Rural health – isn’t it time we brought in the specialists?
BY DR KATHERINE KEARNEY, CO-CHAIR AMA COUNCIL OF DOCTORS IN TRAINING
It’s been a welcome change to see rural health, and the rural health workforce, front and centre of the national policy debate of late. Sadly, while the acting Prime Minister’s advocacy has been well meaning, it demonstrates a lack of understanding of the medical workforce and the medical training pathway.
Undoubtedly, there is massive maldistribution between metropolitan and rural areas for all facets of the medical workforce, including both general practitioners and specialists. The Medical Practitioners Workforce Report from 2015 states that in metropolitan areas, there were 442 FTE (generalists + specialists) per 100,000 population, in stark contrast to 263 FTE per 100,000 population in remote areas. Interestingly, the supply of general practitioners in these areas is 136 FTE per 100,000 population, greater than the national average of 112 FTE. What this demonstrates is that our remote workforce is driven by a generalist model of care and, to this end, it is heartening to see a commitment to a rural generalist pathway by both the accreditation bodies for general practice, as well as from the Federal Government.
This will aim to improve the quality of care delivered in remote areas and the numbers of GPs in regional areas as well. This is the type of pathway that will actively increase the numbers of qualified medical practitioners in remote locations – more medical schools will simply dump more interns and residents, without the ability to practise individually, into a saturated training market without foreseeable exits that have any direct pathway to rural practice.
What this will not change is specialists practising rurally and regionally, and therefore access to specialist care. The specialist workforce changes substantially outside metropolitan areas – the FTE per 100,000 population halves from metropolitan areas to inner regional, drops further to outer regional and are extremely scarce in remote areas. Regional areas see both more complex patients with multiple comorbidities - higher levels of smoking, obesity, being sedentary, using alcohol excessively and high blood pressure relative to their city counterparts (Australia’s Health 2016, AIHW). Mortality is 1.2-1.4 times higher outside of the city, and the most common cause of death is coronary artery disease.
On a broader scale, this speaks to the need for GPs skilled in population health and preventive care, but what about those who are sick now? We need specialist training programs to deliver skilled medical practitioners – cardiologists, lung physicians, endocrinologists, gastroenterologists, surgeons of all descriptions – in the right practice settings to deliver care where and how it’s needed. Primary percutaneous coronary intervention for heart attacks has been the accepted gold standard treatment since the 1990s – every regional setting needs access to 24/7 cath lab services. Cancer services being delivered close enough to home that patients don’t have to choose between moving or treating their cancer. Haemodialysis availability and delivery of nephrology care for the same reasons. No one should have to choose between living in regional Australia and the best health care our system can deliver.
Regional specialist trainee pathways have been buzzwords for years. There are rotations – in my cardiology training program we spend four months rurally, as do many other programs – but there aren’t entire pathways. You can’t spend internship and residency rurally, without having to come back to the city for most or all of your basic and advanced training. There’s certainly no surety for your family or spouse to plan lives, careers and schools, and good luck to you if you both happen to be medical (which surely would be the dream for most regional or rural towns!) and want to work close enough together to live together. It can be done – but it needs to be substantially easier than it currently is. The time is ripe for all Colleges to pursue formalising these pathways, and State and Federal Governments to appropriately fund and support them. The precedent has been set with the rural generalist pathway – the next step, the future advocacy from the National party, should be all about rural specialists.
Instead of sinking millions into a new medical school that will turn out freshly made interns without anything to contribute – forcing even more doctors out of clinical careers at great expense to the public hospital system – why not get the specialists rural and regional communities need directly to them, with the right tools, to solve the disparities in mortality that are unconscionable today?
Published: 14 May 2018