Abstract
Introduction
The Australian Government continues to provide sustained investment in rural medical education. Despite this investment, rural and remote populations continue to experience health inequities, including persistent workforce shortages and limited access to health services. In response, Griffith University, in partnership with Rural Medical Education Australia, established the Longlook Rural Medical Program in 2010. Longlook is delivered through a Longitudinal Integrated Clerkship model and is designed as a socially accountable rural training program. This study examined academic performance, rural practice intentions, and workforce outcomes among Longlook graduates.
Methods
This descriptive observational study used cross sectional analysis of academic records, student survey data, and longitudinal workforce tracking for graduates from 2010–2023. Academic outcomes for Longlook graduates were compared with those of metropolitan-trained peers. Rural practice intentions were assessed using survey data from five consecutive cohorts between 2019 and 2023. Graduate practice locations and specialty choices were identified through the Australian Health Practitioner Regulation Agency register and classified using the Modified Monash Model.
Results
Of the 2,274 students graduating from Griffith University’s medical program between 2010–2023, 384 completed at least one year in the Longlook program. Longlook graduates demonstrated higher academic performance compared to their metropolitan peers (p=0.012) and showed a stronger intention to pursue rural practice (p<0.001). In 2024, 65% of graduates who completed the two-year Longlook were practising in rural areas. Additionally, 30% of graduates who undertook a one-year Longlook placement were practising rurally, while 32% of those completing a one-year Longlook placement in Year 3 followed by a 7-week rural General Practice block in Year 4, were also practising rurally. Among Longlook graduates who have completed specialty training and are practising in rural areas, 80% undertook general practice training, aligning with community needs for broad-scope practitioners.
Conclusion
The Griffith University Longlook program demonstrates educational excellence and sustained rural workforce participation among its graduates. The findings suggest that socially accountable, community-engaged approaches to medical education can be associated with strong educational outcomes and improved rural workforce participation. The program’s partnership model, involving collaboration between a public university and a locally governed nonprofit organisation, may contribute to the program’s implementation and community integration; however, further research is needed to determine the specific impact of this partnership structure on outcomes.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09998-8.
Keywords: Rural medical education, Longitudinal Integrated Clerkship (LIC), Public–nonprofit partnership, Rural workforce
Background
Medical education in rural settings, from student through to speciality fellowship, has been shown to foster careers in rural medicine [1–3], developing a medical workforce with the knowledge and interest needed to address the needs of rural communities [4]. Over the past two decades, successive Australian governments have continued to invest in rural medical education initiatives to address the issue of health workforce maldistribution [5]. Despite these efforts, notable disparities in healthcare access and outcomes remain between urban and rural Australians [6]. Whilst a key contributing factor to this disparity is the maldistribution of the health workforce, the issue is further compounded by the tangible mismatch between professional skills, competencies, clinical experience and expectations, and the actual needs of the communities they serve [7]. Limited collaboration between the health and education sectors, along with tenuous connections between educational institutions and the health systems that employ graduates, has created this gap between professional training and the practical demands of healthcare service delivery, particularly for rural and remote communities [7].
Symbiotic medical education proposes a model of curriculum delivery which aims to achieve social accountability [8]. Students are placed at the centre of four key axes: the clinical, institutional, social and personal, where they experience and understand the tensions between key stakeholders [9, 10]. The connectivity created by symbiosis facilitates a high-quality environment for education and the benefit to each axis is essential both for sustainable programs and retention of students in rural communities [9–12]. The Griffith University Longlook program was developed upon the principles of symbiotic clinical education and demonstrates an ongoing commitment to establishing and sustaining relationships across these axes to create a collaborative and mutually beneficial environment for rural medical education. The model was developed to align with calls for medical education programs to be socially accountable and responsive to health inequities in rural communities [13]. While previous studies have described the benefits of rural training programs and longitudinal integrated clerkships (LICs) [14–20], evidence linking community-embedded rural LIC models with both long-term academic outcomes and sustained rural workforce participation remains limited.
