Australia's doctor training a fix for NZ's rural health woes
In a landscape marked by toil and coloured in dusky hues, Margaret Brown shines like a pink beacon.
Standing on the footpath outside Lameroo's only cafe, Brown, wrapped in a vibrant pink jacket, offers a generous hello to two strangers ambling up the town's quiet main street.
"People will be wondering what Brownie's up to, chatting away to two Kiwis," she says with a hint of a smile.
"When your town only has 500 people, everyone knows what you're up to."
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Brown walks with a slight limp, the after-effects of polio.
It's more of an annoyance than a hinderance to the rural stalwart who moves with a casual purpose.
Each year the town of Lameroo in South Australia hosts medical students from Flinders University. CHRISTEL YARDLEY/FAIRFAX NZ
A few months earlier, Lameroo hosted its annual country music festival, a popular fixture which attracts music lovers from around Australia to the small town 210km east of Adelaide.
For three days each year, caravans and campervans fill campgrounds near the town to capacity.
Music aside, the festival also serves to celebrate the enduring spirit of rural folk and their capacity to grow and prosper in the face of adversity.
Like much of rural Australia, Lameroo has faced its share of trials.
The decline of traditional industries, the migration of young people to bigger cities, and the loss of basic services has tested locals' resolve in recent decades.
But despite the challenges, Lameroo retains a sense of optimism thanks, in no small way, to its former GP, Paul Worley.
"People here adore Paul," says Brown, who gives her age as somewhere past 70.
"Some still hold out hope he'll come back."
Flinders University Professor Paul Worley, dean of the School of Medicine, says its rural curriculum has strong community buy-in. CHRISTEL YARDLEY/FAIRFAX NZ
Today, Worley works part-time as a GP in Yankalilla, a job he balances with his other role as professor and dean of medicine at Flinders University in South Australia.
In 1997, Worley pioneered the idea of offering med students a longitudinal placement in a rural or regional community as part of their training.
The move was greeted with scepticism from other universities who argued students' clinical training would be compromised.
Twenty years' later and research has vindicated Worley, with assessors of junior doctors consistently rating Flinders rural graduates as among the best.
Flinders' focus on working with rural communities to address their healthcare needs has captured the attention of educators around the world - including Waikato.
In October, two major Waikato institutions - the university and district health board - presented a proposal to the Government to create the country's third medical school.
The Waikato bid draws inspiration from the Flinders model with its proposal to put graduate-entry students through four years of training, including one year based in a community setting.
In 1997 Flinders University started offering med students the chance to complete a year-long placement in a rural or regional community. CHRISTEL YARDLEY/FAIRFAX NZ
The Waikato school's aim is to address the healthcare needs of disadvantaged, rural and provincial communities as well as address the shortage of specialists in provincial areas.
Its backers say the time for a radical overhaul of medical training in New Zealand is overdue, pointing to the chronic shortage of GPs in rural communities and the country's heavy reliance on overseas trained doctors.
Each year, New Zealand imports 1100 doctors to fill the gaps in its health workforce. Many end up working in rural and provincial communities but don't stay in the country long-term.
Compounding the problem is the fact 40 per cent of current GPs (1850 doctors) are expected to retire by 2025.
Auckland and Otago med schools' response to the Waikato bid has been to propose a new National School of Rural Health.
Since the inception of Flinders' rural placements programme - dubbed the Parallel Rural Community Curriculum (PRCC) - more than 30 per cent of Flinders' medical graduates have returned to work in rural areas.
More than 80 per cent of rural graduates choose to become GPs.
The proposed Waikato med school aims to have at least 50 per cent of its graduates working in community general practice.
Worley says three factors have to be addressed if New Zealand is to fix its rural health workforce crisis: it must select med students with a rural origin, provide them with a rural curriculum, and ensure they have the right post-graduate support.
Two decades on since Flinders pioneered its PRCC programme, the impact on rural communities and on the medical profession in Australia has been considerable.
"What we've done is we've raised the status of rural medicine to be the equal of any of the disciplines in medicine," Worley says.
"When I started this, rural medicine was seen as inferior and second-rate. What we've proven is it's anything but second-rate. To be a rural doctor you need to have certain expertise that's just as valid as that of a highly-focused specialist."
The pride breathed back into the profession is also reflected in many rural South Australian towns.
Brown calls it a sureness.
Worley calls it hope.
"What we've done is give rural and regional communities confidence in the medical education system, that the system is serving their needs.
"That brings a hope to communities that otherwise have every reason to have despair."
Before becoming dean of medicine, Worley was director of Flinders' Rural Clinical School, a position now held by Professor Jennene Greenhill.
Greenhill has been based in the South Australian town of Renmark for 14 years and has witnessed first-hand the difference Flinders' focus on rural medicine has made to the town.
Flinders University Professor Jennene Greenhill has been director of Flinders' Rural Clinical School for the past 10 years. CHRISTEL YARDLEY/FAIRFAX NZ
Like a lot of rural South Australian communities, Renmark has its issues - homelessness, a high teen pregnancy rate, poverty, and drug and alcohol abuse.
But the community of 10,000 residents also a stable core of 10 general practitioners, whereas once they only had two.
