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How Can We Attract More Doctors to the Country?

Roger Strasser

The Australian Journal of Rural Health ©Volume 1 Number 1, November 1992

How Can We Attract More Doctors

to the County? by PROFESSOR ROGER STRASSER

i Drawing on findings from an extensive survey ofrnral general practitioners in Victoria, this ’

train&g and retention of rural doctors. The study :

groups achieved a 75 per cent tesponse rate, providing information : entering rural practice identified by rnral doctors

‘:were: spouse problems; lack of skills; city background and training; ignorance of country practice; lack of self confider@; and inadequate remuneration. Negative attitudes towards the country and general practice plus

! i

i, ‘I~~~~d.hklplessness’ picked up in medical school were rated by rural doctors as being of significant impor- ’ i tan&. af 14 suggestions for improving recruitment, training and retention of rural GPs the foIlowing were

clinical experience in rural hospitals and practices; reciprocal links between ! and medical schools; extra financial reward for isolated rural practice: establishment of Rural ’

Centres; and a program to meet the needs of the rural practitioner’s spouse. Health Services. General MedicaI Practice, Workforce.

Introduction Despite a perceived oversupply of doctors in Australia, there continues to be a significant shortage of doctors, including general practitioners in country areas, against a glut in some metro- politan areas. However, this has not lead to an overflow of general practitioners into rural areas. 1 It does seem true that doctors would rather ‘starve in the city than go to the country’. Clearly there is a need to develop and implement other ways and means of encouraging more medical graduates to go into country practice.

Previous research in Australia and overseas has identified two key factors associated with medical graduates entering rural practice: a rural upbringing. and substantial exposure to rural practice as part of undergraduate education and postgraduate training.‘m7 Over the last 20 years in North America. various programs which combine these two features and a range of structural supports have been in- troduced and subsequently shown to improve numbers and distribution of doctors in rural and other under served areas.“~” In Australia. al- though the problems with rural practice have been

R. Strasser is professor of rural health at Monash University, Moe, Victoria.

identified for some time.” it is only recently that specific programs have been implementedl’.ih and the National Rural Health Strategy developed. i-

In this context. an extensive survey of rural general practitioners in Victoria was undertaken. This article reports findings from the study which explore proposals for improving the recruitment. training and retention of rural doctors.

Method A M-item questionnaire was developed and sholvn to have adequate validity and reliability.‘” Broad areas covered by the questionnaire were: personal background: practice description: reasons for choosing country practice: reasons for staying in country practice: reasons for leaving country practice: and suggestions for improving recruit- ment. training and retention of rural general practitioners (GPs). Using the Medical Board of Victoria Data Base. the questionnaire was mailed to all rural GPs in Victoria and two random sam- ples of metropolitan GPs: one group in suburban practice and one group in fringe metropolitan areas. Dillman’s total design method’” was employed in order to improve response rate. Information col- lected by questionnaire was encoded and com- puterised to enable appropriate descriptive and inferential statistical analysis.

40 The Australian Journal of Rural Health

Results Seven hundred and eighty-seven questionnaires were sent to rural general practitioners, plus 200 questionnaires to each of the two comparison pmups. A response rate of 75 per cent was achieved, providing information representative of most GPs in Victoria.

For the purposes of further analysis, the rural GP group was divided into those practising in town with a population greater than 20 000 and those in small rural communities. In effect, the larger town rural GP sample became a third compari- son group.

parable, with each group working just over 40 hours per week. However, there were significant differences in the numbers of patients seen and in after hours work as outlined in Table 1 (below). When it comes to time off, over two thirds of small town rural doctors experience difficulty obtaining locums and arranging continuing medical education.

There was a series of open questions regard- ing professional and social satisfactions as a doctor, plus perceived key attractions and disadvantages of rural practice. Responses to these questions are summarised in Tables 2 (below) and 3,4 and 5 (opposite).

The picture which emerges from this part of the study indicates that rural general practice is trapped in a self-perpetuating vicious circle. Doctors currently in rural practice carry a heavy workload with long hours, including substantial after hours work, plus difficulty arranging holidays and

Rural practitioners confirmed the perception of a shortage of country doctors with a signifi- cantly larger proportion of the smaller town rural practice group (70 per cent) expressing a need for one or more other GPs in their town or area.

