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13 Nov 2019

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA   

The immense success of the Queensland rural generalist program is noteworthy, particular given its humble and hopeful genesis. People will hopefully be aware that around a decade ago this specific training program commenced, funded by the Queensland Government, that produced rural GPs who have progressively permeated throughout regional/rural Queensland.

Many of the previously mooted disjointed role substitution models and other stresses within the profession relate to attempted compensation for the maldistribution of doctors i.e. they are borne from workforce inadequacies. It is therefore critical we solve this problem. Not only will a more balanced workforce help our patients and improve health outcomes, it can also facilitate doctors to evolve models of care that increase the resilience of the profession.

It is useful to examine why the rural generalist training program in Queensland has been so successful. Of course it is a good program that inherently held appeal for junior doctors. From all reports, the trainees hugely enjoy it. Crucially however, there was a fundamental recognition that rural medicine and hospitals work differently compared to metropolitan or large regional sectors, and that systems and remuneration need to reflect this.

The appointment and work of rural GPs in hospitals is easy and the remuneration for this work is equivalent to senior medical officer salary for any specialist working in a metropolitan hospital. On-call arrangements were appropriate and remunerated to a degree. Doctors have vibrant private practices in their communities that is operated synergistically with their public hospital work. In other words, the industrial and work conditions were good. These important members of our profession in rural and regional communities were appropriately recognised and reasonably rewarded.

I’ve heard it said that this program is not applicable to other States and Territories – though it does appear very close to what Professor Paul Worley has suggested as a national approach. Even if this tension is true, there must be several useful foundation components that can be purloined by other jurisdictions. There will be a cost, but without appropriate investment we’re not going to solve the crippling maldistribution problem. Use Queensland as an example or work from the National Rural Generalist Training Pathway document. Either way, there is an urgent need to get cracking with it, especially given the $65million already set aside to start this process.

Having a good training program is one thing, but how do we allow medical students and junior doctors to have sufficiently sustained, positive exposure to rural practice to enthuse them towards non-urban practice? I have long believed we need to create centres of excellence at the centre of care pathways in regional areas to share the burden of hospital-based training and provide augmented regional infrastructure to attract and retain staff that can support training and research.

There is also no doubt (and a large body of evidence that states the obvious) enduring, positive mentorship and sufficient longitudinal practical exposure/work experience to rural medicine do change career choices of pre-vocational doctors (e.g. Stagg P et al Rural Remote Health 2012; 12). This clearly does not occur to the extent it should. It is not just in rural general practice that the evidence exists. For example, 91 per cent of infectious diseases trainees indicated they felt mentorship was influential on career choice (Bonura EM et al, Clin Infect Dis 2016; 63(2)).

The same is true in psychiatry, with acknowledgement that there is a larger stigma hurdle to overcome. I still recall my time as a psychiatry resident with horror, but now look wistfully at my psychiatry colleagues who have unassailable job security, reasonable income and an enviable work-life balance. This rumination is not trivial because there is intuitive evidence that balance between work, family and lifestyle is (most) important in career choices (Grigg M et al, ANZ J Surg 2014; 84(9)).  Psychiatry and general practice tick these boxes, but junior doctors and medical students seem less aware of this than they should. There is scope here for positive reform that will cost little.

There is helpful evidence that indicates exposure for more than a year is required to change career choice towards rural practice and that interestingly, this exposure should be mixed between regional hospitals and rural general practice, rather than exclusively in either location (O’Sullivan B et al Med Educ 2018; 52(8)). The effect of having a rural background and rural clinical experience is also additive (Kwan MMS et al, PLOS One 2017; 12(7)). 

Only 13 per cent of a recent cohort of UK graduates ranked general practice as their first-choice career despite having a generally realistic and positive view about the specialty (Chellappah M London J Prim Care 2014; 6(6)). I would have thought the reason behind this was at least partially obvious as debt and anticipated income are important considerations which shape career choice of junior doctors (Grayson MS et al Med Educ 2012; 46(10)). The chronic, enervating under-funding of general practice for many years now is abundantly obvious to all and Government cannot be surprised that young doctors, often with partners/families, expensive future training pathways and HECS debts, are worried about future income. Rather than trying to conscript doctors into regional/rural areas by whatever means, simply funding general practice, and rural practice in particular (for all doctors) is absolutely required to repair the maldistribution of workforce.

Reflecting on the above evidence it is clear medical schools’ curricula should echo this evidence and hospitals/policy makers need to take heed. There is a sense of partial understanding, but still much room for improvement.

The Rural Health Multidisciplinary Training program provides funding support to medical schools that encourage recruitment and retention of rural and remote doctors. RHMT program targets include a requirement for at least 50 per cent of medical CSPs to complete a minimum four consecutive weeks rural clinical training in Australian Statistical Geography Standard-Remoteness Areas-RA (ASGS-RA) 2-5 locations despite knowing this short period of time does not change career choices.

By contrast, only at least 25 per cent are to complete a minimum 12 months rural clinical training in ASGS-RA 2-5 locations – a group must more likely to remain in rural practice. Universities also agree that 25 per cent of their medical enrolments will be drawn from a rural background.  In the most recent Medical Schools Outcome Database (MSOD) National Data Report 2019 we find only 22.2 per cent of students have a rural background – which is reduced from the last few years.

In examining the preferred location for future practice among those students from a rural background, it is sobering to note the system seem to have managed to dissuade significant proportion of them against small community/rural practice as follows:

Capital city 31.3 per cent; major urban centre 21.3 per cent; regional city or town 32.1 per cent; smaller town 10.4 per cent; small community 4.9 per cent.

This data indicates we are far from reaching an appropriate experiential and mentoring experience for our students and junior doctors to promote general and rural practice. Universities need to be less concerned with increasing full-fee-paying students who are significantly more likely to choose urban practice (Hays RB et al, MJA 2015; 202(1)) and more concerned with investing in rural training mentorship and pathways that then articulate with rural pre-vocational and vocational training opportunities. This is a clear example of where regulation is needed to constrain the self-interested behaviour of Universities that is significantly exacerbating workforce stressors. Hopefully the much-touted medical force strategy will address these opportunities. The myopic, faintly sardonic assertion that doctor behaviour is to blame for workforce imbalance causes a frustrating loss of focus on true reform opportunities that will make a genuine difference.


Published: 13 Nov 2019