39. If Rural Maternity Disappears, What Then? | Dr Marian Dover

What does it really take to deliver safe, high-quality care when you’re hundreds of kilometres from backup? 

Tune in as Dr Marian Dover takes us inside the reality of rural medicine, where clinical decisions carry a different kind of weight and 'support' looks nothing like it does in the city. As a District Medical Officer, Rural Generalist Obstetrician, and founder of the Australian Rural Maternity Association, Marian shares what it truly means to work at the edge of scope - safely, confidently, and with deep connection to community. 

This conversation reframes what capability looks like in remote settings, while also unpacking the critical role of rural maternity services, the impact of closing local birthing units, and why protecting these services is essential for equitable healthcare. 

This episode is for anyone curious about rural medicine, passionate about healthcare equity, or inspired by people who are redefining what’s possible in challenging environments.

Dr Marian's organisation of choice is the Australian Rural Maternity Association, a not-for-profit organisation with all proceeds going towards recruitment, retention, professional development and support for rural maternity teams across the country.

It Takes Heart is hosted by cmr’s Samantha Miklos and Kate Coomber and recorded at cmr’s head office in Brisbane.

We Care; Music by Waveney Yasso

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Transcript

Introduction

Sam Miklos 0:00

Hi, I'm Sam and I'm Kate. Today we're going to unpack some of the biggest misconceptions about rural healthcare with Dr. Marion Dover.

Dr Marian Dover 0:07

In many ways, you are more connected. You know your team really well, and actually it's safer. I feel less isolated in rural areas. When someone says you're not going to have the skills, we shouldn't be delivering babies out in the middle of the nowhere. We should be centralising maternity services. It actually fueled me and I became really passionate about that.

Kate Coomber 0:25

Don't forget to subscribe wherever you get your podcasts, or you can go over and watch the interview in full on YouTube.

Sam Miklos 0:35

So today we are sitting down with Dr. Marion Dover, who's a district medical officer at Cundanara Hospital. Marion is a rural generalist with advanced procedural obstetric skills who was awarded Accram's Registrar of the Year in 2024. She's also the founder of the Australian Rural Maternity Association. Thank you so much for having me. It's lovely to have you here. So now you and your husband and your two young children are based in Catunara in remote WA. And I read that you said once you're exactly where you want to be. Now are we referencing Cununura or are we referencing the medical profession?

Dr Marian Dover 1:23

Yeah, I think that's that's a deep question to start with. Um I think in many ways I found that, you know, I wrote that shortly after I'd furloughed with Akrom, and I felt like I was where I wanted to be, both like professionally as well as, you know, geographically plus plus socially, you know, personally. Um I feel that our you know our purpose in life kind of evolves as we grow. Um and so, you know, as a child I kind of grew up wanting to develop who I am as a person, to, you know, get that sense of self, um, to learn, you know, what what is important to me, like what what values are really important to me. Um and then, you know, I go through the next phase where, you know, I'm developing that academic um pursuit, you know, trying to um master sort of clinical skills and to to really delve into, you know, medicine and all of that theory that's really important to sort of build up who you are as a doctor. Um and then yeah, I think uh around that time, probably in the last five years or so, I feel that I've moved on to the next phase where I'm now seeing that you know, my purpose is probably in mentorship and leadership and um making medicine as a culture sort of change to be a little bit more welcome and a bit more inclusive. Um and so yeah, I think when I wrote that I, you know, felt that I'd reached a point in my life where, you know, I've got I've got the career, I'm happy with, you know, very lucky to have the family that I have. Um, you know, my husband and I have been a very strong team. He's he trained as a pharmacist, but he's um doing the harder job now, being the stay-at-home dad. Um and yeah, I think in many ways I I was exactly where I wanted to be, found my dream job, um, is you know, becoming a rural generalist in many ways I think is almost addressing a bit of a social issue, you know, like a social justice thing that I really am passionate about. Um and so yeah, I think in many ways I I feel like I've sort of found a new a new zone in my life which is um really fulfilling and really satisfying.

Life In Kununurra Up Close

Kate Coomber 3:28

I think it's wonderful when you can reflect and see every opportunity for what it is, and I think you say a lot that you're exactly where you're meant to be. So it really resonates. Even the hard things, you're you're there for a reason and it's it's where you're meant to be. So maybe for those who may not be as familiar, can you talk to us about Kananara? You live there with you know young children, husband you just mentioned, what's it like? Paint a bit of a picture for us. Where is it? What's there?

Dr Marian Dover 3:58

So Kananara, um, if you're looking at a map, it's um remote northern Western Australia. So you're uh west of Darwin, um, and I've got all these numbers in my head of how far away things are because that's very much the essence of my job. Um but Kananara is in the uh East Kimberley, so it's a very special, very um sacred part of the world. I think everyone just kind of feels that when they're there, it's hard to describe. Um, you know, it's got these like majestic hills, and it's you know, we've got it's always hot, which is nice for me. Always hot, but there's a wet season and a dry season. At the moment we're in the wet season, um, and there's beautiful waterfalls and springs, and my my children are spending a lot of time outdoors, and um it's it's very much that um yeah, that special part of the world where we feel like we've um we've experienced something that we wouldn't have if we had stayed in the city. Um Kananara has a population of about 5,000 people. We've got we've got two schools, um, we've got a Coles, and there's you know very few sort of shopping opportunities, which is why every time I come to the city I have to schedule some shopping.

Kate Coomber 5:09

We're gonna let you out of here quickly and talk to them all. But it is a bit of a hub, isn't it, for people going even further remote so they can stock up at Colts and probably is that stop before they go out.