Turning to practice workload, the mean hours worked per week, excluding on-call, were com-

Table 1: Practice Workload

Fringe Suburban Metro

Mean no. patients in average working week 124.7 143.2

Mean no. week nights on-call 1.2 1.5

Mean no. weekend days on call in 4-week period 1.4 1.8

Mean no. call-outs per night on call 0.3 0.8

Mean no. call-outs per weekend on call 1.4 3.5

* differences statistically significant ~~0.05 (non parametric ANOVA)

Rural Town >20 000

137.3

1.8

2.1

1.5

9.0

Rural Town <20 000

138.5*

2.4’

2.Y

1.9*

10.5’

Table 2: Professional Satisfactions as a Doctor

Suburban Fringe Metro

Rural Town >20 000

Rural Town <20 000

Whole patient/whole family community care 10.2

Varied practice (obs/surg/ anaes/med) 6.3

Continuity of care 5.5 Hospital access/care

of acutely ill patients 0.0 Independence/responsibility 2.4

* differences statistically significant ~~0.05 (x2)

17.2 32.6 40.6*

6.7 22.5 29.5* 7.5 17.7 24.5*

3.7 24.1 23.1* 6.7 12.8 21.1*

Volume 1, Number 1 - November 1992 41

Table 3: Social Satisfactions as a Doctor

Fringe Rural Town Rural Town Suburban Metro >20 000 <20 000

Country environment/ relaxed lifestyle

Community more stable Outdoor living/recreational

opportunities Wide circle of friends Better family life

0.0 0.0 36.2 36.1* 1.6 5.2 22.7 27.7*

3.9 4.5 29.1 25.4* 13.4 7.5 19.2 20.1* 4.7 6.7 13.5 14.7*

* differences statistically significant ~~0.05 (x’)

Table 4: Key Attractions of Country Practice

Fringe Suburban Metro

% %

Rural Town >20 000

%

Rural Town <20 000

% Country environment/

relaxed lifestyle 48.0 Varied practice

(obs/surg/anaes/med) 11.8 Independence/responsibility 11.0 Hospital access/

care of acutely ill 7.9 Whole patient/whole family/

community care 3.2

* differences statistically significant ~~0.05 (x’)

50.0 50.4 47.4

21.6 14.2 24.9* 13.4 9.2 20.0*

11.2 12.8 14.3

10.5 10.7 12.0

Table 5: Main Advantages of Rural Practice

Fringe Suburban Metro

Rural Town >20 000

Rural Town <20 000

Time commitment (lack of holidays/long after hours) 18.1

No regular exposure to medical education 3.9

Lack of assistance/ locums partners 7.1

Big fish in little pond 4.7

* differences statistically significant p<O.O5 (x2)

32.8 14.9 30.4*

8.2 23.4 26.5*

12.7 14.9 15.0 11.2 6.4 14.5*

continuing education. They provide a wide range of clinical services and carry considerable re-

sponsibilities. There are major professional and social satisfactions of rural practice; however, from the view point of undergraduates and new medi- cal graduates, these advantages seem to be over- whelmed by the disadvantages.

All study groups were asked to respond to an open question regarding the main barriers which prevent other medical graduates from entering rural prac- tice. Key responses are summarised inTable 6 (over).

When asked to rate a list of perceptual barri- ers to medical graduates entering rural practice,

rural GPs rated the following items as si,onifkantly more important than did metropolitan GPs: societal negative attitudes towards the country; ‘learned helplessness’ picked up in medical school; nega- tive attitudes in medical school to general prac- tice; and negative attitudes in medical school to the country.

Rural GPs were asked to rate a list of 22 dif- ferent possible reasons for remaining in rural

42 The Australian Journal of Rural Health

practice. Reasons rated highly by both groups were: the independence; continuity of care; enjoyment of community activities; enjoyment of commu- nity respect: a good place to raise children and the country lifestyle. Small town rural GPs rat- ings of the following items were significantly higher: anaesthetics; surgery; other technical skills: the variety of country practice; hospital work: comprehensive care; and the major need. On the other hand, large town rural doctors rated the following reasons significantly higher: dislike of specialists looking over my shoulder; spouse’s job and family in the country.

When asked to rate the top three reasons for remaining in the country practice, both rural groups nominated: country lifestyle; good place to raise children; variety in country practice; continuity of care and comprehensive care. To a question about reasons for leaving country practice all GPs stated that this question was not applicable. In

fact, the vast majority of both rural groups indi- cated that they were planning to stay in the coun- try. On average, members of both metropolitan and rural study groups indicated an intention to remain practising in the same location for around 10 years.

