A significant step in securing a stable rural medical workforce
Dr Ayman Shenouda
A rural renaissance
It is great to see the Federal Government delivering on its commitment to increase the number of rural-based doctors in training.What we are experiencing right now in rural health can only be described as a rural renaissance. We have great leadership in our Rural Health Commissioner and now in our new Rural Health Minister making her mark and building on the great work of her predecessor.
More intern placements in general practice is great news for rural doctors and their communities. This is an essential step in securing the next generation of rural GPs by ensuring our trainees receive broad exposure through prioritising primary care and general practice. These programs really work as they provide trainees with that essential insight to community medicine.
Intern rotations in general practice
The Rural Junior Doctor Training Innovation Fund (RJDTIF) program provides primary care rotations for rurally based first-year interns. It builds on existing state and territory arrangements to provide primary care rotations in addition to hospital rotations.
Last week, Rural Health Minister, Senator the Hon Bridget McKenzie, announced a $1,304,967 Federal Government grant for the Murrumbidgee Local Health District to increase intern rotations throughout the region. I’m proud to be contributing with my practice in Wagga selected to participate and we will be rotating five interns a year through this program.
It was great to show Minister McKenzie around my practice and have a chance to discuss how to provide that valuable community exposure early. The Minister showed a deep understanding of what is required in placing policy priority on general practice. She shared my vision that every junior doctor should have a rotation in general practice as part of the first two to three years of training.
Quality training experience
In our practice, we have GP specialists, new fellows, GP registrars, interns and medical students working alongside nurses and allied health professionals. We aim to support the integration of vertical and horizontal teaching enhanced through a multidisciplinary team environment.
A strong teaching culture and established education networks also ensure we have the hospital and community partnerships to enhance exposure and demonstrate for our trainees the diversity of general practice. We’ve worked hard to build the required supportive infrastructure and systems to make this work which needless to say is also reliant on a solid business model.
Keeping them there
Targeted exposure strategies like these ensure trainees can develop the broad range of skills required. It provides essential rural exposure for interns to learn the complexities of delivering services in rural areas while in a supportive general practice setting.
My own experience with the PGPPP where I had 12 interns rotated in my practice really yielded results. From that cohort, about 70 per cent of them have chosen general practice as their training speciality. They loved the diversity and complexity general practice offered. It challenged them, kept them engaged and provided that important insight into the doctor-patient relationship.
A little on the policy journey
Addressing maldistribution has been dominant in the discussion at many Rural Health Stakeholder Roundtables in Canberra over recent years.
Certainly, greater exposure to general practice for junior doctors has been central to RACGP Rural advocacy around securing an integrated rural training pathway. Particularly in ensuring more emphasis on primary care and generalism early in medical education.
But really making generalism a foundation of junior medical training – a discussion made more difficult on the back of a defunded PGPPP. This was a significant policy obstacle when you consider that what we were pursuing was more of a supercharged PGPPP but specifically for rural areas.
We needed a solution that would boost the number of GPs as well as address the gap in the rural pathway by providing intern rotations in general practice and primary care. We knew there was a strong learner preference for rurally based internships. We also knew that potentially we had lost a cohort of potential rural GPs as the gap from the PGPPP hit hard and narrowed our opportunities.
A win for general practice
It certainly was a long policy process getting here. This is the why this program, which was the result of a long period of sustained advocacy, is such a significant win for general practice. It is clear much of the hard work over many years is starting to pay off particularly in rural health. This is a significant step forward in securing a stable medical workforce to address maldistribution.
Let’s not lose another rural obstetrics service
1 September 2017 Dr Ayman Shenouda
Decline of rural obstetrics services
It was disappointing to see yet another decision without due consultation to downgrade rural maternity services recently and this one was particularly close to home for me. Temora Hospital’s maternity services will be reduced with patients requiring maternity surgery under general anaesthetic moved to other district hospitals. Only a month earlier, in July, it was Emerald in Queensland that was in the spotlight due to a maternity service closure. But none of this is really new, is it? Nationally we’ve seen more than 50% of small rural maternity units closed since 1995.
In this latest downgrade, we’re told Temora’s maternity services for low-risk pregnancies will continue but caesarean births and gynaecological surgery will now be relegated to Cootamundra and Young hospitals. This just shifts the costs in my view and is not a sustainable solution for this community and could see broader impacts on other services too if works are not prioritised and essential staff leave. Surely, part of the cost equation has to also look at the costs transferred to the patient as well as the skills lost and broader safety aspects of NOT having a locally accessible service?
