This is the first national study of RCS students that has specifically evaluated the association between sex and intention for future rural practice. In univariate analysis, female sex was significantly associated with rural intent. Females also had a higher preference for GP training, which is reported to be associated with future rural practice.(29) At this level of analysis, female students were also more likely than males to identify their RCS experience as a factor that increased rural interest. However, when all factors were taken into account concurrently in the multivariate model, sex did not retain significance as a predictor of rural intent. This finding corroborates the incidental reports of numerous smaller, single-centre studies that examined rural intention(26, 28) and work(14, 17, 20, 27, 28, 30) but did not principally investigate the effect of gender.
The validity of our multivariate model is further endorsed by our confirmation of factors already known to be associated with rural intention: older age,(14) rural background,(15) RCS as first preference,(19) GP intention on entry(21) and increased interest in pursuing a rural career(21)) were all significant to rural intent in our analyses, suggesting that the lack of association we identified between sex and rural intention is a real and strong finding from this national-level analysis.
Another study using results from the FRAME survey has indirectly supported the validity of our model. Isaac et al used six questions of the FRAME study that measured self-efficacy to construct a self-efficacy variable, which was demonstrated to be significantly associated with rural intent.(21) In our model using more recent data, four of these self-efficacy variables were similarly associated with rural inclination. It is reassuring that in our cohort, students who had strong positive feelings towards rural work, concurrently disagreed that they experienced anxious feelings towards rural work. These positive students additionally said they identified with others who took up rural practice. They also reported that they received affirmation from others to pursue rural practice. They were more likely than their other peers to indicate preference for future rural work. For these students, their constellation of character traits may respond to the challenges surrounding rural work as a positive incentive, spurring them on to a rural career. A similar pattern of increased resilience as a character trait has been identified among the subgroup of general practice registrars who went on to rural work.(31)
When translated to real-world outcomes, the results from this study are encouraging as they stand in contrast with the historically diminutive numbers of female medical practitioners in the rural workforce. (32) When added to the recent demographic shift in medical school towards a female majority,(18-21, 33), the fact that both female and male students are indistinguishably interested in rural work is a reassuring finding, suggesting that sex-based equity is achievable. It must be noted that female practitioners tend to work fewer hours than their male counterparts,(9) and thus greater numbers are needed to actually achieve equity. Gender equity has positive implications for health outcomes, especially for female-specific medicine, (11) and mental health issues, given that female doctors’ consults are generally longer in duration(34) and more holistic in their approach(35) with a greater emphasis on psychosocial issues,(36) possibly identifying issues that shorter consults would not pick up.
Another reassuring finding is the lack of a significant difference between male and female students in their perception of overall support provided by RCS, positive impact of RCS on their wellbeing, and quality of clinical education received whilst on RCS. This demonstrates that from a pedagogical and a support perspective, the RCS experience appears to be equitable across the sexes. This stands in contrast to the findings of a qualitative study investigating medical student perceptions of rural work two decades ago, where female students reported that they felt intimidated about the difficulty of rural practice and the male-dominated culture.(37)
An area for further investigation would be to determine the reason for the shift towards gender equity. Walters et al have suggested(19) that the high number of female clinical academics in RCSs, as demonstrated by Playford et al,  may serve as positive role models for rural work to their female students. The authors speculate the shift may also be due in part to the downstream effects of the gradual feminisation of medicine,(38) evidenced in the shift towards more females in medical school(18-21) and general practice.(39)
The present study is limited by the fact that we only looked at RCS students, without a non-RCS control. Thus, these findings may not be representative of the medical school cohort as a whole, especially given the intentional differences between the two student groups.(15) Indeed, a relative minority of urban-origin graduates are found in the rural workforce.(15) However, it must be noted that RCS participation is a key factor associated with future rural work, and we can thus validly use RCS data as we have, to infer downstream workforce effects.(14) Another limitation of the study is that intention has been used as a proxy for future medical work, instead of using actual work location. However, intention has been demonstrated as a predictor for future rural work,(40, 41) and graduate tracking studies for individual universities have also shown gender equity in rural recruitment from RCS. Thus, our data suggest that a pan-Australian, longitudinal investigation of both urban and RCS students would be likely to arrive at similar conclusions.
The role of RCSs has been consistently recognised as a substantial contributor to increasing the number of doctors in the rural workforce. By establishing that there is no significant difference in rural intent between male and female students, our study has also importantly demonstrated that RCSs will also contribute to overcoming existing sex-based inequity in the rural workforce. Reassuringly, this study also demonstrates that RCSs are perceived as being equitable in their provision of learning and support to both male and female students.