eMJA: Bruening & Maddern, A profile of rural surgeons in Australia

A profile of rural surgeons in Australia

Martin H Bruening and Guy J Maddern

MJA 1998; 169: 324-326
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Abstract - Introduction - Method - Results - Discussion - Conclusion - References - Authors' details
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Abstract
Objectives: To develop a profile of rural surgeons for comparison with profiles of rural general practitioners in the light of shortages in the rural medical workforce.
Design: Rural surgeons were surveyed by a postal questionnaire in November 1997.
Participants: Members of the Provincial Surgeons of Australia residing in towns with fewer than 50 000 inhabitants.
Results: 239 questionnaires were sent and 137 surgeons replied, a response rate of 59%. Our survey showed that rural surgeons are predominantly male, middle-aged and married. They work long hours, and nominate as their major concerns difficulty in finding locum cover, continual on-call work, peer isolation, children's schooling, and lack of privacy.
Conclusion: Rural surgeons and general practitioners share similar characteristics and concerns.
Introduction
There is a shortage of doctors in rural areas of Australia. For general practitioners this situation has been well documented,¹ and now the focus has shifted to surgeons. The Australian Medical Workforce Advisory Committee has recently published comprehensive information on the general surgery workforce in Australia,² with important demographic information about Australia's general surgeons, both urban and rural. A considerable proportion (estimated at up to 23.3%) of all general surgeons reside in rural or remote areas.^2,3
Despite the current interest by government and College groups, few published reports deal specifically with Australia's rural general surgeons. However, the Royal Australasian College of Surgeons (RACS) undertook a survey in 1997 of about 500 non-metropolitan general surgeons to build a database of surgeon demographics.
Our study attempts to profile rural surgeons in Australia to compare with profiles of rural general practitioners.
Method
Our study was performed in November 1997. We used the 1997 mailing list of members of the Provincial Surgeons of Australia (PSA), an organisation that holds an annual conference at which rural surgeons can meet and discuss issues of relevance. Currently, 350 surgeons are members of the PSA.
The term rural can be subdivided into rural major, rural other, remote major and remote other.² For our study, we identified surgeons residing in towns with fewer than 50 000 inhabitants (ie, encompassing predominantly the categories rural major and remote major). Anonymous questionnaires were sent to these surgeons. From the original postal list, it was not possible to differentiate surgical subspecialties. Non-respondents were not followed up.
Questions asked included specialty, qualifications, sex, age, marital status, number of children, length of time in current practice location, spouse employment and hours worked per week. Surgeons were also asked about the negative and positive aspects of their rural surgical practice.
Discussion
The low response rate of our survey may be attributed to several factors. Given the large number of hours worked by most of the study group, it may be that those who did not respond were simply too busy, or too fatigued or distracted, to do so. The rural workforce, now the subject of increased national attention, may also be suffering from "questionnaire burnout".
Demographics
The profile of rural surgeons developed from the respondents to our survey is that they are predominantly male, middle-aged and married. They work long hours, and most are well established in their current location and will remain there until retirement.
Rural general practitioners and surgeons appear to have similar age distributions. In the early 1990s it was predicted that by 1998, 20% of rural general practitioners would be over the age of 60,⁴ and our proportion of 15% is not far behind. Without adequate input into the more junior ranks, the average age of rural surgeons will increase proportionately over the next few years.⁵ The Australian Institute of Health and Welfare medical workforce survey from 1994 found the average age of all specialists to be 48.8 years.⁶
