Programa Médicos pelo Brasil

NOTA AOS MÉDICOS E À SOCIEDADE

 

 

O Conselho Federal de Medicina (CFM) foi surpreendido com a nota divulgada pela imprensa informando que o relatório da Comissão Mista do Congresso Nacional que discute a Medida Provisória nº 890/2019, que cria o Programa Médicos pelo Brasil, deve prever a inclusão de 1.800 médicos cubanos, além da permissão de que médicos brasileiros formados no exterior que não foram aprovados no Exame Nacional de Revalidação de Diplomas Médicos Expedidos por Instituições de Educação Superior Estrangeiras (Revalida) tenham o direito de prestar a prova para ingressar no Programa, mesmo sem registro em Conselho Regional de Medicina (CRM).

 

Essa notícia surpreende e decepciona, pois não corresponde à proposta apresentada pelo Ministério da Saúde ao CFM por ocasião do planejamento do Programa Médicos pelo Brasil.

 

O CFM tem posicionamento público em relação a essa questão e é inflexível quanto à obrigatoriedade de que qualquer médico, para exercer sua profissão no Brasil, tenha de ter diploma revalidado, estar registrado nos Conselhos de Medicina e ser portador de inscrição no CRM. Não há exceções a essas normas. O CFM não admite nenhum tipo de flexibilização dessas obrigações legais, que garantem qualidade e segurança no atendimento à população, realizado por profissionais qualificados.

 

O CFM solicita que o relator da proposta na Comissão Mista do Congresso Nacional, o senador e médico Confúcio Moura (MDB-RO), como profissional da medicina e conhecedor da catástrofe que é o atendimento da população por médicos desqualificados, resista à pressão de setores interessados em que o Revalida não seja aplicado aos intercambistas cubanos e aos brasileiros formados no exterior, o que contraria promessa de campanha do presidente Jair Bolsonaro, e mantenha em seu relatório a obrigatoriedade de que todos os médicos que pleiteiam entrar no Programa Médicos pelo Brasil sejam portadores de inscrição no CRM, em obediência à lei e pela segurança da assistência médica a todos os brasileiros.

 

O CFM, em passado recente, sob outros governos, sempre atuou contra medidas que ameaçavam a qualidade e a segurança da boa assistência à população brasileira, e novamente o fará caso essas propostas equivocadas sejam aprovadas, desvirtuando e contaminando o Programa Médicos pelo Brasil.

 

 

 

Brasília, 17 de setembro de 2019.

 

CONSELHO FEDERAL DE MEDICINA

Women in Health

Being a Doctor Is Hard. It’s Harder for Women.

Female medical residents and physicians endure bias and a larger burden with home duties. They also face a greater risk of depression.

By Dhruv Khullar

Happy medical residents are all alike. Every unhappy resident would take a long time to count.

It’s no secret that medical training is grueling: long hours, little sleep, rigid hierarchies, steep learning curves. It’s unfortunate but not surprising, then, that nearly one-third of residents experience symptoms of depression, and more than 10 percent of medical students report having suicidal thoughts. But is it worse for women than men?

A new study in JAMA Internal Medicine suggests yes. Dr. Constance Guille and colleagues analyzed the mental health of more than 3,100 newly minted doctors at 44 hospitals across the country. Before starting residency, men and women had similar levels of depressive symptoms. After six months on the job, both genders experienced a sharp rise in depression scores — but the effect was much more pronounced for women. A major reason: work-family conflict, which accounted for more than a third of the disparity.

Despite large increases in the number of women in medicine, female physicians continue to shoulder the bulk of household and child care duties. This unequal distribution of domestic labor is not unique to medicine, of course, but its manifestations are particularly acute in a physically and emotionally demanding profession with a lengthy training process that allows few, if any, breaks.

