Rural health

This unit describes the skills, knowledge and attitudes expected of all general practitioners (GPs) in this area of practice. The extended and additional specific skills and knowledge required for the Rural Generalist Fellowship (FRACGP-RG) are detailed elsewhere.

Rural GPs and GPs in training are central to maintaining the health of Australians living outside major cities, and therefore require additional skills in addition to those normally expected of GPs who work in urban and metro locations. The FRACGP-RG pathway recognises the extra requirements and skills of rural generalists in areas such as emergency medicine, anaesthetics, obstetrics and mental health. It supports them to meet the diverse health needs of regional, rural and remote communities.

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

In 2019, it was estimated that around 28% (7,000,000) of Australians live in regional, rural or remote locations.1 Those living rurally report increased life satisfaction and increased connections with their communities.2

‘Rural’ is defined in many ways, including geographically (size and distance to other places). The Australian Institute of Health and Welfare defines rural as all areas outside major cities.1 Rural towns in Australia are geographically diverse with varying histories and demographics. Practising as a rural GP may be quite different to practising as a remote GP due to the practice location, practice demographics and case presentations. Remote communities are typically smaller, more isolated and have higher percentages of Aboriginal and Torres Strait Islander patients.3

Australians living in rural and remote areas have unique health concerns that relate directly to their potential social isolation, socioeconomic disadvantage and distance from health services.4 Nationally, residents living outside a capital city in Australia are more likely to die from cardiovascular disease.5 Health risk factors include higher rates of obesity, higher alcohol consumption and a greater percentage of smokers than metropolitan counterparts.

People living in rural and remote areas are more likely to die at a younger age than their counterparts in major cities, with higher rates of accidents involving motor vehicles, agriculture and mining. They have higher rates of potentially avoidable deaths, under the age of 75, from conditions that are likely preventable through primary or hospital care in major cities.1

Recruiting and retaining an adequate rural health workforce is a challenge.6 Currently, the majority of our Australian trained medical graduates working as rural GPs are of metropolitan origin.6,7 Governments continue developing strategies to ensure that people in rural Australia have good access to medical care, with regular reviews of the effectiveness of workforce distribution policies.7,8 Incentives, recruitment of overseas-trained doctors, allocating medical school places for students of rural origin and increasing training in rural locations have all been trialled to address our maldistributed medical workforce, with mixed success.7,9

GPs are important for resilient and healthy rural and remote communities and are essential for a coordinated and efficient health system.10,11 Delivering quality healthcare to rural patients can be both rewarding and satisfying, with evidence suggesting that rural GPs enjoy high levels of job satisfaction.12 However, practising medicine safely in a regional, rural or remote setting may require a wider scope of practice, depending on the practice context, and non-GP specialist services available.10,11,13 A rural GP is more likely to deliver procedurally based care and may also practise extended skills in mental health, Aboriginal and Torres Strait Islander health, palliative care, emergency care, obstetrics and other areas of medicine.8,9 GPs practising in rural locations might need to adapt their skills over time to meet their community’s changing healthcare needs.

Rural GPs report challenges related to geographical isolation, reduced access to non-GP specialist care and increased after-hours care provision.11 Practising rurally requires a support network as there are potential challenges around self-care, professional boundaries and work–life balance.12,14

A rural GP often acts as a healthcare team leader and requires sound communication and IT skills, including familiarity with telehealth care.4 Telehealth is an increasingly useful tool to enhance and support the role of rural GPs, especially in more remote contexts, notwithstanding the potential limitations of telehealth in certain situations.15 Travelling to receive care in urban areas is not always an acceptable option for rural patients.

Rural general practice is a rewarding place to work and train. It affords the opportunity to teach and provide positive learning experiences for the next generation of GPs. Positive experiences in primary care in medical student training can have a positive influence on future career choice in rural practice.16 When training rurally, there is the opportunity to be more hands-on, see a greater breadth of common conditions and develop increased procedural competence.17 Additionally, there is the potential to recruit future doctors to work regionally, rurally or remotely.  

