tag:theconversation.com,2011:/us/topics/rural-doctors-3558/articlesrural doctors – The Conversation2019-11-25T19:09:56Ztag:theconversation.com,2011:article/1273182019-11-25T19:09:56Z2019-11-25T19:09:56ZGeographical narcissism: when city folk just assume they’re better<figure><img src="https://images.theconversation.com/files/302817/original/file-20191121-542-brsel3.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4751%2C3276&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It isn't just that city dwellers assume superiority, some Australians living in rural and regional areas also internalise a sense of inferiority.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/proud-confident-businessman-calling-on-cell-1467753617">Mangostar/Shutterstock</a></span></figcaption></figure><p>A self-proclaimed “farmer’s wife” triggered a groundswell of activity on Twitter this month from frustrated rural professionals across Australia. Kirsten Diprose is an ABC metropolitan journalist turned regional reporter. In an <a href="https://www.abc.net.au/news/2019-11-10/stigma-of-working-in-regional-australia-couldnt-cut-it-in-city/11672266">article</a> for the ABC, she declared she always felt the need to play up her city-based credentials and experience to justify her professional worth. She wrote:</p>
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<p>Many people in the country feel they have to justify their careers, whether it’s in the media, health, education or business. Some people think if you’re not working in the metropolitan centre then you must not be good enough at what you do. You never ‘cracked the big time’ or you were too afraid to try.</p>
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Read more:
<a href="https://theconversation.com/bust-the-regional-city-myths-and-look-beyond-the-big-5-for-a-378b-return-79760">Bust the regional city myths and look beyond the 'big 5' for a $378b return</a>
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<p>As academics with professional backgrounds in health care and media respectively who work in regional Victoria, we couldn’t agree more with Diprose’s observations. What she describes is known in academic scholarship as “geographical narcissism”. Swedish clinical psychologist Malin Fors <a href="https://psycnet.apa.org/fulltext/2018-24924-001.html">used the term</a> to explain the rural-urban interactions she encountered while working in a small town north of the Arctic circle in Norway. </p>
<p>The concept has also been described in other terms such as “urban splaining” – rural people are “talked down to” by their city counterparts – and “geographical judgment” as journalist Gabrielle Chan puts it in her book Rusted Off.</p>
<p>Academic literature, from <a href="https://web.mit.edu/esd.83/www/notebook/WorldSystem.pdf">Immanuel Wallerstein’s world systems theory</a> to the <a href="https://en.wikipedia.org/wiki/The_Country_and_the_City">work of cultural theorist Raymond Williams</a>, has long discussed the economic and cultural causes of the rural-urban divide. Geographical narcissism looks at the psychological consequences. </p>
<h2>Anyone outside the city is ‘camping out’</h2>
<p>When big cities are seen as the centre of everything, it gives rise to a narcissistic view in city dwellers that subtly, often unconsciously, devalues rural knowledge, conventions and subjectivity. It fosters a “<a href="https://psycnet.apa.org/fulltext/2018-24924-001.html">belief that urban reality is definitive</a>”.</p>
<p>For example, rural health-care professionals are often asked by their urban contacts why they left the city. And when will they be going back? It’s assumed nobody would voluntarily move to a country town for professional work, especially if they have no family or social ties to the area. </p>
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Read more:
<a href="https://theconversation.com/should-i-stay-or-should-i-go-how-city-girls-can-learn-to-feel-at-home-in-the-country-124579">Should I stay or should I go: how 'city girls' can learn to feel at home in the country</a>
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<p>There is also a suspicion, as Fors <a href="https://psycnet.apa.org/fulltext/2018-24924-001.html">points out</a>, that people with ethical or personal problems are banished to the country. It is a classic film and television trope for the brilliant city specialist to be obliged to work as a rural GP because of alcoholism, cocaine addiction, fear of blood, or crime punished by community service. (A favourite example is the French-Canadian film La grande séduction/The Grand Seduction where a plastic surgeon must work in a small fishing village while coping with the twin deviations of cocaine use and a love of cricket.)</p>
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<figcaption><span class="caption">La grande séduction/The Grand Seduction epitomises the trope of a flawed medical specialist who has to work outside the city.</span></figcaption>
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<p>This year we have each been invited to speak at regional professional conferences and events about this topic. It’s clear many rural professionals who encounter this urban mindset struggle to be identified (or see themselves) as equals.</p>
