The geographic maldistribution of ophthalmologists in Australia is a long-standing issue contributing to eyecare inequity for residents with a regional postcode. Insight talks to regionally-based ophthalmologists and investigates what is being done to fix the issue.
When Dr Kong-Chan (KC) Tang was an ophthalmology trainee in the mid-1990s, all he had ever known was the bright lights of Sydney. But an opportunity arose to spend a year in Orange under Dr Henry Liu, in a move that altered the trajectory of his career.
Almost 30 years later he remains there practising solo at his Midwest Ophthalmology clinic, a situation he wouldn’t have considered if it wasn’t for the exposure he had during his training. It also helped that – after completing his training in 1998 – a position in Orange was waiting for Tang whose wife had a country background.
“I was very fortunate, particularly these days we find it difficult to attract people to areas like Orange because the doctor’s partner and their professional commitments also come into the decision, so it isn’t always possible to make the stars align,” he says.
“To practise in the country, you also need to have broad-based knowledge. When we advertise for locums, many say they don’t see glaucoma patients or kids etc, but I have a paediatric clinic, I do squint surgery, completed my fellowship in retina and even perform the odd glaucoma operation, so you have to be well-trained to be confident to work in the country.”
Part of the problem, according to Tang, is that trainees get into teaching hospitals where fellows oversee their own ophthalmic sub-speciality such as glaucoma, retina and paediatrics. As a result, trainees may not get the hands on experience required to feel equipped for regional practise.
There’s also the issue of succession. Tang, like many regional ophthalmologists, is in his 60s and acutely aware of the need to entice the next generation. In Orange there are two other full-time ophthalmologists with another splitting their time between Dubbo and Orange.
“We’re getting a fellow, a fourth-year trainee, for the first time next year who will come to the area with some funding, which is great because we have been scratching our heads to attract people here,” he says.
“But ultimately I think the fact I had done some prior work in Orange opened my eyes to what’s possible in regional areas, and that’s why it’s important the college tries to expand the network of rural positions to give people that exposure.”
How RANZCO is responding
Fortunately, RANZCO is across many of the issues Tang raises, and has new, evidence-based initiatives to bolster the regional ophthalmology workforce.
The imbalance of urban versus regional/rural eye doctors was laid bare in a 2018 Department of Health ophthalmology workforce report confirming 84% work in big cities (category 1 in the Medical Monash Model [MMM] – a spectrum that extends to MMM7 to determine if a location is city, rural, remote or very remote). That means some 16% of ophthalmologists work in regional areas, which is insufficient for the 29% of the Australian population that lives regionally.
In this 2018 report, based on 2015 data, ophthalmology was considered a priority area by the expert National Medical Training Advisory Network (now known as the Medical Workforce Reform Advisory Committee). The report identifies a maldistribution of ophthalmologists with most working in urban locations, a higher-than-average reliance on international medical graduates, an impending critical shortage of paediatric ophthalmologists and a lack of funded training positions in the public sector.
RANZCO’s own analysis has also shown that of the ophthalmologists who trained and graduated between 2013 and 2016, 90% reside in urban areas. This aligns with the 2018 report that found 85% of trainees are located in major cities (MMM1), with 9% in MMM2, 3% in MMM3 and 1% each in MMM6 and MMM7.
The report recommended an increased intake of trainees to counter the predicted undersupply of ophthalmologists in 2030 of three per year from 2019 – compounding.
But it had a particular focus on regionally-focused initiatives for RANZCO.
This included several steps including formalised training of additional supervisors, particularly in regional, rural and remote settings, as well as potential mechanisms to address maldistribution such as preferential selection of trainees with a rural background, or who have undertaken rural placements as a medical student, or worked as a junior doctor in a rural area.
It was also recommended trainees undertake at least six months training in a regional, rural or remote area and/or experience working within an Indigenous health service and that final fellowship assessment demonstrates fellows can practise the full scope of ophthalmology across Australia.
For several years, Dr Justin Mora, who finished a six-year term as RANZCO’s censor-in-chief in November 2022, and Tasmanian ophthalmologist, Dr Kristin Bell, have been working behind the scenes to bring many of these recommendations to fruition.