References
  1. Australian Institute of Health and Welfare. Rural and remote health. Canberra: AIHW, 2019 [Accessed 15 September 2021].
  2. Wilkins R, Lass I. The Household, Income and Labour Dynamics in Australia Survey (HILDA): Selected Findings from Waves 1 to 16. Carlton, Vic: University of Melbourne, 2018.
  3. Wakerman J, Bourke L, Humphreys J, Taylor J. Is remote health different to rural health? Rural Remote Health 2017;17(2). doi: 10.22605/RRH3832.
  4. Hay M, Mercer A, Lichtwark I, et al. Selecting for a sustainable workforce to meet the future healthcare needs of rural communities in Australia. Adv Health Sci Educ Theory Pract 2017;22(2):533–51. doi: 10.1007/s10459-016-9727-0.
  5. Nichols M, Peterson K, Herbert J, Alston L, Allender S. Australian heart disease statistics 2015. Melbourne: National Heart Foundation of Australia, 2016.
  6. McGrail MR, Russell DJ. Australia's rural medical workforce: Supply from its medical schools against career stage, gender and rural origin. Aust J Rural Health 2017;25(5):298–305.
  7. McGrail MR, O’Sullivan B, Russell DJ, Scott A. Solving Australia’s rural medical workforce shortage. (Centre for research Excellence in Medical Workforce Dynamics. Policy Brief). Carlton, Vic: University of Melbourne, 2017. doi: 10.1111/ajr.12323.
  8. Wakerman J, Humphreys JS. Sustainable workforce and sustainable health systems for rural and remote Australia. Med J Aust 2013;199(5):S14–S17. doi: 10.5694/mja11.11639.
  9. Russell DJ, McGrail MR, Humphreys JS. Determinants of rural Australian primary health care worker retention: A synthesis of key evidence and implications for policymaking. Aust J Rural Health 2017;25(1):5–14. doi: 10.1111/ajr.12294.
  10. Larkins S, Evans R. Greater support for generalism in rural and regional Australia. Aust Fam Physician 2014;43(7):487–90 [Accessed 15 September 2021].
  11. Russell DJ, McGrail MR. How does the workload and work activities of procedural GPs compare to non‐procedural GPs? Aust J Rural Health 2017;25(4):219–26. doi: 10.1111/ajr.12321.
  12. McGrail MR, Humphreys JS, Scott A, Joyce CM, Kalb G. Professional satisfaction in general practice: does it vary by size of community? Med J Aust 2010;193(2):94–98. doi: 10.5694/j.1326-5377.2010.tb03812.x.
  13. Kondalsamy-Chennakesavan S, Eley DS, Ranmuthugala G, et al. Determinants of rural practice: Positive interaction between rural background and rural undergraduate training. Med J Aust 2015;202(1):41–45. doi: 10.5694/mja14.00236.
  14. Joyce CM, Scott A, Jeon SH, et al. The "Medicine in Australia: Balancing Employment and Life (MABEL)" longitudinal survey - Protocol and baseline data for a prospective cohort study of Australian doctors' workforce participation. BMC Health Serv Res 2010
  15. Paige SR, Bunnell BE, Bylund CL. Disparities in patient-centered communication via telemedicine. Telemed J E Health 2021;April. doi: 10.1089/tmj.2021.0001.
  16. Raftery D, Isaac V, Walters L. Factors associated with medical students’ interest in remote and very remote practice in Australia: A national study. Aust J Rural Health 2021;29(1):34–40. doi: 10.1111/ajr.12694.
  17. Couch D, O’Sullivan B, Russell D, McGrail M. ‘It’s so rich, you know, what they could be experiencing’: Rural places for general practitioner learning. Health Sociol Rev 2020; 29(1):76–91. doi: 10.1080/14461242.2019.1695137.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP. These are expressed as core competencies that are required of a GP across all clinical consultations, interactions and contexts. These core competencies are further detailed as measurable core competency outcomes.

Communication and the patient–doctor relationship
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs communicate effectively and appropriately to provide quality care
  1. communicate effectively with other health professionals using available infrastructure
  1. GPs use effective health education strategies to promote health and wellbeing
 

 

  1. GPs communicate in a way that is culturally safe and respectful
 
  1. GPs provide the primary contact for holistic and patient-centred care
  1. provide quality care in a rural and/or remote community
Applied knowledge and skills
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs diagnose and manage the full range of health conditions across the lifespan
  1. develop knowledge and skills appropriate to the practice location 
  1. GPs are innovative and informed by evidence
 

 

  1. GPs collaborate and coordinate care
  1. establish interprofessional networks to ensure quality local healthcare delivery
Population health and the context of general practice
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs practise in a sustainable and accountable manner to support the environment, their community and the Australian healthcare system
 
  1. GPs advocate for the needs of their community
  1. advocate for equitable access to appropriate services for rural and remote communities

 

