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From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005
Professor Ian Wronski
Australian College of Rural and Remote Medicine
Hi, how are you? My name's Ian Wronski. Actually, I'm a Monash graduate - it's good to see some of you are from Monash here - from 1976. But I saw the light and at the end of the 70's I went tropical and never went back. Since then really, I moved to Northern Western Australia, and from then on, I've really been developed and focused on indigenous health and rural remote medicine as an entity, and have worked around that field ever since. Though I changed coastlines in the early 90's and took up a position at JCU.
I enjoyed Bob Birrell's presentation. Clearly Bob has been in discussions with numbers of politicians because I was following some of those decision making periods in the mid 90's when we were trying to deal with some more work force issues, and I was involved in some of the tiffs with Michael Wooldridge at the time, in terms of what the real Australian workforce position was at that time, what it was likely to be, and where it was going.
In particular, my interest has actually been the rural remote workforce. Actually, it's quite sizeable. There are 4,000 docs. It's a middle aged workforce, and although most are male, it's increasingly female. There's a lot of private practice there, and it depends a lot on States and how the States are interested in running them. But they do a whole range of things. And very large numbers of them are involved in procedural activity, either accident emergency surgery, obstetrics, anaesthetics, or procedural surgery itself.
Importantly, and I think an important fact in this, is that this is despite the massive assault on small hospitals in Australia. Even given the massive close down of hospitals in small towns in rural Australia over the last 20 years, particularly the last 5 years - lots and lots of these people are proceduralists.
Now the workforce shortages - I have to tell you a bit first - in rural remote areas. It's nice to see it spread everywhere else because now there's a lot more interest in the problems. It's actually not just the medical profession. So I do think, in the discussions about the shortages of medical doctors, there's a whole lot of really interesting points. But actually it's just that medicine collects the data. The nursing shortages are fundamental to problems in hospitals. There are dramatic shortages in allied health, and in pharmacy and in various other areas. So essentially, Australia wide, we have a massive workforce shortage that has extremes in rural areas, but exists now in metropolitan areas, particularly, say, the western suburbs of Melbourne, Sydney and others.
I think it's getting worse, and it's going to get a lot worse before it gets better. There's an aging workforce; increasing demands; there's gender change but in actual fact there's declines in the amount worked by both males and females; and there's changing social attitudes to long working hours; and continued mal distribution.
We're bound to be affected by the impact of things like the European Working Time Directive. We're systematically - Anglo/American country, Bi-Anglo/American country, and Western European country - we are reducing the allowed hours that practitioners are allowed to work because it's related - just like in airline pilots - it's related to poorer outcomes.
Now, Government is doing stuff. I guess under my other hat as an Executive Dean, one of the schools --- the larger schools being a medical programme, which we established in 99, we've played a key role in trying to push these things. So we do have a Government response. And in the medical school system and across most medical schools now, there is a pipeline bolus of rurally oriented kids coming through the medical school system.
The question is where are they going to go, and will they stay there. These are the sort of things that improve the likelihood that kids coming through medical school are going to go rural. That's rural origin - that's 2.5 times - rural schooling, rural spouse, rural undergraduates, rural internships, rural training. The intellectual capital for all these developments has systematically really been put in place since the end of the 90's with things like rural clinical schools, university departments of rural health. So a lot of the infra structure is there.
Nonetheless these kids are just about to come out of the pipeline. JCU, which is my university - and the first of the new medical schools for 25 years - has its first graduation this year. So 60 something students, each year incrementally increasing to about 100 students in about four years, are going to be coming out and very large numbers of them are rural oriented kids, all looking to work in rural areas. And so they need career structures.
Rural docs have already established a medical college, the Australian College of Rural and Remote Medicine, but the post graduate career structures that are usually enjoyed by specialisations in Australia are still in the process of development. This process is now with the AMC, and the AMC has three or four criteria that I won't go through in detail but the criteria include: does a new specialisation improve patients' safety; does it improve standards. I'd have to say there's a whole heap of reasons why rural medicine as a medical speciality will improve patients' standards.
Bob said that he thought it was actually the generalists - the rural areas are really bearing the brunt of really State boards allowing under-trained generalists to work in rural areas. Some of the scariest experiences I've ever had in my life relate to the State boards placing under-trained specialists in rural remote areas, in areas where their skill set really has to be very broad because there aren't three other surgeons in town to do their stuff. I could tell you some of the scariest experiences I've ever had occurred in Western Queensland.
So the impact of the absence of official training programmes and specialisation I think are huge. I think it will result in more cost effective care, although the real issue for those who are public people is the cost benefit there. Cost effective to economists will actually mean, can you do more for the same money. Cost benefit means, is the dividend to society greater. I'd have to tell you that rural medicine becoming a medical speciality in Australia, the dividend to the Australian rural population will be huge. There are lots of rural benefits. There are lots of community benefits.
Most of these kids that I talk to, who are in year 6 and year 5 of our medical programmes now, are asking questions about, okay if I do this, and I do this, and I actually want to be a proceduralist and work in the local hospital, but also run generalist clinics in my township, what pathways should I go, and what's going to sustain me, and how do I get recognition, and if there isn't any training programme, what sort of benefits are there in Medicare rebates, in infra structure, in access to referrals, in me being able to recruit others, in official programmes that allow me to mentor the new kids coming through.
So what's missing? Well, actually lots of rural doctors have been working very hard over the last few years and have got pieces of this action in place. And parts of vocational recognition are in place but via a third party really. ACRRM does have its professional development programmes or CPE or CME, whatever you want to call it. The proposal is, with the AMC being considered at the moment, there are in fact rural training pathways and independent pathways that people can get fellowship, and remarkably large numbers of docs are doing these pathways, even though the fellowship of ACRRM doesn't quite give you a specialist tick yet, other than in the mind of other rural practitioners (inaudible) of rural medicine and future specialisation look like.
I think that the current models we're working with, even though we'd all like to think about the past and try to maintain the fundamentals of it, I believe that specialisation and the way universities and colleges relate to each other in terms of professional development in the future is going to be different.
I think that we will find that there's going to be more pathways. We are going to see consortia of universities and colleges finding joint ways of approaching the training of post graduate programmes. I think we're going to see things like conjoint awards. For instance, universities learnt a long time ago that lots of students are interested in dual awards.
My guess is that one of the future possibilities is for colleges to get together. So for instance, you could have conjoint awards between the College of Rural and Remote Medicine and surgery, and you could have joint programmes, with the usual things that we see in other educational programmes like recognition of prior learning, some streamlining, and allowing us to do training postgrads modules of activity that are dually recognised by several colleges, so that postgrads don't get caught up in one training stream too early. They'll be able to switch and they'll be able to move back to urban centres if they want to.
So in summary, I think that, in a patchwork sort of way, Australia has stumbled to the front of the international moves to try to deal with rural and remote medicine problems. But the problems in rural and remote medicine are really just an exacerbation of what we're seeing in terms of workforce shortages in the broader populations in all the Anglo American countries.
The medical crisis, or the medical workforce crisis is more extreme. I think that's largely because we count it. But a lot of the fundamentals in terms of the problems with the health system, the problems with surgical turnover in hospitals, is actually related to nursing shortages for instance.
So I think here lies an opportunity for the colleges to find a way of maintaining, I think, a grand tradition of the profession keeping control of medical specialisation, but at the same time finding ways of joining together with universities, joining together with new emerging areas, and finding ways of dealing with Australia's number one or two health care issues.
Thank you very much.
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