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Shortage of Rural Doctors in Australia
(and what can we do about it, if anything?)

Stephen Milgate
Country Mayors Association (NSW)
August 1999

Forward

I am able to give this talk and to undertake this research largely because of the efforts of one person, Dr Bruce Dalway Shepherd AM, Chairman of the Australian Doctors' Fund. Dr Shepherd, the brother of a rural GP, was born and educated in Tamworth. He has never stopped working for better rural practice, using his own money and money he has raised from colleagues he established the Australian Doctors' Fund which has constantly advocated solutions and identified non-solutions to the improvement of rural practice in Australia.

Shortage of Rural Doctors in Australia
(and what can we do about it, if anything?)

It is time for some straight talking about the rural doctor issue.

Truths

1. The shortage of qualified medical practitioners in rural and remote areas is a problem for almost every country in the world including communist China where medical manpower is strictly controlled by government.
2. There is no reason for a doctor to work in any particular locality. A doctor's job is to treat the sick. A person with chronic asthma in Wagga is as much a patient in need of a doctor as a person with the same condition in Woolloomooloo and visa versa. Illness knows no geographic boundary. A doctor can morally justify working anywhere where there are patients.
3. Since most people in Australia live in the cities then most doctors will live and work in the cities. Furthermore, the more illness you see and treat the better doctor you become. Doctors do not like to feel that they are "out of the mainstream" professionally particularly, early in their careers. There is an attractiveness about being "where the action is".
4. Medicare gives middle and upper income earners easier access to medical services at low cost than would be the case without it. Hence, Medicare will always reinforce the attractiveness of the city versus the country as far as a viable professional practice is concerned. Former Labor Federal Health Minister Dr Neal Blewett was warned by the medical profession that Medicare would create an unacceptable imbalance of doctors in the city versus the country (Dr Bruce Shepherd has a letter to this effect on file). Dr Blewett ignored the warning. Subsequent health ministers from all political parties have shown no sign of changing the demand conditions brought about by Medicare hence, this problem will remain for the foreseeable future. Politicians love bulk billing.
5. Most electorates are in the city. Unless a political party can win the majority of city seats in State or Federal Parliament it cannot win government and that means winning lots of city seats.
6. The rural doctor shortage in Australia is one of the most over-researched issues on the medico-political agenda. Rural doctors and their families have been surveyed by numerous social workers, university researchers and thesis writers. The result of most of this research is to call for more research. The problems simply become recycled. Some even deny the problem. "Perceptions about doctor shortages in rural areas have more to with relativities of rural v. city doctor populations rather than absolute numbers. On raw numbers there are now more GPs in remote areas than there were in the cities 15 years ago" - Professor Stephen Duckett, a former Secretary of the Commonwealth Department of health and now Dean of the Faculty of Health Sciences and Professor of Health Policy at La Trobe University, Melbourne.
7. State governments have deliberately downgraded health care infrastructure in the bush. Doctors are being replaced with managers, often nurses or other non-medically qualified staff, who have the authority to dictate what can and can't be done in country hospitals (particularly smaller country hospitals). Not surprisingly, this is a complete turn off for doctors in particular, rural GPs who have been traditionally in charge of their own destiny. Senior nurses who have traditionally worked compatibly with rural doctors are also an aging and diminishing group. There is a looming shortage of senior rural nurses.
8. Country towns, in particular smaller country towns, are by definition parochial. They have their share of ruling elites who fight effectively to hold on to their own turf. Outsiders take some time to assimilate and "break in".
9. There has been an acceleration generated by the State health department in the process of restricting the smaller hospital's ability to perform surgical procedures. This is also being reinforced by the growth of specialisation in medicine. Not all of this is necessarily bad eg, the death rate from anaesthesia is now around 1 in 26,000, down from 1 in 10,000 in the days when General Practitioners regularly performed anaesthesia. (GPs have given up anaesthesia voluntarily because they realise that it is a complex and difficult area to dabble in). On the other hand the transferring out of country towns skills and facilities capable of undertaking medical procedures is not always the cost effective and more efficient solution. In the long term it may be far more expensive (after accounting for the total cost to the patient). There is an urgent need to insist that medical treatment be performed locally when there are the facilities and skills to do so. Big city hospitals are not necessarily more efficient or safer places to be treated and much depends on the type of problem and the availability of senior colleagues to back up the front line medical practitioners. Added to this is a view held strongly by many rural doctors and nurses that patients treated locally do better because they are looked after by people that they know. This may be particularly appropriate in cases of mental illness but also other conditions where TLC plays a major part in the recovery process.
10. The move to downgrade health facilities in the bush has a double whammy effect. It reduces career opportunities for new doctors and degrades general practice for established doctors. 11.Sadly, the Greater Upper Murray Health Region is one of the most degraded in NSW. Due to a systematic downgrading of smaller health facilities across the region. This process have received little, if any, publicity outside the local affected area.
