RANZCOG’s vision of excellence in women’s health underpins the approach of the College to all of its training programs. Issues of workforce distribution represent the single greatest challenge to reaching the highest possible standard of healthcare in Australia.
RANZCOG has long made it a high priority to ensure, excellence in women’s health is not confined to the suburbs of our capital cities. However, maldistribution of the O&G workforce remains a problem in many jurisdictions and the College must continue to strive toward equitable healthcare for all women.
Training for rurality
The education directorate of RANZCOG has long prioritised an improvement in workforce distribution. Strategies begin with selection for FRANZCOG training, continue during FRANZCOG training and further with post-FRANZCOG training support.
Before FRANZCOG training
Selection for FRANZCOG training
The first strategy in addressing the workforce maldistribution is to select a cohort of trainees who are more likely to practice in regional centres. While other colleges may reward the trainee who does the most research, RANZCOG rewards a variety of attributes that will enhance specific areas of the women’s health workforce. There is very good evidence that a childhood spent in a rural location substantially increases the likelihood of a medical graduate choosing a rural location for practice.1 In consequence, applicants for FRANZCOG training with evidence of a rural upbringing are awarded substantial selection points, more than double the maximum selection points attainable through multiple research publications. Furthermore, selection points can also be gained for attending a rural clinical school, time in general practice in a rural area and time spent in a rural prevocational O&G position.
During FRANZCOG training
The compulsory rural rotation during basic FRANZCOG training
All trainees must spend at least six months in a rural location during the minimum four years of Core FRANZCOG training. Many of the most successful rural rotations encourage trainees to spend 12 months rather than six months at their hospital. My own observation is that these trainees are more likely to ultimately practice rurally, albeit not necessarily in the same centre.
Paradoxically, a 12-month rotation can be less disruptive, especially when considering issues like childcare, schooling and partner employment. It is sometimes easier to manage in a 12-month block than for six months. Unfortunately, there are insufficient rural positions for all trainees to spend 12 months in a rural centre.
The success of the Integrated Training Program (ITP) rural rotation is in part attributed to the excellent surgical opportunities referred to later but also to the efforts made by many regional Fellows to ensure the trainee has an enjoyable term. Those efforts have been historically rewarded with a reputation that ensures sufficient new Fellows want to work in that environment. Those that ultimately choose a subspecialist career in a capital centre, often retain their links to the regional centre to the ongoing advantage of the regional centre, the subspecialist and the patients.
The Regional Integrated Training Programs
The College now has four approved Regional Integrated Training Programs (RITPs): Dubbo, Orange, Bendigo and Mackay. Trainees still spend at least twelve months in a tertiary centre but spend the remaining three years of their ITP rurally.
The RITPs are the result of the vision and hard work of many regional Fellows with a particular need to acknowledge the vision of Dr Tony Geraghty during his term as Chair of the Provincial Fellows Committee. It is too early to determine the probability of rural practice of RITP new Fellows, but it would be very surprising if it were not higher than for urban-based ITPs.
Rural advanced training
Observational data quickly reveals that most of the new regional O&G specialists spent one or both of their advanced training in the same or another regional centre. Of course, the decision for future rurality may already have been made before selecting a rural advanced training position but it also speaks to a very positive experience in rural sites at later stages of training.
The generalist O&G Advanced Training Module (ATM) is expected to incentivise advanced trainees seeking rural positions. The obvious fact is that the elective gynaecological surgical training obligated in the ATM can be difficult to attain in urban centres where a small volume of available surgical training must be shared amongst a large number of trainees. Average elective major gynaecological surgical numbers per six months for Core FRANZCOG trainees by hospital type are as follows:
- Tertiary 12.7
- Suburban 18.0
- Rural 26.7
While the above figures reflect only Core FRANZCOG training data, the same almost certainly applies to Advanced FRANZCOG training. If trainees need elective gynaecological surgical experience, it is obvious where they should go to train.
Gynaecological subspecialty and laparoscopic surgery training programs need to become aware that an advanced trainee who has spent time in a regional centre is likely to be much better equipped for further surgical training than another trainee from a tertiary hospital who has been working on research papers.
