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ACROSS rural Australia, many communities struggle to gain access to adequate health care, due to the unique challenges posed by their diverse demographics and geographic isolation. Such challenges have required innovative solutions, such as the Royal Flying Doctor Service, Heart of Australia, and the Integrated Cardiovascular Clinical Network.
Despite such innovative measures, there is one major challenge that has been particularly resistant to change: workforce distribution, or more accurately, maldistribution. The Bonded Medical Program, rural entry pathways, District of Workforce Shortage/Distribution Priority Area requirements for international medical graduates, increases in medical student numbers and opt-in placement programs such as the John Flynn Placement Program, have all been implemented to address the shortfall of doctors in rural communities; however, there remains a significant imbalance. In recent years, a number of initiatives have emerged that are focused on improving rural training pathways, and new solutions at the medical school level are also being explored.
One potential solution being championed by the current National Rural Health Commissioner, Professor Paul Worley, is the concept of end-to-end rural medical schools. This model has been implemented in Port Macquarie by the University of New South Wales and in the Northern Territory by Flinders University. The Northern Territory Medical Program (NTMP) produced its first graduates in 2014 and was developed with the explicit aim of increasing the number of Indigenous doctors. It maintained the same overarching curriculum as the existing Flinders University medical program. The evidence of the NTMP’s success in improving doctor numbers in the Northern Territory demonstrates that there is merit in utilising end-to-end programs that are tailored to the needs of the community. These successes are aided by specific choices such as a return-of-service obligation and entry criteria designed to attract those students most likely to remain in the NT. These are important lessons that should be considered in the development of other end-to-end programs.
Perhaps the most controversial end-to-end program is the Murray Darling Medical Schools Network, funded as part of the Stronger Rural Health Strategy in the 2018 Budget. The initial proposal suggested 180 new Commonwealth Supported Places (CSPs) which was likely to further exacerbate the predicted oversupply of doctors nationwide. After much pushback from major stakeholders, such as the Australian Medical Students Association (AMSA), a more sustainable compromise was made to reallocate CSPs from the existing pool, which shows a stronger intent to address maldistribution. The majority of these positions are 32 CSPs granted to a joint program between Charles Sturt University and Western Sydney University in Orange, although it is not yet clear how the redistribution will be balanced among existing medical schools. Unfortunately, the universities that will lose CSPs in this redistribution have not been prevented from replacing these with full fee-paying positions. The increase in full fee-paying positions risks undermining the very purpose of these end-to-end programs.
As the Murray Darling Medical Schools Network comes closer to fruition, there remain a number of concerns that will be applicable to any proposed end-to-end program. Return-of-service obligations are a significant consideration for applicants, so it is important that there is clarity about the presence or absence of any such requirements. The NTMP is very clear about its 4-year return-of-service obligation, which provides a template for other programs. Further, targeting of the program towards specific specialties, such as rural generalism, is reasonable in the context of tailoring training towards community needs; however, applicants need to be clearly informed of this. The solution to both of these concerns is quite simple, as all that is required is transparency and clear communication.
Increasing evidence of poor mental health among medical students and doctors makes it imperative for end-to-end programs to take seriously the health and wellbeing of their students. Beyondblue’s National Mental Health Survey of Doctors and Medical Students noted that rural and remote doctors and students may be “particularly vulnerable to psychological distress”. The NTMP identified on-site student support services as a vital component of a successful end-to-end program, and having experienced a rural placement that only had on-site support provided by a different university, I completely agree with their assessment. While the staff of the other university provided as much support as they could, their limited understanding of our course structure and requirements was a significant barrier.
A counterpoint to these concerns over health and wellbeing is that a longer duration placement may allow students to become more involved in community groups such as sporting clubs and cultural groups, which is likely to foster a stronger sense of belonging and allow these students to develop new support networks that may otherwise be lacking during a shorter rotation.
End-to-end rural medical schools hold significant promise as part of the solution to workforce maldistribution; however, there must be clarity around the expected career paths of graduates, return-of-service obligations, and student support. Crucially, these programs cannot exist in a vacuum. There already is a strong and flourishing interest for rural health among medical students, which AMSA Rural Health and others work hard to support, but this passion is for nought if there is no way to sustain it between graduation and specialty training.
The next steps into post-graduate training must also be available to allow doctors-in-training to remain in rural communities in the long term beyond medical school, otherwise these efforts will be wasted.
Andrew Baker is a 5th-year medical student at the University of Adelaide, and is a member of the 2019 AMSA Rural Health Committee. He was born and raised near Wauchope, on the Mid North Coast of New South Wales.
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.
The American model has some merit. The top centres are not necessarily in the capital cities, but were established on greenfield sites in cheaper real estate. The Mayo Clinic or the Cleveland clinic or the Kleinert hand unit in Louisville are the best of the best, so that doctors travel to live and teach there, patients travel to be treated there, and students get a top quality education there.
