Ups and downs of rural practice: general practice Dr Olga Ward, a general practitioner in a remote town located in the Eastern Wheatbelt or Western Goldfields of Western Australia (depending on your direction of travel), shares some of her experiences of rural practice. She has lived in the town, Southern Cross, for nearly three years, after visiting with monthly women's health clinics for two years before that. She trained in Western Australia, graduating in 1991, and was part of the Royal Australian College of General Practitioners' rural training stream as a GP registrar. |
MJA 1999; 171: 621-622 | ||
|
As with all things in life, so with rural practice: there is the good and
the not so good (and occasionally the downright awful). I've been
asked to share with you some of the ups and downs of rural practice in a
small, remote rural town in Western Australia; this is a distillation
of my experiences.
Southern Cross is a town of about 1000 people in a shire of about 3400. It is a two-doctor town; both of us are female doctors, with quite different skills. We often consult with each other about our patients and cross-refer on a regular basis. This was once a solo-doctor town, but there is no way that I would settle into a town this far from any other knowing that I would always be on call. Even with a second doctor life gets hectic. Indeed, most towns in this sort of situation probably need to look at a shared-practice model. There is a lot of value in one uninterrupted night of sleep. We have a hospital, and it is most enjoyable to work with a team of good nurses and office staff, who can really make the difference. We feel part of a team that also encompasses the specialist units in Kalgoorlie and Perth; an orthopaedic surgeon who visits the town of Merredin, 110 km away (and also consults by e-mail); a paediatrician who visits quarterly; and others. We have a very close working relationship. Mostly, we can deal with the emergency patients and stabilise them, after which we call in the Royal Flying Doctor Service (RFDS) cavalry. We still see plenty of coughs and lurgies, many of which are quite advanced by the time the patients decide to trek into the surgery. We can usually find a hospital bed, and when we discharge the patient we know exactly which medications have been changed without having to wait for the illegible third carbon copy of the intern's summary to arrive. Four features of life in the town stand out for me. First there's the telephone. It's the lifeline of communication, especially with the RFDS and the helpful specialists, who are unfailingly polite, even at 3 am. It allows Internet access. It allows me to snivel on the shoulder of a friend 400 km away. It allows us doctors to leave town and play golf on the two holes that are in mobile telephone range. It also interrupts dinner, drinkies and busy afternoon surgery. It plays "bing-bongs" as hold music and we are expected to stay calm after hearing this for six minutes at peak long distance rates. It's also not a bad means of contraception for a doctor in a small and isolated town with a busy hospital. Secondly, there's the hospital. An excellent institution with nurses to triage away the non-urgent, call about the urgent and to help clean up the mess when a child vomits all over the room. I couldn't stay in this town without the hospital: it functions as a major doctor-retaining factor. Having access to an emergency department, inpatient facilities and a limited theatre adds much to my day. It also adds much to my hours, especially when I'm trying to get away to the surgery at 9 am with the nightshift workers' compensation injuries from the gold and iron ore mines, farms and gold mill rolling in. Thirdly, there's the travel. Commuting time is less than four minutes, as long as the school zone isn't active (that adds another 20 seconds). However, if you wish to be somewhere other than in town or at the hospital, you have to start by driving at least an hour, and that's just to the next town! Of course, being in an isolated place means that there are lots of tax-effective reasons for owning an (elderly) aeroplane and flying round to other towns. It is also possible to hangar the said aircraft without needing to file for bankruptcy at the same time. An added bonus is that the airfield has a flush toilet and lighting for night flights, both essential items in their own way. Fourthly, everyone knows you, your spouse and your pets. This makes for a sense of belonging and a closeknit community, but you can't buy chocolate without half the town commenting on your cholesterol (or waistline)! Professionally, with such a closeknit community, there is a deep sense of failure and loss when a friend comes in after a serious accident and you fail to save them. The voice in your mind is always asking: "Did I do enough?" "Could I have done something that would have made a difference?" Then you have to face the family and hold your own feelings at least partly in check, although I think the town allows more space for a female doctor to grieve than they might for a bloke. A rural community allows the kind of involvement that is hard to find anywhere else. The doctors scarcely have a free moment between work, karate, repertory group, flying, badminton, corporate bowls (beer and socialising thinly disguised as lawn bowls), golf, gardening and computing. The town is not large or "well-serviced", but we still manage to have more fun and pack more into the average week than most of our city colleagues would in a month. Cinemas, opera and symphony concerts are a bit thin on the ground, but we survive. Downtime and non-medical interests keep us sane. Difficulties with continuing medical education (CME) requirements and budgets, however, represent other downsides. For a doctor to function effectively in a rural setting, some extra level of skill is required and must be maintained. This necessitates extra CME courses, which are often hard to access and are frequently held only at 6 pm on Tuesday nights in the city. The Division, the Western Australian Centre for Remote and Rural Medicine and the RACGP are excellent in providing for local CME (local being 230 km away), but, for maintaining specific skills (such as colposcopy, surgery and acupuncture), we still need to make the 800 km round trip to the city. With locums in short supply, such trips can't be too frequent. Oh for the nice easy dinner at a local restaurant, with speaker provided by the drug company! The word "budget" is also a dirty word, particularly in planning regional healthcare services. The hospital has a hundred places to put every dollar, and prescribing an expensive drug or performing an expensive procedure means cheaper meals for patients or putting off the purchase of equipment to try and balance a budget that allocates 5% less for a 10% increase in complexity of service. Try as one might to prevent it, the dollar signs do intrude on patient care. That said, though, I do see rural practice as being very rewarding and definitely worth the lack of sleep. The chance to practise truly general medicine in a community context allows you as a doctor to belong to the community in a way not experienced in the city. When you start to rely on yourself, you realise that the 14 years of post-secondary training have been a worthwhile investment. The most exciting discovery is that you actually know something and can make a difference! I'm now trying to impart some of this excitement to the senior medical students who come our way. Working with a good team makes the difference. If the local hospital and the shire were not so cooperative, it could make life pretty awful, but they are keen to work together and make the best of the healthcare service we can provide. We have a way to go, but I think we are providing it. Olga Ward ©MJA 1999
Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1999 Medical Journal of Australia. We appreciate your comments. |