Ep109: Cultivating a rural workforce

Ep109: Cultivating a rural workforce
Date:
11 June 2024
Category:

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Australia is a big continent and sparsely populated continent. 28 percent of Australians live in areas classified regional, rural or remote and their access to health services is much more limited. It’s estimated that between 2009 and 2011 there were 19,000 excess deaths in regional and remote areas as compared to the major cities. No doubt, socioeconomic disadvantage is factor in that mortality gap, but inequitable access to healthcare is also a major driver.

In this podcast we focus specifically on the shortage in health practitioners in the regions. Even in regional centres, the density of physicians by population count is two thirds what it is in the major cities. By the time you get to large rural towns it’s just over a third that baseline. In this podcast we discuss opportunities to lift recruitment and retention. This means improving the experience for trainees and the esteem for rural medicine in the eyes of the profession at large.

Credits

Guests
Adjunct Professor Graeme Maguire PhD FRACP MHM MPHTM (President Adult Medicine Division, RACP and Director of Medical Education, WA Country Health Service)
Dr Sarah Straw FRACP (WACHS Kimberley Regional Physician Team; Northern Hospital, Melb; Rural, Regional and Remote Working Group, RACP)
Associate Professor Matthew McGrail PhD (Head Regional Training Hub Research, University of Queensland)

Production
Produced by Mic Cavazzini DPhil. Music courtesy of FreeMusic Archive includes ‘The Envelope’, ‘Cast in Wicker’ and ‘Planting Flags’ by Blue Dot Sessions. Music licenced from Epidemic Sound includes ‘The Mission’ by J. F. Gloss. Photo by Pearshop on behalf of RACP.

Editorial feedback kindly provided by RACP physicians Steve Flecknoe-Brown, Zac Fuller, Aidan Tan, Sasha Taylor, Jia Wen Chong, Joseph Lee, Fionnuala Fagan, Stephen Bacchi, Chris Leung, David Arroyo, Nele Legge, Li-Zsa Tan and Thazin Thazin.

Further Resources

Regional, Rural, and Remote Physician Strategy [RACP]
STP Training Program RACP coordinates 300 places

Increasing doctors working in specific rural regions through selection from and training in the same region: national evidence from Australia [McGrail; Hum Resour Health. 2021]
The pathway to more rural doctors: the role of universities [McGrail; MJA. 2023]
Building a sustainable rural physician workforce [Ostini; MJA. 20201]
The value of extended short-term medical training placements in smaller rural and remote locations on future work location: a cohort study [BMJ Open. 2023]
'Surfing the coastal wave' - a new way to consider workforce distribution [Rural Remote Health. 2018]
Health Workforce report 2022 [AIHW]
Comparison of performance outcomes after general practice training in remote and rural or regional locations in Australia [Med J Aust. 2023]
Rural training pathways: the return rate of doctors to work in the same region as their basic medical training [Hum Resour Health. 2018]
Selection, training and employment to encourage early‐career doctors to pursue a rural postgraduate training pathway [Aust J Rural Health. 2021]
Rural medical workforce pathways: exploring the importance of postgraduation rural training time [Hum Resour Health. 2023]
Exploring doctors’ emerging commitment to rural and general practice roles over their early career [Int J Environ Res Public Health. 2021]
Exploring preference for, and uptake of, rural medical internships, a key issue for supporting rural training pathways [BMC Health Serv Res. 2020]

Transcript

MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini for the Royal Australasian College of Physicians. Australia is a big and sparsely populated continent. 26 percent of Australians live in areas classified as regional or rural and another 2 percent live more remotely still. It is a national shame how far health outcomes in some isolated Aboriginal communities trail behind the rest of the nation. But it’s less well known that there is disparity in health as soon as you leave the metropolitan centres.

A crude but striking figure is that between the years 2009 and 2011 there were 19,000 excess deaths associated with living regionally. Preventable deaths.  For coronary heart disease and lung cancer the age-standardised death rate for Australians living in rural areas is thirty percent higher than it is in metro areas and for COPD and diabetes it’s over 60 percent higher. No doubt, socioeconomic disadvantage is one driver behind that mortality gap as it impacts lifestyle and the ability to pay for consults and medication. But there is great inequity in access to crucial healthcare services leading to delays in the diagnosis of and intervention for serious disease. Aotearoa-New Zealand certainly shares some of the same challenges, but the vastness and jurisdictional complexity of the Australian setting warrants a podcast of its own.

