My name is Penny Wilson and I am a bonded doctor under the Medical Rural Bonded Scholarship Scheme. It’s a topic that it still considered somewhat of a taboo and although opinions on its fairness and effectiveness abound, no one seems to talk about what it is like for those who are bonded. So here I present my story which I hope is of interest to others.
Background to the MRBS
The MRBS is a federal government initiative which took its first cohort in 2001 with one hundred medical students from across Australia having been enrolled each year. The deal: a payment of $20,000 per year of medical school (indexed annually, now over $25,000) in return for working in a rural area for six years after achieving fellowship, minus any scaling discounts. The penalties for changing your mind are considerable. If you pull out of the scheme during med school you lose your university place and aren’t permitted to re-apply to study medicine for a further 5 years. If you pull out after graduation you are required to repay the money with interest and you lose your access to a Medicare provider number for 12 years – essentially preventing you from earning a living through clinical medicine. (NB: This is different to the Bonded Medical Places scheme which started in 2004.)
It has been described as “exploitative” by AMSA in their policy document and the AMA guide for prospective medical students also encourages candidates to carefully consider if “there are other options that would suit you better, other than accepting a bonded place.” A 2011 review of rural workforce policies projects that rural bonding programs will have a significant positive impact on clinician numbers in rural and remote areas and improve access to health care over the coming years. So is it the answer to our country’s rural workforce woes? The first group of bonded doctors have just been starting to trickle through fellowship in the last couple of years so the real impact on rural communities has yet to be seen.
In December 2000, just weeks after year 12 exams, I was anxiously waiting to find out if I had been accepted into medicine at UWA. The day before university offers were due to be released I was surprised with a phone call from the Faculty of Medicine and Dentistry telling me that not only had I been offered a place in medicine, but that I had also been offered a MRBS. It was made quite clear to me that regardless of my decision regarding the MRBS, my entrance scores were high and so a place in medicine was guaranteed. You can imagine how overjoyed and overwhelmed I was with the news that not only had I achieved my dream of landing a place in med, but also had this offer of a substantial scholarship to help me on my way. For someone straight out of high school that sum of money seemed enormous, particularly as I was earning $7 per hour at Hungry Jack’s at the time!
After some careful discussion with my family I decided to take the scholarship, based on the fact that (a) my family wasn’t in a position to support me through university so it would have been a struggle financially, (b) I had enjoyed occasional family holidays to “the country” so figured I living out there someday would be quite fun, and (c) I liked the idea of providing a valuable contribution to a community. I was only 17 at the time and making a decision that would affect me for at least another 17 years into the future. It is easy to see in retrospect how naive I was. I had this wildly romantic idea of what it was like to be a country GP and had a teenager’s optimism that everything else in my life would have worked itself out perfectly by then. Admittedly, at 17, my favourite band was Savage Garden, my dream car was a mazda 121, my best friend wanted to be a mermaid and I wanted nothing more than to marry Brett Lee and live in a castle. It’s no wonder that I really had no concept of the reality of rural practice, knew nothing about medicare, provider numbers, fellowships and training options and couldn’t have imagined what a major influence this decision would have over every aspect of my life.
In the early days of uni, I felt that there was a fair bit of stigma about being bonded, particularly as we were the very first year group which had it. No one really felt comfortable admitting that they were bonded and I would often find myself in the awkward situation where other students were talking about it in a negative way and I kept quiet in an attempt to fly under the radar. I think a lot of people had the (erroneous) belief that we only took the scholarship to secure a place in med and maybe for that reason we were considered second class students. Or perhaps they just thought we were crazy to agree to it.
Things got a bit better in 4th year when the Bonded Support Program started through ACRRM. It put on networking functions for bonded students, sponsored attendance at conferences, provided access to ACRRM’s online learning platform and generally helped me to feel less isolated. I was lucky enough to be supported to attend three conferences through the program which I found really valuable for making connections with others and gaining more personal confidence. Unfortunately the BSP program is aimed at medical students and junior doctors and any support completely disappeared during the registrar training and post-fellowship years. I suspect that this may be partly due to the fact that it is being run through a college (ACRRM) so if you decide to train through another college (eg RACGP or presumably any specialty college) then you are banished from the community and lose any access to support resources. I’m not sure if this was the case for others, but it was certainly how it seemed to me.
Effect on training
Having the scholarship certainly did affect some of the choices that I made during my training. As a medical student I took a John Flynn Placement, spent my 5th year in Kalgoorlie at the Rural Clinical School and took an intern rotation in Port Hedland. These were fantastic experiences and I’m glad that I did them as I had a great time and they certainly boosted my enthusiasm for rural practice.
As a student I discovered a passion for both general practice and O&G and was lucky enough to be able to pursue a career combining them both by training towards GP obstetrics. I could have used the obstetrics as an Advanced Rural Skills Post for FARGP or ACRRM and in fact that would have been the most sensible course of action, given my future career as a rural doctor. But a funny thing happens psychologically when you know you have this bond stretching out for years and years ahead of you; you try to minimise its impact on your life as much as possible. So as city girl knowing that I HAD to move to the country at some stage, I decided to stay put in the city for as long as I was free to do so. I also wanted to get my fellowship completed as soon as possible so I could get the damn bond service over and done with and get my freedom back. That meant getting going down the RACGP general pathway and being finished after only 18 months of further GP training, all of which was done in the Perth metro area.
