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).

Socially conscious doctors

Physician advocates for more socially conscious doctors

by Kemantha Govender

The focus in producing new medical graduates should be as much on creating socially conscious doctors, as it is on increasing the numbers of medical professionals

This was a common consensus at the annual Centre for Rural Health seminar held on 8 September 2015 at the Alder Museum, Wits Medical School.

Dr Henry Campos, rector of the Federal University of Ceará, in Fortaleza, Brazil, shared his experiences about health care challenges in his country and the measures that are being enforced to address them.

Brazil's challenge

Campos said there is an imbalance in the way doctors are distributed throughout Brazil. In more than 1900 municipalities, there is only one medical doctor for every 3000 inhabitants in primary care settings.

There is also severe shortage of medical doctors in 700 other municipalities, where the majority of them do not have a doctor living in the municipality.

To address this critical shortage, it became compulsory for all medical students in Brazil to do their training in the health system since. "Thirty percent of the internship has to be done in primary care and emergency settings of the public health system," said Campos.

During the two-year internship, the students are supervised by the faculty of their medical school and by preceptors recruited in the health system.

The internship is done in the region where the medical school is located, as students who come from rural areas to urban areas to study often do not return home.

Campos is an advisor to the Brazilian Ministries of Health and Education, and is currently coordinating the Commission for Expansion of Medical Schools.

He has played a major role in the expansion of medical training in Brazil over the last five years, including leading the development of 29 new rural medical schools.

Shortage in SA

South Africa's challenges are similar to those of Brazil. Director of the Centre for Rural Health, Professor Ian Couper said South Africa needs to scale up its training of medical doctors.

"We currently have about 0.8 per 1000 population, compared to the minimum of 1.4 per 1,000 recommended by World Health Organisation. Brazil has 1.9 per 1000, but has a target of 2.7 per 1000, with ambitious plans to reach that," said Couper.

"A major component of the plan is to scale up training by starting new medical schools. We can learn a great deal from these ambitious efforts, and other health professional development initiatives in Brazil in which Professor Campos has played a leading role."

Professor Vic Exner, Dean of the Faculty of Health Sciences at the Nelson Mandela Metropolitan University (NMMU) in Port Elizabeth said his institution wants to start getting students involved in communities in their first year.

"There must be a shift in health science training to global, rather than individual, focus. Students need to learn how to operate in teams and should not see themselves as one more important than the other. They need to prioritise the health concerns of the community," said Exner.

Bottom-up approach

Exner said traditional teaching in classrooms must be replaced with facilitating blended learning in groups.

His bottom-up approach seeks to look at what can be done internally and trying to eliminate endeavors such as building new buildings. He believes there should be an assessment of available resources and infrastructure.

Exner said his university is looking to establish a new School of Medicine to give effect to national imperatives, such as the National Health Insurance.

But the vision is also to deliver a broad spectrum of scarce skill health professionals Eastern Cape.

This school aims at also address regional needs in the National Health Sciences Training Platform.

The faculty has already commenced with a four-year emergency medical care practitioner degree and is gearing to have a three-year clinical associate's degree approved by the Health Professions Council of South Africa in 2017.

The NNMU is working towards offering the Bachelor of Medicine and Bachelor of Surgery degrees by 2020 and Masters in Medicine by 2025.

To bring about some of these changes, Exner said there should be transformation within the academic staff and a workplace-based learning on a common clinical training platform.

Exner said NMMU is exploring opportunities for collaborations – they want to partner with Walter Sisululu University to address health problems in the Eastern Cape and with the University of Cape Town who are expanding into George, an area in which NMMU has a campus. 


Provided by: Wits University