Today’s story will focus on the gaps in the physician workforce in the regions. To get more doctors out there will require the creation of more training opportunities and more targeted selection of candidates to fill them. But trainees need oversight, and more flexible models of supervision will be needed to provide that. Finally, we tackle head-on the unwarranted stigma against rural medicine as being a second-rate career pathway. To discuss all this I invited Professor Graeme Maguire, President of the College’s Adult Medicine Division.

GRAEME MAGUIRE: I'm Graeme McGuire. I'm a general and respiratory physician. I'm a director of medical education for a rural and regional health service in Western Australia.

MIC CAVAZZINI: Also, Dr Sarah Straw who sits on the RACP’s Rural Regional and Remote Working Group.

SARAH STRAW:
My name is Sarah Straw. For the last five years I've been a consultant physician in the Kimberley regional physician team and I've recently transitioned to Melbourne where I'm working at the Northern Hospital.

MIC CAVAZZINI: And finally, Associate Professor Matthew McGrail, a statistician who’s been looking at workforce distribution for twenty years.

MATTHEW McGRAIL:     Matthew McGrail. I'm with University of Queensland. My role is head of regional training hubs research. So I'm a research-focused academic.

MIC CAVAZZINI: Matthew McGrail was actually one of the architects of the Modified Monash Model for comparing regional isolation. This is an algorithm that assigns each postcode a classification on a 7 step scale that’s based on distance from services and population clusters. MMM1 only captures our capital cities and metropolitan satellites. In fact, it doesn’t even include Hobart and Darwin which fall under MMM2, along with regional centres like Bendigo and Mackay, with populations in the ballpark of 90,000 or more. Modified Monash 3, 4 and 5 are the large, medium and small rural towns which we’ll focus on today. MMM tiers 6 and 7 are the most remote communities which will always depend on outreach models of care. 

So, our biggest cities host 89 percent of the RACP’s 27,000 members practicing in Australia, a significant skew given these locations are home to 72 percent of the population.
If you normalise for population density that gives you about 120 physicians per 100,000 people, though that number is not adjusted for those working part-time. The major specialty groups of General Medicine and Paediatrics each have about 11 doctors per 100,000 people, and they don’t see much of a drop in density in regional centres. But in Modified Monash 3 areas the density of those specialties is down to six and half docs per 100,000, or 60 percent what it is in the cities. We’re talking about rural centres like Lismore in New South Wales, population 44,000, or Bussleton in Western Australia, about half that size but not as isolated. I started by asking Professor Graeme Maguire what level of care can be provided by this sort of workforce.

GRAEME MAGUIRE:       In a place like Busselton care is particularly provided by non-consultant specialists and often rural generalists. So GPs, who have extended skills in particular areas, including such things as particularly emergency medicine, obstetrics and anaesthetics. There is some outreach to those communities, but their resident physician workforce is very much on a sort of visiting basis. And in a place like Busselton, it's somewhere approximately 40 minutes drive from Bunbury, which is a sort of a larger centre with at least general and some sub-specialty physician services. Is there a need? Yes, I think there is a need;. And one of the key things about healthcare is providing health care as close to home as possible. Because we know as soon as people have to leave where they live, they leave their support networks behind, discharge planning, readmission all start to increase.

MIC CAVAZZINI:                Yeah, we'll look at the different hub and spoke model in different states later, but sticking with our distribution of generalists, the next Monash category, number 4, includes medium rural towns like places like Port Augusta with a pop of 14,000 some 3.5 hours from Adelaide, or Charters Towers which is 90 minutes out of Townsville. In this category the doctor density drops to just 1.5 paediatricians and 2.4 internists per 100,000 population. Sarah, could we really expect parity to the cities across those MM3 and 4 regions or does the gap need to be filled in other ways?