<p>Take this tweet responding to <a href="https://www.abc.net.au/news/2019-11-10/stigma-of-working-in-regional-australia-couldnt-cut-it-in-city/11672266">Diprose’s article</a>:</p>
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<p>And another:</p>
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<p>It’s also our personal observation in health care and higher education that geographical narcissism affects professional life by warping perceptions of time and distance. It always seems longer for city-based professionals to travel to the country to visit regional campuses and hospitals than for their regional colleagues to travel to the city. </p>
<p>Many rural workers will identify with the expectation that they travel both ways in a day to attend a meeting in the city. As for employees of the city office, they need a night’s accommodation and a little narcissistic praise for their intrepid travel to the country. </p>
<p>This lack of appreciation can also interfere with the effectiveness of well-meaning urban professionals who want to improve rural practice. An urban professional seeking to reorganise an area of rural practice may feel bewildered at the passive-aggressive behaviour of their rural colleagues. As Fors observed, they are mistrusted as colonisers when they had expected to be welcomed as rescuers.</p>
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Read more:
<a href="https://theconversation.com/settling-migrants-in-regional-areas-will-need-more-than-a-visa-to-succeed-114196">Settling migrants in regional areas will need more than a visa to succeed</a>
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<h2>Stereotypes are internalised too</h2>
<p>Rural professionals often laugh with recognition when hearing of geographic narcissism. But it’s confronting when they realise they themselves have internalised and ultimately reinforce the same stereotypes. </p>
<p>As Diprose experienced, many rural professionals will legitimise their skills to an urban colleague by listing their urban education and work credentials – as if these are the experiences that matter. This leads to a rural dialectic, where rural professionals hold the seemingly opposing views that rural work is, and is not, of high quality. </p>
<p>Juggling these polarised views can lead to unhelpful psychological compromises. One of these is to split elements of rural practice into good and bad. Of particular concern is the belief that an individual professional is of high quality, but the rest of the rural organisation is not, so they must leave to progress their career.</p>
<p>There are, of course, social spaces and professional fields where geographical narcissism is not apparent. It’s less of problem when those who work and live regionally have their key economic, professional and social connections within one location. But when one competes with or is exposed to resources based at the “centre” – so often in the big cities – you can’t miss it. </p>
<p>The rise of digital technology – with its promise to eradicate issues of distance – has perhaps exposed the prevalence and unspoken acceptance of geographical narcissism.</p>
<p>Rural and urban environments bring different challenges for working professionals. Good and bad practices can occur in both. But it is narcissistic to believe geography is a key determinant of quality.</p><img src="https://counter.theconversation.com/content/127318/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy Baker receives funding from the Department of Health and Human Services Victoria and Alcoa of Australia</span></em></p><p class="fine-print"><em><span>Kristy Hess receives funding as lead investigator on an Australian Research Council's Linkage project examining the future of local news in Australia (LP180100813) and is a chief investigator on the Australian Research Council's Discovery Project examining the role of media in the Royal Commission into Institutional Responses to Child Sexual Abuse (DP190101282)</span></em></p>Big cities are seen as the centre of everything, which creates an attitude that often devalues the work and skills of rural professionals. And sometimes even they subconsciously buy into this.Timothy Baker, Associate Professor and Director, Centre for Rural Emergency Medicine, Deakin UniversityKristy Hess, Associate Professor (Communication), Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/175062013-09-04T04:56:44Z2013-09-04T04:56:44ZWhy the next government must reform medical training<figure><img src="https://images.theconversation.com/files/30642/original/kwv3hsf6-1378257256.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The number of doctors in major cities is ballooning, but we need are more doctors in rural areas.</span> <span class="attribution"><span class="source">becky bokern</span></span></figcaption></figure><p>Health care is a tough nut for governments because it’s the largest source of <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">growth</a> in government spending. Salary costs are the major part of this cost so workforce policy decisions have profound implications for health-care access and affordability. </p>
<p>Recent governments have made big policy decisions about medical training, but we still need to ensure we get results that resolve the problems we face. The next government needs to act on this quickly.</p>