Dr Marian Dover 5:19

Yes, exactly. So yeah, we see we see a you know the population swell in that tourist time and you know the the medicine changes a little bit. Um the really I think the really privileged part of what I get to do is that of the the the population that's there, 40% of them are first people.

Speaker 1 5:37

Yeah.

Dr Marian Dover 5:37

Um and that's really special. I think the the cultural um emotion that I've had and the training that I've had has been really special to be able to, you know, understand their connection to land um and their yeah, just their resilience, that their courage, their resilience and um what it means to be a first first person or a first n First Nations person, that's that's been really special. So yeah, Kananara, beautiful place. I'm not gonna lie, I'm absolutely trying to recruit people. Yeah. And yeah, we get we get lots of lots of um locans, lots of um agency staff that come through. Um and it's nice to see sort of fresh perspectives as we're doing things, and I I think that that's really important.

Sam Miklos 6:18

What's the um is Perth or Darwin closer?

Dr Marian Dover 6:21

Yeah, Darwin by a lot. So I'll tell you the distances, the numbers that I have in my head. So we are 827 kilometres from Darwin, which is nine hours by road. We're about a thousand and thirteen kilometres from Broome, which is our like regional centre. Um, Perth is 3,201 kilometres away. So it is the biggest retrieval zone in the world. Um, and yeah, I've I've learned a lot from that. I think you know that that tyranny of distance that we talk about as rural generalists is very much something that I get to deal with every day and it's my specialty. You know, I I have to not just sort of do the clinical side of things and the medicine, but also factor in what resources have I got available, who who is in town at the moment. Sometimes we get visiting specialists who come up. Um, and what is best for this patient is sending them away a thousand kilometres away to birth or to be somewhere um where they're going to be separated from their children is good. And so that that really becomes a a strong part of what I do.

Kate Coomber 7:26

Huge consultation around that idea. And imagine that the family and the community of what that works best. So I guess what's uh what's in the how big is the hospital for someone who's thinking, you know, um is it for them? What's what's the size? What is it what does it have there or doesn't have?

Dr Marian Dover 7:41

Yeah, so Kananara has got a doctor there 24-7. I've worked in towns of similar size where it's a population of 5,000, but our emergency department is actually very busy. Um so 24-7 there is a doctor on site. We I do on-call for the obstetric side of things, and if we get um rural generalists who've got I call them superpowers, who have superpowers in anesthetics or emergency um or neonatal resus, they uh sort of on-call things that you do, and we don't always get called in, which is nice. Um, but there is always a doctor there. Um and you kind of rotate between we do emergency, we do, you know, we've got the maternity unit and I do obstetrics, we've got an inpatient department where you look after sort of the internal medicine and make sure that people are sort of improving. They need a bit of time in hospital for antibiotics or treatment.

Sam Miklos 8:32

And how many beds is there in the inpatient?

Dr Marian Dover 8:34

Yeah, that's a good question. I think it's about 22, but I could be wrong.

Sam Miklos 8:37

I haven't actually not like a massive health service there for all of the things that you're s you know that you're doing.

Dr Marian Dover 8:44

Yeah, exactly. Um and the really nice thing that I get to do as well is that um as a sort of permanent doctor that's there, they also fly us out to the more remote communities. So I do primary care there. We do antenatal clinics for you know the our pregnant mums. Um but we also do primary care. So, you know, we're the ones that they'll follow up with after they've been in hospital, we're the ones who are managing their diabetes. I see some very interesting medicine we get. We've got people who are in their twenties who are on dialysis, who've got end-stage renal disease, we've got lots of rheumatic heart disease. So it's it's interesting medicine, and I love the variation that you get to do. Very diverse sort of skill set that you need to be able to really thrive.

Sam Miklos 9:27

So if we think about the journey to get to where you are today, um, there's a lot in that journey. You migrated out to Australia when you were just eight from Egypt. How do you go from an eight-year-old landing in Australia to then now today in Kandinara?

Speaker 1 9:47

Like, fill in the gap.

Dr Marian Dover 9:49

Fill the gaps, yeah. So I think, you know, a lot of the reflection that I have about, you know, growing up and you know, the the juxtaposition that I saw when I came to Australia, I think of the things that I, you know, really remember when we arrived here. I remember thinking, you know, this gosh, the the streets are so beautifully organized, everything is so clean, and there is a button that you can press on a busy road that tells you when it's safe to cross. And and where was this? This yeah, so my parents migrated from Cairo to to Sydney. Yes. They're still in Sydney. I'm trying to convince them to get out. I haven't won that yet. Um and so yeah, when when we ended up in Sydney, um, yeah, I think the the biggest thing that I remember was that I just thought the government in Australia must really care about its people, just from the infrastructure and you know, the um the things that I could see were, you know, part of normal living. And I have always wished that, you know, for my children, I I don't want them to grow up feeling like, you know, all of this stuff is just on a silver platter. I wanted them to experience, you know, different different ways of living, different places where, you know, we don't have as many resources or we don't have um the same access to things because I I didn't want them to grow up with that sense of privilege. I wanted them to know that we are privileged and that not everyone gets the same things that we do. It's very easy to take for granted.

Kate Coomber 11:15

It is otherwise, isn't it? Yeah, it is.

Sam Miklos 11:17

Was there a um was there something for for you and your childhood that I guess prompted that interest in healthcare or all that? And then you talked a little bit about social justice and what was it? Or did you always want to be a doctor?

