Ups and downs of rural practice: a surgeon's view Dr Anthony Green, a solo surgeon in a rural district hospital located in the Atherton Tableland region of Queensland, describes the pleasures and pressures of his varied professional life | 
MJA 1999; 171: 625-626 |
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It was 4am New Year's day when the phone rang. I had only been in bed for
three hours after New Year's Eve celebrations with friends and
family, but the urgency in the Accident and Emergency sister's voice
woke me abruptly. Could I come in straight away to the department, as a
young man had been stabbed deeply in the right chest?
I arrived in the resuscitation room of the A&E department 10 minutes later and it was immediately apparent that it was a serious injury. The 17-year-old had been in an altercation after New Year celebrations and had been stabbed some 45 minutes earlier; fortunately, he had been brought to the hospital promptly by ambulance. He was cold, pale and shocked and clinically had a very large right haemothorax. Prompt and adequate resuscitation improved his clinical state but his respiratory distress was increasing; he was otherwise alert, but very frightened. Insertion of a right intercostal chest drain after x-ray confirmed the diagnosis, with a free and rapid flow of bright red blood, and precipitated a further hypotensive episode. He obviously needed an urgent thoracotomy. The resident hospital doctor had no anaesthetic experience in thoracotomies (not a procedure performed electively in a district hospital!) and was unhappy at the prospect of anaesthetising a young, exsanguinating patient with the prospect of one-lung anaesthesia. Fortuitously, my brother-in-law, Emile, who had been with us for the New Year celebrations, was an experienced (although off-duty) anaesthetist and he agreed to come in and assess the patient. By this time all the theatre staff were standing by ready to perform an emergency thoracotomy, and crossmatched blood was ready. Emile agreed that urgent thoracotomy was the only option and at about 5.30 am we proceeded to surgery. Fortunately, it was not difficult to find the 2-cm laceration in the right pulmonary artery and repair it and then to allow the resuscitation to stabilise the patient. Then it was a straightforward matter to find and repair some lacerations in the bronchi and bronchial arteries. It was all over within an hour or so and a somewhat jaded surgeon and anaesthetist could return home for breakfast. The patient was subsequently transferred to the regional intensive care unit and made a rapid and uneventful recovery. This case is extraordinary but highlights the advantage of having doctors trained in surgery (and anaesthesia) "on the ground" in country areas. I am increasingly asked these days how can I be the solo surgeon in a small country hospital? How do I cope without all the facilities that are available in city and regional hospitals? How can I stand being on call for such long periods? Indeed, the number of towns in Australia where solo surgeons practise has diminished as fewer of the younger generation of surgeons want to do so. Governments and health departments argue that it is not cost-effective to have surgeons in such a situation and that patients are better off being transferred out. So why do I do it? I believe strongly that the 20% of Australians who live in the rural and remote areas are entitled to have access to the highest quality of surgical care that can be made available in this country. Even the best-equipped and most efficient aeromedical evacuation service and outreach services can't be as effective as an appropriately trained and equipped surgeon on site. While it is inappropriate to have specialist surgeons in every country town, Australian Medical Workforce Advisory Committee (AMWAC) studies suggest that a population of 10 000 to 15 000 in a rural or remote area is adequate to justify and sustain the services of a specialist surgeon.1 A solo surgeon needs back-up from appropriately surgically trained general practitioner colleagues and hospital doctors. There are about 46 rural towns in Australia with one or two surgeons and another 15 with vacancies.2 I could not cope with all the minor surgical problems that occur in the district (in both the public and private spheres) without the contribution of some GPs and hospital doctors. Similarly, I rely on my GP colleagues to provide after-hours anaesthesia services and, indeed, all anaesthesia services, except for the one day a week when a visiting specialist anaesthetist is with me in the operating theatre. The provision of surgical services in a rural town is truly a team effort and requires the ongoing cooperation and collaboration of not only medical colleagues but also nursing and ancillary colleagues. A solo rural surgeon also needs a network of colleagues who cover virtually all the specialties to call on for advice; I have never had any problems in this regard. While I am on call five days a week, because of the team effort I am only actually called in after hours on average once or twice a week -- most other problems are dealt with over the phone or by assessment during more civilised hours. I live in a truly beautiful part of Australia, on a cattle property, and, although I am eight km from the hospital, can always manage this distance within five minutes (there is no traffic!). The local community is, by and large, appreciative and I enjoy good support and cooperation from the hospital and medical colleagues. My professional life is extremely varied, with the full spectrum of general surgery plus a significant amount of urology, minor reconstructive plastic surgery, hand surgery and other minor orthopaedics being managed. Obviously trauma management is important in a farming district. Continuing medical education (CME) opportunities are now numerous, and the Royal Australasian College of Surgeons (RACS) has the Commonwealth-funded Rural Locum Service, which can help find a replacement while you are away -- previously this was a major problem. Decision-making bodies at all levels in the healthcare system are usually metropolitan-based and need input from rural practitioners. This is now increasingly sought and I find a lot of my and my colleagues' time is now spent in these activities. This is, I believe, useful and worthwhile. What about the downside? For me personally, as I approach 50 (and my friends tell me how tired I look!), it is becoming apparent that, for an ongoing service, I really do need more surgical support, perhaps in the form of a half-time surgeon or even another full-time surgeon, which would allow me to be half-time. The problem of burnout does indeed seem to be real! We, the RACS, now have a training scheme (the RACS Rural Surgery Training Programme) under way to adequately and appropriately train surgeons for rural and remote practice. Soon these young surgeons will be available, we hope at a rate of eight to ten per year, to go to the areas of Australia which are currently in need. Additionally, the Joint Consultative Committee (JCC) in Rural Surgery for GPs (Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine [ACRRM], RACS) is developing a training program for rural GPs who need some surgical skills to cope in areas without specialist surgeons (or to assist solo surgeons like me). I expect that fewer of the young surgeons will spend their lifetime in rural areas, but, with the ongoing supply, there will be a presence in the bush for at least a number of years, allowing the adequate provision of surgical services. It is to be hoped that other specialties, particularly medicine, will also see the need to train their doctors specifically for these regions. On an Australia-wide basis I am very aware, in my role as Chairman of the Divisional Group of Rural Surgeons of the RACS, of what is probably best described as an "impending crisis" in the provision of services to the rural and remote parts of Australia. The main source of the crisis now is the lack of funding and provision of equipment and facilities for surgeons to operate and carry out their duties effectively in many rural hospitals, both for resident surgeons and outreach services. This is partly because modern surgical management is more expensive (and even more expensive relatively in rural areas) and also because the dollar amount in the overall health budget Australia-wide is insufficient to maintain the level of care that Australians think they have or expect to have. The adequate provision of healthcare to rural Australia is expensive. Until a greater proportion of taxpayer dollars Australia-wide is fed into the healthcare (particularly public hospital) system, I can see no simple solution to the delivery shortfalls in Australia's healthcare services. Australia needs its rural areas and benefits from them. Australians in these areas deserve access to high quality healthcare. Anthony Green | |||
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Above picture: The author applying surgical techniques to a bull's
testicles.
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