Canadian Journal of Rural Medicine

 

A critique of the Scott Report

Alan J. Drummond, MD, CM, CCFP(EM)
Perth, Ont.
Ontario Medical Association
Section on Emergency Medicine

Can J Rural Med vol 3 (1):27-30


Correspondence to: Dr. Alan J. Drummond, 20 Drummond St. W, Perth ON K7H 2J5; tel and fax 613 267-6222; drummond@perth.igs.net

© 1998 Alan Drummond


Contents


Introduction

The Report of the Fact Finder on the Issue of Small/Rural Hospital Emergency Department Physician Service (the Scott Report) was released on Mar. 22, 1995.

Despite its focus on the issue of staffing emergency departments, no representatives of organized emergency medicine have ever been asked to critically review the document or to comment on its potential to improve the provision of emergency care in rural environments.

This brief review of the Scott Report has been requested by the Section of Emergency Medicine of the Ontario Medical Association (OMA) in preparation for its leadership role in negotiating fundamental and positive change to the delivery of emergency services throughout the province.

The report is divided into 4 sections:

  • a discussion of the circumstances leading to the release of the report
  • a brief synopsis of the recommendations of the fact finder
  • a critical analysis from the emergency medicine perspective
  • recommendations for change.

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The release of the Scott Report

In the early 1990s, many small communities were experiencing significant difficulties with the maintenance of adequate hospital-based emergency services.

According to a 1991 survey of small-hospital medical services in Ontario, "44% reported a shortage of local GPs interested, willing and able to staff the emergency department now. 71% predicted a shortage of local GPs willing to staff the emergency department in the next 5 years."1

A 1994 Ontario Hospital Association (OHA) survey revealed that "54 of 169 hospitals surveyed were having difficulty operating their emergency departments, 46 were paying physicians extra to be on call, 46 were under threat of having emergency services withdrawn and 16 had reduced emergency services."2

The underlying reasons for the potential disintegration of small-hospital emergency services were multifactorial but were in large measure due to physicians withdrawing from emergency department service. Reasons cited included factors such as comfort and competence in dealing with acute medical illness and injury, including the issue of maintenance of competence,3,4 life-style issues, particularly those of burnout and the economic issue of poor remuneration, on a fee-for-service basis, in low-volume departments.5

It was the economic factor on which the tripartite overseers of the health care system (the OHA, OMA and Ontario Ministry of Health [MOH]) elected to focus in response to the growing crisis, perhaps betraying a lack of understanding of the fundamental problems of the emergency health care system and the attendant need for a comprehensive solution.

A working group made up of members from the 3 interested parties was established to find a way for physicians to be compensated adequately for the time and effort they devote to emergency service. Despite several potential options, the parties could not reach agreement on either the source or mechanism of the proposed payment schemes.

The MOH therefore obtained agreement from the OMA and the OHA to sponsor an independent assessment of the situation by a fact finder, Mr. Graham Scott.

After an intensive but brief (4-month) review, which included discussions with a multitude of stakeholders and the receipt of numerous briefs (none of which were from the OMA Section of Emergency Medicine or the national specialty association (Canadian Association of Emergency Physicians [CAEP]), Mr. Scott released his report in March 1995. It was approved in principle by all 3 concerned parties.

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The Scott Report: a brief synopsis of the findings as it relates to emergency medicine6

Emergency medicine and the rural environment

  • Rural medical practice differs from urban and suburban practice.

  • Rural physicians believe the differences are not fully recognized and this contributes to a strong sense of dissatisfaction.

  • There is a crucial shortage of GP/FPs skilled in emergency medicine.

  • There can be no physician stability in communities where the physicians are required to provide on-call service more often than 1 in 5 in a hospital with a 24-hour emergency service.

  • There are service problems, or threats of service problems, in almost all small hospital settings.

  • Recruitment and retention requires a broad and comprehensive solution.

Financial factors

  • There is a strong financial incentive for rural physicians to avoid emergency on-call duties.

  • The fee-for-service mechanism does not serve the physician well in low-volume departments (see letters page 254).

  • Rural physicians on fee-for-service remuneration must sacrifice income to maintain emergency coverage without an income top-up. In some communities the daylight hours are competitive with fee-for-service hours, but almost universally that is not the case during the 12-hour overnight shift.

