Dispelling the myths about rural consultant physician practice: the Victorian Physicians Survey

Rural practice was defined by the postcode of the primary residence and the primary practice and according to the Rural, Remote and Metropolitan Areas (RRMA) classification.5 Five physicians had rural postcodes for registration but lived and worked in metropolitan Victoria.

Questions regarding barriers to rural practice were developed by us using both closed questions (ie, "yes" or "no" responses to the seven domains in Box 4: "Which of the following do you perceive as barriers to staying as or becoming a rural physician") and open questions (requests for a list of procedures they preferred not to perform and for physicians to give any other reasons for not becoming or not remaining a rural physician). Closed questions were asked about access to locums.

Data were entered into an Excel spreadsheet and then imported into the Statistical Package for the Social Sciences (SPSS) for analysis.6 All tests are two-tailed. Discrete variables were compared using the χ2 test and continuous variables using Student's t-test or Mann–Whitney U test. For the logistic regression, we used a forward conditional approach and then repeated it with a direct entry approach (threshold for entry, P = 0.05; for exit, P = 0.10; 20 iterations). No differences were found and direct entry results are shown. Age was divided into tertiles for the logistic regression.

Responses were obtained from all 52 rural physicians and 634 of 929 (68.2%) metropolitan physicians. Of the 295 non-responding metropolitan physicians, 40 refused, 98 could not be contacted and 157 were contacted but did not respond. Box 1 shows the practice locations of the rural physicians.

Box 2 shows the characteristics of respondents.

• Age/sex: Metropolitan and rural physicians were of a similar mean age (mean [SD], 46 [9] years), but had different age distributions (age ranges: metropolitan, 30–69 years; rural, 34–66 years). Their median (range) year of qualification was 1978 (1954–1999). There were no female consultant physicians working in rural Victoria.

• Hours worked: Rural consultant physicians worked more hours overall (particularly in private practice), but less in research and were more likely to have an intern. While the proportion of rural and metropolitan physicians with a resident was similar, rural hospitals rarely had access to advanced trainees.

• Place of birth: Rural physicians were more likely to be born in a rural area. Although only 17 (3.4%) metropolitan-born physicians worked in rural areas, they contributed 32.7% of the rural physician workforce.

• Practice support: A range of practices in rural areas were supported (ie, there were subspecialists working there), although most rural physicians were general physicians. Metropolitan physicians provided visiting services to rural Victoria for a total of 226.5 hours per week.

• Locums: There was no difference in the proportion of physicians obtaining a locum when needed, but rural physicians were more likely to seek a locum and more likely to cancel and change plans as a result of difficulties finding a locum.

The major obstacles to rural practice for both metropolitan and rural physicians were social (spouse's occupation [65.7%], children's schooling [72.2%] and other issues related to children [66.7%]). A substantial proportion were concerned about problems getting back to metropolitan practice (45.7%). Unfamiliar procedures (eg, ventilators, pacing wires, endoscopy, intensive care, coronary care and emergency management) were a concern for many (25.2%), as well as housing and depreciation in the value of housing (21.6% and 21.8%, respectively). Other barriers reported included loss of wider family support, ageing parents, access to religious and cultural venues, access to subspecialty facilities, academic isolation and lack of facilities, and long after-hours cover. The frequencies of the barriers were similar within each of the major specialties.

Box 4 shows the relationship using logistic regression between each of the key physician characteristics and the seven major barriers to rural practice for the metropolitan physicians.

• Clear sex differences were found: female physicians were more concerned about spouse occupation and less concerned about getting back to metropolitan practice and housing depreciation than male physicians.

• Physicians born in rural areas were less concerned about schools.

• Physicians aged ≤ 40 years were more concerned about returning to metropolitan practice, those aged 41–50 years were more concerned about schooling, and those aged ≥ 51 years were more concerned about unfamiliarity with procedures.

• Physicians not born in Australia were more concerned about returning to metropolitan practice.

Several respondents emphasised the contribution made by services visiting from the city, but we have shown clearly that this is relatively trivial. Furthermore, such services do not contribute to after-hours cover (commented upon by some respondents as a barrier to becoming a rural physician). Indeed, another study has shown that between 13.3% and 49.1% of rural patients (depending on remoteness of their residential area) travel to metropolitan areas for physician consultations,5 reflecting the limited capacity of both resident and visiting consultant physician services in many parts of rural Australia. There were no reported concerns regarding competition with visiting metropolitan physicians, although difficulties can occur in accessing health records during acute episodes in patients cared for by city-based services.

Rural consultant physicians were more likely to have interns. Access to resident staff was similar in rural and metropolitan areas, but until recently residents in rural areas were almost invariably basic trainees. The importance of placing advanced trainees in rural practice has been demonstrated previously — lack of exposure to rural practice during advanced training was associated with all physicians who were undecided about their preferred place of practice ending up in metropolitan practice, as did several of those intending to become rural practitioners.7

The ethics of attracting overseas-trained physicians to rural positions is debatable,8,9 but our data suggest that there may be additional risks. Non-Australian-born graduates expressed significant concern about not being able to get back to metropolitan practice, which might mean a greater likelihood of overseas-trained physicians moving to the city from rural areas once this is possible.

Physicians born in rural areas and now practising in the city are less likely to view schooling as a barrier to rural practice. This suggests that those born in metropolitan areas have an exaggerated negative view of schools in provincial centres. While those in rural and remote settings are less likely to go to university,10 many of the schools in towns able to support consultant physician practice perform well educationally. The negative metropolitan view of rural schools parallels the negative view of rural health services and practice, which appears to be instilled at a young age. In a recent study among first-year medical students, those born in metropolitan areas were less likely than rural-born students to view rural practice positively.11 A key feature was a difference in the source of metropolitan and rural students' information — the media and personal exposure, respectively. This suggests that proactive approaches to media reporting, and rebutting unbalanced reporting, may be needed, along with, of course, genuine attempts to deal with the cause of any negative stories (eg, schools with difficulties in retaining or attracting suitably qualified teachers).

The major importance of education and other family issues in choice of practice location is similar to that found among general practitioners.2 Clearly, female participation is a major issue for the whole medical profession,12 but the absence of any female consultant physician in rural Victoria is a measure of the extent of the need for urgent action in rural practice. Family and professional issues have been identified as an issue for younger male physicians,13,14 and without intervention the ability to maintain the rural consultant physician workforce is likely to become increasingly difficult.

This was a common theme, and, for some, a reason for departure from rural practice. Coping with bureaucracy has also been found to be a reason for leaving rural practice among general practitioners.15 It is unclear whether such conflicts were in response to the greater difficulties experienced in rural hospitals during the economic limitations imposed in Victoria in the 1990s.16 An alternative explanation is that the impacts of conflicts are amplified in rural areas, where people have multiple roles and "strong ties", and where mutual avoidance can be difficult.17 In such a setting, conflicts have more severe and wide-ranging implications.

While performing procedures is attractive to many rural GPs,15 we found that this may be a barrier to practice as a rural consultant physician, particularly among older physicians. This finding is significant in that there appear to be older physicians whose children are grown up (and perhaps have left home) who may be willing to move to rural practice if the problem of unfamiliar procedures can be overcome. Increasing the number of advanced trainees should help, as well as courses which upskill (or reskill) older consultant physicians.

Through its Rural Workforce and Training Program, the RACP already undertakes a number of initiatives in support of Fellows and trainees in regional and rural Australia. Funding assistance has been received from the Commonwealth Department of Health and Ageing and various State government health departments to implement some of these activities (Box 5).