Table 7 (below) outlines the major ideas for improving recruitment and retention of rural general practitioners. Subsequently, respondents were asked to rate 14 specific suggestions for improving recruitment, training and retention of rural general practitioners drawn from previous studies. Items rated as likely to be most success- ful by all groups were: significant experience in rural hospital and practices; reciprocal links be- tween country hospitals/practices and medical school/teaching hospitals; rural medical education centres which co-ordinate undergraduate vocational training and continuing medical education in ru- ral areas; rural rotations for part specialty training;

Table 6: Main Barriers to Entering Rural Practice

Suburban %

Spouse problems 10.2 Lack of skills (real

or perceived) 19.7 City born, bred and trained 9.5 Ignorant of content/value

of country practice 3.2 Lack of self esteem/

confidence 2.3

* differences statistically significant ~~0.05 (x2)

Fringe Rural Town Metro >20,000

% % 14.2 24.8

23.9 14.2 14.2 21.3

11.9 28.4

12.7 9.9

Rural Town < 20,000

% 29.7*

27.0* 21.8*

20.4*

14.3*

Table 7: Suggestions for Improving Recruitment and Retention of Rural GPs

Fringe Rural Town Rural Town Suburban Metro >20 000 <20 000

% % % % More positive exposure

and attitudes to rural practice in medical school 15.8 16.4 31.2 26.8*

Better fee structure (financial return for after hours work and number of calls) 11.0 12.7 7.1 19.3*

Locum relief 4.7 9.0 8.5 14.7* Increase intake of country

students into medicine 4.7 3.7 10.6 10.9” FMP to include a rural

training scheme 0.8 3.7 4.3 6.8*

* differences statisticallv significant ~0.05 (7’)

Volume 1, Number 1 - November 1992 43

and a program to identify and meet the needs of rural general practitioners’ spouses.

Rural GPs rated the following items as poten- tially more successful: rural vocational training streams for general practice; rotating locums or ‘registrars’ for rural practices; and earlier under- graduate exposure to general practice. Metropolitan groups tended to rate extra financial reward for isolated rural practice more highly. Ratihgs by small town rural GPs of suggestions for improving recruitment, training and retention of rural GPs in order of priority were:

1. Clinical experience in rural hospitals and practices;

2. Reciprocal links between the country and medical schools;

3. Extra financial reward for isolated rural practice;

4. Establishment of rural medical education centres;

5. A program to meet the needs of the rural practitioner’s spouse.

Given the strong support indicated for various education and training strategies, including es- tablishment of rural medical education centres, a greater involvement by rural doctors in teaching would be required. When asked specifically, substantial proportions of both groups indicated a willingness to teach. Large town rural GPs were significantly more likely to be willing to take on a teaching role, although at least one third of the small town rural group were willing to teach in various settings.

Discussion These findings are consistent with similar stud- ies undertaken elsewhere in Australia’,’ and complement Piterman’s survey of final year medical students and junior hospital doctors in Victoria.20 In North America several programs have been implemented and shown to be effective in improving the recruitment of rural doctors.8-‘j Key aspects of these programs are selective intake to undergraduate education of students from a rural background; a specific rural medi- cine stream at undergraduate level; substantial exposure to rural practice as part of the under- graduate curriculum; and specific vocational training in and for rural practice.

In order to attract more doctors to the country, new strategies will need to be developed which:

Counteract the negative perceptions of rural practice in medical schools;

Overcome the disadvantages of rural practice;

Promote the positive aspects of rural practice, including major professional and social satis- faction.

The major recommendation from this study is that there should be established an integrated career path for rural general practitioners in Victoria, with components of education and training plus specific support for doctors in rural practice.

Specific consequent recommendations which arise from the study are:

1. A minimum quota of students from a rural background in medical schools. This may be achieved through:

1.1. A program promoting medicine as a career to rural secondary schools:

1.2. A selection bias for rural up bringing in the medical school intake process.

2. Substantial exposure to rural practice in the undergraduate curriculum. This may be achieved through:

2.1. Block attachments to rural hospitals and practices for all medical students;

2.2. For those students committed to rural practice, a rural medicine stream which provides a substantial proportion of clini- cal experiences in rural settings rather than teaching hospitals;

2.3. Earlier exposure to general practice for undergraduates.

3. Specific rural general practice vocational training programs with particular emphasis on training in procedural skills.

4. Tailored continuing education for rural doctors supported by a ‘rotating registrar’ or locum relief scheme.

5. Rural medical education centres should be established in rural areas with the aim of coor- dinating undergraduate education, vocational training and continuing medical education for rural practitioners. Such centres would greatly facilitate implementation of recommendations

44 The Australian Tournal of Rural Health

6.

2, 3, and 4. An important consequence of establishing rural medical education centres would be reciprocal links between country hospitals/practices and medical schools/teaching hospitals.

Development of such links was seen as par- ticularly important by rural doctors who also strongly supported the proposal for rural medical education centres. Most rural GPs indicated a willingness to teach in these centres as well as in vocational training schemes, their local hospital and their practice.

