Issue 35 / 22 September 2014

IF you haven’t heard of FIFO, rest assured it is not the name of latest rap star but something more commonplace — fly-in fly-out workers.

FIFO’s sociocultural and economic impacts have been much discussed, particularly with respect to mining communities. There are even websites and forums for FIFO families.

However, it’s not just the mining industry that has to deal with FIFO workers. Despite the glut of medical graduates coming through the system, FIFO doctors are one of the solutions used in rural and remote areas to resolve workforce shortages.

Governments and workforce agencies pour millions into retention and relocation grants and easy-entry-gracious-exit schemes to encourage doctors to work in rural and remote areas. The aim is to ensure rural patients have access and continuity optimised by a resident doctor.

Telemedicine, outreach clinics (hub and spoke models) and role substitution are often used as adjuncts to a resident doctor. Sadly, many communities have to make do with adjuncts alone.

FIFO offers an in-between solution. If managed well, reasonable continuity can be achieved and adjunct services can complement the FIFO doctor effectively.

Rural hospital administrators, agencies and even private practices seem to be embracing FIFO doctors, and many praise the flexibility it offers.

So, given this increased utilisation, isn’t it time our profession and funders had an in-depth discussion about FIFO?

Money will top the list. FIFO services come with the added costs of travel, accommodation and agency fees. Additional costs also include disbursements and higher remuneration because of remoteness.

So who pays? Government, as usual? Currently, the extras tend to be borne by the states. But should it be a Medicare item number with a load for remoteness? Or should local councils or local communities shoulder the economic cost?

A risk in FIFO practices is that they can become dehumanising for what should be the most human of professions. Individual doctor–patient relationships can be forgotten as FIFO rosters are packaged with an emphasis on times and days rather the people.

Given the growing prevalence of FIFO, is there a bigger role for our universities and colleges in this domain?

The current obsession with standardising medical assessments, along with time and budget pressures, has resulted in exams being multiple-choice, quick vignettes (like the objective structured clinical examination) and short answer questions. Assessing a doctor’s ability to write and talk in detail has been de-emphasised, but these are the skills that are paramount in making FIFO and adjunct models work.

This is best illustrated by the clinical handover. These need to be written with detail and clarity as a number of parties will receive them at different places and different times. For example, you leave town at 6pm and the next doctor is not there until 8am the next day. Handover has to cover three nursing shifts, the remote service doctor and the colleague arriving tomorrow.

In 2014, it’s no longer adequate to tell the nurse “you know the patients, just tell the next doctor”. Time and logistics mean it’s not possible to ring and discuss the patients with all parties concerned.

No matter what protocols are in place at hospitals and clinics, these skills need to be acquired earlier as part of the medical education process.

Another challenge is that FIFO can be forced upon those who don’t want it and worse, those who don’t need it. Rural doctors in small towns could be shut out of hospital work because administration finds it easier to deal with one locum agency to compose a FIFO roster instead of working with local medical officers.

Rural folk attach a lot of credibility to professionals who actually invest in their towns. A FIFO workforce will never achieve that degree of trust and understanding in rural areas.

While we need to be au fait with new workforce models and maintain high standards within them, we should not lose hope that the graduate tsunami will one day resolve the maldistribution of doctors and FIFO will become part of our medical history.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.


Do you support a fly-in fly-out medical workforce as a way to relieve the rural doctor shortage?
  • No – it's a poor stopgap (52%, 62 Votes)
  • Maybe – there are problems (27%, 32 Votes)
  • Yes – a good solution (22%, 26 Votes)

Total Voters: 120

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10 thoughts on “Aniello Iannuzzi: Flying blind

  1. Duncan Murray says:

    FIFO works. 

    It’s not a universal solution for rural workforce issues, but in certain scenarios it works.

    Let’s consider the singe doctor town. In the past the sole doctor ran their General Practice and the local hospital, worked long hours and provided on-call services 24 hours a day, seven days a week. Some lucky individuals got leave, covered by a locum. These doctors are a dying breed. When they retire the usual stopgap is rotations of junior staff from urban hospitals – giving the poor old locals a never ending series of new, under skilled, and unenthusiastic doctors (I may be exaggerating… but only a little).

