Being able to train in rural areas is not only critical to keeping doctors in the bush – it also affects their choice of speciality.
By Cathy O’Leary
Medical specialists who had the chance to train in rural areas are almost three times more likely to choose to work there after finishing their training, according to an Australian-first study.
Led by Notre Dame University, the study of 1220 medicine graduates from nine Australian universities also showed the impact of doctors’ specialisations on their decision to work in rural areas later in their careers.
Published in BMJ Open, the study’s findings come amid a critical shortage of doctors in rural, regional and remote areas of Australia, with both general practitioners and other medical specialists in short supply.
The Notre Dame study found about 30% of GPs – the specialty that gives doctors the opportunity to do most of their training in rural areas – were practising in the country 10 years into their careers.
But only 10% of other medical specialists such as psychiatrists or paediatricians, and 15% of surgical specialists, ended up in non-metropolitan areas a decade after graduation. These specialists do most of their training in the city.
Lead author and researcher from Notre Dame’s Wagga Wagga Clinical School, Dr Alexa Seal, said meeting the medical workforce needs of rural Australians continued to be a major challenge.
“This study reinforces the impact of rural training pathways on a doctor’s longer-term work location,” she said. “Specialist training needs to be expanded to support more rural training opportunities for doctors outside general practice because we know that rural exposure is associated with the likelihood of living rurally in the future.”
According to the Australian Medical Association, research continues to show rural Australians have higher rates of hospitalisations, death and injury, and poorer access to primary health care than people living in major cities.
There are seven times fewer specialists in remote areas than in metropolitan areas, leaving many patients with no choice but to travel extensively – often with significant financial and familial burden – to attend appointments.
The Notre Dame research built on two earlier studies on the same group of medical graduates from the class of 2011 – one that looked at their practice location after five years and another after eight.
It found the number of specialists working in regional, rural or remote areas increased from 15% at five years after graduation, to 19% at 10 years. This is mostly attributed to non-GP specialists moving to the country after finishing their training in the city.
The study’s findings also underline the value of rural immersion, such as that offered by the Wheatbelt Medical Student Immersion Program – a collaboration between Notre Dame and Curtin universities, Rural Health West, WA Primary Health Alliance and the Wheatbelt East Regional Organisation of Councils.
That program was developed in direct response to the acute doctor shortages in regional WA, which has one of the heaviest reliance on overseas-trained medical graduates, by providing first-hand experience of medicine in a rural community.
While some medical students already harbour a strong interest in rural medicine before medical school, others can develop an interest through rural immersive experiences as part of Rural Clinical School placements and other rural placements.
Changing lives
For Notre Dame graduate-turned GP obstetrician Dr Clare Hardie, the decision to work in WA’s Wheatbelt was born out of a rural stint during her third year of studies.
“I had an interest in rural medicine, and I jumped at every opportunity at my rural medical school in Northam,” she says.
Brisbane-born and a self-described “city girl through and through,” she was doing her Rural Clinical School Placement in Narrogin in 2015 when she met a farmer who would change the course of her life.
The pair hit it off and Dr Hardie made the decision to join her now-husband Brendon Gilbride in the town of Wandering, but before that could happen, she had to do most of her obstetrics training in Perth.
She was grateful to be able to finish her training under a mentorship program in Narrogin but admits the move from being well-supported in the city to working far more autonomously in a country hospital was daunting.
“For me it was probably a combination of meeting my husband at the right time, and working rurally and loving it, so it was a case of killing two birds with one stone,” she told Medical Forum.
“And at Notre Dame, rural medicine is ingrained from day one of medical school, with case studies to problem solve often based rurally, and the university is really directed at creating rural generalists, so that has an impact by encouraging us to go through third year Rural Clinical School immersion and getting us back out into the country.”
With a farmer husband and two young sons – four-year-old George and two-year-old Henry – she says life is now very busy – “we’re absolutely in the thick of it.”
Dr Hardie is now the only local obstetrician in Narrogin, with the on-call service run by locums.
