Dennis Pashen: Staying rural

“Will they stay or will they go?” – (with apologies to The Clash)

SEVERAL years ago, approaching my departure from a long-standing rural practice, I contemplated on what had made me stay in my rural community for 20 years.

Many things contributed to my staying longer than average — my community, my patients, my scope of practice, my friendships, my financial commitment to the community, the significant personal financial cost in departure, recruiting a replacement, my rural background and my personal comfort in smaller communities.

In 2010 I worked with a group of researchers on a systematic review of the factors involved in retention of rural and remote health workers. At that time, little was known about retention, yet there had been numerous publications on recruitment into rural and remote practice.

As anyone who has worked in rural and remote practice knows, there are three main issues in management — workforce, workforce and workforce. The capacity to obtain an appropriately skilled and sustainable workforce has always been the predominant challenge.

Successive governments have introduced many incentives to encourage health professionals to enter and remain in rural and remote communities. While many of these are appreciated, they have never been challenged as to their effectiveness.

Last month, Social Science & Medicine published results from the Medicine in Australia: Balancing Employment and Life (MABEL) study. It examined preferences for different types of retention incentive policies among more than 1100 rural GPs by asking them to indicate whether they would choose “Neither”, “Option A” or “Option B”.

Unsurprisingly, the study found an increased level of locum relief incentive, retention payments and rural skills loading would increase the probability of attracting GPs to stay in rural practice.

Some time ago I suggested to university colleagues that it would be interesting to examine the personality characteristics of long-staying and surviving rural doctors.

They took up this challenge and the study subsequently confirmed some interesting characteristics of this small group of doctors. Comfort with uncertainty was one of the characteristics, as well as being “mature, responsible, optimistic, persevering, and cooperative”.

I suspect this group fits nicely into the “neither” category of the recent MABEL study — the 25.6% who chose “Neither option would influence my decision to stay”. No incentive necessary — but perhaps appreciated.

These are the “dyed in the wool” rural doctors we hold as totemic exemplars of rural medicine. Perhaps cloning could be an option?

Unfortunately many of these doctors have been in situ for 30+ years, and have either retired or are rapidly approaching the end of their careers. Some continue to provide part-time locums back to their communities as a lingering presence.

The MABEL study identified some significant issues I hadn’t, but perhaps should have, considered.

The interesting “neither” group partly comprised a combination of international medical graduates who had geographical restriction on their practice (indentured labour so to speak) and “rural background” graduates.

The study also showed — understandably — that the rural locum support programs were the most appreciated. It has always been thus.

When the rural divisions of general practice and their state coordinating bodies were set up in the early 1990s, they conducted surveys that showed access to locums, professional development, rural background and satisfaction of spouses/partners were consistently pivotal in rural doctor satisfaction.

Time out in any form was considered important for the mental health and wellbeing of rural doctors and families.

Does this suggest that retention would be better served by shifting other less effective incentive funding towards the oversubscribed Rural Locum Relief Program? Perhaps.

And what will be the effect of the other rural programs — rural clinical schools, the Prevocational General Practice Placements Program (now doomed it appears, although effective in recruitment) and, in particular, the National Rural Generalist Pathway, aimed at repopulating the skills base of rural practice?

Many of these fit into a category to which the General Practice Rural Incentives Program often does not apply, such as the salaried medical officers working in and running rural hospitals. Rural procedural grants may apply but many of the other Medicare-billing-dependent programs do not.

Rural incentive schemes must be measured as part of a broader suite of policy initiatives, which interact and are codependent, to retain rural doctors.

If dismantling any of these schemes or programs, care must be taken not to obtain “perverse outcomes of good intent”, as so often happens. Applying rural incentives to rewarding the broader skills base of rural doctors may amplify the effect on groups such as rural generalists.

Yet, as the MABEL study suggests, these may not be the prime driver for retention.

Professor Dennis Pashen is the president of the Rural Doctors Association of Australia, a former president of the Australian College of Rural and Remote Medicine, professor of medicine at Griffith University, Queensland, and a GP practising in Tasmania.