Letter from Australia

Peter Hutten-Czapski, MD

CJRM 2000;5(1):28-29.

Australia is quite similar to Canada (Table 1). Its population and territory is about two-thirds that of Canada's. It, too, is highly urbanized, with most of the population huddled in the 5 largest cities. The average rural population density is 1/km², similar to that in Canada, and in remote areas (the outback), the population density approaches 1/1000 km².

Australian physicians are paid a fee-for-service, the majority of their income being generated through Australia's medicare system. Because that system has historically paid the same regardless of location, it is perhaps not surprising that Australian physicians generally prefer the less-demanding lifestyle of the urban office practice.

In the late 1980s, many of these urban physicians found that after-hours high-volume walk-in work was quite lucrative because of the after-hours premiums involved. In an effort to crack down on increases in utilization of the premium codes, the state of New South Wales (NSW), early in 1988, proposed to reduce drastically the after-hours premiums. This effectively kick-started the rural doctors' movement. Rural doctors, who need after-hours premiums to make low-volume hospital work viable, resigned from hospitals en-masse in protest.

By July 1988 the brand new Rural Doctors Association (RDA) of NSW negotiated an on-call allowance and appropriate after-hours consultation rates that have been indexed to the consumer price index ever since. Rural doctors' movements emerged in the other Australian states within months, and the national Rural Doctors Association of Australia (RDAA) was founded in 1990.

Leaving rural "industrial relations" and contract work to the various state RDAs, the RDAA set to work on national issues of rural manpower and advocacy.

It was clear early on that the existing training programs of the Royal Australian College of General Practitioners (RACGP) were inadequate in providing graduates with the skills and attitudes required to practise in rural and remote settings. Despite, or perversely because of, an extensive 3-year training program, fellows of the RACGP were much less likely to "go bush" than GPs with other types of training.

Negotiations between the RDAA and the RACGP resulted in the formation of the Faculty of Rural Medicine (FRM) in April 1992. The FRM developed a rural program with provision for late entry, basic and advanced training, standards and accreditation. Contemporaneous papers on the standard curriculum¹ and some advanced curricula² detailed the content of the program. This pioneering work set the standards that the Society of Rural Physicians of Canada and the College of Family Physicians of Canada have referenced in the bibliographies of their own training papers that were published in Canada last year.³

Initially, the Australian venture was quite successful, with development of a rural training stream of the RACGP residency program. However, things quickly deteriorated for reasons that are hidden in partisan smoke. Some say that it was a reactionary tide in the RACGP countering the rural revolutionary forces. Others point to the personalities involved. But whatever the case, evidence mounted that the initial enthusiasm for rural training shown by the RACGP was waning.

Tension rose gradually at first, but matters came to a head when the FRM and the president of the RACGP (Col Owen) were at odds with Council over the nature of the qualification to be given to the graduates of the program. Members of the FRM wanted a separate rural fellowship as a reward for all the training involved, and the College was only prepared to provide a diploma. Col Owen accurately predicted in a press release on July 26, 1995, that this would lead to a schism within the profession. In August 1995 Council withdrew the responsibility for the rural curriculum from the FRM.

In October 1995 the RDAA announced a plebiscite of the rural and remote constituency regarding custody of rural GP training. The overwhelming response favoured a new and independent college. The Australian College of Rural and Remote Medicine (ACRRM) was established on Mar. 13, 1996.^4,5 The federal minister of health was sympathetic, but to prevent the two rural training programs from competing insisted that the two Colleges work together.

How to manage approximately $20 million of training funding was contentious, but a joint agreement was hammered out in February 1999 between the ACRRM and the RACGP.⁶

Existing rural doctors with 5 years training are allowed to apply for fellowship of the ACRRM under grandfather provisions and 550 have already done so. This will serve as the basis of the faculty and will be added to as registrars finish their training.

1. Strasser R. So you want to do rural practice? Aust Fam Physician 1994;23:735-6.
2. Craig M, Nichols A, Price, D. Education for the management of obstetrical conditions in rural general practice. A curriculum statement for a major in obstetrical studies in the rural training programmme of the faculty of rural medicine, Royal Australian College of General Practitioners. Aust N Z J Obstet Gynaecol 1993;33:230-9.
3. Iglesias P, Hutten-Czapski. Joint position paper on training for rural family practitioners in advanced maternity skills and cesarean section [published erratum appears in Can J Rural Med 2000;5(1):36]. Can J Rural Med 1999;4(4):209-16.
4. Moyniham M. Genesis of ACRRM: Who would best be responsible for rural GP training? Country Doctor Journal of the Rural Doctors Association of Australia 1999;7(1):3-4.
5. ACRRM Prospectus foreword. www.medeserv.com.au/acrrm/open /fore.htm. Accessed Nov. 26, 1999.
6. Royal Australian College of General Practitioners and Australian College of Rural and Remote Medicine. Joint venture agreement. www.racgp.org.au/index.html. Accessed Nov. 26, 1999.

© 2000 Society of Rural Physicians of Canada