical practitioner who is trained to meet the specific current and future health care needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care and required components of other medical specialist care in hospital and community settings as part of a rural health care team." The definition, the so-called Collingrove Agreement, enables a pathway supporting doctors to practise and live rurally and ensures they are supported to attain and maintain the advanced skills required to meet community need 4,5 .
In Australia, as in many other countries, GPs and rural doctors generally undertake formal postgraduate training and complete relevant summative assessments.In Australia, this training is a minimum 3 years for general practice and 4 years for rural medicine, and auspiced by the relevant Colleges who also administer barrier examinations.Completion of training and assessment confers Fellowship of the College and an ability to undertake independent, unsupervised, vocationally recognized practice.

Attracting and retaining rural doctors
Many workforce strategies focus on recruitment and retention via education and training.The high turnover of rural health professionals exacerbates workforce shortages, highlighting the critical importance of retention strategies 6 .A recent scoping review noted many more papers on recruitment compared with retention, observing that effective strategies were feasible in a range of settings but dependent on a national commitment to act 7 .These authors described the importance of the social accountability of medical schools in facilitating a sustainable rural and remote workforce.They cite the WHO definition of social accountability -'the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, the region or the nation they have a mandate to serve' -noting evidence to support rural focused recruitment and rural training including rural experiences.
A 2021 systematic review of 34 papers, all observational studies, concluded that policy makers would be 'prudent to strengthen rural training pathways and limit the use of strongly coercive interventions' 8 .This review found evidence that educational interventions including preferential selection of rural health professional students and distributed training in rural sites were associated with increased rural retention, as well as recruitment.They did note that 'strongly coercive interventions are associated with comparatively lower rural retention than interventions that involve less coercion.'A review of retention of GPs in remote Canada and Australia identified six synthesised findings: peer and professional support; organizational support; uniqueness of remote lifestyle and work; burnout and time off; personal family issues; and cultural and gender issues 9 .These authors observed their findings spanned a spectrum of policy domains and service responsibilities, arguing that 'a central coordinating body could well be placed to implement a multi factorial retention strategy.'Their study identified excess bureaucracy and lack of organisational support and resourcing as the key reasons for doctors leaving remote practice, with burnout, cultural and gender issues, and family issues also having an impact on retention.
Veitch and Battye noted in 2008 that, 'Retention is the successful outcome of recruitment when health professionals are recruited into rural practice and remain for extended periods.'They cite numerous studies which recognise that retention involves a different set of issues from recruitment, observing that 'decisions to take up rural practice (recruitment) are made outside of the contextual setting of rural practice, whereas decisions to remain (retention) occur within that setting and are based on experience there' 10 .
The same authors describe retention decisions as 'a dynamic equilibrium of positive and negative factors,' noting that the equilibrium can be upset by changes in workload and role changes.They further set out 26 factors that influence retention, grouped into the broad dimensions of security, freedom, and identity 10 .

Methods
This project explored an important component of retention, the post-Fellowship support needs of vocationally registered Queensland rural doctors.Two key workforce bodies, Queensland Country Practice (Queensland's Rural Generalist Coordination Unit), and Health Workforce Queensland (the state rural workforce agency), pooled their collective expertise in rural workforce using a Delphi method to define a set of Guiding Principles, tailored to the rural Queensland context (Table 1).
These guiding principles were used to develop a post-Fellowship support framework for Queensland rural doctors.This framework provides a blueprint for a retention strategy aiming to building a strong, sustainable, and skilled medical workforce capable of meeting community needs.This project aimed to validate and evaluate the interconnected guiding principles.Post-Fellowship rural doctors and registrars were asked to comment on the importance of each principle and to outline any further principles necessary to support rural generalists.These findings were used to inform the educational approach, development, and implementation of a bespoke support framework relevant to current and future rural generalists in both the private and public sectors.

