John Dwyer. Politics trumps health policy yet again.

Current Affairs.  Health.

A new medical school in Perth will create more problems than it will solve.

 As must also be true for many colleagues who have been focussed on evidence based solutions to the serious shortage of Australian trained doctors working in rural communities, I am frustrated and annoyed by the Prime Minister’s capricious decision to fund a new medical school in Perth. In an attempt to solve the maldistribution of Australian trained doctors that has resulted in almost 50% of the General Practitioners available to people in rural and remote communities having been trained overseas, governments have applied a “market place” philosophy to the problem. This logic suggested that if we doubled the number of Australian trained doctors there would inevitably be competition for rural careers, as metropolitan opportunities would all be taken! In 2016 our intake of Australian students into medical schools will peak and many readers will know that (a) we are already having difficulty in finding quality clinical placements to maintain educational standards and (b) the flood of new graduates has done nothing to ease the shortage of Australian doctors working in “the bush”. This continuing problem is responsible for much unacceptable inequity with health outcomes in all categories being less satisfactory for rural Australians. Were rural patients able to access medical services as readily as their city cousins it would increase Medicare payments by two billion dollars a year!

Here is the irony. To solve this problem we do need new medical schools but not schools situated in metropolitan areas providing a standard metropolitan centric curriculum. Here is the major cause of frustration. At least three thorough enquiries seeking evidence-based strategies to address the above inequity have been conducted in the last four years and all have agreed on the major initiatives required. These have been presented to government and as far as I know only one of the suggestions has been accepted (but not implemented).

There is abundant national and international experience that tells us that medical students who will actually want and pursue a rural career are students who are emotionally, intellectually and even financially wedded to a preference for rural life and hence a rural career. The closest we have come to applying this knowledge involves all medical school having a quota for 25% of their students to be “rural”. The definition of what constitutes “rural” is ridiculous. You are so designated if you have spent five years of your life in a rural postcode. You could have been born in Broken Hill, moved to Melbourne when you were five and not laid eyes on a cow since then but still qualify as “rural” student. The accepted suggestion referred to above would see medical schools fined if they did not achieve their 25% quota.

At least five universities have been lobbying government for funds for rural based medical school.  In general these would involve expansion of excellent existing rural clinical schools into rural medical schools. I have been heavily involved in developing an evidence-based initiative proposed by a Charles Sturt/ Latrobe partnership for the Murray Darling basin. As had been true for other universities both the Gillard and Abbott governments have said they were attracted to the models but there was no money available. In the background many existing medical schools, concerned that such developments might require them to reduce the number of students they admit, have argued against the establishment of rural schools. Now to have the Abbott government, without consultation with key players, announce a Perth based medical school is nothing short of disgraceful; a “keep WA happy” imperative trumps any need to improve the health of rural Australians.

What are the key recommendations that we must continue to pursue despite the damaging political intransigence so far on display? Space will only permit a summary.

Create opportunities for whole of medical education requirements to be fulfilled in the country, too many medical graduates dependent on city placements for vocational training will not return to a rural community. For this reason rural medical schools should be based on undergraduate programs. Admission to a rural based medical school will involve “affirmative action” philosophies to provide for example, the flexibility to overcome rural high school educational disadvantage and an interview to assess genuine “rurality”. Students will enjoy a rural specific curriculum with an emphasis on early development of procedural skills and a focus on indigenous health issues. The medical course will have strong inter-professional learning modules that will involve shared learning with other health related students. Team learning to prepare for team medicine is an imperative for the best use of a scare workforce in the country. Graduates will be guaranteed an internship in a rural based hospital. It is worth debating the merits of redistribution of existing medical school placements rather than increasing further the number of enrolled students.

A lot of work by dedicated knowledgeable professionals from a number of universities, rural community advocates, the now defunct Health Workforce Australia and numerous rural health organisations has generated the above suggestions and all would have expected that a rural based medical school with the above features would be the “next cab of the rank”.  ‘How naïve’ says Mr. Abbott.

John Dwyer is Emeritus Professor of Medicine at UNSW. 

print

This entry was posted in Current affairs, Education, Health, Politics and tagged , , . Bookmark the permalink.

One Response to John Dwyer. Politics trumps health policy yet again.

  1. I go much further than my friend and colleague, John Dwyer. I have long pointed out that no sizeable country has solved their ‘rural doctor’ problem. Why should Australia be any different? I see two quite distinct problems:
    1. Why can this not work?
    2. What is the only workable solution to providing rural ‘health care’?
    1a. Our doctors are all trained to the highest standards, supported by the latest whizz-bang technology. These facilities (apart from remote radiology) are not available in small towns. By definition, they are ill-trained for remote practice.
    1b. The hand-on jobs in hospitals are reserved for the registrars who will become specialists. The medico-legal risks of allowing juniors who are not in specialised training are too great, nor do the specialist teachers have the time to train non-would-be specialists.
    1c. Most medical students now are female. Most medical graduates are female, including two of my daughters. It has been shown by Peter Brooks and others that medical women, over a life-time, work 40% less hours than men. In general, they choose jobs which can be done part-time: half- or part- days in general practice, dermatology or psychiatry (collect the kids from school), rostered intensive care, rostered emergency medicine, rostered neonatal medicine, scheduled anaesthetics etc.
    1d. Doctors want their kids to have a good education. If they go rural and remote, that often means boarding school away from parents. Who wants that for their kids nowadays?
    1e. Doctors who have trained in cities and large towns are accustomed to having all the facilities and convenience of cities and large towns. They simply do not want to live in the country – money might tempt them for a few years, but will not keep them there. “Doctors come and go!’ is the cry of many a small town.
    1f. One doctor in a small town 24/7 burns out. Two are better, but each now must have time off for continuing professional education, need holidays and might become ill. In reality, three is the minimum for a long-term solution. But, at something like 750-1,000 patients per doctor if he or she is not to twiddle their thumbs, the area needs a population of close on 3,000 to keep its doctors.
    1g. Doctors marry doctors. (Both my daughters did, as did so many of their friends). How do doctor couples manage specialisation in different areas of interest and often with training opportunities at different hospitals? Even general practice is the oxymoron of a ‘specialty’, taking almost as many years to complete the postgraduate training as the ‘real’ specialties. How does the couple find a location where both can practise their chosen field?
    2. The solution lies in NOT trying to provide many rural and remote areas with ‘medical care’. I know of no successful scheme, of any duration, anywhere. The answer lies in providing ‘health care services’, supplied by local people trained as health care workers, capable of handling most problems which would, in the cities, present to a GP. We have the example in Aboriginal health services. Many countries are now adopting the long-standing tradition in Russia (feldschers) and in China (‘barefoot doctors’). They are showing that it is feasible.
    Why do Australian academics persist in chasing a chimaera?

Comments are closed.