ATTRACTING GEN Y DOCTORS TO THE BUSH: Do we need to breed GP Chameleons?

Chameleon

The face of the future rural workforce?

Health outcomes in the bush, while significantly better than decades past, remain the worst in Australia. Rural health care delivery is impeded by geography, attitudes, government funding, health workforce issues and other social determinants of health. I’ve been ruminating on rural GPs – how do we create a future sustainable rural workforce in Australia?

These common thoughts stop young GPs going bush:

It sounds intimidating out there, I don’t have enough skills to cope.

There will be crazy breech deliveries and airway emergencies everywhere!

I don’t know if I want to commit to a life in the bush.

I’m scared of ‘something bad happening’ and finding myself out of my depth.

I can’t face another few years in the hospital upskilling, I need out of the hospital – NOW.

We all know a capable, immensely experienced rural GP who’s seen and done everything, who’s as handy with a pair of obstetric forceps as they are with a tonsil snare, or a gas machine. Who’s worked around the clock, in the clinic and on call, for most of their working life – and has made an enormous contribution to the wellbeing of the local community. I was lucky enough to work with one such GP, Dr John Menzies from Camperdown, who was recognised by ACRRM for his outstanding service as a rural generalist.

Such skilled generalists are less common than they used to be, and they often have difficulty retaining younger doctors to fill their (formidable) shoes. In the traditional job description of the Rural Generalist, it lists long hours, relative professional isolation, and an intimidating list of competencies. I suspect it’s a generational thing: it’s hard to attract young doctors to such a career, particularly given Gen Y’s proclivities for a work-life balance, expectations of a satisfying intellectual career and multiple job changes during their professional life.

How then, do we attract young docs to the country? The Rural Generalist Pathway has a role. At the very least, it offers a certain ‘frontier allure’ with a no-ties-here-sleeves-rolled-up kind of attitude towards medicine, attracting bright young things back to the bush again. It also recognises that a different skill set is required by the true rural generalist. However, I suspect it also intimidates the hell out of many young GPs, who now think they can’t go bush because they haven’t stocked their saddle-pack with every Cert. and Dip. known to humankind.

How then do we encourage more young GPs to give the bush a go? There is a simple truth worth considering – you can’t be an expert in everything, all the time. No matter how many scout badges you’ve earned prior to leaving the hospital system, if you don’t deliver any babies for the next 10 years your Dip.Obs is next to useless. If you only tube 1 one patient in a crisis every year, you’re hardly an airway expert anymore, despite your Dip.Anaes.  If you don’t have the opportunity to continually practice in these specialty areas, your skills will wane. It’s not a realistic solution to train up large numbers of GP registrars before they leave the hospital, disperse them across the countryside and expect the skills to last them a lifetime. Continuing education and professional development is key, and its vital to be able to access it at all stages of your career.

What if we focused on trained every cohort of GP Registrars to be ‘GP Chameleons’? A GP Chameleon who is taught to be adaptable, practical and confident with uncertainty. A continual learner, who is capable of utilising the resources available to them to up-skill as the need arises, depending on the community they’re in.  This would suit Gen Y down to the ground, of course.

Gen Y loves an unplanned adventure, an Odyssey – they’re always off backpacking around the world, hiking in far-flung mountains and roughing it in desert villages. How do we tap into this desire for an experiential existence, coupled with itchy feet, and use it to tempt young doctors to the bush? We have the ability to metamorphose in General Practice, more so than our specialist colleagues.  Rather than labeling it a ‘failure’ of this generation to commit to one long career for the next 40 years, we should be embracing change and encouraging more adaptability and flexibility in rural General Practice.

Besides, across all fields of medicine, there is a rapidly expanding knowledge and evidence base. It’s impossible to ‘know’ everything, because ‘everything’ changes rapidly these days. With the advent of FOAMed, rural GPs may even find themselves outpacing of some of their specialist colleagues in evidence-based practice. The modern rural GP must have the personal and professional resources to adapt and upskill as required for the community they are working in.

It would be great to open up the bush to more GPs – through confidence-building, and professional development. Ideally the options would be wider for upskilling in specialty areas at any point in your career, including on a part-time basis. It would be wonderful if the State and Federal powers could improve the accessibility of the hospital learning environment for GPs.

Attracting capable GPs to the bush is critical.  However, applying historical expectations onto young doctors is likely to be a fruitless exercise in solving the rural workforce shortage.  I don’t claim to have the answer, but I suspect we need to re-brand rural medicine. If we can train all our Registrars to be adaptable, practical and confident GP Chameleons, we can then sell rural medicine as an exciting – not scary – adventure.

Thoughts, y’all? *chews on a piece of straw*

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10 thoughts on “ATTRACTING GEN Y DOCTORS TO THE BUSH: Do we need to breed GP Chameleons?