Rural emergency departments and external relations

  • Medical schools and academic health science centres (AHSCs) contribute to the problem by: (a) projecting a negative attitude about rural practice and (b) inadequately supporting rural centres from the perspectives of both training and clinical support

  • Hospitals contribute to the problem by: (a) insisting on unreasonable service demands and (b) failing to provide leadership in the regionalization of services

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Recommendations of the fact finder

  • Rural physicians should receive appropriate recognition for the unique nature and demands of their practice.

  • They should receive competitive fees for their work and degree of responsibility.

  • Since fee-for-service remuneration does not serve the rural practitioner well, it should be replaced by other payment mechanisms.

  • Rural physicians who remain on fee-for-service remuneration and are qualified would be entitled to claim a $70 hourly rate for the 12-hour overnight on-call service in the emergency room and for each hour on call during weekends and official holidays.

  • Specialty training for FPs must be increased.

  • AHSCs should become affiliated with certain geographic areas of the province to develop permanent links and relationships with the small hospitals and physicians in the communities.

  • A rural hospital consultant access program should be established.

  • An Ontario rural emergency advisory program should be established between the hospital in the affiliated community and the AHSC to provide advice and assistance to rural physicians in patient diagnosis and case management.

  • Rural regions, particularly in the North, should organize around the population centre concept, in which an area hospital would provide 24-hour emergency services and support to satellite hospitals and clinics within the region.

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An emergency medicine perspective

The Scott Report is commendable for recognizing the unique nature of rural medicine, particularly the unique stressors associated with the provision of emergency care within that context. It should also be commended for its recommendations with respect to lifestyle issues and the prevention of burnout, a systemic problem common throughout emergency medicine, both rural and urban.

Recognition of the need for and promotion of the concept of regionalization as fundamental to the development of a systems approach to the delivery of adequate emergency care in Ontario is an important recommendation. Similarly, the call for a more meaningful and supportive relationship between rural community hospitals and AHSCs is consistent with appropriate system development.

Despite these positives, however, the Scott Report remains a fundamentally, and perhaps fatally, flawed document.

Emergency Medicine, as a discipline and as a benchmark knowledge base and skill set is never defined in the document.

The document does not try to define a basic minimum level or standard of emergency care for all Ontarians; rather it seeks a mechanism to maintain the status quo.

The status quo, however, may not be acceptable. In 1987, the MOH developed guidelines for hospital emergency units in Ontario. A subsequent survey of compliance with the admittedly minimum guidelines in 1991 revealed that "there are some disturbing gaps between reality and the minimum standards set in the guidelines and that 100 of the 200 hospitals surveyed do not satisfy the guidelines' basic demands."7

The Report fails to address adequately the important issue of initial training in emergency medicine in both the undergraduate and postgraduate years for the undifferentiated medical practitioner, the workhorse of the rural emergency department for years to come. Similarly, the basic need for more training opportunities in emergency medicine beyond the PGY2 year receives mere lip service, despite its fundamental importance to the development of regional networks.

The need for meaningful research into such issues as recruitment and retention of physician resources, the nature of meaningful CME and its role in maintenance of competence, the role of nurse practitioners and alternative service providers (i.e., paramedics) is ignored. Without research, we will be condemned to further decades of trial and error.

The issue of physician compensation, particularly in terms of volume and acuity levels, is poorly defined. There can be little doubt that a sessional fee of $70/h is more than adequate for a community emergency department that has a service volume of 5000 patients per year. It seems highly unlikely, however, that it will be adequate for an emergency department that has a service volume of 20 000 to 25 000 patients per year. Recognition of the immense variability within the definition of "basic" emergency service and the need for greater flexibility in compensation packages within that broad category is needed.

The Scott Report alludes to greater clinical support by AHSCs of rural emergency departments. It fails, however, to embrace the currently available technologies as a means of providing quality emergency care. CT scans represent 1970s' technology but are only available in secondary and tertiary centres. Similarly, distance imaging, digital radiography and telemedicine are technologies of the 1990s that would be of immediate benefit to rural emergency physicians (see pages 5 and 39).

