Who will be the rural GPs of the future?

Dr Robin Chan has always been drawn to rural and remote work.
 
Her parents left Brisbane for a small village in the central highlands of Papua New Guinea when she was very young. She returned to Brisbane to study and then train as a doctor.
 
She then started moving northward – Townsville, a stint as a medical officer in the military and another at the Royal Flying Doctors servicing remote Aboriginal and Torres Strait Islander communities, a period in a private practice in Cairns.
 
She finally made it to Thursday Island Hospital – about as far north as you can go in Australia – with her husband and two small children.
 
‘For me, it was normalised by my childhood, plus a spirit of adventure,’ Dr Chan told newsGP. ‘I like to see what we can do and where you can go.
 
‘Rural generalism can take you amazing places, open up parts of Australia that are not open to other specialties.’
 
The work for a rural GP is hugely varied, ranging from treating Irukandji jellyfish stings to crocodile bites to figuring out how to retrieve patients from isolated outer islands.
 
Dr Chan believes the doctors who are more likely to stay in the bush long term are those who grew up there.
 
‘We have learned that [these doctors are] more comfortable living, practising medicine, having families and settling down in rural environments. We understand that we’ve got to grow our own doctors,’ she said.
 
‘Who are the rural GPs of the future? They might be from the bush, and they’re going to be flexible, adventurous, confident and resourceful doctors, who are comfortable outside their comfort zone,’ she said.
 
There are joys to working in the bush, but it is definitely not without its challenges. Rural doctors who return to the city often do so because their partner cannot find a job, or because they want to return to a larger metropolitan area for their children’s education, Dr Chan said.  
 
Dr Chan’s experience speaks to a wider challenge for Australian healthcare. After years of undersupply in the medical workforce, will the thousands of freshly minted doctors go bush – or stay closer to friends and family in the big cities where most of us live?
 
It’s well known that it can be hard to find a GP outside of Australia’s major cities. Many come for around five years, only to return to the city once they have children. The rural doctors who stay longer are getting older. The average age for a rural GP in 2014 was 50 years.
 
And that, in turn, leads to worse health outcomes for the seven million Australians who live outside the major cities. Shorter lives, poorer health outcome and greater difficulty accessing health services are common factors in rural areas.
 
A key part of this challenge is attracting and retaining GPs to rural and remote clinics.
 
For years, the recruitment gap has been taken up by international medical graduates (IMGs), who face a moratorium in which they must practise in rural or remote areas for up to 10 years after arriving in Australia in order to be able to bill Medicare. More than 40% of GPs in rural and remote Australia were trained overseas.
 
In this month’s edition of the Australian Journal of General Practice (AJGP), Professor Simon Willcock observes that efforts to deal with the undersupply of rural GPs have had patchy success at best.
 
‘If indeed there is an irresistible drift of practitioners to larger population centres, and if emphasising the differences (rather than the similarities) in rural and remote practice means that any such rural and remote workforce is passionate but numerically tiny, do we need to develop new approaches to workforce development and distribution across the full span of a medical career?’ he writes.
 
But change is coming. In this year’s Federal Budget, the Government announced that it would cut the number of visas for IMGs by 200 a year – and boost funding to rural medical schools.
 
The implication is clear: the undersupply of locally-trained doctors is over.
 
The move came two years after a call by prominent medical figures to cut visas for IMGs.
 
‘As the number of Australian-trained doctors has increased substantially over the past decade, it’s timely to consider whether existing immigration markers are still appropriate for our health workforce needs,’ a Department of Health spokeswoman told the ABC in 2016.
 
Supply not meeting demand
Will locally-trained doctors go bush? Is it as simple as it seems?
 
Not exactly, according to Alex Farrell.
 
It seems odd to have the president of the Australian Medical Students Association (AMSA) opposing plans for more medical students.
 
But that is precisely what happened after the Federal Government this year announced its $95 million expansion of medical schools in the Murray-Darling region.
 
According to Ms Farrell, the issue is that there are now significant bottlenecks for medical students in gaining an all-important internship, as well as major difficulties in getting into specialist training.

Australian Medical Students Association President, Alex Farrell, believes many young doctors who might go rural are instead drawn back to the major cities in order to pursue specialisation.
 
‘If I had a magic wand, I’d say no more medical students. We’ve got a massively overcrowded system,’ she told newsGP.
 
‘It’s bizarre; we create these junior doctors and give them nowhere to go.
 
‘When we talk about doctors in the country, we don’t need juniors, we need specialists. You talk about towns without a GP, but to be that doctor, it’s med school, junior doctor and then speciality training.
 
‘Graduating [medical] students have doubled in the last 10 years. So we’ve had this explosion at student level, but it hasn’t translated upwards to specialty training.’
 
What that means, Ms Farrell said, is that many young doctors who might go rural are instead drawn back to the major cities in order to pursue specialisation.
 
In contrast, La Trobe University Vice-Chancellor Professor John Dewar told the ABC that the announcement to expand medical schools in the Murray-Darling region would lead to an increased number of rural doctors.
 
‘The evidence is that the retention of graduates from programs like this increase to about 70% or above, whereas the proportion of graduates coming out of the metropolitan-based schools – even those who’ve come from regional areas – is far lower. Somewhere around 10%,’ he said.
 
The question of whether locally-trained doctors will go bush is a daily concern for Martina Stanley, the director of medical recruiting firm Alecto. Earlier in her career, she was the interim CEO of Rural Health Workforce Australia.
 
Ms Stanley does not believe that locally-trained doctors will leave the major cities.
 