SARAH STRAW:
Yeah, it's a really difficult question to answer with a lot of things to balance and weigh up. I guess, in the larger rural centres having access to resident physicians is ideal. People who know, the local region, the local people, the local services, and it's really important to try and attract physicians to these areas and to keep them. And we’re very reliant on multidisciplinary teams and our colleagues from different colleges because you've got a much lower density of physicians, and they can't do everything. It's absolutely essential that the different health professionals are working really closely and balancing their skill mixes and sort of working within their strengths and not working outside of their scope.  So, in a place like the Kimberley we've got some very talented and experienced district medical officers who are often ACRRM or RACGP-trained and run our hospitals. They hold the bed card for the adult inpatients, for example, not only in Broome, which is our Regional Resource Centre, but in the smaller hospitals such as Derby, Kununurra. And we basically work with them finding out what can we value add as a specialist physician service, and we do that in a way that, I think, works quite well. We consult as per their needs on the complex patients. And as well as that, we run an outpatient specialist physician service, so we can look after chronic conditions, titrate medications, see patients after acute admissions. And we also provide an on-call service to the places we can't be all at the same time—so DMOs working in those smaller hospitals or, remote area GPs in the Aboriginal community-controlled health organizations, or even calls from Aboriginal Health Workers and remote area nurses where we provide advice and assistance in caring for those complex patients throughout the region—all of that requires a very healthy relationships and dynamics and cooperation and shared understanding of what the goals are for our patients.

MIC CAVAZZINI:                Right. So we're always going to be relying on the rural generalists to be filling a part of that gap?

SARAH STRAW: Yep.

MIC CAVAZZINI:                So moving from general medicine and paeds the biggest specialty is cardiology with about 1700 members. And then you've got geriatric medicine, gastroenterology, oncology, respiratory and sleep medicine, and endocrinology, all above 1000 members. In the big cities they number between five and eight doctors per 100,000 people. In the regional centres, MM2, you've got half the service intensity you do in the big city. And in the large rural towns, it drops to below a third. So the service goes over a cliff much more quickly than it does for paeds and general medicine. Can you get by in Lismore or Busselton or Gladstone or Goolwa with just one or two of these specialists per 100,000 people?

GRAEME MAGUIRE:       The structural limitation in providing physician services in more remote areas is often that you need to actually have a sustainable healthcare model that actually doesn't result in burnout and unsafe work practices. So, we're often limited in my mind, we're often limited by; you need three of something if you really want to provide an inpatient service. Because people cannot be on call every second day, and every second weekend. You need three. And so that often is the structural limitation and two things; you need to be able to recruit and sustain and retain three. You also have to be willing to actually fund it within your funding envelope as a health service. And for some of these MM3 sites particularly, it really depends whether they're ABF funded or they're block funded, and many of them actually ended up being ABF funded; so Activity-Based Funding, which creates a significant difficulty in that space. But, the interesting thing about distribution, particularly of physicians, is that we have some places where we can actually support a physician-led inpatient and outpatient service—Horsham and Hamilton are both MMM3, and they manage to sustain physicians services in that regard.

MIC CAVAZZINI:                That segues to the next question quite well. From one jurisdiction to the next, the weighting of population and physician numbers across those Monash classifications is quite different. Queensland has half as many physicians as New South Wales overall, but many more who work outside of the major cities. Interestingly, in Queensland, they're almost entirely based in regional centres were in whereas in Victoria, the numbers taper more gradually through the classifications. And in the Kimberley, the population centres are all remote towns like Derby, Windham and Kununurra. Matthew, perhaps you've got a good sense of this. I'm wondering if each jurisdiction needs a very different hub and spoke model or? Or is it just a sort of sliding scale?

MATTHEW McGRAIL:     Simple answer, yes. The geography, the distribution of populations, changes quite a lot per state or jurisdiction. I'm sitting in Queensland now and, absolutely, we have a strong regional centre distribution. And that's where the healthcare is really driven through those MM2 locations and quite large, non-metropolitan hospitals, and that's where most of the resources and efforts go through and, obviously, that's where the workforce lands. New South Wales, on the other hand, doesn't really have the same MM2 locations, they have—very few actually. It steps down from MM1 to 3, so it's going to be a slightly different model and approach.

MIC CAVAZZINI: There were a couple more comments from my reviewers that captured the pressure on the existing framework. One Fellow does casual shifts with the Neonatal and Paediatric Emergency Transport Service, NETS. When she wrote to me, she had just returned from the Port Macquarie PICU where she had retrieved a 3 year old with sepsis from a Strep B infection, an all too common and deadly phenomenon. She reflected that many callouts of this nature could be obviated by having more paediatricians on the ground in MMM3 settings. It’s certainly no more economical to operate a retrieval service like NETS. Another reviewer pointed out that about a third of paediatric service in New South Wales, by volume, is provided in regional and rural settings. He said that ruralist generalist practitioners aren’t trained to provide the same level of specialty care and it’s naïve to expect them to fill the physician gap.