11. Public servants with little or no career reason to be committed to rural medical practice (their destiny lies in big city opportunities) have been given immense power to determine the shape of rural medicine and health care in general. The career future of these public officials is based on their ability to ration and limit health care expenditure to a predetermined budget. This is an impossible task given the public perception that Medicare offers unlimited medical and hospital treatment on demand.
12. There is no one "type" of rural medical practice. Medical practice in remote regions of outback Australia is a different experience entirely to practising medicine in Dubbo NSW where back up from colleagues is more abundant. Furthermore, you find in NSW a town with adequate medical coverage and half an hour away by car a country town of a similar size has difficulty attracting doctors. Again, personalities appear to play a central role and the reputation of a town as a good or not so good place to work is an important, often invisible factor in attracting doctors.
13. The more attempt there is to manage rural doctors, the worse the reaction. Rural GPs, are by nature, independently minded and self-assured individuals who enjoy multi-disciplinary work and opportunities for using personal initiative. Such personality types do not respond to bureaucratic management and control. To the contrary, they react against it.
14. Lifestyle benefits or disincentives are an increasingly important part of the decision to undertake most jobs particularly those which require a relocation to a non-traditional place of abode. This is the case with medical practice where work is abundant in most geographic locations. The role of the non-medical wife or husband (mostly wife) as a prime decision maker or decision reverser as to whether or not a relocation will happen at all is often overlooked. Few husbands would be willing to work where his wife is reluctant to go when alternatives are available. This is probably even more pronounced for female practitioners with non-medical husbands. Unless the spouse is committed to a move it is pointless proceeding with a recruitment process. I usually insist on interviewing the spouse or partner before the practitioner in cases of rural doctor recruitment.
15. The universal genius is a rare individual and medicine is no exception. Most doctors have two or three predominant strengths or areas they enjoy and these strengths must be matched to the available work . It is no good trying to attract a doctor with an interest in obstetrics to a town which has a predominantly aged profile (ie, high percentage of females in the post fecundity stage).
16. The systematic research processes involved in the recruitment of professionals to various locations applies to doctors as well as any other professional group. Those occupations whose services are in high demand have within their ranks a more mobile group who are prepared to move even at short notice. This group must be well documented and regularly advised directly of job opportunities in which they are likely to show interest. Constant surveying must be undertaken to determine whether or not an individual doctor would you be prepared to move and under what conditions and circumstances and to where? The process of moving must begin well before a job ad appears. This process follows the awareness, interest, desire, action (aida) decision making cycle.
17. There has been a change in the standards used to judge professional negligence. Traditionally Courts have accepted the relevant peer test ie, would the doctor's colleagues in similar circumstances have acted in the same manner? This has been replaced by a test which seeks to judge the doctor's behaviour by what is considered to be the best practice at the time the incident occurred. Even if the doctor had little opportunity to access this so-called best practice knowledge the test is still being applied. What this means is that rural practitioners may be judged by what a leading professor in a large teaching hospital in a capital city with abundant resources, may or may not have done if confronted with the same circumstances. Many now consider the rural general practitioner to be at a severe disadvantage in a medico-legal situation and that this disadvantage is unfair and adding to the lack of attractiveness of rural practice.
18. Like most machinery in country towns, doctors are road tested by the locals and there is little sympathy for perceived incompetence or inexperience. The question of whether a doctor's skills will be accepted or be good enough is really only determined after the doctor has established him/herself in a town and if things don't work out the price of failure is very obvious and visible. Hence, doctors without considerable self confidence and individuality are not easily attracted to such a make or break situation.
19. Where a country town is located near a major highway there is a high probability that the doctor will become involved in road trauma. For many road trauma means difficult out-of-hours work with limited professional and infrastructure back up. This can be a turn off for those who believe they would have difficulty coping with these demands.
20. The degrading of social infrastructure in some country towns eg, less clergy and social support services, often means that the doctor and/or spouse becomes the defacto spiritual adviser, grief counsellor and socio/emotional counsellor as well as social security adviser. Many rural GPs and their families find these additional demands difficult to cope with on top of a busy medical practice but have no way of avoiding or escaping the responsibility for responding at least initially to these needs on top of heavy surgical and medical work loads.
21. A senior Riverina GP claims that around 60% of a rural GP's work is filling in forms (this even now extends to giving sick notes for school children). Many rural GPs claim that they have become deluged by clerical work to the detriment of being able to practice medicine. Government directives from numerous departments often recommend that doctors authorise on some relevant form some details of a patient's health. Many rural GPs maintain that the paper workload in rural practice is greater than their city colleagues where some high turnover clinics do not involve themselves or can pass on onerous routine administrative demands by patients. Who would want to go into rural general practice when what you want to spend most of your time doing ie, treating sick patients, is being gradually diminished by administrative functions.
     
