Perceived inhibitors to rural practice among physiotherapy students ■ Reg Mitchell There is not a considerable body of literature on the need for allied health professionals in rural practice. Much of the relevant literature is principally in the form of unpublished reports and m anpow er studies conducted by various pro­ fessional organisations. Consequently, it is not in the public domain. In rural com m unities, allied health professionals may provide the sole source of patient m anagem ent, or their services m ay be com plem entary to that of other health professionals including m edical practitioners. Their profes­ sional decision m aking is autonom ous and they are legally accountable for their actions. Very little work has been done to determ ine the charac­ teristics of undergraduate students in health disciplines which make them m ore or less likely to enter rural practice. Australian and Am erican studies of medical students indi­ cate that students from a rural background are m ore likely to return to rural practice than are students who originate in the cities (Kam ien and Buttfield 1990, Knopke et al 1986, Rabinow itz 1988). Piterman and Silagy (1991) exam ined the attitudes of junior hospital doctors towards rural training and practice in Victoria. This study found that these respondents from a rural background were more likely to express an intention SA J o u r n a l P h y s io th e r a p y , V o l 5 3 N o 1 to train and practice in the country. The m ost im portant determ inants in choosing a rural training p ost w ere found to be perceived quality of ed u catio n /train in g facilities and the view of the practitioners' partners or spouses. The shortage in A ustralia of doctors in rural practice is also addressed by Silagy and P iterm an (1991). T hese authors reported that 87 per cent of their respondents ex­ pressed a desire to do their internships and postgraduate training in a m etropolitan hospital. A strong relationship was observed betw een a student's rural background and the student's subsequent intention to train and w ork in a rural area. Hanson et al (1990), in a study of 167 nurses in rural practice in the United States of Am erica, found that dem o­ graphic factors (age, education, salary, m arital status and num ber of dependents) were not strong predictors of reten­ tion in rural practice. N ursing autonom y was the most effective predictor of intention to rem ain in their current positions. H ealth professionals w orking in rural areas face handicaps like distance, deficient support services, profes­ sional isolation and lack o f continuing education opportu­ nities (Hanson et al 1990). A shortage of m edical practitioners entering rural prac­ tice has also been reported in N ew Zealand (Barnett 1991). This author reports a declining availability of general prac­ titioners in rural areas over a 16 year period. A sim ilar trend is also reported in studies conducted in the USA (Kirk 1991). Hodgson (1991) identified issues in rural health practice such as the need for m ore staff, better career and support structures, greater team work, developm ent of specific re­ sources, recognition of different m odes o f service delivery and the need for greater aw areness of the profession out­ side urban centres. M cA llister et al (1992) and Craig and M udge (1989) suggest that the shortage of rural health practitioners may be due to the urbanisation of under­ graduate health science program s and the predom inance of students from urban centres in these program s. The purpose of this report is to present the findings of a study which attem pted to identify perceived reasons which would or would not attract graduates in physiotherapy to rural practice. The study also exam ined changes in these reasons as students progressed through their course from the first to the final year. Method During the period O ctober 1992 to June 1994, a total of 607 self adm inistered questionnaires were distributed to undergraduate students in physiotherapy schools. Items in this instrum ent included student identification num ber (to facilitate follow up of students) and inform ation about both semester and perm anent hom e postcodes (to facilitate iden­ tification of students whose perm anent residence was in a rural location). In keeping with U niversity ethical require- F e b r u a r y 1997 P a g e 9 This descriptive study was undertaken to determine perceptions of undergraduate physiotherapy students which would make them more or less likely to enter rural practice. A total of 607 self-adm inistered ques­ tionnaires were distributed to undergraduates in The University of Syd­ ney and 546 com pleted docum ents were returned. Students perceived the major inhibitors as social (isolation from family, friends and partner) and recreational (lack of theatre, entertainm ent, etc). Influences which would attract graduates to rural practice were lifestyle (relaxed, less stressful, healthier), lower cost of