A lot of effort has been put into selling rural medicine to junior doctors from the capital cities. I did a couple of episodes on this theme back in 2019 where we heard some Advanced Trainees and new Fellows tell us how much they cherished the tight professional teams, the deep-end immersion into new skills, not to mention the time they got back from living in a small town without traffic. Those podcasts were framed around the STP or Specialist Training Program, a Commonwealth scheme which funds registrar positions in places of greatest need. The RACP curates about 350 of these positions across the country.  

I want to look at the impact that such training opportunities have on long-term staffing of rural hospitals. Do training rotations in the bush get converted into medics who want to spend their careers there? Or is it better to actively recruit from the regions right back at the start of the pipeline, on entry into medical school? Associator Professor Matthew McGrail conducted a massive longitudinal survey, known as MABEL, an acronym for Medicine in Australia: Balancing Employment and Life. In a report published October 2021, he and colleague Belinda Sullivan presented ten years’ worth of data from 6600 medics of all specialties. When it came to predictors of establishing a career in regional and rural areas, Matthew McGrail and colleagues described a “dose response effect” with regards to time spent in the regions, whether as a child or as a trainee. Rural place of origin was independently associated with an increased rate of working in the same region with a relative risk ratio of over 3. I started by asking Associate Professor McGrail more about the trajectory of medical students selected from the bush.

MIC CAVAZZINI:                So, Matthew, you also collected some data showing that growing up in a particular region was a predictor of working there after medical school. The “grow your own” strategy as it gets called it is nothing new, and often it does require quotas or concessions for rural students at entry to medical school, given the patchy quality of high school education. But with any such admission scheme there are always questions raised about how such “quota students” perform over the longer term. And that question was asked and answered by Margaret Hay and other old colleagues of yours at Monash in a pretty high powered 2016 paper. So, while rural origin students had lower scores in their undergrad or admission tests, after nine years this wasn’t associated with an increased rate of failure, or reduced performance during training. Not all the studies point in this direction but is that the general picture you’ve got?

MATTHEW McGRAIL:     I do regularly, use that piece of evidence in some of my research. I'd say most evidence or data supports the findings of Marg Hay and her colleagues. There was a different piece of work that was done in New South Wales and published by the MJA a couple of years ago which found something similar, which supports that nature of; “Yeah, sure that they might come in slightly behind their metro peers, but they catch up after a few years to be almost indistinguishable”. And yeah, there's pretty strong evidence about the inequities of school students in rural opportunities and that sits behind a lot of the low entry scores rather than potential. So, I’m definitely a supporter of giving that the rural kids a fair chance, you know, putting it more on an equitable playing field.

MIC CAVAZZINI:                I think that already, a quarter of Commonwealth-supported places at medical school are allocated to students with a rural background. And we’ve got 19 Rural Clinical Schools and 26 Regional Training Hubs around the country. But one of my reviewers noted that it’s such a long pathway from med school to fellowship, that candidates who want to train as specialists end up get sucked into the urban workforce anyway because they’ve got to spend so much time at big teaching hospitals. Graeme, is there some truth to this that, if take your eye off the ball you will lose those rural doctors you’ve been cultivating?

GRAEME MAGUIRE:       So I think the point to make is that we'd like to see training as a pathway with choice. Okay, but what we want to see is a pathway that proactively recruits people who are more likely to end up working in non-metropolitan centres. And we know there are predictors, where you grow up where your partner lives where you went to school, then actually. And that's why the existing Commonwealth support of medical schools in Australia through our RHMT funding, the regional recruitment, focus, the Rural Clinical schools, and now the end-to-end medical school program that's being implemented across most jurisdictions, for selected cohorts of students, is key.

The next phase of that that's been demonstrated is that you can lose traction if you don't actually allow them to train on country and in place. And that means actually having opportunities for prevocational training, so in those first few years. So, internships that link to training rurally as a medical student are key because it's been demonstrated, if people move to the city to do their internship, there's a real risk that those three things that we usually talk about that tie people is marriage, mortgage and kids. And so those things need to happen, actually, on country. And then having vocational training pathways that are rurally based and rurally focused and actually develop the skills that are needed for physicians who are going to work in non-metropolitan settings. But unfortunately, the system we have at the moment is very structurally and culturally attuned to metropolitan-focused training.

MIC CAVAZZINI:                And, in fact, Matthew’s work has shown that training rotations of a year or meant that people were five times more likely to do so than those with short rotations of 12 weeks. Those medics who had both a rural origin and a long stint of training were 17 times more likely to end up working rurally compared to those from the city who’d only done the minimum rotation. But did I understand correctly that this effect was much stronger in general practice than physician training?