    

What Can We Do?

1. Realise that to attract doctors to country practice is a continuous process, not a one off 'run an ad', see what comes up, job.
2. To make a town doctor-attractive, requires community involvement in determining what medical needs are required in the town and what the community is prepared to see shipped out to other areas or more major centres. This has to be done before the recruitment process starts.
3. It is no good attracting a doctor to a town if those who are in a position to influence local decision making as far as health care is concerned are not prepared to relinquish their autocracy in favour of the newly arrived doctor (some even see the arrival of a doctor as an opportunity to engage in or escalate a turf or status war). Unless the doctor is given the authority and support required to run the facilities and decision making process that the town requires to be properly looked after then there is no point in attempting to attract a doctor. A failed recruitment is the last thing a country town needs.
4. There are some country towns that, if asked, I could not in all honesty, advise a doctor to go to because of the attitude of the local health bureaucracy. To attract doctors, a town must have doctor-friendly administrators and doctor-friendly nurses.
5. The provision or a willingness to provide suitable housing for the newly recruited doctor and his/her family is a basic must do condition to making the position attractive. I continue to hear of doctor's families being invited to accept fairly marginal and uncomfortable conditions to relocate. The standard of a house will be compared by the medical practitioner and his/her family to the house and educational opportunities that are being foregone in order to accept the position. There should be a considerable improvement in the current living situation. This does not always involve the provision of a lavish house but at least one that is functional and well located.
6. The attitude of existing General Practitioners and Specialists in the town is also important. What complimentary skills do they want from a new colleague? What is their economic viability?
    
   

What Not to Do

The use of sticks to force doctors to undertake rural practice may appear to be superficially attractive but in the long term, I believe, only creates more problems. A doctor who is serving his/her time in a country town because of some potential penalty or some need to fulfil a government requirement is not a viable long term rural practitioner. Such systems breed resentment and a minimum involvement attitude.

The importing of lesser qualified doctors is also a non-solution. Any lowering of the standard of medical practitioners simply degrades the profile of the town. Incompetent practitioners create burdens and problems for already overworked competent rural practitioners who have to clean up, if they can, the mistakes of others.

Furthermore, competent imported doctors will not stay in country towns if they perceive better opportunities in the cities. Their motivations are identical to any highly qualified professional ie, they seek to maximise career and personal opportunity.

Does the Town have a Viable Future?

Many country towns will have to come to the sad realisation that their days are numbered. They may believe that if they could attract a doctor their fortunes would improve. However, it is rural prosperity that attracts professionals to a town and the future of many towns will be determined on their ability to achieve long term prosperity.

Medicare Provider Numbers

The issuing (or non-issuing) of Medicare Provider Numbers as an incentive or an opportunity to create an obligation on young doctors to undertake rural service will, in my view, be unproductive. Government policy is already restricting and rationing opportunities in General Practice for young doctors. There has never been greater training requirements for General Practitioners than there is at present. If it is made difficult to get into general practice it will be more difficult to get into rural general practice. There is benefit in exposing young people to rural general practice during their training and even early in their careers providing they are happy to be so exposed and that this system does not impose undue burdens on the already overworked rural general practice population. Such exposure should not be a mandatory system but built into existing training programmes at a time when the trainee can add some value to the rural practice where he/she is training.

A Viable Long-Term Solution

After much deliberation on all aspects of this problem I am firmly of the view that the only way to address the current rural GP shortage is to provide maximum support for rural medical training scholarships and fellowships.

We must provide every opportunity for young people with rural backgrounds who have the required intelligence and skill to pursue a medical career. We have to grow our own rural GPs.

Rural scholarships have been advocated over the last fifteen years but only recently have they received any form of support. Bright young people from rural areas wanting to pursue medicine, should be and must be given the red carpet treatment both financially and administratively but not so as to lower standards. We have to win them back from business and legal studies.

Finally, there is a lot more that can be done in the recruitment of rural GPs however, this will only contribute marginally at best. The bright young people in rural Australia are the ones who will determine the viability of rural medical practice into the next millennium.

Stephen Milgate
Executive Director
Australian Doctors' Fund