Despite large increases in the number of women in medicine, female physicians continue to shoulder the bulk of household and child care duties.CreditKaren Bleier/Agence France-Presse — Getty Images

The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties. Support for those trying to balance home and work life hasn’t kept pace with changing demographics, nor has the division of domestic labor shifted to reflect the rise of women in the medical work force. Today, women account for more than one-third of practicing physicians and about half of physicians-in-training. In 1966, only 7 percent of graduating medical students were women.

There’s a saying that you can’t take good care of patients unless you take good care of yourself, but as a colleague recently told me, “Try taking care of patients, yourself and two kids at home — while working 80 hours a week.”

Female physicians are more likely to cut back professionally to accommodate household responsibilities. Among young academic physicians with children, women spend nine more hours per week on domestic activities than their male counterparts, and are more likely to take time off when a child is sick or a school is closed.

Households in which both spouses are doctors are particularly illustrative: Women in dual-physician households with young children work 11 fewer hours per week (outside the home) compared with women without children. There’s no difference in hours worked by men, and this disparity hasn’t narrowed in the past two decades. Female physicians are also more likely to divorce than male physicians — and working more is associated with higher divorce rates for women but not for men.

These work-family conflicts are crystallized by the intensity of medical training, but gender bias within hospitals — both subtle and overt, from patients and colleagues — may be just as pernicious.

As a man of Indian descent, if I’m mistaken for anything, it’s for a cardiologist. (Which I am not — much to my mother’s chagrin). But for many female physicians, just getting others to call you doctor can be a daily struggle.

“I wear a white coat; I introduce myself as doctor,” said Dr. Theresa Williamson, a neurosurgery resident at Duke. “But patients still assume I’m a nurse or medical assistant or pharmacist. If there’s a man in the room — even if he’s a medical student and I’m the doctor — he’s the one they make eye contact with, tell their story to, ask questions of.”

It’s not just patients. A recent study explored how physician speakers were introduced at formal academic lectures, known as Grand Rounds. Female introducers almost always referred to the speaker as “doctor,” regardless of his or her gender. Male introducers used the formal title only two-thirds of the time — and were much more likely to use “doctor” for men than women. They used a woman’s professional title less than half the time.

“I remember being on a panel with all men, and the moderator thanking Dr. X, Y, Z — and Julia,” said Dr. Julia Files, an associate professor at the Mayo Clinic in Arizona and lead author of the study. “It happens all the time.”

After her study came out, Dr. Files said, “we heard from women across the world who said: ‘Thank you, this is our shared reality.’ ”

These biases can bleed into the way we do business. A new working paper by Heather Sarsons, a Ph.D. candidate at Harvard, examines whether surgeons’ gender affects their referrals after a good or bad patient outcome. Ms. Sarsons finds that physicians are much less likely to refer patients to a female surgeon after a patient death, but barely change their referrals to a male surgeon.

A bad experience with one female surgeon also makes physicians less likely to establish referral relationships with other female surgeons. There was no similar effect for men.

“That individual men and women are treated differently is obviously not a nice result,” Ms. Sarsons said. “But what’s really concerning is the broader spillover effects to other women.”

Medicine styles itself as both art and science. The science creates new knowledge and treatments. The art helps us recognize another’s humanity. But it also creates space for bias — conscious and unconscious — in how we treat patients and how we treat one another. These biases influence who is respected, who burns out and who is promoted.

By these measures, we’re not doing well. Female physicians are more than twice as likely to commit suicide as the general population. They earn significantly less than their male colleagues. They’re less likely to advance to full professorships — even after controlling for productivity — and they account for only one-sixth of medical school deans and department chairs.

There are steps that might help. A pilot program at Stanford, for example, allows physicians to “bank” hours they spend mentoring others or serving on committees. Those hours can then be used as credits for child care, dry cleaning pickup, ready-made meals, housekeeping and handyman services. Preliminary results are promising, and suggest that the program has increased job satisfaction, improved work-life balance and reduced turnover.