MATTHEW McGRAIL:     I'll explain a little bit more why that sort of is true, what you're saying. The nature of medical training, as you've just mentioned, occurs over a long period of time. And once you finish medical school, those who are on a GP pathway, there's a much higher chance and or ability to stay rural the whole time. GPs, obviously they can work in a much smaller population, group and density and be still viable, successful. Once you're outside of general practice, as much as you might want to stay rural, it often is the case you can't, or you feel you can't. Some of those differences between general practice and other specialties are often system-driven, rather than anything else. A lot of what Graeme was saying about the opportunities to enable pathways, to enable what I call confidence in staying on that path, that you're not going to be limiting the options, you're still going to have equal chance of reaching the specialty destination of choice, are really important.

MIC CAVAZZINI:                Interesting that you point to the system. I could imagine it's easier for a GP trainee to find supervision where they want rather than having to move. And if the RACP wants to lean into more intensive rural rotations, one proposal that's been discussed is for trainees to mandatorily have to spend a year of their basic and/or advanced training in a regional setting. And a recent consultation report— it was quite controversial—prompted strong reactions, both for and against from various specialty groups. I mean, just logistically, first, you'd need to create and fund a couple of thousand regional registrar positions, in a program that would be several times bigger than the specialist training program. Then you'd need to get more consultants out there so that they could so that those trainings could be supervised. And, in the workforce surveys that Matthew and colleagues conducted, rural trainees were less likely than their metro counterparts to report having good access to support and supervision. Sarah, what models for supervision could you imagine if we were to scale up this rural training?

SARAH STRAW: Yeah, so obviously, scaling up of that magnitude, it would be difficult. In the Kimberley, we have consultants who could supervise trainees, but not every region would be in that position. And we'd also be limited in the number of trainees that we could supervise. There have been some examples and some thinking about how else could we supervise and support these trainees. For example, having sub specialist trainees that might be mentored by a general physician who is resident, but supervised by distance from a sub-specialist who also visits and knows the region. These sort of models are possible. We do need to make sure that we are giving these trainees the best possible experience in terms of support and their learning experience as well that makes them want to come back again.

MIC CAVAZZINI:                As we’ve already mentioned, the capacity to train problem is particularly tricky for those smaller specialties. There just aren’t enough consultants to go around, and in that discussion, some of the specialty societies asked for a more flexible model to be considered. Graeme, when you and I spoke on the phone last time, you told me that we need to change what we think a training hospital should even look like, does it need a nuclear medicine department and so on.

GRAEME MAGUIRE:       I think from a training point of view, the first point to make is the word mandatory. And I don't believe that mandatory non-metropolitan training for everyone is a way to solve this problem. Dragging people kicking and screaming to Paradise, as I say, is not a good workforce strategy and it makes everyone's job harder. What we need is very much—I think we can learn so much from what's happened in the medical school space—is we need active recruitment models, and we need rurally-based and focused training pathways that equip people for rural practice, but also provide them and make them high quality physicians who, like Sarah and myself can very easily step back into the city and use our broad skills productively. So, I think there are also some structural elements that exist in achieving this and those structural elements particularly exists within our college and its slightly archaic educational principles it adopts around requiring time spent in places rather than, learning outcomes and clinical experience. So, it seems strange to me that basic physician training can only actually require—you can only have 12 months in what we call a level 1 hospital which is actually a fantastic training environment.

And that is difficult, but it's been interesting that with the recent Kruk review into international medical graduates, the primacy of the specialty medical colleges to actually be the final arbiter of what is competency is being challenged. Not, at this stage, in the College of Physicians, but certainly in general practice, obstetrics and gynaecology and psychiatry. So, I think it's in the best interest of our profession, of our rural communities, and of our College to actually try to reimagine what physician training and actually apply contemporary academic pedagogy, because the current model is not necessarily achieving what we want. The other thing I would point out is that this is not a problem where we need a huge number of people. We just need to flip the balance so that we can create those sustainable systems as we've mentioned here of at least three physicians in a site with a basic physician and an advanced trainees, suddenly you've got a sustainable system. So, this is not rocket science, nor is it trying to put someone on the moon, it's really quite achievable.