Methods
Informed consent was provided by all participants.Verbal consent was sought (and audio-recorded) from those who participated in the interviews.Confidentiality was discussed, with an explanation that responses would be de-identified as appropriate.Participants who completed the online survey questions provided written consent.This project aimed to validate these guiding principles with Queensland stakeholders in the context of a mature Queensland Rural Generalist Pathway and an evolving National pathway.Interviews and an on-line survey (Qualtrics™) were used to develop themes which reflect the key areas of support that rural doctors identify as necessary to assist post-Fellowship doctors to practise in accordance with the Collingrove Agreement 5 .These themes will form the foundations used to design the post-Fellowship support framework.
A purposive sampling strategy was used with a variety of rural doctors invited to contribute in order to maximise the likelihood of contributions reflecting the diversity of rural doctors working across primary care, secondary care, and Aboriginal Medical Services (AMS).Participants included administrators (Directors of Medical Services) and clinicians (Rural Generalists and GPs).
The pilot project utilised a mixed methods approach using qualitative and quantitative methods.
The qualitative component, which is the focus of this paper, involved in-depth one-on-one semi-structured interviews by a doctor from the project team.An interview guide (see Extended data 11 ) was developed to: • Document career history.
• Ascribe a weighting for each of the proposed guiding principles used in developing a post-Fellowship support framework; and • Discuss awareness and understanding of the National Rural Generalist Pathway and the Collingrove definition.The questions were piloted with two experienced rural doctors.
A variety of rural locations were deliberately chosen for the project interviews: so-called 'Town A' (a single site) and 'Town B' (an amalgamation of six separate sites across Queensland).Town A was an exemplar site with recognised success in delivering innovative local services, excellent leadership, and integration of rural medical workforce across public and private sectors, hospital, and primary care.Various employment models were utilised resulting in high levels of retention and job satisfaction.
Town B was a 'virtual town' consisting of six locations with similar demographics to Town A, but with varying degrees of clinical leadership, staff stability, job satisfaction, and collaboration across sectors.Integrated models of care were less well developed with a relatively smaller number of doctors working across both primary and secondary care.The Town B sites were chosen to explore local inhibitory factors and to ensure geographic representation across Queensland.(Table 2) The Town A and Town B sites were selected on the basis of the project team's knowledge of local workforce supported by a desktop audit.A community profile developed for each site, included geographic factors, population demographics, Socio-Economic Indexes for Areas (SEIFA) 12 and a description of the current health workforce and services.

Participants
Participants were recruited by members of the project team in mid-2020 using the selection criteria described above (Table 2).Contact details were sourced from databases held by the project team.
A total of 31 doctors (15 female and 16 male) from Towns A and B were interviewed.In Town A, all clinically active doctors participated in the interview process.Three doctors (a private GP, a rural generalist, and a Director of Medical Services / medical administrator) from each of the six Town B sites were recruited.In addition, a GP working solely in an Aboriginal Medical Service was also interviewed.

Approach
Semi-structured interviews were conducted between August and October 2020 by two doctors (DD, JC) from the project team.Interviews were conducted face-to-face in person in Town A and via either telephone or videoconference using Microsoft Teams for Town B sites.Interviews generally lasted 60-90 minutes and were transcribed verbatim.Recordings were Interviewees were asked to describe their rural medical experience.Those with at least ten years' rural experience were asked to further comment on any changes to rural medical practice over this time.
The interviews went on to explore the draft guiding principles.Prompting questions were used to explore interviewees' perceptions of the key enabling and inhibiting factors associated with each principle.The interview included a facilitated discussion about the Collingrove definition and the National Rural Generalist Pathway: how well were these new initiatives understood; what impact did interviewees perceive on them and their communities; and what were the implications in designing and implementing a post-Fellowship support framework?
Rural practitioners on the Health Workforce Queensland database were asked to complete an online survey in order to rate each principle on a Likert scale regarding applicability in their workplace and provide further comments (see Extended data 11 ).The quantitative data from the 156 responses will be reported separately.An inductive thematic analysis approach was used to analyse qualitative data from the semi-structured interviews and online survey.This provided a systematic process to generate codes from the interview data, focusing on specific characteristics related to post-Fellowship support to develop patterns of meaning by producing and revising different themes 13 .

Ethics
This project qualified for the exemption review pathway 'Not Requiring Ethical Review' (Darling Downs Health Human Research Ethics Committee, February 22, 2022: EX/2022/ QTDD/81643) with collection of data not likely to adversely impact on participants' opportunity to contribute to the project aim.

Results
The 31 interviews conducted (12 in Town A and 19 in Town B) validated the ten interconnected guiding principles developed by the project team to underpin a post-Fellowship support framework for rural generalists.(Table 1) 14 .
Principle  15 .This has the effect of improving attraction and retention of a skilled workforce 16 and promotes quality and safety of patient care 17 .

Themes
Four main themes emerged from inductive thematic analysis of the qualitative data: Each of these overarching themes can be mapped to one or more of the Guiding Principles.Multiple subthemes also emerged, key factors impacting on and contributing to the associated themes (Table 3).
Theme 1: Connecting primary and secondary care Rural generalists need to work across primary and secondary care, with integration facilitated by cross-collaboration, streamlined credentialing processes and flexible employment models underpinned by effective medical leadership with strong trust and culture.
Theme 2: Valuing a rural career Rural doctors see their work as exciting, challenging, stimulating, and intellectually demanding and were very satisfied with opportunities to use their skills.However, they were concerned about access to schooling and employment opportunities for their partner.Personal factors and work-life balance are essential for job satisfaction and retention.

