Rural Round up: the importance of training in rural areas.

The recent Rural Health Conference in Gramado gave us time to reflect on a number of important issues facing rural communities across the world – along with the pressures of climate change, population growth and increasing burdens of chronic disease the “perfect storm” is compounded by the continued problem of access to the quality medical services.

New Zealand began life as a rural nation, and our national identity takes pride in our ‘can-do’ approach to life. It is a fundamental human right that people living in all regions have access to high quality health services, perhaps especially in regions at distance from main population centres, regions that are often the backbone of a country’s economic wealth, and centre of leisure activities (1).

Having a healthy, engaged and well educated health workforce is important to the wellbeing of all communities. Attracting health professionals to live and work in rural areas is an international problem familiar to all WONCA members (2).

It may be a little confusing why this is a problem for those of us that have made this lifestyle choice, but it may be more prevalent in areas where there is a high demand, especially on after hours care, low reward and professional isolation and where family and social issues put pressure on rural providers (3).

In New Zealand year after year GP workforce surveys have detailed the on-going problems of recruitment and retention into rural practice (4-6), and the shortage of providers in rural areas continues, with over 25% of practices currently seeking full time GPs and Nurses (Rural General Practice Network unpublished data 2014.)

The medical workforce is the best studied example of a need that is widely reported to affect rural nurses, pharmacists, midwives, dentists and physiotherapists (7).

New Zealand needs 50% of its medical graduates to choose General Practice as a career, currently only 29% have a “strong interest” in doing so at the end of the medical degree offered by Auckland University, (8) and it is unclear how many NZ graduates actually become GPs and even less is known about how many of them to choose rural practice.

We do know that currently only 9.2% of doctors working in rural areas are NZ trained, and only 16.4% of NZ trained GPs choose to work in rural areas (9). We do know that as a proportion of the workforce the number of GPs is falling compared to specialists (10).

Rural workforce statistics show that the average age of rural General Practitioners continues to age and these communities rely heavily on international medical graduates to provide services. This leads to a continuing need for recruitment as we are failing to “grow our own” health workforce (9).

If we are to “grow our own” workforce it is very clear from international studies that choosing students with rural interests and backgrounds, exposing undergraduates to positive training experiences in rural areas, and providing well supported career pathways in rural practice increases the intention of medical students to work in rural communities once they graduate (2, 11).

We know that the career decisions of students and young professionals in the future will be affected by the way health career choices are viewed by society, available financial incentives, appropriate professional development and career opportunities, the availability of locums, a good quality of life ability to achieve balance, and the lifestyle choices of their spouses and family needs (2).

Many of us involved in education will be aware of the idea of “constructive alignment” of intended learning outcomes – what we hope to achieve – and the assessment and learning activities that are planned. The same theory applies to issues that face us in our rural communities.

We want to see an improvement in the health outcomes for rural communities, “Health for All Rural People”, we need our governments, colleges and colleagues to be measuring these outcomes – because of it is not measured it won’t be changed – and then we need our recruitment and retention and service delivery model thinking to be focused on achieving these outcomes.

This may seem bigger than Ben Hur but from what we do know it is clear that in order to meet the needs of our current and future population, in order to achieve equity and fairness or health outcomes for rural communities, in order to support and further develop the economic health of our rural sector, government needs to further support and expand initiatives that that increase exposure of training health professionals to positive rural experiences.

Dr Jo Scott-Jones

References:

1. Ministry for Primary Industries : Rural Communities 2014 [09/05/2014]. Available from: http://www.mpi.govt.nz/agriculture/rural-communities.
2. WHO. Increasing access to health workers in remote and rural areas through improved retention:global policy recommendations. Geneva: World Health Organisation, 2010.
3. Burton J. Rural Health Care In New Zealand. Wellington: Royal New Zealand College of General Practitioners, 1999.
4. London M. New Zealand Annual Rural Workforce Survey 2000. Christchurch: Centre For Rural Health; 2001.
5. Mel Pande M, Fretter J, Stenson A, Webber C, Turner J. Royal New Zealand College Of General Practitioners Workforce Survey 2005 part 3: General Practitioners In Urban and Rural New Zealand. 2006.
6. The New Zealand Medical Workforce 2007. New Zealand Medical Council; 2008.
7. Health Workforce Development: An Overview. In: Health Mo, editor. Wellington, New Zealand2006.
8. Poole P, Bourke D, Shulruf B. Increasing medical student interest in general practice in New Zealand: where to from here? The New Zealand medical journal. 2010;123(1315):12.
9. Garces-Ozanne A, Yow A, Audas R. Rural practice and retention in New Zealand: an examination of New Zealand-trained and foreign-trained doctors. The New Zealand Medical Journal (Online). 2011;124(1330):14-23.
10. Medical Council of New Zealand: The New Zealand Medical Workforce in 2012 Wellington, New Zealand2013.
11. Walker JH, DeWitt DE, Pallant JF, CE. C. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural and Remote Health. 2012;12(1908):Online.
12. Farry P, Hill D, Isobel Martin I. What would attract general practice trainees into rural practice in New Zealand? NZMJ. 2002;115(1161).
13. Worley P, Strasser R, D. P. Can medical students learn specialist disciplines based in rural practice: lessons from students’ self reported experience and competence. Rural and Remote Health. 2004;4(338):Online.
14. Ministry of Health: Voluntary Bonding Scheme Wellington, New Zealand2014 [09/05/2014]. Available from: http://www.health.govt.nz/our-work/health-workforce/voluntary-bonding-scheme.
15. Rural Health Interprofessional Immersion Programme Wellington, New Zealand2014 [09/05/2014]. Available from: http://www.rhiip.ac.nz/.
16. University of Otago: Rural Medical Immersion Programme Otago University, New Zealand2014 [09/05/2014]. Available from: http://rmip.otago.ac.nz/.
17. P Poole, W Bagg, B O'Connor, A Dare, J McKimm, K Meredith, et al. The Northland Regional-Rural program (Pukawakawa): broadening medical undergraduate learning in New Zealand. Rural and Remote Health. 2010;10(1254):Online