Preparedness for rural practice
The upshot of all of those training decisions is that now I am a fellow of the RACGP with an advanced DRANZCOG. A fully fledged GP obstetrician, in fact. And I am discovering now that I am woefully unprepared for rural practice. I have really very little idea as to where I want to work and what kind of job I want so I’m trying to get a better idea by starting off as a locum (read more about my plan here). Unfortunately I am discovering that I actually don’t have the skills required for a lot of the jobs that I am looking for. Basically, it is not all that common in WA that a GP obstetrician just does GP and obstetrics. Mostly the jobs involve inpatient and emergency work, often as the sole doctor on duty. I haven’t worked in an ED since I was a resident 4 years ago and have never intubated anyone older than 5 minutes of age, managed a major trauma, inserted a chest drain, thrombolysed a STEMI, palliated a cancer patient, managed renal dialysis or any number of other things that independent rural generalists could be expected to do. I can count the number of successful LPs I’ve done on one hand. I also have little or no recent experience with Aboriginal Health, which is obviously a big part of rural practices in many areas. At the moment I feel a bit stuck between a rock and a hard place in wanting to use my obstetric skills but not feeling quite ready to plunge into the complete spectrum of rural generalism without any supervision. I can’t help but feel some regret that I didn’t prepare myself better during my registrar training, but at the same time, I’m glad that after so many years of anticipation I can finally get on with starting to pay back my bond time.
From my perspective, the biggest issue is the potential impact on my personal life. I guess I assumed that by the time it came to starting my return of service obligations that I’d be married and have my family life all sorted out. Every boyfriend that I have had since starting uni has been (consciously or otherwise) screened for rural suitability, and every relationship has included a discussion along the lines of “If we end up together in the long term, you will have to sacrifice your freedom to come with me to the country just because you had the misfortune of falling in love with me.” I happened to be in a long-term relationship during my GP training and my partner’s successful Perth-based career was a major factor in why I stayed in the city during my training. As my training came to an end we agonised over where we could live that would both fulfil my bond requirements and allow him to keep working in his chosen field. We really struggled to find any solution which wouldn’t make one or both of us completely miserable.
As it turned out, that relationship came to its natural end anyway, so at least now I don’t have to suffer the guilt of dragging an unwilling partner with me to the bush for a decision I made 13 years ago. But, while I hate to fall into a stereotype, as a single woman approaching the age of 30 who is keen for a family, I can’t help feeling a bit nervous that my options for finding a partner will be restricted to the 30% of the population who live outside of major cities. The parental pressure to produce grandchildren has begun and although I gather that there are plenty of eligible blokes in country towns, it’s still a cause of some anxiety. Maybe a reality TV show for medics along the lines of “Doctor Wants a Wife/Husband” would be a better recruitment and retention strategy for rural health services!
Suggestions for change
Here are my thoughts about how experience of MRBS scholars could be improved:
- 17 year olds should not be allowed to sign up to the MRBS. Undergraduate students should be eligible only after completing one or two years of undergraduate study when they have had a chance to experience life as an adult and are a bit more informed about what a career in medicine involves.
- Specific support should be offered to more senior bonded doctors in the registrar training and early post-fellowship years. Eg, networking with peers at the same career stage, formal mentoring from experienced rural doctors, access to rural skills training, access to psychological support etc
- Registrar training should count (at least in part) towards the return of service period. This would give doctors an incentive to train in the sort of area they will ultimately end up working in and allow them to gain appropriate rural skills while still having access to supervision.
- The penalty for breaching the bond should not include such harsh provider number restrictions. If someone’s life or family circumstances are such that they really are better off staying in a major city then they should be able to repay the scholarship amount and still be able to make a living from clinical work.
- There should be more flexibility in the return of service period. For example:
- Bonded doctors are required to work rurally for an average of 20 hours per week for at least 9 months each year but are not allowed to work in a major city during the rest of the time. Allowing doctors to do some work in a major centre could allow them to maintain or gain new skills and perhaps stay more up to date with clinical practice (for instance by working in a teaching hospital) which would be of benefit the rural communities they service.
- Bonded doctors do not have to commence working in a rural area until 12 months after fellowship, but are forbidden to work in a major city immediately after attaining their fellowship. This makes no sense. If people are working in a city when they get their fellowship, it’s better to let them finish up their final employment contract and get their life sorted out in that 12 months before having to start the return of service.
Overall, I have been very grateful to have had the MRBS as it allowed me to concentrate on my studies during med school instead of working, come out of university in a stable financial position and to travel to some interesting conferences. I made a conscious effort to appreciate all of those things at the time because I knew that although times were good then, I still had the consequences to deal with later. Still, looking back, I can’t help but feel that my naive 17 year old self was taken advantage of, to be asked to make such a huge commitment at such a young age. Luckily, I still feel enthusiastic about rural medicine and am sure that the next stage of my life will bring many rewards. In a few years time when I have completed my contract I expect that it will feel somewhat strange to have absolute freedom over my own destiny for the first time. In the meantime I can only hope that I will find satisfaction and contentment in living and working in a rural town somewhere, maybe plant a veggie patch and get a few chooks, and even hopefully be lucky enough to one day find someone to settle down with and have a family. If those dreams come through, then it definitely will have been all worthwhile. If not, them I’m sure I will be left wondering whether taking an MRBS was the right thing to do.
If you are a bonded doctor or student I would love to hear from you about your experiences. Or, are you a rural doctor and have an opinion to share? Comment below or tweet me @nomadicgp.