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Training in a rural/regional facility: A trainee's perspective

Ever since medical school, I’ve had a tendency to steer clear of large hospitals and major referral centres. The sheer size of the buildings, the bewildering array of departments, the hours spent wandering the corridors looking for the staff canteen or having to shout to be heard as one student among so many, did not seem the best learning environment to me. Throughout my medical training I worked first at district general hospitals in the UK, then at a rural hospital on the South Island of New Zealand. Moving back to a major referral centre for the first time since medical school, for the final steps of my ACEM training, has given me the opportunity to reflect on the pros and cons of training predominantly in a regional or rural base setting. At all levels of training, experience is what really matters. When it comes to managing that paediatric resuscitation or diagnosing a bizarre constellation of symptoms, there is nothing as valuable as simply having been there and done it before. Although major referral centres see a greater volume of patients, and therefore rare and serious pathology, this does not necessarily equate to increased exposure for individual trainees. The ratio of doctors to patient attendances tend to be similar whatever the size of the ED, but fewer absolute numbers of other trainees means less competition to be involved with interesting cases. In addition, I have confronted a number of less common pathologies or later presentations of diseases in rural settings. There are other subtle, but important, differences in rural centres. Smaller workforces tend to improve collegiality and community feel. This effect may be diluted by these rotations only being accredited for short placements, leading to more frequent trainee rotation. Fewer ACEM trainees may mean only one or two people sitting exams at any one time, limiting group study opportunities. However, this allows individualisation of teaching and mentoring. Research opportunities may be more limited but the chance to get involved in quality improvement projects at a relatively junior level and enact real change seems easier in smaller, less monolithic organisations. Quality of life is, of course, one of the big selling points of living and working outside major urban centres. Not having to waste your precious time commuting and fighting traffic certainly has its advantages. Cheaper housing prices allow more chance of financial comfort. If you like to spend your spare time in the hills, rivers and forests, rural centres allow unparalleled access. City cuisine and entertainment will often be out of reach, however, and this is the trade-off to be made. Now I’m working in a major referral centre, I realise, of course, that things on the clinical floor are much the same. It might be a bit noisier, the computer systems that bit more bewildering and a higher turnover of patients, but essentially the medicine hasn’t changed. My colleagues are lovely and I continue to gain valuable experience with every patient I see. My rural training has more than adequately prepared me for this environment as well. After nearly a month here, I might even try and find the staff canteen on my own. I feel that one of the great strengths of the ACEM curriculum framework is that it is just that, a framework. While it specifies what minimum portions of our training we must spend in each area or type of hospital, as trainees we have the freedom to choose how we meet those requirements and can, to an extent, personalise our training as emergency physicians. It can sometimes be tempting to see the gold standard in training as maximising our time in major centres, with minimal ‘taster’ terms in a rural setting. I would argue that an equally valid route to becoming a highly skilled, knowledgeable and experienced emergency physician is to do things the other way round.