The Griffith University Longlook program
The Griffith University partnered with Rural Medical Education Australia (RuralMedEd) to develop and implement its rural medical program, Longlook, in 2010. RuralMedEd is a rurally located, community-governed, nonprofit organisation in health education. RuralMedEd aligned and translated Griffith University’s (the institution’s) curriculum to the rural context, with systematic curriculum mapping undertaken to ensure equivalence. Delivery of the program was implemented by RuralMedEd, drawing on its strong community links with clinical teaching hospitals and primary care facilities in rural Queensland. Faculty development and program evaluation were jointly performed by both organisations.
Longlook immerses students within rural communities during penultimate and final years of the Griffith University’s four-year postgraduate Doctor of Medicine (MD) program. Student placements are funded through the Australian Government’s Rural Health Multidisciplinary Training (RHMT) program [21]. The program offers at least 25 places each in Year 3 and Year 4 annually. Placements are open to all domestic students, who may opt to enrol in Longlook, with any remaining quota filled through a preferencing system.
In contrast to the Griffith University MD program delivered on the Gold Coast and Sunshine Coast, where students fulfil their clinical curriculum requirements through 6–7 week speciality block rotations, Longlook students cover the same core clinical disciplines concurrently through a LIC model over the course of a year. Students are based in a rural site, typically a rural hospital or general practice, and participate in the ongoing care of patients across multiple settings, including inpatient, outpatient, and community care. Clinical learning is structured around continuity of patient care, supervision, and curriculum, with students regularly following patients over time and across disciplines rather than rotating between specialties.
Clinical placement capacity is determined by each site’s level and range of clinical activity, reflecting the patient presentations available to students. This is mapped against curriculum requirements to ensure sufficient exposure across the core clinical disciplines and to determine appropriate student numbers at each site. As it is well established that LICs support the concurrent development of core clinical competencies across multiple disciplines, strategic rostering is used to ensure that all curriculum requirements are met. Regular review and consultation with local clinical educators allow any gaps in clinical exposure to be identified and addressed.
Supervision is primarily provided by local generalist clinicians, with most placements offering one-to-one supervisor to student ratios and additional academic oversight from the university. The longitudinal structure also enables program delivery in more remote communities than traditional rural block rotations [22] and rostering to be planned around local workforce capacity, helping to distribute supervision demands and minimise supervisor burnout [23]. Over time, Longlook training sites have expanded across rural Southern Queensland, ranging from large regional centres to very remote communities. Rurality is classified using the Modified Monash Model (MMM), an Australian classification system that categorises locations according to remoteness and population size, from MMM 1 for metropolitan areas to MMM 7 for very remote communities [24]. Longlook sites range from MMM 2 to MMM 7. The current Longlook health services network includes a regional referral centre, seven rural hospitals, two large private hospitals, private general practices, Aboriginal Community Controlled Health Organisations, and private specialist practices across the area demarcated in Fig. 1. The population size and activity levels of the public hospitals that have participated in the Longlook program are provided in the supplementary material.
Fig. 1.
Current footprint of the Griffith University Longlook program
A distinctive feature of the Longlook program is the governance and operational partnership between Griffith University and RuralMedEd. A jointly appointed Rural Sub Dean manages the year 3 and 4 clinical leads who implement the program through co-ordination with the locally based medical educators employed by RuralMedEd. These educators support student integration into local health services, and provide context-specific support such as accommodation, mentorship, and community engagement. Together, these elements align university curriculum and quality requirements with local service capacity and community priorities, while reflecting established principles for sustaining successful rural LICs [11, 12].
This study aims to examine three key outcomes of the Longlook program: academic performance, rural practice intentions, and graduate workforce trajectories. It also describes graduate specialty pathways, particularly whether Longlook training was associated with general practice-oriented careers and rural practice locations. By providing long-term follow-up data on graduates from a Australian rural LIC program, the study makes an important contribution to the evidence base on rural medical education and workforce development.
Methods
This descriptive observational study used a mixed cross-sectional and longitudinal design to evaluate educational and workforce outcomes associated with participation in the Longlook program. Three complementary data sources were integrated: (1) student survey data on rural practice intentions, (2) academic performance records, and (3) longitudinal workforce data obtained from national registration records. Ethics approval was obtained from the Griffith University Human Research Ethics Committee (GU 2019/490, 2020/076).