Support and assistance for rural general prac- titioners. This might include:

6.1. Extra financial reward for isolated rural practice;

6.2. A program to meet the needs of rural doctors’ spouses.

These recommendations represent the strate- gies seen by Victorian rural GPs as most likely to succeed in improving recruitment, training and retention of rural doctors. They are consistent with Kamien and Buttfield’s‘solutions to the shortage of general practitioners in rural Australia’21-24 and provide clear endorsement for recommendations in the National Rural Health Strategy.17

REFERENCES

1. Rosenman, S.J. & Batman, G.J. 1992. Trends in general practitioner distribution from 1984 to 1989. Australian Journal of Public Healih. 16(l): 84-88.

2. Report of the Ministerial Inquiry into the recruitment and retention of country doctors in Western Australia. Government of Western Australia, December 1987.

3. Review of General Medical Practice in South Australia: First Report Identifying Problems and Issues in General Practice. September 1988.

4. Humphreys, J. and Rolley, F. 1991. Health and Health Care in Rural Australia, Armidale, NSW: University of New England.

5. Cooper, J.K., Heald, K. and Samuels, M. 1972. The de- cision for rural practice. Journal of Medical Education, December, 47: 939-944.

6. Cooper, J.K., Heald, K. and Samuels, M. 1977. Affecting the supply of rural physicians. Australian Journal of Rural Health, August, 67(8): 756-759.

7. Fromm, B., Konen, J.C. and Boska, R.B. et 01. 1985. Exposures leading to the selection of family medicine and rural practice. Family Pracfice Research Journal, 5(2): 127-136.

8. Rabinowitz, H.K. 1983. A program to recruit and edu- cate medical students lo practice family medicine in

underserved areas. Journal of the American Medical As- sociation, 25 February, 249(8): 1038-1041.

9. Adkins. R.J., Anderson. G.R. andcullen. T.J. et al. 1987. Geographic and specialty distributions of WAMI pro- gram participants and non participants. Journal of Medical Education, October, 62: 810-7.

lO.Brazeau, N., Potts, M.J. and Hickner, J.M. 1990. Upper Peninsula Program: a successful model for increasing primary care physicians in rural areas. Family Medicine, September-October, 22(5): 350-5.

1 l.Verby, J.E. 1988. The Minnesota rural physician associ- ate program for medical students. Journal of Medical Education. June, 63: 427-37.

12.Norris, T.E. and Norris. S.B. 1988. The effect of a rural preceptorship during residence on practice site selection and interest in rural practice. Journal ofFamily Practice, 27(5): 541-544.

13.Bloom, F.J., Vatavuk, M.K. and Kaliszewski, S.E. 1988. Evaluation of Gannon-Hahnemann Program to provide family physicians for underserved area. Journal of Medical Education, January, 63: 7- 10.

14. Walpole, R. (ed) 1978. Rural Healfh. Proceedings of the Rural Health Conference of the Royal Australian College of General Practitioners, 1978. RACGP.

15.PGMEC. 1991. A rural practice training programme. Mission statement prepared by the Postgraduate Medi- cal Education Committee, University of Queensland, 5 April.

16.Jackson, W.D. &Jackson, D.J. 1991. The Western Aus- tralian Centre for Remote and Rural Medicine. The Medical Journal of Australia, 155: 144-6.

17.Department of Community Services and Health. A fair go for rural health. National rural health strategy: a dis- cussion paper for the National Rural Health Conference, Toowoomba, 14-16 February 1991.

18. Strasser, R.P. 1990. Progress report: a study of the atti- tudes of rural general practitioners to country practice and training. (Presentation) Monash University Primary Care Research Forum, Melbourne, November.

19. Dillman, D.A. 1978. Mail and telephone surveys: the total design method. New York: John Wiley and Sons.

20. Piterman, L. 1989. A study of final year medical students’, interns’ junior resident medical officers’ and senior resident medical officers’ perceptions of rural training and prac- tice in Victoria (1988). Monash University, Department of Community Medicine, East Bentleigh, April.

21.Kamien, M. and Buttfield, I.H. 1990. Some solutions to the shortage of general practitioners in rural Australia: Part 1: medical school selection. The Medical Journal of Australia, July, 153: 105-7.

22.Kamien, M. and Buttfield, I.H. 1990. Some solutions to the shortage of general practitioners in rural Australia: Part 2: undergraduate education. The Medical Journal of Australia, July, 153:107-l 12.

23.Kamieq M. and Buttfield, I.H. 1990. Some solutions to the shortage of general practitioners in rural Australia: Part 3: vocational training. The Medical Journal of Aus- tralia, July, 153: 112-I 14.

24.Kamieq M. and Buttfield, I.H. 1990. Some solutions lo the shortage of general practitioners in rural Australia: Part 4: professional. social and economic satisfaction. The Medical Journal of Australia. July, 153: 168-171.