Removing choice will not increase regional GP numbers

Deborah Carrington

10/08/2021 3:44:14 PM

Incentives, not restrictions, should be used to encourage more doctors to practise outside the major cities, writes rural GP Dr Deborah Carrington.

Wheat field.
One of the biggest attractions to general practice is the freedom GPs enjoy.

Recently I had the novel experience of participating in my first radio interview.
I had written a blog post about the shortage of GPs in my rural community and was invited to talk about this on our local ABC Radio breakfast program. In true rural style, I sat huddled in my freezing car on the side of the highway as I could not get decent phone reception at my house.
Just after my segment, our local federal member was interviewed and asked about the rural GP shortage. He acknowledged the current crisis in our area and expressed frustration that none of the initiatives that had so far been tried by the Government had worked.
One of the solutions he proposed was the introduction of geographic allocation of provider numbers. This idea seems to have come up intermittently over the years and aims to address the workforce distribution imbalance by forcing GPs to move outside of major cities to access Medicare rebates.
Essentially, rural Australia needs doctors, and if doctors will not go willingly then the choice may be taken away.
I have been sitting with this thought ever since. Such a policy would not impact me personally as I am already living and working in an area of great need. We would welcome new doctors to our clinic with open arms, a red carpet and daily baked goods.
However, I cannot honestly see how forced distribution of provider numbers is going to help general practice as a profession, when we are already seeing falling numbers of junior doctors choosing our specialty. This seems to be a policy along the lines of ‘beatings will continue until morale improves’.
It will likely breed resentment and the impression that rural medicine is a punishment that must be endured until one can be free again to live a real life in the city. We can see from the outcomes of the rural bonded scholarships scheme how this has played out.
My journey to being a rural GP was unusual.
I was born and raised in Melbourne with very little exposure to rural life apart from occasional school holidays. I attended a city-based university and metropolitan clinical school.
After being immersed in the environment of tertiary hospitals I was drawn to the humanness and connection of general practice. I could see that within the four walls of the GP’s consulting room there was a freedom to develop one’s own style of consulting, and to follow one’s passions and interests.
GPs seemed to me to have been free to develop as unique individuals in the world of medicine in a way that deeply impressed me.
I was a married general practice registrar with two small children when my husband was offered a job in a small country town. After transferring my training to the local practice, we moved four hours away from all our friends and family.
Over the next few years, I learned the art of general practice whilst I adjusted to life in a rural community. The learning curve was steep, but there were kind and experienced hands to support me as I navigated it.
After gaining Fellowship, I stayed on. We bought a house on a little acreage and had two more children. I am now a supervisor and medical educator myself, and I have followed the journeys of many registrars as they have entered rural training and come out the other side.
I have also silently mourned when excellent registrars have completed their training and gone back to the city.
The truth is that there are many reasons why making a long-term move to the country can be challenging. I have battled with this myself.
The grief of separation from friends and family. The frustration of partners unable to find satisfying employment. The worry about educational opportunities for our kids. The loss of privacy and struggling to fit in socially. Missing the lifestyle aspects of city life. Sadly, even racism can be an unspoken issue.
There can be a tendency for both patients and government to blame doctors for being selfish in not wanting to live rurally, without acknowledging that there is genuine sacrifice involved.
On the other hand, there is so much to love about rural living.
My children are having a happy childhood growing up on an acreage. Where we are living, housing is dramatically cheaper which removes a significant financial burden. Although the drive to the city is long, our day-to-day life is free of traffic congestion or parking issues. The medicine is fantastic, with never-ending variety.
Once I adjusted to the lack of anonymity, I came to find joy in feeling a part of the community. I am proud to call this my home. I doubt, however, that I would have come to love it here had I been forced into it.

Although the drive to the city can be long, the day-to-day life of rural GPs is free of traffic while the medicine is filled with variety.