Study population and data sources
The study included Griffith University medical graduates from 2010 to 2023. For analyses comparing training pathways, participants were classified as “Longlook” (rural) if they completed at least one full academic year in the Longlook program, and “metropolitan” if all clinical training was undertaken in standard block rotations.
Student survey data were drawn from the Federation of Rural Australian Medical Educators (FRAME) annual survey, administered to all students undertaking rural clinical training [25]. The survey tool and data are accessible to all FRAME member institutions, which currently includes 19 Australian medical schools. The survey captures key domains relevant to rural medical education, including background characteristics, training experiences, and intended practice location at program entry and exit. Data from five consecutive cohorts (2019–2023) were included in this study. Rural practice intention was defined using standard FRAME categories and dichotomised as rural (MMM 2–7) or metropolitan (MMM 1). All respondents provided informed consent.
Academic performance was assessed using final university results, as these were the most consistently available measures across the study period. At the time of data extraction, final academic results data were available only for graduates from 2010 to 2022. These data were extracted from the Griffith University School of Medicine and Dentistry’s assessment database. Academic results were categorised into four achievement levels, consistent with the university’s grading standards. Categorised data were used to compare academic outcomes between Longlook and metropolitan training pathways.
Workforce outcomes were assessed longitudinally for graduates from 2010 to 2023, with up to 14 years of follow-up. Current practice location, internship location, and speciality information were obtained from the publicly accessible Australian Health Practitioner Regulation Agency (Ahpra) register and categorised according to MMM (rural: MMM 2–7; metropolitan: MMM 1).24 Current practice location was based on the principal place of practice recorded at the time of data extraction in 2024. Internship location was determined from the principal place of practice recorded at initial registration. Systematic extraction of internship location data by the study team commenced in 2014, and these data were available only for graduates from 2013 onwards. Postgraduate year (PGY) was defined as the number of years following graduation from medical school. PGY1 corresponded to the internship year, with each subsequent PGY representing the next year of postgraduate clinical training. Where possible, student data were individually matched to the corresponding Ahpra registration records. A waiver of consent was granted by the Griffith University Human Research Ethics Committee for the use of de-identified administrative and registry data.
Data analysis
Descriptive statistics were used to summarise participant characteristics, academic outcomes, and workforce distribution. Frequency distributions and 95% confidence intervals were calculated to illustrate the percentages of graduates practising in rural locations in 2024.
Comparisons between Longlook and metropolitan cohorts were conducted using chi-square tests for categorical variables, including rural practice intention, academic achievement categories, specialty choice, and practice location. These analyses were unadjusted and intended to identify associations rather than infer causality, given the observational design of the study. Trends over time were explored descriptively using stacked bar charts for the most recent four years. All statistical analyses were performed using IBM SPSS or Windows, Version 29.0.2.0 Armonk, NY: IBM Corp. For all statistical tests, a p value of < 0.05 was considered as significant.
Results
Academic outcomes and rural practice intentions of Longlook graduates
Longlook graduates achieved stronger academic outcomes than metropolitan peers, with a higher proportion receiving Distinction or High Distinction awards overall (Table 1). The distribution of academic grades differed significantly between the two groups (χ2 = 10.973, p = 0.012, Table 1), indicating a favourable academic advantage for Longlook students.
Table 1.
Comparative academic performance of graduates from Longlook vs. metropolitan program
| Academic achievement | Training | |
|---|---|---|
| Longlook (n = 346) | Metropolitan (n = 1719) |
|
| Pass | 32 (9.2%) | 251 (14.6%) |
| Credit | 113 (32.7%) | 605 (35.2%) |
| Distinction – Academic excellence award | 159 (46.0%) | 707 (41.1%) |
| High Distinction – Academic excellence award | 42 (12.1%) | 156 (9.1%) |
χ2 = 10.973, p = 0.012
Our data indicate a significant shift in preference toward practising in rural locations following completion of Longlook. At program entry, 34% of survey respondents preferred a rural practice location; this proportion increased to 61% at program exit (p < 0.001, Table 2).
Table 2.