    There is an alternative – FIFO. You can have a small pool of experienced doctors that WANT to be there. A pool of 2 or 3 doctors working 2 weeks on, 2 off. Reasonable continuity of patient care is achieved. Physician burnout avoided. Even if one doctor leaves you have an eased transition as the rest of the pool is intact. Additional cost? Pretty minimal. Including flights and agency costs probably 20% over standard CMO/SMO rates. And you’re not spending all that money on ineffective retention bonuses etc.

    FIFO can be a long term solution for our smaller towns, providing good quality care at a reasonable cost. The doctors like it, the patients like it – and the RN’s at the local hospitals love it.

    (Disclosure: I’m a doctor, who also happens to help run a locum agency)

  2. Diane Campbell says:

    As an itinerant emergency physician of some 25 years I completely endorse Dr Iannuzzi’s comments.

    I hope that a formal examination of FIFO would reform some issues – particularly the anticompetive nature of agency contracts.

    Qld DOH now has a policy that all hospital temporary contracts must be via an agency. This is a blank cheque to agencies, and no incentive to perform. Instead, they rely on restrictive contracts.  I have visited or even worked at a site to be then told that an agency now manages locum contracts. They specify that the agency must be employed or compensated, for 12 months from the last placement, so one is effectively locked in. Where is the ACCC when needed?

    Small hospitals reluctantly specify minimum quals, and that is all they get; agencies want seniors to take the highest bidder.

    Some hospitals spend literally millions a year on casual staffing, administered by a junior clerk. Call to speak to the DMS or DEM director to ask about the work and is told  “the girls deal with all that.”   “That”  may be a 6 month contract if covering long service!  

    Minimal standards need to be set for orientation. The UK did this some years ago; there are  good models to follow.  Some (few!) agencies insist that both employer and employee submit evaluations for all placements of 2 weeks or more.  This should be mandated and open to scrutiny. I am glad Dr Iannuzzi raised this important issue.


  3. steve sonneveld says:

    what about provider numbers based on geography or population need for both gp and certain specialities?

    This would reduce the 10 gp on one street corner and non in rural areas.

    Medical training should require everyone to spend 12 months in rural areas as a minimum. Soon after graduation and early training , this would not be too onerous , would not interfere with childrens schooling , be enjoyable and educational for the individual.  Some may consider remaining in the rural areas and reduce the undersupply to these areas.

    Too many doctors practicing in an local area reduces the experience of all , reduces incomes and job satisfaction and variety – time for drastic changes  not throwing more money around.





  4. Horst Herb says:

    Speaking as one of that dying breed of “always on” rural doctors, I must say that the so called workforce shortage is my least problem – there are plenty of well trained doctors looking for work, but the system is putting too many hurdles in front of them. The REAL problem is the obscene bureaucracy in primary care and the gross injustices of the MBS system that rewards paper pushers and “quick script” medicine.

    If we would get fairer remuneration in rural health where average consultations take much longer than in urban ares (but get paid the same, hence much less dollar per time worked) it would be easier to attract doctors to work here.

    If the remuneration system wouldn’t be geared towards rewardig administrative overhead (care plans etc), small practices would stand a greater chance competing in attractiveness against the “sausage factories”.

    If we would get a fixed number of provider numbers for the practice (determined eg by average doctors per 1000 inahbitants of the area) that we can self-administer it would take the excruciating pain and unrecoverable administrative cost out of recruiting short term cover as well as long term work force. As a small practice owner I don’t have the luxury of throwing around taxpayer’s money as the hospital system can for that purpose.

    Lastly, the one thing that might keep me working beyond early retirement next year would be a pool of locums that I could draw on at short notice at 65% of billings. Even RDN subsidized locum rates are ruinous for a small  practice. I would have saved tens of thousands of dollars if I would have simply closed my practice and left the locals without medical services each time I had to leave for educaton or family reasons.

  5. Christopher Maclay says:

    I can’t overemphasize the truth in the previus commenters words. As a GP who is in the process or returning to a rural practice these are the issues that are foremost in my mind. I still think the benefits outweigh the detractors.

  6. Monash University Publisher Packages says:

    Great discussion. As a researcher studying medical workforce outreach in Australia (MABEL survey), I agree that outreach strategies need to be balanced with investment in the recruitment and retention of permanent staff. A Parliamentary Inquiry into FIFO (2013) already endorsed health sector outreach work and gave clear recommendations. A key distinction in this forum, however, is that compared with locum workers, outreach workers re-visit the same community over time, often for limited remuneration, particularly when travelling further to remote communities. AMWAC agreed long ago that outreach models were suitable for specialist doctors unlikely to achieve viable full time practice in small communities. We hope that systematic data about outreach workforce dynamics will help provide objective information about current activity so as to inform policy and planning around sustainable, equitable and efficient models that centre on the needs of rural communities and rural health staff. 