living, seeing more of Australia and professional autonom y. Knowledge of these perceptions will enable educators, the profession and potential employers to develop and imple­ ment strategies that will negate the negative and re-enforce the positive perceptions. (Mitchell RA: Perceived inhibitors to rural practice among physiotherapy students. Australian Journal o f Physiotherapy 42:47-52) Key words: Career Choice; Rural Health; Social Environment; Stu­ dents, health occupations RA Mitchell MSc, MEd, PhD is a senior lecturer in the Department of Behavioural Sciences, Faculty of Health Sciences, The University of Sydney. Correspondence: Dr Reg A Mitchell, Departm ent of Behavioural Sci­ ences, Faculty of Health Sciences, The University of Sydney, PO Box 170, Lidcombe NSW 2141. This project was funded by the NSW Department of Health, Housing and Community S ervice s Rural H ealth S upport E ducation and T raining Program (RHSET). The SA Journal of Physiotherapy gratefully acknowledges the Australian Journal of Physiotherapy for permission to publish this article. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) merits, participation was voluntary and a guarantee of anonymity was given and m aintained. Included in the questionnaire were lists of reasons for and against entering rural practice. These lists were gener­ ated using a pilot group of 35 filial year physiotherapy students and five senior instructors in the faculty, asking them to respond to two open ended statements, viz: "G ive five reasons why you would not enter rural practice on graduating", and "G iv e five reasons why you would enter rural practice on graduating". All reasons generated from this process w ere incorporated into the final questionnaire. On the final protocol subjects were requested to respond to "In your case which of the follow ing would be reasons for you not entering rural practice on graduation? (You m ay tick m ore than one.)". A total of 19 specific reasons plus "O th e r" com prised the list of inhibitors (see Table 1). Each respondent's total num ber of reasons for not entering rural practice was obtained. It was assum ed that the higher this score, the less predisposed the respondent would be to enter rural practice. Subjects w ere also asked to respond to "In your case, which of the follow ing would be reasons for your entering rural practice after graduating? (You may tick m ore than one.)" There w ere 16 reasons plus "O th e r" to which the students m ight respond (see Table 2). A total score for each individual on this variable was generated by sum m ing the individual reasons for entering rural practice. This score was interpreted as a high score, indicating a positive atti­ tude and predisposition to entering rural practice. On return of the com pleted instrum ents, data were coded and entered into a Personal C om puter in 80 colum n form at. A ll analyses of the data were carried out using the Statistical Package for the Social Sciences (SPSS) PC soft­ ware. Responses to each of the for and against item s were coded as " 0 " for not identified and " 1 " if identified by the student. Reasons for and against rural practice for the total sam ple and by year were com puted for each item. U sing SPSS P C + total scores for reasons for and against were com puted by year and for the entire sample. U sing the t test statistic (in SPSS P C +), com parisons were m ade between urban and rural sourced students on their total mean scores for and against entering rural practice. The chi-square test was used to com pare responses across years on each of the individual for and against items. T a b le 2 . R e a s o n s f o r e n te r in g r u r a l p ra c tic e , p e r c e n ta g e b y y e a r REASON YEAR 1 2 3 4 TOTAL Relaxed lifestyle 70.2 65.5 64.9 59.4 66 Healthier lifestyle 52.9 56.9 70.3 66.2 60.1 No polluted air 57.7 60.3 64.9 58.1 69.7 See a bit more of Australia 54.8 51.7 54.1 59.5 55.7 Get away from city stresses 56.7 48.3 48.6 54.1 53.5 Professional independence 35.6 44.8 43.2 36.5 39.2 Cheaper rent/housinq 36.5 44.8 40.5 29.7 37.4 Like small towns 30.8 41.4 35.1 33.8 34.8 More able to save money 31.7 25.9 29.7 36.5 31.9 Member of a close community 26 27.6 27 32.4 28.6 No jobs in city 26.9 27.6 18.9 21.6 24.9 More respected member of community 15.4 15.5 18.9 21.6 18 Family lives in the country 22.1 27.6 10.8 0.0 16.2 Life more adventurous 17.3 8.6 13.5 20.3 16.2 Can "live o ff land" 14.4 17.2 13.5 16.2 15.8 Better pay 15.4 17.2 18.9 8.1 14.7 Other 7.7 13.8 13.5 12.2 11.4 Results A total of 607 questionnaires w ere distributed to ph ysio­ therapy students through the Behavioural Science sem inar groups. A total of 546 (90 per cent) com pleted question­ naires were returned. Of the com pleted surveys, 322 (59.0 per cent) were from students who originated in the city and 224 (41.0 per cent) from the country. T a b le 3 . S ig n if ic a n t r e a s o n s a c ro s s y e a r s f o r n o t e n te r in g r u r a l p ra c tic