Hanging on a wall inside Greenhill's Renmark office is a print of an eighteen century etching depicting a medical lesson.
The focus of the etching is a female patient undergoing a mastectomy, while around her an all-male class of med students looks on.
A rural property on the main highway between Renmark and Adelaide. CHRISTEL YARDLEY/FAIRFAX NZ
The only other female present is a rather stern looking nurse.
Greenhill says the etching serves as a constant reminder of everything a medical school shouldn't be.
"Here you have students, half of them falling asleep, learning about a body part rather than the whole person.
"Rather than objectifying patients, the kinds of people that we're trying to attract to medicine are people with a real strong sense of social justice and that we are all very accountable to our community."
Community engagement is a cornerstone of Flinders' rural curriculum, with members of the public invited to sit on panels to choose med students for the PRCC programme.
Doctor James McLeod, 32, was selected for the PRCC programme and completed his rural placement in Renmark in 2008.
Despite growing up in Adelaide, McLeod says he always had a natural wanderlust and a desire to live rurally.
Renmark GP Doctor James McLeod says becoming a rural GP was an easy decision after his positive experiences as a med student. CHRISTEL YARDLEY/FAIRFAX NZ
During his year-long placement in Renmark, he joined the local Lions club and struck up friendships with several members.
"Every fortnight I'd go to the Lions club and because a lot of members are in their late 60s, they didn't mind me coming along to help with the heavy lifting," he laughs.
Returning to Renmark to take up a position as a GP felt like a homecoming of sorts.
"Because you're encouraged as a student to get involved in your community, you make all these connections and friends. Deciding to come back was an easy decision."
Many rural communities in South Australia now find it easier to access a GP thanks to Flinders University's focus on rural healthcare. CHRISTEL YARDLEY/FAIRFAX NZ
McLeod describes his job as varied and challenging. On any given day, he could treat a young person with minor trauma injuries or see an orchard worker with skin cancer. On a quiet day he can sneak home and feed his chooks.
This year has been particularly bad for redback spider bites.
Snake bites aren't as common, although McLeod sees his share of stick bites.
"That's when someone's been walking through the bush and they think they've been bitten by a snake but it's a false alarm."
The job can be demanding but the rewards of being a rural doctor are hard to beat.
"I always try to be a simple, humble bloke but some people are really, really impressed that I've come back to work here. You sometimes have to say, it's alright, I'm not going out of my way, I love doing this."
About 455 kilometres south of Renmark sits Mount Gambier, a city of 27,000 people.
It's here, Flinders University Professor Lucie Walters leads the med school's PRCC programme.
Walters, a GP obstetrician, moved to Mount Gambier in 1992 and remembers having a six week-long waiting list of patients.
Flinders University Professor Lucie Walters has seen the positive impact Flinders' rural curriculum has had on communities. CHRISTEL YARDLEY/FAIRFAX NZ
In 2002, she started the transition from being a fulltime GP to a Flinders academic after learning about the community-based PRCC programme in Renmark and the surrounding Riverland region.
"I thought we want this in this town," she recalls.
As with the Riverland experience, Walters says community engagement has been crucial to the success of the PRCC programme in Mount Gambier.
It's not by chance the city now has the doctors it needs.
About a quarter of South Australia's population of 1.7 million live outside Adelaide. Here a windpump draws water on a farm near Mount Gambier. CHRISTEL YARDLEY/FAIRFAX NZ
But the impact of Flinders' rural programme goes beyond bolstering the healthcare workforce of small communities, Walters says.
"Rural communities often lose their best young people because they go away to university and that means the school children don't have good role models and university seems to be a far off and inexplicable goal. Bringing young people back to these communities, particularly the vibrant young people who are clever and engaged, has an amazing knock-on effect."
Mark McShane, City of Mount Gambier chief executive, says having a med school based in the city generates short- and long-term benefits.
The immediate impact is the positive spin-off from having med students training in the community.
Longer term, these students might come back to work in rural and provincial centres.
"Although we're the second biggest city in South Australia behind Adelaide, we promote ourselves as rural living. By having students here, we hope we enlighten them to the benefits of working in a regional environment.
City of Mount Gambier chief executive Mark McShane says a community-engaged med school generates short- and long-term benefits. CHRISTEL YARDLEY/FAIRFAX NZ
"We know some of the students we help train might not stay, that's just part of the gig, but they might come back when they're in their 30s and 40s and want this sort of environment for their kids."
In Lameroo, Brown says the arrival of Flinders' med students generates a sense of excitement among the tight-knit community.
For some students, it can be their first time living away from the comforts of home.
Brown helps students settle in and feel part of the community.
During one year, word went out a student needed a pushbike to get around town.
A bike was found for him at the local school.
Worley began his medical career in Lameroo, working as a sole practice GP.
The memory of his time there continues to ground him.
Creating Flinders' rural medical programme required courage, community support, and innovative thinking.
Similar attributes will be needed by the backers of the Waikato med school.
"British Prime Minister David Lloyd George once said you can't cross a chasm in two small jumps. Sometimes you need to take a big leap," Worley says.
"That's what we did."
* Aaron Leaman and Christel Yardley travelled to South Australia as part of a Fairfax NZ-funded trip to examine Flinders University's rural medical programme.