<p>How we conduct medical training demands urgent action because, since 2000, Australia has trebled medical school intakes and boosted the importation of overseas trained doctors. </p>
<p>That’s because we were short of doctors, right? Wrong!</p>
<h2>The real issue</h2>
<p>Among high-income countries, Australia has an above-average number of doctors for its population, as you can see below; at 3.3 per 1,000, this is many more than comparable English-speaking nations.</p>
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<img alt="" src="https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=478&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=478&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=478&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=601&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=601&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30443/original/j39v9zxq-1378063865.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=601&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Doctor numbers across comparable countries.</span>
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<p>The real challenge is the concentration of doctors in big cities. And the imbalance between the number of doctors who provide a narrow scope of “sub-specialist” care (often jobs that are more lucrative and lifestyle-friendly) than roles providing a more comprehensive scope of clinical care. </p>
<p>As the graph below shows, maldistribution pretty much explains the real shortage of doctors in rural areas as well as in outer suburbs and generalist clinical roles. </p>
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<img alt="" src="https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=547&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=547&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=547&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=688&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=688&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30309/original/dtbncyyh-1377836613.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=688&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>In spite of incentives and programs to address this maldistribution, the number of doctors in major cities is ballooning, particularly specialist consultants. A <a href="http://www.aihw.gov.au/publication-detail/?id=60129542627">net number of 11,577 clinical doctors</a> were added to major cities between 2007 and 2011 – three-quarters of the national growth for two-thirds of the population. </p>
<p>Only one in ten of these were general practitioners or GPs-in-training; the rest were consultant specialists and other hospital doctors. </p>
<p>The bush has seen growth too - but a good portion of this was due to vacancies being filled by overseas-trained doctors. Governments made this happen by providing working visas and bans on Medicare billing that restrict them to working in areas of need.</p>
<h2>Shifting the focus</h2>
<p>Clearly, we need to <a href="https://www.mja.com.au/journal/2012/197/5/do-available-predictions-future-medical-workforce-requirements-provide-sensible-0">shift the focus</a> of medical workforce planning from numbers to better use expensive medical labour.</p>
<p>After graduation from medical school, doctors pursue further training in one of the medical specialities, including general practice. In order to get doctors working in the communities and roles where they are most needed, they should be trained in those locations and specialities. </p>
<p>Efficient use of expensive medical labour is important too – this means efficient and flexible models of team-based care with nurses, allied health workers, extenders and assistants. </p>
<p>With money increasingly tight, we simply cannot afford to feed the apparently insatiable appetite for sub-speciality medicine in major cities, nor the expense of narrow disease-focused care that it leads to. </p>
<p>This arrangement of medical care is actually not good for patients either. Anyone with a loved one who lives with chronic and complex health conditions knows that health care that’s delivered organ by organ is not good for health, suffering or human dignity – let alone the bank balance.</p>
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<span class="caption">Providing training for doctors in regional areas has been identified as a key health workforce investment.</span>
<span class="attribution"><span class="source">Moyan Brenn</span></span>
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<p>This is why the Commonwealth government’s <a href="http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-review-australian-government-health-workforce-programs-toc%7Echapter-4-addressing-health-workforce-shortages-regional-rural-remote-australia%7Echapter-4-health-education-strategies-rural-distribution">recent review of health workforce programs</a> considered generalism in clinical care and regionally-based training as key health workforce investments.</p>
<h2>Moving in the general(ist) direction</h2>
<p>National reforms toward a regionally-managed health system, transparent funding streams, more flexibility in public-private arrangements and regionally-organised primary care are now well underway. It’s time to add medical workforce reform to the mix. </p>