Preferred practice locations of Longlook graduates from 2019–2023
| Preferred practice location | Program entry (n = 170) |
Program exit (n = 170) |
|---|---|---|
| Metropolitan (MMM 1) | 112 (65.8%) | 67 (39.4%) |
| Rural (MMM 2–7) | 58 (34.2%) | 103 (60.6%) |
χ2 = 23.890, p < 0.001 (Preferred practice location data were not available for 25 Longlook graduates who were invited to participate in the FRAME survey between 2019 and 2023)
Workforce outcomes of Longlook graduates
A total of 2,274 students graduated from the Griffith University MD program between 2010 and 2023; 384 of them completed at least one academic year in the Longlook program. Longterm workforce follow-up showed that rural practice was more common among Longlook graduates than among metropolitan-trained graduates (Fig. 2). Of the graduates who completed the two-year Longlook program, 65%were practising in rural locations in 2024. Among graduates who completed one year of Longlook, 30% were practising rurally, while 32% of those completing a one-year Longlook placement in Year 3, followed by a 7-week rural General Practice block in Year 4, were also practising rurally. Follow-up data were unavailable for 36 graduates (1.6%).
Fig. 2.
Association between rural training and practice
Figure 3 presents internship choices of Griffith University graduates. Longlook graduates were more likely than metropolitan graduates to accept a rural internship, although the proportion varied across cohorts (Fig. 3). In addition, across postgraduate years (PGY) 1–13, Longlook graduates consistently showed higher rural practice participation than metropolitan graduates during the four most recent follow-up years (2021–2024; Fig. 4). PGY1 corresponds to the internship year. PGY14 data were not included in Fig. 4 because the first Longlook cohort comprised only four students, and cohort-level reporting risked identifying individuals; these data are presented only in aggregated form.
Fig. 3.
Comparison of Longlook and metropolitan program graduates’ selection of a rural internship
Fig. 4.
Percentage practising in a rural location by postgraduate year (PGY); PGY1 corresponds to the internship year
Specialty career data were available for 90 Longlook graduates. Those who entered rural practice were significantly more likely to pursue general practice pathways (p = 0.02) (Table 3). Of the 40 Longlook graduates who chose a rural practice location, 80% (n = 32) pursued general practice training through the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM). Furthermore, 58% (29 of 50) of Longlook graduates entering metropolitan practice also pursued general practice training (Table 3).
Table 3.
Specialty career choices of Longlook graduates (n = 90)
| Specialty | Current practice location | ||
|---|---|---|---|
| Rural (n = 40) | Metropolitan (n = 50) | ||
| General Practice | 32 (35.6%) | 29 (32.2%) | |
| Australian College of Rural and Remote Medicine (ACRRM) | 10 (11.1%) | 1 (1.1%) | |
| Royal Australian College of General Practice (RACGP) | 22 (24.4%) | 28 (31.1%) | |
| Other Specialties | 8 (8.9%) | 21 (23.3%) | |
| Internal Medicine | 0 (0.0%) | 7 (7.8%) | |
| Surgery | 1 (1.1%) | 4 (4.4%) | |
| Pediatrics | 1 (1.1 %) | 1 (1.1%) | |
| Obstetrics and Gynecology | 0 (0.0%) | 1 (1.1%) | |
| Other | 6 (6.7 %) | 8 (8.9%) | |
χ2=4.924, p=0.026
Discussion
This study presents an analysis of the Longlook program, an Australian LIC uniquely structured as a public nonprofit partnership. The findings represent one of the most extensive follow-ups of a rural LIC program in Australia and demonstrate that graduates of the Griffith University Longlook program achieved educational excellence and substantially higher rates of rural workforce participation compared with their metropolitan-trained peers. Longlook graduates were more likely to achieve Distinction and High Distinction awards, showed a significant increase in rural practice intention at program completion, and notably, 65% of those who completed two years in the program were practising rurally at the time of analysis. Graduates practising rurally were also more likely to pursue general practice training pathways, aligning with rural community needs.
The academic benefits of LIC programs are well established with students performing equivalent or better than peers in traditional programs [19]. The superior academic performance of Longlook graduates in our study may reflect several pedagogical advantages inherent in the rural training model. The longitudinal integrated approach allows students to follow patients over time, providing deeper understanding of disease progression, treatment outcomes and the social determinants of health [26]. The closer mentoring relationships typical in rural settings, combined with increased clinical responsibility and autonomy, may further enhance clinical reasoning and professional development in the students [17].
