Building a rural physician workforce

UQ research study of the needs and perspectives of rural physicians and paediatricians

Timely access to medical care is important for all Australians, including the one third who live and work rurally, but their health is generally poorer compared with those in large metropolitan cities. Rural doctors, including rural physicians and paediatricians are also part of these communities practising rural medicine whilst servicing the increased health needs in a maldistributed health system. Despite huge increases of rural training of medical students, specialist training nationally continues to occur largely in metropolitan areas and thus sees little access improvement for rural populations. It is known there is a need for improved distribution of  rural specialist services, including building a stronger and larger rural physician workforce, an integrated framework supporting the training of rural physicians and provision of rural services and an education and learning environment supporting physician trainees and supervisors, as they live, train and work in a health system network based in any or all of rural, regional, metro or remote areas. This study aimed to identify specialist needs of training, supervision and clinical practice to support building a rural physician workforce. Whilst recognising the current national strategies of the Commonwealth to improve workforce distribution, this study identifies the service and workforce gaps and inadequacies, training challenges, organisational issues and policy weaknesses  - which can all be strengthened from innovative academic research as in this Study.

Research on training pathways and professional support for building a rural physician workforce

This research study, completed in April 2019, engaged 859 College members through a national survey and 70 interviewees. It focusses on producing evidence across five research themes that together support building a larger and more sustainable rural physician and paediatrician workforce. It was funded by the Commonwealth Department of Health and is a research partnership between University of Queensland’s Rural Clinical School and School of Public Health with the Royal Australasian College of Physicians and the Queensland Rural Medical Service (Queensland Health). The Study has developed evidence about the training experience and perspectives, the valuing of training and supervision, training pathways for rural physicians, an improved training environment, the individual intent and attraction for rural service, notions of characteristics of the professional identity of rural physicians, the participation of colleges and departments and integrates concepts for an improved/strengthened Australian rural specialist training and service framework.

This research evidence supports a focussed and sustainable rural physician workforce.

Download the brochure of study findings (PDF, 389.5 KB)

Theme 1 - Observing rural physicians in practice

Satisfaction of Rural Consultants

Evidence from the Study demonstrates that rural physician specialists are as satisfied as other rural specialists and their metropolitan counterparts.

Notably, increased support to minimise feelings of isolation from peers and fellow workers among rural physicians could help further attract a regional workforce.

Targeted support to ensure rural physicians in regional and rural areas are able to take time off when they want to will likely improve satisfaction and hence retention. This study confirms the influence of rural background on doctor’s rural work and practice. Being female, overseas-trained and having more than 5 years of rural background in the all rural specialist group and being female in the rural physician cohort have significant and negative impact on retention in rural hospitals.

Future research needs to explore the determinants and pathways supporting uptake of long term rural careers among physician specialists, particularly among females, and identifying solutions to other factors related with rural attrition.

Satisfaction of Junior Rural Doctors

Junior rural physicians are as satisfied as their metropolitan counterparts after taking into consideration key aspects of their work.

Those training rural mostly have a positive experience. Results of this study suggest pre-enrolled and enrolled rural physician doctors might benefit from better support from consultants and improvement of doctor network in rural areas to attract more junior physicians to rural training and practice.

Furthermore, addressing issues of long work hours and more on-call might potentially attract more junior physician consultants to work rurally.

Dr Matthew McGrail, A/Prof Srinivas Kondalsamy Chennakesavan and Dr Odewumi Adegbija

Theme 2 - The professional identity of rural physicians

This research has sought to unearth the variety of terms currently in play as a prelude to the deeper investigation of what that identity means.  It is hoped that this can clarify whom it is the Study is talking about and shed light on the problem of non-metropolitan Australia’s deficiency of specialist physician services.

Rural physicians demonstrate rural-relevant psychological profiles involving personality traits such as caring, compassion, social warmth and empathy, traits which overlap with those implied in popular stereotypes of rural physicians (/country doctors) as ‘missionaries.’ Many of those in our study cohort evinced so-called ‘missionary’ characteristics, such as a strong sense of moral purpose, an orientation to helping others, a commitment to social and health justice, and an ethic of altruism.

Other personality traits deemed favourable in rural physicians/doctors, including resilience, persistence, self-determination, decisiveness, tolerance of ambiguity and the ability to improvise in conditions of uncertainty, were highly in evidence among the Rural Physicians in the study cohort. Such qualities lend themselves to an analysis that draws on anthropological theories of liminality.

This study shows that Rural Physicians have crafted identities for themselves in unique ways, ways that go far beyond the scope of administrative fiat or bureaucratic planning. Their career trajectories indicate agency, self-directedness, and active control rather than the passive embrace of ready-made lives or artificially contrived professional identities.

Interviewees from the Study said…

I'm a general physician in [remote Australia] and I love my job and I have the best life (R8_yP).

For governments, the funding offer is there. The academic infrastructure is there. The support from the rural hospitals themselves, the local health networks is generally pretty strong… [But] I think it [the shortfall of rural specialists] is a challenge that the profession needs to generate some answers for (M8_B).                   