As these initiatives evolve, they could be evaluated to see not only if they improve physician well-being, but also if they promote career advancement, cut medical errors or improve patient satisfaction.

We can all also examine our own biases. Those of us evaluating medical students and residents, for example, could make it a point to ask ourselves whether a trainee’s gender — or race or ethnicity or accent — might have affected our assessment.

And more women in leadership and mentorship roles may help with the larger cultural shift that seems necessary. It’s possible that gaps in gender pay, promotion and mental health will narrow as medicine shifts from a boys club to one with more women. It’s also possible they will not. Disparities don’t close on their own. They close because we close them.

Dhruv Khullar, M.D., M.P.P., is a physician at NewYork-Presbyterian Hospital and a researcher at the Weill Cornell Department of Healthcare Policy and Research. Follow him on Twitter at @DhruvKhullar. 

Foreign doctors in USA

Trump's Immigration Policies Are Making It Harder for Foreign Doctors to Work in the U.S. — And That Could Hurt Patients

It's only the latest threat to foreign medical graduates

Jamie Ducharme

For the past four years, Daniel, an Israeli-born doctor completing a medical residency in the U.S., has secured an H-1B visa for temporary specialized workers without a hitch. But this May, without warning, the government put his status in the U.S. in danger.

Daniel, who withheld his last name for fear of retaliation, is one of many foreign-born medical residents across the country who have received visa rejections or delays since mid-April — similar to rejections thousands of H-1B applicants in other high-paying industries have recently received — prompting a flurry of legal activity from medical groups, hospital systems and individual doctors.

His situation is only the latest threat to international medical graduates. Several immigration policy changes under the Trump administration have left them deterred from or unable to practice medicine in the U.S. — which could be disastrous for a health care system already in the midst of a growing physician shortage. The changes could particularly affect patient care in community and underserved urban hospitals.

“I don’t want to sound paranoid, but I just think the current administration is trying to intimidate foreign workers and trying to intimidate hospital systems,” Daniel says. “For somebody who’s lived in the country for four years, that’s definitely not something I was expecting.” (A White House spokesperson referred TIME to United States Citizenship and Immigration Services (USCIS) and did not offer a separate comment.)

In Daniel’s case, after presenting USCIS with the same Association of American Medical Colleges resident stipend estimates that he’s used in his application for the last four years, USCIS responded with a request for evidence (RFE) seeking more specific, localized data — data that he says does not exist for resident physicians. Unless he can come up with it or mount a convincing enough legal argument before his visa expires on June 30 — the day before many medical residency programs begin across the country — Daniel will have to go back to Israel almost immediately, leaving his training unfinished and his hospital short a doctor.

The visa situation threatens the status of thousands of training physicians nationwide — roughly 25% of foreign medical residents in the U.S. rely on H-1B visas — and prompted a number of medical organizations to send a joint letter to the USCIS on May 30 expressing concern about the change. USCIS spokesman Michael Bars told TIME that any requests for evidence are in line with existing laws and standards.

“USCIS recognizes the use of valid private wage surveys by petitioners to establish the prevailing wage for an H-1B petition,” Bars said in a statement. “However, USCIS will continue to issue RFEs or denials, if appropriate, when officers determine that the petitioner has not established eligibility for the benefit sought. In keeping with the law as directed by the President’s Buy America, Hire America Executive Order as well as the intention of Congress, ensuring that H-1B employers are complying with all eligibility requirements serves to safeguard the integrity of the program to protect the wages, working conditions, and jobs of U.S. workers.”

In a second statement, Bars added that, “USCIS continues to review issues pertaining to private wage surveys and will consider issuing additional guidance to our officers in the future, if needed. If a petitioner has questions or concerns about its case, it may send an inquiry to USCIS through appropriate customer service channels.”

While the exact number of foreign doctors affected by policy changes isn’t known, signs of the trend have appeared in a few ways. Fewer non-U.S.-citizen international medical graduates registered for the residency match this year than in any since 2005, according to the 2018 Main Residency Match report. The number who became active applicants (7,067) was the lowest since 2012, the report adds. In 2016, for example, that number was closer to 7,500.