Our study adds to evidence that well designed rural LIC programs, based on symbiosis and social accountability, have academic advantages over traditional metropolitan programs [27]. As a nonprofit organisation, RuralMedEd has been able to leverage additional public and private funding streams to develop and maintain an extensive network of purpose-built accommodation at rural training sites. This strategy has provided safe, high-quality housing at a subsidised rate, reducing financial and logistical barriers to rural training and directly addressing placement poverty [28]. The symbiosis also facilitates rural-based educators to be efficiently and effectively equipped with the systems, curriculum and support structures of a large university. Multidisciplinary teams, comprising educators from generalist medical and nursing backgrounds, deliver curriculum locally while holding fractional appointments within local health services. By embedding student education within local staff development and clinical practice, these arrangements have been able to create a genuinely collaborative model of teaching.
Longitudinal workforce tracking data demonstrate that the Longlook program is effective in translating training experiences into sustained long-term rural practice. Notably, 65% of graduates completing the two-year program were practising rurally at the time of analysis, exceeding rural retention rates reported in the literature [29–33]. This adds to the evidence that both the LIC structure and the length of rural exposure are important factors in retaining graduates in rural practice [34]. Longlook provides additional opportunities for students unable to commit to a two-year placement to access multi-year rural exposure. The strong retention rates observed among students completing a one-year LIC combined with a rural GP block provide further evidence to support the importance of extended, structured rural exposure [30]. These findings suggest that multi-year rural pathways may represent an effective design principle for workforce retention [2, 34, 35].
Preference for rural practice was observed in the early career stages of Longlook graduates. This trend demonstrated higher intention to practice rurally at program completion and higher rates of rural internship uptake compared with metropolitan-trained peers. Although some fluctuation across postgraduate years was observed, rural practice rates increased again in the later postgraduate years (e.g., PGY 11–13). This interest in rural practice may reflect shifts in personal or professional priorities that favour a return to rural practice after completing postgraduate training in metropolitan hospitals [36, 37]. The findings suggest that positive attitudes towards rural practice developed during the Longlook program persist throughout early to mid-career stages among doctors and appear resistant to factors which might otherwise promote a return to metropolitan practice [38, 39].
The alignment between graduate specialty choice and community need further reflects the program’s social accountability vision of addressing the health needs of rural communities. Longlook graduates practising rurally were significantly more likely to pursue general practice training through RACGP or ACRRM pathways. This is consistent with other rural LIC findings and strengthens the argument that rural immersion-based models can influence not only geographic location but also scope of practice [34].
The substantially higher rural retention rates observed in this study may reflect the partnership’s locally governed, community-embedded structure and its deliberate investment in connectivity [11]. Previous literature highlights the importance of immersion, community integration and institutional support in influencing rural workforce outcomes [29–33]. The Longlook model extends this evidence by demonstrating how a public-nonprofit governance structure can operationalise these principles, potentially strengthening both student experience and long-term rural workforce retention. Investment in high quality student accommodation, mentorship and community engagement promotes connectivity which is the central theme of successful and sustainable rural LICs [11, 12]. Careful recruitment of locally embedded educators and staff further reinforces this connectivity, with educators functioning as community brokers who facilitate connections within local clinical and social networks [40]. These structural and relational features help explain the sustained rural retention and general practice career choices observed among our Longlook graduates. However, the partnership model and community-embedded structure of Longlook were not directly evaluated in this study. Future studies should examine these mechanisms directly, including how governance, educator continuity, and student support influence graduate outcomes.
Our findings contribute to ongoing discussions regarding the optimal design of rural medical education pathways. While increasing rural placement numbers remains important, this study suggests that infrastructure, faculty development and governance arrangements that support connectivity and sustained immersion may also play a critical role in workforce retention. Building on 15 years of program experience, Griffith University’s planned end-to-end Rural Residential Medical Program based in its regional hub in Toowoomba represents a progression of this model, integrating pre-clinical and clinical training within a rural context. This next phase extends the program’s commitment to sustained rural immersion and offers a setting in which the impact of comprehensive rural training on workforce outcomes can be evaluated over time.
