RACS Fellows are working with regulatory bodies and other medical colleges on improving rural surgeon training and retention to create a more accessible and equitable system.

The surgeons were among 60 delegates at the National Rural Surgeon Training and Retention Workshop in Melbourne earlier in the year.

The workshop was a milestone in the implementation of the RACS Rural Health Equity Strategic Action Plan and aimed to identify solutions to rural surgical workforce shortages.

Professor Brendan Murphy chaired the workshop, which was also attended by RACS President Associate Professor Kerin Fielding and National Rural Health Commissioner Adjunct Professor Ruth Stewart.  

The need to break down barriers in training and retaining rural surgeons and other specialists was urgent, according to Professor Murphy.

“The idea was that we have to do something fairly dramatic and fairly quickly to improve the number of Australian-trained surgeons working in non-metropolitan areas,” he said.

“We're seeing governments increasingly frustrated by the slow progress in getting non-GP specialists such as surgeons into non-metropolitan areas. As a result, governments are increasingly looking to fill these gaps with overseas trained specialists." 

The Rural Health Equity Strategic Plan 2020 reported that 29 per cent of Australians and 25 per cent of Aotearoa New Zealanders lived in rural and remote locations, but only 12 per cent of RACS Fellows live and work rurally in Australia. For five of the nine surgical specialties, less than five per cent of surgeons were based outside cities.

Professor Murphy said medical colleges could play an important role in ensuring training opportunities were available in regional and rural areas.

Recommendations emerging from the workshop included removing barriers to training accreditation in rural areas, providing greater administration support and updating Trainee selection processes.

“The single biggest thing we can do to get surgeons or other non-GP specialists to want to work and stay in rural areas is to provide training positions outside the big cities,” Professor Murphy said.

“Most surgeons are attracted to train in the large metropolitan teaching hospitals as that’s where most of the training positions are. They then get locked into the Melbourne/Sydney axis that is currently oversupplied in some specialties.”

Professor Murphy said RACS training committees could implement changes to accreditation to ensure training opportunities were available outside cities.

“We have to look at how we accredit training positions—the specialist training committees have accreditation standards, which are based on a very careful consideration of what those committees think is the ideal training environment for Trainees.

“These standards include having a significant number of supervising surgeons who have the right level of experience, the case mix, and a range of other factors.

“The problem with that is, while these criteria have been set up with the best intentions to get an ideal training experience, it's very, very difficult for many rural sites to meet those accreditation standards.”

The standards usually fail to identify the unique benefits of training in rural settings, including the diverse caseload and enhanced assisting/first surgeon opportunities available outside metropolitan centres.

“We need to look at accreditation in a different, more holistic, way that considers the overall quality of the training experience and is more flexible with the criteria that the specialist training committees have established,” Professor Murphy said.

“That’s not to say that anyone supports reducing the quality of training, but to acknowledge that the training experience in the bush is different.”

Another barrier to training opportunities in rural areas is the administrative load that accompanies accreditation. This is often impossible to undertake in small rural hospitals and could be addressed through the introduction of a RACS training unit to support rural training centres.

The third step to increase surgeon numbers in rural areas is the recruitment of Trainees who are more likely to choose to work outside cities.

“There's a lot of good evidence now that people who are more likely to stay and work in the bush in the long term are those who have come from a rural origin,” Professor Murphy said.

“So, there is a need for some sort of affirmative action bias in Trainee selection. At the moment selection and advanced training is very competitive, and it's mostly based on academic results. But if you've got someone who has done their medical student undergraduate training in a rural clinical school, done their residencies in a rural hospital and is a very solid, good doctor, who we can get into an orthopedic or urology training program, for example, the chances are that they will stay in the bush. There needs to be a way of preferentially selecting people who are likely to stay and work in the regions.”

As a rural orthopaedic surgeon in Wagga Wagga, RACS president Kerin Fielding is aware of the training and professional benefits available outside metropolitan centres.

In her own career, Associate Professor Fielding decided to move to Wagga Wagga from Sydney after several training stints in the country town.

She valued the training and support she received in a rural hospital and enjoyed the diversity of medical experience available.

“As I was the first woman in orthopedics in New South Wales and the second in Australia, the country was a really safe place for me. I was very supported, allowed to do a lot of surgery and I was supervised really well.”

She says a significant factor preventing Trainees from settling in rural areas was the need to move locations as part of their training. Plans for a rural training pathway to address this issue are underway.

“By 2026 we want to have a rural training pathway so Trainees can do about 70 per cent of their training in rural areas,” Associate Professor Fielding said.

“The idea would be to attach training to regional training hubs, which are already set up with universities, and then having those Trainees identified in medical school and providing support throughout the continuum of training.

“For example, in Wagga we have four advanced Trainees, so potentially they could do four years of their training in Wagga, but at the moment they're only allowed to do one, which is quite ridiculous.”

Associate Professor Fielding said it was crucial for medical colleges like RACS to work closely with governments at all levels to address workforce shortages and share data.

She said the recent workshop had provided an opportunity to collaborate in creating a more accessible and equitable health system.

“We have to solve this problem—we're 30 per cent of the country and we get ignored because people have a metro-centric view of the system.

“We know we need to supply qualified people to our communities in this country and Aotearoa New Zealand.

“When you look at some of the health outcomes of our Indigenous people, which are some of the worst health outcomes in the world, we should be ashamed of what we've done.

“It's serious and it’s not negotiable; it's now part of our accreditation with Australian Medical Council. The government's holding us to account, and we know what we need to do,” she said.