MIC CAVAZZINI:                                My review group were also split on whether mandatory rotations were a good idea or not, or were fair or not. But it sounds like some of the barriers were very trivial. Like, many trainee placements had been thwarted simply because the trainee wasn't able to find childcare for the kids or they weren't allowed to bring their dog into the accommodation provided. So, surely those are quite easy things to solve and much cheaper than spending three or four thousand a day to hire a locum. My reviewers also spit-balled some other sorts of incentive models—perhaps an area-of-need stipend. But another reviewer noted that bonuses, even large ones, have already been offered in the past without success.

Are any of you familiar with comparable health systems, such as Canada's where, it’s a big and sparsely populated place with its population quite concentrated in a handful of major cities and regional centres. And the Canadian College of Physicians and Surgeons is even part of our trination collaboration on training standards. But do they have any more success recruiting people to the regions?

GRAEME MAGUIRE:       So, Mic, I was recently talking to the Canadian College of—it’s Physicians and Surgeons, isn’t it? So I was chatting to Northern Ontario Medical School. One thing that they do do is they have rurally-based training pathways for physicians. The other thing that they have is they have very much University-hosted training pathways. And if you recall, I was talking about introducing greater academic and pedagogical rigor into training, and I think there's more of that. So, they've got a more decentralized model where the jurisdictions have greater input into how training might be delivered locally is key.

The interesting thing with basic physician training is we have an exit exam or a progression competency-based assessment at the end of basic physician training before you progress to advanced training. So, we shouldn't be worrying so much about the details of what the training is because we're actually making sure they're competent before they progress anyway.

MIC CAVAZZINI: I’ve heard many perspectives on the quality and safety of the rural training experience that sometimes pull in different directions. One response to the RACP’s consultation report was that “the very absence of advanced diagnostic facilities on site in rural hospitals [means] the trainee has to hone and then rely upon their clinical diagnostic skills. The training curriculum should emphasise clinical diagnosis and early identification of patients who may need more advanced facilities."

But this has its limits. One doctor on my review group had worked on the remote Palm Island as a locum, where he says there was only one person in the community who could operate the x-ray machine and they weren’t always available. Another told me that in a country hospital reporting to her, there weren’t enough nursing staff to observe complex patients safely over the weekend. These kinds of resourcing gaps can lead to long hours for the medical staff who are stationed in these places and increase the risk of burnout.

But a small workplace is very sensitive to the leadership culture. There’s a paper titled “Leadership in a fragile environment” authored by public health physician Linda Selvey. It forms part of a bigger research project out of University of Queensland called “Building a sustainable rural physician workforce” that was published in 2021 as an MJA supplement. Associate Professor Selvey says that enthusiastic leaders inspire their staff and this vibe can attract more people with the same spirit. But these workplaces are fragile because if key individuals leave, and worse still if they’re replaced by people with more tetchy egos, then that bubble can burst in an instant. And when a training site gets a bad reputation, it can be hard to shake off. So, Colleges need to be vigilant about burnout and harassment in smaller training sites.

In a qualitative study coordinated by Professor Selvey and colleagues, many junior doctors interviewed were enthusiastic about the “exciting medicine” they were exposed to in smaller centres; the autonomy and sense of responsibility of working in a place with a flatter hierarchy. But there were also concerns about missing out on educational opportunities, not getting exposure to some of the more complex medicine that’s performed at tertiary centres. One trainee said explicitly that if the clinical exam is based on “unicorn case, a rare, weird condition… it would be very hard to pass that exam having trained in a regional centre.” I asked Sarah Straw if that’s the sense she had as a Trainee in Broome with the Specialist Training Program.

SARAH STRAW: I think it's quite the contrary, actually. Doing your training and preparing for exams in a metro centre, yes, you've got more consultants and sub-specialists available to you, perhaps, during tutorials and things. But you also have a dense number of trainees, almost competing to see patients with the clinical signs and symptoms. When I was working in Broome, there is such a vast number of patients with signs and symptoms which, I guess, points to the heavy amount of morbidity that is also there. It sounds bad, but you're not competing with so many other trainees. I think it's actually easier to come across those patients, develop relationships with them, be able to spend some time with them, getting to know their stories, learning from them, examining them.

MIC CAVAZZINI:                                And now that everyone's using Zoom, and listening to podcasts, you know, it's easier to do journal clubs and Grand Rounds. RACP has even developed an eLearning unit titled Divisional Exam Readiness. And this reflects that, unicorn case or not, the point of the exam is to allow a trainee to demonstrate a systematic process for patient examination and diagnostic thinking. I want to move on from the training itself to the big picture sense of identity and the stigma that Graeme has already alluded to. What did you call it nihilistic?

