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

There is abundant and not really surprising evidence that training rural based students, who seek a rural based career, in the country with a rural specific curriculum will greatly increase the number of well trained doctors available to help improve the currently unsatisfactory health outcomes for rural and remote based Australians. If you examine the career development of students graduating in clinical disciplines such as nursing, pharmacy,  and allied health at  Charles Sturt university in Orange, some 70-80% of graduates are working in the country ten years after graduation. Most of the university’s students are rural based and want to stay in their rural community.The approach suggested has been pioneered at the medical school run by James Cook University based in Townsville and about 60% of their medical graduates are working in rural communities. Contrast that with the overall figures of about ten percent of Australian trained doctors working in “the bush”.

So we need more rural based medical schools with an affirmative action admission policy. Students would be selected by assessing their academic potential (not just a TER Score) and their “Rurality”. The latter is determined by looking at their positive affiliation with rural life and the intention to pursue a rural career. Then, the evidence tells us that such students need to study a curriculum adapted to provide the skills needed to practice rural medicine. It is not widely enough appreciated that the health problems encountered in rural communities include problems

that are uniquely rural. An understanding of rural culture and rural challenges is essential as is, of course, training to best help our first Australians. This is particularly true for the mental health problems associated with the uncertainties inherent in rural life. It is also clear that rural trained doctors need to have early exposure to the development off procedural skills not needed by city doctors. We need to return to the era when rural GPs were competent and confident in providing an anaesthetic, delivering a baby, setting a fracture and performing minor surgery etc. Again research shows that the application of such skills boosts job and community satisfaction. Such education must be offered to undergraduate students as a postgraduate course would find it harder to attract the medical students we want as most post graduate studies would have been pursued at city universities. If offered from a rural university offering  a large array of academic programs, rural medical students would have the benefit of maturing in the challenging  environment that is university life. Such a medical education program would be linked to a university sponsored small town project with the university offering a number of support measures to doctors in such towns.

There is another essential change to medical education that should apply to all medical schools but is particularly relevant to rural medical training. I am talking about “Inter-professional learning”. Increasingly doctors are accepting the proposition that efficient health care, emphasising prevention and care in the community rather than hospital requires primary care to be a team effort, not a doctor centric endeavour as is currently the case. A number of contributions to P and I have discussed this imperative in detail as the “Medical Home” concept was explored. The health workforce in rural Australia is limited and there are crucial advantages to having the team approach become the “norm” in rural settings. To facilitate this rural medical students should experience “Team learning to prepare for Team practice”; a proportion of the curriculum should involve problem orientated sessions with clinical but non-medical students.

Students graduating from the described program would need to be guaranteed an

“Internship” in a rural hospital. We now have many excellent “base” hospitals in major country towns and an internship in these hospitals is much sort after by city students. Most have no intention of staying in the country but hear positive reports of better training with more interesting terms in a country hospital  where they have more maturing responsibility than they would have in a major tertiary institution in the city. States have the responsibility of providing internships and their guarantee of places for rural students would be essential.

Finally our restructuring must make it possible to obtain speciality training in rural settings. This is particularly important for would be GPs. Medical colleges, the AMA and universities are all committed to this becoming  a reality. Such opportunities are useless of course if there is not a pipeline of medical graduates would want to enter such training. That brings us  back to step one, the training of rural medical students.

One of the reasons for sharing this information with the P and I family is that, despite the evidence that supports the initiatives outlined here, none of are being implemented and for the worst of reasons; entrenched vested interests. Take for example, the proposal  from Charles Sturt and Latrobe universities to provide medical education for rural students applying all the initiatives described herein. The partnership has the capacity to graduate 160 doctors a year from a six year undergraduate course with the majority of graduates wanting to work in rural and remote Australia. The proponents recognise that the last thing we need is to train more Australian  doctors. So the universities are asking for a redistribution of 160 existing places at other universities to the new medical school. None of the existing medical schools are happy with this proposal. The loss of those places is associated with a loss of the financial subsides attached. Universities are struggling with the government’s reduction in university funding. There are arguing that changes they want to implement will make it unnecessary to create the programs described herein. The proposals they have forwarded are very unlikely to supply the numbers of graduates required to enter the rural based post-graduate training programs that would solve the problem. The Minister for rural health, a doctor himself ( David Gillespie) opposes the initiative preferring to concentrate on setting up postgraduate training programs in rural settings. (where are the students coming from for such programs Minister?)

Sydney University will establish a satellite medical school for 40 students in Gosford while UNSW will offer all of medical school training for students in Port Macquarie. Neither offer changes to the selection process for students nor a curriculum that differs from  the curriculum taught on there major campuses. National party leadership supports the proposals described here (with the exception of the Minister). More funding for Rural Clinical Schools is promised but money is not the problem. Universities say that the loss of medical students places for Australians would force them to recruit overseas full fee paying students. Meanwhile as rural Australians remain so disadvantaged a new Medical school opens in Perth, Macquarie university starts a Medical school not asking for government money but whose graduates will need post graduate training adding to the excess of doctors not needed and a small medical school is started with zero fanfare on the Sunshine Coast with student places being transferred from other universities!

A petition asking for rural Medical schools for rural students has been signed by more than 40,000 country residents. There wish should be granted for none of the other changes suggested are likely to solve a solvable but seemingly intractable problem.

John Dwyer is an Emeritus professor at UNSW and much involved in efforts to address health care inequality in rural Australia.

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