Rural medicine in Victoria

Rural Medicine was finally recognised, after much opposition, as a medical Specialty in 2006 after lobbying by RDAA, ACRRM, National Rural Health Alliance and crucially the Queensland Government. It has been allied to a world-wide theme of recognising Medical Generalism as an accepted quality medical discipline. The ACRRM fellowship is now recognised, along with the FRACGP, though not the FARGP, as a specialist qualification.


Victoria is a small State but has a considerable population living away from the metropolitan conglomerate at some hours remove from specialist and main ancillary services. Specialists are disinclined to live in rural areas. Ancillary medical services struggle to find recruits.


Whilst rural, in addition to the full range of disease, has higher rates of injury and mental illness, the ageing population is as everywhere developing an increasing mass of complex illness requiring local management. Good medical care is crucial to the viability of rural small business and farming.


The Commonwealth is responsible for community medical practice. The State carries the hospital budget. There is now joint carriage of responsibility through the national Council of Health Ministers. Rural Hospitals in Victoria, unlike other States, are independent crown entities for whom the State can only make certain rules. The State and Commonwealth both, often independently, fund community ancillary services. Rural Casualty is a grey area not fully accepted by either. The division of responsibility has led the two jurisdictions to focus on their own areas to the detriment of the whole. The function of rural hospitals as a group has hugely attenuated and the State is belatedly trying to remedy this.


Rural Doctors are also responsible for 50% of all GP registrar and 25% of all medical undergraduate training in Australia, and the training infrastructure that supports this training. These processes are being progressively compromised by Government policy, which is actively supporting introduction of non-training, non-VMO, and non-Fellow practices into rural. This is a worrying trend, because the relatively poor return to rural of such trained doctors is testing the good-will of rural doctors.


Community Medicine


Victorian Rural GPs conduct primary and secondary care and are challenged when they do not have hospitals or at least limited hospital facilities. Rural Practices are often de facto casualty departments, carrying an extensive range of emergency equipment. Rural doctors aim to manage illness within the community, whether in hospital or otherwise. A high degree of skill is needed to know the range of possibilities in any given condition and to manage it accordingly without unnecessary referral.


Starting with registrar training, such skills steadily increase the longer the doctor stays on in rural. On-site mentoring of all doctors in training is essential and RDAV strongly disagrees with now widespread distance supervision policies, except for very small locations unable to recruit trained rural generalists.


Studies have confirmed that rural GP consultations are more complex and that rural practice is more expensive to run. The Federal Government has in the past instituted a number of initiatives and programs to support rural practice to overcome these problems. RDAV and RDAA maintain strong opposition to policies that undermine rural practice where tertiary facilities are not locally available.


Victorian Rural Emergency Medicine


Except for a few larger ones, Victorian rural hospitals do not have the volume of work to sustain full time Hospital Medical Officers and are reliant on GP VMOs. Distance, lack of ambulance stations and MICA officers mean that rural doctors are often essential to save life and limb. Very few Victorian Rural Hospitals have funded casualty or emergency departments and most rely on Medicare to pay the GP, apart from State funded on-call.


Rural doctors have to attain a high level of expertise in a wide variety of specialities enabling an effective response in a wide variety of situations, including minor orthopaedics. They teach on the emergency courses and undertake major hospital emergency work. There has been substantial attrition of trained rural GPs in Victoria and the process to replace them has commenced formally only in 2012. Safe working hours are essential together with full hospital support and proper remuneration. It is the Hospital’s responsibility to ensure a safe working environment for its VMOs.


The RDAV regrets and opposes the removal of XRay facilities from many small locations. Limb, chest and skull XRays have always been within the competence of Rural Doctors, who have access to appropriate training and accreditation. Without them there is much unnecessary travel for rural residents to get diagnosis of often simple to treat conditions.


Retrieval


First (‘golden’) hour response is critical in saving lives and is superior to uncritical ‘scoop and run’ transfer without proper stabilisation and resuscitation, so often practiced without utilising superior local resources. Trained rural generalists, in active emergency and anaesthetic practice especially, have superior skills to exercise in emergency and retrieval situations. There are few MICA ambulance officers in rural locations.


Weather very often prevents the use of air transport through cloud, wind and ice, leaving rural doctors to provide intensive care for prolonged periods. Helicopters unfortunately crash sometimes. Especially in Alpine areas the State needs to ensure an effective complement of rural doctors. Effective best response means flexible combination of medical and ambulance resources.


Procedural medicine


About 40 Victorian rural hospitals still provide theatre, obstetrics, and advanced casualty resuscitation skills. This needs capable GP VMO anaesthetists, obstetricians and generalists with emergency skills. It relies on hospital policy that encourages visiting surgeons to use GP anaesthetists to maintain their skills for when they are needed for obstetric and general emergencies. Funded training is available to interested registrars and GPs in practice.


Anaesthetics


About 120 General Practitioner Anaesthetists (GPAs) are available to rural GP hospitals. They provide 24 hour, 7 day a week anaesthetic and emergency cover, operate several lists a week, and work as general practitioners. They have one year’s large hospital training and are accredited by the Joint consultative committee for anaesthesia. There are now 12 or so graduating every year.


The Australian Society of Anaesthetists (ASA) supports the RDAV and GPAs and recognizes the essential service they provide to rural communities. GPAs have their own webpage on the ASA site on www.asa.org.au go to "News and Issues". GPAs having problems of any sort can get assistance.


Obstetrics


The loss of so many obstetric units has been distressing. Fortunately a number of smaller hospitals still have active units. Despite whatever may be said to the contrary, small units that have access to on-site Caesarean section remain very safe to have a baby in, especially when balanced against the perils of travelling in labour. Obstetrics has to deal with unexpected situations. The RDAV does not support stand-alone midwifery units without available obstetrician back-up. Death of a baby is devastating not only to the mother but to the midwife. Likewise, because of risk, the RDAV is opposed to independent home-birthing, and views with alarm instances of out of town breech and twin deliveries.


Traveling in labour is hazardous and needs to be minimised. ½ hr traveling time is optimum but no longer achievable because of unit closure. 1 hour travel distance should be feasible for the State to keep the currently many babies 'born before arrival - BBA' to a minimum.


Repeated studies have shown rural obstetrics to be safe no matter how small the unit. 8-12 rural GP obstetricians are now graduating in the State every year, training for 1 year in large hospitals. The Diploma of Obstetrics is a qualification aimed at antenatal care only. Rural Obstetricians currently obtain an advanced diploma, which includes training in instrumental delivery, Caesarean section and some Gynaecological surgery. The Joint consultative Committee (ACRRM, RACGP and RANZCOG) operates a system of certification.


Surgery


Most rural generalists have, or are otherwise encouraged, to acquire skills in minor general, skin and orthopaedic surgery. Prior experience in tertiary hospitals is of great help. 1 year GP advanced surgical training positions are available for interested candidates.


Mental Health


GPs, especially in rural, are responsible for the majority part of community mental health care, and become skilled in the treatment of acute crises and long term mental health conditions. They take full responsibility for medical aspects of care, where possible, unfortunately not always, with the support and assistance of visiting psychiatrists. Community Mental Health Services case manage difficult and complex cases and discharge them to GPs once they are stable.