“There is no practice more salubrious, or which tends more to renovate the constitution, than a temporary retirement to the country.”
– Sir John Sinclair, The Code of Health and Longevity, 1844
When I first told people that I wanted to spend my fourth year of medicine in the rural town of Tamworth, they were nothing if not surprised. Born and raised in Sydney before moving to Newcastle for medical school, I was definitely a city kid, albeit one with a significant horse-girl phase. But when the time came to pick our preferences for fourth year – our first year of full-time hospital placement – there was something about Tamworth that just appealed to me.
Partly it was the fear of placement in a big city hospital, where I would have to compete with a hundred other students for opportunities. Partly it was my desire to get out of Newcastle and minimise distractions during what’s widely regarded as the toughest year of medicine in our degree. I also liked the size of Tamworth – it was rural enough to be a big change for me, but it wasn’t as small or far away as some of the other clinical schools available, such as Armidale. In the end, I was lucky to get a spot in the popular Tamworth, but it was the best decision I’ve ever made for my medical education. Since then, nobody that I’ve spoken to regrets taking a rural year – it is certainly a unique learning opportunity and one I would wholeheartedly recommend!
Smaller hospitals mean fewer students, and this is by far the biggest learning advantage you will have if you choose to go rural. In Tamworth, I was the only fourth-year student on my medical team, and the only student at all on my surgical team. As a general rule, smaller number of students = greater number of opportunities. As the only student on your team, you’ll have the chance to do everything from short cases to cannulae on a daily basis. In addition to being good for learning, it also means that you form a really strong relationship with the doctors on your team; instead of being a nameless face in a sea of a hundred students, you are a valued and involved member of the team.
The other advantage to fewer students is that patients are happier to see you! It’s a sad but real fact that many patients at tertiary teaching hospitals see a high volume of students every day, and it’s easy to imagine how this might be tiring or difficult. In my rural referral hospital, however, I encountered very few patients who were “student-weary”. Although it is always the patient’s right to refuse a student, I was consistently humbled by the patience and selflessness of the patients I saw. I lost track of how many times I was told “You’ve got to learn somehow!” as a generous inpatient allowed me to examine her neurological system or auscultate his child’s lungs. This generosity extends to the team of dedicated clinicians at the hospital; students are invited to everything from grand rounds to JMO education sessions to ED teaching.
Finally, you can’t talk about rural placement without mentioning life in a rural town. I was a little apprehensive about living in a town almost a hundredth of the size of my birth city – but I loved it. With a population of roughly 50,000 Tamworth is big enough to have the key amenities (aka Kmart and several Thai restaurants), but small enough to retain the small-town atmosphere. Everyone you meet is friendly, genuine, and down-to-earth, and the landscape is beautiful and wild. A word of warning, though: you will see doctors and patients everywhere in town – the gym, the pub, the theatre – so be very careful discussing confidential clinical cases when in public, even if you are debriefing with other students. Remember that in a small town, everyone knows everyone.
Although I would definitely recommend the rural experience to any medical student, there are bound to be some downsides when you move 3.5 hours away from your urban clinical school. One of the greatest dangers is isolation. Mental health in medicine is emerging as a paramount issue, and, unfortunately, doctors who work in rural and remote medicine have been identified as an at-risk group for psychological distress (1). Though there are fewer data on medical students in the same position, it seems reasonable to assume that the dramatic change in location, support network, and workload (transitioning from non-clinical to full-time clinical placement) can be very daunting.
Fortunately, I was lucky enough to live in purpose-built university accommodation with fifty other students from different health disciplines, so I never felt alone or unsupported. Your peers and uni mentors are a great place to start in terms of building a new support network. I would also encourage anyone moving to a smaller town to investigate social activities in the area; whether it be a sporting team, musical society, or worship group, these activities give you the opportunity to meet new people, while also fulfilling the key role of non-medicine hobby – especially crucial in clinical years. Finally, if you find yourself struggling, AMSA has some good resources regarding isolation (2) and support services (3).
Another potential downside of rural placement is the reduced focus on subspecialty work. Most medical and surgical teams are generalised, and cases that require specialised services, such as long-term ICU or high-risk obstetrics, must be referred to tertiary centres. In saying that, I didn’t feel disadvantaged compared to my cohort by being attached to general medical and surgical teams. On the contrary, it can actually be an advantage when it comes to examinations such as long cases. Some of my peers spent eight weeks attached to a medical team that only saw endocrinology patients, so when their long case was on a cardiology patient, they felt like they hadn’t had much experience in that field. Meanwhile, I had seen a good variety of patients on my general medicine rotation.
Finally, it’s an unfortunate truth that living away from uni means you miss out on uni events. While this includes social events like MedBall and my personal favourite, MedRevue, it also includes specialised lectures and panel discussions only offered on campus. I didn’t often feel like I was missing out, but certain events, like end-of-semester review lectures and interprofessional Faculty of Health panels, were more difficult to access from our rural school. Hopefully, future improvements in videolink technology will maximise rural students’ participation in panels and lectures held at urban clinical schools and tertiary centres.
There are also some experiences that are utterly unique to rural placements. One of the highlights was travelling to towns of less than 1,000 people to run basic first aid courses and Teddy Bear Hospitals. These “hospitals”, where young students bring in their toys for check-ups, are a key chance for rural kids to familiarise themselves with visiting the doctor in a safe environment. The University of Newcastle’s Department of Rural Health also hosts monthly Interprofessional Learning Modules (ILMs), where students from all allied health and medicine degrees come together to learn about their roles in caring for patients with conditions such as diabetes and cancer. Members of the community would sometimes participate in the ILMs too, giving us a key insight into patients’ perspectives.
Another example of the uniqueness of rural placement is tackling the issue of health equity and access to care in the rural setting. Unfortunately, health outcomes, such as life expectancy and disease prevalence, are poorer in rural areas than in major cities (4). The GP consultation rate is generally lower, while the hospitalisation rate is higher (5). Other issues include reduced access to specialist care and increased accident rates due to less safe environments and occupations (3).
Fortunately, this healthcare disparity is gradually improving. One example that particularly stood out to me was explained by a cancer survivor in one of our ILM sessions, who spoke of her experience battling cancer several decades ago. She described having to travel all the way to Sydney for radiotherapy to treat her disease. This experience was costly both financially and emotionally, as it meant being away from her family and support system for long periods of time while receiving treatment.
Almost five years ago, the North West Cancer Centre was built on the Tamworth Hospital grounds. This new centre has allowed people from the surrounding regions to receive cancer treatment without having to travel to a major city, with additional facilities for family and carers as well as patients. Hopefully, interest in working rurally (for both students and doctors) will continue to grow, and we can all work towards resolving these equity and access issues.
Overall, my year in Tamworth was a comprehensive, challenging but ultimately an inspiring introduction to clinical medicine. Signing up for a year of rural placement can be daunting, but I want to assure you all that it is absolutely worth it. You will meet incredible doctors, be humbled by patients’ experiences, and learn more about medicine and about yourself in a week than you would in a year in a familiar urban setting. I miss it already!
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