Practice profile
Frequent on-call work was identified as a major negative aspect of rural surgical practice. This is also often cited as a major disincentive to rural general practice, both in Australia⁷ and other countries.^8,9 The rural divisional group of the RACS is establishing a national locum service and aiming to recruit surgeons nationwide to participate in the service. If successful, the service will relieve the burden of many rural surgeons, especially those in solo or two-person practices.
The problem of lack of locum cover is also experienced by rural general practitioners and has long been a major cause for disenchantment and increasing the drift of practitioners back to urban areas.^10,11
Another way of alleviating the pressure on a solo surgeon would be to provide a second resident surgeon in the same location. Some government reports have argued that, to provide a specialist service in a rural area, there should be a workload to justify a minimum of two specialists.¹² This recommendation, although sound in theory, ignores the current shortage of rural surgeons.^1,5 Moreover, the introduction of a second surgeon may disrupt long-established referral patterns, and any proceduralist general practitioners may be reluctant to give up one of the major incentives for pursuing rural general practice, as well as the extra income they receive for procedures.¹³
The issue of peer isolation has been raised in previous studies and continues to be a major concern for rural surgeons.^14,15 A strategy such as the proposed RACS rural locum service, whereby metropolitan surgeons can appreciate the unique demands of rural practice, will not only achieve the immediate aim of providing locum cover, but may also change long-held city attitudes regarding rural medicine in general.¹⁶ Increasing links and support from tertiary institutions as a result of the locum service will give a higher profile to rural hospitals. A separate initiative, which depends on the correct infrastructure being in place, is the introduction of rural surgical attachments for undergraduate medical students. This could provide many long term benefits: exposure of students to rural surgery may encourage more of them to take up the challenge of country practice,^17-19 and an appreciation of the skills of rural surgeons could lead to a change in attitude regarding the overall standard of rural medicine. On the other hand, the rural surgeon may enjoy teaching and fostering university links.
Family issues
Schooling opportunities for children of surgeons were identified by our survey as a major negative aspect of rural practice. Many respondents were apparently dissatisfied with the available local schooling, as over 50% were sending or had sent their children to boarding school, no doubt at significant cost. General practitioners nominate the education of their children as one of the major reasons for not practising in the country.²⁰ Given the shortage of education funding, it appears that, in the short term at least, the problem of establishing high quality schooling in all rural areas is insoluble.
The importance of an understanding partner when deciding on country practice has been stressed recently.²¹ The high proportion of married surgeons among the respondent group would seem to support this theory. Moreover, a large number of the surgeons' partners were in some way employed within the practice.
From the results of our study it would seem that, with 41% of surgeons having spent some time as children in a rural area, a rural upbringing does significantly influence the decision to practise in the country. This concurs with numerous studies.^17,22
Conclusion
The results of our study indicate that rural general practitioners and rural general surgeons share similar concerns and characteristics. Major efforts will be needed to arrest the ageing of the rural surgical workforce and improve the working conditions of current rural surgeons.
References