The Scott Report's greatest failing, however, is that it places the needs of the physician above those of the patient. To be sure, rural physicians are in desperate need of support and are deserving of much greater attention from government and academia. However, it is more important to emphasize that every Ontarian has a right to a defined minimum standard of emergency care; that should be the primary focus of this document. In striving to maintain the status quo, Scott supports the unfortunate myth that any physician with ACLS/ATLS training and a valid licence, working in an unsupported, substandard "emergency room," without benefit of a regionalized system of care for the acutely ill and injured, is acceptable. Rural Ontarians have a right to expect more.

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Recommendations of the OMA Section on Emergency Medicine

The Scott Report

Despite its imperfections with respect to emergency medicine in the rural environment, the Scott Report has an important message for the development of rural medicine in Ontario. Through its recognition of the unique problems of the rural physician and its offer of a comprehensive solution to a particular aspect of rural care, it gives hope to a generation of dedicated but somewhat beleaguered physicians. Such hope will evaporate in the absence of the following:

  1. A comprehensive approach to the problems of rural physicians should be developed and introduced. The piecemeal approach to implementation that has been adopted by the present Government of Ontario will not lead to long-term positive change.

  2. The sessional payment of $70/h should be reviewed. This represents more than adequate compensation for low-volume departments of 5000 patient visits per year but is of doubtful benefit for "small-volume" departments of 20 000 to 25 000 patient visits per year.

  3. Since implementation, 70 small hospitals have accepted the sessional payment plan. In this era of fiscal restraint and the need to demonstrate cost-effectiveness, it would seem prudent to demonstrate to the public of Ontario that such a plan has indeed improved the standard (and not merely quantity) of emergency care in the province.

Emergency medicine and the rural environment

To promote an improved standard of emergency care in small-volume emergency units in the Province of Ontario, the OMA Section on Emergency Medicine recommends the following:

  • Rural physicians should be recognized for the unique nature of their practice.

  • Rural physicians should be trained appropriately in emergency medicine.

  • Maintenance of competence is of particular importance in low-volume, low-acuity emergency departments and must be approached innovatively.

  • Appropriate compensation packages defined by geographic imperative, service volume, acuity level and participation in system development activities should be developed. Fee-for-service mechanisms are inadequate for most rural communities.

  • A classification system for all hospital-based emergency departments in Ontario, sensitive to the issues of rural and remote areas, should be instituted on the basis of adherence to a minimum set of guidelines for hospital emergency units.

  • Technologic advances with regard to telemedicine and diagnostics should be embraced.

  • Rural emergency departments should be supported through commitment to a minimum distance/time factor for appropriate critical care. This may mean a more consistent approach to aeromedical support.

  • Regionalization of emergency departments should be a priority in order to conserve precious manpower and scarce technologic resources.

  • All rural emergency departments should be married to an AHSC for educational and clinical support.

  • Greater research into the delivery of emergency care within the rural context should be encouraged through the development of a centre of excellence in rural emergency studies.

  • The Scott Report, as a template for the development of rural emergency services, should be rejected. A comprehensive approach is required and it must recognize emergency medicine for the specialty it is and emphasize the need to achieve a defined and acceptable minimum standard of care.

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References

  1. Rourke J. Small hospital medical services in Ontario. Can Fam Physician 1991;37:1720-4.
  2. Emergency room doctors...meeting the needs of rural and small hospitals. Final submission to Fact Finder Graham Scott. Toronto: The Ontario Ministry of Health; February 1995.
  3. Ovens H. Who will practise emergency medicine? Survey of family medicine graduates. Can Fam Physician 1993;39:1356-65.
  4. O'Connor M. Emergency medicine skills: Are primary care physicians adequately prepared? Can Fam Physician 1992;38:1789-93.
  5. Rourke J. Medical manpower issues for small hospitals. Ont Med Rev 1988; September: 17-23.
  6. Report of the Fact Finder on the Issue of Small/Rural Hospital Emergency Department Physician Service. Graham W.S. Scott, QC, Mar. 22, 1995.
  7. Sublett S. Is it time to close your hospital's ER? Can Med Assoc J 1991;45(11):1489-92.

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