Retaining a medical workforce in rural Australia

Professional satisfaction is a major concern for rural doctors

MJA 1998; 169: 293-294

For at least 10 years, the imbalance of general practitioners in rural and remote areas of Australia has been addressed by successive health policies and strategies. These activities are driven in large part by a desire for equity of access to and quality of medical care in our rural and remote communities. Seminal in the early considerations in attracting and maintaining a rural medical workforce were the reports by Kamien1 to the Western Australian and Shehadie2 to the New South Wales departments of health. Both reports disclosed a need for support for rural doctors, particularly in access to continuing medical education (CME) and provision of locums. These reports were instrumental in the formation, in 1988, of the NSW Rural Doctors Resource Network and, in 1990, of the Western Australian Centre for Rural and Remote Medicine. In 1993, the Commonwealth Department of Human Services and Health launched the General Practice Rural Incentives Program (GPRIP), which aimed to attract doctors through relocation, retraining and remote area grants, and to retain them by addressing access to CME and locum support. This issue of the Journal includes two reports which have implications for Australia's rural workforce. Bruening and Maddern3 disclose a profile of rural surgeons that is one of predominantly middle-aged men whose major concerns include continual on-call work, lack of locum relief, and peer isolation. Although the majority of surgeons intend to remain in rural practice until retirement, the ageing of our rural surgical workforce has obvious implications. Kamien4 provides unique information on why doctors stay in or leave rural practice by examining the major concerns and practice intentions of rural doctors in 1986 and their practice locations by 1996. Those doctors who remained in rural practice had successfully resolved their 1986 concerns; those who left had not. For the latter, unresolved concerns included access to CME, overwork, forced deskilling, and professional isolation. Kamien also highlights the major concerns which would influence doctors currently in rural practice to leave; these include problems in achieving professional satisfaction as pressures (such as hospital closures) on the provision of rural health services increase. The whole issue of retention of doctors in rural practice is attracting renewed attention and recently several researchers have addressed this issue. Hoyal has proposed that important influences in this are professional factors influencing the doctor, social and other factors affecting the doctor's family, and community influences.5 While listing a range of professional factors, he also highlighted the need for community backing for the local hospital as well as emotional, professional and financial hospital support for the doctor. In a survey of Queensland doctors who had recently left rural practice, Hays and colleagues6 found that these doctors emphasised the positive aspects of rural practice to be professional autonomy and support, community relationships, work variety, family lifestyle and continuity of care. The downside included after-hours workload, poor access to CME and locums, personality clashes, and lack of family educational opportunities. In proposing retention strategies, Hays et al developed a conceptual model of a balance between influences to stay or to leave, and triggers that could shift this balance. While acknowledging that personal (eg, personality clashes) and family (eg, children's education) triggers may be difficult to address, they proposed professional retention strategies that could be readily addressed. These include provision of CME, locum cover, management training for doctors, and educational packages for families. They also suggested that local support and early intervention structures could be developed through Divisions of General Practice. A recent consultancy to GPRIP has produced a discussion paper on models of sustainable practice in rural and remote Australia.7 The focus on "sustainable practice" instead of "retention" helps to highlight another element of focusing on a continuity of rural medical service. The discussion paper proposes that strategies for sustainability include those issues that promote sustainability of the individual doctor (including access to CME, locums, and family support), those that promote sustainability of the practice environment (including the relationship with the local health service provider), and those that promote sustainability of the community. It is evident that the strategies for practice sustainability are largely concentrated on the needs expressed by rural doctors over the past 10 years. In many States these have been coupled with rurally targeted financial support for services provided in public hospitals. The concept of a continuous workforce by readily available replacement of doctors has been taken up in the short term with relocation and retraining support by GPRIP, and in the longer term by early exposure of undergraduates to rural medicine and support for entrance to medical schools of students from a rural background. At the national level needs have also been identified. Those proposed in a discussion paper of the Australian Medical Association and the Rural Doctors' Association of Australia8 include a national medical workforce recruitment and retention scheme; a nationally consistent system of granting clinical privileges; continued and increasing refinement of postgraduate, vocational and continuing medical education; the introduction of retention payments and development of information technology; innovative practice structures; and Aboriginal health strategies. Some or all of these can be developed or implemented at State level. The new Rural Workforce Agencies and Divisions of General Practice are ideally placed to develop the strategies that allow both long term and emergency impact on the triggers for leaving rural practice. It would seem that a major task for the Rural Workforce Agencies and Rural Doctors Associations in each State will be to bring cohesion to retention strategies while promoting regional and local flexibility. While those support strategies that have been working must continue, the major challenge will be in promoting the autonomy and self-esteem of rural doctors that Kamien suggests. This will need to be done by negotiating with health service provider organisations and communities to develop strategies that allow doctors the professional satisfaction of providing their medical skills to those communities, thereby maximising the health status of rural Australians. Ian Cameron Chief Executive Officer, NSW Rural Doctors Network Suite 19, 133 King Street, Newcastle, NSW 2300 Western Australian Health Department (M Kamien, Chairman). Report of the Ministerial Inquiry into the Recruitment and Retention of Country Doctors in Western Australia. Perth: Western Australian Health Department, 1987. Shehadie N. Report of the Committee of Enquiry Into Services Provided by General Medical Practitioners to Country Public Hospitals. Sydney: New South Wales Department of Health, 1987. Bruening MH, Maddern GJ. A profile of regional surgeons in Australia. Med J Aust 1998; 169: 324-326. Kamien M. Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions. Med J Aust 1998; 169: 318-321. Hoyal FMD. Retention of rural doctors. Aust J Rural Health 1995; 3: 2-9. Hays B, Veitch PC, Cheers B, Crossland L. Why doctors leave rural practice. Aust J Rural Health 1997; 5: 198-203. Models of sustainable practice in rural and remote Australia. Discussion paper. Rural and Remote General Practice Program, Commonwealth Department of Health and Family Services, Canberra, March 1998. Increasing rural medical services. Discussion paper. Australian Medical Association and Rural Doctors' Assocation of Australia. Canberra, March 1998.