  7. Diane Campbell says:

     Dr Horst Herb has my sympathy

    Years ago my DMS asked me, as a favour, to cover an admitting GP at a smaller town so the poor man could  go to his FRACGP  exams. $500 for the weekend, then Friday was added. Then my insurer slugged me for, duh, $500. Out of pocket on arrival, 2 sessions and 3 days on call to go.

    Conversely, I don’t think that the practice earnings  covered what I was paid.

    But the real  reason I wasn’t keen to return – and understand why this doctor is no longer a GP – was the  clients. Knocking at the door Saturday night for sleeping pills, a  4 am call for a sore shoulder because someone driving on the highway – who may well have had a sore shoulder if they’d driven from Brisbane! – “noticed the  hospital light on” – and there had been a hospital board decision that the doctor must be called for all presentations.  Patient calls put directly through to me with demands that I go immediately to the hospital and wait so that the caller need not.

    People move from cities but still want 24-hour access for non-urgent problems.

    Some short-term workers put up with this stuff, it increases FFS income, but it must be a major deterrent to someone considering long-term commitment to the town. 

  8. DR stephen betheras says:

    Having done FIFO for 8 years to the most isolated NT Town it used to work. It takes a long time to gain the trust of Aboriginal people understandaby but is achievable. The KPI’s for Chronic disease were as a consequence the highest for the region. BUT the NT Remote Health bureaucrats are only worried about dollars not results. So at the first whiff of budget cuts who goes – the Clinicians.The KPIs deteriorate, morbidity and. mortality go up and helloooo eventually health costs go up. They continue to have Third World Clinics with Third World results. Check out their overall KPI’s for Chronic disease. The poor old RAN’s perform heroics. But the Senior NT Remote Health Doctor is of the opinion that Doctors in Communities shouldn’t be on-call! Imagine the outcry in Southern Australia if this was introduced. So if you work in Remote NT you don’t get paid to be oncall.  Of course if you are around (which most times you are) then you can be asked to come in if the oncall DMO on the phone in Darwin (or wherever) decides you are needed. Claytons oncall. Mining Companies have been successfully doing FIFO for years. The difference is they value their workforce, pay appropriately ( $250,000 for a Pilbara Train Driver ) and religiously study KPI’s and have a medium/longterm view. This is not the case in the NT. I am now in relatively remote WA (Roebourne) doing FIFO – clean well thought out Clinic, Aboriginal people working in it and being respected and a productive focus on Chronic disease. Not a constant battle to stop the dam wall falling as is the NT case. An absolute breath of fresh air.





  9. Mary Hall says:

    On ya Stillatruebeliever!  The focus on budget slashing without taking into account the impact on outcomes for patients is abhorent.  However FIFO is still a less desirable option which can work but needs to value the vital factor of continuity of care for patients and knowledge of the big picture which is best acquired when you are part of their community and familiar with the history and background to fully inform the presenting issues as the local GP. 

    The issue raised in the article regarding the reduced focus in medical education on communication skills and the administrative hurdles to handover is also vital, the former both in communicating and building trust with patients as well as colleagues and the latter from both a professional and legal perspective.  We all know what happens with chinese whispers.

  10. Alfredo O Aiello says:

    Regarding  FIFO

    I believe that there are many excellent  FIFO  Doctors.

    Junior doctors should not do do remote rural work. Not efficient if not supervised at work site. 

    Very costly due to the increased transfer of patients. They will be calling Registrars and consultants all day.

     This cost is far more than FIFO Doctors.

    Remote Rural Doctors need to be GPs with appropriate emergency skills. Safe approach when associated with telemedicine. Plus, better if same locums work in each town.

    Junior Doctors can be useful in Larger Towns with experienced SMO support for example Mareeba, Emerald and Roma in Qld. 

    I have worked in many Qld Rural Hospitals. Have found the work fantastic and organised. Have worked as permanent staff and as locum. 

    Have stopped travelling due to preferring work close to my family.







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