Specialty spotlight: Rural generalist medicine

For Dr Helen Fraser, rural generalism has not only offered diverse and challenging medicine, it’s also been an opportunity to champion health equity for rural hospitals and take a clinical leadership role for the region.

Senior Medical Officer (SMO) at Ayr Hospital for the past six years, Dr Fraser chairs the Townsville Hospital and Health Service Clinical Council, which gives clinical staff a voice in the management of the region’s health service.

Dr Fraser grew up on a farm between Hamilton and Warrnambool in southwest Victoria. “Some of my friends’ parents were the doctors in town and they practised rural generalism before it was known as rural generalism. They were the people who I really looked up to at that time.”

After graduating from James Cook University in 2012, she stayed in Townsville for her intern and Registered Medical Officer (RMO) years and completed advanced skills in emergency medicine and anaesthetics before taking up an SMO role in Ayr, 88km to the city’s south.

“As a rural generalist in Ayr with advanced skills, we're using all of those emergency medicine skills and then we're using internal medicine skills because we look after everyone on the ward,” Dr Fraser says. “I use my anaesthetic advanced skill for emergency presentations with imminent airway risk, but also with our obstetric deliveries and providing epidurals after hours. We do a lot of gastroenterology procedures, and going forward, we're hoping that more surgery will be performed in Ayr.”

Life as a rural generalist

The National Rural Health Commissioner, Adjunct Professor Ruth Stewart, and trainee rural generalist Dr Preston Cardelli, a JCU graduate, talk about the rewards and rich experiences of rural generalism.

‘All types of medicine’

Rural generalists do an additional year of specialised training in an area that aligns with the general practice colleges’ curriculum during their GP training.

Australian College of Rural and Remote Medicine (ACRRM) Advanced Specialist Training areas

Royal Australian College of General Practice Rural Generalist Fellowship Additional Rural Skills Training areas

The Queensland Rural Generalist Pathway (QRGP) gives interns and Junior House Officers priority access to in-demand rotations such as obstetrics and gynaecology, paediatrics and anaesthetics. The QRGP coordinates a recruitment and placement process for medical officers wishing to undertake advanced skills training in mental health, adult internal medicine, anaesthetics, obstetrics and paediatrics. Applications are via the Queensland Health RMO and registrar recruitment campaign.

Drawn to the procedural aspects of medicine, Dr Fraser chose anaesthetics and emergency medicine advanced skills for their versatility in rural settings. “Anaesthetics is one of the procedural advanced skills that is often well utilised within rural generalism,” she says. “With any birthing service, you're going to need anaesthetics and obstetrics to be able to deliver that. You've also got crossover skills into emergency medicine, a core part of what we deliver in rural hospitals.

“Having those skills to be able to deal with emergency situations in our rural sites and be confident in your approach sets you up to have a good experience and provide good care within these communities which otherwise they may not necessarily have.

“We get to perform lots of procedures for our patients, and it requires technical skill and obviously experience as well. That's a that's something that really drew me in, to be able to use both soft and hard medical skills in my career.

This wide scope of practice is a key drawcard of rural generalism. “We get to do all types of medicine,” Dr Fraser says. “You get paediatrics, women's health, aged care, palliative care, general medicine. So if people have an interest in lots of different types of medicine, rural generalism is the perfect way to be able to fulfil those criteria.

“It's a really broad role so we’re part of a very tight-knit team in rural communities with nurses and allied health. We all have to have an understanding of each other's role, be able to be open and honest with each other and work within the limits of what's available to our best abilities.”

Meeting a need

The National Rural Health Commissioner, Professor Ruth Stewart, is a rural generalist doctor with the advanced skills of a general practice obstetrician. Her three-decade career included SMO roles at Mareeba and Thursday Island hospitals.

She told the Australian Medical Students’ Association 2022 Rural Health Summit in Mackay that it was imperative for rural communities that Australia focuses on generalism, including GPs, rural generalists, general surgeons and general physicians.

“We have a desperate undersupply of generalists in Australia,” she said. The decisions you guys make are vital for the health of Australians in rural areas, and if I can persuade you of the importance of working in rural and remote health, I'll have done something worthwhile this year.”

Choosing an advanced skill

The QRGP encourages trainees to choose an advanced skills training position based on the needs of the rural community to which they wish to relocate after completing their training.

“There are procedural and non-procedural advanced skills,” Dr Fraser says. “The procedural advanced skills are things like surgery, anaesthetics, and obstetrics, and then your non-procedural advanced skills are things like internal medicine, mental health, paediatrics, public health and Aboriginal and Torres Strait Islander health. 

“It's really important that doctors do consider what they do enjoy and the types of medicine that they enjoy as well and not just consider procedural advanced skills as their only option because as medicine evolves, there are going to be lots more opportunities for non-procedural advanced skills as well.