The downturn seems especially pronounced among residents of countries included in President Donald Trump’s original 2017 travel ban. (A revised travel ban looks likely to be upheld by the Supreme Court.) By recent estimates, about 8,000 doctors practicing in the U.S. were trained in countries included in the original ban.

Eighteen percent fewer doctors from countries included in Trump’s executive order came through the group that helps international medical graduates get certifications necessary to practice in the U.S., the Educational Commission for Foreign Medical Graduates (ECFMG), in 2017, according to the group’s president, Dr. William Pinsky. There’s also been an overall drop in the number of people applying for ECFMG certification over the past two years, he says.

“I’m hoping that the trend, or almost trend, that we’re seeing is because people are just waiting to see what’s going to happen,” Pinsky says. “But the fact is, there are opportunities for training around the world other than the United States.”

That’s something Sanaz Attaripour-Isfahani knows well. An international medical graduate trained in Iran and currently completing a fellowship in the U.S., Attaripour-Isfahani says she doesn’t regret the five-year logistical battle and multiple visa application denials it took to get here for residency. But she’s already seen that not everyone feels that way: Her sister, a doctor in Iran, decided to pursue residency in Canada, because the obstacles to getting into the U.S. are too great.

“I am very proud of what I gained here. [But] she does not think it’s worth it,” Attaripour-Isfahani says. “In the future, definitely, we will have a lot less Iranian doctors, comparing with what we had over the last 10 years.”

International medical graduates may increasingly gravitate toward programs in Europe, the U.K. and Canada if political trends continue, says Dr. Yusuke Tsugawa, a Japanese-trained doctor who has studied international medical graduates and is now an assistant professor of medicine at the University of California Los Angeles’ David Geffen School of Medicine. “In addition to the actual changes that have been made in the last one or two years, I think there’s some concerns about uncertainty around what’s going to happen in the future,” Tsugawa says. “They don’t want to come to the U.S. to start their training and get kicked out during the training, because that would be devastating for their careers.”

That uncertainty could have repercussions for patients, since foreign-born physicians occupy a pivotal place in the U.S. health care system. About an eighth of the resident workforce was born in a foreign country. With the American College of Physicians already projecting a shortage of between 40,800 and 105,000 doctors by 2030, any drop in the number of physicians who choose to practice in the U.S. could have significant effects.

Underserved areas may be the hardest hit. Studies have shown that international medical graduates are more likely to practice in inner cities and rural communities, and to enter essential practice areas such as primary care and family medicine — two fields U.S. grads are increasingly eschewing in favor of high-paying specialties like surgery and dermatology. Because of that trend, “Just training more doctors in the current system in the United States will overcompensate for specialists, and under-compensate for primary care docs,” says Dr. G. Richard Olds, president of St. George’s University in Grenada, a leading provider of foreign-trained U.S. doctors. International medical graduates “play a very important role, because we have had an insufficient number of U.S.-trained doctors for some time.”

There’s also evidence that international medical graduates provide care that is just as good, if not better, than that of domestically schooled doctors. A 2017 study by Tsugawa found that patients treated by international medical graduates had slightly lower 30-day mortality rates than people at the same hospital who were treated by U.S.-trained physicians. The two groups also had similar rates of hospital readmission, a metric often used to quantify quality of care. These results underscore the talent of international medical graduates, Tsugawa says.

“I don’t think the quality of the U.S. medical schools are worse than the quality of that in foreign countries,” Tsugawa says. “I think what explains it better is that the selection criteria for foreign medical graduates in the U.S. is pretty rigorous.” The residency match rate for Americans this year was 94%, meaning the vast majority of American students on track to graduate from U.S. medical schools were accepted to a training program. Only 56% of non-U.S.-citizen international medical graduates, by contrast, matched with a residency program this year.

