Rural health: time to end geographic narcissism

WE hear a lot about rural medicine in the media, in policy circles, and in politicians’ media releases. We hear a lot about what is being planned to enhance the profile of rural medicine in the broader landscape, and how to recruit and retain doctors and other health professionals in some of our most underserved areas.

This has been a long-standing policy goal of successive governments. As I have come into the Chair of the Australian Medical Association’s Council of Rural Doctors, I have had to ponder, why are we still having problems after so much goodwill and political pressure? After all, we now have a National Rural Generalist Pathway, we have a new Rural Health Commissioner – a passionate rural doctor in Associate Professor Ruth Stewart – and we have a Department of Health that, at least nominally, supports the development of rural and remote health. We are finally seeing funding provided for non-GP specialist training via Specialty Training Program funding, supported by Regional Training Hubs.

Despite all of this, we have seen rural maternity services close and services centralised in urban settings. Many services (including those provided statewide and governed by metropolitan colleagues) do not seem to understand the rural skill set and, therefore, unnecessarily and unfairly restrict the ability of rural doctors to practise what they have trained to do. We have seen clinical governance and credentialing – the “formal process used to verify the qualifications, experience, and professional standing of doctors for the purpose of evaluating their competence, performance and professional suitability to provide high quality health care for patients within specific organisational environments” – spiral out of control in our rural hospitals to the point where rural generalists can no longer practise their craft due to onerous restrictions. We have seen undersubscription in the rural pathways of Australian General Practice Training. We have seen well intentioned programs such as More Doctors for Rural Australia Program struggle to gain traction, and the viability of rural practices is more in doubt than ever before.

To understand why this is occurring requires considerable reflection on the role of rural doctors in determining their own destiny. In too many cases, decisions about the fate of rural doctors are left to bureaucrats in federal and state governments, as well as to city-based clinicians who, while perhaps well meaning, do not understand the rural context in which we practise.

If you ask a doctor to show you their CV, many of them will focus on their years of experience in metro areas and subspecialty practice. In fact, it is a requirement for credentialing in many fields that you have “time served” in these areas, as many credentialing committees consider time served equivalent to competence and safe practice. In my opinion, very few will focus on the doctor’s experience in rural or regional Australia, time spent acquiring valuable skills in independent practice, understanding of context, and managing many patients who, in the city, would be managed in subspecialty practice.

Therein lies the concept of “geographic narcissism”: the notion that metropolitan experience is more valuable than rural experience, and that people only practise in rural areas because they are unable to “make it” in the city. This term, first coined by Swedish psychologist Malin Fors and described in an article in the journal Psychoanalytic Psychology, describes why many people are reluctant to take on rural experiences as a junior doctor and why ultimately many will choose not to pursue a rural career. There are of course other factors surrounding family, living arrangements, schooling etc, but none of these problems are insurmountable. The current generation of doctors is used to flexible working arrangements, and if jurisdictions and practices collaborate on offering these doctors conditions that are favourable, I believe recruitment and retention will improve.

When decisions are made by metro-based policymakers and clinicians through the lens of geographic narcissism, you can understand why our rural towns and doctors struggle. Why would any junior doctor in 2020 want to enter a career where your scope of practice is decreasing year on year, and where the aspects of rural practice that make it interesting (procedural work, hospital inpatients and specialised practice to name a few) are becoming less accessible, due to centralisation? Why would you be a non-GP specialist in a regional area when you are not provided the appropriate support and services to practise your craft?

You will note, I haven’t once mentioned remuneration in this article. While money and remuneration are important, this is not the be all and end all of why doctors are not coming into rural Australia. There is so much more that allows for improvements in rural workforce planning, recruitment, and retention, for minimal (if any) cost on the part of the government.

Often, senior leadership positions in rural hospitals (and Departments of Health) are occupied by metro-based specialists. This further entrenches geographic narcissism in our policymaking when “metrocentric” solutions are applied to rural medical problems. This has led to many issues, the most notable of which is the current state of clinical governance and cost cutting/centralisation that has led to the decline of rural maternity services and the denial of women the right to birth close to home, despite good quality evidence suggesting that rural birthing is safe. All of this contributes to increased cost and pressure on our metropolitan hospitals, as well as to the significant oversubscription of some metro-based subspecialty training positions by doctors in training who would, in the right circumstances, be attracted to a rural career.

Rural doctors (GPs, rural generalists, and non-GP specialists alike) are the experts in our craft. We are “ruralists” and specialise in providing context-specific care to our communities. The coronavirus disease 2019 (COVID-19) pandemic has taught us that decentralisation is a good thing, as travel for medical appointments can be cumbersome, difficult, and can contribute to the spread of illness to rural and remote areas. We embrace multidisciplinary care and learn to work with our colleagues in other professions to achieve a common goal.

Rural communities and the rural context form the bedrock through which policy decisions should be made by all levels of government. The focus on the National Rural Generalist Pathway and the appointment of a rural doctor as Rural Health Commissioner (including her predecessor, Professor Paul Worley) is a testament to self-determination for rural medical practitioners and ultimately the patients whom we serve.

The Australian Medical Association (AMA) Council of Rural Doctors is a dynamic group of individuals committed to solving many of these issues and more. We are expert rural doctors working on rural policy to solve problems for our rural communities and patients. We represent every state and territory, as well as our Doctors in Training and the Australian Medical Students Association, to ensure the view of every rural doctor in Australia is represented in our policy. We are always open to the membership to provide us with feedback on any issue of rural health that concerns them. As the Chair, it is my responsibility to ultimately prosecute this case in the Federal Council of the AMA as well as to government and other stakeholders.

The future of rural health needs to be determined by rural practitioners and communities, nothing more, nothing less. The carnage brought about by geographic narcissism ends now.

Dr Marco Giuseppin is Chair of the AMA Council of Rural Doctors.

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