Australian Medical Workforce Advisory Committee. The medical workforce in rural and remote Australia. Sydney: AMWAC, September 1996. (AMWA Report 1996.8.)
Australian Medical Workforce Advisory Committee. The general surgery workforce in Australia. Sydney: AMWAC, May 1997. (AMWA Report 1997.2.)
Australian Institute of Health and Welfare. Medical Labour Force Survey 1994, Canberra: AIHW, 1996.
Davies PG. Problems with training for general practice in South Australia. Med J Aust 1992, 155: 459-462.
Royle JP. Rural surgery initiatives. RACS Bull 1996; 16(1): 42.
Australian Medical Workforce Advisory Committee. Annual Report 1995-96. Sydney: AMWAC, 1996.5.
Wise AL, Hays BRB, Adkins PB, et al. Training for rural general practice. Med J Aust 1994; 161: 314-318.
Forti EM, Martin KE, Jones RL, et al. Factors influencing retention of rural Pennsylvania family physicians. J Am Board Fam Pract 1995; 8: 469-474.
Anderson E, Beryeron D, Crouse BJ. Recruitment of family physicians in rural practice. Minn Med 1994; 77: 29-32.
Kamien M, Buttfield IH. Some solutions to the shortage of general practitioners in rural Australia. Part 4. Professional, social and economic satisfaction. Med J Aust 1990; 153: 168-171.
Hamilton IJ, Gillies J, Ross S, et al. Attitudes of general practitioners who practice in remote island communities. Health Bull 1997; 55(2): 103-108.
Gadiel D, Ridoutt L. The specialist medical workforce and specialist service provision in rural areas. Canberra: AGPS, 1994. (MWDRC Consultancies No. 1.)
Sax S, Andrews G, Brand I, et al. Enquiry into hospital services in South Australia. Adelaide: SA Health Commission, 1983.
Nelson PG. General surgical manpower, Victoria, Australia. Aust N Z J Surg 1991; 61: 576-588.
Faris I. The making of a rural surgeon. Aust N Z J Surg 1997; 67: 153-156.
Chesterfield-Evans H. A mantle of care. 1991: 105-106 (available from Provincial Surgeons of Australia, PO Box 30, Kingaroy, QLD 4610).
Rolfe IE, Pearson SA, O'Connell DL, et al. Finding solutions to the rural doctor shortage: the roles of selection versus undergraduate medical education of Newcastle. Aust N Z J Med 1995; 25: 512-517.
American College of Physicians Position Paper on rural primary care. Ann Intern Med 1995; 122: 380-390.
Kamien M. Undergraduate rural incentives programme. Med J Aust 1995; 162: 228-229.
Kamien M, Buttfield IH. Some solutions to the shortage of general practitioners in rural Australia. Part 4. Professional, social and economic satisfaction. Med J Aust 1990; 153: 168-171.
Adamthwaite DN. The making of a rural surgeon: comment. Aust N Z J Surg 1997; 67: 813.
Fryer GE Jr, Stine C, Vojir C, et al. Predictors and profiles of rural versus urban family practice. Fam Med 1997; 29: 115-118.
(Received 22 May, accepted 28 Jul, 1998)

