One for all, not all for one: Emergency medicine training beyond the metropolis

Abstract

Rural, regional and remote Australian communities continue to suffer higher mortality and poorer access to healthcare compared with those residing in metropolitan centres. Part of this can be explained by the significant shortage of skilled clinicians, with the ratio of medical specialists to population being up to four times higher in the cities compared with remote areas. Over recent years, there has been an increase in the number of Fellows of the Australasian College for Emergency Medicine (FACEMs) working in regional areas. However, the FACEM training programme lacks prioritisation of the nuances of regional and rural emergency medicine (EM), producing new FACEMs preferentially suited to metropolitan EM practice and subsequently encountering significant challenges when lack of specialist positions compels them to work in regional sites. The Australasian College for Emergency Medicine (ACEM) needs to consider strategies that not only ensure it is producing excellent generalist emergency physicians but also fulfilling its obligation to the regional communities those physicians serve. The Australian Institute of Health and Welfare categorises areas as major cities, inner regional, outer regional, remote and very remote. The provision of EM for each category requires overlapping yet unique skill sets. ACEM-accredited training facilities are located across major cities, inner and outer regional areas and must meet the minimum standard of FACEM supervision outlined in the Accreditation Requirements. The outer regional, remote and very remote healthcare facilities not accredited by ACEM have a variety of staffing models, and there is a paucity of reliable data to indicate the nature of the workforce at these sites. Some of the outer regional communities are served by Fellows of the Australian College of Rural and Remote Medicine (FACRRMs), who throughout their training develop the skills required to practice independently across multiple areas of the hospital. Remote and very remote communities are even more difficult to characterise, some being served by permanent skilled general practitioners, while others are staffed by locums, junior doctors on rural relieving terms, or international medical graduates fulfilling an area of need requirement. One survey of doctors practicing in remote sites found that as many as 27% of respondents did not have a postgraduate qualification nor had even completed an EM-relevant course. In recent years, ACEM has been working to improve access to quality EM education for many rural, regional and remote health practitioners via the Emergency Medicine Education and Training initiative. Conversely in New Zealand, the data does not reflect a similar inequality in health outcomes between rural and urban populations. The classification system categorises an area as ‘urban’ or ‘rural’. There are several rural sub-categories, based on a measure of ‘urban influence’. As a result of this fairly ambiguous categorisation, there can be significant differences in access to healthcare between sites belonging to the same rural category. Nevertheless, it is clear that regional and rural Australia are bearing the brunt of healthcare inequality.