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Fields and Citadels Print E-mail

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One of the repeated catchcries is the lack of rural health services in Australia. My response has always been that one has to actively transfer intellectual capital to the “regional, rural and remote areas” to encourage a positive outcome. In this essay, “rural” will be used to encompass all.
One of the most important developments in the medical system, amid all the jeremiads over the past two decades, has been new medical schools with a rural emphasis, the rural clinical schools and the university departments of rural health.
These teaching institutions have facilitated transfer of intellectual capital to rural areas.  Medical teaching has been shown to occur more than adequately outside the metropolitan teaching hospitals; and significant intellectual capital exists already in both the larger and the smaller rural hospitals.
Without this innovation, the health education system would have had great difficulty in handling the increase in medical students that has occurred in the decade following the introduction of these new rural facilities.
However, this rural dispersal needs good medical management, and especially with the Government’s recent announcement of Regional Training Hubs.
Where does the College fit into this policy initiative?
Let us take a step back.
One inspiration underpinning the recommendations of my Rural Stocktake in 1999, which led to Government funding for the establishment of rural clinical schools and university departments of rural health, was the story of the Mayo Clinic and visits made to both to the Rochester Minnesota and Scottsdale Arizona campuses some years before I did the Stocktake.
The Mayo Clinic was formed by the Mayos – father and sons – in Rochester in the 19th century and to me has always exemplified that excellence is not confined to the largest conurbations. The Mayos proved to be very good managers and developed intellectual capital involving a wide range of skills, in the “wilds of Minnesota”.
Then one also remembers the story of a gifted doctor named Samuel Fitzpatrick, who was based in Hamilton in Western Victoria. He was a world authority on the surgery of hydatid disease, then a major affliction – particularly in Western Victoria where sheep farming was a major component of the local economy. The disease was of such importance that the then Royal Australian College of Surgeons established a national hydatid registry in 1926 that, until its cessation in 1950, identified over 2,000 cases.  Such attention helped in the campaigns to reduce the incidence of hydatid infection in humans – the intersection of Fitzpatrick the surgeon and Fitzpatrick the public health doctor.
At the height of his practice Dr Fitzpatrick dreamt that this niche disease could propel Hamilton into having its own Australian version of the Mayo Clinic.  However hydatid disease lessened as a major disease and, unlike that of his Mayo exemplar, Fitzpatrick’s dream faded.  While Hamilton doctors have maintained a high reputation for medical care and procedural competence, this remained a country practice in Victoria.
The surgical virtuosos of the bush, like Fitzpatrick – the doctor who was that generalist with an equal ability to treat any disease or condition – increasingly disappeared. The intellectual capital that they possessed was not translated into major teaching and research facilities in rural Australia, let alone centres for public health as had occurred with the Mayos and their stake in rural America.
The rise of specialist medicine and then sub-specialist medicine, together with their resultant perceived skills and knowledge, concentrated teaching and learning in metropolitan teaching hospitals, and in so doing emphasised the importance of the individual at the expense of the total population denominator.
Public health was dismissed in some quarters as surveillance of “tips and drains” Yet public health training for many years was concentrated in the School of Public Health in the University of Sydney. Public health education as a medical specialty was invigorated by a consultant physician, Sue Morey, and a number of like-minded people following the Kerr White report. She headed the resultant Faculty of Public Health Medicine, which ended up within the RACP.
Yet this public health movement could just as easily have been linked to the RACMA. Many of the early medical administrators had a background in public health, much of their experience derived during war service. In many respects, the natural home of public health could have been RACMA given that public health and medical administration have an affinity.
Now a new opportunity has arisen -for the involvement of the College in medical education, especially in rural areas.
One of the important outcomes of the growth of rural medical education has been the opportunity to be both director of medical service and director of clinical training. I was able test this association personally and found it fruitful, being involved in the establishment of a medical intern program that requires the intern to undertake 20 weeks in rural general practice, plus the mandatory hospital terms. Health education (rather than medical education per se) has been attached to a group of academics primarily in traditional teaching hospitals.
However, medical education is one of those areas that, in the undergraduate field, have been attached to universities and the post-graduate qualifications left to the various Colleges. As I found out this leaves a gap in the first two post-graduate hospital years as intern and resident medical officer when there is often a high level of angst and where appropriately qualified Fellows of the College could have a useful role. There is a need for expertise and experience to assist the doctor in those first two years. I realised this need for pastoral help with the interns – surely an accompaniment of an empathetic educational environment . Why not explore the College fellowship being involved? Can one person’s experience be generalised by the College?
Taken seriously being a medical administrator in rural Australia when combined with a medical education without forgetting the importance of public health, provides a challenge just as the Mayos and Samuel Fitzpatrick accepted the rural challenge, still relevant despite being in a different era.
As one famous person once said: “Before you capture the citadels, secure the fields first!” Therefore, for the young medical administrator think of gaining experience in a rural post before tackling, rather than being absorbed into, the “citadel culture” of metropolitan Australia.
Dr John (Jack) Best AO
Last Updated on Friday, 15 September 2017 12:43