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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
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All these solutions will fail unless governments attempt to halt the urbanisation of Australian soceity. This has nothing to do with medicine per se. The same difficulties apply in veterinary science, dentistry, accountancy, law etc…Unless the rural areas are funded to maintain adequate education, healthcare, employment and infrastructure the urban drift will continue. Attempts to address the medical officer shortage in the face of these more global trends are almost certain to fail. Almost invariably the reason medical officers don’t go bush includes: decisions by spouses, schooling, healthcare, social economic factors etc…Hypothesise all you will about types of medical schools but doctors are a subset of soceity, albeit a very high socioeconomically advantaged group, and the urbanisation will continue, particularly for these subsets. Many of the things high socio-economic strata value are not present in rural areas.
The evidence coming from JCU shows that a medical school focussed primarily on rural health outcomes will deliver a majority of graduates who choose to live and work rurally. The evidence of the last 13 years of rural incentive funding to the metro medical schools is one of abysmal failure on ROI. 31% of the population live outside RA1, so at the very least universities that accept taxpayer funds whose sole aim is to improve the rural medical workforce should be making sure at least 31% of their graduate cohorts choose to live and work rurally. The evidence cited shows how poor the return rate is. It is also well recognised that many of the universities did not even have the requisite number of ‘rural origin’ students in their cohorts. If I had accepted Medicare payments knowing that I had not met the Medicare conditions, it would be labelled as fraud, I would have to repay the money, possibly get a fine and get publicly named.
The letter writer also assumes that a rural medical school needs ‘new’ funds. This is not the case. Those of us who support a new rural mediacl school are arguing for a transfer of rural incentive funding from the medical schools that have poor performance records in ‘rural retention’ of their graduates, to a new rural medical school.
With respect to the development of rural training pathways, I and many of my rural medical colleagues agree that there needs to be a major expansion of rural training positions in all specialties. While that will require multi-party collaboration, we have no doubt that it will be achieved more quickly by having a Dean of Medicine and senior academic and administrative staff and their families (and friends) based rurally.
I spent two years in the country after graduation before travelling by ship to the UK for 5 years surgical experience and an FRCS. On returning, on an immigrant ship this time, I found there was only one surgeon practicing on his own in country NSW and most of his referrals were from small country towns. The city GP’s did not want to know him – they had there own GP/surgeon rring to send their difficult cases to Sydney. Things are different now with mutiple specialties represented in country areas but there are still big problems especially with the standard of the hospitals. I have probably missedmany of the difficulties facing a country doctor but I fully support the idea of a country medical school where the patients available for teaching would be far better than the obtruse and usually rare conditions seen in thie bg city. Otherwise country life is as good or better than the big city depending on whether you want to be a little fish in a big pond or a big fish in a littlepond. Incidentally I ended up as a general surgeon in a teaching hospital; but today I might have chosen the country. KBO
It seems to me JCU medical school was an expensive exercise in self indulgence for JCU; when I was at UQ the clinical school funcgtioned well, many students went to Townsville for the last 2 clinical years of the course, and many of them remained in FNQ. Ipso facto, the clinical school worked. What has JCU achieved apart from creating more academic jobs and satisfying someones ideology on how a medical cirriculum should be taught? The clinical schools have and do work, leave them alone (or work on improving them futher. Toowoomba needs one too if we have some money to throw about..)
Specialist training cannot be undertaken in smaller units for many of the training programs because you need the numbers of a tertiary unit to become competent / proficient.
I am rurally bonded and have almost completed specialist training. My husband has also almost completed specialist training through another college. We cannot get work together. It seems there are no pathways for medical families to stay together, meaning that we will most likely move to New Zealand for the sake of our kids. I still seem to be competing with overseas trained specialists for regional Australian positions. While I can appreciate the skills and services these doctors have provided us over the past decades, I am worried that the pathways still exist. Surely we should fill positions with our own trainees?
There is an important agenda that Elise should probably acknowledge – AMSA represents the interests of medical students who, having gotten their hands around the greasy pole are loath to see their privileged position undermined by any new increase in the numbers of students coming through who will inevitably compete for the dwindling post-graduate opportunities available. However, I largely agree with her. I am a medical student who spent the entirety of last year on a rural placement. And I wouldn’t rule out a return to the bush. I don’t, however, foresee that happening any time soon. Going on a rural placement as a student was extremely advantageous but those advantages don’t translate to post-graduate opportunities. Workforce planners naively rely on ‘passion’ instead – hoping that any student with exposure to rural medicine will somehow fall hopelessly, head over heels in love with the rural experience. That’s not good enough: cold, hard incentives, in the form of training opportunities, are what’s needed. And these rural communities don’t need more students. My small rural hospital was saturated with them. They need trained, expert, experienced doctors. A rural medical school can’t satisfy that need. Enough tweaking of medical student numbers. That’s not where the problem lies. Let’s instead look seriously and with maturity to what happens to those students once they enter the workforce. Where we need them, what we need them to do, and what we can afford to pay them. It’s not rocket science.
Elise and the AMSA are right on the money. Yes, students who come from rural backgrounds are more likely to return to rural locations than those who don’t, but despite persistent efforts to recruit from the bush, the rural workforce shortage remains.
As far as I am aware, only James Cook University in Far North Queensland has succeeded in producing more than the average proportion of graduates returning to the regions. There are probably local factors at play here.
The real problem is that the Royal Colleges dominate the postgraduate training programs and accrediting bodies. They push the ‘quantity [of supervisors] trumps quality’ argument. Yet students and junior medical staff consistently rate their learning experiences in rural centres as far better than in Metro sub-specialist terms.
Distance makes it hard for rural people to be adequately represented on committees of the Colleges and accrediting bodies. Electronic alternatives such as telephones or video conferencing dull the exchange, and travel time is never factored in.
Then there’s the Metro hospital Professor who merely has to raise an eyebrow and ask, “Why would you go there?” to ensure that the best and brightest are kept on a short leash.
The answer is rural-based postgraduate training; all or in part. Governments are not permitted to force people to work where they don’t want to work, but it is the Colleges which grant the licence to practice as a specialist. Rural postgraduate training should be Commonwealth-funded. The Colleges (including the RACGP) should have the rest of their funding made conditional upon success in increasing numbers of their Fellows living and working in rural areas.
Struggling with maintaining quality training for doctor shold be prioity rathe rthan uilding new uncrdited facilities. Stop this before we turn into a third world service prvice prvider.
The proposed MDMS is not just another medical school that will be based in rural towns in NSW and Victoria. The initiative responds to the evidence based imperative that we train more doctors who are intellectually and emotionally committed to rural life. Only 10% of Australian medical graduates over the last decade are working in rural and remote areas and most of them are attracted to coastal communities. The current definition used by medical schools in fulfilling their quota for rural students has nothing to do with one’s rurality and intention to practice in rural Australia. Our Rural clinical schools offer a most enjoyable and educative experience to students but there overall success in attracting students to a rural career is inadequate. Most medical students are metropolitan based. It is unrealistic to think that RCT exposure will capture the numbers of doctors we need for rural and remote Australia.
The MDMS will ensure that 80% of its students are already committed to rural life and will use an affirmative action plan to ensure it can enrol sufficent rural students. They will enjoy a uniquely rural focussed curriculum. The James Cook medical school has demonstrated how succesful this approach can be.
More work is needed to alllow for the whole of one’s medical training to take place “in the bush” and much progress is being made on that front. Rural Australians desrve to be looked after by doctors with the special expertise they need and who actually want to work in their communities. Our dependence on OTDs to serve rural Australia will not be reversed unti we train many more Australians who want a rural career. The MDMS initiative is important, unique and worthy of entusiatic support
Building rural schools is not just about filling the rural doctor gap. Urban dwellers might not be aware – but Australia is really a third world country with small pockets of 1st world development. Rural areas suffer from absent public transport, poor road infrastructure, abysmal communication connectivity with Internet access often well behind many third world countries, and a gap in health outcome second only to the aboriginal health gap. The little infratsructure the govenmnet can be bothered with (if any) generally goes exlusively to the urban or suburban area.
The fact that the author mentions Bendigo in the context of rural or regional highlights that arrogance and ignorance or urbanites – from the point of view of a rural doctor, Bendigo is a major city with all urban amenities one could wish for, and just within few hours drive from Melbourne, a true 1st world city.
A rural school bring s money to underdeveloped areas. It brings infratsructur. It brings jobs. Shops open, schools stay open, roads and telecommunications infrastructure gets built. It might keep farmers in the area too. This is about building a nation and developing a country, not just spending a few bucks on hopefully a few more doctors in the bush. ANd speaking of money – for the price of a single of those completely pointless new submarines or fighter planes, the rural health crisis could already be solved. While the government has money to spare for silly war games and pork barrelling football clubs, I have no sympathy for any austerity arguments as an excuse for substandard public health provision.