<p>We have already invested in developing rural and regional health workforce training capacity through university departments of rural health, rural clinical schools and regional university medical, nursing and other health professional schools. This infrastructure can be used to support expanded regional training pipelines for medical specialities. </p>
<p>Rural generalists – country GPs who can provide primary care in the community as well as hospital, emergency, population health and extended speciality service – have always had a central role in the bush and <a href="http://www.aph.gov.au/Parliamentary_business/Committees/Senate_Committees?url=clac_ctte/completed_inquiries/2010-13/rur_hlth/report/report.pdf">their numbers should be bolstered</a>. There’s scope to expand their effective and value-for-money roles into cities. </p>
<p>In emphasising the role of the generalist, we must re-assert the effective and judicious use of the medical consultant – the specialist doctor with focused expertise for the rare or tricky problems. E-health and <a href="http://www.ehealth.acrrm.org.au/">collaborative tele-health solutions</a> provide us with great tools to do this in new, technologically-savvy ways. </p>
<p>With the surge of medical graduates on its way, it’s time for action. If these people are trained in sub-speciality medicine in big-city teaching hospitals, the unprecedented taxpayer investment in this medical workforce “solution” might yet sink the health system financially - and exacerbate the doctor drought in the bush!</p><img src="https://counter.theconversation.com/content/17506/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Murray works for James Cook University and is also President of the Australian College of Rural and Remote Medicine. He has received funding from Health Workforce Australia and other agencies for health workforce and health services research. He is a member of the Mackay Hospital and Health Service Board.</span></em></p>Health care is a tough nut for governments because it’s the largest source of growth in government spending. Salary costs are the major part of this cost so workforce policy decisions have profound implications…Richard Murray, Dean of Medicine & Dentistry, James Cook UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/146422013-05-30T04:29:28Z2013-05-30T04:29:28ZCountry practice: recruiting doctors to work in the bush<figure><img src="https://images.theconversation.com/files/24579/original/tcrgsxsf-1369789318.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One-third of rural patients wait 24 hours or longer for an urgent GP appointment.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>If you live far from a city, you are likely to be in <a href="http://www.coagreformcouncil.gov.au/sites/default/files/files/Remoteness%20supplement%20-%20FOR%20WEBSITE.pdf">poorer health</a> than your urban counterparts; you’re also less likely to use health-care services and if you do, you’ll have to wait longer for care. In rural areas, almost one-third (29%) of patients wait 24 hours or more to see a GP for an urgent appointment. Waiting times for emergency hospital care are also getting worse in rural areas but <a href="http://www.coagreformcouncil.gov.au/sites/default/files/files/Health%202011-12%20-%20Chapter%203.pdf">improving in major cities</a>. </p>
<p>If you live in the country, your GP is more likely to have qualified in Europe, the Indian sub-continent, or Asia, than Australia. GPs from overseas are <a href="http://www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/Content/5_Year_Overseas_Trained_Doctor_Scheme">forced to work in rural areas</a> for a fixed period after they arrive, with around 40% of doctors in rural areas qualified in other countries. </p>
<p>These GPs fill an important gap; in the absence of effective policies to encourage Australian-trained GPs to work in rural areas, we will continue to rely on overseas-trained doctors for some time. This is a very cost-effective policy for Australia, but the ethics of depleting the <a href="https://www.mja.com.au/journal/2004/180/4/brain-drain-or-ethical-recruitment">supply of doctors from developing countries</a> are murky. </p>
<p>Many of these doctors want to eventually work in the city, and so they are difficult to retain once their obligatory time in the bush is completed.</p>
<p>The release on Friday of a Commonwealth-commissioned, <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/work-health-workforce-program-review">independent review of Australia’s health workforce programs</a> is one in a long line reports that have attempted to shift the balance between metropolitan and rural access to health care. Yet after each review, we find ourselves in the same position: spending hundreds of millions of dollars on new programs with no evidence of their effects.</p>
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<span class="caption">Waiting times for emergency hospital care are getting worse in rural areas.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
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<p>Yes, there are many and well-intentioned policies that focus on recruiting people into medicine who grew up in rural areas, and increasing the amount of medical training based in rural areas through rural-based clinical schools. But these policies are expensive and we don’t know whether they work.</p>
