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Rural Medical Training Pipeline (vertical integration) issues - National, State and Territories round up and Panel Discussion
David Meredyth, Richard Murray, Judi Walker, David Garne, David Campbell, Ruth Stewart, Geoff Riley, Georgia Von Guttner
 
David Meredyth
  • The Federal government is genuinely interested in the concept of vertical integration and the timing is right to progress. The government requires proposals for practical implementation rather than further discussion about the concept.
  • The Department has made significant investment in research on vertical integration. The RACGP has undertaken an extensive consultation process across states, and released a comprehensive report with rural training hubs a key theme. ACRRM has undertaken a similar project.
  • Training for GPs and Specialists have competing needs in the training space.
  • The debate around rural generalism and rural training pathways is similar but not the same.
  • The Department is open to thinking about what might work best in this tight fiscal environment. The Ministers are interested and engaged but the Commonwealth is not in a position to fund new positions in rural areas.
Richard Murray, ACRRM
  • ACRRM has prepared a position paper on the implementation of a national rural generalist pathway.
  • The paper applies a population health approach, focussing on rural doctors providing primary care, secondary care in hospitals and being able to respond to emergencies.
  • The paper includes a literature review and outlines key parts of the pipeline, how training occurs, factors around selection, information for graduates on surviving the junior doctor years, identifying purpose and sense of direction.
  • The paper is currently being circulated for consultation.
Action: Make the ACRRM report available on the FRAME website.
 
Discussion
  • It was agreed that the Specialist colleges need to be part of the vertical integration discussion.
  • The Department has not funded Specialist colleges to look at rural training pathways, however the College of Physicians has received funding for some dual training positions.
  • Accreditation systems are starting to broaden. In recent times there have been applications for more accredited training posts than the Department could fund.
  • Surgeons in the Western district of Victoria have reversed the polarity with regionally based positions rotating to metropolitan hospitals. Physicians in Hamilton and Warrnambool are doing the same.
  • The FITCH project report, funded through GPET, has been submitted but has not yet been released.
Geoff Riley, WA
  • Western Australia remains metro centric with training revolving around the Royal Perth Hospital.
  • Between 2007 – 2014 not a lot has happened to further vertical integration.
  • A Committee of representative agencies has been formed and there has been some investment by the state government.
  • New training posts have been established but there is no real rural generalist pathway.
  • Kris Batty, from Rural Health West has been engaged to further the project.
David Garne – NSW
  • A proposal has been driven by graduates wanting to undertake internships & vocational training in rural settings but the places aren’t available.
  • The proposal builds on existing infrastructure in 10 hubs – 1 regional and 9 rural and investment in human capital.
  • The proposal has been submitted to the Federal government for funding for 3 key academics in the hubs – a general surgeon, general physician and general practitioner to facilitate training of graduates from any medical schools wishing to train in a rural setting.
  • The Clinical Academics would also contribute clinical service to the areas and provide supervision to increase capacity.
  • The proposal is contingent on funding..
  • NSW is working in collaboration with other health services, Colleges, Medicare Locals, ICTN, to encourage further training opportunities.
  • The proposal is strengthening medical education linkages, academic links, research links and program evaluation is an important component. It is also tailored to the various hubs’ unique flavour and needs.
Richard Murray & Ruth Stewart, JCU, North Qld (See Appendix 5.1 in Documents)
  • The Northern Clinical Training Network connects regional sites, providing critical mass and linkages in areas of common interest.
  • The network provides integrated medical training towards a specialty career in the tropics.
  • Clinical Deans provide leadership across the links.
  • Students are selected on rural merit and aligned with a rural scholarship.
  • There are close links with undergraduate training, rural generalist training and GP Training.
Georgia Von Guttner, Murray to Mountain program, Victoria
  • Monash & Melbourne universities’ Extended Rural Cohort undertake longitudinal clerkships for 1 year with GP Medical Educators provide training in small regional hospitals.