GRAEME MAGUIRE:       Rural-nihilistic, metrocentric. And the final one is citysplaining. Where your colleagues tell you exactly…

MIC CAVAZZINI:                                …what you need for your own good. And Matthew, again, going to that big research piece published in the MJA, you and your colleagues picked up some of these comments after surveying 5000 physicians. First and foremost, rural practitioners reported equivalent professional satisfaction to their metropolitan counterparts across all stages of the career. [See also] But those who followed this career path sometimes describe the feeling that it was looked down upon, seen as fallback option for those who didn’t succeed elsewhere. Or here are some quotes; “These surgeons here are garbage”, or “you need to get your tests done in the city” or the backhanded compliment, “you’re too smart to work in the bush.” Is your sense from these surveys- is it just a few snobs, or is the negativity very pervasive?

MATTHEW McGRAIL:     Firstly, I’d throw in another phrase, and that's “professional narcissism” or “geographical narcissism”. I've got a PhD student who's looking at that right now, and how that impacts on locational choice of junior doctors. But yeah, that is common. I guess, what we're finding is more and more medical students and junior doctors, because of the rural exposure or whatever, they're more aware of these attitudes, they do have thicker skins generally. They can fob it off and again, I’m not the clinician here, but often, some of these perceived outcomes and way that patients are handled, it all comes down to the resourcing available, or what support you have around you, and which dictates how these outcomes get managed. And so, if there's not an understanding of that context it is a bit silly, and completely unfair.

MIC CAVAZZINI:                I've interviewed rural physicians before, and it sounds like those that have, the will and the attitude and the thick skin, that it doesn't hold them back. It's not a barrier to recruitment. But I was struck by one of the another respondent to your surveys who suggested that this lack of respect even posed a challenge to the quality of care that they were able to provide, quote, “It has taken 10 years and a deliberate cultivation of referral pathways that are based largely on personal relationships to expedite access to complex care in tertiary centres, and the cultural disrespect for anything west of the sandstone curtain (the Blue Mountains) is fully entrenched even in very junior trainees.” Sarah, is that your experience that you have to fight for your referrals to be taken seriously by tertiary centres?

SARAH STRAW: So, I think in in some states, in some regions, that stigma and that sort of negativity from tertiary to more rural and remote sites is definitely alive and well. But I was actually surprised in in the Kimberley of how good that relationship was and how many of the consultants in the tertiary centre had a good understanding of the complexity of the patients in the Kimberley and how hard we work to try and provide best care on country for our patients. Most of the people who have been through training in WA seem to have worked in the WACS regions, they have some understanding of, of what it's like, I think that that really helps. I was certainly very lucky in WA Country Health Service, that there are so many incredible physicians who are dedicated to rural health care; all big names, very respected. And as you said in that quote, it is so important to have those good relationships with your metro centre, your tertiary referral centre.

MIC CAVAZZINI:                And let’s turn these stereotypes on their head. Graeme, again going back to that conversation we had last time, you said that, really, rural medicine should be considered as a core competency, a pillar of professional practice. Can you unpack that idea a bit more?

GRAEME MAGUIRE:       Well, I suppose there are a couple of things here. I think all clinicians, all physicians need to understand the communities they serve. It's part of our social contract, so they need to appreciate the bush. I don't think everyone needs to be a rural physician nor to be trained to be a rural physician, but I think there are competencies and things we should value in rural practice. You'll often be called upon as a general physician, working in a rural regional setting, to have an expanded scope of practice in managing other specialties. So, in the case of the Kimberley, I recall, we would be actively involved in managing, SLE and other autoimmune diseases that you would never even think of doing of you were sitting in the city because they'd be taken over by a subspecialty. General physicians are actually able to work across specialty areas of practice, so they can manage heart failure, a heart attack, a stroke, these are things that they can actually manage, perhaps not at the same level as a sub-specialty, but they can actually provide acute care services. So, you work in these specialty team-based models, which I think is a unique skill that you don't necessarily have or need in the city.

MIC CAVAZZINI:                The RACP Council did just last year endorse the Regional, Rural and Remote Physician Strategy which is prefaced by a commitment to “achieving equitable health outcomes for Australians and New Zealanders living in regional and rural locations.” But to that point whether you want to mandate training rotations or not, one of the submissions from the Medical Deans of Australia and New Zealand was that “this would inadvertently frame [the] rural experience as one that needs to be forced or suffered.” And Matthew you wrote something similar about bonded scholarships into medical school.

