Aniello Iannuzzi: Flying blind

IF you haven’t heard of FIFO, rest assured it is not the name of latest rap star but something more commonplace — fly-in fly-out workers.

FIFO’s sociocultural and economic impacts have been much discussed, particularly with respect to mining communities. There are even websites and forums for FIFO families.

However, it’s not just the mining industry that has to deal with FIFO workers. Despite the glut of medical graduates coming through the system, FIFO doctors are one of the solutions used in rural and remote areas to resolve workforce shortages.

Governments and workforce agencies pour millions into retention and relocation grants and easy-entry-gracious-exit schemes to encourage doctors to work in rural and remote areas. The aim is to ensure rural patients have access and continuity optimised by a resident doctor.

Telemedicine, outreach clinics (hub and spoke models) and role substitution are often used as adjuncts to a resident doctor. Sadly, many communities have to make do with adjuncts alone.

FIFO offers an in-between solution. If managed well, reasonable continuity can be achieved and adjunct services can complement the FIFO doctor effectively.

Rural hospital administrators, agencies and even private practices seem to be embracing FIFO doctors, and many praise the flexibility it offers.

So, given this increased utilisation, isn’t it time our profession and funders had an in-depth discussion about FIFO?

Money will top the list. FIFO services come with the added costs of travel, accommodation and agency fees. Additional costs also include disbursements and higher remuneration because of remoteness.

So who pays? Government, as usual? Currently, the extras tend to be borne by the states. But should it be a Medicare item number with a load for remoteness? Or should local councils or local communities shoulder the economic cost?

A risk in FIFO practices is that they can become dehumanising for what should be the most human of professions. Individual doctor–patient relationships can be forgotten as FIFO rosters are packaged with an emphasis on times and days rather the people.

Given the growing prevalence of FIFO, is there a bigger role for our universities and colleges in this domain?

The current obsession with standardising medical assessments, along with time and budget pressures, has resulted in exams being multiple-choice, quick vignettes (like the objective structured clinical examination) and short answer questions. Assessing a doctor’s ability to write and talk in detail has been de-emphasised, but these are the skills that are paramount in making FIFO and adjunct models work.

This is best illustrated by the clinical handover. These need to be written with detail and clarity as a number of parties will receive them at different places and different times. For example, you leave town at 6pm and the next doctor is not there until 8am the next day. Handover has to cover three nursing shifts, the remote service doctor and the colleague arriving tomorrow.

In 2014, it’s no longer adequate to tell the nurse “you know the patients, just tell the next doctor”. Time and logistics mean it’s not possible to ring and discuss the patients with all parties concerned.

No matter what protocols are in place at hospitals and clinics, these skills need to be acquired earlier as part of the medical education process.

Another challenge is that FIFO can be forced upon those who don’t want it and worse, those who don’t need it. Rural doctors in small towns could be shut out of hospital work because administration finds it easier to deal with one locum agency to compose a FIFO roster instead of working with local medical officers.

Rural folk attach a lot of credibility to professionals who actually invest in their towns. A FIFO workforce will never achieve that degree of trust and understanding in rural areas.

While we need to be au fait with new workforce models and maintain high standards within them, we should not lose hope that the graduate tsunami will one day resolve the maldistribution of doctors and FIFO will become part of our medical history.
 

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.