Mora tells Insight many factors contribute towards ophthalmologists choosing to practise in capital cities. One is that RANZCO trainees typically don’t get on to the course until they are around 30-years-old. This is because, after leaving medical school, they can spend up to four-and-a-half years trying to bolster their CVs with experience and training.
Ophthalmology is a highly competitive speciality among trainees, with around 135 applications each year for around 32 positions across Australia and New Zealand. In previous years, the ophthalmology trainee selection process has rewarded those with the best academic record and experience. At a minimum, all have done a mandatory two-year internship out of medical school, usually followed by one year of ophthalmic experience.
Some then go even further to stand out.
“There was one particular year where out of 32 new entrants, we had 18 Master’s degrees and four PhDs. And of course, that adds time to people’s post-medical school experience,” Mora explains.
“By the time you’re 30-years-old, if you’ve spent all that time in an urban environment and have a spouse or partner, it gets harder to leave that lifestyle to go work in a regional area. A lot of trainees also have young families by the time they qualify, and they’re worried about schooling.”
While RANZCO is attempting to address this issue by enticing younger medical school graduates through different selection pathways, Mora and Bell have been focusing on two key areas, as highlighted by the 2018 workforce report, to strengthen the regional workforce at the trainee level. These are:
1. A greater emphasis on accepting trainees with a regional background and First Nations applicants
2. The establishment of RANZCO’s Regionally Enhanced Training Network (RETN), which will commence its first rotation in February 2023.
At the same time, RANZCO is also advocating for more training positions in public hospitals, stating that a healthy workforce is dependent on a healthy public ophthalmology service right across Australia because this is where most specialist training does and should continue to occur.
“We have repeatable data from our workforce surveys that tell us that people from regional backgrounds proved to be 2.7 times more likely to end up practising regionally, either living regionally or doing outreach regionally,” Mora says, noting that only 9.3% of RANZCO fellows had a regional background in 2017.
“Therefore, we had the evidence to give higher priority to people from regional areas. That has proven successful. The way the system works is RANZCO creates a shortlist based on objective criteria, and then the hospital networks put their selection criteria around it.”
As a result, more than 40% of trainees during the past two to three years have a regional background.
Mora says RANZCO has been addressing concerns about the level of training too.
He points to a trend during the past 20-30 years where graduates increasingly subspecialise in their final year, potentially impacting their confidence to work regionally where ophthalmologists need to be generalists.
“We’re trying to address that as part of our curriculum review where we’ve refocused our attention on creating general ophthalmologists. And as part of that, at the end of their fourth year, trainees have to prove through various means, including logbooks and rotations and the number of surgical procedures and so on, that they have reached the standard of a competent general ophthalmologist,” Mora explains.
“If they pass, they can go into a subspecialty year, and if they haven’t, then they have to do more general ophthalmology in their final year.”
Greater regional exposure
Kicking off in February 2023, the Regionally Enhanced Training Network (RETN) is a new Australia-wide training network RANZCO has developed that will ultimately see trainees on the program spend 60% or more of their time in regional Australia.
RANZCO has proposed four pathways: the Top End Pathway, Northern Victorian Pathway, Northwest NSW Pathway, and Western NSW Pathway. The first two RETN trainees are set to commence in February 2023.
Each takes five years to complete with the ‘first foundation year’ spent in a regional centre public hospital setting, the ‘second consolidation year’ in a regional private practice or public hospital, the ‘third subspeciality year’ in a major city, and the ‘extension and challenge’ final two years based regionally in a comprehensive practice, including care for Aboriginal and/or Torres Strait Islander patients.
For example, the Northern Victorian Pathway is: Year 1: Geelong, Year 2: Albury- Wodonga, Year 3: Melbourne, Year 4: Shepparton, Year 5: Shepparton.
According to RANZCO, the major differences between the RETN and existing networks are that trainees will complete their entire five-year vocational training program with the RETN, and trainees will complete an increased proportion of their training in regional Australia.
