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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.
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Thanks for your thoughtful article Imogen. It is very pleasing to read of your passion for rural practice and bodes well for the future of rural communities, especially the ones in which you may work. Best wishes for your future.
I have had 4 John Flynn medical students, 1 each from Hobart, Melbourne and Sydney and 1 from Blue Mountains so don’t think can say biased against metropolitan students. None of them seemed to want to work rurally, just to get a rural experience eg never rode a horse or swum in a creek before
Imogen
As the person whose Rural Stocktake in 1999 led to the creation and funding of the rural clinical schools, I find yours and other comments fascinating, given that you often don’t live to see what you recommended still largely unchanged after 20 years. Not as successful as I hoped! Why, because there is still opposition among the elitist corps who inhabit the denizens of the city teaching hospitals.
There are four major challenges to a rural practice career.
(a) social dislocation – that is, where your spouse/partner won’t go or from where you have send the kids away to school;
(b) professional isolation – probably the challenge that has been the best tackled;
(c) community tolerance – where you know that unlike the city you cannot be anonymous – a factor that is often overlooked. If you, the doctor, are at war with the pharmacist, for instance, it is not a happy town;
(d) succession planning – the hardest thing to do is to recognise that you are not indispensable – I’ve seen a number of doctors who have gone well past their ‘use-by date’.
Always keep these challenges in mind and realise that five years in any place is long enough – because there is always that fifth problem – burn-out. Professionally it has worked for me. And if you aim for five years then succession planning becomes easier. If you go longer, no problem, but then deal in five year professional “chunks”.
Money – how successful were the retention payments?
A final point. The M2M intern training scheme (renamed rural generalist for political correctness) in Victoria showed that small health services can become effective small teaching health services complementing the regional health service – in the case of M2M, at Wangaratta and Albury. I also suggest you look at Mount Beauty in Victoria.
My blog – a continuation on my writings in the MJA and “HealthCover” – https://thebestmousetap.com.au/ regularly looks at these issues.
Good article Imogen but experience may change some of your ideas later. The Rural Clinical Schools do seem to be helping, but mainly Regionally, which is better than nothing. They’re not producing many rural GPs, nor are the NSW RDN Cadetships producing many rural, as opposed to Regional, GPs.
Of the five recent [last 20 years] med students I can recall from our town of 2300 people, drainage of perhaps 5000, all but one have specialised. The one GP is very rural, and indigenous, two of the Specialists are Regional and the remaining two are urban [understandably as they are sub speciality surgeons. Still that’s a 60% return.
So the reforms of the last 20 years are showing some results. Before then, Sydney, Melbourne and WA Uni med schools had regional/rural intakes of 4% of the entire annual cohort. Now they have to aim at 25%.
You alluded to the John Flynn Scholarship being hard for a metropolitan student to be awarded one. I was very involved in the setting up of that and RAMUS – both replaced now I think. John Flynn was purely to get metropolitan med students over the great divide, into the country and see the many advantages of country living. It never worked. Every John Flynn I mentored for 4 years, and there were many, came from rural origin and there was nothing RDAA could do to correct it as the Fed Government decided rural students couldn’t be excluded and they simply ticked more of the boxes. In my view it was a failure because it forgot its raison d’être.
RAMUS on the other hand was initially only for rural students who had done their primary schooling in a rural area – by far the strongest evidence of returning, both in Australia and the USA. After John Anderson Deputy PM from Gunnedah and it’s main promoter, left Federal Parliament some components were relaxed so it began to go a bit awry but was still very successful. Great to hear the varying views you’ve stimulated. Good luck with your studies.
The problem is there is no way to truly judge whether someone has true rural intention in regards to medical school entry. It is so competitive that people will say anything to get in. I’m not sure what the solution is. As a final year student I am happy to acknowledge I only got in due to my rural background. During medical school I have stayed urban the entire time due to my partner needing to work in the city to support us. I think I would’ve enjoyed a rural clinical school, but it wasn’t a possibility for me. I have received my intern allocation and am returning rurally (first preference) as I desired at the beginning. I do see rural clinical school students (originally from urban areas) from my university who have chosen to intern rurally as well so it does seem to be working. Our rural clinical school wasn’t oversubscribed though as in the story so some people were sent who didn’t desire to.
It is so good to see such passion for rural practice – and to have urban as well as rural students aspiring to RCS! May it ever be so. However, since RCSs are a workforce initiative, an evidence-based approach to selection requires that we take the workforce evidence into account. And the evidence is clear that rural background students with rural intent are 7-fold more likely to end up in rural practice, and that 50% of rural students taken into RCS will eventually settle rurally. This suggests that a rural emphasis at selection can only be a good thing for rural work. However, in our RCS, urban students who show clear and evidenced attraction to rural work are amply able to get in.