Dr. Anupam Jena, a professor of health care policy at Harvard Medical School, agrees that the quality of international medical graduate care tends to be high. “We’re attracting the best and the brightest from all over the world,” he says. “Not surprisingly, the best and the brightest from India or China or Russia or wherever are probably going to be pretty good.”

Still, it can be difficult and costly to secure visas for foreign clinicians. That’s especially daunting for small, community-hospital-based residency programs — the type that tend to produce critically needed primary care physicians and doctors who end up practicing in underserved areas. “If you have a program with 15 first-year residents and one or two don’t show up, it could be devastating for the program,” ECFMG’s Pinsky says. As a result, small hospitals may simply not take the risk, leaving international medical graduates who don’t make the cut for the most selective programs in the lurch.

Some schools that did take the risk may be punished this year, given the current situation with H-1B visas. The letter sent to the USCIS by various medical groups notes that, for “at least one internal medicine training program,” 60% of incoming residents are on, or are supposed to be on, H-1B visas.

“I don’t even want to know what’s going to happen if [programs like that] have to start without having any of those people working,” Daniel, the medical resident, says. “That is really going to affect patient care.”

Better distribution of medical workforce

EMCM/UFRN relata a sua experiência de implantação do Curso de Medicina de Caicó

 

A implantação de um curso de medicina situado na cidade de Caicó (RN), no semiárido nordestino - a 280 quilômetros da capital do estado - e seus tensionamentos nos sistemas de saúdes locais. É esse o tema do relato feito por Lucas Pereira de Melo e outros sete autores, publicado em setembro de 2017 na Revista Interface.

 

A experiência institucional e curricular do curso de Medicina na da escola Multicampi de Ciências Médicas do Rio Grande do Norte (EMCM), da UFRN, que teve início de sua implantação em 2012. Partindo da missão constitucional do SUS de ordenar a formação de recursos humanos na área da saúde, a inadequação da formação médica às necessidades do SUS e da população e o lançamento do Programa Mais Médicos em 2013, o artigo descreve o processo de construção do projeto pedagógico do curso. A partir de uma série de reuniões e audiências públicas nos municípios da região de inserção da EMCM, havia o objetivo inicial de produzir um currículo “mais sensível às realidades locais e às necessidades de saúde da população”, com módulos, por exemplo, vinculados à Saúde Ambiental e a inserção dos graduandos nas comunidades da área.

 

Destaca também a iniciativa política da UFRN de garantir o acesso de estudantes da própria região do entorno da faculdade ao curso. A partir de um instrumento denominado Argumento de Inclusão Regional, os estudantes que terminaram ensino médio em localidades vizinhas ao campus ganhavam um bônus de 20% na nota do Sistema de Seleção Unificada (SISU). Com essa política, os pesquisadores afirmam que atualmente 67,5% dos alunos do curso são oriundos de munícipios do sertão potiguar e paraibano.

 

Destacam também a prioridade que a formação e o desenvolvimento docente tiveram nesse processo. Foram realizados uma série de cursos e oficinas sobre metodologias de ensino e disponibilizadas vagas do Mestrado Profissional para a titulação de todos os docentes do campus.

 

O projeto curricular do curso foi dividido em eixos pedagógicos estruturantes: o Ensino Tutorial, as Habilidades Clínicas, Morfofuncionais e de Comunicação e a Integração Ensino-Serviço-Comunidade. Em consonância com as Diretrizes Curriculares Nacionais, o curso tem a primeira fase de Fundamentos da Prática Clínica, com 31 módulos interdisciplinares nos quatro primeiro anos da graduação, a partir dos eixos de ensino tutorial, de habilidades e na comunidade.  E, posteriormente, a segunda fase, com os dois anos finais de Internato Médico.