One of the biggest attractions to general practice is the freedom we have. We can choose where and how much we work. We have vast opportunities to develop special interests and portfolio careers. We can start side-hustles and pursue a full and varied life outside of medicine.
This is what keeps many of us going in spite of the trials the profession is facing. To take away this freedom would be the final straw. I can see many good GPs walking away from the profession rather than lose their autonomy.
Recently, we have seen the call for a new Senate Inquiry into GP shortages in regional areas. Whilst I am pleased to see this issue getting greater attention, I have some trepidation about what solutions may be proposed. I hope that strategies will be focused on incentives and training to encourage a willing and eager workforce.
The Prevocational General Practice Placements Program, the rural incentive program and rural-based medical schools have all borne some fruit. I don’t think we should regard these previous initiatives as failures.
The problem is that while these schemes have been tried, there has been a simultaneous defunding and devaluing of general practice as a profession. Until this wider issue is addressed, the rural workforce will continue to struggle.
The key time to encourage more doctors to embrace rural health is in the training years.
Building a life in the country is hard to do when you have an established general practice, a family and a mortgage in the city; the seed needs to be sown earlier in one’s career, when adventure is attractive and the possibility of a fresh start is exciting rather than daunting.
I am not privy to the current plans for the new RACGP training program, but I fervently hope that nurturing our rural registrars will be a priority.
Being the only registrar in a small town can be isolating. Regular face-to-face teaching and the opportunity to bond with nearby registrars can transform the experience. Supervisors need to be generously resourced so they can spend the time needed to support new registrars well as they find their feet.
I am living proof that feeling supported and valued in a practice can be enough of a reason to stay.
Rather than imposing restrictions on an already demoralised workforce, our Government should be working towards making rural general practice so professionally, financially and personally rewarding that doctors like me seek it out with enthusiasm.
We have many of the key ingredients here already. Rural GPs are a resourceful and passionate group of highly qualified health professionals with intimate knowledge of their communities.
I hope someone listens to us before it is too late.
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Dr Marjorie Winifred Cross   11/08/2021 7:37:52 AM

Thank you very much Dr Carrington. There is so much that is relevant here - a great article
I applaud your careful wording about some initiatives so far The rural clinical schools program would benefit from an audit - some of them have not been successful, some of them have .
I also applaud your statement that the College's new training program is now pivotal and rural communities cannot be let down

Dr Michiel Mel   11/08/2021 8:03:27 AM

Nail on the head Deborah. Many thanks for writing that down. I hope you continue to bring that message forward!

Dr Matthew Laurence Byrne   11/08/2021 8:14:42 AM

Excellent summary of the pluses and minuses of rural general practice. Deborah is right in identifying the real issues facing general practice , it is devalued and thought to be too hard . We need carrots not further sticks

Dr Peter JD Spafford   11/08/2021 8:43:32 AM

Well said. Carrots not sticks. The issue is complex. Unfortunately being burdened by excessive GP Registrars and Medical students rurally is one of the reasons I no longer practice. Supporting the existing GPs is crucial otherwise this key element is lost. I loved teaching, but it is demanding and, when excessive, tiring rather than rewarding. Asking a rural GP what will attract people is not going to give the answer. Most love being rural will not understand why more do not chose it. Rather ask the urban GP, "What would make you consider moving to a small rural town?" Rural Australia really needs more GPs rather than trainees and doctors needing supervision.

Dr Ian   11/08/2021 8:58:51 AM

Don’t like saying it but the rebates ought be doubled and the training extended for Two years for Emergency Medicine and Psychological Councelling .
Telemedicine and Five Star Ecological Green Housing ought be provided free .
Plus Ambulance fitted Four Wheel Drives
Work 9 months a year for a Decade .

Dr Peter John Killey   13/08/2021 9:08:28 PM

Yeah.... good luck with that. Been here 30 ye

Dr Mehdi Sanati Pour   19/08/2021 2:53:51 PM

In my 12 year experience in rural general practice I noticed most GP relocate to city not because they dont like rural GP or community but because their family needs are not met.
It is either their spouse, which are mostly professionals, cant find a job or their children need higher schooling.
One incentive that could keep GPs in rural area is to allocate scholarship for high school positions in selected reputable high school specifically for rural GPs families.
This would be like requirement of schools to have certain number of ATSI student enrolled.
This will have an impact to keep doctors in rural area.
This will reduce the number

Dr T   24/08/2021 8:14:19 AM

I'm from the city. It is obvious that the job of a rural GP is more demanding in many respects than that of an urban GP and should attract higher rebates. That will attract more young graduates. But that won't happen.