A new report focused on the roles of specialist physicians in regional centres calls for an emphasis on developing more generalists to build a sustainable medical workforce beyond the current models of urban specialist outreach and telehealth programs.

The report also highlights the need for practical steps to support women doctors working rurally and attitudinal shifts to overturn a “pervasive culture” among senior physicians and administrators of undermining generalism and rural physician practice.

The Building a Rural Physician Workforce (BRPW) study report comes ahead of the federal government’s long-awaited National Medical Workforce Strategy, intended to be a springboard for collaboration to address imbalances in healthcare equity and vocational specialties.

Professor Jennifer May, director of Newcastle University’s Rural Health Department and co-chair of the workforce strategy advisory panel, says generalism will be a priority focus in the coming reform blueprint, going against the tide of increased subspecialisation seen in the past decade.

“I’m expecting that will enliven the discussion, and there may well be some discourse on what the solutions might look like,” Professor May told the limbic.

“What we need to do is look at it constructively,” she said. This would involve finding models that provide critical mass for physicians and resolve workload challenges, while providing a wide scope of practice that gave patients needed healthcare without having to travel long distances.

Increasing specialist shortages

Summing up the study findings in an MJA editorial, Professor May and Melbourne University health economist Professor Anthony Scott are blunt about the size of the challenges.

“Clear short-term policy solutions do not exist, and long-term solutions rely on fundamental changes to the way doctors are recruited, trained and supported, which require a high level of coordination between the many stakeholders involved in medical training,” they write.

“Sustaining the supply of rural physicians is becoming increasingly difficult, with the need for a generalist skillset against a background of high levels of sub-specialisation and metropolitan-based training.”

Drawing on RACP data, the BRPW study shows there were nearly 13,000 active Fellows across all specialty groups in 2018, but only 12% were practising outside the cities, where 28% of Australians live.  Of them, 1104 were in inner regional centres, 407 in outer regional areas and 65 in remote communities.

However, the research found that rural-based physicians and paediatricians at all career stages had similarly high rates of professional satisfaction to urban colleagues on most job aspects.

It found remuneration was significantly higher for rural physicians across most career stages, while rural consultants tended to be more involved in direct patient care and teaching than city colleagues.

Compared with their urban counterparts, rural physician trainees found it less difficult to take time off work, and registrars and pre-registrars were more likely to report a good balance between work and personal commitments. They were also less likely to have unpredictable work hours and inadequate study time.

But differences emerged in terms of professional isolation and support. Rural consultants were more likely to feel they had a poorer professional support network, while pre-registrar trainees were less likely to agree they had good access to support and supervision from qualified consultants.

Gender gap

The research also found a strong gender disparity, with women significantly less likely to work rurally as consultant physicians, despite being a clear majority in junior roles and training pipelines.

In interviews about professional identity, general physicians and paediatricians spoke of the benefits of greater diversity of rural practice, including management of complex cases that would be seen as by a team of sub-specialists in an urban setting.

They believed their breadth of training meant they were “fit for purpose” across a range of health services, particularly with rising multi-morbidities in an ageing population, the study found.

Some generalist rural physicians and paediatricians noted that reliance on fly-in fly-out doctors left gaps in acute care, did not relieve on-call demands and limited collegial exchanges. Some had developed expertise in a specialty area in response to specific gaps in services.

In a chapter on the importance of leadership in rural practice, however, interviews revealed “many examples of attitudes and practices that consistently devalued the work of rural physicians, influenced trainee recruitment negatively and applied metro-centric criteria when assessing training sites for accreditation”.

“Many factors contribute to excess rural mortality and morbidity, but the lack of specialists compounds the health effects of these factors. A stronger rural specialist medical
workforce could be a strong ameliorating influence,” concludes Dr Remo Ostini, Senior Research Fellow at the Rural Clinical School Research Centre, The University of Queensland.

“The BRPW study shows the importance of recognising the distinctiveness of rural contexts, and the need for positive action towards these settings, in designing training programs
that better equip specialist physicians for a rural medical career, identifying the opportunities and the risks, and showing a way forward,” he says.