Fear of Going Bush; the Misconceptions Surrounding Rural Health

Peta O’Brien - Australian National University (II)

The state of rural healthcare in Australia grows grimmer with each passing year. Small towns are experiencing difficulties recruiting and retaining local doctors, and vital services such as maternity units are being closed down due to a lack of adequately trained staff. The extent of the situation was laid bare in 2019, when the Western NSW Primary Health Network (WNSWPHN) predicted that 41 small towns in the region would be without a GP within 10 years1 . For years, the Commonwealth’s answer to this crisis has been to issue 10 year moratoriums of service for international medical graduates (IMGs) coming into the country. Under this legislation, IMGs can only access Medicare benefits if they work or train in ‘priority’ areas. Often, these are exclusively rural and remote regions. As a result of this policy, in 2012, 41% of rural and remote doctors in Australia were overseas-trained2 . But, in 2018, the Australian Government announced it would be cutting 800 visas for IMGs over the coming 4 years3. With this announcement came an unspoken promise; the number of locally-trained doctors in rural areas would have to increase.

It is now commonly accepted that the ‘rural doctor shortage’ is, more accurately, a geographical maldistribution of doctors. Australia has a sufficient amount, if not a surplus, of doctors — in fact, the number of medical graduates has doubled over the past fifteen years4. The problem — as it has always been — is encouraging medical graduates to move away from the city.

Many initiatives have been implemented to try and achieve this. Medical schools have received funding to establish rural clinical schools, graduates have partaken in ‘bonded’ work schemes, and rural placements, cadetships and incentives have all been introduced. With so much work being done, how exactly did we end up with this current crisis and why isn’t the situation getting any better?

Photo by Daniel Morton on Unsplash

A variety of reasons have been offered to explain why doctors don’t want to practice rurally. Many of these are practical in nature, such as needing to stay in a metropolitan centre for spousal work, or to access specialty training pathways. But it seems that some doctors also hold on to misconceptions which affect their willingness to go rural.

A recent media report suggested that doctors are reluctant to move to rural areas as they will have less patients5. This belief is underpinned by the fact that rural towns have smaller populations. However, what urban doctors may not realise is that due to the undersupply of rural doctors, and the geographical distribution of populations, the GP-to-patient ratio is often higher in the country1. Consequently, rural GPs are often fully booked for weeks in advance. And it’s not just GPs who find themselves in this position. For example, the town of Wellington, in the Central-West of NSW, only has one on-duty doctor at the local hospital. They serve a population of more than 4500 people6. So, not only would doctors moving to a rural area find themselves with more patients, but they would also be assisting by reducing the patient-doctor ratio to a safer level.

Urban doctors are also reportedly concerned that they would have less opportunities to use their skills if they were to relocate to a rural area5. Research shows, however, that rural GPs actually perform more procedural work compared to their metropolitan counterparts7. In order to meet the needs of their communities, rural GPs must also often learn skills across the emergency, obstetric and anaesthetic fields. Research has also shown that rural interns are often afforded more responsibilities than their urban counterparts, and are given more opportunities to perform clinically-based work8 .

It has also been reported that rural medicine is not challenging enough in order to attract high achieving doctors5. Even a cursory review of the rural doctor’s job description provides evidence to the contrary. Data shows that rural patients suffer from higher rates of chronic illness. Rural doctors must care for these patients with fewer resources, and in environments that are often understaffed9 . Furthermore, due to the difficulties that rural patients experience in accessing specialist care, rural GPs also routinely oversee the management of very specialised and complex conditions.

Doctors and medical students also seem to hold misconceptions about the options available to them in the field of rural health. The majority of discussions about rural medicine focus on generalism. Medical students can often be heard saying that they enjoy the rural lifestyle, but can’t practice rurally as they don’t want to be a GP. While it is true that those pursuing specialty training will likely have to do so in metropolitan facilities, in the longer-term, students should consider a move to the country. Rural areas have a persistent need for both specialists and generalists. Specialist ratios decline from 143 per 100,000 people in metropolitan areas, to just 22 per 100,000 in very remote regions9 .

The factors contributing to the maldistribution of doctors across Australia are complex. However, as this article has demonstrated, several of these factors are reliant upon falsities. Moving forward, universities, student bodies, and the media all have a responsibility to properly represent rural health. Dispelling harmful misconceptions will be key to attracting more doctors to settle in rural communities.

Peta O’Brien is a second year medical student at the Australian National University and has a strong interest in rural health issues. She also holds a Bachelor of Clinical Science from Charles Sturt University.

References

1. Western NSW Primary Health Network. Securing the future of Primary Health Care in small towns in Western NSW [Internet]. Mar 2019 [cited 5 Apr 2021]. Available from: https://www.wnswphn.org.au/uploads/ documents/corporate%20documents/Securing%20 the%20future%20of%20Primary%20Health%20 Care%20Services%20in%20Small%20Towns%20in%20 Western%20NSW.pdf

2. Standing Committee on Health and Ageing. Lost in the Labyrinth: Report on the inquiry into registration processes and support for overseas trained doctors. Mar 2012 [Cited 6 Apr 2021]. Available from: https://www.aph.gov.au/parliamentary_business/ committees/house_of_representatives_committees?url=haa/overseasdoctors/report.htm

3. Hendrie D. Government reduction of visas for overseas GPs to save $400 million 2018. NewsGP [Internet]. 31 May 2018 [Cited 6 Apr 2021] Available from: https://www1.racgp.org.au/newsgp/professional/ government-reduction-of-visas-for-overseas-gps-to.

4. Medical Deans Australia and New Zealand. Student Statistics Tables 2021. Available from: https:// medicaldeans.org.au/data/

5. Woodburn J. Doctors deterred by regional NSW’s ‘professional isolation’, consider general practice ‘poor cousin’. ABC Central West [Internet]. 26 Feb 2021 [cited 1 Apr 2021] Available from: https://www. abc.net.au/news/2021-02-26/doctor-shortage-regional-rural-nsw-towns-plead-for-answers/13178224#:~:text=The%20’poor%20cousin’%20of%20 medicine,within%20the%20next%2015%20years.&text=%22General%20practice%20is%20the%20poor,specialties%2C%22%20Dr%20MacKinnon%20said

6. Drinkwater D. Doctor shortage at Wellington Hospital forces residents to ramp up the pressure. ABC Western Plains [Internet]. 19 Nov 2020 [cited 7 Apr 2021] Available from: https://www.abc.net.au/ news/2020-11-19/wellington-ramps-up-pressure-toaddress-doctor-shortage/12900460.

7. Larkins S, Evans R. Greater support for generalism in rural and regional Australia. Australian Family Physician. 2014;43:487-90.

8. Bailey J, Pit S. Medical students on long-term rural clinical placements and their perceptions of urban and rural internships: a qualitative study. BMC Medical Education. 2020;20(1):188.

9. Australian Institute of Health and Welfare. Rural & Remote Health [Internet]. 2019. [Cited 1 April 2021] Available from: https://www.aihw.gov.au/reports/rural-remote-australians/rural-remote-health/ contents/summary