e REASON CHI-SQUARE VALUE Away from family/friends 10.45* Family house in city 9.78* No niqht life in country 8.14* Country life "too slow" 12.97** Uproolinq family/spouse 9.07* Lack of jobs in the country 10.77* Higher cost of living 14.55** * p < 0.05 ** p < 0.01 The percentages for each of the individual reasons, by year, for not entering rural practice is given in Table 1. The percentages of students selecting each reason for entering rural practice are given in Table 2. The reasons given in Tables 1 and 2 are presented in rank order from m ost to T a b le 1 . R e a s o n s f o r n o t e n te r in g r u r a l p r a c tic e , p e rc e n ta g e b y y e a r REASON YEAR 1 2 3 4 TOTAL Away from fam ily/friends 57.7 58.6 67.6 73 63.4 Family house in city 35.6 44.8 51.4 50 43.6 Varied employment in city 37.5 41.4 40.5 37.8 38.8 Lonq distances to travel 36.5 29.3 37.8 33.8 34.4 No niqht-life in the country 26.9 31 40.5 39.2 33 Lack of entertainment 28.8 29.3 27 33.8 30 Lack of professional contact 25 34.5 27 29.7 28.6 Do not know anyone in the country 28.8 36.2 29.7 25.7 29.7 Country life "loo slow" 17.3 15.5 24.3 31.1 21.6 Experience in city hospitals more hiqhly reqarded 20.2 20.7 18.9 20.3 20.1 Uprootinq family/spouse 13.5 17.2 21.6 25.7 18.7 Boyfriend/qirlfriend works in the city 15.4 20.7 16.2 18.9 18.7 Cannot keep pace with professional de­ velopment 13.5 20.7 16.2 16.2 16.1 Rural hospitals/clinics poorly equipped 12.5 17.2 16.2 17.6 15.4 Lack of jobs in country 18.3 10.3 8.1 8.1 12.5 Little promotion opportunity in country 7.7 6.9 10.8 13.5 9.5 Hiqher cost of living 4.8 6.9 10.8 16.2 9.2 Rural community "small minded" 8.7 6.9 8.1 9.5 8.4 Other 2.9 0.0 2.7 1.4 1.8 Too much responsibility in country 1.9 0.0 0.0 0.0 0.7 Percentage of respondents 38.1 21.2 13.6 27.1 B ta d s y 10 F e b r u a r ie 1997 SA T y d s k rif F is io te r a p ie , D e e 1 5 3 N o 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) least frequently selected by the total num ber of respon­ dents. A chi-square analysis was carried out on the response by year to each statem ent, in Table 1 and Table 2. Reasons for not entering rural practice which yielded significant chi- square values are given in Table 3. Only one reason for entering rural practice, i.e. "fam ily lives in the country", y ie ld e d a s i g n if i c a n t c h i- s q u a r e v a lu e , (X 2̂ = 39.08, p < 0.001). Finally, com parisons betw een urban and rural sourced students on their m ean scores for and against entering rural practice were analysed using student t tests. There was a significant difference ( t ^ ) = 8.97, p < 0.001) on the reasons against rural practice. Rural-sourced students had a signifi­ cantly low er m ean (x = 3.4, SD = 1.95) num ber of reasons for not entering rural practice than their urban-sourced peers (x = 5.3, SD = 2.81). W hile the source of the student does not appear to differentiate students on reasons for entering rural practice, those with a rural background iden­ tified fewer reasons against entering rural practice. Discussion Three of the top 10 ranked inhibitors (Table 1) related to social factors: aw ay from fam ily and friends; family house is iii the city; and does not know anyone in the country. There is little than can be done to replace family and friends. However, consideration m ight be given to providing the new graduate entering rural practice with some form of social support. A variety of m easures m ight be adopted, for example a local resid en t/h ealth professional could be des­ ignated a "b u d d y " to help in the new graduate's integration into their new com m unity. The buddy system m ight also reduce the anxiety associated with separation from family and friends. M em b ers of the lo cal com m u nity m ight "ad o p t" the new graduate or a regional physiotherapist m ight have, as part of their duties, responsibility for ensur­ ing the welfare of new ly arrived graduates. There were three profession-related reasons for not en­ tering rural practice ranked in the top 10 inhibitors. These reasons were: varied em ploym ent in the city; lack of p ro­ fessional contact in the country; and experience in a city hospital m ore highly regarded. Upon graduation, students may wish to focus their p ro­ fessional career on a particular speciality rather than work in a situation with m ore diverse calls on their skills. Speci­ ality physiotherapy units are extrem ely rare in rural insti­ tutions. A nother possible interpretation of this response m ight be that the students perceived that rural institutions, being relatively small, offer a limited range of clinical areas in which to work and therein consolidate their new ly ac­ quired skills. In large city institutions, students may believe that a new graduate is able to be rotated through a large num ber of diverse clinical specialties, thereby consolidat­ ing their clinical skills. A lthough there is no internship for the new physio­ therapy graduate, it is considered by m