MATTHEW McGRAIL:     Yeah, that that idea of forcing behaviour choices is—yeah, has limited power, really, and is probably not—a big stick, whatever you want to call it, is probably not the right approach here. There is limited published evidence of the effect of bonding and it suggests it makes little difference, negligible difference almost, other things take over.

MIC CAVAZZINI:                Yeah, you talk about is sticks and carrots or honey and vinegar. The Paediatrics Curriculum Renewal Group may have been listening to this kind of conversation, this kind of advice, or complaints from trainees. They've recently proposed the removal of any mandatory rotations at all, to be replaced with a competency-based approach and Graham alluded to this earlier. That’s to say there will be required competence competencies mapped to rural medicine that are best learned on site but might also be met through other learning captures. The idea is to provide flexibility and standardize the kinds of skill that you might learn out there. Sarah, do you have a sense of what this would look like? And would it actually create real incentives for trainees who really want to be there and learn the skills in the best place possible?

SARAH STRAW: Yeah this is obviously a complex issue and within the regional and remote working group we've talked a lot about incentivizing training in remote areas. I think as a trainee, you're trying to sit there and plan out, “what are my next few years going to look like, and how can I achieve all these tick boxes, the requirements that will get me my fellowship at the end of this. And I think there are some really important aspects that you can gain a much better understanding about in rural and regional areas. Things like understanding resource allocation; how to make decisions with less resources available to you; how to make decisions taking into account patient culture and health beliefs; we get a much greater sense of continuity of care in the rural, regional and remote areas. And I guess there's some of the professional attributes as well of working in true multidisciplinary teams, so you may only have one person of your professional background in that team, and you have to work really closely with other health professionals and really build on those professional qualities and dynamics.

MIC CAVAZZINI:                Finally, Graham, another one of the stereotypes that people hear when they're considering rural medicine is that it will limit your career progression. You're someone that's spent a majority of your career working in rural areas and have taken on many leadership positions and started many projects. What advice would you give a young recruit to manage their expectations about how to achieve those steps in a rural career?

GRAEME MAGUIRE:       Yeah, I think that rural practice actually provides you with leadership and management opportunities at an earlier stage of your career. It challenges you but it allows you to grow. You are the voice that speaks to expertise to your area. The other thing is that you just have the opportunity to be involved in so much and diverse areas, whether it's from policy, procedure, clinical care, and the great thing I found is that with smaller communities comes simplicity and so you can get all the key decision makers is in a room having a cup of coffee together. And you can actually implement and achieve positive change much more easily than you can in a large, complex, static metropolitan health service. So, I don't want to spruik rural practice too much, but it's been a very good friend to me, and I've managed to undertake a range of research, management leadership roles while also thinking I've actually been a decent clinician and serve the communities that I am meant to serve.

MIC CAVAZZINI: Many thanks to Graeme Maguire, Sarah Straw and Matthew McGrail for contributing to this important topic. The views they’ve expressed are their own and may not represent the position of the Royal Australasian College of Physicians. Many thanks also to the physicians on my editorial group who provided feedback. They’re all listed by name in the show-notes at our homepage racp.edu.au/podcast. There you’ll also find credits for the great music tracks you’ve heard and lots of links to academic literature embedded in the transcript. For Trainees, there’s also some information on and first hand accounts from the Specialist Training Program, those Commonwealth-funded training places we’ve talked about all over Australia. There’s the extensive library of videos called the College Learning Series or CLS which now has hundreds of detailed lectures framed around the basic training curriculum in Paediatrics as well as Adult Medicine.

There’s also an eLearning course titled Divisional Exam Readiness that will show you what to expect from your written and clinical exams and another on Quality and Safety in Rural Australia. And for senior doctors there’s one titled, Telesupervision, on top of the Supervisor Professional Development Program. You can continue the conversation by leaving a comment on the podcast episode page or starting up a thread in the ROC, the RACP’s Online Community app. And feel free to send me any thoughts and ideas via the address podcast@racp.edu.au. This podcast was produced on the lands of the Gadigal clan of the Eora nation, practitioners of rural medicine for tens of thousands of years. I’m Mic Cavazzini. Thanks for listening.

 

 

 

 

 

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17 Jul 2024
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