  1. Hi Marlene,

    I find your blog an interesting and at times contradictory read. I appreciate that a robust medical workforce for the health of rural communities is your motivation. However, it bemuses me that you feel in a position to be so critical and pessimistic as to the future of rural generalist medicine (RGM). You are not a rural generalist and you seem unfamiliar with the ACRRM (not ACCRM) curriculum.

    Rural GP and RGM are often incorrectly used as synonyms. Universal acceptance of a definition of RGM is an important starting point. As an ACRRM Registrar, and therefore a RGM Registrar, I understand the RGM scope of practice to encompass primary care and secondary care (including emergency medicine plus at least one other advanced skill- usually obstetrics or anaesthetics) tailored to meet the needs of a relatively resource poor community (usually but not always rural).

    RGM is not a historical profession- there are many practising rural generalists providing invaluable services to rural (and urban) communities and there exists enormous interest and enthusiasm in RGM amongst medical students and trainees, locally and globally. The 2013 World Summit on RGM had huge support, interest and attendance. The Qld RG Pathway is oversubscribed.

    There are many factors to rural retention. Having adequate training and confidence for the required scope of practice is a major factor. The ACRRM Primary Curriculum is second to none in its preparation of rural doctors. FACRRMs have excellent rural retention rates. Access to technology and teams also improve retention.

    I agree with you that as rural doctors we need to have the skills that our particular community needs us to have. Basic RG training should occur in rural locations but advanced skills are often taught in larger centres with the patient numbers, case mix and supervision required to acquire a skill to a recognised curriculum and standard. To learn new advanced skills on the job in small centres, as I think you suggest, would be slow, highly variable in quality and ineffective. No one expects that RGs will not continue their professional development to maintain or evolve their skills after attaining their primary qualification. There are organisations, courses and funding available to ensure upskilling of proceduralists to maintain safe and effective practice and hospital accreditation.

    To improve the health of rural communities we absolutely need more rural generalists. To have more rural generalists we need effective selection, number and quality of distinct training places (preferably via a National RG Pathway), supported RG trainees and supervisors (and their families), recognition and continued upskilling opportunities.

    As an ACRRM Registrar I am very optimistic about my future career as a Rural Generalist, and about the impact that my ACRRM training will have on the health of my community.

    I appreciate you raising the discussion Marlene. Whilst I don’t agree with much of what you have written in this blog I am interested in your perceptions and those of others.

    Kind regards,
    Marion Davies
    (opinions my own)

    • Thanks Marion, and I am glad to hear your opinions. I was prompted to write the blog after attending the RACGP City GP, Country GP workshop in Bris and listening to some rural generalists and RFDS retrieval specialists, along with other city GPs, discuss their experiences with rural medicine + their ideas on retention. The summary, particular from a panel discussion, was that people fear going bush. However, once they’d tried it, they loved it – particularly if they could upskill as required (with a course, a hospital term, or on-job training). Most of the speakers, including the generalists, lamented skills lapsing depending on your particular location/facilities. I wasn’t suggesting Rural Generalists don’t continually do professional development – of course they do, and there’s plenty of funding for it. I’m talking about non-RGs having more access to it, if they do choose to go bush.

      I’ve trained in a rural GP procedural hospital and clinic for a year, so I have a little – but not a great deal – of insight into some of the retention issues. You make some great points that are also vital to retention, and you’re very passionate about ACRRM & RG training, which is great to see. However, there’s plenty of little rural towns that don’t need dedicated proceduralists – and while the RG training programs have a role to making better doctors for the bush, it’s not the only solution. We also need more docs out there, regardless of training pathway, period. How would you improve the attractiveness for them?

      • Hi Marlene,

        Thanks for your reply.

        Rural communities are heterogenous and unique in the expanded scope of practice that they require their health workforce to have. I disagree that more doctors of any scope is the solution. We need the right number of doctors with the right skills in the right communities. When a critical mass of skilled workforce can not be maintained then communities lose local services. It is a reasonable community expectation that every (rural) doctor must have at least current basic training in airway, resus and obstetric skills. I agree with you that medical training quality and capacity are ongoing issues. The motivation to go rural most often starts early. These people should be encouraged and selected to supported and coordinated training.

        Remember how daunting it was to drive a car at first? But you repeatedly see more senior people doing it and realising the possible benefits you have the motivation to learn, meet the selection criteria, source quality training and once qualified you practice driving often and maintain the requirements for safety. If you know that you will have a manual then you don’t only learn how to drive an automatic.

        Cheers,
        Marion

      • Marion, I removed the ACRRM typo to make you happy! And changed the sentence that accidently implied Rural Generalists don’t engage in professional development. Please don’t assume I think Rural Generalists are redundant, or historical – they’re often the best we’ve got! Mentoring certainly is important, and I take your point about seeing senior people doing it.

        I was looking at this issue from another perspective – how to attract more young doctors to consider spending time in the bush, if the RG Pathway isn’t their initial cup of tea. If they’ve already signed up for the RG Pathway, there are no issues! It’s fantastic there’s so much interest, as you’ve said. But, how to we get them interested if they’ve chosen an alternative training model in the first instance, due to lifestyle / partner / young kids / family / fear of the task?