‘Who will be the rural GPs of the future? We have to face the fact that we won’t have enough, and we need to think about alternatives – AI, wearable devices,’ she told newsGP. ‘It’s a shocking thing to say, I know, but we tend to live on hope and sometimes that’s not enough.’
 
It’s a strong statement, but Ms Stanley is at the coal face.
 
‘At present, our rural workforce is [around] 40% overseas-trained doctors,’ she said.
 
‘We know that, over time, overseas-trained doctors gravitate to metro areas to meet the needs of their family. A lot won’t stay in bush after their moratorium. Who’s moving to the country to replace them?’
 
‘We’re saying that the solution is that we’re going to replace all of them with [a locally-trained] workforce, but the local graduates will not go to the bush long term.
 
‘Once they graduate, what we see is that Australian graduates – even now, with all the numbers – don’t want to work in the bush and not even in outer-metropolitan areas.’
 
Ms Stanley’s company has not had a single locally-trained GP apply for open positions in Melbourne’s booming western suburbs in the last three years. This is a situation, she said, that is in danger of going unnoticed.
 
‘All the policy is so focused on rural areas that we are completely forgetting all the millions living in outer areas, and the fact Australian-trained doctors are not interested,’ she said.
 
‘I’ve got two bulk-billing clinics in Dandenong [30 km south-east of the Melbourne] desperate for doctors. No Australian doctors are applying.’
 
The same goes for many other outer-metropolitan areas around the country. 
 
‘We’re going to see practices closing in Perth, just because they can’t find doctors,’ Ms Stanley said. ‘I’m not exaggerating. It all comes back to workforce.
 
‘What I see happening is, while we have such great need in outer-metropolitan areas, we’re not going to see [locally-trained] doctors wanting to go beyond that.’
 
The recent cuts to visas for IMGs, will, Ms Stanley believes, mean there will be no one willing to do the work.
 
‘Our shortfall of unfilled positions is around 300. Over the next 12 months, we might be able to fill 50 of them,’ she said. ‘We have positions that have been open for literally years that remained unfilled.’
 
Ms Stanley’s concerns are mirrored by Dr George Alhorani, a Wollongong-based doctor who trained in Jordan. He spent seven years in rural Tasmania upon arriving in Australia.
 
‘[Cutting visas] is the most unwise decision the [Department of Health] and our government will take,’ he told newsGP.
 
‘If they do that, in two years we will not find any doctors to work after-hours or on weekends and public holidays. Australian graduates will not work these hours.
 
‘We can’t get local graduates to work in our medical centres in Western Sydney. I really care about my country and I can see these [moves] will only make our health system collapse in these vulnerable areas.’
 
A beautiful life
For Australia’s current rural and remote GPs, the satisfaction of the job is the real drawcard.
 
The challenge, though, is making the pitch to city-born GPs.
 
‘It really is an enjoyable, lifelong career with a lot of job satisfaction. You get drawn back to the place.’
 
That’s Dr Adam Coltzau, President of the Rural Doctors Association of Australia. He’s been in the bush for 18 years.
 
Dr Coltzau knows firsthand that many rural GP clinics are under significant financial and staffing strain. But he believes the long mandatory stint of rural or remote work required of IMG graduates simply doesn’t work.
 
‘After that, they go back to the cities,’ he told newsGP. ‘We need a combination of carrots and sticks.

‘We want to tell people how enjoyable it is to work in the country. The relationships you develop with patients over time is unique in a rural area. You’re more a member of the community and, as a GP, you get professional respect as well.’
 
Like Dr Chan, Dr Coltzau believes common, albeit hidden, factors stopping GPs from going bush for a long period are their partner’s careers and the education of their children.
 
‘Access to education and spousal employment are definitely a factor in people deciding to leave a rural area,’ he said.
 
Dr Coltzau believes the Department of Health should better tailor rural GP incentive programs, and potentially switch to a rural-loading model for bush GPs, to make the move more financially appealing.  
‘We do have a lot of overseas-trained doctors who enjoy it and stay on after the moratorium,’ he said. ‘To get more locally-trained doctors, I think they need exposure to rural medicine as a student. That’s how I ended up in [Queensland town] St George.
 
‘Then they need to be repeatedly exposed to rural general practice, and make sure they see rural general practice as a specialty just like any other – one that’s worthwhile doing.’ 
 
There has been recent progress on that last front.
 
Emeritus Professor Paul Worley was appointed as Australia’s first National Rural Health Commissioner in October last year.  
 
At a historic meeting in February, Professor Worley and Australia’s two GP colleges, the RACGP and the Australian College of Rural and Remote Medicine (ACRRM), came to an agreement over the future of rural generalism – a medical specialty designed to adapt general practice to the needs of the bush, where a GP may need to do everything from childbirth to anaesthetics to emergency medicine.

L–R: ACRRM’s Dr Michael Beckoff, National Rural Health Commissioner Professor Paul Worley, Minister for Rural Health Bridget McKenzie, RACGP Rural Chair Dr Ayman Shenouda after agreeing on rural generalism at a meeting in February.
 
A rural generalist, the colleges proclaimed, would be a medical practitioner
 
[W]ho is trained to meet the specific current and future healthcare needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural healthcare team.
 
That announcement met with strong approval from the medical students at AMSA, which represents many of the GPs of the future.
 
AMSA rural health committee co-Chair Nic Batten described it as an ‘exciting opportunity’.
 
‘[It’s] a clear rural training pathway, options to pursue their interests, and the flexibility of having their qualifications recognised across states,’ she said.
 
The move towards formalising rural generalism was, Ms Batten said, a first step towards addressing the persistent need for doctors in the bush.

rural doctors rural generalism rural health workforce