Professional and ethical role
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs are ethical and professional
  1. GPs are self-aware
  1. implement an ongoing plan to overcome professional issues related to geographical isolation and boundaries
  2. be prepared, resourceful and adaptive to challenges that arise in geographic and professional isolation
  3. identify and acquire extended, or specific local knowledge to meet the healthcare needs of their community
  1. GPs mentor and teach
 
Organisational and legal dimensions
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs use effective practice management processes and systems to continually improve quality and safety
  1. manage time and priorities efficiently when undertaking on-call roles
  1. GPs work within statutory and regulatory requirements and guidelines
 

 

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. When you arrive in a rural town, get to know the local team, in-town resources and local management pathways/referrals. Introduce yourself to aged care staff, allied health practitioners, the pathology collector, pharmacist, imaging support service, ambulance officers/paramedics, police and funeral directors. This will be invaluable if you need to call them at 2.00 am. Also, if appropriate, meet with the local Aboriginal or Torres Strait Islander Elders and the Aboriginal and Torres Strait Islander health service.
  2. The scope of GP services increases when alternate health services are sparce. Patient and community advocacy might be a more significant part of a rural GP practice to make sure that lack of access to services doesn’t impact patient outcomes.
  3. Maintaining professional boundaries and confidentiality might require additional skills in a rural context. Think about how you will manage the potential to ‘run into a patient’ in a social context, and talk with an experienced rural mentor about how to manage these complexities.
  4. Professional and personal isolation can be the enemy of a good rural experience. Pre-plan your external support options and how you will integrate into the rural community – join a club and get involved.
  5. As a rural GP, you will see a wide range of presentations. Unusual infections, such as zoonoses, are more prominent, and managing after-hours emergencies is more common. It is appropriate that you ask for help, as you will see many unfamiliar conditions. Work out how and where to ask for help early so that you can access this help quickly when you need it. Following up on your cases, reading letters from non-GP specialists and undertaking random case analyses are great ways to improve your learning.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Rural health

You are a GP in a town of 15,000 people. Sally presents with her three-year-old daughter, Jasmine, who has been unsettled and feverish for the past two days. Everyone in the family has a ‘cold’. Jasmine woke up this morning with a discharge from her left ear. She has been swimming in the local pool most days.

Questions for you to consider Clinical exam assessment area Domains

What are the important considerations in communicating with Sally and Jasmine?

How would you change your communication if Sally were Jasmine’s 16-year-old sister or if Sally were not fluent in English? What if Sally and Jasmine were Aboriginal or Torres Strait Islander, and Sally were Jasmine's grandmother?

What if this were a telehealth consultation? How would you adapt your history-taking?

  1. Communication and consultation skills
1,2,5
 

What further history do you need?

Is Jasmine's immunisation status relevant? Why or why not?

What specific aspects of examination are important in Jasmine?

  1. Clinical information gathering and interpretation
2   

What is the most likely diagnosis?

What if there were no obvious focus for Jasmine’s infection?

How would your decision-making differ if this were the fourth time Jasmine presented with otitis media with perforation in the past three months? In the past six months?

What difference would it make to your diagnosis list if Jasmine were an Aboriginal or Torres Strait Islander?

  1. Making a diagnosis, decision making and reasoning
2   

What treatment would you recommend?

If Jasmine were an Aboriginal or Torres Strait Islander, would that change your treatment/management?

How might working in a rural context affect management?

If Jasmine were under six months old, how would that affect your decision-making?

What if Sally mentioned she was concerned about Jasmine's language development? Would that prompt you to consider other investigations?

How would you explain the diagnosis of recurrent otitis media to Sally and Jasmine?

What if Sally insisted Jasmine needs to be able to swim? What advice would you give?

How would your management change if Sally and Jasmine live out of town and can only come in on the community bus once a week?

  1. Clinical management and therapeutic reasoning
2   

Describe shared decision-making as it relates to otitis media in children. Are there resources to help you? Does the rural location impact your shared decision-making? 

What would you need to consider if the presentation was otitis externa and it was the fourth case you had seen this week? The common thread was all patients had been swimming at the local pool. Do you have any concerns? What would you do next?

  1. Preventive and population health
1,2,3      
 

During your consultation with Jasmine, your receptionist calls you to say that a patient has arrived with chest pain. You are the only doctor in your practice today. What would you do?

It is the next day and you are at the supermarket. What if Sally's mother (Jasmine's grandmother) approached you for an update on her granddaughter? How would you manage that?