Dr Marian Dover 11:32

Yeah, I think no, I didn't always want to be a doctor. I think there were different experiences that sort of um led me down that path. So, you know, growing up in Egypt, it is a developing country, and so you know, it's quite normal to sort of be out in the streets and there's people who are begging for money, people with chronic health conditions that you can tell have never been managed. And so I saw that and thought, you know, there's so much need in the world. Um and there's different challenges in Australia. In Australia we're very lucky to have such a good welfare system, um, but it's the engagement, it's you know, things like closing the gap for you know for our first peoples and and recognizing that um community-led projects and things are are the ones that are going to create the most impact. Um and so yeah, once once we came to Australia and um my family has gone through sort of different health challenges, and I remember thinking medicine has a little bit of a culture where um it is quite competitive. It's you know, it is that very sort of privileged pathway that people will take. You know that you're you're never going to be sort of um hopefully never going to be sort of wanting in any way. You know, you've got the finances to be able to support yourself and your family, and that's that's privilege. Um and so uh when my my uh family was going through those health challenges, I just remember thinking there was one time I could tell that the doctor seemed burnt out, like they were rushing through the appointment, they're actually de delivering some bad news and didn't do it in a sort of warm, empathetic way.

Speaker 1 13:04

Yeah.

Dr Marian Dover 13:04

And I remember turning to my dad at one point and being like, Dad, I think I could do this. And he said, Absolutely you can. How old were you at that point? Uh I was probably ten. I feel like I've been, you know, like filling out centering forms and trying to navigate the health system with my migrant parents who are so courageous and so strong um from a young age. And yeah, I carry that with me. I think, yeah, every every obstacle, every challenge that I've experienced, I'm grateful for because even if I've seen things that are difficult to swallow, diff diff things that are um, you know, quite um difficult for a child to process, I'm I'm really thankful for that because I know that for me I can connect with people in in a way because I understand.

Sam Miklos 13:47

I bet that that has had such an influence on the way that you empathize and and absolutely connect with not just your patients but with their families, you know, and especially from that experience with migrant parents and language barriers would have been so much in that moment that would have made you such an incredible health professional down the line. You probably didn't even realise it at the time.

Training Path And Mentors

Dr Marian Dover 14:09

I I wouldn't say that I'm incredible in any way, but I I'm not I'm not a particularly intelligent person by any means, but I'm someone who, you know, if if I find something that I really care about and I can see that it's a an issue, I can see that there is an injustice. I've definitely got that strong sense of justice and that strong work ethic from my parents and that's when I know that I'm gonna put my 110% into something.

Kate Coomber 14:32

So did you from medical school, you know, because Sydney then, um Cara to Sydney is one thing, and then Sydney to Catanara, like were you in your training exposed then to remote medicine or like Yeah, and even where to medical school because I I imagine after you've gone through that with your family, you'd have such connection with your family and trying to build community and to step if you had to leave to go to university, that would have been really hard.

Dr Marian Dover 15:00

So ironically, I moved out of home when I was 18. It's um it's a very culturally unacceptable thing to do. Probably a bit of teenage rebellion, I'm not really sure what it was, but at 18 I was like, I'm gonna move out of home. I was lured lured into sort of a a regional centre to do a science degree before I did medicine. Um and I did that work.

Kate Coomber 15:23

Yeah.

Dr Marian Dover 15:26

Didn't go down well with the parents, you can imagine. But I wanted to develop that that sense of independence. And so, you know, I knew that we weren't in a financial position to be sort of um trying to cover a lot of the costs of moving. Um, and so I was very lucky to get this scholarship and I knew that you know the housing would be more affordable in in that regional centre, and it's just been the best thing. Like, not only did I meet my now husband in Orange, but I um I also just felt that sense of community. You know, in in the city, in many ways, you can feel like you're just a tiny like small fish in a big pond, but you go out to a country area and suddenly you're a big fish in a small pond. Um, and so you know that it empowers you, I think, in a way to say, I I can lead, I can I can have a voice, I can talk about things that are important and try to improve things for others. Um, and that's that's what I managed to develop before even before even getting into medicine. So that that to me is quite special, and I'm really grateful that I did, even though in my mind that's not what I thought it would end up being. He was like, I'm out. Exactly. Yeah, I was like, I just had a sense of adventure. My parents had showed me you can migrate from another country not knowing how to speak English, having to start from scratch. If they can do that, I can I can move to the country from Sydney and that's what I did.

Sam Miklos 16:51

And so then um once you graduated, what what was the pathway? You know, tell us about that.

Dr Marian Dover 16:58

Yeah, so um I was very lucky that um in medical school I got onto uh the New South Wales Rural Doctors Network cadetship and that was like a really nice way of just giving me constant nudges to be like, you should go rural. Yeah, this room. Yes, exactly. Um and yeah, because I I'm pretty sure I went into medicine thinking I'm going to be, you know, some other sort of non-GP specialty.

Sam Miklos 17:24

I was gonna say, was that the specialty? Was it general practice or obstetrics?

Dr Marian Dover 17:27

Yeah, yeah. I wanted to be a pediatrician. I thought, you know, yeah, being with children totally fits me. I'm small in stature. I can talk to kids, I love this. Um and then realizing sort of in medical school that I'm probably more of a doer than a thinker, um, and doing sort of physician type work probably didn't suit me as well. I like procedures, I like being able to really um, you know, get involved sort of with with different um a big broad range of things. Um and so yeah, the cadet ship was really helpful. Um, but the other thing that I got to then have an opportunity to do is to do a 12-month rural clinical school um placement. So I was in Lithgow, New South Wales, sort of just past the Blue Mountains for 12 months. I actually had my first baby there. Um, and the mentors that I had there, like I could see them working in general practice, I could see them delivering babies doing cesareans, I could see them doing anesthetics, working in the emergency department. They had this amazing continuity with their patients, just really got to know those families really well. And I thought, oh my gosh, I'm still trying to become them. They are my mentors, and I think they really cemented my my decision to become a rural generalist.

