Thursday, December 7, 2023

Training our rural doctors

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Attracting general practitioners to work in small rural areas has been challenging at times, which has led people to delay seeking medical care. Ross Nolly caught up with one Taranaki rural GP who says there are a lot of benefits to working in small communities.
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In recent years finding doctors willing to work in rural general practices and rural hospitals has been difficult.

The Rural Hospital Medicine Training Programme is a subset of the Royal New Zealand GP College. It’s a relatively new programme and its aim is to give doctors an experience of rural hospital medicine. 

The programme has been operating at Hawera Hospital in South Taranaki for three years and shares some elements with general practice with many doctors practising rural GP and rural hospital medicine simultaneously.

Dr Anna Fischer, who is Hawera Hospital’s rural hospital medicine registrar, has worked at the hospital for more than six months. Before moving to Hawera she did four years of rural training in New Plymouth abd Dunedin and GP training in Auckland and Central Otago. 

“The rural hospital programme was born 11 years ago and is a separate training to general practice. It’s generally four years long and undertaken after completing two years as a hospital house surgeon,” Fisher says. 

“The aim is to become a generalist and gain a wide range of experience that will enable doctors to run a small hospital and its emergency department in a limited resources environment.”

Programme doctors need to gain experience in general medicine, intensive care, paediatrics and anaesthetics to enable them to care for critical patients for an extended time before a helicopter or ambulance arrives. 

It has become difficult for some people in the rural areas to find a GP to register with or even get to see their GP in a prompt time. 

“Due to the shortage we sometimes have patients presenting quite late with illnesses. If we can catch those problems earlier we can often avoid hospital admissions or more intensive treatments,” she says. 

“Chronic diseases are sometimes not as well managed as we’d like them to be. That can result in avoidable complications and more people accessing and clogging up the emergency department.”

Some urbanites have a preconceived idea of rural life, just as many country folk have preconceived notions of city life.  

“Even though I came from Auckland I hated the rat race,” Fisher says.

“Here, there’s a sense of community. People are proud to be from the region and they know and connect with each other. When you live in a busy city you can sometimes miss out on those connections.”

Fishers feels it’s easier for rural doctors to be in tune with a patient’s family and social circumstances. That can be extremely important in mental health cases. 

“You are able to take a step back and think this patient has come to us three or four times with different issues. 

“They may not have actually stated that they’re struggling with their mental health. When you have the time and more scope of their situation you can recognise those factors.” 

Small hospitals such as in Hawera are vital as some people live a long distance from a larger hospital but the rural context is not just a case of being further away from a major hospital. In a limited resource rural hospital the doctors must be prepared for any eventuality. 

“The programme aims to create a workforce that’s equipped to maintain a high level of health care for their rural population. About 90% of the trainees who have completed the programme now work in rural areas. The programme is working and gathering momentum.” 

Rural hospitals save money by proactively being the ambulance at the top of the cliff rather than at the bottom. 

They have a distinct role compared to the large hospital specialist model. Their role is a generalist model with the knowledge that specialists are available at the larger hospitals when needed. 

“You can often manage without a specialist or by consulting a specialist for advice. Working in a rural hospital gives you a wide exposure to many different specialties. You need to be able to manage quite a lot more than you would in an urban hospital. Some patients need to be sent to a large hospital but we can do many procedures and do them very well.” 

Fisher enjoys the generalist nature of her work. She finds it more satisfying than caring for a single aspect of her patients’ health. At Hawera Hospital she treats her patients across different specialties. 

“Job satisfaction is very high and I really enjoy the rural population. I guess it’s a generalisation but rural people are very approachable and open. There’s a tangible sense of community and a strong sense of family,” she says.

“I like being able to connect with people and I feel that I’ve been able to do that better in a rural community. I enjoy that aspect of medicine.” 

She knows all the nurses and other staff. It feels like a family where everyone gains strength from each other in a supportive work environment. 

The difference between the rural regions has been a surprising revelation for Fisher. In Dunstan adventure tourism injuries were prevalent whereas in South Taranaki there are more injuries from agriculture.

Central Otago has a different demographic to South Taranaki, which has a larger Māori population and she also feels that depravation is higher in South Taranaki than in Central Otago. 

“I didn’t realise how diverse the rural regions were and how the job differs in different parts of the country. It surprised me to learn parts of New Zealand had different access to specialists and resources.” 

Access to health care around NZ can be variable. Dunstan is a three-hour drive from Dunedin, its closest referral hospital. That distance requires doctors to manage more conditions due to the time it takes for an ambulance or helicopter to arrive.

“Hawera is only an hour’s drive from New Plymouth so we probably manage a few less conditions because we’re closer to referral services and specialists. Our training aims to give us skills in acute care in a rural environment.

“We’re a small team with only two doctors on at one time but that maximises experience. There’s more responsibility due to there being fewer doctors but we receive wonderful support. It’s a very well-balanced system.”

Fisher enjoys working in Hawera and feels she has a better work/life balance than when she lived in the big smoke. She loves the outdoors and her rural training has enabled her to live in parts of NZ she probably would have never otherwise considered. 

“I’m always encouraging people to visit or work in Taranaki. Many have never been here. I’d encourage any doctor to come to a rural region for the job and the lifestyle.

“If you’ve never been exposed to a rural region then you don’t know what you’re missing. I’ve never felt as though I’m stuck in a backwater, I love it. Living here has been awesome and the people are awesome too.”

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