Lessons from my first term as a rural medical registrar

I GOT mixed reactions when telling friends and family I was off for 3.5 months on my rural placement, my first term as a medical registrar.

Mum said “oh, isn’t there a zoo there?” My sister said “don’t worry, it’s not that far from Sydney”. A senior colleague mused that “we weren’t really supported out there; I heard things are better now”.

A mixture of excitement and trepidation settled in as I drove west of Sydney and the skies became bigger and bluer, the land flat and golden. As Google Maps told me to “continue straight for 70 km, turn right and continue straight for another 90 km”, the scope of how much I was going to learn began to crystallise in my mind.

Much has been written about the role of rural training in building a sustainable rural physician workforce. Separately, there are advantages to studying and working in rural medicine. We advocate that a rural placement is not only beneficial but essential for a junior doctor – intern, resident or registrar – hoping to practice anywhere in Australia. In our experience, the rural placement drives a junior doctor to improve their clinical acumen, better understand health economics and resource allocation, and enhance their communication skills within a team.

As I drove and drove, Dorothea Mackellar’s “pitiless blue sky” represented the immense distances between the city and regional and rural centres. The expansive distances that meant a nurse working at a remote outpost near the South Australian border had the crucial role of recognising a patient presenting with an acute myocardial infarction or gastrointestinal haemorrhage and relaying that urgency to the nearest regional centre. The distances that meant the clock on the 24-hour thrombectomy rule for stroke management was already ticking if someone lived 100 km from town. As a doctor working in a regional centre, you may be the person at the end of the nurse’s phone call, or the first medical staff member that stroke patient sees. As a brand new registrar, you rely heavily on your team of interns, senior colleagues and nursing staff. You learn to listen carefully to that voice over the phone and very quickly learn to ask clear, precise questions to get to the nub of the problem. When time is tight and the distances are far, efficient, coherent communication and early identification of the patient’s disposition are keys to improved patient outcomes.

The distances to travel also entail hidden costs for the health care system and patients alike. For example, the Western NSW Local Health District covers 250 000 km². For this area there are 7000 medical, nursing and allied health staff, who travel 13 million kilometres each year to look after their patients. Emergencies need air retrieval, transfers and nursing and medical staff to travel with the patient. How do you choose who to transport if simultaneous, urgent transfers are required? In this setting, you will work with medical administrators, who play a key role in resource allocation and triage that will save a life on a busy shift.

For less urgent situations, resource allocation and costs still colour patient care. Those boundless plains reminded me that for patients needing specialty care, their specialist might be a 6-hour drive from home. Patients may find it difficult to attend their appointments because of the costs involved in a doctor’s visit – petrol or flight costs, accommodation, food, parking – not to mention the doctor’s bill. One patient needing a valve replacement told me I had “Buckley’s chance” of convincing him to head to Sydney for treatment. He’d left the “Big Smoke” years ago and had no intention of returning. The lack of easy access to health care means that the rural patient often has signs or symptoms that are rare in a well-managed urban setting. As a medical registrar, each day, each patient and each presentation was completely unique. I percussed retrosternal thyroids and palpated pitting oedema to the umbilicus. I saw necrotic toes and auscultated severe mitral stenosis. When there is no routine access to overnight imaging without calling a radiographer in to the hospital, I was reminded to trust my history and examination and rely on my clinical judgment to devise differentials.

A rural doctor is a true general physician, a jack of all trades. And a junior doctor’s clinical judgment is necessarily influenced by the epidemiology of regional and rural medicine and the particular issues facing centres in these areas. Eleven per cent of the Western NSW LHD is Indigenous. Understanding the complexity of the relationships between Aboriginal and Torres Strait Islander peoples and our health care system is a crucial part of being a doctor, regardless of your intended specialty. Closing the gap in part means working to forge a relationship between the patient, medical and nursing teams and Indigenous support officers to help to enable early screening, referral and management for Aboriginal and Torres Strait Islanders at risk of chronic disease.

The opioid overuse crisis is a health care issue that disproportionately affects our regional and rural centres (here and here). Recognising the effects of drug intoxication may save a young rural person’s life in the acute setting. Emphasising the importance of allied health involvement and communication with family members may facilitate early referral to rehabilitation centres. In a broader sense, awareness of issues facing Australians across the country makes us better and more informed health care advocates. Why is this epidemic affecting our young people and what can we do about this growing threat?

The reciprocal reliance on nursing and allied health colleagues and the abrogation of traditional medical hierarchies is an enjoyable part of the rural experience. Resource allocation may be constrained, but the support and camaraderie of the rural multidisciplinary health care team is considerable. Those days of unnerving, unsupported night shifts out bush are long gone, and consultants and registrars emphasise that help is only a phone call away. A physiotherapist can help you to determine whether an elderly woman is safe for discharge, when home is 4 hours further west. The pharmacist knows that a patient’s medications need to be ready for the only bus leaving for a remote community that day. Pleading for imaging is a non-event when you jog around the river on Saturday mornings with the radiographer. And knowing to put aside what you are doing when a nurse states “we have to act quickly” is invaluable.

Now, when my friends and family ask if I am excited to be heading west on another rural placement next year, I can say a definitive and enthusiastic yes. A rural term shapes and cultivates a junior doctor. It gives you an insight into the complexities of the public health care system. Without a rural term, a city doctor cannot understand the sacrifices made by a patient to make their specialist appointment, or the significance of including family in health care discussions for an Indigenous patient. Working rurally as a junior doctor involves being a part of the symbiotic relationship between medical, nursing and administration staff, a relationship built on crisp communication and combined clinical gestalt that may save a life for a patient living out the back of Bourke.

And yes, the zoo was definitely worth a visit.

I would like to acknowledge the help and support of Dr Jeniffer Fiore-Chapman, who was my supervising consultant during my time as a registrar.

Dr Antonia Clarke is now an Advanced Trainee with the Department of Neurology at Royal Prince Alfred Hospital, and a Clinical Lecturer with the University of Sydney.

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.