Sam Miklos 18:37

And did you move to other places from Lithgow or straight into Katunara? And how how did you land on Kanunara? Yeah, Sydney to Catonara too, like the family are like, what?

unknown 18:48

Yeah.

Kate Coomber 18:48

It sounds very lucky to have that experience too, because if you didn't, do you ever think about what could have been? And if you didn't have those people to really be inspired by?

Dr Marian Dover 18:58

Yeah. I think yeah, in many ways, I think the the foundations that I had with all of the mentors that I'd built helped me sort of get through the next phase of training. So um I was really ambitious and I just decided to apply for a board position on the Rural Doctors Association of Australia as an intern, so PGY1. Um and how did that go? I just yeah, I must be a bit gutsy, but I loved it. I um yeah, so I was on the board for RDAA. Yeah, I did. Yeah. So I was on the board for RDAA for seven years. Yep, PGY one. That's incredible for people to hear that that is possible.

Kate Coomber 19:36

Because I think people just assume that's not something they could do.

Dr Marian Dover 19:40

Yeah, I think yeah, it's important not to assume that you have to be a certain person or be from a particular family to to have these opportunities.

Sam Miklos 19:50

Or even the years of experience. Yeah, exactly. Exactly.

Dr Marian Dover 19:54

Yeah, exactly right. And I think, you know, as as I went through my pathway, you know, thinking surely everyone who wants to be a rural generalist is just going to be snapped up by different rural towns, and you know, it's gonna be an easy pathway to to pursue. But I actually found that as I as I was going through that path, there were there were quite a few sort of it is that culture issue where um people consider rural to be sort of the poorer younger brother of of other specialties. Um and so yeah, being able to have those mentors, you know, I had I had contact with people from the RDAA who have been presidents of the colleges, who've been presidents of RDAA, who've been leaders in their rural communities, strong advocates like trailblazers, people who've really fought to get things done, and that inspired me. And so anytime through training where people would say things like, Marion, your skills are far too good to waste in the bush. Good intentions behind that. So, you know, I appreciated the comment, but um it very much isn't true. You actually need to be very skilled to be working as a rural generalist. And so I had the mentors and the exposure to be able to challenge that. Um but yeah, there were other other challenges, sort of particularly for rural maternity, where, you know, in some ways people think that working remotely where you're doing things that are fairly high risk, you know, doing a cesarean section when you are in a remote town, when people would say, you know, you're gonna be in the middle of nowhere with no support, that was another big thing that I really wanted to challenge. Um, because I found that going to a rural area, in many ways you are more connected, you know your team really well, and actually it's safer, I feel less isolated in rural areas. And so when, you know, when someone says you're not gonna have the skills, we shouldn't be delivering babies out in the middle of the nowhere, we should be centralizing maternity services, it actually fueled me, and I became really passionate about that because it's the opposite. You know, women traveling hundreds of kilometers. In labour, not knowing whether the hospital they're going to is going to accept them is not okay. We're a first world country, we can do better. And so, yeah, being able to challenge those things as you go through training and challenging that culture that's in medicine at the moment, I I can feel the tide turning and I know that with discussions like these we're going to be able to turn things around.

Sam Miklos 22:21

Yeah. You talked about that earlier too, like um some of the change that needs to come from medicine. What else is the change that you need to see or that you feel might be starting to be on the horizon?

Dr Marian Dover 22:34

I think, you know, now that rural journalism is recognised as a specialty, that was a huge step. Can you talk about that and what that means and what is it and what's changed? Yeah. I kind of joke that, you know, because I'm one of those people who knows how how big a deal that was, we kind of um it was myself and a couple of other rural generalists who were examining for one of the obstetric exams that day. And you're like, gosh, in like 10 years we're all going to be talking about what we were doing that day that the announcement was made. And so yeah, I had the privilege of being able to examine um rank trainees who are wanting to do obstetrics. And that's that's special. I'm I'm so glad that I was because I was part of something huge. Um but yeah, I think recognition of rural generalism as a sp as a specialty, in many ways that recognition has value added to it. So, you know, recognizing that the skill set that we have isn't inferior, it's just different. I, you know, I having to train sort of in a uh bigger centre to be able to get the obstetric skills that I needed, I really needed to have that sense that, you know, it's it's not that I'm upskilling in something, it's that I'm maintaining skills that I've developed and I'm getting a little bit more of a broad view of what it means to to be meeting the needs of a rural community. So, you know, when when they say that, you know, a GP obstetrician or a rural generalist obstetrician um is in any way inferior to an ONG consultant, I challenge that because there's things that I can do that an ONG consultant doesn't. And there's things that an ONG consultant does that I can't do. But together we're stronger and together we're a team, and it gives the best care for the patient. As an O you know, as a um as a rural generalist, I will be, you know, putting a chest strain in emergency at one minute and then I'll be doing a cesarean section the next. I can look after that baby and resus that baby if we need to. An ONG consultant wouldn't. There's things that an ONG consultant obviously can do that I can't. So, you know, if if we have a high-risk twin pregnancy, for example, or if we have a mother who um requires intensive care treatment, I can manage them for the first, you know, make sure that they're stable before they get onto the plane to be retrieved. But I have different skills to an ONG consultant. And that respect and that, you know, that mutual understanding between those specialties to know that we are different, we're not inferior, is important and that needs to change. So is is that coming from the specialist side? I think so. I think historically, you know, having to get education usually meant that you needed to be in a big city because that's where the libraries were. But now you reflect on today and what modern medicine is like. I've got all of that on my phone. Like I can look up the guidelines.