Authors' details

Martin H Bruening, BM BS, FRCS(Edin), Lecturer in Rural Surgery.
Guy J Maddern, MD, FRACS, R P Jepson Professor of Surgery.

Reprints will not be available from the authors.
Correspondence: Professor G J Maddern, Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA 5011.
E-mail: sirelandATmedicine.adelaide.edu.au


Abstract	*Objectives:* To develop a profile of rural surgeons for comparison with profiles of rural general practitioners in the light of shortages in the rural medical workforce. Design: Rural surgeons were surveyed by a postal questionnaire in November 1997. Participants: Members of the Provincial Surgeons of Australia residing in towns with fewer than 50 000 inhabitants. Results: 239 questionnaires were sent and 137 surgeons replied, a response rate of 59%. Our survey showed that rural surgeons are predominantly male, middle-aged and married. They work long hours, and nominate as their major concerns difficulty in finding locum cover, continual on-call work, peer isolation, children's schooling, and lack of privacy. Conclusion: Rural surgeons and general practitioners share similar characteristics and concerns.
Introduction	There is a shortage of doctors in rural areas of Australia. For general practitioners this situation has been well documented,¹ and now the focus has shifted to surgeons. The Australian Medical Workforce Advisory Committee has recently published comprehensive information on the general surgery workforce in Australia,² with important demographic information about Australia's general surgeons, both urban and rural. A considerable proportion (estimated at up to 23.3%) of all general surgeons reside in rural or remote areas.^2,3 Despite the current interest by government and College groups, few published reports deal specifically with Australia's rural general surgeons. However, the Royal Australasian College of Surgeons (RACS) undertook a survey in 1997 of about 500 non-metropolitan general surgeons to build a database of surgeon demographics. Our study attempts to profile rural surgeons in Australia to compare with profiles of rural general practitioners.
Method	Our study was performed in November 1997. We used the 1997 mailing list of members of the Provincial Surgeons of Australia (PSA), an organisation that holds an annual conference at which rural surgeons can meet and discuss issues of relevance. Currently, 350 surgeons are members of the PSA. The term rural can be subdivided into rural major, rural other, remote major and remote other.² For our study, we identified surgeons residing in towns with fewer than 50 000 inhabitants (ie, encompassing predominantly the categories rural major and remote major). Anonymous questionnaires were sent to these surgeons. From the original postal list, it was not possible to differentiate surgical subspecialties. Non-respondents were not followed up. Questions asked included specialty, qualifications, sex, age, marital status, number of children, length of time in current practice location, spouse employment and hours worked per week. Surgeons were also asked about the negative and positive aspects of their rural surgical practice.
Discussion	The low response rate of our survey may be attributed to several factors. Given the large number of hours worked by most of the study group, it may be that those who did not respond were simply too busy, or too fatigued or distracted, to do so. The rural workforce, now the subject of increased national attention, may also be suffering from "questionnaire burnout".
Demographics	The profile of rural surgeons developed from the respondents to our survey is that they are predominantly male, middle-aged and married. They work long hours, and most are well established in their current location and will remain there until retirement. Rural general practitioners and surgeons appear to have similar age distributions. In the early 1990s it was predicted that by 1998, 20% of rural general practitioners would be over the age of 60,⁴ and our proportion of 15% is not far behind. Without adequate input into the more junior ranks, the average age of rural surgeons will increase proportionately over the next few years.⁵ The Australian Institute of Health and Welfare medical workforce survey from 1994 found the average age of all specialists to be 48.8 years.⁶
Practice profile	Frequent on-call work was identified as a major negative aspect of rural surgical practice. This is also often cited as a major disincentive to rural general practice, both in Australia⁷ and other countries.^8,9 The rural divisional group of the RACS is establishing a national locum service and aiming to recruit surgeons nationwide to participate in the service. If successful, the service will relieve the burden of many rural surgeons, especially those in solo or two-person practices. The problem of lack of locum cover is also experienced by rural general practitioners and has long been a major cause for disenchantment and increasing the drift of practitioners back to urban areas.^10,11 Another way of alleviating the pressure on a solo surgeon would be to provide a second resident surgeon in the same location. Some government reports have argued that, to provide a specialist service in a rural area, there should be a workload to justify a minimum of two specialists.¹² This recommendation, although sound in theory, ignores the current shortage of rural surgeons.^1,5 Moreover, the introduction of a second surgeon may disrupt long-established referral patterns, and any proceduralist general practitioners may be reluctant to give up one of the major incentives for pursuing rural general practice, as well as the extra income they receive for procedures.