 

Os três eixos englobam sessões tutoriais, conferências semanais e oficinas práticas de habilidades e atividades inseridas diretamente em serviços do SUS. Diferentes formas de avaliação são descritas para cada um dos eixos foi desenvolvida, mediante as características do processo formativo das modalidades de ensino.

 

Os autores apontam obstáculos a implementação do projeto como a resistência ao modelo pedagógico baseado em metodologias ativas de aprendizagem, o comprometimento insuficiente de docentes com o curso e a sobrecarga dos estudantes e do trabalho docente.

 

Destacam também, além da graduação, a constituição de programas de Pós-Graduação, com funcionamento de dois cursos de Residência Médica (Cirurgia e Medicina de Família e Comunidade) e dois de Residência Multiprofissional em Saúde (Atenção Básica e Saúde Materno-Infantil), totalizando 71 vagas anuais.

 

Além disso, trazem à tona a prioridade na construção da Extensão Universitária no processo, com um total de 24 projetos, 5 cursos e 2 Programas de Extensão entre 2014 e 2016. Aponta-se aqui estas iniciativas como o elo entre a universidade e a comunidade, com suas complexas necessidades de saúde. Temas como a pesquisa, a titulação do corpo docente e a estrutura do campus também são abordados no relato.

 

Em suma, o artigo relaciona a implantação de um curso de Medicina inserida na luta em defesa dos princípios do SUS. Segundo os autores, “apesar de todas as potencialidades e conquistas, ainda são grandes os obstáculos e desafios a serem vencidos para que a EMCM-UFRN funcione em toda a sua capacidade e plenitude”.

Novo edital do Mais Médicos

Mais Médicos abre vagas para mil profissionais brasileiros

Médicos serão direcionados para 462 municípios. Profissionais vão substituir 838 profissionais cubanos e 166 desistentes

 

 

por Portal Brasil

 

 

 Tânia Rêgo/Agência Brasil

A meta do governo federal é chegar a 4 mil substituições de médicos cooperados por brasileiros em três anos

Na próxima sexta-feira (11), o Ministério da Saúde coloca em prática a primeira medida para ampliar a participação de brasileiros no Programa Mais Médicos. Haverá o lançamento do edital para substituição de médicos da cooperação com a Organização Pan-Americana da Saúde (OPAS).

Ao todo, são mil novas vagas em 462 municípios, sendo 838 ocupadas atualmente por profissionais cubanos e outras 166 relativas a reposições de desistentes.

A meta do governo federal é chegar a 4 mil substituições de médicos cooperados por brasileiros em três anos, reduzindo de 11,4 mil para 7,4 mil participantes cubanos. Para isso, o Ministério da Saúde quer atrair os brasileiros ofertando vagas em locais que estão entre as opções mais escolhidas por esses candidatos nas últimas seleções e que, atualmente, são ocupadas por cubanos do 1° e 2° ciclos do Programa. 

Vagas

Nesse primeiro edital, as oportunidades estão, em sua maioria, localizados em capitais, regiões metropolitanas e em municípios com mais de 250 mil habitantes. Outra novidade é que o médico terá 15 dias para permutar sua vaga com outro profissional selecionado. Com isso, os candidatos terão mais uma chance de o médico garantir atuação onde deseja entre as cinco opções que podem fazer. A cada três meses, um edital trará novas vagas.

“São postos mais atraentes e ainda há a possibilidade de permuta dos selecionados, que é a novidade do edital. Nosso esforço é no sentido de que os médicos que entrem no Programa permaneçam o máximo de tempo possível, para se integrar à comunidade, conhecer as famílias”, ressaltou o Ministro da Saúde, Ricardo Barros. 

A expectativa é chegar a 7.800 brasileiros no Mais Médicos, representando mais de 40% do total de profissionais. Atualmente, dos 18.240 médicos participantes, 5.274 são formados no Brasil (29%), 1.537 tem diplomas do exterior (8,4%) e 11.429 são da cooperação com OPAS (62,6%). Mais de 63 milhões de pessoas são assistidas por esses profissionais. 