Sam Miklos 25:34

It really was. Yeah.

Dr Marian Dover 25:35

Exactly. And it's yeah, it's a shift in thinking. So being rural or remote is not going to give you a worse experience or an inferior experience. It's a different experience. We have all of the resources that that uh you know the city has because we've got the guidelines, we're following the same things. But in a way, as a rural generalist, I am dealing with that tyranny of distance and I'm having to manage things slightly differently because retrieval could be hours away, could be days away, actually. Um and so I get to use a broader skill set, I get to really practice to the edge of my scope as a rural generalist. Um, and that's that's something that I think also needs to shift.

Sam Miklos 26:15

And if if we were to um, you know, encouraging, like to try to encourage more healthcare professionals to want to follow that pathway of rural generalist work, um I guess first, uh who suits that career? You know, because if you think about coming out of medical school, like some are going to be cracking in anaesthetics and some are really great.

Kate Coomber 26:36

Like, what are the social skills must be critical out in those rural roles because what you're talking about there and the holistic approach to health, but then the but you're so connected with the community, so that is that ongoing approach. So you would obviously need to be a certain type of person to maintain that.

Dr Marian Dover 26:53

Yeah, and I think, yeah, I think, yeah, absolutely being being patient-centred is really important as a rural generalist. And yeah, it's funny, you know, trying to work out the qualities that we need for someone to want to do rural medicine, you know, when we're selecting medical students or selecting students at university level, I think that's still something that we're researching and we're really keen to tr to get right. Um, but yes, in many ways the social skills and I think the adaptability, being able to sort of pivot from one way of thinking to a different one, being sort of team focused, so being someone who's really good at working with others and collaborating with others, in many ways, working in a rural team, it flattens the hierarchy. You work in a city hospital and you may be the medical student and you're expected to stand in the corner, not do much. The intern is just doing paperwork, they just do the discharge summaries. Whereas I, as a as an intern in a regional centre, I'm actually getting involved. I was, you know, assisting with cesarean sections, I was um, you know, sorturing perineums, doing things that there's no way I would have been able to do that in a big city. You just think, you know, in the hierarchy that they have in the city, I would have been seventh or eighth down the line to be able to do certain procedures.

Kate Coomber 28:10

Which then breeds that culture, right, of almost elbowing your friend to get to the top, I imagine, just to be seen.

Dr Marian Dover 28:17

Exactly. Yeah. And I yeah, I think as a as a person, you know, there there was a point in medical school where I just had this crisis, just thinking, am I gonna have to change who I am to be able to become a doctor?

Sam Miklos 28:31

How so?

Dr Marian Dover 28:32

Yeah, I I found that I was surrounded by personalities that I didn't want to become. Just surrounded by people who were quite competitive. Um, people who, you know, just wanted to be sort of task focused, get this done, didn't really have the time um to be able to sort of delve into a person's story and understand their motivations or what's important to them. Um and yeah, just being surrounded by that, I just thought, I don't want to become this person and this isn't the kind of doctor that I want to be. And so it actually took me taking quite a long sabbatical off medicine to to relearn that, to, to go back to um I actually worked in admin, so I went back to an admin job in a regional town. Yeah. Right. So I actually I actually took more than twelve months off medicine while I was studying. Um just thinking, you know, I've got to put a stop. This is this is not good. I'm spiralling.

Kate Coomber 29:27

It's been awful just to think that you have this real passion for what you're learning and wanting to do, but but feeling almost displaced in the environment that you're trying to do it in.

Dr Marian Dover 29:39

Yeah, that's how it felt. And I yeah, I remember just thinking, you know, if this if this is the culture that I have to adapt to, I'm not ready. And I I don't think I ever will be. And so, you know, everyone was like, Don't don't leave medicine, don't, don't drop out, just just take a year off and see see what you want to do. Just just kind of reconsider, just re-evaluate where where you're at and where you want to be. And so in that year off, I um worked in a regional hospital, went back to the country a little bit and um found some amazing, inspiring doctors who weren't like that, who were very much patient focused, very much sort of took the time to get to know people. So, you know, people realizing you're a medical student and you're doing this job. What's happened? Yes. Um and then just yeah, just seeing that people can be true to who they are and not be affected by the burnout and the volume that we see.

Speaker 1 30:37

Yeah.

Dr Marian Dover 30:37

And that, yeah, I think that that made me realise actually I do have a strong sel sense of self. I do know who I am, I do know what what my values are and what's important to me. I can go back and challenge these things.

Speaker 4 30:49

That's what we think.

Sam Miklos 30:50

What do you think about um that culture of medicine? But it is there different cultures that um, you know, like if you'd not had the opportunity to go and work in a remote centre, uh would you have been able to practice the way you wanted to practice in a city?

