JOHN DWYER: When will we seriously tackle the Inequity associated with the delivery of health services to rural and remote Australians? Part 1 of 2.

Health outcomes for Australians living in rural or what are characterised as “remote” areas are far inferior to those of their city cousins. If you don’t live in metropolitan Australia your life expectancy is reduced by about four years. You are four times more likely to die of a stroke. Rates of obesity, infant mortality, mental health disorders, and diabetes are all much higher than is the case for our urban population. There is nothing new here, we have known about these realities for decades as well as the strategies needed to address the  problem. At least five major enquires have reached similar conclusions over the last decade yet hardly any of the recommendations have been implemented as needed policies are stymied by political wrangling and incompetence.This is particularly true for attempts to solve the biggest problem of all; the shortage of Australian trained doctors in the “bush”. (Part one of two contributions)  

We are a wealthy country. The 36% of Australians who live in rural or remote communities provide 66% of that wealth. In my experience they are well aware and accepting of the reality that rural life must necessarily result in some reduction in the availability, locally, of some services more readily available in cities but rightly expect to have basic services supplied in a timely manner by health professionals who want to work in the country and have the necessary clinical and communication skills. Us city folk find it hard to imagine waiting six weeks to see our GP, who may well have been trained overseas, has limited English language skills, little understanding of rural culture and is only working in a rural community to get a ticket to eventually work in our cities. About 47% of rural GPs are overseas trained doctors (OTDs). Most are competent and I hasten to add that without them rural health outcomes would be worse than they are. They are needed as over the last twenty years, fewer than 10% of our Australian trained doctors have pursued rural based careers.  Most of those are scattered along our coastline in towns reasonably close to big cities.The current situation is made all the more troublesome by the ethical  challenges inherent in our appreciation that many OTDs are needed more in their countries of origin than here. Now a number of countries who feel “robbed”of the doctors they trained are suggesting they will impose restrictions on their availability to countries like Australia. The federal government is committed to reducing the number of OTDs. For many reasons then, it is more important than ever to develop strategies to produce Australian trained doctors who want a rural career.

We know a lot about strategies that do not work. John Howard used market place philosophy and argued that if we doubled the number of doctors we train at Australian universities the additional graduates would have to seek work in the country as there would not be city jobs to absorb them all. We were training about 1500 doctors a year now we train more than 3000 and we know we are training too many doctors. The reality has been that city populations have absorbed the extra doctors who in the open-ended fee for service Medicare system (often discussed here in P and I as a policy that must be scrapped for genuine healthcare reform) can generate a living.

Additional policies that have not worked include, “bonding” medical students providing financial assistance in return for work in a rural community on graduation; almost all “buy” themselves out of the bond. Offering large tax-free cash incentives for city GPs to move to the country, and mandating that all medical students be exposed to rural medicine during their training. This latter policy needs some detailed analysis as it has not worked but has provided evidence for what might work.

All medical schools are required to have 25%of the students they enrol each year meet the definition for a “rural student”. That definition requires a student to have spent ten years of their life in a rural post code. They may have been born in Broken Hill moved to Melbourne when they were ten years old and never seen a cow since. Its ridiculous as it has no relationship to any intention to practice medicine in a rural community. Most of these students are city dwellers at the time they enrol. All medical students must spend a minimum of four weeks during their course in a rural setting. These weeks may be spent in a large or small rural town and for most universities placements are organised by “rural clinical schools” established in major rural towns. These schools are run by dedicated and  and talented rural clinicians. It is possible for students to elect to spend a year or more studying at a rural clinical school should they be considering a rural based career. A few students do but the majority settle for their four weeks. In essence the rural clinical schools despite there excellence, are not able to achieve the goal of manipulating the career intentions of sufficient numbers of student to make a difference to the shortage of doctors in rural communities.

Of particular importance is student reaction to time spent in small towns with very few GPs. So often they have made comments such as “ The one thing I know for certain is that I do not want to work in a small town. Those guys are saints. They can’t have a holiday, they feel isolated and some who wish to retire feel they cannot as they can’t find anyone to replace them”. This problem can and must be addressed as part of the overall solution to the problems we are discussing.

With the exception of the “rural” tag all medical students are selected by the same process and study the same curriculum with no particular emphasis on rural medicine. My observations over the last seven years that I have studying the situation intently make it clear that even if a student wanted to study medicine, educational disadvantage in rural high schools make it very difficultly for a student to achieve the marks required for entry into medical school. No study has established that those marks are essential for finding students with the capacity to study and practice medicine. Equally important and, of course predictable, is the 80% attrition rate for students who have a genuine rural background after they have spent 4-6 years in the city.  “how are you going to keep them down on the farm——- “ as the old song queries.

Recognition of this latter problem makes it clear that solving the shortage of doctors for rural Australia requires structural changes to medical education so that all of one’s training is available in a rural setting; medical school, post graduate hospital internship and specialist training.

There are evidence based solutions for the situation described. They require major changes that need university, community and political support and will be addressed in the second party of this contribution.

John Dwyer is an Emeritus Professor of Medicine at UNSW with a continuing interest in strategies for training doctors who will want a rural based career.

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