Discussion
The guiding principles developed by the project team and validated by the interviewees enabled development of a grounded, contextually relevant approach to post-Fellowship support framework for rural generalists working in other jurisdictions.
The principles were designed in the real-world context of a mature Queensland Rural Generalist Pathway and an evolving Australian National pathway, so are highly relevant to these jurisdictions and validated with relevant Queensland stakeholders.
These principles are inter-connected as indicated in the four overarching themes and would be incomplete when considered in isolation.The principles, whilst designed in the real-world context of a mature QRGP and evolving NRGP, encourage an ongoing conversation about the challenges and priorities identified by rural doctors.Engagement and consultation with rural stakeholders is needed as a next step to discuss and achieve consensus on the Coordination Unit support functions and governance.
While integrated training concepts are important, policy makers, health administrators and funders need to go further and ensure rural communities can access integrated and sustainable medical care via joined-up practice models.This will require future commitment and investment in innovative service and workforce design that includes support elements to enhance and retain Rural Generalists.
The implementation of the NRGP provides an opportunity to expand the coordination function beyond vocational training and support, as is currently the case in Queensland.
The next phase in a national roll-out could well involve coordination of rural generalist workforce models in order to develop and support approaches that will attract, retain, and sustain rural generalists capable of meeting community needs.
The four themes identified reflect the key areas of support which rural doctors felt were necessary to support post-Fellowship doctors to practise in accordance with the Collingrove Agreement.These themes are the foundations upon which the post-Fellowship support framework will be built with the aim of facilitating two specific retention strategies: • Supporting existing rural doctors in both primary and secondary care to attain the necessary skills and develop practice models aligned to the Collingrove Rural Generalist definition.This would enable national recognition as a Rural Generalist for those rural doctors who wished to do so.
• Establish a coordinated national approach that delivers a highly trained integrated medical workforce likely to remain in rural practice beyond Fellowship and who are capable of adjusting to emerging community changes, expectations, and evolving needs.

Importance of retention
These findings mirrored those from other studies that doctors currently working in rural communities intend to remain in those sites for several more years.This in turn strongly argues for further focused retention strategies to support the long-term commitment of rural doctors in both private and public sectors 18 .
Such approaches support Australia's well-established recruitment and training strategies.Rural Generalists also need to be able to acquire and maintain advanced skills at any stage in their career in order to develop a resilient and self-sustaining multi-skilled rural workforce able to meet local service gaps and address the broader challenges of rural generalist practice 18 .
One The National Rural Generalist Pathway can lead the development of a stronger and better-distributed rural medical workforce, as increasing the numbers of Rural Generalists would ensure more sustainable workloads and improve retention 5 .However, rural doctors should be aware of national developments like the Collingrove agreement and the NRGP for this to occur, and they further need access to the support required to navigate the pathway requirements.
The next phase of this project will progress the design and development of the post-Fellowship support framework and describe the quantitative survey findings.

Conclusion
The widespread international rural medical workforce shortage has consequent effects on service delivery in both primary and secondary care.Recruitment and retention strategies form the cornerstone of addressing these workforce shortages.
Increasing recognition of the differences between recruitment and retention has led to a growing appreciation of the different approaches needed for each.
This report presents ten guiding principles for the development of a support framework for rural generalists who have achieved Fellowship.The principles encourage an ongoing conversation about the priorities and challenges raised by rural doctors.
These real-world principles undertaken by two rural workforce organisations in Queensland, drawn from the local experience in the context of an evolving national pathway may well be relevant in other jurisdictions and would be worth exploring in other settings.
This Post Fellowship Support Framework was designed to support and sustain practice integration for rural doctors across primary and secondary service domains in their post graduate careers.The framework addresses domains that focus on procedural practice and advanced skills enabling doctors to provide comprehensive general practice, specialised care including emergency care in hospital and community settings.This project utilised a mixed methods approach to validate these guiding principles.

Introduction:
Provides excellent background on the Australian context and Rural Generalist Programme, as well as literature or recruitment and retention.