We have a much more government controlled and less entrepreneurial culture when it comes to hospitals and medical schools, so that when the central Sydney Hospital was downgraded, the melanoma unit ended up in Crows Nest, the renal unit in Camperdown, and the colorectal unit in Concord. Minimal geographic diaspora. There is no reason why the government could not simply transfer a specialist facility such as the Chris O’Brien Lifehouse from Sydney to Bathurst, or the Peter McCallum clinic from Melbourne to Shepparton.
There was a furore when I was surgical registrar in Orange in 1985, as the government proposed transferred the Department of Agriculture offices from Central Sydney to (shock horror) a rural area. Some people quit their jobs rather than move, but 30 years on, the department functions perfectly well and is expanding. (https://www.dpi.nsw.gov.au/__data/assets/pdf_file/0008/822707/a-new-place-for-dpi-to-call-home)
No doubt many latte-sipping urbanites would be horrified for their faculty or entire University to be moved lock stock and barrel to a regional area, but that is the sort of move that would solve this problem.
See anonymous comment number 2: “The scope of clinical practice in the country has dramatically shrunk over the decades and is now approaching that of a suburban general practice with its attendant mass of bureaucratic red tape but with isolation and minimal clinical support also a factor to be faced.
So the question has to be asked: what is it that would draw some bright young local graduate into General practice in a truly remote country area?”
This is gold and sums up the current state of play very well. We need to untangle the barriers that LHDs, Medicare and state health departments impose.
Let the rural doctors be rural doctors!
Brilliant article! Congratulations, Andrew. I’m sure that the vibrant medical community in Port Macquarie will continue to sustain you and whatever your career aspirations are in the future. And you have identified many other new “end-to-end” initiatives all over the Commonwealth. One under active development is in the Wide Bay and Rockhampton area in Queensland.
Dr Ianuzzi refers to “a much bigger jigsaw puzzle.” He is right, but solutions to many of these issues are in place. Students and junior doctors consistently report positive experiences and much more fulfilling training than their urban counterparts. The key is now to expand the opportunities for specialist training in the regions. This has always been the hardest nut to crack. But the Colleges are all trying to help.
The Hon Dr David Gillespie, himself a pioneer of the medical community in Port Macquarie, announced the Integrated Rural Training Pipeline for Medicine when he was Rural Health Minister in 2016. Part of this is the re-introduction of general practice terms for Interns specifically in rural areas. Another was the Regional Training Hubs, based in the Rural Clinical Schools. The Rural Training Hubs do not actually do any training. This is the proper bailiwick of hospitals, governed by Postgraduate Medical Councils for prevocational years and Specialist Colleges for vocational training. The Hubs are there just to help develop the regional training continuum.
I am the Senior Academic Clinician for the Wide Bay Regional Training Hub and we have just completed a comprehensive review of training opportunities in the region, barriers to further increasing specialist training and suggested solutions. Perhaps as a result of this facilitation, the Wide Bay is increasing its number of applications for specialist training accreditation by a large amount. Most encouragingly, most of these are with the RACP; previously considered the hardest of the nuts.
We are all looking forward to the outcome of these applications.
Whilst the ‘end to end’ concept of medical school training is obviously singularly designed to get more ‘bodies’ into country practice, what is not discussed is the very constricted exposure in training that occurs in country general practice compared with the vast array of clinical and surgical and obstetric cases that are available constantly in large tertiary hospital training settings.
It is thus not just a demographic maldistribution that has been occurring for decades, but also a clinical maldistribution (constraint) from the point of view of learning for young graduates.
In truth this has always been an issue that has always bedevilled attempts to get young local graduates to ‘go country’ with the knowledge that they are highly likely of be foregoing any chance of other specialty training down the track given the massive competition for places in other Specialist College courses.
I was a fellowship holder in the 1970s in central Queensland when at the time there was a huge array of acute and chronic clinical, traumatic, surgical and obstetric cases that were all dealt with locally but under the supervision of highly skilled local GPs or general surgeons. These people no longer exist in any numbers and all urgent cases are now dealt with by air retrievals for obvious reasons.
i.e. The scope of clinical practice in the country has dramatically shrunk over the decades and is now approaching that of a suburban general practice with its attendant mass of bureaucratic red tape but with isolation and minimal clinical support also a factor to be faced.
So the question has to be asked: what is it that would draw some bright young local graduate into General practice in a truly remote country area?
I’m not sure that there is a solution to this issue other than a massive increase in remuneration.
This article talks about some pieces in a much bigger jigsaw puzzle. The rural centres are seen as less and less desirable by many young adults and professionals, not only in Medicine. And then we have the Medicare mess that rewards big volumes, repetitive procedures and over-referring. Finally, general practice as a whole is in crisis, with practices struggling to achieve financial viability as government itself (via LHDs, Centrelink, NDIS and PHNs), corporate interests and allied health bog it down in red tape and turf wars.