The NSW Health Minister Hon. Brad Hazzard MP says he was kept in the dark on the decision by the Murrumbidgee Local Health District (MLHD) and wants the service retained. There is at least some hope for this community with the Minister making clear his views on the matter. But why do we need to get to this level in the first place? Local level planning and consultation should have occurred on such an important issue and well before it got to ministerial intervention level and preferably not debated through the media in this way.
Impacts for the local workforce
Putting aside the clear impacts of this decision - including higher risk birthing outcomes - for one moment. What now for the three obstetric providers who have been providing this service? One GP obstetrician in the town stated in the Harden Murrumburrah Express that she did not want to see Temora become a victim of bureaucracy.
We know that driving decisions to close or reduce rural maternity services is often around doctor shortages, safety concerns or funding constraints. This decision according to media reports comes down to physical infrastructure costs. The issue is the obstetrics theatre room was deemed unsafe for surgery following an audit by the Australian Council of Healthcare Services.
Rural patients need viable maternity and surgery services near to where they live. And doctors who invest in training to ensure a service for their community need some certainty around service continuity. They most certainly need to be involved in local service decision making which certainly seems not to have been the case in the Temora downgrade.
A strong focus on policy
This is a decision which seems contradictory to what we’ve seen from NSW HETI in terms of its rural generalist pathway. There has been an expansion of training positions this year with 40 positions being made available.
It is also contrary to the focus nationally which has seen committed action over an eight-year period. There has been a strong policy focus in the form of a Maternity Services Review (2009), a National Maternity Service Plan (2010-2015) and the current development of a National Framework for Maternity Services.
We’ve seen such a strong policy response in recent years and it’s important that local level planning decisions work within these broader nationally set priorities. Both the National Maternity Services Plan (2010-2015) and new National Framework for Maternity Services (2017), which is still being finalised, have set specific priorities to secure more equitable outcomes for rural patients including in the areas of access and workforce.
Some great policy outcomes have resulted already including in terms of tools to inform planning and in areas of national data development.
The Australian Rural Birthing Index (ARBI) was a key outcome of the Plan which has provided an important index to help in the planning for maternity services in rural locations. The index can be downloaded here: http://ucrh.edu.au/wp-content/uploads/2015/07/ARBI_FINAL_PRINT.pdf .
While the AIHW-led National Maternity Data Development Project aims to enhance maternity data collection and reporting in Australia. Both are important national planning tools which aim to utilise a population based planning approach as the basis for demand driven evidence-based decision making.
Protecting rural services
Despite such a strong policy focus and commitment, it is evident that we still need to improve maternity services in rural and remote communities. There is clearly state-level support for the development of rural GP procedural skills. However, this needs to also extend to rebuilding rural hospital infrastructure when required to ensure service continuity. Here in NSW, we have a policy commitment to develop workforce capacity by expanding rural generalists being potentially compromised by a local level decision driven by infrastructure costs which have led to the downsizing of maternity services.
The critical role of procedural GPs – both GP obstetricians and GP anaesthetists – in providing maternity services in rural Australia is well understood. Decisions which see closures or a downgrade of services will have a direct impact on the long-term commitment of both current and future rural doctors. Let’s not lose another rural obstetrics service – operative obstetrics and gynaecological procedures are needed in Temora and funding should be found to upgrade the operating theatre.
 Rural Doctors Association of Australia. Maternity services for rural Australia. Manuka: Rural Doctors Association of Australian, 2006.
 The Daily Advertiser. Media Article: Minister ‘kept in the dark’. Published 22 August 2017.
 Harden Murrumburrah Express. Media Article: Temora Hospital theatre closure could see expectant mothers transferred to Cootamundra or Young Hospital. Published 21 August 2017. Available at: http://www.hardenexpress.com.au/story/4870112/obstetrics-theatre-room-closing-at-temora-hospital/
 Longman J, Pilcher J, Morgan G, Rolfe M, Donoghue DA, Kildea S, Kruske S, Grzybowski S, Kornelsen J, Oats J, Barclay L. (2015) ARBI Toolkit: A resource for planning maternity services in rural and remote Australia. University Centre for Rural Health North Coast, Lismore.
25 August 2017 Dr Ayman Shenouda
RECRUIT, TRAIN AND RETAIN
Getting the policy settings right
I don’t think there’s ever been a better time to secure the next generation of rural GPs. Now more than ever before we have the right policy settings in place. We need to seize this opportunity to ensure we select the right doctors for rural Australia.
Once we’ve overcome that first hurdle in getting them there, we need to then ensure those registrars who choose rural practice, that once secured, they remain there. But not only remain there that they continue to thrive. To do this we need to ensure the right supports are in place.
The policy momentum has been building for some time with the help of thousands of rural GP champions – possibly most now reading this blog – who have advocated for change over many years.