Fairly poor opinion piece. Heavily biased, suggestions of clandestine discrimination, a targeted attitude, and a significant lack of understanding that medical school is difficult and you will not always get what you want or feel you deserve. (University is meant to challenge you.)
The one MJA article you posted doesn’t really agree with what you are saying, and the population was only 500 West Australian students.
This opinion piece is full of anecdote and conjecture.
Nice to start this conversation, but the poor research and heavy bias is the wrong way to go about it, it comes across as pushing a personal agenda.
Excellent article and insights.
There is no reason why those from a rural background should have forced upon them the assumption that they will return and fix the rural medicine shortfall.
Nor should this solution depend on love alone: the best incentive is usually money.
Weighted Medicare rebates in the country would help a lot (particularly to help with boarding school fees if a city-based education is still desired for children of). It works for the rural public system with fee-for-service for surgery.
With what is now (apparently) an unprecedented number of Australian trained medical graduates, the impression I get as a rural surgical sub specialist of 30 years is that very few of them are leaving metropolitan areas, even with the advent of rural clinical schools and the pressure of competition in the cities. A recent experience with a locum uncovered a naive and delusional perception of living in the country which was entirely negative.
If there are truly “countless aspiring rural doctors” from the cities that need their passage to rural practice facilitated in some way, then offer them bonded training positions. If the rural intent is there, they shouldn’t be concerned about 3-5 compulsory years of rural practice. Think of it as three extra, but very well paid, years of their course.
Why the concept of bonded training positions is heresy to most of the medical community is beyond me. We should be using it as a way to take advantage of the situation where there still appears to be more people wanting to do medicine as places available. It probably won’t be the case for too much longer.
Like much of medicine, our knowledge is by inductive reasoning (rather than deductive) and our conclusions are merely generalisations. This means, for example, that candidates applying to enter medicine or medical training who have favourable characteristics (e.g. have grown up in regional areas) are more likely to establish their careers in the country as you have pointed out. I agree with you that we should be remain vigilant that these are helpful generalisations and this should temper gatekeepers to avoid the following mistakes: (i) Having an unreasonable expectation that candidates of regional origin should pursue a rural career, or (ii) That candidates from the city are passed over in favour of candidates with broad favourable characteristics (for staying in the country). Those who are responsible for selecting applicants for rural medical schools or rural medical training will need to be more nuanced. We need to careful and avoid denying promising suitable applicants.
I too have been a regional specialist ( in psychiatry) for 30 years after growing up and studying in Sydney. We have a severe and worsening shortage of psychiatrists on mid north coast. We have 2 rural clinical campuses in the region and I have been teaching medical students for about 15 years. I think the reasons for the shortage are complex. They include the factors mentioned above and the location and structure of post graduate training, the increasing move to sub-specialization and the trend in mental health to employ staff specialists rather than VMOs.
@ #2 From what I am reading, it’s that rural students require lower GAMSAT scores for entry to medicine, not that the system be bypassed.
Universities think rural students are more likely to “go rural” therefore they lower the entry standard. e.g. USYD current GAMSAT is 68 non rural, and as low as 58 for rural. Isn’t that in and off itself saying that the rural workforce can be of a lower standard.
This is simplifying the problem.I have been a rural GP Obstetrician for 30 years.I have been a medical student and junior doctor supervisor throughout this period.Very few of the students or doctors have returned to rural practice.They all rave about the experience and clinical opportunities but rarely return.Their partners either live in metropolitan areas or they have concerns about work life balance.
Very good overview but with one reservastion: “I have spoken to countless aspiring rural doctors who are resitting the GAMSAT (graduate entry exam)… It is counterintuitive to have a tremendous shortage of qualified rural doctors yet such a significant bottleneck to get there.”
Are you suggesting GAMSAT somehow is discriminatory? This is a science theory test. It does not require a person to live in major cities, nor does it require hospital exposure. To imply that it should be waived or bypassed to facilitate rural doctor training is to propose a second-class rural workforce, something neither rural patients nor city-bound medical students would consider reasonable.
Excellent article, Imogen!
As a former city-born and city-aspiring medical student I changed my perspective through medical school and positive rural placements and now work in some of the most remote parts of the country as a GP registrar. Now looking back I really did have rural intent quite early which I am lucky was able to be fostered through programs such as the John Flynn Placement Program.
I wish you well on your journey to rural medicine.