The big problem with single-employer models

Meet the ACRRM president-elect, Dr Rod Martin.

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When word got around that NSW rural generalist Dr Rod Martin would be the next ACRRM president, his friends and family all had a similar reaction: congratulations, sure, but how was he planning to fit it in?

Based out of Armidale, Dr Martin wears many hats – he works as a GP but serves as a VMO in anaesthetics, obstetrics and emergency medicine, runs a remote patient monitoring service and, in his spare time, is a keen ice swimmer.

With rural generalism on track to become a fully-fledged specialty, an incoming shakeup to scope of practice and the introduction of a new international doctor registration system happening within the next 12 months, Dr Martin’s friends may have a point.

He will officially take up the role at the joint ACRRM-RDAA conference in Darwin in October.

Dr Martin sat down with The Medical Republic shortly after his win.

TMR: You’ve got advanced skills training in anaesthetics, obstetrics and emergency medicine and you’re also in general practice. How do you describe what you do?

Dr Martin: Probably about five or six years ago, we as a college decided that we needed to start to shift our language.

People started to ask me what a rural generalist did … [but] in reality, being a rural generalist is not just the skillset, it’s actually the mindset as well.

It’s not that I’m a GP some days and an obstetrician at five o’clock this morning or an anaesthetist on Sundays.

It is the overarching, pervasive – gosh, I sound like the DSM-5 – way of thinking about how you do things during your day or week.

Like one big, overarching hat as opposed to several different hats.

I had one Christmas Eve where I was standing at the counter of the nurses’ station at Armidale Hospital in obstetrics, and I did have all three hats on – emergency and anaesthetics and obstetrics – all at the same time.

We had a no-show obstetrician and an anaesthetist who was supposed to cover things who was in the high dependency unit, sick himself, and then I was on emergency the same night.

I turned up and my now-registrar, who I was meant to be taking over from, was already up there and the baby was already out.

She wasn’t an obstetrician, she was a rural generalist in emergency at that stage, but she’s about to go on and do anaesthetic training.

One of the challenges facing rural health is that the non-GP specialist colleges don’t have well-developed regional training programs and junior doctors end up going back to metro areas for training. Do you have a strategy to help fix that?

The anaesthetic and obstetrics colleges have already got good experience and understanding.

ANZCA probably has a better understanding now than they would have had six or seven years ago, when the diploma of RG anaesthetics first started.

So those two colleges are good templates.

RANZCOG is probably the longest-standing template in that it’s a clear recognition from another specialist college that it is not tenable for them to provide obstetric services in every small town.

What are the challenges for you locally in the Hunter-New England area?

The challenge is that there are still pockets where people don’t see the benefit or the opportunity to have proper rural generalist training in hospitals, particularly where we’ve got specialists in hospital.

In the last 18 months we’ve gone from one person doing not even rural generalist anaesthesia – they were doing an unaccredited year to be able to get onto the ANZCA training program – to having two get onto the program.

The issue that we’ve got now is that if you build it, they will come.

We’ve got five or six different people where we have gone a fair way down the process of accrediting a post for them to be able to train in but there’s still a bit of reluctance, and we can’t work out what tier of health service management it is coming from.

All the doctors in town are saying “this is fantastic, we finally got some of the solutions that we’ve been looking for and we’ve got people coming for those positions”.

We’ve got a post, it’s ready to go, but having the hospital administration become more flexible to fit … the rural generalist model [has not been easy].

Do more jurisdictions need to be looking at working a single employer model?

I would say that the model has very good promise, but we have to be very deliberate about how it gets executed.

If we’re saying that the state health department is the employer, state health might say “well we’ll have more control over what happens with this particular registrar”.

The larger partner could almost dictate [what happens] – they might say “we have to pull this employee from your primary care setting and put them in a hospital setting because we have a workforce requirement”.

That’s the thing that we’re going to have to be guarded against.

The single employer model makes really good sense, it just has to be executed properly.

The state hospital systems are wearing the financial and administrative burden [on single employer models] and they are going to want a pound of flesh for that cost.

Dr Martin, you’re set to be walking into the president role just as the final scope of practice review report comes out. When you spoke to TMR before the election, you were saying that rural tends to be a guinea pig for new schemes.

The continuing theme and message for that still has to be that we’re rural generalists, and we spend a lot of time, often deliberately, working right out on the edge of our scope of practice.

We think other professions should have the right to work to their full scope of practice, but increasingly what we’re seeing is scope creep.

There’s plenty of fantastic clinical advice that pharmacists can give, but [prescribing] has quite a high risk of disaggregating patient care.

If you’re a rural town and the doctor only comes two days a fortnight, for example, but there’s a pharmacist there the whole time, the risk is that you’ll bolt on five or six different things that a pharmacist can manage by doing a couple of weeks-long course in this, or a week-long course in that.

Eventually you get so many different things that are bolted on that there’s not – it sounds arrogant, but there’s not a “doctor way” of thinking about things.

We get trained quite specifically to say, “let’s recognise what this condition is and treat it, but what about the rest of the patient?”

What about the context of the patient and the other medical conditions that that we know are going on?

What are things that we don’t know that are going on that might be contributing to this?

In medical training, we get four or five or six years of [practice in] this way of thinking.

It’s not an additional small-scale skillset that you have to look at a couple of things.

Case in point – we’ve had … an aged care nurse practitioner [in town] who flew up from Sydney to go through all of the patients in our [aged care homes].

What we’ve ended up seeing is a whole bunch of unnecessary tests proposing maybe that this patient needs MRI scans to identify exactly what the problem is with them, when at 96 the greatest likelihood of the problem is that they’re a 96-year-old with a 96-year-old brain.

Wildcard question: how’s the ice swimming?

It’s getting warm up here – 23- or 24-degree days.

When it gets up to about 24 or 25 in the dam [I stop swimming], because at above 25 you start to get a bit of blue-green algae.

I’m happy to chill myself down to 29 degrees, but blue-green algae comes with a motor neuron disease risk.

This interview was edited for length and clarity.