Why the West Coast Needs Rural Generalists
Let’s put this plainly: West Coast South Island needs rural generalists. Their enhanced skill set as GPs affords them a swiss army knife practicality in terms of primary and secondary care, and according to Dr Brendan Marshall, they could just be the answer to health inequities that affect NZ’s rural areas, particularly the West Coast.
Brendan is a Queensland-trained rural generalist who has been practicing in the small town of Greymouth on South Island's West Coast since 2013. He hails from that first wave of doctors to emerge from the Rural Generalist Pathway in Queensland after it was launched in 2007. His experiences in Greymouth have really informed him of the need for NZ rural generalists who possess obstetric and antenatal scopes, and consequently he became the first GP to earn an Advanced Diploma in Obstetrics from an accredited NZ provider.
It’s worth pointing out that rural generalism is more structured and well-recognised in Queensland than in New Zealand. In the NZ context there are competing opinions about what constitutes a rural generalist, and there is more than one way of being formally qualified. Added to that, it’s variously referred to as rural hospital medicine and rural medical generalism. Brendan calls it rural generalism so that’s where we’ll leave it for this piece.
Brendan Marshall is strongly advocating for a more structured and formalised rural generalist workforce with an O&G scope in hospitals and clinics on the West Coast, something he refers to as “the project”.
He kicks things off with this example:
“Currently we have two obstetrics and gynaecology specialist positions, two and a half actually. But both were working a one-in-two roster in O&G, which is pretty onerous. That person left, and now fifty percent of our workforce is gone,” he explains. “That pattern has happened five times in my seven years here, because when you rely on two people and it’s not really that interesting a job for a specialist, like you don’t have a huge gynae load and largely low risk obstetrics, it’s just not sustainable.
“There was a twelve-day stretch where no one was in labour,” he continues, “so no obstetric intervention was required. Your O&G in that period could do a couple of gynae clinics, a couple of antenatal clinics, and that’s the entirety of their work, yet they’re on call for that entire period. For a Rural Generalist, the whole model is predicated on primary care being the core of your work in support of those services, so almost turning that model on its head, saying: our need and the bulk of our work is in primary care as in most rural centres but with extended skills. By using rural generalists you can make sure that the sustainability of the hospital in secondary services is maintained."
“What we’re targeting here is the full breadth of rural medical service delivery”
How will this workforce goal be achieved? With the uncertainty of travel, now and in the near future, Brendan is thinking locally, with something he refers to as a “grow our own” mentality.
“Ward work and acute call should be covered off by rural generalists and we should be training our own cohort to come through,” he says. “We see this as a great opportunity now for people to be trained in a really broad range of skills in the rural hospital medicine setting. So not just ED and the wards, but beyond that as well: obstetric type exposure, anaesthetic type exposure, as well as primary care.
“What we’re targeting here is the full breadth of rural medical service delivery, that’s really what we want to provide—we want to be somewhere that can train its own workforce and provide a pipeline supply. We’ve got bits of that, but by only having a sort of partial workforce at the moment, we’ve just not been able to train as many as we’d like to and should be able to.”
So what would be the main barrier to a more foundational rural generalist workforce for West Coast?
“The key barrier is the lack of frameworks nationally to encourage this and therefore doctors coming through wanting to do this type of medicine. For us this is noticeable in the pre-vocational space. We want more PGY 1 and 2 doctors on the Coast. The body that accredits our pre-vocational training won’t accredit us to deliver more than one rotation in the pre-vocational space—that’s a direct issue,” Brendan believes.
“To get more doctors here, we're targeting the ability to deliver more pre-vocational runs; doctors based in Christchurch who come over to the coast for three to six months, for example. In order to do that we need rural generalists working across the whole of the system, in particular providing some inpatient work. The reason at the moment we can’t do that is it’s international medical graduates filling specialist positions who don’t have vocational scope. By opening that up, all of a sudden our pipeline’s more linked. We’ve got some students coming to the Coast, but we’d love to expand that. Christchurch has 53 interns a year: that’s our natural flood plain, really, that we want to collect from. We want many more of those junior doctors coming over to the Coast, even if it’s for three months.”
Let’s discuss the health inequity issue that affects rural NZ, West Coast South Island in particular.
“It’s clear on the Coast we’ve got health inequities, but when you look at markers of health inequity at a whole-of-system level, it’s been hard to recognise. The Health Research Council in New Zealand are currently commissioning a piece of work looking at the way they classify rural areas, because the way they’ve traditionally done it is poor and doesn’t actually represent what ‘rural’ really is,” Brendan states.
"Somewhere within 45 minutes of Starship hospital in Auckland could be classified as rural whereas Greymouth is considered urban. But West Coast rural health inequity is a real thing: people here travelling to appointments, sometimes choosing not to have care, delays in seeking care, troubles with access, staff turnover... all of those things that feed into care in a rural area being worse—they exist here.
“It’s just that in Australia you can look at the statistics and go ‘rural people: their diagnoses of cancer, they’re such and such times more likely to die.’ You won’t get that sort of data at a national level in New Zealand because of the way rural and urban have been classified. Really making that more visible at a national level is one of the key things. Your Modified Monash and the various schemes that came before that… Australia’s 20-30 years ahead with this stuff.”
How can the specialism of rural generalism help to bridge that gap? Rural Generalism is a relatively new term, so it has spent its first decade getting established as a “real thing”, according to Brendan. Now that it’s more recognised as a specialism, he feels the next steps are to get some academic momentum behind it and find a larger group of people to “provide a voice and a bit of medico-political presence.”
“That’s what I feel on a personal level, and if you look at someone like John Hall who’s head of Ochre now, I met those guys when I was going through med school in the early 2000s and that was part of what encouraged me. You could tell that for want of a better term, they punched above their weight—doctors in little rural towns who really gave a voice to the rural setting in Australia, and I quite like that, that suits my personality. I don’t know if that holds as true in New Zealand at the moment beyond a couple of individual people, but I think that the cohort of rural hospital medicine has to get a real voice that strongly advocates around these issues of equity and access.”
What advice would you give to junior doctors who wish to pursue a rural vocational scope?
“All I can say is I finished med school in 2004 so a decade and a half into my chosen career path I’m still incredibly passionate about it, I think it’s incredibly diverse and an incredibly rewarding area of medicine to work in. In terms of things that give you satisfaction beyond your job, rural medicine provides these because you genuinely, both in your day-to-day clinical practice and in your non-clinical activities, feel palpably like you’re making a difference to systems of patient care,” he emphasises.
“It’s incredibly interesting and an incredibly rewarding area, and with a growing base of people in the area, that academic component behind it is growing, meaning real opportunities to look at the way we can make health systems better. The other thing is it used to be that you’d have to ‘take a hit’ if you wanted to be a rural doctor. Increasingly governments are recognising it and it’s being paid well. I feel that I’ve been well rewarded and that my skills are recognised by the training bodies that I’ve worked through.”
How optimistic are you that this workforce vision will continue to develop?
“The Coast is proportionately such a large rural area and its service should really be up on a rural health type model; we’re getting a bit of momentum here, which is starting to gain some back traction at a national level and some of the DHBs are becoming interested. I think there will be a bit of action in this space in the next decade. The Health and Disability Review does talk about the Coast specifically and some of the conversations we have around a generalist workforce are flagged in that. I do think some of the actions that will happen post-Covid will match it as well.”
Thank you so much for your insights Brendan.
If you're a General Practitioner who loves the combination of clinic and hospital work, you might just have a 'generalist' mindset. Rural Medicine gives you the scope to practice a variety of different disciplines and offer comprehensive care in non-urban settings.
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