How do you keep them down on the farm?

Specialist training in the first two postgraduate years must be made available in both large and small rural hospitals

Some years ago, when I was seeking views on priorities in rural health, I went to a rural town, where the desert met the sea, the local river flowed under the sand and the streets were wide enough to turn a bullock train, to interview the mayor. What did she want for her municipality with a population of 7000? A radiotherapy service and a cardiac catheter laboratory — her husband had both cancer and cardiac disease.

While her wish was extreme, it illustrates the high expectations within our communities — large and small — for medical care. Indeed, these expectations are reinforced by the popular mantra that ours is the best health system in the world, and a pervasive myth that health care is free. Australia's population, spread over an area the size of the United States minus Alaska, is concentrated along the eastern seaboard. It is in the area where this population is concentrated, particularly Melbourne and Sydney, where subspecialty medicine is sustained. Can anybody find a similar demographic collage elsewhere in the world from which our policymakers can draw inspiration?

The Australian Medical Workforce Advisory Committee (AMWAC) has set benchmarks for numbers of specialists per 100 000 population.1 Such ratios do little to inform the concerns expressed by the rural town mayor. Yet, ratios are always quoted to show the difficulty of assuring an “optimal” rural workforce, with assumptions based on an urban specialist paradigm. Fascination with workforce distribution solves nothing.

For instance, a Royal Australasian College of Physicians (RACP) position paper stated that five to seven full-time equivalent general physicians per 100 000 population are required to provide adequate service, and teaching and research capacity in general medicine.2 The AMWAC position paper1 did not consider general physician numbers.

What occurs in reality? In regional Victoria, the hospital at Wangaratta (population 28 000) has six consultant physicians. The hospital serving the towns of Echuca and Moama (population 20 000) has no consultant physicians. While both hospitals have registrars and interns, they provide after-hours care differently. The senior visiting medical staff at Wangaratta is predominantly specialist, while in the hospital at Echuca–Moama, medical care is provided predominantly by general practitioners with special procedural and non-procedural skills. Both hospitals supply the needs of their respective communities. The difference is that the general practitioners at Echuca–Moama also have the skills to undertake obstetrics, anaesthetics and emergency medicine — skills reserved for specialists at Wangaratta.

The aim must be to assure 24/7 medical cover while avoiding “doctor burnout”. So, when the hospital worlds of physicians, specialists and GPs collide in the rural setting, the first response should not be to fight for control of the hospital. The arrival of specialists should not see the gradual extinction of GPs in the hospital, because this invariably diminishes the pool of expertise and, importantly, a component of the sustainability of specialist services as GPs with specialist skills enhance such services

Echuca–Moama and Wangaratta have both interns and registrars. They form an engine room of intelligent, motivated young graduates who, under supervision, provide the continuity of purpose, as occurs in metropolitan hospitals. It is an engine room essential for succession planning

Australia has to balance a strong research metropolitan-centric hospital system with robust intellectual capital in rural and regional Australia. Rural areas require not only university commitment, but also a commitment to train doctors through a minimum of postgraduate years 1 and 2 (and possibly 3). This should ensure that there is a well trained cohort of doctors with “specialist skills” among both specialists and GPs. The aim should be not only to maintain a 24/7 roster, but also to provide young graduates with continuing intellectual stimulation. There are young graduates who prefer the rural lifestyle, but not as isolates. Those who want to become specialists need to go to a major metropolitan teaching hospital for part of their training. These young doctors need a stable job environment to which they can return, knowing that they will be welcome.

The rural clinical schools host initiatives such as the Murray to the Mountains (M2M) Intern Training Program.3 For prospective GPs, this provides the opportunity to gain further training in obstetrics, anaesthetics or any general specialty for which there is a demand, as rural medical generalists.

Postgraduate training is not the sole prerogative of metropolitan teaching hospitals, and it is crucial to acknowledge the importance of maintaining a strong education base in rural Australia.4 The development teaching hospitals where research is an integral part of their operation has previously been advocated,5and funding for such research should be set aside. However, the provision of such funding should acknowledge the increasing intellectual capital in rural medical schools, so any approach should be inclusive not elitist. One criticism that can be made of the US system is the disparity between the very best and the worst, resulting from the way resources are distributed.

With universities connected to regional health care services and mechanisms in place to meet the educational needs of the local medical workforce, the mayor of the small town can be confident that there will be sufficient expertise in her rural community to satisfy her expectations.

The key to recruitment and maintenance is the collegiality of the local workforce where universities have an important supporting role, together with connectivity of the whole workforce by way of either face-to-face meetings or by video or webinar links. The gap has been where there has been a rural clinical school, but no opportunity to undertake the first two postgraduate years in a rural hospital — the essence of collegiality.

Australia is a country where delivering medical services will always be a challenge if there is not a strong sub-stratum of doctors who have special interest skills, and who are available over the 24-hour cycle. Such doctors must also be sufficiently acquainted with subspecialty medicine to both explain the meaning of the limits of the health service and allay the concerns of the mayor about not having a radiotherapist or interventional cardiologist on her doorstep.