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14 Mar 2019

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA, CHAIR OF THE AMA MEDICAL WORKFORCE COMMITTEE

I recently advertised for a full-time private specialist to join our team in Hervey Bay, where a couple of my colleagues and I conduct regular outreach clinics. I know that a new physician joining us would be immediately greeted with full books. The lifestyle is fantastic, the schools are very good and it’s only a short commute to Brisbane. Still, no one is applying!

I honestly do not know what the problem is. Numerous advertisements have gone unanswered. We recently received an application from an overseas trained doctor who was in the process of completing his supervision and training period with the College to gain specialist registration. The hospital and I worked with this doctor for several months. Then he unexpectedly pulled out and is now somehow working full-time in the centre of a capital city. This is concerning when Australian trained physicians in some metropolitan areas are already scratching for a living.

By contrast, another physician colleague has completed his supervision period and now works (with his doctor wife) in a regional public hospital providing a vital service to the community. He is happy and the community has access to two highly-skilled medical professionals. The two doctors in these stories share many similarities: both have families, are of similar ages and were trained overseas, yet one ended up in a regional public hospital and one ended up in one of Australia’s major cities competing with fourteen other like physicians at the same institution. It shines a light on the immigration of doctors and how effective (or ineffective) it is in filling the gaps of maldistribution. 

In the regional centre I alluded to above, I noted the dearth of FACEMs in both the public and private emergency departments despite there being widespread agreement, including by the Commonwealth Government, that this specialty is in substantial over-supply. Interestingly, there were quite a few GP proceduralists in the emergency departments. This is fine, but I do wonder if that is exactly what the National Rural Health Commissioner envisages for his national rural generalist pathway graduates. No matter how we conceive of programs, doctors will always practice where and how they want – which so far is not helping us solve the maldistribution problem. Current solutions leave us dangerously exposed to more short-sighted role substitution or nefarious workforce solutions that rebound badly on the profession as a whole.

The AMA has proposed regional training networks as a potential solution, but I perceive we have not quite developed this hugely valuable concept fully. We need training to be focussed in regional areas with occasional attachment into the city, not the other way around.  It is critical that the bureaucratic need for service delivery is conceptually separated from training requirements and workforce supply. Moreover, if we truly believe in specialist generalism (accepting that the rural generalist pathway will progress GP generalism) we need to foster additional acquisition in general specialty qualifications without compelling registrars to do dual training. For example, a general physician who can proficiently and expertly perform echocardiograms would be an incredibly valuable asset to many communities, while making the job more enjoyable and attractive to junior doctors considering their career. 

General physicians and surgeons who can perform upper and lower scopes are not unusual, but we could be encouraging it more. They are definitely preferred to nurse endoscopists. There are international examples we could emulate: in the USA respiratory physicians do their own right heart catheter studies. We should encourage the Colleges to do more to make generalism a more appealing and diverse specialty for selected individuals based in regional training networks with a rural focus. We know that doctors who train (particularly at the end of the training) in rural and regional areas are more likely to remain there, so let’s build these networks to encourage this.

Lastly, I perceive for non-GP specialists that the attraction of regional work depends on having a combined appointment to the public and private systems.  While advertising for a physician in Hervey Bay I contacted management within the district and within Queensland Health to plead for funding for 2-3 sessions only so we could attract a full-time specialist to the region (remember Medicare billing would have helped to offset the salary costs).  I got no help – in a region where the closest single respiratory and sleep physician is a full-time private physician 120km away and beyond this you need to travel for another 150km or so to reach another. There was no real risk here in funding the sessions I asked for to get a physician into the area for both the public and private system, yet I received no support.  What are our local health district and services there for if not to take these small, measured risks to build a broader, credible service for the community?  Too much managing up instead of managing down!

It strikes me that sometimes non-medical managers are happier to fund role substitution models than even pay for two or three sessions for a doctor. Perhaps our largest hurdle in solving the maldistribution problem is to have the States, Territories and Commonwealth work cohesively together (and with us) in the provision of regional training and appropriately remunerated employment opportunities in both the public and private sectors. Apparently small hurdles remain colossal impediments.


Published: 14 Mar 2019