If it’s training in complexity that you want, go bush.
Waiting for rural health funding can feel like waiting for Godot.
Just ask Dr Michael Livingston, a GP in the small town of Ravensthorpe on Western Australia’s south coast, who has come to the conclusion that a hub-and-spoke model would work for his region.
The model he’s proposing is a rural generalist hub, to be based in a bigger rural town and be complete with training rooms and consult rooms, staffed by a mix of medical students, interns, registrars and fellowed rural generalists.
Between them, they could develop a fly-in-fly-out or drive-in-drive-out model for surrounding towns and communities, with supplementary telehealth as needed.
According to Dr Livingston, it’s a proposition with a wealth of upsides – communities get continuity of care, doctors aren’t forced into moving permanently to a remote town, fewer expensive air retrievals, easier knowledge-sharing between colleagues and a hands-on rural experience for doctors-in-training.
He’s put the idea to several politicians.
“I did that thinking, ‘you’re a smart bum, this is the answer they all need to hear’,” he told The Medical Republic.
“But I guess the problem is, do they? Because the more I go through it, the more I wonder – does anybody like general practice?”
Taking matters into his own hands, Dr Livingston plans to open a version of his hub model in Albany later this year, using that as a base for his clinics in Ravensthorpe, Hopetoun, Jerramungup, Bremer Bay and Varley.
Albany is classified as an MM3 zone, but the other locations are all MM6 and MM7.
A rural hub model, while relatively uncommon, is not a new idea.
“There’s various different models all around Australia now that are variations on that theme,” past ACRRM president Dr Ewen McPhee told TMR.
“In northwest New South Wales, where Dr Shannon Nott is, they run a virtual rural generalist model where they basically do about 25% of their time in rural communities and 75% of their time covering various rural communities remotely.
In north Queensland, Dr McPhee said, there are people like RACGP rural chair Associate Professor Michael Clements, who do fly-in clinics and the like on a more ad-hoc basis.
“In southwest Queensland there’s a similar sort of virtual generalist model in some of these very small towns where they really only have access to a virtual clinician,” he said.
“I think the next step for them will be some sort of face-to-face component to that work.
Dr McPhee himself, who is based in the central Queensland town of Emerald, has a role with Queensland Health in developing models to “leverage the need for many people who choose … to stay on the coast, but want to give some commitment to rural communities”.
The main variation in the model Dr Livingston is proposing is a focus on training and recruitment.
“We should be having somewhere we can foster rural generalism, where we train our own, we look after them and we support them,” he said.
Too often, he said, young doctors do “rural placements” in towns that, realistically, are not too far from a major city. Then they graduate and are dropped into rural areas with little actual experience and support and end up burning out.
There is also something to be said for students, doctors-in-training and internationally qualified doctors getting a taste of “real” rural and remote healthcare.
“Rural general practice, in a medical student’s head, is just general practice but somewhere else,” said Dr Livingston.
“When they get down here and see all this crazy stuff they go ‘holy moly, this is not what I was expecting’.
“But only a few of them will get to do this. [Most people] will go for the whole medical career not realising this exists.”
It’s not just anecdotal evidence, either – a paper published earlier this month in BMC Medical Education found that GP trainees who learned in rural and remote settings had more opportunities to see high complexity patients. As a result, the rural and remote trainees learned to apply greater levels of clinical reasoning to manage their cases.
“Remote GP trainees were learning from a significantly higher proportion of patient cases rated by medical educators as medium or high complexity which involved having to apply greater levels of clinical reasoning,” the authors wrote.
“These trainees had a broader scope of practice seeing more chronic and complex patients and in addition they were rated by medical educators as seeing more complex patients than their rural and regional counterparts.”
ACRRM president Dr Dan Halliday said the research was a “valuable piece of evidence” supporting Dr Livingston’s idea.
“Models of care within rural and remote practice are very much team based and collaborative,” he told TMR.
“And there is a significant opportunity for developing independence of practice in rural and remote areas that you may not necessarily find within metropolitan and major regional centres.”
Of course, a rural generalist hub won’t work for every community.
“To paraphrase one of my preeminent colleagues … if you’ve seen one rural town, you’ve seen one rural town,” Dr Halliday said. “And models that work in one place may not necessarily work in others, and those models of care may not necessarily work for the practitioners providing that care.”