We now have the right set of policy conditions: an overall increase in medical school intake with quarantined placements for rural; a rural emphasis and exposure with a focus on generalism as a priority in the training; and, of course, the regional training hubs which will soon be in place to help link the various stages of training.
We finally have the makings of an integrated rural medical training pathway. This includes a priority on rural community internships – a clear gap which needed fixing – and soon with the regional hubs, training can be structured in a more coordinated facilitated way.
The hubs, in particular, will strengthen the efforts of the Rural Clinical Schools’ and help build the facilities and infrastructure and teaching capacity needed to make this work. For the trainee, it will help to provide the navigational supports that have been so lacking in the past from medical school to rural practice. Importantly, we have a focus on non-coercive strategies in securing the next generation of rural GPs.
Why enter, why stay, why leave?
We know that many factors influence rural intention and that it is getting those supports right and across the full training continuum that counts.
Ruralising the curriculum is a key one. Embedding more primary care early into the medical curriculum is essential and this has certainly been said often enough. But other simple things like placing a rural scenario in the exam would also help to formalise assessment to enforce primary care and emphasise the important role of the generalist.
Getting them in early and interact as often as possible is another key requirement. Nurturing your registrars once there requires a whole of community effort.
I think it is instilling that sense of belonging that is vital at this point so the emphasis then needs to be multifactorial. Positive exposure offering a mix of rural experiences including clinical and nonclinical competencies and of the latter leadership being a key one here, the ability to lead and work in teams cannot be emphasised enough.
Trainees want broad exposure and the opportunity for multiple levels of clinical learning through blended placements. Trainees need to be empowered to make informed career decisions and to obtain the skills they need in the local setting. A community with the right structures and partnerships in place can facilitate this well.
Next is community connection and engagement and getting that right. This really gets to the heart of the issue – this is why they stay – that sense of place and identity. Ensuring a strong rural connection is hard work in training terms but worth the effort in the long run.
This is all part of developing a professional identity and mentoring plays a key role here. Longer-term placements in and around the same community also help to build those lasting relationships.
While I think an intrinsic characteristic of most GPs is their altruism there are also limits. We need to formalise that mentoring point – and at every learning stage – so that rural GPs and broader teaching staff are able to commit their focus towards mentoring.
More funding for mentoring has to be part of the suite of incentives in support of rural intention. Formalising succession planning in this way would help to ease the pressure on those nearing retirement too. That’s the ‘gracious exit’ part that often gets forgotten but just as vital as ‘easy entry’ for rural.
A rural pipeline functioning well can support these broader retention outcomes in terms of supplementing supply over time through a constant stream of new entrants. This would help make rural practice even more attractive as it provides an exit strategy for rural GPs without having to make that lifetime commitment. Rural GPs could stay for a shorter period, up to five years, without causing the workforce disruption that currently occurs upon exiting. Rural practice could become a standard part of the GP journey with supportive policy offering more flexibility and opportunity to spend at least part of your career within a rural community.
Now finally, getting to the hardest bit. Once you have them, then the focus then shifts to keeping them there. And getting to the bottom of that is a whole new set of questions which tend to include broader impacts including those on family.
Factors including an adequate income, appropriate workload, locum provision, access to specialists’ advice and continuing education, spouse career opportunities and children education all come in to play. Again, it takes a whole community to help make this work.
Bringing it all together
Piecing it all together there are a lot of factors that need to come together to get rural recruitment, training and retention right. Ensuring we have the right set of incentives in place for those making the commitment is key to policy success including rewarding advanced skills, procedural and non-procedural.
In understanding intentions to practice rurally, we know that rural origin plus a rural clinical school placement is a significant predictor. But there are many ways to get there and we should keep an open mind as many get there by accident. I think I fit that last category having only come to rural practice at the age of 35 after commencing in a completely different specialty to being with.
In securing strong rural outcomes, it comes down to nurturing those with an interest and being able to bundle those known influences. We’ve certainly come a long way in securing the right supports and focus to realise a fully integrated rural training pathway. It’s a multitude of factors including supportive policy and a strong local commitment from each and every one of us, but not least the trainee to secure the next generation of rural GPs.
 RACGP. New approaches to integrated rural training for medical practitioners. Royal Australian College of General Practitioners. 2014. Available at: http://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
 Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians. Acad Med. 2017 Aug 1. doi: 10.1097/ACM.0000000000001839. [Epub ahead of print]Availablat: http://journals.lww.com/academicmedicine/Abstract/publishahead/The_Road_to_Rural_Primary_Care___A_Narrative.98154.aspx
 RACGP 2014, op. cit. p.65.
