Training rural doctors: is there a formula for (Swedish) success?

1. August 2015 Training rural doctors: is there a formula for (Swedish) success? The theoretical part of the equation Dean Carson Glesbygdsmedicinbskt Centrum (Visiting Professor) Northern Institute, Charles Darwin University, Australia.

2. Why rural training? • To improve the recruitment and retention of rural doctors – a global challenge

3. But not a new challenge! • Mesopotamia 3000bc • Hard to get physicians to work outside the city walls • Donkeys, goats, wives, housing, holidays... 3

4. Many solutions have been tried • Wilson, N. W., I. D. Couper, E. De Vries, S. Reid, T. Fish and B. J. Marais (2009). "A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas." Rural and Remote Health • Coercion • Financial incentives • Personal and social support • Limited evidence of success – successful cases, but no universal indicators

5. The best evidence • ‘Rural background’ • Family home • Schooling • ‘Rural Exposure’ • Clinical training • Maybe other rural based activities like research or community projects • The ‘Rural Pipeline’

6. Does it work here? • Aaraas, Ivar J., Peder A. Halvorsen, and Olaf G. Aasland. "Supply of doctors to a rural region: Occupations of Tromsø medical graduates 1979-2012." Medical Teacher • Carson, Dean B., Adrian Schoo, and Peter Berggren. “The ‘rural pipeline and retention of rural health professionals in Europe’s northern peripheries.” Health Policy • Recruit and Retain project and survey • Scotland, Ireland, Norway, Greenland, Iceland, Sweden, Canada • Sweden – 80% with rural training want to stay rural (vs. 70%) • Rest of European participants – 70% vs 60% • Canada – 90% vs 80%

7. When does rural training ‘work’? • When the quality of education and exposure to ‘real practice’ is high • When training is ‘immersive’ (students live the rural doctor life, not just visit it) • When the community is involved • When it happens at the right scale (usually one or two students per supervising doctor)

8. Will rural training solve everything? • Geographic limitations – 70% go where they were trained (or where they grew up) • So need to have ‘exposure’ to as many places as possible • Time limitations – when do people ‘go rural’? What ‘markets’ are there (early career, mid life changers, pre-retirement)? • We might need different rural training systems for different ‘markets’ • Scale limitations – can we train enough in enough places? Competition with Umeå…

9. International lessons • QA - Rural training is higher quality in every case – personalised and practical learning. Partnerships between small and larger hospitals address curriculum issues. • Host Hospitals – Local doctors enthusiastic about becoming teachers. Many hospitals well equipped in medical and communications technology (and used to using it). • Student Selection – works best if community involved in process, and students visit the community first. • Student Costs – participating communities often cover costs of travel and accommodation. • Social Satisfaction – students offered opportunities for sport, culture, volunteering… and students WANT this. • Community Demand – Unis in Australia and Canada have developed proven process for community engagement and ensuring community participation in the program.

10. What could be done here? • QA – Partnerships with regional hospitals (Lycksele, Kiruna etc). Oversight from Umeå - Umeå remains the ‘home base’ for students, allowing continuous monitoring. Borrow evaluation processes from Australia and Canada. • Host Hospitals – Storuman (for example) has 3 qualified GP educators. Many sjukstuga equipped with distance bridging technologies. Rural hosts can form a network to share experience. • Student Selection – participating communities can host student visits prior to selection. Community representative can help interview students. • Student Costs – formal contract with Kommuns can secure housing (and internet and transport to Umeå) at no cost to student. • Social Satisfaction – students can have a local ‘buddy’ from the community to help them get involved in community life (it works for my students!). • Community Demand – Demonstrated in many communities here already who host student research and other visits. Community engagement process can be implemented here.

11. How GMC can help • Offer advice on which pilot communities • Liaise with communities, run the engagement process • Help train and mentor rural educators • Assist with QA and evaluation – especially impacts on communities • And connect with our international partners • Support other ‘rural exposure’ options like ‘training doctors for towns without doctors’ (research and community projects etc.) • Be an advocate for rural training models in Sweden

12. Quick Summary • ‘Rural training’ works to improve recruitment and retention (Canada, Australia, South Africa, USA…) • Some evidence it already works in Sweden, even though we don’t do much of it • It is not easy and it does not solve everything, so we need to research how to do it here in the context of other things we need to do • A good opportunity to start moving forward with Umeå Uni pilot • GMC is a critical part of the equation