Sally is the family day carer for your young son. How might this impact your relationship and/or this consultation?

What strategies/guidelines do you use to treat and manage friends, family or employees? What other challenges might you face in a rural context? How might you manage these challenges?

If you were working rurally, how would you access courses to increase your skills? How would you determine what skills you need?

  1. Professionalism
4   

If Sally does not bring Jasmine for her follow-up appointment, how would you manage that? What practice management systems do you have to alert you to a missed appointment?

Current guidelines for managing acute otitis media suggest Jasmine should be reviewed in four days. If you were planning to be away on leave and there is no locum to replace you, what would you recommend?

Do you know how to access allied health services in your community?

  1. General practice systems and regulatory requirement
5   

How do you do an ear, nose and throat examination in a three year old?

What if Jasmine were an adult with a discharging ear thought to be from otitis externa? What is involved in aural toilet and ear wicks?

If Jasmine had a fever but no ear signs, how might you collect specimens to help you make a diagnosis?

  1. Procedural skills
2   

The result of Jasmine’s ear swab M/C/S (microscopy, culture and sensitivity) is likely to take a week to return. Her previous ear swab showed multiple antibiotic-resistant Pseudomonas aeruginosa. How will you manage Jasmine?

  1. Managing uncertainty
2   

You have diagnosed otitis media in Jasmine. What are the potential risky sequalae? What are the signs and symptoms of a deteriorating child that would cause you concern?

What serious illness would you need to exclude in a child or young person with a fever?

If you were the only doctor in the area, how would you manage the deteriorating child? Who would you call on and what resources would you use to inform your decisions? Do you know where to find these resources at short notice?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Consider a recent patient you have seen with diabetes. What barriers to accessing chronic disease care might exist for patients who are more geographically isolated? If you work in a rural area, the barriers might be more evident to you, but if you are working in an urban area, then imagine you were managing your patient in a rural setting. Consider the impact that barriers to healthcare will have on the patient’s health, their family/carers and also their GP, and how these barriers might be managed.

  • What resources might assist rural patients to travel to access care? Look at this resource for state-specific options: A Guide to Patient Assisted Travel Schemes.
  • What role does telehealth have in the rural setting? Consider the pros and cons of telehealth for patient care. What limitations might affect telehealth access in rural settings? Consider possible access, infrastructure, language and cultural barriers.
Identify the incidence of farm accidents, motor vehicle accidents, coronary artery disease and breast cancer health outcomes for rural Australia compared with urban Australia (the Australian Institute of Health and Welfare website will assist).
  • Were you surprised by the differences? Why might there be such differences in health outcomes?
  • What strategies could a rural GP use to reduce the incidence of these accidents and conditions?
Look at the  health workforce locator website. Follow the link to ‘rural, remote and metropolitan areas’, and consider workforce distribution.
  • Do you understand the Modified Monash Model?
  • What distribution priority areas are currently highlighted in your local area or state?
With a supervisor

Procedural skills are likely to be needed in a rural setting. Consider what procedural skills would be useful for a rural GP. Discuss with your supervisor what opportunities there might be in practice to brush up on these.

  • Has your supervisor got any general tips or tricks to share?
  • Can you use a slit lamp? Are you able to manage simple fractures? Can you use the ECG machine in your practice? How comfortable are you using a dermatoscope? Has your supervisor got any tips or tricks to share?
  • Ask them to demonstrate a procedure you have identified. Have you seen this done before? Have you performed it yourself? How confident would you be repeating the procedure by yourself? Did you note an equipment list? Is there an item number for this procedure?

Do the following role play with your supervisor. You are a GP in a town of 10,000 people, and your supervisor is playing the role of Joe, a local policeman who presents requesting assistance with their drinking. Joe admits to drinking until passing out most nights, and is keen to stop drinking. Take a brief history and then present your findings with the main issues to be considered.

  • What are the key points in this situation? What further history is needed? What specific ethical issues arise here?
  • Does your supervisor have any tips on managing professional boundaries in a rural location?
In a small group

Have each member of your group identify and research one common medical condition/presentation and then consider how practising in a rural context might affect treatment and management. Include both acute and chronic conditions. Examples include myocardial infarction, diabetes, alcohol and other drug use, asthma, chronic back pain, family and domestic violence, mental illness, chlamydia infection, rheumatoid arthritis and obesity.

  • As a group, share your thoughts and brainstorm some solutions to the challenges that were raised.
  • What resources might be helpful for a rural GP before going rural and when practising rurally?
  • What experience have your group members had in rural practice?
  • What differences in practice did you notice? Does the size of the town matter?