 Humphreys J, Jones J, Jones M, et al. A critical review of rural medical workforce retention in Australia. Aust Health Rev 2001;24:91-102. [PubMed]
 Walker JH, DeWitt DE, Pallant JF, Cunningham CE. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural Remote Health. 2012;12:1908.PubMed
11 August 2017
Dr Ayman Shenouda
Developing a skill set around your community’s needs.
Just like lifelong learning, community needs assessment is a continual process that helps us to ensure our community has the best possible service mix. Health needs assessment is developmental and has to be added to or adjusted over time as the community’s needs change. It is alongside that process that we commit to continual learning, to adjust our skills over time to ensure these needs are met.
For a rural community, where resources and infrastructure are scarce, needs assessment is a critical process. It helps you to prioritise where you can make the biggest impact, to plan and deliver the most effective care against those areas of critical need. It enables you to work collaboratively with the local community to develop the infrastructure required. Most of all it becomes a partnership as people centred health relies on community participation and through this process, you find yourself fully immersed in community life.
When I arrived in Wagga Wagga 17 years ago, I was armed with some advanced surgical skills acquired while working as a surgical registrar in Egypt, then further honed in Tasmania during my initial few years in Australia. Naturally, my fellow GPs in the practice referred to me patients with surgical skin conditions. This was great as it allowed me to utilise my skills, on the other hand, though patient expectations increased as they were under the impression that I was a Dermatologist!
In all honesty, my dermatology skills weren’t all that flash and it was clear the local service gap in Dermatology needed fixing. I subsequently completed a Diploma of Dermatology in 2003 through the University of Wales in Cardiff. I became very popular and started to have referrals from other practices in town, as without a local area specialist that role continued to fall to me. It was out of unmet need that this became a necessity of course but it really was the community driving that decision to upskill.
Now the Wagga community has access to dermatology services I am adjusting again but to a new requirement in palliative care. This is demonstrative of lifelong learning in practice – The good GP never stops learning – in providing lifelong care there relies a commitment to lifelong learning to adapting your skills to meet changing needs.
For those looking for more inspiration, there were some great rural stories produced some years ago. During 2012, the RACGP rural faculty celebrated its 20th anniversary and as part of our commemorating that milestone we produced a series of inspiring stories “Getting to know our rural GPs”. These stories were truly demonstrative of just how diverse the profession is and the depth of skills needed in supporting the often-complex needs of rural communities, while also highlighting the unique nature and rewards of living and working in rural general practice.
Applying a lifelong learning framework
In applying a lifelong learning framework, we already have the key structures to facilitate this. The Fellowship of the Royal Australian College of General Practitioners (FRACGP) signifies that a GP has been assessed as competent across the core skills of general practice enabling him or her to practice safely, unsupervised, anywhere in Australia.
The FARGP is a qualification awarded by the RACGP in addition to the vocational Fellowship (FRACGP). Providing a dedicated pathway for both general practice registrars and experienced practising GPs, the FARGP aims to develop advanced rural skills and broaden options for safe, accessible and comprehensive care for Australia’s rural, remote and very remote communities.
The FARGP is unique here in terms of using a population health approach to plan and execute health service needs for a community. The community-focussed project is undertaken over a six-month period and enables you to get to know your community and engage with them to improve health. This important requirement equips the candidate with essential planning tools and establishes leadership in a community.
Skill development in policy
For trainees, key to ensuring broad skill exposure is the need to map the training process to ensure a wide variety of experiences can be provided. Needs analysis is again critical here and this level of planning is something we should be doing more of at both the state and national levels. This level of planning provides a comprehensive training program and a way to ensure skills learned are transferrable to their practice after the completion of training posts in building a resilient workforce.
After all, it is these trainees that will provide vital services in the future. Ensuring broad exposure and allocating placements according to specific learning needs and against community need at this early stage makes perfect sense in planning a future generalist workforce. The new regional training hubs should help to support this needs assessment to tailor a training package which provides for the level of flexibility required to truly immerse in the community as well as ensure relevant clinical exposure.
Just as vital is the requirement for a skill-acquisition pathway for practising rural GPs acknowledging the lifelong learning requirement and addressing unmet need. A stronger focus is required at both the state and national levels in terms of providing that structure or mechanism in the current arrangements to facilitate training for those who wish to go back and retrain to meet a skill need in their community.
The Commonwealth’s Rural Procedural Grants Program is vital in supporting skill maintenance in some key hospital-based skill areas. Applying a population health needs assessment in terms of skill acquisition requirements should guide decisions at the policy level. This process would see an expansion of the procedural grants program to include essential non-procedural advanced skills. Policy planning needs to factor and be responsive to current and future need just as the GP does in responding to the changing health needs of their community over a lifetime.