Inscrições

As inscrições serão realizadas entre 20 de novembro e 23 de dezembro, e as vagas que não forem preenchidas por médicos brasileiros com atuação no País serão ofertadas aos brasileiros formados em qualquer país.

Nos editais realizados em 2015 e em julho deste ano, 100% das vagas foram ocupadas por médicos brasileiros formados no Brasil e no exterior, o que demonstra maior interesse desse público pelo programa.

O Mais Médicos oferece aos profissionais bolsa-formação mensal de R$ 11.520,00, R$ 30 mil para o médico que optar por uma vaga longe da cidade onde reside, auxílios moradia e alimentação garantidos pelos municípios mensalmente, além de Especialização em Saúde da Família por uma Universidade pública do sistema UNA-SUS.

Confira a apresentação com os dados das novas vagas para médicos.

Rural Medicine

Rural recruitment and training promotes rural practice by GPs, but is it enough to retain them?

Geetha Ranmuthugala1,2

1 University of New England, Armidale, NSW

2 Rural Clinical School, University of Queensland, Toowoomba, QLD

Challenges to keeping general practitioners in the bush remain

The findings reported by McGrail and colleagues in this issue of the MJA support the effectiveness of Australian government incentives for recruiting and training general practitioners in rural areas as a strategy for reducing rural medical workforce shortages.(1) The study found that rural origin of trainees and rural vocational training of GPs were each strongly associated with their practising in rural areas in the early years after completing vocational training. However, their findings also suggest that these effects had started to diminish by 4 years post-training.(1) This finding is consistent with another recent Australian study, which found that the effects of rural recruiting and training diminished over time.(2)

As evidence emerged in the early 1990s that a rural background and a positive rural training experience promoted the subsequent uptake of rural practice by trainees, the Australian government introduced several initiatives for recruiting and training medical students in rural areas. The Rural Undergraduate Support and Coordination Program (RUSC) was in 1993 among the first of these initiatives, followed by the Rural Clinical School (RCS) and the Rural Clinical Training and Support Program (RCTS). These initiatives required that 25% of the intake of students by federally funded medical schools be from a rural background; that all federally supported medical students undertake a 4-week structured rural placement; and that 25% of students undertake at least 12 months’ clinical training in a rural location.(3) Initiatives such as the Australian General Practice Training Program followed, ensuring that at least 50% of general practice vocational training placements are in rural or remote areas.(4) These training initiatives have contributed to the success achieved in increasing the number of GPs who adopt rural practice: it was recently reported that the rural and remote GP workforce increased by 23% between 2010 and 2014, compared with a 3.5% increase in the rural and remote community population, and a 10% increase in the metropolitan GP workforce over the same period.(5)

It is now timely to consider whether an increase in the number of rural and remote GPs necessarily translates into a sustained and well supported workforce which can deliver quality health care that meets the needs of rural communities. Factors that motivate practitioners to remain in rural areas include access to training, professional development and career development opportunities.(3) While I focus in this article on the role of training and education in rural retention, other factors known to be important include peer and professional support, assistance with heavy workloads and on-call requirements, locum relief,(3) access to infrastructure (such as information and communication technology and electronic health data systems), housing, and family support.(6)

In addition, being a principal of the medical practice has been identified as significantly increasing the likelihood of a doctor remaining in a rural location (by 72%), while being a salaried or contracted employee significantly reduces the likelihood (by 20–30%).(7) GPs in rural and remote locations work longer hours than their metropolitan counterparts, increasing steadily from an average of 38 hours per week in metropolitan locations to 45.8 hours in very remote locations.(5) Such demands, and the need to travel, make it more difficult for rural or remotely located practitioners to participate in professional development and to take up training opportunities. Innovative business and work model solutions are needed to support the rural GP workforce.