Dr Marian Dover 31:06

I'm sure you can. I think, yeah, I I think you can. You can continue to do a pathway that makes you have that fulfillment and have that relationship with your work and your patients that that you do find satisfying. But I do wonder if, you know, if there are lots of people who are still in the city who haven't experienced the world that's out there. Australia's a big country. There's there's so many different rural communities to try. And, you know, there is that saying, if you've seen one rural town, you've seen run one rural town. Because they are also very different from each other. You go to one rural town and the culture could be quite different. It could be that, you know, the doctors that are there are quite established, older, you know, their children have moved out of home. And so the environment there will be very different to a place like Kananara, where I um actually selected because I knew that there were other fairly young families that were there, and I knew that, you know, as as a family we would be able to connect and network with people who are going through similar life phases. Um and so yeah, I I think it's really important for people to know that you know, if you're working somewhere and you don't have that satisfaction or you're you're getting a bit burnt out, just try something different. Just have that sense of adventure, have that courage to go. There is other things that I can explore. Yeah, it's not that medicine isn't for me, it's just that maybe the environment's not.

Sam Miklos 32:28

Exactly. Would you say um you know there's a lot of assumptions about working remote. What are, you know, some of the biggest myths that you hear that you feel like that is absolutely not the way it is?

Dr Marian Dover 32:41

Yeah. So yeah, I think that um professional and social isolation is one that I love tackling. I think that's a big misconception. You work, you know, let's say if you are in Sydney and I grew up in Sydney, for years we didn't talk to our neighbours. We didn't we didn't get to know who else was living around us. You could be very anonymous working in Sydney or living in Sydney. Um and then you move out to the country. I when when we went to Lithgow, you know, that's my final year of medical school. I was pregnant at the time, and our neighbours like instantly came to like meet us and offer to babysit after this baby was born. Like I was like, oh my gosh, this is just mind-blowing blowing. I I yeah, I couldn't fathom that. Um and going, you know, going to Orange and living on campus and you know, getting to know the other students who were there, people who are very like-minded, very, you know, very approachable, very warm people, very generous people. And I was like, you know, for years I've been in Sydney and this wasn't this is this wasn't the way that people lived. You can't have I shouldn't say you can't, but there's few places in Sydney where I would be comfortable letting my kids ride their their scooters on the street and you know go and slide down waterfalls and do things like that. Whereas now I'm in Candinara, and yeah, that's the norm. That's what they do. When it rains, the kids put their gum boots on and they go and play in the puddles. Um and I love that. I think that's that's one of the things that I I love tackling. I don't feel socially or professionally isolated, I actually feel connected as ever.

Kate Coomber 34:13

What about families moving in? Um you mentioned earlier your husband is taking over the parental responsibilities at the moment, which is a huge job. When um I guess if couples are considering relocation, is that certainly something to think about of, you know, can the partner work? Um is there enough to do?

Dr Marian Dover 34:33

What I really like about rural communities is that they value the workers there so much that they will embrace you. They will actually support you to do something where you feel fulfilled and you want to stay. So um I remember when we had our second child, my husband still wanted to work, and yeah, absolutely I was happy with that. So we tag teamed. So I would do, you know, my GP clinic and be on call for the first half of the day. We'd high five getting home and he would go to work for the evening or for the afternoon. Um and that worked. And, you know, the community absolutely, you know, got together to make sure that that was something we could sustain. If we needed babysitting or we needed, you know, someone to pick up the shopping or something like that. There were people that would always put their hands up to do that. Find that in Sydney. You know.

Sam Miklos 35:21

And so many places you wouldn't find that. Yeah. You talked about um earlier, you know, rural practice taking kind of to the edge of the scope of your practice. Are there things that that you do um safely, obviously, working, you know, rurally that just would never fly?

Kate Coomber 35:40

Yeah, something that might blow someone's mind.

Dr Marian Dover 35:43

Yeah. I think it still blows my parents' mind that they're like, you're a GP, but you do cesareans. It's very hard to explain to someone who's living in the city.

Sam Miklos 35:52

Which that's a really fair point. How are you a GP that does cesareans? You know, for for those listening who who aren't in the healthcare space, how is that possible?

Isolation Myth And Family Logistics

Dr Marian Dover 36:00

Yeah, so rural generalism as a specialty, you know, it's it's remarkable that we can adapt and we can pick up skills that we know are going to be valuable for the community. So what I did was I, you know, did um I actually started off with a different college. I started off with RACGP and did training um with them. Um excellent college, very big college, very influential college. Um, but I struggled to get through their exams and so I pivoted to Akrom. Um and with the College of Rural and Remote Medicine, it's actually essential that you are trained and assessed by a rural generalist the whole time. Um and your your rural training is very much enmeshed in the curriculum the whole way. And so reflecting back, I think, you know, it does maybe make sense that with RAC GP I struggled a little bit because I was made to be a rural generalist from the beginning. I've worked rurally the whole time, I managed things a little bit differently than a city GP would. And that's that doesn't mean that one way is more correct than the other, it's just how I train, so it suited me better. Um and so with rural generalist training, it does mean that you kind of pick up a superpower, as I like to refer to it. Um and I remember at at one point I was like, well, I'm I'm gonna do anesthetics. I'm I'm I like procedures, I think anesthetics is gonna be really helpful with you know managing a difficult airway of someone's um becoming unwell in front of you or managing really difficult pain that's um that someone needs some relief from. Um I visited some rural towns and I, you know, asked them, do you need a GP anaesthetist? And it was a no. No, we don't need GP anaesthetists, we've got enough of them.

Sam Miklos 37:42

Oh really?

Dr Marian Dover 37:43

Because what are the superpowers when you talk about that?

Sam Miklos 37:45

Pediatrics is one, what are the other options?

