1. Rural temperament and character: A new perspective on retention of rural doctors Diann Eley The University of Queensland, Rural Clinical School, School of Medicine Louise Young The University of Queensland, School of Medicine Thomas R Przybeck Washington University, Department of Psychiatry, School of Medicine, St. Louis, MO USA

2. The rural doctor is an entity in itself but not well defined  Mostly anecdotal & narrative descriptions  Rural practice requires different skills & traits from urban counterparts  Temperament and Character Inventory (TCI)  Psychobiological model of personality Cloninger, Svrakic, Przbeck. Archives of General Psychiatry 1993; 50: 975-990. Study Aim To describe how individual profiles (levels & combinations) of temperament & character traits influence GPs who flourish or fail in rural medicine

3. Temperament Traits  mildly heritable,  developmentally stable,  emotion based &  not influenced by socio-cultural learning Four dimensions of Temperament  Novelty Seeking: NS (exploratory, impulsive, curious vs stoicism, frugality, regimented)  Harm Avoidance: HA (anxious, worrying, doubtful vs outgoing, confidence, vigour, risk taking)  Reward Dependence: RD (sentimental, warm, attached vs aloof, withdrawn, independent)  Persistence: PS (industrious, ambitious perfectionist vs indolent, modest)

4. Character Traits  a reflection of personal goals & values  are moderately influenced by socio-cultural learning  mature progressively throughout life Three dimensions of Character  Self Directedness: SD i.e. self-concept (responsible, reliable, long term goals vs blaming, ineffective, short term goals)  Cooperativeness: CO i.e. concept of relationships (empathic, constructive, vs critical, opportunistic)  Self-Transcendence: ST i.e. global concept (idealistic, humble vs practical, arrogant)

5. Methods  Two successive studies  Mixed method, cross sectional design - qualitative & quantitative methods Study 1: Exploratory/Pilot Study 1: Exploratory/Pilot - Purposive sampling, Rural GPs (n=13), 7- 40 years (mean = 23.1) experience in RRMA 5-7 practice in Central & Southern Queensland  All completed demographic questionnaire and TCI-R140 plus a semi- structured interview  Triangulation of data sources described the findings Study 2: Comparison of rural & urban GPs Study 2: Comparison of rural & urban GPs - Postal distribution of research materials to 286 rural GPs & 258 urban GPs Multivariate statistics compared the two groups & logistic regression predicted rural or urban practice from TCI dimensions

6. RESULTS Study 1: Pilot study of 13 rural GPs Study 2: Comparison of rural versus urban GP cohorts  Interview findings concur with the literature  CHARACTER: ALL docs highly self-directed (SD), cooperative (CO), & objective (ST)  TEMPERAMENT: ALL very caring & reward dependent (RD) & persistent (PS). But more variation in Harm Avoidance (HA) & Novelty Seeking (NS )  Longer serving GPs, intent on staying rural = lower HA & higher NS compared to shorter serving GPs intending to leave (p<.01)  Response rates: 42% (n=120) for rural & 36% (n=94) for urban GPs  Rural GPs = significantly lower HA & higher NS compared to urban GPs  NS & HA independently predictive of rural or urban membership (p<.01)

7. Implications for Recruitment  Differences detected were Novelty Seeking (NS) and Harm Avoidance (HA) – both temperament traits – more innate & not likely to change  These traits could be identifiable in persons regardless of prior life experience or educational exposure  Character traits are developmental & identification in established rural doctors may suggest areas for special training or counselling of students with an interest in rural practice  The higher curiosity level of a person high in NS might suggest that this is the impetus responsible for students/graduates to engage with rural medicine  The majority of medical students are not of rural origin with little or no knowledge of rural life. High levels of NS could be a contributing factor to ‘testing the unknown’ i.e. going bush!

8. Implications for Retention  Harm Avoidance (HA) has many adaptive advantages. A measure of anticipatory anxiety & the ability to tolerate uncertainty  Persons low in HA portray greater confidence when faced with uncertainty & optimism in situations that would worry most people  Rural GPs with low HA may be innately more suited to their environment & more likely to be retained for longer periods  Consider the rural GP as a unique entity - a mixture of both a primary care specialist who is also a proceduralist  Data imply that temperament levels of Reward Dependence (RD) [warm, dedicated, sociable] may vary  Levels of Novelty Seeking (NS) & Harm Avoidance (HA) may be most descriptive of individuals who cope in rural medicine

9. SUMMARY A starting point to establish a psychobiological profile for rural doctors This preliminary work may be the precursor to a new approach to the recruitment and retention of rural health professionals  Predicting students who may be best suited to a rural career  Provide medical schools with more information regarding counselling students for (or against) rural medicine  Inform policy associated with incentives & retention strategies for existing rural doctors, nurses & allied health professionals

10. This paper was compiled from the following citations: Eley D, Young L, Prysbeck T. Exploring the temperament and character traits of rural and urban doctors; implications for retention of the rural workforce. Journal of Rural Health (USA) In Press: Accepted 07 March 2008. Eley D, Young L, Shrapnel M. Rural temperament and character: A new perspective on recruitment and retention of rural doctors. Australian Journal of Rural Health 2008; 16, 12-22 Acknowledgements This research was supported by grants from the Australian Research Council and the Central and Southern Queensland Training Consortium Study Limitations  Cross sectional study – measuring variables at one point in time  Small sample size, from one state  Acknowledge the myriad of demographic, developmental & environmental factors that influence an individual’s life choices & psychological profile  Response rate – long questionnaire, rural focus, busy doctors

12. TRAITHigh ScorersLow Scorers HA - Harm Avoidance worrying & pessimistic fearful & doubtful shy, fatigable relaxed & optimistic bold & confident outgoing, vigorous NS – Novelty Seeking exploratory & curious impulsive, disorderly extravagant & enthusiastic indifferent, reflective frugal & detached orderly & regimented RD – Reward Dependence sentimental & warm dedicated & attached dependent practical & cold withdrawn & detached independent PS – Persistence industrious & diligent hard-working ambitious & overachiever perseverant & perfectionist inactive & indolent gives up easily modest & underachiever quitting & pragmatist Temperament Descriptors Taken from Cloninger et al, 1994

13. TRAITHigh ScorersLow Scorers SD – Self Directness responsible & reliable purposeful, self accepted resourceful & effective habits congruent with long term goals blaming & unreliable purposeless, self-striving inert & ineffective habits congruent with short term goals CO – Cooperativeness socially tolerant empathic, helpful compassionate & constructive ethical & principled socially intolerant critical, unhelpful revengeful & destructive opportunistic ST – Self Transcendence wise & patient creative & self-forgetful united with universe impatient unimaginative & self- conscious pride & lack of humility Taken from Cloninger et al, 1994 Character Descriptors

14. Queensland AUSTRALIA (a BIG place & a LONG way away)