any in the profes­ sion that these graduates still require exposure to and practice in a wide variety of clinical areas. It is common practice in some large city hospitals to rotate the new graduate around a range of clinical areas. If the new gradu­ ate is to be attracted to rural practice, then undergraduate students need to be informed that there is a continuation of this in-service training in rural and urban placem ents. Ex­ posure to a total range of clinical areas for these graduates may be facilitated by exchanging the new graduate practis­ ing in a rural area with a new graduate practising in a large city hospital where the opportunity to rotate through a variety of clinical specialities is available. Such a practice would expose both groups of new graduates to rural and urban practice. The perception of undergraduate students that the more varied em ploym ent available in the city w ould be advan­ tageous may not necessarily b e related to their need to be exposed to a variety of clinical settings as early practitio­ ners. Som e may seek to specialise quite early in their careers and believe that opportunities to specialise are lim ited in rural institutions Lack of professional contact, ranked seventh, was per­ ceived to be an inhibitor to rural practice. Certainly, a physiotherapist entering practice in a sm all rural com m u­ nity may well be the sole practitioner in that com m unity. If this is the situation, there needs to be established and maintained a m eans whereby these practitioners are not professionally isolated. A variety of strategies m ight be em ployed to overcom e this professional isolation. These strategies m ight include regular visits by a regional coordi­ nator. Consideration m ight also be given to establishing an electronic facility such as Em ail, thereby enabling the prac­ titioner to m aintain professional contact and obtain profes­ sional support. Em ploying authorities, governm ents and professional associations should facilitate rural practitio­ ners' attendance at professional conferences and w ork­ shops. Rural practitioners m ight be provided with access to professional journals through a circulating m ail library. Issues related to rural practice m ight also be considered at designated sessions at professional conferences. Sim ilarly, rural practice issues m ight constitute either a regular sec­ tion or a special issue of professional journals. That experience in a city hospital is m ore highly re­ garded iii the profession m ay well be an incorrect percep­ tion am ong undergraduates. The near and new graduate physiotherapist needs to be assured that rural practice is of professional value and equal to urban practice. This assur­ ance would norm ally be given by both training institutions and em ploying authorities. It is possible that responses to this inhibitor were related to their perception of the limited range of clinical specialities available in som e rural towns. While long distance (ranked fifth in Table 1) is certainly true in centres rem ote from the coastal fringe, the availabil­ ity of adequate public transport betw een towns, regional centres, and the large cities needs to be assessed and pro­ moted to potential rural practitioners. W here a new gradu­ ate accepts a position in a town remote from the family hom e, consideration m ight be given to supporting the graduate, especially in the early years, with som e m eans of inexpensive com m unication with hom e and perhaps sub­ sidising an annual trip to the fam ily home. The other perceived major inhibitors to rural practice relate to recreational activities, lack of entertainm ent, and SA J o u r n a l P h y s io th e r a p y , V o l 5 3 N o 1 F e b r u a r y / 9 9 7 P a g e 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) country life being "to o slow ". If new graduates are to be attracted to rural practice there is a need to prom ote the special and unique recreational activities that are available in a rural com m unity. These activities m ight be promoted to final year students as benefits associated with entering rural practice and m ay thus contribute to attracting more new graduates to such practice. Differences across the years on reasons for not entering rural practice (Table 3) were obtained for seven of the 20 reasons listed in Table 1. Three of these reasons (uprooting fam ily /sp o u se, lack of jobs in country, and higher cost of living) w ere not ranked in the top 10 reasons against rural practice and are not considered to be differential inhibitors. O f the other four reasons, final year students gave the highest percentage and third year students the next highest percentage of yes responses to "aw ay from family and friends" and "coun try life too slow ". For the inhibitors "fam ily house in city " and "n o night life in country", third year students gave the highest percentage and final year students the next highest percentage of yes responses. It appears that for third