“Dr Kristin Bell’s projections are that we could see 10 rotations within the next 10 years, which is ambitious but possible with appropriate funding. This would equate to 40 trainees – that’s a lot when you consider we take around 35 across Australia and New Zealand each year, with around 25 in Australia alone,” Mora says.
“That’s potentially another eight people per year just in the regionally-enhanced scheme, so that would have a major impact.”
Mora says it has been a long and arduous process to establish RETN, which demonstrates RANZCO’s leadership among the medical colleges. As the trainee progresses through RETN, RANZCO is required to work out a bespoke funding model due to the various ways regional ophthalmology training is provided in Australia.
A mixed model of funding for the RETN training posts is used consisting of a combination of conversion of existing unaccredited registrar positions to accredited positions, the Federal Government’s Specialist Training Program (STP – more detail on this below), and State Health Services funded positions. It’s also important to note the funding covers each training ‘post’ so each position is filled each year to ensure continuity of regional service provision, and the funding doesn’t necessarily move with the trainee.
“The funding of RETN encompasses not just the salary for the trainee, but also access to cases, funding of surgical cases and clinics, accommodation, teaching money, transportation back-and-forth and so on. It’s a significant package and it all has been accounted for – we can’t set up an under-funded program,” he says.
Mora says Bell has been influential in bringing the complex RETN to life, twisting arms to make it happen, including commitments from state governments. Both state and commonwealth health departments are keen to deliver regionally enhanced specialist training programs, however, with the health dollar under pressure and the complex interplay in health funding between the state and the commonwealth and within each state health department, navigating this complex funding environment has been challenging and remains so.
“It’s been gratifying in the last 12 months to see things start to gel. We’ve been pursuing this during the past three to four years and it felt like it was falling on deaf ears,” Mora says.
“And then with RANZCO’s Vision 2030 and beyond project – which highlighted the need for more ophthalmologists overall, regional ophthalmologists, First Nations ophthalmologists, and presented the many issues as a package – suddenly, federal and state governments have been spurred into action. They’ve realised how serious we are about addressing this issue.”
According to RANZCO, regional posts have a lot to offer trainees. They provide broad comprehensive ophthalmology clinical experience with increased opportunities to follow each patient through the course of their presenting problem. This contrasts with the patient journey in big city teaching hospitals, where patients are typically funnelled into subspecialty clinics. Regional terms typically offer trainees a wider range of surgical training.
The primary aim of the RETN is to train well-rounded ophthalmologists who have the skills and confidence to practise comprehensive ophthalmology post-fellowship in any area.
The college says it’s designed so that trainees can develop a solid foundation of knowledge and clinical and surgical skills which they then build on over the initial three years, culminating in them taking the RANZCO Advanced Clinical Examinations (RACE) at the beginning of their fourth year of training.
In the final fourth and fifth years, Mora says RETN is deliberately designed so the trainee spends two continuous years in the same regional area.
“That’s in the hope they will become embedded in the local community and encourage them to continue working there once qualified,” he says, noting that RANZCO can’t ultimately dictate where RETN trainees go.
Flaws in specialist training program
RANZCO’s RETN wouldn’t be achievable without in-part funding from the Federal Government’s STP; especially the Integrated Rural Pipeline Funding (IRTP) part of the STP which allows for in-part funding of urban posts for regionally enhanced trainees.
STP was introduced in 2010 to support medical training positions outside of traditional metropolitan teaching hospitals. The latest extension of this, announced in March 2022, will see $708 million spent from 2022 to 2025 to fund 920 full-time equivalent places annually, with at least 50% of training occurring in regional, rural and remote locations or private settings.
To help cover the annual salary of trainee specialists, STP provides RANZCO and other medical colleges with $105,000 per full-time equivalent position, an additional $25,000 Rural Support Loading allowance for training positions in regional, rural and remote areas, and a Private Infrastructure and Clinical Supervision allowance of $30,000 for training positions in a private sector setting.
However, STP funding does not fully cover the cost of a state health funded Local Hospital Network (LHN) employing the trainee but does cover a large proportion of the costs. There is an expectation from the Federal Government from the state health departments will also contribute. The challenge is to get a commitment from LHN to employ the registrar and cover any additional costs.