Dr Marian Dover 37:47

There's quite a few. So um anaesthetics, obstetrics, um, you can do palliative care, you can do mental health, you can do pediatrics, um, but the yeah, I think the the only one that takes two years instead of one is um if you want to do surgery as your advanced skill. And so a rural generalist surgeon will um, you know, they'll do scopes, they'll do colonoscopies and gastroscopies, they will do appendisectomies, they'll do colosystectomies. Um but the really nice thing is that it is very much about sort of meeting the community need. If you find yourself in a town where, you know, patients are having to wait mo more than a year to see someone to diagnose their child with ADHD, for example, you can choose that as your superpower.

Sam Miklos 38:36

And you can layer other superpowers, so to speak. Absolutely. Yeah, so if the town that you're in, you find yourself needing this and then and then this, and that you it's not just limited to one.

Dr Marian Dover 38:45

No, exactly. And you can do a bit of all of them if you wanted.

Sam Miklos 38:49

Which is great for someone who who really yearns for that lifelong learning as well.

Dr Marian Dover 38:55

Yes, absolutely. So, yeah, you know, do you have crazy plans of adding on a couple more? What are you?

Sam Miklos 39:02

So you didn't do anesthetics because they were like, we don't need anesthetics. Was it straight into obstetrics from there?

Superpowers And How A GP Does Surgery

Dr Marian Dover 39:08

Yeah, pretty much. I was like, oh, I can't understand why people wouldn't want to do obstetrics. You get a mix of surgery as well as sort of looking after a woman or a birthing parent from the beginning, and you get that lovely continuity to be able to look after the baby and the family too. And I thought, that totally makes sense. Like, why does nobody want to do this? And you thought you were gonna be a pediatrician. I did exactly yeah, so I get to do a bit of everything that I want to. Um and so yeah, then then I went into obstetrics, and that's that's the pathway, and it can be very flexible. You know, you could be someone who wants to do the primary care and add on sort of the superpower at the end, or you could add on the superpower at the beginning, which is what I did, and then go through your um your rural GP training. Um it's it's flexible, and it's probably the only specialty where you can tell them, you know, I will only work between 9 a.m. and 3 p.m. on a Tuesday. Try doing that in another specialty. I think it would be a real struggle. So I really like that about our specialty. What's your next superpower that you it's I want it to be anaesthetics because it's still sort of the thing that yeah, that keeps drawing me back. But it's a g it's gonna be a bit challenging to maintain both, so we'll see how we go.

Kate Coomber 40:22

And so I guess your passion then you found an obstetrics and then you've gone on to found the Australian Rural Maternity Association. Tell us about that. How did that come about? What do you do? What's it there for?

Dr Marian Dover 40:34

Yeah, so uh there's some really impactful stats that I've come to learn. So we've lost probably close to half of our rural maternity units um across Australia in the last 20 years, since 1990. Um and so you know that question.

Kate Coomber 40:52

That means to centralise them, is that what you mean?

Dr Marian Dover 40:55

Yeah, exactly. So trying to understand the reasons that that has happened. Um, you know, there's there's reasons for maybe that rural town doesn't have enough midwives, or maybe that rural town hasn't got enough rural generalist obstetricians who've chosen to do obstetrics as their advanced skill. Um maybe there is a little bit of a political reason that they want to centralise and actually close down that maternity unit. But what's important to remember is as soon as you take birthing away from a rural town, you've made that hospital a place for sick and dying people. It's no longer a place for new life where you're treating healthy people. Um and it takes away the draw card sometimes for for young families to want to move there. It means that, you know, for for some towns it could be the place where people go to retire. It's not the place where I know that if I fall pregnant I'm gonna get the care that I need. And women's health in many ways is sort of enmeshed in that. You know, as soon as you do your obstetrics as your advanced skill, I can manage menopause really well, I can manage contraception and offer all of the options. I can make sure that someone has got, you know, the operating theatre if we need to give them a general anesthetic for them to have their, you know, their their IUD insertion. Um and so trying to delve into sort of the the reasons and the ways that we can support people to maintain their birthing unit is so much bigger than that. And I found that in Queensland where they're doing some amazing things, you know, they've re-reopened the birthing, yeah, in Bow Desert, they've reopened it in Weepa. They're working on Cooktown at the moment. Um and the way that they did that, you know, looking at the stories of what what it took to be able to do that, because that is that is huge. That's very difficult. Yeah. It's like a lot of our midwives. Yeah, yes, exactly. Midwives, patients. I think, you know, when when the voice comes from a patient and they say, This is a problem, this is this is affecting how safe I feel to be here, it it's so much more impactful than a doctor going, Ah, we need to make sure that I can still do obstetrics here. And so the Australian Rural Maternity Association that we founded combines the voices of consumers, midwives, anyone who's working in rural birthing, and anyone who believes in rural birthing so that we can we can tackle those issues. We can research which towns are at jeopardy and which towns are sort of looking at downgrading or closing their service. Um, and we want to build a bit of a mentorship program so that anyone who's interested in doing rural birthing, you know, either a midwife or a medical student, we support them and we get them through all of those hurdles, you know, where they get fed those misconceptions of you don't want to go to the middle of nowhere, you're too good for that. Um and we give them, I call it sorry for the Harry Potter reference, but I call it casting the countercur the counter curse to say someone has told you that you're going to be less supported in a rural town. Let me tell you how untrue that is. Um, and being able to support them through their examinations, their Interviews, all of those things, I'm at a place where I'm more than prepared to be the mentor for those people to make sure that they get through that path because it wasn't smooth for me, but I wanted to be smooth for others.