<p>A lack of any proper and rigorous evaluation means that we cannot move on because we do not know if anything has changed. In the meantime, rural waiting lists are getting longer and health inequities widen between those living in rural and metropolitan areas, suggesting we need to do more. </p>
<h2>Not just money</h2>
<p>Persuading a doctor to move to the bush, or to persuade doctors already there to stay, depends on a complex mix of family, professional, and social factors. </p>
<p>Funding and financial incentives play an important role – and are the government’s main policy lever. Funding can be paid directly to GPs, or can be used to fund locum cover (replacement doctors) or other means of support. But a financial solution alone isn’t cheap; a <a href="http://www.melbourneinstitute.com/downloads/working_paper_series/wp2012n13.pdf">recent study found</a> that GPs would need to be paid A$270,000 in take-home pay to move to the “worst” rural area. But improved working conditions would reduce this amount. </p>
<p>Financial incentives are certainly not the only way to recruit and retain doctors in the bush. The <a href="https://mabel.org.au/">MABEL survey of Australian GPs</a> identified six <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1584.2011.01252.x/abstract;jsessionid=28D39D1069B5442F3E9E05B6459DB670.d01t03?deniedAccessCustomisedMessage=&userIsAuthenticated=false">key factors</a> that influence doctors’ decisions: on-call requirements, hours of work, the ability to take time-off, spouse employment opportunities, schooling arrangements, and public hospital work. </p>
<p>These six indicators have been used to develop a <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/work-health-workforce-program-review">new rural classification system</a> based on population size, which will be developed further over the coming months.</p>
<p>This new system will be used to improve the allocation of funding for rural incentive schemes. Ideally, the distribution of these funds should be based on which areas and towns are in more “need” of doctors than others. The areas that have higher needs than others – poorer health and worse risk factors for disease, longer waiting times, and GPs who working long hours and provide 24-hour care – should therefore receive a greater level of funding to attract more doctors.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/24578/original/q3dkv3j4-1369789318.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/24578/original/q3dkv3j4-1369789318.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/24578/original/q3dkv3j4-1369789318.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/24578/original/q3dkv3j4-1369789318.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/24578/original/q3dkv3j4-1369789318.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/24578/original/q3dkv3j4-1369789318.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/24578/original/q3dkv3j4-1369789318.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Financial incentives aren’t the only factor to influence a doctor’s decision to move to the country.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
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</figure>
<p>So will this new classification system lead to more doctors in the bush? Better targeting of incentives <em>should</em> mean that areas that really need a doctor are more likely to get one. </p>
<p>But to demonstrate this and ensure the goals are being met, we need good evaluation built into the program roll-out. Policymakers are often too keen to get the money out of the door than spend some time and money building in proper evaluation. This needs to change, otherwise we will be having the same discussion in five to ten years time. </p><img src="https://counter.theconversation.com/content/14642/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the Australian Research Council and National Health and Medical Research Council (NHMRC). The NHMRC funds the Centre for Research Excellence in Medical Workforce Dynamics, which houses the Medicine in Australian: Balancing Employment and Life (MABEL) longitudinal survey of doctors. A key research theme of the Centre is rural workforce supply and distribution, and MABEL data were used in the latest government report mentioned in the article.</span></em></p>If you live far from a city, you are likely to be in poorer health than your urban counterparts; you’re also less likely to use health-care services and if you do, you’ll have to wait longer for care…Anthony Scott, Professorial Fellow & ARC Future Fellow, Melbourne Institute of Applied Economic and Social Research, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/92522012-09-04T02:19:28Z2012-09-04T02:19:28ZHealth care in rural areas: the answer is not more of the same<figure><img src="https://images.theconversation.com/files/14992/original/szzvgkk3-1346722073.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We need to rethink how we provide health services in rural areas.</span> <span class="attribution"><span class="source">Alan Levine</span></span></figcaption></figure><p>The recent report of the <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate_Committees?url=clac_ctte/rur_hlth/report/index.htm">Senate Inquiry into rural health services</a> gave tantalising glimpses of how the future of rural health services should be. But its central theme is not new. The persistent and consistent message (that it’s hard to get health professionals to work in rural areas because it’s personally and professionally challenging) does little to get the policies rural communities really need to sustainably address health challenges.</p>