This study has several limitations that should be considered when interpreting these findings. First, the observational design limits the ability to draw causal inferences about program effects. While associations were observed between participation in Longlook and academic and workforce outcomes, it cannot be determined whether these outcomes are directly attributable to the program itself or to pre-existing characteristics of students who chose Longlook. Selection bias is another consideration, participation in Longlook is voluntary, and students who elect to undertake extended rural placements may already possess stronger rural intentions and attributes associated with academic performance and rural career choice. Pre-clinical progression through the program is non-graded, therefore, academic achievement at entry to Longlook was not considered in data analysis, which limits our ability to control for baseline academic differences between rural and metropolitan cohorts. A further limitation was that academic performance was assessed using final university grades, which capture only one dimension of achievement. Other indicators, including standardised examinations, workplace-based assessments, and measures of clinical competence, were not consistently available across the study cohorts. In addition, the analyses were unadjusted and based on bivariate comparisons, so potential confounding from factors such as rural background, prior rural interest, and demographic characteristics cannot be excluded. We also did not report effect sizes or confidence intervals for all comparisons, which limits assessment of the magnitude and precision of observed associations.
We obtained the workforce location data from the Ahpra register which reflects primary practice location at a single point in time. These data may not capture multiple concurrent practice locations, short-term rural locum work, or changes in practice over time, potentially underestimating graduates’ broader contributions to rural health services. Our analysis classified practice locations according to rurality categories and did not examine whether graduates returned to their original training locations, limiting our ability to assess the place-based model. In addition, specialty outcome data were available for only a subset of graduates as many are still progressing through specialty training. Their current practice locations may therefore reflect temporary training placements rather than longer-term career destinations, limiting the interpretation of rural workforce outcomes for these cohorts, as well as statistical power and strength of conclusions about specialty choice pathways. Although additional subgroup analyses may have further clarified some findings, small cell sizes in several categories limited statistical power and interpretability; therefore, further post hoc testing was not undertaken. The focus of our study was the impact of rural training on workforce retention within a single medical school and a specific public-nonprofit partnership model, however, changes in career intention and practice location are subject to a range of influences in addition to training [41]. Future research incorporating prospective designs, multiple data sources and broader program comparisons would help address these limitations.
Conclusion
The Griffith University Longlook program demonstrates that a longitudinal integrated clerkship delivered through a public-nonprofit partnership model can support rural workforce development alongside strong educational outcomes. Graduates who undertook longitudinal rural training, particularly over two years, were more likely to practise in rural locations and to pursue general practice careers, aligned with rural workforce needs.
The program’s public-nonprofit partnership model, which enables local governance, continuity of educators, and investment in student support and infrastructure, may have contributed to the observed outcomes; however, these mechanisms were not directly evaluated in this study. Further research using adjusted analyses and designs that explicitly evaluate program components is needed to better understand the drivers of these associations and the role of partnership-based models in rural workforce development.
Supplementary Information
Acknowledgements
The authors acknowledge Dr Sherrilyn Walters for developing the map used in Figure 1.
Authors’ contributions
All authors were involved in the study concept and design. JP collected and analysed data, developed figures and tables and prepared the first draft of the manuscript. All authors contributed to revising the draft and approved the final version for submission.
Funding
A portion of the time of JP, RH, KB and BC during the study period was funded by the Australian Government Rural Health Multidisciplinary Training (RHMT) Program.
Data availability
The data generated and analysed during this study are not publicly available due to the confidential nature of student academic records. Data in an aggregated form are however available from the authors upon reasonable request and with permission of Griffith University, Australia.
Declarations
Ethics approval and consent to participate
The study complied with the ethical standards of the 1964 Declaration of Helsinki and received ethics approval from the Griffith University Human Research Ethics Committee (GU 2019/490, 2020/076). Informed consent was obtained from all students participating in the survey. A waiver of consent was approved by the Griffith University Human Research Ethics Committee to obtain academic and public registry data for its graduating cohorts from 2010 to 2023.
Consent for publication
Not applicable.
Competing interest
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data generated and analysed during this study are not publicly available due to the confidential nature of student academic records. Data in an aggregated form are however available from the authors upon reasonable request and with permission of Griffith University, Australia.