Kate Coomber 44:10

And you've seen how you almost left it. Yeah. And I guess trying to make sure that that doesn't happen for the future is is a beautiful thing.

Dr Marian Dover 44:18

It's important, yeah. I really believe in that.

Saving Rural Maternity Units

Sam Miklos 44:21

When you reflect on on your career and and your journey, do you how do you think it's changed your outlook on life?

Dr Marian Dover 44:31

Yeah, I think in many ways I've, you know, I've had an upbringing where I probably didn't think that, you know, people's lives were as important as they are. I probably lived in a system where, you know, you can be a number in a system or, you know, the the government or the place that you live in doesn't value that life. Um but as I've sort of gone through, you know, understanding rural medicine and how much of an impact it can make to a community, it has made me really passionate about certain things to say this isn't something that I will accept. Seeing things like the preterm birth rates, maternal mortal mortality in a rural area. So there's this map that I like to show people where the Tropic of Capricorn kind of runs um across Australia and shows you sort of the the northern northern parts of Australia compared to the south. There are less people that are living up there, and it means that they're a much more vulnerable, sort of geographically dispersed population. And the outcomes show like they the the rates of pretern birth, maternal maternal mortality are double above that tropic of Capricorn compared to under it. And that's not something that I'm willing to accept. That's that's something that I think as a as a country we owe those people that we do better, not just for me and my family, but for every every person who lives above that Tropic of Capricorn. I think it's it's important that we support not just our First Nations people, but also our farmers, our producers, people who contribute, you know, $500 billion to the Australian economy. Why are we letting those people down? Why are we spending less on their health? That's that's not something I accept.

Kate Coomber 46:20

And so you're speaking tomorrow at a conference here in Brisbane, which is all around maternity care. Share a little bit about, I guess, what that is looking to highlight and or um raise awareness around tomorrow.

Dr Marian Dover 46:32

So I've titled the talk Bridging the Distance, because I think it's really important that we not only physically bridge the distances that women need to cross to be able to access good care. I also think bridging the distance in terms of being able to understand what is important to a woman, what is important to a consumer or a patient, and trying to bridge that with what a politician values or what our administrators really value. Bridging that distance to make sure that we combine those strong voices and we we see that actually our aims really align. A politician wants to make sure that their people are happy. We're going to do that if we make sure that they can access good healthcare. A patient just wants to be able to be able to know that there is a safe space for them to be able to share their story and to feel heard and to feel in control of their birthing journey. And so, you know, you can see how those things are very easy to marry up and bridging that distance is important. So that's what we're going to try and talk about.

Sam Miklos 47:38

Excellent. There's a lot to go at. If there was one change that you could just make tomorrow that would have the most impact on rural communities, what would that be? So hard to say. When you think of all the things, if there was just one that would have the greatest impact, what would it be?

Measuring Outcomes And Supporting Mentorship

Dr Marian Dover 47:57

I'd really like to see as a country, as a nation, that we look at projects or we look at innovations that don't just look at whether we've spent the money, you know, let's say you've applied for a grant. Um I don't want to see that we're just going, yep, tick, you've spent the money, you've you've performed that project. I want to see that we're actually looking at outcomes. I think that's especially true for our First Nations people. It's important that we make sure that First Nations people feel empowered, that it's community-led innovations that are important to them, that give them this the sense of identity and their connection to land, rather than just going, tick, they've spent the money. Um, and that's I think that's something that's going to change how we look at healthcare and how we look at our outcomes as a as a nation. I want to see that people are looking at the outcomes. Have you actually got more midwives and doctors working rurally because of the thing that you've started, or have you just spent the money and we've given you that tick?

Kate Coomber 48:59

Yeah, very true. CMR are going to be making a small donation to a charity of your choice with your episode. Where would you like that money to go?

Dr Marian Dover 49:09

Well, because of my passion in rural maternity, I I really want to see us grow that mentorship program that we want to do thro through the Australian Rural Maternity Association. Um, we've already got people who've applied who've expressed interest to say, I'm wanting to do midwifery, I worry that I can't afford it, and I worry that I can't get through the training because I have a family of my own. Or students in high school even who don't feel that they're smart enough or good enough to be doing that when they're probably the people that we most need. All of those vulnerable people that, you know, actually have experienced so much and can contribute a lot, they're the ones that I want to support.

Kate Coomber 49:49

Fabulous, yeah.

Sam Miklos 49:51

Marion, at the beginning, we referenced, you know, you are exactly where you should be, and just sitting here listening to you talk, you are exactly where you are meant to be. You are um, you are just such an incredible, inspiring woman. The way that you think, the way that you talk. Um the courage that you have. Yeah, there's there's just so much depth to you, and how lucky are we to have doctors like you in Australia and how lucky are the people of Kananara to have such an eloquent, just considered, thoughtful doctor on their side. It's just been an absolute pleasure to sit with you this morning. Thank you so much for being you and for sticking with medicine. Because absolutely imagine if someone like you hadn't have gone back. Like, we are just so lucky. I actually feel quite emotional hearing you talk. I'm like, we're so lucky to have you in the profession. So thank you for your time today. I appreciate it.

Dr Marian Dover 50:48

You've made me emotional too. Thank you. It's been really nice having a chat. Thank you. Thank you.

Speaker 1 50:55

We care for the letters.

Kate Coomber 50:59

We acknowledge the traditional custodians of the land of which we meet, who for centuries have shared ancient methods of healing and cared for their communities. We pay our respects to elders past and present.