<p>But research considering what would make doctors and nurses (and now allied health professionals) work “out there” lumbers on, considering, for the most part, the carrot or the stick. It misses the fundamental point that addressing rural health care isn’t about providing incentives or bonding individuals, but about changing the system.</p>
<h2>Town and country</h2>
<p>Rural is not simply urban with trees and animals. And not all rural is alike – coastal, regional and extremely remote areas all have different challenges. To varying degrees, there are fewer people, they’re ageing and they’re sparsely spread. And there isn’t enough local work for specialised practitioners to retain their skills, as noted by the Senate Inquiry. </p>
<p>Increasingly, someone who might be regarded as a specialised practitioner in an urban area (such as a doctor who just works on arms) is dramatically different to what specialisation might be considered in a rural context, where even some allied health professions are considered specialities. </p>
<p>A rural diabetes patient might need dietetics, podiatry, exercise advice, prescribing and pain relief. But requiring a clutch of health professionals each with their delineated specialist role to deal with all of this individual’s needs is unrealistic. </p>
<p>A better approach understands that a set of health and social care competencies are needed locally for flexible practice – continuity and security as opposed to platoons of detached fly- or drive-in, fly- or drive-out specialists.</p>
<h2>A new way</h2>
<p>Focusing on traditional doctors and nurses is outdated and unsuitable due to modern health needs and demographics.</p>
<p>In a <a href="http://www.abdn.ac.uk/crh/uploads/files/remote-service-futures-project-final-report.pdf">Scottish rural community study</a>, we turned service design on its head and let local citizens decide on priorities. We acted as researchers for communities and provided data and evidence on which to base decisions. </p>
<p>Community members were given the current local health-care budget, and all four communities arrived at similar priorities: the ongoing presence of a locally-resident health practitioner; 24/7 access to triage to detect real emergencies; monitoring of vulnerable people to avoid crisis; local community volunteer activities for health improvement and maintenance, led by a paid, knowledgeable (health) leader. </p>
<p>From a choice of existing health roles, community members couldn’t find the practitioner they truly desired. They wanted parts of the skill-set of nurses, doctors and health promotion advisers. The closest they could find were physician assistants, nurse practitioners and paramedics.</p>
<p>Communities found designing the services they needed was the easy step. But getting their innovative models implemented was pretty much impossible. Archaic health-care organisational and financing structures and professional groups’ interests got in the way.</p>
<h2>Rethinking old ways</h2>
<p>Providing health care for rural communities is different to what happens in cities and trying to impose a one-size-fits-all model isn’t working. Rural health services are part of a complex web, spreading out from the individual, to the local community, to regional hospitals, to the big metropolitan tertiary hospitals. </p>
<p>Different places in the system need different levels and mixes of skills. Good e-health and transport links should enable connections between its parts, allowing people access to the level of specialist treatments they need.</p>
<p>In spite of its awesome wildernesses, Australia is a metro-centric country with a confused and confusing relationship with the countryside. Inequities will not be addressed if we continue trying to provide rural health services by enticing individual professionals to work in places they don’t want to go. Instead, we need to make it easier to implement changes that rural communities themselves know they need. </p>
<p>The Senate Inquiry’s recommendations are good within the current paradigm, but do little to fundamentally change our understanding of how we ensure rural communities are healthy communities.</p><img src="https://counter.theconversation.com/content/9252/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Farmer currently receives research funding from community health services in Victoria; and has previously received funding from UK Economic & Social Research Council, European Union and Scottish Government sources.</span></em></p>The recent report of the Senate Inquiry into rural health services gave tantalising glimpses of how the future of rural health services should be. But its central theme is not new. The persistent and consistent…Jane Farmer, Head, La Trobe Rural Health School, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.