Ali Broadhurst – Doctor at Canzibe Hospital in the Transkei.


canzibe

So, you want to do a rural com serve? Dreams of nature and beauty, dreams of plucky altruism at the coalface of an embattled community and dreams of just getting out of the monotonous merry-go-round of competitive medical ladder-climbing. Those experiences are truly attainable, however the decision to go to the corners of the country should be one that is informed. Even if your perfect idea of work is checking on your veggie patch between ward rounds, there are still a few things about rural life that nobody tells you.

Firstly, the notion of “going rural” is a misnomer. “Rural” is a continuum. It’s not like there is a dichotomous choice of either practising in downtown Sandton, or a place without a name where you have to wash your clothes in a river. There are plenty of smaller towns sprawled across this beautiful country that will give you the experience of working in a community setting, but where you still have tar roads, some shops and there are people to meet and befriend. In essence, it is being a doctor in a smaller town and just how small that town is or just how remote that location is makes the difference. Importantly, there is a place for everyone, so if you want to try it, there is guaranteed to be a place that you will love. And if you abhor tar roads, street lights and general infrastructure then it will be even easier to find a spot for you.

Unless you are planning on going back to a small town where you are from, it may be unlikely that you have ever been to many of the small towns on the community service lists. There are towns on that list with names that even the most creative of us couldn’t make up, and even if you have visited them, it’s unlikely that the first thing you do on holiday is unpack your bags and rush to see what the local casualty looks like. If you want to do a rural com serve, pick a part of the country that you love. It may be in your home province for some (especially bursary holders) or it may be on the opposite side of the country. One of the benefits of medicine is that it acts as a kind of passport that lets you work almost anywhere, and community service is such a great chance to get guaranteed employment in a part of the country that you have always enjoyed.

Although, having aimed your compass at some part of the country, it still doesn’t mean that you will spend your com serve in the Kruger Park or sunbathing on the Wild Coast. You need to work in a hospital at some point, so you need to find out things about the hospital. Of crucial importance is the number of doctors there. With most hospitals, you can google their switchboard number and ask to get put through to one of the doctors who will normally be more than happy to tell you. Often articles on the internet tend to be slightly outdated and it may be disappointing if a 2009 article spoke of an easy-going hospital with a great team of 15 doctors, and when you get there in 2017 you find one overly-stressed doctor frothing at the mouth and one-and-a-half clinical associates (Ed – check out the information at Thumela Career Portal, we are busy building a database of hospitals and ratings to provide up-to-date info, ratings, galleries, and so on).

And herein exists one crucial concept of the decision to do a rural com serve: you live and work with an exaggeratedly small amount of other people. This may be overwhelmingly positive, as the quality-not-quantity of inter-personal relationships mean that instead of stockpiling superficial friendships, you experience each other in the realms of colleagues, friends and neighbours. That often results in a tightly-bound and fulfilled clinical staff, and it incentivises people to stay longer as the personal unit of the hospital is a significant pull-factor (notwithstanding the fact that even in the age of Global Warming, posts are freezing faster than you can say “healthcare crisis”). When people stay, continuity begets better working standards and the cycle of improvement becomes self-perpetuating. The opposite is challenging. If your clinical team has disparities in work ethic, or polarised personalities that have immiscible visions for the hospital, these issues are magnified because of the small pool of people. You cannot just bump off one another and move departments; you have to learn how to best rectify differences or things can unravel and the work will get divided by fewer and fewer doctors.

The work itself is wonderful. Places in the world are running out where you can be as general as waking up, starting with performing a Caesar, then reducing a fracture, rehydrating a child with gastro, diagnosing one of the myriad infectious diseases that exist in this country and finally putting a chest drain into someone from Friday night’s stab-a-thon.  The clinical exposure is almost second to none. Sure, it is not remotely career-advancing in any way (and that’s a big thing – your friends will all be moving on with their academic careers) but it teaches you something that is absolutely invaluable in medicine: it teaches you to make decisions and stand on your own two feet. Because when the cow-dung hits the generator-powered fan, you are it. Help is hours away and you have to make a plan.

It can be a rollercoaster of stress. When things go according to the script, and you have enough doctors, work becomes a bucolic pleasure. Alas, the script is often torn up or redirected into a horror film. The types of patients you see are no more complex than any casualty, but it’s the resource-limitation and the lack of help make the difference. Probably the most important concept of practising rural medicine is that in medicine, you are dealing with the downstream problems of a society that is so twisted and unfair. And when the system fails, it fails as a whole. When someone dies who should not have, because you don’t have the correct drugs, you don’t have the expertise or you cannot transfer the patient, that is the system failing as a whole and it is not you. It is everything, from the fact that the patient was born into a powerless socio-economic state, presented late to the hospital because they were financially unable to come earlier, were delayed by the plagued infrastructure in many rural areas and finally got to the end point which is you. In the hospital, you may not have support, you may not have investigations to guide you, you may not have a helpful referral centre. Later in your career you may have the answers, and you may look back at what you may have done differently, but in the moment you must use what you have and what you do know. The broken system is not your fault.

Those scary and frustrating moments are tempered by the types of patients that you see. It seems that the lower the population density, the nicer the people. I am pretty sure that my work will never be better-appreciated than it is now, and it is an understatement to say that working in rural areas is a lesson in human resilience. Often a patient’s neighbour will bring them in and sit uncomplainingly next to them day and night on a chair next to their bed. And working in a smaller environment allows you to feel the ripple effects of your work over time: seeing previously malnourished children sprint into your room, watching people get better from month to month. Instead of losing your patients back into the big pot of population, your patients will drop in just to say hello or they will stop you for a chat during an evening jog. You get the feeling that your actions in your consulting room emanate out in concentric circles into people’s lives around you. It happens everywhere, but being in a small enough place where you are able to notice it is special.

So you want to do a rural com serve? Do it. It’s a rare experience that this career which takes so much from you can give you. It’s hard and you will feel overwhelmed at least once. But you have your life to be the suburban GP or the acclaimed surgeon. And more than making life a little more interesting, it lays bare the fact that inequity in this country is far bigger than any of us or our ambitions.


The Thumela Team thanks Ali for his article! If you wish to submit an article of your own, please contact us at james@thumela.org

*The views and opinions expressed in this article are that of the author and not necessarily of Thumela as a whole*