“There's going to be a bit more working out where you fit in some of the non-procedural skills as to what they could bring to some of those rural areas and how they could work in with some of the referral centres to be able to deliver more care at the community level, as opposed to for people having to travel.

“It's good to have an understanding of where your interests lie and where your skills lie. If you enjoy your job and you're interested in it, you're going to have longevity in your work life.”

Finding your own way as a rural generalist

“The Generalist Pathway is a fantastic pathway for people who are already in that mindset, but I also want to stress that if people develop a passion for it through exposure to rural sites at junior doctor level, it's also okay to be able to make your own way,” Dr Fraser says.

“It's really good clinical medicine and clinical exposure because you don't have the dilution by numbers. There are fewer people in the hospital so you're going to be able to see things and participate in things that you might not necessarily get at some of the major hospitals.

“When you do develop a passion, it's important to know that you don't have to be on the rural generalist pathway to become a rural generalist. There are ways to be able to do it that are awesome opportunities as well.

“It's good to get exposure to lots of different areas of clinical medicine as a junior doctor before you decide. Endocrinology, cardiology, renal, all of those subspecialties, actually provide you with exposure that can help you in your clinical medicine at a rural site when you're a rural generalist.

“There's a lot of pressure for people to feel that they need to know what they want to specialise in as soon as they become interns. But it's okay not to know, and to work out where your passion lies, working as a doctor because it's a very different prospect to being a medical student on a team. You get a very different exposure.

“You have very different levels of responsibility, and you might experience something completely differently when you're working there as a junior doctor. It's important to keep your eyes open to opportunities and to actually say, ‘It's okay, I'm exploring different areas of medicine to work out where my passion lies.’”

Work, family, and life changes

Dr Fraser and her husband have two daughters, aged 1 and 4. “We've been living between Ayr and Townsville, depending on how it worked for us at different times of our lives,” she says. “At the moment, we're largely based in Townsville, but I stay down in Ayr when I'm on call. 

“It's important to consider what your needs are, in terms of both work and family, when you're thinking about working somewhere and how the community might be able to support you and your family during different times of your life.”

“Know that there are different ways of doing things as well in terms of rostering that mean that you can sometimes split time between places, and think about things not just in a nine to five kind of concept. We're providing 24 hours a day, seven day a week, services in these places. It's not a weekday job. Work-life balance and having the supports outside of our job strengthens our ability to perform our job.”

Leadership and health equity

Dr Fraser is enjoying the opportunity to promote frontline clinician issues in the Townsville Hospital and Health Service (THHS) and to advocate for rural hospitals in the region as chair of the Clinical Council. Part of her week is dedicated to clinical governance, workforce management, strategy and organisational planning. “Having that time to be able to dedicate to it is really good for the Clinical Council itself because it creates organisational memory and an ongoing work plan that's easy for people to take over,” she says.

“I was offered the opportunity to do some upskilling in administration to develop more skills in the non-clinical work that's required in rural sites, creating more understanding so that hopefully, going forward, there'll be more people within rural hospitals that have the skills to be able to work effectively and work within the system and optimise the opportunities within the system,” she says.

“Townsville HHS is committed to providing that opportunity because they want to be able to resource some SMOs to be able to go back and work in areas and have those skills and actually support the rural hospitals to get the best that they can rather than expecting people to just have a knowledge of very complex mechanisms that are behind how hospitals run.

She says the Clinical Council’s role is to identify issues within the HHS and highlight obstacles to clinical staff delivering effective patient-centred care. “Basically, it's about giving clinical staff a voice when it comes to issues being addressed in a timely manner.”

“Health equity to a lot of rural sites means a lot more because we know that there's a difference in outcomes. We know that there's a difference in health outcomes for First Nations people as well.

“I'm hoping to advocate for better consideration of resourcing so that we can work just as effectively in rural hospitals.

“If you're working with good equipment, you feel like they're investing in you. If you have access to certain levels of resources and educational opportunities, you feel invested in. That's what I want to promote, for not just doctors but nursing and allied health staff to have those opportunities so we're recruiting and retaining staff in our rural sites.”

Read the inspiring stories of some of the stellar rural generalists serving rural and remote communities across North and Central Queensland: Drs Clare and David Walker, Dr Riley Savage (Weipa), Dr Steve Johnston (Weipa), Dr Adam Holyoak (Thursday Island) Dr Nichole Harch (Emerald) and Dr Megan Bates (Cloncurry).

NQRTH connects medical students, intern and junior doctors with a network of opportunities and resources designed to create a supportive and clear path to specialist (including general practice) training, and beyond, in our regions. Our network works together to strengthen medical specialist training with the view to build a health workforce prepared to meet the health needs of our regional and rural communities in Cairns, Central West, Mackay, North West, Torres and Cape, and Townsville. NQRTH is facilitated by James Cook University, who partner with hospital and health services and training providers to create a connected career pathway beginning at the medical undergraduate level right through to fellowship.