It should also be noted that the proportion of GPs practising procedural skills increases with remoteness (from 8.0% in inner regional areas to 13.8% in outer regional and 20.9% in remote and very remote locations).(5) Recognising that rural and remote practitioners must have procedural skills in general surgery, obstetrics, anaesthesia, radiology and endoscopy, the Royal Australian College of General Practitioners has incorporated procedural skills training into their curriculum.(8) Additional training is provided through the General Practitioner Procedural Training Support Program. Nevertheless, the period 2010–2013 saw a drop in the proportion of GPs practising procedural skills; (5) the decline was greatest in outer regional areas (4.1%), followed by remote (3.9%), inner regional (1.9%) and very remote locations (0.6%). Reasons for this decline are not clear and need further exploration, especially given a recent finding that undertaking hospital work significantly increases the likelihood that rural and remote GPs remain in rural locations (by up to 40%).(7) As exercising one’s skills contributes to increased job satisfaction, motivation, commitment and retention,(9) there is a need to provide the infrastructure and opportunity for these practitioners to enhance and practise the procedural skills that have been identified as an important aspect of rural practice.

The early training initiatives are having positive effects on recruitment, but they must be reviewed and updated as new evidence emerges. Accordingly, in light of consistent support for the influence of longer term rural clinical placements on the likelihood of choosing rural practice, the initial requirement that all federally supported medical students undertake a 4-week rural placement has been reduced to 50% of students, but with no change to the proportion required to undertake a year-long rural clinical placement.(10) It will be another 5–10 years before the effect of these revised funding parameters on the recruitment and retention of the rural medical workforce will be apparent.

References

1. McGrail MR, Russell DJ, Campbell DG. Vocational training of general practitioners in rural locations is critical for Australian rural medical workforce. Med J Aust 2016; 205: 217-221.

2. Hogenbirk JC, McGrail MR, Strasser R, et al. Urban washout: how strong is the rural-background effect? Aust J Rural Health 2015; 23: 161-168.

3. Mason J. Review of Australian government health workforce programs. Canberra: Department of Health and Ageing, 2013. http://www.health.gov.au/internet/main/publishing.nsf/Content/review-australian-government-health-workforce-programs (accessed June 2016).

4. Australian Government, Department of Health. Australian general practice training. 2017 handbook. Canberra: Department of Health, 2016. http://www.agpt.com.au/ArticleDocuments/183/2017%20AGPT%20Handbook%20Final.pdf.aspx (accessed July 2016).

5. Rural Health Workforce Australia. Regional, rural and remote GP workforce trends: developing evidence-based health workforce policy. Melbourne: RHWA, 2014. http://www.rhwa.org.au/client_images/1743949.pdf (accessed July 2016).

6. Rural Health Standing Committee (Australian Health Ministers’ Advisory Council). National strategic framework for rural and remote health. Adelaide: RHSC, 2016. http://www.health.gov.au/internet/main/publishing.nsf/Content/national-strategic-framework-rural-remote-health (accessed July 2016).

7. Russell DJ, McGrail MR, Humphreys JS, Wakerman J. What factors contribute most to the retention of general practitioners in rural and remote areas? Aust J Prim Health 2012; 18: 289-294.

8. Royal Australian College of General Practitioners. RH16 Rural health. Melbourne: RACGP, 2016. http://www.racgp.org.au/download/Documents/Curriculum/2016/RH16-Rural-health.pdf (accessed July 2016).

9. Skills Australia. Better use of skills, better outcomes: a research report on skills utilisation in Australia. Canberra: Commonwealth of Australia, 2012. https://docs.education.gov.au/system/files/doc/other/skills-utilisation-research-report-15-may-2012.pdf (accessed July 2016).

10. Australian Government, Department of Health. Rural health multidisciplinary training (RHMT) 2016–2018 programme framework [website]. Updated Mar 2016. http://www.health.gov.au/internet/main/publishing.nsf/Content/rural-health-multidisciplinary-training-programme-framework (accessed July 2016).