¹³ The issue of peer isolation has been raised in previous studies and continues to be a major concern for rural surgeons.^14,15 A strategy such as the proposed RACS rural locum service, whereby metropolitan surgeons can appreciate the unique demands of rural practice, will not only achieve the immediate aim of providing locum cover, but may also change long-held city attitudes regarding rural medicine in general.¹⁶ Increasing links and support from tertiary institutions as a result of the locum service will give a higher profile to rural hospitals. A separate initiative, which depends on the correct infrastructure being in place, is the introduction of rural surgical attachments for undergraduate medical students. This could provide many long term benefits: exposure of students to rural surgery may encourage more of them to take up the challenge of country practice,^17-19 and an appreciation of the skills of rural surgeons could lead to a change in attitude regarding the overall standard of rural medicine. On the other hand, the rural surgeon may enjoy teaching and fostering university links.
Family issues	Schooling opportunities for children of surgeons were identified by our survey as a major negative aspect of rural practice. Many respondents were apparently dissatisfied with the available local schooling, as over 50% were sending or had sent their children to boarding school, no doubt at significant cost. General practitioners nominate the education of their children as one of the major reasons for not practising in the country.²⁰ Given the shortage of education funding, it appears that, in the short term at least, the problem of establishing high quality schooling in all rural areas is insoluble. The importance of an understanding partner when deciding on country practice has been stressed recently.²¹ The high proportion of married surgeons among the respondent group would seem to support this theory. Moreover, a large number of the surgeons' partners were in some way employed within the practice. From the results of our study it would seem that, with 41% of surgeons having spent some time as children in a rural area, a rural upbringing does significantly influence the decision to practise in the country. This concurs with numerous studies.^17,22
Conclusion	The results of our study indicate that rural general practitioners and rural general surgeons share similar concerns and characteristics. Major efforts will be needed to arrest the ageing of the rural surgical workforce and improve the working conditions of current rural surgeons.
References	Australian Medical Workforce Advisory Committee. The medical workforce in rural and remote Australia. Sydney: AMWAC, September 1996. (AMWA Report 1996.8.) Australian Medical Workforce Advisory Committee. The general surgery workforce in Australia. Sydney: AMWAC, May 1997. (AMWA Report 1997.2.) Australian Institute of Health and Welfare. Medical Labour Force Survey 1994, Canberra: AIHW, 1996. Davies PG. Problems with training for general practice in South Australia. Med J Aust 1992, 155: 459-462. Royle JP. Rural surgery initiatives. RACS Bull 1996; 16(1): 42. Australian Medical Workforce Advisory Committee. Annual Report 1995-96. Sydney: AMWAC, 1996.5. Wise AL, Hays BRB, Adkins PB, et al. Training for rural general practice. Med J Aust 1994; 161: 314-318. Forti EM, Martin KE, Jones RL, et al. Factors influencing retention of rural Pennsylvania family physicians. J Am Board Fam Pract 1995; 8: 469-474. Anderson E, Beryeron D, Crouse BJ. Recruitment of family physicians in rural practice. Minn Med 1994; 77: 29-32. Kamien M, Buttfield IH. Some solutions to the shortage of general practitioners in rural Australia. Part 4. Professional, social and economic satisfaction. Med J Aust 1990; 153: 168-171. Hamilton IJ, Gillies J, Ross S, et al. Attitudes of general practitioners who practice in remote island communities. Health Bull 1997; 55(2): 103-108. Gadiel D, Ridoutt L. The specialist medical workforce and specialist service provision in rural areas. Canberra: AGPS, 1994. (MWDRC Consultancies No. 1.) Sax S, Andrews G, Brand I, et al. Enquiry into hospital services in South Australia. Adelaide: SA Health Commission, 1983. Nelson PG. General surgical manpower, Victoria, Australia. Aust N Z J Surg 1991; 61: 576-588. Faris I. The making of a rural surgeon. Aust N Z J Surg 1997; 67: 153-156. Chesterfield-Evans H. A mantle of care. 1991: 105-106 (available from Provincial Surgeons of Australia, PO Box 30, Kingaroy, QLD 4610). Rolfe IE, Pearson SA, O'Connell DL, et al. Finding solutions to the rural doctor shortage: the roles of selection versus undergraduate medical education of Newcastle. Aust N Z J Med 1995; 25: 512-517. American College of Physicians Position Paper on rural primary care. Ann Intern Med 1995; 122: 380-390. Kamien M. Undergraduate rural incentives programme. Med J Aust 1995; 162: 228-229. Kamien M, Buttfield IH. Some solutions to the shortage of general practitioners in rural Australia. Part 4. Professional, social and economic satisfaction. Med J Aust 1990; 153: 168-171. Adamthwaite DN. The making of a rural surgeon: comment. Aust N Z J Surg 1997; 67: 813. Fryer GE Jr, Stine C, Vojir C, et al. Predictors and profiles of rural versus urban family practice. Fam Med 1997; 29: 115-118. (Received 22 May, accepted 28 Jul, 1998)

A profile of rural surgeons in Australia

Abstract

Introduction

Method

Discussion

Demographics

Practice profile

Family issues

Conclusion

References

Authors' details

Other articles have cited this article: