Rural medical workforce: look to intent, not origin

This article is one in a monthly series from members of the Australian Medical Students’ Association.

IN 2015, the ABC aired a program called Outback ER which was designed to provide insight into medical care in the bush. However, this program inspired something far deeper in me; it made me realise I wanted to be a rural doctor.

Australians are crying out for medical professionals in the bush, yet this career pathway was far more convoluted than I could ever have predicted.

As a student from metropolitan Sydney, medical schools with a focus on rural practice were largely inaccessible to me. Throughout the application process it seemed my interest was not taken seriously, but rather I was thought of as another applicant saying whatever was required to get the letters “MD” next to their name.

This experience is far from unique. I have spoken to countless aspiring rural doctors who are resitting the GAMSAT (graduate entry exam), studying in the libraries of metropolitan clinical schools or working in city hospitals while dreaming of being out bush. It is counterintuitive to have a tremendous shortage of qualified rural doctors yet such a significant bottleneck to get there.

We speak ad nauseum about how rural and remote areas have less than half the number of medical practitioners per capita compared with metropolitan areas. We also see a shorter lifespan and greater burden of disease in people living in rural and remote Australia. We know that the two strongest predictive factors of future rural practice are rural intention and a positive rural clinical experience, once we account for the fact that those from a rural background are more likely to have a rural intention. Yet much of our time, effort and discussion focuses on geographical origin; with repeated calls to increase the rural quota within Australian medical schools. We currently have a situation where there is an expectation on rural origin students to solve pervasive and systemic problems with the medical training pathway in order to repay an implied debt that they owe for their very presence within our vocation. Conversely, students of metropolitan origin with genuine rural intent may be denied the opportunity to have a positive rural clinical experience and realise this intent. Anecdotally, their exclusion is due to scepticism that metropolitan origin students are only interested in rural opportunities for certain perks, such as one-on-one teaching, greater clinical exposure or CV bonus points.

Within my own university, the University of Notre Dame, we had 60 applicants for 30 positions at our Rural Clinical Schools. While the successful applicants were all highly deserving, so were most of those who missed out. And those who missed out shared a common feature – metropolitan origin.

This is not specific to any one medical school. In my experience, it rings true for students from across the country and is just the first stage of a rural bottleneck from medical school through to specialty training that opens into a glass that is empty of fully qualified rural doctors.

I know numerous medical students who have applied for rural clinical opportunities such as John Flynn Placements, Rural Clinical Schools or NSW Rural Doctors Network Bush Bursaries and Cadetships and were unsuccessful in every endeavour. These are passionate, competent medical students who will one day make fantastic doctors, turned away time and again, seemingly because their postcode pushes them to the bottom of the pile in a milieu that is lacking in rural experiences.

The solution is to make rural opportunities more accessible, which for vocational doctors is a no-brainer. For medical students, however, it is not as straightforward as this. If we oversaturate country hospitals with more students than they can handle, we burden the hospital while compromising the quality of the experience.

Substantial change cannot happen overnight, but in the short term we can implement and broaden successful programs such as the NSW Rural Doctors Network Bush Bursary where pre-clinical students have the opportunity to complete a brief clinical experience in a country town while being supported by the local council. At the very least this provides all students – but in particular metropolitan background students – with a taste of authentic rural medicine and experience they can call upon when it comes time to apply for other competitive rural opportunities such as scholarships and extended rural placements.

Identifying students with rural intention early in their medical training will allow selection for extended rural experiences and scholarships to be streamlined such that it is their intent that sees a student selected, rather than factors beyond their control. This is paramount when we know that time at a rural clinical school is the crucial ingredient to turn a passionate medical student into a rural doctor. Identifying these students isn’t rocket science, it is as simple as sending out a survey.

At present, we appear to have a self-fulfilling prophecy at work. We select people based on factors that have been found to make them more likely to stay rurally, such as rural background or being in a long term relationship. By providing them with these rural opportunities they are, in turn, more likely to remain in the country than those we don’t afford those opportunities, thus increasing the effect. The end result is data that exaggerate the effect of rural origin on later practice by compounding it with other factors such as positive clinical experiences.

Instead, we should focus on success stories such as Dr Marian Dover, a rural generalist trainee in Taree, NSW. Dr Dover grew up in Sydney and as a result faced significant hurdles to being accepted into the rural medical community. Now she is providing vital women’s health care in the midst of a GP/obstetrician shortage and is also a Board member of the Rural Doctors Association of Australia.

The University of Notre Dame recently successfully introduced interviews as a part of Rural Clinical School selection, which will see a more diverse group headed out bush in 2020. Anecdotally, this system favoured those who had a demonstrated commitment to rural health, such as being involved in their rural health club or volunteering for a special interest group. It is hoped this will help to create a diverse rural workforce made up of doctors with different life experiences and cultural backgrounds that are well equipped to serve patients.

It is undeniable that doctors of rural origin are more likely to practice rurally, but forcing them to work in the country while denying the opportunity to others is like a teacher grilling a student who doesn’t know the answer while another, in the back row, has their hand up waiting to be called upon. No one student or group is the solution to rural health workforce inequality and we can only start moving towards a sustainable workforce when we stop looking at where someone has been and start focusing on where they are going.

Imogen Hines is the Vice Chair of the Australian Medical Students’ Association Rural Health Committee and is currently completing her 3rd year of medical school at the University of Notre Dame’s Wagga Wagga Rural Clinical School.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.