“I am here because of the Rural Clinical School and all of my GP training could be done regionally, but not the obstetrics,” she said. “When I came there were two obstetricians, but they have both since left, so if I was to go, there would be no one here permanently to replace me.
“That continuity of care is so important. If you see a woman throughout her pregnancy, you have automatic rapport in the birth suite – and she has trust in you – which makes the birth experience more positive.”
She has also learnt to deal with the challenges of triaging patients to work out who really needs to be seen.
“I’m aware that if I see one patient too much, then that takes away from another patient. And while that’s partly because I do limited hours anyway, it is also because there isn’t anyone else in town who is practising, so they might be retired or they’re not credentialled to deliver.
“If you’re relying on locums, these women are relying on someone they have never seen before during the most special time in their life when their baby is being delivered.”
Four years into her job in Narrogin, Dr Hardie is now starting to see some mothers for their second babies, which is one of the most rewarding parts of her work.
“I seem to get hit up at Coles a lot now,” she said. “Every time I do my click and collect, I run into a mum who is eager to show off their baby to me.
“You get that because it’s a small town. You’re seeing the same patients continually, you see them for the birth and then a few years later you get to do it all again.”
She said there were currently two GP clinics and about 10 doctors in Narrogin, and that was a respectable number.
“During COVID we really struggled with very limited doctors, and it was definitely more stressful then, with patients waiting six weeks to get in to see us, when you just shouldn’t be waiting six weeks to see a GP,” she said.
The Notre Dame study comes hot on the heels of a position paper by Australia’s peak medical school deans’ group, with 25 recommendations to turn around the struggling rural health workforce.
That includes encouraging a rural-first training model, with metropolitan-based training being the exception rather than the rule.
Deans advocating
Medical Deans Australia and New Zealand argues that non-GP specialty colleges need to consider how training could be restructured to allow more opportunities for rural doctors, with rural generalism on track to become a fully-fledged specialty.
According to the association, 7% of doctors in training listed rural generalism as their first preference of future specialty in 2023 – a rise of more than two percentage points since 2021. General practice, meanwhile, was first preference for about one in 10 students.
The working group which wrote the position statement had representation from WA, including the Rural Clinical School of WA.
It noted that in Australia in 2020, there were 309 medical practitioners per 100,000 population in major cities, compared to 273 per 100,000 population in outer regional, and 223 per 100,000 population in very remote Australia.
Among Australia’s 2022 graduating cohort, just under 40% of domestic medical graduates indicated a preference for future practice outside capital cities, and this increased to over 72% for students from a rural background.
Similarly, almost three quarters of graduates who undertook a rural placement for more than a year indicated a preference for future careers outside capital cities, irrespective of their rural origin.
The deans’ association said the key going ahead was to adopt a flipped model of training where learning takes place in and for rural communities, with rotations to metropolitan or large regional hospitals only if required.
In another recent development in rural training, the Rural Generalist Pathway WA has developed a tool known as the Career Navigation Record to help trainees through each stage of their rural generalist training.
The electronic record follows each trainee documenting their aims and the outcomes of their career discussions.
Trainees receive personalised career advice and mentoring, and each one is paired with a dedicated director of clinical training to help them work towards fellowship and beyond.
More than rhetoric
Meanwhile Dr Hardie says there are still many logistical challenges of rural medicine, and despite some of the rhetoric about support for training doctors and those wanting to upskill, when push came to shove, it was not always forthcoming.
“One thing I’m hearing is that a lot of genuine rural doctors want to upskill and bring back their skills to the communities that they’re already based in, but the support in city hospitals where it needs to be done is just not there,” she said.
“When I was going through my training, there was a specialist obstetrician who really encouraged us to do GP obstetrics and go rural.
“She was an advocate for us at KEMH in that she gave us access to good jobs like 10 weeks straight of caesarean sections, and in my case, experience that would help me set up in Narrogin. But she’s left now and I’m not sure that sort of advocate is still there in the big hospitals.
“And that’s really sad because if we want to get people with specialist skills out to rural areas, we need the city to be onboard. That means clear training pathways, and priority for those who are genuinely regional as opposed to someone who has no interest in going rural.”