        I think its important to point out to people that you haven’t ‘missed the boat’ with your training if you didn’t train as a Rural Generalist on the Pathway. Many roads lead to Rome, and if we want to attract more doctors to go bush, we need to encourage alternative pathways + continual learning, as well as alternative workforce arrangements. Saying ‘this is the only proper way’ isn’t the solution.

  2. Very well articulated opinion piece , thankyou
    GP chameleon to replace the traditional missionary devotional model ?
    Maybe …lots of maybes to this challenge

    Here is a thought that my own workforce had moved to and other industries are currently using
    FIFO

    Live somewhere else , work somewhere else .
    That maybe GenY enough … Maybe

  3. My other thought is limited rural positions . Commit to say 5 yrs in remote area then you are guaranteed another job elsewhere . Like a 5yr backpacker trip :-)

  4. thanks to both of you, Marlene and Marion. My colleague spoke at that RACGP conference. I appreciate his views and respect his word. However times have changed. Marlene has a good point about the challenges we face. Equally Marion is right in that ACRRM and Rural generalist pathway is a successful model and is producing results…we will have to wait the test of time to see in longterm how it all pans out. Interestingly I helped my colleague prepare his talk on the challenges of bush medicine. He wanted to give the City docs a taste of the true problems of rural health. I think he wanted to spur them to consider helping out in the challenges. But I agree with Marion that this can have the exact opposite effect and scare people off!

    The RFDS Womens GP service mainly has city female GPs who flying to remote areas to provide a visiting service. Thats a great example of how city folks can help out.

    As I said before, the FIFO model maybe another useful strategy for rural GP service. Its not traditional and its not ideal but its workable.

    • I wondered if you knew him, Minh! He was an excellent speaker, and the talk was inspiring. Does that I mean I give you the credit? ;)

      I think the FIFO model definitely has a role too – it particularly addresses those people who want the perks of city/regional living, but to work in rural practice. Especially for those whose wives and husbands must work in major centres. It obviously has its drawbacks as well, on community engagement and relationship building compared with the standard model. We need lots of creative approaches to solving this.

  5. Hi Marlene,

    To work rurally you need to satisfy the accreditation requirements of the facility where you plan to work. To meet these recent training courses and clinical experience, and sometimes VR, are required.

    Often the courses are oversubscribed and the clinical experience is difficult to secure. With limited training resources available rural communities will get best bang for buck if training goes to those willing to make a serious commitment.

    You don’t have to be an RG to work rurally, but personally I would not be comfortable working in relative professional isolation without current emergency (incl airway) and obstetric skills (core RG). Why put yourself or your patients in an unsafe situation? If you want to work in a larger rural centre where you have ready access to procedurally trained colleagues then RG skills may not be necessary for you.

    For RG work I consider accreditation requirements the minimum, and that the gold standard for rural practice is to be able to satisfy the ACRRM Primary Curriculum (whether or not you already have, are or aren’t working towards FACRRM). All current and aspiring rural doctors should have a read of the ACRRM Primary Curriculum- it really is excellent! If you are an experienced doctor and want (recognition, CPD and networking that comes with) a FACRRM then you can apply for the Independant Pathway (with significant RPL possible). On IP you can better access the supervision, training and support not otherwise readily available to gain the extra skills. The RG Vocational Pathway is not the only way to be an RG. ACRRM is unique amongst the medical colleges in its ability for tailored learning and recognition of previous experience. If you don’t have significant relevant training or experience then, as for all medical specialties, there are no shortcuts to VR.

    I hope that I am understanding your question.

    Kind regards,
    Marion

    • Great article Marlene. The debate needs to consider lots of ways to improve rural recruitment (and retention) and I think that your comments about branding (or ?re-branding) are very valid.

      Here’s just one perspective from Scotland…

      There is a stereotype of rural practice that often gets in the way of folk choosing it as a first-step after qualification… and yet rural GP can be one of the most demanding, stimulating and professionally satisfying career moves to take. We know that students and trainees enjoy rural practice, but the demands of 24/7 cover and the spectrum of clinical presentations is often what puts potential rural GPs off.

      Here in Scotland, there is ongoing work to develop Rural-Track pathways of training, and supported GP Rural Fellowships for newly-qualified GPs. These are all important (the fellowship is what eased me into my career in rural GP), but I think we also need to be better at getting the word out about the benefits of a career in rural GP and making the challenge something that new GPs can feel is within their grasp – it normally is.

      Social media, and folk like you writing about the realities of rural practice, is key to that.

      Thanks for taking the time to write, and adding to the debate. Here’s a video from Arran which stimulated some thoughts over here: https://www.youtube.com/watch?v=YuUlKwxPtXU

      David Hogg
      Rural GP, Isle of Arran, Scotland
      MRCGP 2010 (possibly Generation Y!)

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