Specialist Training Program funding
Funding for regional training positions has been greatly enhanced through the Specialist Training Program (STP) which, according to its website, seeks to extend vocational training for specialist registrars into settings outside traditional metropolitan teaching hospitals, including regional, rural and remote and private facilities.’ RANZCOG has been maximally utilising this funding for its regional training positions.
After FRANZCOG training
Continuing Professional Development
It is absolutely critical that the College is pro-active in assisting regional Fellows in meeting Continuing Professional Development (CPD) requirements. For many urban Fellows, CPD points come from everywhere, they fall from the sky and some examples include teaching sessions, unit audits, case reviews, morbidity and mortality meetings as well as participation in research studies, which can make CPD very easy for a Fellow in an urban teaching hospital. Little of this is readily available to the regional Fellow. There is more work to be done by the College to attain equity in this area.
COVID-19 taught us physical presence is not actually needed for most of these CPD activities. Let us learn from that and ensure our regional Fellow colleagues find it just as easy to attain CPD points as those in big city hospitals.
Training the generalist
Generalism versus subspecialisation
Subspecialists are often keen to point out that by focusing on a narrow scope of practice, they can sometimes get quite good within that narrow field. However, a workforce consisting entirely of subspecialists would not serve all women well.
Women with multiple gynaecological problems would need a separate specialist for each. Women in rural areas would be particularly disadvantaged, having to travel sometimes considerable distances at great cost and time, perhaps to multiple different people, when all could have been managed locally by a competent generalist.
The College is graduating approximately 80–100 FRANZCOGs annually. Approximately 25% or 20–25 of these will become subspecialists.2 The balance between generalists and subspecialists is largely determined by the availability of subspecialty training posts, the number of applications for those posts and the number of applicants ‘deemed suitable’ by the relevant subspecialty training committee.
While some jurisdictions have deficiencies (even absence) of a specific subspecialty, there is not such a perceived shortage of generalists. The bigger issue is equipping the generalist trainee with sufficient surgical experience to enable them to confidently take up a position in a regional centre as a new Fellow.
Impact of variable gynaecological surgical training on the generalist
If maldistribution of the medical workforce is the number one issue in health in Australia today, the number two issue is the decline in gynaecological surgical opportunities, both in training and as a new Fellow. As can be seen on the College website, there is enormous variation in surgical training by hospital, ITP and region.3 Many trainees are not getting the volume of gynaecological surgical training that they need to become confident generalists. Reasons are many but two factors are particularly notable: a) medicalisation of gynaecology; and b) reduced opportunities to train overseas.
In attempting to make 75% of trainees into generalists but without the necessary volume of surgical training, the College risks creating a generation of trainees that lack the confidence in their surgery to embark on a rural generalist career. The large number of new Fellows embarking on obstetric-only careers and referring out all gynaecological surgery may partly reflect the remuneration for private obstetrics alluded to above, but also may reflect a lack of confidence in taking on major gynaecological surgery.
Strategies to improve generalist gynaecological surgical training
As far back as November 2013, the AMC referred to improved surgical training volume as a priority for the College in the forthcoming accreditation cycle. A number of strategies have been developed with a particular focus on the linkage between training performance and hospital accreditation by the College. If a hospital needs FRANZCOG trainees for obstetric service delivery, then in turn it must provide the necessary FRANZCOG training, taking particular note of ultrasound training and gynaecological surgical training.
One possible unexpected strategy that is being considered, is the creation of an ‘Obstetric Pathway to Fellowship.’ By not obligating that every non-subspecialist must be a generalist, there would be more gynaecological surgical training available for the true generalist. In the hope that they will then have the confidence to undertake a generalist O&G career in a regional centre.
RANZCOG has been a leader in taking steps to address the workforce maldistribution, but the task is far from complete. Strategies to increase rural generalists must begin with selection of FRANZCOG trainees, continue during training and beyond. Trying to make every non-subspecialist into a generalist is not working because there is simply not enough elective gynaecological surgery to train them all.
The obstetric pathway offers a strategy to meet the urban workforce needs in obstetrics whilst developing a cohort of true generalists who are confident in their surgical abilities and able to embark on a career as a regional generalist.