Dusty stethoscopes: Why the bush is best for rookie medicos
In 2010, Dubbo Base Hospital had eleven applicants for the five available permanent internship positions. This was not only a record number and thus an amazing achievement; it was also a watershed moment for Dubbo Base, prompting me to write an article claiming we were witnessing a ‘Renaissance in Rural Health’. This claim was based on the growing trend for young doctors to apply for internship positions in rural areas, instead of (and in preference to) going though the normal metropolitan allocation process.
This year Dubbo Base Hospital has attracted seventeen applicants and will, once again, be welcoming five permanent interns to the hospital next year. The hospital has gone to great lengths over the last few years (with considerable community support) to build its reputation amongst final year medical students, and as a result Dubbo’s popularity continues to climb sharply. But does all this truly herald the beginnings of the renaissance, or have we just had a few good years before things return to normal over the next few recruitment cycles? Given that Base Hospitals all over New South Wales have been experiencing record numbers of applicants too, it appears the former is most likely.
So what’s going on? Whence comes the influx that Dubbo Base, and for that matter all Base Hospitals in New South Wales, must happily contend with? A large portion of the accolades belongs to the Schools of Rural Health dotted around the countryside, of which The University of Sydney’s Orange and Dubbo campuses are just two. These establishments have been at the vanguard of the campaign to bring doctors back to the bush, and while providing the opportunity for country-born medical students to study closer to home, they have also contributed to a ‘net gain’ of doctors for rural areas by attracting city-born and raised to country areas. The Schools of Rural Health have been very effective at promoting the idea that much of what makes Australian medicine unique can be found in the country.
Unfortunately, for a small number of people, skepticism that ‘rural is better’ continues to prevail. The sheer magnitude of the rural doctor shortage seems to imply there is something remiss in rural medicine, and this may be why many doctors have shunned the country for decades. For others, it’s the perceived lack of training opportunities available that turns them off; Base Hospitals seldom being centres of excellence, with most of the ‘top dogs’ preferring to patrol tertiary kennels in the city. And yet it is probably the seductiveness of the status quo that is the biggest reason why skepticism remains; safe in predictability, secure in mundanity, Sydney is the keep to the country wastelands. It was once fearsome to venture beyond the confines of the colony, and evidently much of that fear lingers still.
To get an idea of why so many junior doctors are taking the plunge and heading west, imagine the total sum of medical knowledge represented by a vast pyramid of Egyptian design. At the very top is the pinnacle of medical knowledge; the very latest, most advanced, most sophisticated, and most complicated. This is the domain of medicine where great heroes and great television coexist. This is the domain of the prohibitively expensive and the vanishingly rare.
Descend down the pyramid and you will encounter the less advanced and the less complicated; a place where heroes are replaced by mere doctors. Here, at the lower altitudes, the rare gives way to the common. Triumphs occur on a daily basis, yet the increased frequency of such triumphs mean they fail to inspire the same level of awe as those higher up the pyramid, and are sometimes taken for granted.
The pattern continues until the base of the great pyramid is reached. Here, at the bottom, are the foundations upon which everything else stands. Broad is the coverage, fundamental is the content, and every-day is the context. Here is the foundation of modern medicine, and here dwell the junior doctors, learning their craft while building upon the principles gleaned during medical school.
Rural Base Hospitals represent the best location for junior doctors to commence their career because most of the medicine they encounter is at this foundational level. Every day the opportunity to gain further experience in the general principles that underpin the pyramid of knowledge presents itself; consequently, savvy doctors are starting to see rural medicine as an opportunity to boost their careers to more lofty heights. In addition, even though the core business of Base Hospitals remains general medicine, an immense variety of interesting pathology still comes through the emergency department every day; and quite a bit of it is unique to rural medicine.
Contrast this with the experience available to an intern in a large metropolitan hospital, where, out of the five ten-week blocks that make up the internship year, the majority of those blocks must be completed in one of the so-called ‘super-specialties’. cardiothoracic surgery, liver transplant, medical oncology; these are certainly fascinating and exciting areas of medicine, representing the very pinnacle of the medical pyramid in Australia, but they can hardly be considered foundation knowledge of the sort many junior doctors are now seeking.
To be fair, for some individuals the opportunity to spend ten weeks on a ward devoted to a particularly appealing super-specialty is worth enduring the remaining forty weeks in a large metropolitan hospital. Such an opportunity would be hard to pass-over for the young doctor with a clear and definite desire for a career in that particular area of medicine. Yet considering that most interns are still to develop a firm idea of what they would like to do in the future, those ten weeks (and for that matter, the whole year) would probably be better spent consolidating ‘bottom of the pyramid’ knowledge, rather than trying to learn medicine in a top-down approach.
It is therefore the lack of super-specialisation that makes rural hospitals so special, and given that the majority of medical graduates are inevitably destined for a career in general practice, super-specialties of the type already mentioned will remain an interesting yet questionably relevant curiosity for the junior doctor.
Other benefits aside from more ‘stage-appropriate’ training are prompting young doctors to venture west of the Great Divide. The size of Base hospitals, in that they tend to be much smaller than the large metropolitan centers, is actually one of the most appealing aspects because it creates a more pleasant place to work. A grisly, miserly, nasty attitude won’t get you far in a place small enough for everyone to be on a first-name basis. Too small for arrogance to remain unchecked, and too small for petulance to remain tolerated; Base Hospitals everywhere enjoy the kind of environment the Sydney Swans ‘no dickheads’ policy strives to create.
Friendships evolve in a network that extends horizontally and vertically. In a Base hospital a junior doctor is just as likely to form a friendship with a peer as with anyone else, be they auxiliary staff, allied health, administration or a senior clinician. There are no barriers and plenty of potential, thus profound opportunities exist through the relationships that develop. And there is nothing better than a letter of recommendation written by a senior doctor who, along with being a supervisor, has been a close friend as well; someone who took a direct hand in your training and experience.
And finally, there is the country lifestyle to consider. Much can be said about living where the air is clean, where the night sky is full of stars, and where doctors are valued as much for their rarity as for their skill. And with an average daily commute of less than ten minutes, compared to an average close to one hour in Sydney; time continues to accrue on a daily basis. This means ample time to exercise, relax, read a book, take up a hobby; or even write a series of articles for the local newspaper. In a country town, because there is time to explore, life expands outwardly.
It’s hard to fathom how the secrets were lost for so long, or why the number of doctors in the country continued to dwindle for so many years. Plato’s cave allegory provides a measure of insight into how this came to pass, and a reason why it has taken so long for the renaissance to begin. For most people, the benefits of a country practice may have seemed exaggerated, the costs under-played, or the promises fantastical; and thus the gamble was too much. But for the few, and the few is steadily growing into many, the courage to take the plunge has returned so much more than what was promised, and now junior doctors are starting to see that there is no better way to launch a career in medicine, than to start their career in rural medicine.
Opinion by Daniel Stewart (MBBS 2011)
First appeared in the Dubbo Weekender