or fourth year students, these particu­ lar inhibitors do differentiate them from students in more junior years The lifestyle offered in a rural com m unity predominated in the top 10 reasons for entering rural practice. The top five ranked reasons for entering rural practice were: relaxed lifestyle; healthier lifestyle; no pollution; see more of Aus­ tralia; and less stressful. These positive attributes of rural practice could be em ployed to prom ote rural practice to intending graduates. Those wishing to prom ote and attract students to rural practice should take advantage of these perceived attributes of rural practice. Students also perceived that the cost of living in the country is cheaper than in the city, and that they would be b etter able to save m on ey and o btain ch eap er h o u s­ in g /re n ta l accom m odation in the country. However, the general cost of living in a country town can be considerably higher than in the city. O ther positive attributes of rural life ranked by the stu­ dents were that they perceived com m unity structures as being positive attributes of rural practice. They stated that they liked sm all tow ns, and that they liked to be m em bers of a close com m unity. The only profession-related reason for entering rural practice was the perception of professional autonomy in rural practice. This parallels a sim ilar findings am ong nurses in the USA (H anson et al 1990). C om parisons across years in the top 10 ranked reasons indicated no differences in the proportions choosing rea­ sons for entering rural practice. It m ust be noted that the majority of respondents (38.1 per cent) were first year students who would have had only m inim al exposure to clinical practice in general, let alone a rural practicum . These students' perceptions of either rural or urban clinical practice may have been based on their own preconceptions and biases or on culturally communicated impressions and biases from their peers, students in higher years, or staff. W hat m ust be questioned is the validity of their responses to many of the questions asked. However naive the attitudes of first year students may be, if we are to actively prom ote rural practice in our training program s, the perceived positive attributes of rural practice should be reinforced as early as possible in the curriculum . Early identification of the perceived negative attributes of rural practice will allow teachers and curriculum designers to counter such attitudes. This paper does not address the specific content in the physiotherapy curriculum that m ay be influential in shap­ ing students' attitudes and perceptions towards rural prac­ tice during their four-year course. It is highly likely that such content, the specific nature of any clinical practicum and personalities of teachers and clinical supervisors will all have considerable influence on a student's attitudes to rural or urban practice. Further research on the effects of curriculum and instructors in influencing students' percep­ tions of rural practice is considered to be highly w orth­ while. Instructors should be aware of the extent to which they and the m aterial taught influences their students. It m ust also be noted that any quality curriculum is an evolving entity and that the curriculum and instructors will vary with time. Thus, for exam ple, second year students in 1993 m ight have had slightly different m aterial taught by different instructors than that presented to second year students in 1992 or 1994. This source of variability, albeit small, m ust be acknowledged as a further source of error in the present study. The students' perceptions of practice will be influenced cum ulatively as they proceed through their course. Differential influences in the course will, of necessity, yield differential perceptions. Students' perceptions of factors that w ould influence their selection of practice will be prem ised on inexperience. Even final year students have not entered the w orkforce and the students' perceptions are likely to reflect neither the realities of the workplace nor the attitudes of urban or rural practitioners. A potential follow -up to the present study might be to exam ine the perceptions of practitioners to­ ward rural practice and com pare these attitudes with the students' perceptions. Another related project m ight be to assess the im pact of clinical supervisors and clinical place­ m ents on students' perceptions of rural practice. The reasons given in Tables 1 and 2 were generated from a sam ple of fourth year students. It m ust be recognised that had these reasons been generated from students in other years, then a num ber of different reasons m ight have emerged. How ever, the lists in these two tables were not generated entirely from the stu dent base. Student re­ sponses were supplem ented by m aterial from senior staff within the Faculty and School. Reasons identified by in­ structors may not necessarily be those identified