Yesterday, a colleague sent me a link to a petition. Our regional dermatology service is losing their registrar training position due to lack of funding.
This is going to be a huge blow for a region where we already wait for weeks or months for appointments. As a rural GP, when I moved here from the city I quickly realised I needed to drastically upskill in dermatology. I no longer had the luxury of referring on when I was stuck.
The statistics quoted on the link were shocking. Less than ten percent of dermatologists work outside major cities. Only TWO training positions existed outside cities, and one was about to close. How on earth is this considered acceptable? I can understand that to be a liver transplant surgeon, training realistically would need to be in a major hospital. But dermatology could be taught to a very high standard in rural areas, with a wide range of presentations and pathologies to learn from. Does their training college think we don’t have skin out here?
Ugh. As a rural doctor, a patient myself, and a mother of four - this is so frustrating. The devastating reality is that now, living in a rural area, my life is worth less. To those who decide the healthcare budget and medical training, my life is worth less now than when I lived in the city.
Have you ever heard the term geographical narcissism? The first time I heard it, I laughed. I must have been feeling pretty burnt out and cynical that day. Somehow it captured so much of the frustration I feel about the inequities in the healthcare system.
The term geographical narcissism was first written in a journal article by Associate Prof Malin Fors, a Swedish clinical psychologist working in a remote town north of the Arctic Circle. It refers to the assumption that urban life is superior to rural life, and that those who choose to live and work rurally are inherently inferior.
It is the belief that cities are the centre of everything and must be the correct and superior way to live. Those who live and work in small towns must not have been good enough to make it in the city. Or, as per the popular trope in movies and TV, they are running away from professional disgrace or personal problems. They were substandard in the city, but they are good enough for the country.
Geographical narcissism is a belief that rural education, healthcare, government and those who work within them, are less competent or qualified than their city counterparts. Surely, nobody intelligent or qualified would choose to live outside of the city?
I personally don’t feel that narcissism is the right term. Narcissism is an over-inflated sense of self-importance, an insatiable desire for admiration, and a lack of empathy for others. It is a form of abuse. A personality disorder. I don’t feel comfortable painting everyone who lives in an urban area with such a brush.
I do, however, know that there is truth to the accusation of urban prejudice against rural areas. There is also a reverse kind of prejudice that can exist amongst rural people. It is a miserable two-way street that is killing the nation’s healthcare system.
It starts in medical school. In my time as a medical student, our coursework paid lip-service to the importance of rural health, but the doctors in the hospitals spoke a different language. A good career meant connections, references, research. You needed to know and impress the right people. Applying for internship was highly competitive. It wasn’t enough to just get a job, it needed to be in a big hospital with gravitas. If you were unlucky, or ranked poorly, you would be forced to go to one of those outer suburban hospitals, or worse. The worst was rural. That was where careers went to die. Nobody chose that path unless they had already given up and decided to be ‘just a GP.’
It continues through working life. City specialists dismiss our opinions and experience. Hospitals reject our referrals or refuse to provide discharge summaries. Specialist training programs, even in disciplines like dermatology that could be trained to a high standard in regional areas, are centred in large cities. Rural rotations are treated as a necessary evil to be endured. Urban doctors coming to rural areas sometimes arrive with the attitude of a missionary, gracefully bestowing their superior gifts to an ignorant community.
Conferences and meetings are held by default in cities, and we are expected to travel as a part of our ‘lifestyle’ choice. As stated in a Deakin article on geographical narcissism, ‘Many rural workers will identify with the expectation that they travel both ways in a day to attend a meeting in the city. As for employees of the city office, they need a night’s accommodation and a little narcissistic praise for their intrepid travel to the country.’
One of the great tragedies of this prejudice is that city doctors are missing out on the wealth of knowledge and skills their rural colleagues hold. We make do with so little because we have no choice. We come up with unusual solutions when the standard ones aren’t possible. We learn to stretch ourselves because our patients need more than what the local area can offer. We must practice clinical courage every day, because we don’t have the same safety net they have in the city. As for dermatology, if you want to see weird and wonderful pathology, try working in a farming community.
As Associate Prof Malin Fors writes, ‘When your rural colleague phones for advice, take the call. When your rural colleague wants to attend a course or meeting online, open it up for digital attendance. And when you have a dilemma to solve yourself that you cannot find the answer to in a textbook, call your rural colleague. Rural clinicians are among the most experienced people at solving extraordinary problems that no textbook has ever covered.’
City doctors are often surprised by the reception they receive from rural communities. Instead of praise and gratitude for their great sacrifice in working there, they can be met with suspicion. Subtle or not-so-subtle hostility. Racism.
This is the flip side to geographical prejudice - rural people have it too. Often fed-up with a rotating door of doctors who never stay, they put their defences up. They don’t like being looked down on, ignored, neglected. They take pride in their families and their community. The result can be prejudice against city dwellers.
Stereotypes cut both ways. For every racist, homophobic, ignorant small-town dweller there is a latte-sipping, overdressed, intellectual wanker from the city. As someone who has lived in both city and country, I have heard all of it.
The difference, I guess, between urban and rural prejudice, is that there is a huge imbalance in power and resources that cannot be ignored. Rural is the underdog in this war of mutual prejudice, and it is being driven by a scarcity of resources.
When resources are plentiful, most people aren’t too worried about what others are getting. As long as they know they have everything they need, the average human will be happy to know that others have the same.
When resources are scarce, it is human nature to grasp and hoard. People will look after their own interests first, then their family and loved ones, then their own community. Those outside this circle - the others - are left out.
Geographical prejudice makes is easy to other those who live remotely. Those who look differently to you, speak differently, live differently. When someone is other, we can close our hearts and minds to their humanity. We can convince ourselves that they are less deserving, less worthy, that it is their fault if they are outside the circle. They choose to live out there, what do they expect?
The human heart can tell any number of lies in order to justify what we know deep down is unjust.
Because it is unjust, of course it is.
How can we honestly accept this inequity?
I promise you, we bleed, we give birth, and we feel fear and pain just as much as those who live in the city.
To sign the petition to support our local dermatology service, click here.
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