eMJA: Wakeford, Medicine in the bush: a consultant physician's view

Rural Healthcare

Medicine in the bush: a consultant physician's view

Peter Wakeford, a consultant physician in Tamworth, in the northwest of New South Wales, reflects on the joys and challenges of his professional life and on the changes seen during his years in the bush.

MJA 1999; 171: 623-624

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In February 1967 I made the six-hour journey from Sydney to Tamworth, via the mostly unsealed Putty Road, to join Doug Harbison as the second physician in the town. In doing so, I became the third physician in the northwest of New South Wales (an area the size of Tasmania), and the fourth physician between Newcastle and the Queensland border. The other physician in the northwest was John Corey, in Armidale, who supplemented his income as a sought-after anaesthetist before he left to return to Sydney to pursue occupational health.

Doug and I worked in a general practice with a general practitioner, John Bosler, seeing physician patients on referral; this included paediatrics. I refused to do anaesthetics. Doug did anaesthetics and was good at it. I was obliged to participate in the practice obstetrics roster and delivered 30 babies in all.

At that time, anaesthetic, obstetric and gynaecology services were well provided by general practitioners, who felt that physicians contributed no more to patient care than they did.

Working in general practice as well as supplying a consultant medical service eventually became untenable with various government legislation. There was total lack of support from the Royal Australasian College of Physicians and the Australian Medical Association for our problem. In fact, the President and Secretary of the College asked us to cease writing to explain our position -- we were truly isolated then!

So, in 1970, we began a physician partnership, working a one-in-two roster supplying a consultant service to the northwest. It was very quiet at first, so we extended services to other towns, travelling by car and sometimes by light aircraft to outlying areas. At that time sick patients were seen at their local hospital rather than being moved to the base hospital. Our notion that an ambulance was really a travelling bed was not accepted. We began weekly visits to Armidale and monthly flights to Wee Waa and Collarenebri (see Map). Collarenebri afforded an insight into the problems of the Aboriginal community and the work of Archie Kalokerinos in Aboriginal health.

Late-night drives to outlying centres were not without risk. We were often tired, and on occasion a sleep beside the road was mandatory. Once my wife was notified I had not arrived at Quirindi after leaving with four bottles of O-negative blood to see a patient with a gastrointestinal haemorrhage (who died shortly after I left Tamworth). The elderly GP in Quirindi questioned the serviceability of my vehicle and offered to drive along the road to look for me. Conscious of the GP's age, my wife and colleague politely declined and waited fearfully while I limped home; my car's engine had overheated because of a defective thermostat, necessitating frequent stops for water.

Specialist services were gradually set up, with a Gastrointestinal Endoscopy service starting in 1970. The first Department of Nuclear Medicine in country NSW followed in 1974. A Cardiorespiratory Unit with respiratory function testing, Holter monitoring and stress electrocardiogram (ECG) facilities commenced in 1974. Meanwhile, in 1975, two more physicians arrived, giving us an opportunity to take long-service leave for postgraduate studies; both Doug and I went to the Hammersmith Post-graduate School, London.

A Renal Unit, sponsored by the Lions Club of Tamworth, which raised $100 000, was opened in 1978. The University of Newcastle set up its rural term for second-year students in 1989.

A stand-alone Diabetic Clinic opened in 1997, with overnight accommodation and integration of the various disciplines involved in the management of diabetes. The Lions Club of Tamworth raised $350 000 to complete the initial Diabetic Clinic that Doug Harbison had shown such foresight in setting up in 1979.

Physician services progressively evolved to include Nuclear Medicine, Nephrology, Respiratory Medicine, Rheumatology and Neurology, with local physicians with interests in Cardiology and Gastroenterology. All physicians participate in the general roster. Visiting services were developed to Moree, Narrabri, Coonabarabran, Gunnedah, Warialda, Armidale, Manilla, Bingara, Barraba, and Quirindi.

Over time, secondment and local recruitment of resident medical officer staff modified our service role with teaching and consultant components. The secondment in 1997 of a medical registrar from John Hunter Hospital (in Newcastle) following initiatives by the Rural Workforce Committee of the Royal Australasian College of Physicians brought further change.

Country communities give active support to their local hospitals -- more so than in the city. The first gastroscope and nuclear medicine scanner received seeding funding from the Tamworth and Northwest Medical Foundation Trust Fund (set up with community support and moneys paid to honorary medical officer staff for lectures at the Nursing Training School). At present, we have similar subspecialties and facilities to the city hospitals, although we have had to wait longer to get them and we sometimes have had to inject local funding, and our registrars in the base hospitals have unique training opportunities in the broad spectrum of hospital medicine, which is no longer available at many of the major teaching hospitals.

Being part of a community in which the medical practitioner is "our doctor" can be somewhat daunting. To hear the sick lists and deaths reported at Sunday church services makes me feel close to my community. Country people in the main are generous, stoic and sensible patients to treat. And Christmas brings its share of gifts for the "doc".

But workloads for country physicians remain a significant problem. There is no one else down the road for patients to see. While the hideous one-in-two roster -- originally worked with five hours sleep a night when a partner was away on holidays -- was bad enough, the current roster sees physicians admitting 20 to 30 patients on a 72-hour weekend on call, up to 40 on one peak occasion. A weekday on call can sometimes yield 10 to 15 patients.

What keeps me in the country? Here, life is always stimulating, never boring. The challenge of true clinical medicine, away from the internecine competition of the Sydney teaching hospital circuit; the resilient and appreciative patients; the lifestyle in an unpolluted environment, with five minutes' drive through casual traffic to work or play; the medical staff who appreciate each others' foibles, egos and skills, and get on with the job with minimal politics; the mostly local nursing staff who are not affected by the impersonal nature of agency nursing and who have maintained great loyalty and caring skills in the face of the financial and political battering of rural medical health services over the years -- these things keep me here.

Am I intellectually, professionally and socially isolated? It's all in the mind. It depends what one wants of life. Practice in partnership allows us to see, learn from and criticise our partners much more freely than can isolated teaching hospital physicians. Conferences keep one up to date with one's peers, as does a network of acquaintances and specialists in the major teaching hospitals. Local practitioners readily exchange information from attendance at meetings, probably much more so than in the city. Roster sharing with other physicians means cross-fertilisation of many ideas. We are certainly less isolated than many suburban consultants. Participation in organisations such as the Australian Council on Healthcare Standards, the Internal Medicine Society of Australia and New Zealand, the New South Wales Branch of the Australian Medical Association, and the Newcastle country student term -- all these things are intellectually, socially and professionally stimulating.

Socially, while a trip to Sydney means operas, plays, contact with the "cappuccino set" and a taste of the "good life", it is good to return home to the tranquillity and the beauty of country living and the basic values of this community. I still marvel at the ever-changing landscape of the northwest on my monthly early-morning drives to a day of consulting at Warialda, 200 km away.

The clinical problems, the patients I meet and the staff with whom I work continue to stimulate and teach me. I learn something new every day. Access to general medicine and treating the whole person are the advantages of country physician practice.

Could I regret coming to the country? One regret is that our children often have to leave their homes for tertiary education and to find work as opportunities in country areas decline. But, overall, the regrets are few. I think now of the comments of a recent psychiatry graduate, who, when approached to come to Tamworth, replied, "I am a high achiever -- why should I want to practise in the country?".

Well, we can and do have high achievers in the country. Sure, the hours are long and the work can be demanding, but there is immense personal satisfaction to be gained from the work we do.

Peter R C Wakeford
Consultant Physician
31 Dowe Street, Tamworth, NSW

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