by, or pertinent to, students. The extent to which the perceptions discussed in this study do in reality influence students entering rural or urban practice could well be exam ined in a further study. New and recent graduates could be sam pled and studied as to the extent to which their perceptions as students influenced their choice of practice. Clearly, those wishing to attract new graduates to rural practice should accentuate and prom ote the positive attributes of rural practice. The negative aspects of rural practice, as perceived by under­ graduates and identified in this study, can be addressed Bladsy 12 Februorie 1997 SA Tydskrif Fisioterapie, Deel 53 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) and, if not entirely elim inated, prom otionally offset by the advantages. Further research should also be undertaken to examine the extent to which the p ositiv e/n eg ativ e perceptions of u nd ergrad uate stu dents becom e offset by the ad van ­ tages/d isad vantages of rural practice. In other words, to what extent do these perceptions influence the reality? Conclusion In sum m ary, the m ajor perceived inhibitors (ranked in the top 10) to undergraduates seeking positions in rural practice were social (away from fam ilies and friends; family lives in city; do not know anyone in country), physical (long distances to travel), recreational (no night life in the coun­ try; lack of entertainm ent; country life too slow), and pro­ fessional (varied em ploym ent in city; lack of professional contact; experience in city more highly regarded). In con­ trast, the top 10 reasons for entering rural practice could be generally described as being related to lifestyle. This descriptive study suggests that further research is needed to determ ine reasons why graduates do and do not enter rural practice, whether undergraduate perceptions outweigh the realities of professional practice, and the critical roles played by those who may be described as "significant others" during the students' undergraduate training. W hether the students' perceptions do or do not reflect the realities of rural practice those wishing to attract the new graduate to rural practice need to be aware of the perceived positive and negative characteristics held by stu­ dents. This know ledge will enable practices to be devel­ oped and im plem ented which will negate the negative perceptions and accentuate the positive perceptions. References D n m e tt J R (1 9 9 1 ): W h e r e h a v e all th e d o c to r s g o n e ? C h a n g e s in th e ' g e o g r a p h ic d is trib u tio n o f g e n e ra l p r a c titio n e r s in N e w Z e a la n d s in ce 1975. 1: R eg io n a l a n d u r b a n -r u r a l d iffe r e n c e s . N a v Z e a la n d M e d ic a l jo u r n a l 1 0 4 :3 1 4 -3 1 6 . C r a ig M a n d M u d g e P (1 9 8 9 ): T r a in in g fo r ru ra l p r a c t ic e - still in th e too h a rd b a s k e t? B ris b a n e : U n iv e r s ity o f Q u e e n s la n d . H a n so n C M , Je n k in s A S an d R y a n R C (1 9 9 0 ): F a c to r s re la te d to jo b s a tis fa c tio n an d a u to n o m y a s c o r r e la te s o f p o te n tia l jo b r e te n tio n for ru ra l n u rs es, jo u r n a l o f r u ra l h e a lth 6 :3 0 2 -3 1 6 . H o d g s o n L (1 9 9 1 ): R e p o r t to th e m e m b e r s h ip o f th e A u s tra lia n A s s o c ia tio n o f S p e e c h a n d H e a r in g o n th e N a tio n a l R u r a l H e a lth C o n fe r e n c e . A u s tr a lia n C o m m u n ic a tio n s Q u a r te r ly 2 :8 -9 . K a m ie n M a n d B u ttfie ld 1H (1 9 9 0 ): S o m e s o lu tio n s to th e s h o r ta g e o f g e n e ra l p ra c titio n e rs in ru ra l A u s tra lia . M e d ic a l jo u r n a l o f A u s tr a lia 1 5 3 :1 0 5 -1 0 7 . K irk K (1 9 9 1 ): R u ra l a re a s lo s in g a p p e a l fo r y o u n g d o c to r s . O h io M e d ic in e 8 7 :2 4 -2 7 . K n o p k e H I, N o rth r u p R S an d H a r tm a n JA (1 9 8 6 ): B io P re p . A p r e m e d ic a l p ro g ra m fo r ru ra l h ig h s c h o o l s tu d e n ts , jo u r n a l o f th e A m e r ic a n M ed ic a l A s s o c ia tio n 2 5 6 :2 5 4 8 -2 4 5 1 . M c A llis te r L, E a d ie P a n d H a y s R (1 9 9 2 ): P r o m o tin g r u ra l c a re er s . U n p u b ­ lish e d m a n u s c rip t. P ite rm a n L an d S ila g y C (1 9 9 1 ): H o s p ita l in t e r n s ' a n d r e s id e n ts ' p e r c e p ­ tio n s o f ru ra l tr a in in g an d p r a c t ic e in V ic to ria . M e d ic a l j o u r n a l o f A u s ­ tra lia 1 5 5 :6 3 0 -6 3 3 . R a b in o w itz H K (1 9 8 8 ): R e la tio n s h ip b e tw e e n U S m e d ic a l s c h o o l a d m is ­ sio n p o licy an d g r a d u a te s e n te r in g fa m ily p r a c tic e . F a m ily P r a c tic c 5 :1 4 2 -1 4 4 . S ila g y C an d P ite rm a n (1 9 9 1 ): T h e a ttitu d e s o f s e n io r m e d ic a l s tu d e n ts fro m tw o A u s tra lia n s c h o o ls to w a rd s ru ra l tr a in in g a n d p ra c tic e . 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