The main drawback of STP and STP-IRTP funding is that the program works on three- to four-year funding cycles and can’t guarantee what will be available in the following five- to 10-year period. This presents a challenge in medium to long term workforce planning but RANZCO has been told it is unlikely to change in the foreseeable future.
Mora notes: “We need more certainty – we need to know if we’re setting up a training program for five years, that it’s covered for the entire time span. The way STP is designed means funding is rotated every four years, so there are no guarantees.”
However, the Federal Government, as well as several state health departments, have indicated their support of the RETN and communicated that existing funding is likely to be continued and further development of the program supported. This gives RANZCO the confidence to further develop and extend the RETN.
What it’s really like to practise regionally
Dr Christopher Bailey, who has been practising in Wagga Wagga for 28 years, is aware of the RETN and other schemes to encourage more trainees to settle regionally. While he’s supportive of the idea, he believes it’s important RANZCO selects trainees that will stick with the spirit of the program.
“When I was trying to get on to the ophthalmology training program 30 years ago, some people would say they intended to work in the country and so they got picked, but now they’re working in the eastern suburbs of Sydney,” he recalls.
“You can’t dictate where people go at the end of the day, but it will perhaps get people to strongly consider a career in the regions.”
Originally from Sydney’s west, as a trainee Bailey was destined to head overseas for a fellowship. But the funding fell through, and a call went out for registrars to give Wagga a try. With a young family, he initially gave it six months – and hasn’t left.
Of the four ophthalmologists in Wagga, Bailey and another are in their 60s and another is in their mid-50s. He’s concerned about an impending workforce shortage. When the town accepts eight registrars on rotation from the Sydney Eye Hospital each year, it’s a key opportunity to present the benefits of a regional lifestyle.
“When you work in the regions, the first thing you notice is the amount of work coming your way, you’ll hit the ground running – and no one’s going to be unhappy if you take away some of their work,” he explains.
“In Wagga, we’re at the point now where we could easily help someone who wants to sub-specialise. One of the other ophthalmologists here subspecialises in oculoplastics and if someone arrived and said I’d like to do glaucoma, we’d ask them when can you start? And we also have a retinal surgeon 100km away.
“When registrars come on rotation, some say they didn’t realise that things were so good away from the city. They don’t have to travel an hour to get 15km; it takes me seven minutes to get to work. The housing prices are much lower and you can get 60 acres of land 10km out of town, if that’s what you want to do.”
Fellow Wagga Wagga ophthalmologist Dr Brent Skippen, the previously mentioned oculoplastic surgeon, believes the main barriers to a regional ophthalmology career are the fact many have family in Sydney, or a perception that a city job is more prestigious.
In terms of ways RANZCO could incentivise young eye specialists into the regions, he supports moves to prioritise rurally born doctors, those with rural families and those rurally educated. During training, he said more registrar training could be performed in the country with six- and 12-month rotations, rather than rotate every three months.
“Post-training, we could encourage more rural locum placements for junior specialists – this might convince some to change course posttraining and relocate to a regional practice,” he said.
In the early stages of his career, Skippen was a junior doctor at St Vincent’s Hospital, a smaller city hospital that had a similar feel to a large rural hospital. Wagga was the rural secondment on several occasions. He’s also worked for Médecins Sans Frontieres in Armenia, and in regional Australian areas such as Goulburn (student) and Armidale, Wagga and Lismore (doctor). He completed his oculoplastic fellowship in the UK and Italy.
He met his wife – a Wagga local – in Sydney, before getting married in the regional NSW town and deciding it was the best place to raise their family.
He’s found his career is well balanced between general ophthalmology training and subspeciality training (oculoplastics).
“In terms of fulfilment from regional practice, clinically I have great patients and close collaboration with likeminded colleagues. Teachingwise, I’m an Associate Professor with the UNSW clinical school and senior lecturer with University of Notre Dame rural clinical school, and in research, I maintain close ties with an Italian colleague (mentor), and we are able to generate research and publications and mentor UNSW students.
“I’m also only a 10-minute drive from home – on five acres – to the office.”
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