Introduction: Much of regional Australia continues to face challenges in recruitment and retention of medical practitioners, despite the apparently successful rural medical education initiatives funded by the Commonwealth Government. International fee-paying (IFP) medical students are a significant component of Australian medical education, contributing additional income and more diverse learning environments for universities. Their contribution to the Australian medical workforce is harder to determine. After obtaining registration, IFP graduates may apply to remain in Australia as skilled migrants. Since 1999 there has been a 325% increase in the number of international medical students in Australia, with approximately 73% of IFP graduates remaining in Australia for at least some postgraduate training. Recognising the potential contribution of IFP students to the Tasmanian medical workforce, the authors sought better understanding of the career intentions and work locations of IFP graduates from the medical program in Tasmania, Australia, through two studies. Firstly, a quantitative study was conducted of the locations of all IFP graduates from the Tasmanian medical program, and then a qualitative study exploring graduating students' intentions and factors that contribute to their decisions about work location choices.

Methods: This was a cohort study of IFP students who graduated from the University of Tasmania School of Medicine over the period 2000-2015. Work locations for 2016 were mapped to a Modified Monash rurality classification. Semi-structured interviews were held with 15 final year IFP medical students, exploring career intentions and location preferences.

Results: There were 261 IFP graduates, 54.4% male. The most common country of origin was Malaysia (55.2%). In 2016, 189 (72.4 %) were working in Australia, 42 (16.1%) in Tasmania and 126 (66.7%) in areas categorised as Modified Monash 1. Recent graduates in postgraduate year 1/2 (71.3%) were more likely to be working in Tasmania but most left for specialty training. All 15 interview participants intended to remain in Australia for at least their intern year, although at enrolment only six had planned to remain. Factors influencing workplace location decisions were (1) 'professional': greater appeal of Australian medical workplaces, intention to pursue a speciality, and to complete this at an Australian metropolitan hospital; (2) 'social': proximity to family/partner or opportunity to meet a prospective partner, family obligations, positive rural experiences; and (3) 'location': direct travel access to family.

Conclusions: IFP graduates from the Tasmanian medical program make an important contribution to the Australian mainland metropolitan medical workforce, but play only a small role in workforce development for both Tasmania and the broader Australian rural and remote context. Most IFPs do not choose to work rurally. Rurally focused medical programs need to consider how they place IFP students to meet both the learning and career needs of IFP students and the goal of the rural medical programs in developing a rural workforce.