Medical students' rural practice intention: Academic performance matters

Many countries are driving forward policies and practices to train medical students for later rural practice. Previous research has investigated individual (e.g., rural upbringing) and structural factors (e.g., curricular exposure) associated with rural practice intention. However, the relationship between academic performance in medical school and rural practice intention has been neglected, although optimisation theory suggests there may be a relationship. To address this gap, our aim was to identify the relationship between academic performance and rural practice intention.Data were collected via a cross-sectional (self-report) survey in 2021. Participants were students from 60 of the 96 rural order directed (RODs) medical programmes across China. We asked students their rural practice intention. We conducted univariate analyses to test for associations between rural practice intention and independent variables, including socio-demographics, ROD location, grade year and academic performance measures. We used multilevel logistic regression models to test whether students' academic performance in medical school could be used to predict rural practice intention, holding the other factors constant.There were 13 123 respondents, representing roughly 77.6% of the student population from the 60 schools. There was a statistically significant relationship between student (self)-reported academic performance in medical school and rural practice intention. Higher performers had a lower likelihood (ORs: 0.65-0.78) of rural practice intention. This held across all performance measures (GPA rank, academic awards and student leadership) and for the sub-group with rural upbringing (ORs: 0.68-0.78).This is the first study to identify a relationship between medical school performance and rural practice intention. The findings suggest that students maximise their utility when choosing career options, with higher performers having lower rural practice intention. These data provide insight into the complexity of medical career decision making and can be used by medical school and workforce planners to inform rural training, recruitment and retention strategies.