We're looking for medical specialists who work in rural hospitals and across a network within a rural setting who have a generalist skill set, which is what all the evidence shows us those communities need (M8_B).

Dr Megan Jennaway and A/Prof Peter Hill

Theme 3 - Contexts and experiences for trainee physicians and paediatricians

The study sample captured a large cross-section of Trainees from a wide range of locations across Australia with a diversity of training experiences. Additional In-depth interviews gave further insights into their perceptions and experiences of rural training and practice.

Overall, the majority of the findings from this Theme reinforce several established and some emerging concepts in regards to building a rural physician workforce in Australia.  Trainees are generally high in levels of work and life satisfaction regardless of geographical training location. These are positive findings because satisfaction is an important contributor to recruitment and retention. 

A caveat is that overall satisfaction ratings can be deceiving.  Less encouraging are the lower satisfaction levels that imply concerns around the administration of their training.  Here common themes point to the importance of attention to the ‘entirety’ of the training experience. Entirety in this context refers not only to training but also to the myriad of life and social circumstances that are associated with the training experience

Key messages focus on improving communication to provide more information in a consistent and uniform manner and greater flexibility in training options.  Regular communication helps address real and perceived disadvantages and helps to allay concerns about future career opportunities. Here, probably more than any other message from this data is the importance of mentors and accessible supervisors with time and advice, and who can help fight against the harmful culture of negative stereotypes associated with rural training or rural careers. 

A critical requirement of any training experience is the context, in particular the leadership and governance, in which it is framed.  A notable quote from the interview data referred to the “fragile environment” of rural training.  This fragility is characterised by small shifts in the work environment (eg turnover in staff) that translate to large and often undesirable consequences. 

Theme 3 used the concept of ‘self-efficacy’ to investigate Trainees’ perceptions around their intentions to pursue a rural career. This has been associated with rural medical career interest and intent among Australian medical students. 

The key message is that Trainees should be nurtured through a supportive rural training environment with strong role models and a confident culture of worth and recognition.  Addressing training in its entirety and longitudinally, from the earliest stages and throughout training and career transitions, has the potential to distinguish the next generation of rural Physicians.  

A/Professor Di Eley, A/Professor Fran Boyle, Dr Zoe Dettrick

 

Theme 4 - Insights of Fellow and Supervisors' context, experience and rural intentions

Theme 4 provides a detailed picture of the context and experiences of RACP supervisors and has a particular focus on Fellows working in rural areas.

Vast opportunities exist for training in rural settings, not only with regards to addressing issues around workforce distribution but also in producing physicians who are equipped with the necessary  skills to practice independently in a multitude of clinical environments . Yet some of these opportunities remain relatively untapped or under-developed. Adequate and rural-specific support for supervisors and attention to practices that may inadvertently reinforce the rural and urban divide could further boost these training opportunities.

Many of the issues we identified in terms of sustainability of supervision in rural and regional areas are similar to the issues involved in attracting and retaining specialists to these settings. Developing stronger partnerships between rural/regional and metropolitan settings to support supervision and training may help address the issues relating to providing supervision in isolation.

We found that the supervisory experience was variable within all geographical settings, (rural/regional and metropolitan). Much depends on the trainee and on the work environment. Our research highlights the importance of support from the local hospital setting for successful training, including resourcing and recognition of the important role of training as opposed to just service provision. Finally, we also found that even successful training in a rural or regional area does not guarantee that the trainee will return to the area for work.

Much needs to be done to attract and retain a sustainable specialist workforce in rural and regional areas of Australia.

While on the surface the metropolitan and rural workforces appear to be relatively similar in terms of overall job satisfaction and career intentions, it is apparent that it is the details that matter. Attracting additional Physicians to replace those retiring in regional areas, and keeping them there for any length of time, requires detailed understanding and careful consideration.

  • Multi-level strategies are needed to foster attitudes and practices to reduce the rural/urban divide. Supervisors require adequate support to provide best possible training. High quality training sites depend on good leadership, including recognition of training as core business.
  • Flexibility in the accreditation of sites is needed to enable high quality training in diverse settings that are responsive to population needs.
  • High quality training sites depend on good leadership, including recognition of training as core business
  • Supervisors require adequate support to provide best possible training.

A/Professor Linda Selvey, A/Professor Fran Boyle, Dr Zoe Dettrick, Ms Liz Barber

Theme 5 - Principles for a sustainable regional and rural physician workforce

A set of seven Foundational Principles are proposed and are designed to guide efforts to build a sustainable workforce of physicians and paediatricians in rural and regional areas.

These principles acknowledge fundamental parameters including the autonomy of the health professional, the wide range of organisational and broader cultural contexts in which health care delivery and medical training occur, and the reasonable expectation of all communities that they will be provided the best health care available.

These principles represent a change in mindset, which when applied, would result in a substantially different approach to rural workforce development.

Complementing this set of foundational principles is a Vision Statement, that captures the aspiration for future activities that arise from the Study.

Professor Sarah Strasser and Dr Remo Ostini