No evidence new rural school will solve anything

OVER the past decade, our nation’s rural doctor shortage has persisted, even though Australia has seen a record number of medical graduates across the country. It has long been recognised that there is an ongoing issue of workforce maldistribution, rather than workforce numbers.

For years Charles Sturt University and La Trobe University have advocated building a new Murray Darling Medical School (MDMS) as a “simple” solution to the rural doctor shortage in New South Wales and Victoria.

I’ve spent my life growing up in country Australia and I’m currently studying medicine with the intention of returning to regional and rural areas. As such, I (and any rurally based doctor) can attest that the causes of the medical workforce maldistribution are multifaceted, and so too must be the solutions.

I represent the Australian Medical Students’ Association (AMSA), the peak body of 17 000 medical students across the country, in saying that the suggestion of a new medical school does not provide an adequate solution. A rural training package, however, would be an effective contribution.

• Related: MJA InSight -- Nurture beats nature for rural career
• Related: MJA InSight -- James Churchill: A school too far

Using the same amount of funding proposed to establish the MDMS, the Australian government could instead fund 300 doctors to train in a rural area for 1 year, or could support 60 doctors to do all 5 years of specialty training primarily in a regional area. This rural training solution has been proposed by AMSA in a package called “Doctors for Rural Communities” (DFRC).

While students at a proposed MDMS would require 4 to 6 years to graduate, the DFRC training package would allow doctors to begin working in rural communities immediately. Creating more training positions will increase the rural medical workforce capacity and will reduce doctors’ waiting lists in these communities. This investment in more training positions will also take a step towards relieving the pressure of the current bottleneck in medical training.

At all three proposed sites of the MDMS – Bendigo, Orange and Wagga Wagga – there are existing rural clinical schools (RCSs) with established infrastructure and connections to the community. These sites are already at capacity. As such, creating a new medical school will displace current students at these sites, and will not result in additional students being trained rurally.

This is a very expensive way to maintain the status quo.

In the face of pro-MDMS claims that RCSs are ineffective, evidence from Western Australia’s RCS (the RCSWA) clearly demonstrates that in the fight to provide doctors to rural communities, RCSs are already achieving their aim.

Of the 258 students who completed a 1-year placement between 2002 and 2009, 42 (16.3%) were working rurally compared with 36 of 759 controls (4.7%). Significantly, for those 195 RCSWA graduates from an urban background 29 (14.9%) were working rurally compared with 26 of 691 urban background controls (3.8%).

MDMS proponents have repeatedly cited the figure that just 4.6% of medical graduates intend to practice rurally. However, this statistic does not capture graduate intentions to practice in large regional centres like Bendigo, one of the proposed MDMS sites.

In fact, data from the Medical Deans of Australia and New Zealand (MDANZ) 2012 report showed that 33% of students intended to practice outside of capital cities. This figure provides a more accurate representation of graduate intentions of working in rural and regional communities including Bendigo.

MDANZ figures tell us we have parity between the Australian population living outside of capital cities, and the number of medical graduates intending to work in those same areas. Intention, however, is only one half of meeting the demand for rurally practising doctors; opportunity is the other.

• Related: MJA -- Rural general practice placements: alignment with the Australian Curriculum Framework for Junior Doctors
• Related: MJA -- Regionalisation of general practice training — are we meeting the needs of rural Australia?

Regardless of graduate desire to work outside of metropolitan areas, there is a scarcity of vocational training positions for doctors in rural and regional areas. Recently, we’ve seen examples (1, 2, 3, 4 and 5) of rural medical students at RCSs emphatically describing to local media that despite their intention to work rurally, they can see that specialist training positions in rural locations are lacking.

Currently, the majority of registrar training positions are located in metropolitan hospitals. This means that even if students from a rural background are able to train rurally during their medical degree, they are frequently forced to move to the city for their postgraduate training. Many regional and rural hospitals have the capacity to support long-term registrar positions, and to provide more vocational jobs for everyone. That means more doctors for rural communities, and more jobs for all.

Creating a new medical school not only requires a “waiting game” as students are trained – it also provides no guarantee that these students will remain in these communities. There is evidence that having completed rural training, and specifically training of 1 year or more, is a predictor for future rural employment. However, this is already occurring via existing clinical sites.

There is no evidence that graduates of MDMS would be more likely to work rurally on graduation than those currently undertaking long-term placements at these rural sites. Creating more rural and regional vocational training positions provides an alternative, one that has a guaranteed return – positions would only be funded rurally and regionally, so any money invested would directly fund a doctor rurally, where they are needed.

The MDMS proposal is not the most effective way to deliver its promise of more rural doctors to regional and rural communities in NSW and Victoria. It would duplicate established rural clinical schools, displace current rural students, provide no guarantee of a return on investment, and offers no evidence base that its graduates will be more likely to work rurally than the students already being training in its proposed sites.

Medical students support a proposal that supplies doctors for rural communities, not an expensive duplication of medical schools that already exist.

Elise Buisson is President of the Australian Medical Students’ Association