Methods
Is the Delphi project a part of the study being reported here?If so the methods and the results need to be reported in the appropriate section.That is table 1 should be in results and the Delphi method described in the methods.But I get the impression it is not and is work done prior to this study -in which case it needs to be referenced.
The study aim should be at the end of the introduction.In fact much of the early methods section would be better placed in the introduction.I appreciate that this is part of a larger study that may be mixed methods but the research presented here is a qualitative interview based study?
Results: I am unclear if the qualitative parts of the survey formed part of this study or not?If the survey is included then its results need to be presented in the results section and care taken to explain how the interview and survey results were integrated.A major omission from the results is the data -in a qualitative interview based study the data is normally presented as quotations.It is not possible to determine if the data and the findings are consistent. Discussion: The discussion could be improved by starting with a brief summary of the main findings (table 3 might be better in the results section), consideration of what new knowledge the study adds in relation to existing literature and then moving to policy implications.

Is the work clearly and accurately presented and does it cite the current literature? Partly
Is the study design appropriate and is the work technically sound?Partly

Are sufficient details of methods and analysis provided to allow replication by others? No
If applicable, is the statistical analysis and its interpretation appropriate?Not applicable

Have any limitations of the research been acknowledged? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Rural health research.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

James Rourke
Faculty of Medicine, Memorial University Newfoundland, St. John's, Newfoundland and Labrador, Canada This article addresses the issue of rural doctor retention with a framework for developing a postfellowship support program.Ten guiding principles were developed in a pilot project completed in 2021 in Queensland, Australia.The article provides a summary of the qualitative component of that project.31 rural doctors in various locations were interviewed and validated the guiding principles.A thematic analysis produced four main themes.As noted, this study was limited to one Australian state.However, the guidelines and themes are relevant to rural practice and will interest readers worldwide.A link is provided to the full pilot project report as the underlying data, which provides expanded interview input, including informative quotes from the rural doctors.The article could be made more interesting by including some of these quotes.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes

Have any limitations of the research been acknowledged? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Rural Medicine, Medical Education, Social Accountalbilty, I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.Reviewer Expertise: Rural health, rural obstetrics, rural workforce, screening in primary health care I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Table 1 . Guiding Principles for a Post-Fellowship Support Framework.
Principle 9The viability of existing rural general practice is enhanced Principle 10 Clinical leadership capability is recognised, enhanced, encouraged, and supported

Table 2 . Selection criteria for sites participating in the qualitative component of the pilot. Selection Criteria for Town A
1: Collaboration and coordination between primary and secondary care is vital It is critical for all sectors to work together across primary and secondary care and in the public and private sectors, particularly in rural communities.Collaborative care across the continuum provides holistic patient care and is an intended endpoint of the NRGP.Principle 2: Rurally based career paths are recognised and valued Many factors are involved in the choice of rural career.Understanding how these factors motivate and/or influence an individual is a vital component in developing attractive recruitment and retention strategies.Principle 3: Job satisfaction is a critical element in working in rural and remote areas Job satisfaction and the likelihood of retention are higher when employers and communities can appreciate and accommodate the personal and professional skills of rural generalists and support their aspirations.These principles are essential for any support framework.Principle 4: Support is provided to attain advanced skills in order to meet community needs While many rural doctors already demonstrate an extended scope of practice, there is currently no defined national approach to recognize and support the advanced skills of existing practitioners The evolving NRGP should provide a nationally recognised pathway for training the future workforce.National policy development is needed to understand the needs, potential barriers, and support requirements of currently practising rural practitioners who are aiming to meet the definitions laid out in the Collingrove Agreement.
Principle 5: The ability to attain, maintain and upgrade procedural skills in hospitals or general practice is supported to meet community needs Rural doctors utilise more procedural skills than their urban colleagues.Identifying, developing, and maintaining procedural skills is needed to ensure doctors remain safe and competent.While posing a challenge, this approach can enable development of appropriate solutions to deliver upskilling locally as an integral part of a support framework.Principle 8: Professional peer support is availableThe demands and professionally isolation of rural medicine have been well documented, as have the rewards and satisfaction.An effective support framework needs to facilitate connection of rural generalists with professional peer supports and key organizations.

Theme 4: Valuing Rural General Practice
important training focus should be on exploring opportunities to overcome challenges of completing advanced skill / procedural training in terms of the time constraints and the need for rural doctors to travel to larger sites.Strategies are needed which remove inequality in terms of access to or cost of continuing professional development activities, which will require cooperation between colleges, training institutions and jurisdictions.This project's findings indicate that both access to flexible training pathways and flexible funding solutions would be required for private rural GPs to practise in accordance with the Collingrove Agreement and meet the NRGP endpoint.
Considerable effort is already directed towards recruiting and training rural doctors.These principles may aid retention, ensuring rural doctors are, in the word of pioneering Australian rural doctor Col Owen, 'comfortable and contented,' as well as 'confident and competent' [Dr Col Owen, pers comm 2022].
• The online survey questions used in developing and validating the Post Fellowship Support Framework Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).