Ending the Drought

WHY CAN’T all medical graduates who wish to become rural doctors have that opportunity? Many will not have access to the necessary training as post-graduates to allow them to practice independently in rural areas after the completion of vocational training programs (VTPs). We need to advocate for what is simply decent; a system which ensures equity of care for our rural and regional communities.

We are in a rural doctor drought, but we know where sufficient water is, and we can sink a bore. But for bores to function, their location, engineering, capacity and the integrity of the connecting pipework are critical.

Record numbers of Australians have entered medical programs over the past 15 years, resulting in a commensurate and considerable expansion of graduations. Realistic modelling assumptions regarding medical productivity gains were estimated by Health Workforce Australia (HWA, which is now disbanded) to result in “a small” oversupply of 7,052 doctors by 2030, as Assistant Minister for Health, Dr David Gillespie noted.

We are at a juncture where Commonwealth and State Governments, the profession and the Medical Royal Colleges must accept the need for increased access to pre-vocational training program (VTP) internships and subsequent VTPs, as well as deliberate structured changes to those programs, to give students who want to practice rurally, the
opporunity to do so.

The health disparities experienced by rural communities deserve no less.

Seventeen universities currently operate Rural Clinical Schools and Departments of Rural Health with the objective of creating a stable and sustainable rural generalist workforce. The majority of alumni from Rural Clinical Schools indicate a strong preference to work in a rural/regional setting, typically in generalist disciplines. But how are these intentions actualised?

In 2016, there were 1441 applications for 992 NSW PGY1 positions in 2017; of these 131 were rural preferential positions or 13% of intern positions for 26% of the population. Rural preferential internships are popular to the point of considerable over-subscription; University of Sydney Teaching Hospitals at Dubbo, Orange and Lismore received 267 applications for 32 PGY1 positions in 2017, for example.

Dr Ewen McPhee, President of the Rural Doctors Association of Australia recently stated: “Many graduates of…existing rural medical schools desperately want to stay in rural locations to undertake the next stage of their training, but they can’t find the training places or rotation opportunities they need — the demand for existing places is too high.”

Any proposed expansion of intern positions must be considered in light of capacity. Factors such as, the size of rural and regional hospitals, the need to achieve adequate exposure and case mix, adequate supervision, recruitment retention and accreditation of supervisors who can meet certification standards and serve also in this capacity for the Medical Royal Colleges are imperative, lest rural PGY1 (and in NSW PGY2) positions leave graduates “stranded” and with less satisfactory training than their metropolitan counterparts, and disadvantaged in access to VTPs.

The future options open to persons not accepted in VTPs include hospitalist / career medical officer roles or several years of Medical Royal College unaccredited service positions. An expanding pool of such service positions may detract from the potential number of VTPs.

Prof Richard Murray, President of Medical Deans Australia and New Zealand observed: “Australia is seeing what happens when you double the number of medical schools and almost triple the number of graduates without giving thought as to what comes next. Belatedly, Australia is now paying attention to how specialist training after graduation should be structured in order to train doctors where they are most needed.”

There are insufficient GP-VTPs to meet demand, and in regard to non-GP specialist training positions (STPs), Medical Deans estimate that there may be a deficit of 569 STPs in 2018. This deficit is disproportionally evident for rural post graduates. They are compelled to undertake metropolitan training positions, with the result that for non-generalist training, these potential rural doctors are often lost to the city.

Again, quoting Prof Murray, “What is needed are programs that allow doctors to complete further training while living and working in a regional location…to provide vertical integration.”

In this context, the Integrated Rural Training Pipeline (IRTP) measure to establish rural training hubs operated by universities with established Rural Clinical Schools and Departments of Rural Health in MYEFO 15 was most welcome. The remit of rural training hubs is to “coordinate across all stages of medical training, streaming medical students into rural training pathways at an early stage in their careers, and negotiating ongoing training opportunities with local health services, specialist colleges, postgraduate medical councils and other rural training stakeholders”. These are to be operationalised through salaried university staff positions supporting the rural Junior Doctor Innovation Fund and 150 new specialist training positions.

The hubs are brokers and facilitators in this process, being neither employers nor certifiers, and are currently negotiating with stakeholders and Colleges to establish specialist training positions relevant to local workforce needs. There is complexity in this aspect, since for non-GP and other nongeneralist specialists the intention is that the incumbents of new rural specialist training positions will complete 66% of their training
rurally. This time requirement is problematic, as it has not generally been agreed to by the Medical Royal Colleges; and it does not easily align with the RACP’s four-year dual training pathway. Both trainees and Medical Royal Colleges may very reasonably and appropriately question whether the required breadth and depth of training can be delivered in two years at an Integrated Rural Training hub (or across multiple hubs) with one additional year of tertiary placement and yield comparable results to “traditional” metropolitan pathways.

Finally, the precise reason why a specific disciplinary training position may need to be created is that there are insufficient senior staff to provide service in that discipline, and hence disciplinary supervision is – by definition – lacking, thereby making that position un-accreditable.

When medical graduates are surveyed about the perceived barriers to long-term rural practice, the practicalities of partner employment, social isolation and concerns regarding children’s education are identified. These matters are not addressed by the above-mentioned initiatives. Financial incentives are not considered influential by the majority of GPs as distinct from locum-relief incentives, and work-life balance related to on-call demands disproportionately affect GPs in smaller areas along with reduced opportunities for career development.

If incentives are unsuccessful, is bonding a viable strategy? Leaving aside discussions regarding International Medical Students and International Medical Graduates, in 2016, 25.1% of Australian domestic graduates’ tuition fees were supported either through the Bonded Medical Places or Medical Bonded Rural Scholarship schemes which require recipients to work in rural/workforce shortage areas. Bonded Medical Places require a return of service in an area “sufficiently rural” or in a district of workforce shortage equivalent to the length of the student’s course, less any period of eligible pre-vocational or vocational training (pre-2015). For students commencing in 2016 or later, the return of service is “…equal to 12 months… worked in blocks of no less than 12 weeks…completed between commencing internship and five years after fellowship is achieved”.

Practically, bonding schemes do not compel a medical graduate to work rurally in the long term after being certified for independent practice, nor could there be a sound moral basis to compel with more proscriptive programs being tantamount to civil conscription.

Each year, Australian Rural Clinical Schools graduate several hundred students who could be the future rural workforce. Though we are very grateful to have rural needs tangibly acknowledged and supported by current programs, further work in rural internship numbers and VTPs in consultation with Medical Royal Colleges, with stakeholders and employers is needed for the establishment of a stable and sustainable rural medical workforce in the late 2020s and beyond.

In other words, a pipeline must be well located, designed and engineered, leak-proof and have sufficient capacity to deliver water to where it is needed.

A/Prof Mark Arnold is the current Associate Dean and Head of School at the School of Rural Health. He is a practicing physician in the field of Rheumatology, with practices in Dubbo, Gloucester and Orange.