Discuss the scenario where each of you is moving to a rural location.

  • How do you feel about the move? What preconceived ideas do you have about practising in rural locations and how could you prepare for practising in this location? What strengths do you have that will help you get the most out of the experience? What challenges are you most concerned about and how will you manage them?
  • Rural health seems to thrive on acronyms. Can you name and state the purpose of the following organisations: RDA, RWA, CRANAplus, ACRRM, RACGP Rural?
  • What Australian medical journals have a rural focus?
With a friend or family member

Find a friend, relative or colleague who has lived and worked in a rural location. They do not need to be a doctor. Ask them about their rural experience and engagement with health services.

  • What did they find rewarding? What was different about the rural context? What was particularly challenging? Did they find a GP? Did they find it difficult to access specific healthcare services (imaging, non-GP specialists)?

Discuss your current self-care strategies with a friend.

  • What changes would you need to make if you were working in a rural area? How might you adapt?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Identify and manage vulnerable groups in rural and remote communities (noting that vulnerable groups often overlap, and many patients might have more than one vulnerability), and consider increased challenges with time pressures and lack of access to allied health or other social services. Groups include:
    • Aboriginal and Torres Strait Islander people
    • individuals from culturally and linguistically diverse communities, including refugees and asylum seekers
    • LGBTIQ+ individuals
    • individuals with low health literacy
    • socially disadvantaged individuals (people who are unemployed and/or homeless)
    • substance-using individuals and their families
    • individuals with severe mental health issues
    • individuals with disabilities
    • individuals who have been exposed to intimate partner/family violence
    • families with special needs, such as those with a hereditary disease, single parent families or those with marital problems.
  • Develop a range of communication skills, including:   
    • collaboration and networking with other individuals and agencies and providing care coordination to optimise patient care
    • use of available communication infrastructure when face-to-face consultations are not possible, for example, telehealth.
  • Manage emergencies:
    • Provide emergency care appropriate to the situation and the community.
    • Work with emergency services in the community to prepare for and respond to emergencies, including local disaster management.
    •  Acquire and maintain appropriate advanced life support skills.
  • Develop skills necessary to provide comprehensive care, such as:
    • a broad range of diagnostic, therapeutic and clinical management skills
    • procedural skills relevant to context of practice; for example, obstetrics and gynaecology, anaesthetics and emergency medicine
    • provision of care in multiple contexts, such as private clinics, community settings and the local hospital, including inpatient care
    • additional skills in aged care, mental health, palliative care, and Aboriginal and Torres Strait Islander health.
  • Identify and address community health issues through health promotion and advocacy, including:
    • public health risks
    • depression and suicide
    • alcohol and other drugs
    • risk-taking behaviours
    • occupational risks
    • conditions specific to the local area and patient population.
  • Address barriers to accessing care by:
    • advocating for and participating in the provision of appropriate care and care services for the community
    • providing appropriate care to people who live in isolation.
  • Practise professionalism and self-care by:
    • participating in after-hours patient care, as required
    • maintaining professional boundaries
    • managing personal and professional isolation, geographically and socially
    • accessing own healthcare when living and working rurally.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Morbidity, mortality and the patterns of suicide and accidental death in farming communities. How mortality from chronic disease varies by remoteness areas of Australia. A case commentary on a rural doctor’s overlapping professional and personal roles. A medical legal advisor discusses how to maintain professional boundaries. An interview with a rural doctor on his approach to self-care.
Textbooks

A practical guide to the delivery of healthcare in rural and remote Australia.

  • Smith JD. Australia's rural, remote and Indigenous health. 3rd edn. Chatswood, NSW. Elsevier, 2016. (Available from the RACGP library.)
Online resources
A short video with self-care advice for rural professionals. Stories of rural doctors.
  • AMA New South Wales. Rural doctors: Outstanding in their field.
The logistics of rural and remote health, with links to services and supports. Health support for farmers. The importance of improving access to health for Aboriginal and Torres Strait Islander people in rural and remote areas.
Learning activities
RACGP rural health webinar series.
  •  The Royal Australian College of General Practitioners. RACGP Events:
    • Climate change and rural health
    • Walking the walk: Reducing burnout and improving wellbeing for rural GPs
Webinars on a range of topics for rural doctors, including locums.
  • The Royal Australian College of General Practitioners. Rural health.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/rural-health 23/05/2022