  • The Murray to Mountains program was established in 2012 and is funded by the State government as part of the Victorian Rural Generalist Program and through PGPPP funding through Bogong Regional Training Network.
  • In 2012 5 interns participated in the M2M program and 4 have stayed in the region.
  • In 2013 10 interns participated in the program and recruitment for 2014 is underway.
  • There has been a great deal of interest in the program from RCS students.
  • Selection is focussed on rurality and commitment to rural practice.
  • The outcomes have been positive with regional hospitals having joint stands at intern recruitment and joint selection panels.
David Campbell, GRIT Gippsland Regional Intern Training Program
  • 10 intern places are funded for a full year in Gippsland.
  • The majority of GRIT places are filled by graduates from Rural Clinical Schools.
Victorian Rural Generalist Programhas been in place for 3 year.
  • 10 rural generalist training places.
  • In Gippsland the model focusses on obstetrics training via the Advanced DRANZCOG with basic anaesthetics, paediatrics and psychiatry.
  • Regional trainees spend time in metropolitan hospitals to top up learning, eg: Northern Hospital for caesarians.
  • Funding has now been received from the Victorian Department of Health to establish a community base intern model. $130,000 per intern. A total of 20 places across Victoria.
  • East Gippsland Community Based Intern Model: 5 intern places for Sale and Bairnsdale to undertake core rotations in medicine, surgery, emergency medicine and 20 week community based placement.
  • The model will be in place for January 2015 subject to accreditation.
Judi Walker, Victorian Regional Medical Training Network (See Appendix 5.2 in Documents)
  • The proposal is unique in that all 3 Victorian medical schools are working together.
  • Promoted as a solution to the maldistribution of medical practitioners.
  • Leverages off investments in RCTS program, PGPPP, GP Training Program and Specialist Training Program.
  • The proposal aims to bring together the different training programs and take advantage of the increasing numbers of rural medical graduates who want to stay rural.
Lucie Walters, South Australia
  • Mt Gambier has a hospital training program for junior doctors - 6 interns are funded for PGY2 and trained in paediatrics, anaesthetics, emergency medicine and obstetrics.
  • The pipeline is producing an oversupply of rural generalists in the region. There are not enough registrar positions so graduates are migrating to western Victorian and the rest of SA.
  • Mt Gambier is unique in that it has a large resident specialist population.
  • A community based internship program in the Riverland was developed 5 years ago, but was unsuccessful in achieving accreditation. There is currently a hybrid rural hospital / community based 20 week GP placement under consideration. 5 interns based for a full year in the Riverland.
  • The 2 universities, 2 rural training programs in SA and Southern GP Training are interest in progressing 2 proposals in SA for accreditation.
 Discussion
  • Region size needs to be determined by community need and critical mass.
  • The challenge is the shift from working only with rural GPs to working with Specialists.
  • Hub and spoke models preserve the uniqueness of regions but gains critical mass.
  • It is important not to cross referral boundaries.
  • As educational models take shape with pathways, there will be an impact on referral patterns.
  • It is a strength that vertically integrated programs rely on the same educators, but there is also potential risk of burn out of clinical teachers across the spectrum (depends on the model of teaching).
  • We need to move away from the assumption that all medical education occurs in office based practice. This is problematic with fee for service.
  • University of Adelaide final year students have an elective option of working in the “medicine learning and teaching unit” at the University of Adelaide. This involves teaching junior students, helping write exams, etc. and produces graduates with an understanding of the program, life long educators, registrars keen to be involved in junior doctor & medical student training.
  • Don’t expect more from existing people, add capacity to the region through academic leadership.
  • Shared educational infrastructure – Clinical Deans provide educational input – positive way to go.
  • Education reinvigorates a site and the community. Studies have proven that rural doctors are refreshed by having medical students and registrars in the town.
  • Rural Clinical Schools have a key role to play in brokering partnerships for training pathways.
Action: Provide David Meredyth with a summary of the discussion around vertical integration.