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Canadian Journal of Rural Medicine
Summer 1998/Été 1998

Letters / Correspondance

CJRM 1998;3(3):178-80


Please send us your comments and opinions. Letters to the editor should be addressed to: Canadian Journal of Rural Medicine, Box 1086, Shawville, QC J0X 2Y0; cjrm@fox.nstn.ca; fax 819 647-2845

© 1998 Society of Rural Physicians of Canada


UBC rural elective program

The eyes of medical students in British Columbia contemplating a career in rural medicine are opening wide as we witness the job action in our province. Specifically, the strike of doctors in the north-central communities of Burn's Lake, Fraser Lake, Fort St. James and others. It appears that the situation of rural doctors in our country is in the midst of a crisis. As medical students interested in rural health, we want to know how we can be part of the solution to problems such as overwork and under supply.

Thus, a group of students in the "Medical outreach elective program" at the University of British Columbia believe that fourth year electives for medical students may be an avenue to encourage new graduates to work in underserviced areas. Traditionally, the program has been to send students overseas, but Canada has underserviced areas of its own, so we are hoping to extend electives into rural Canada.

We are writing to ask physicians in rural/underserviced parts of Canada to contact us if they are interested in having senior medical students for 4 to 8 weeks. Students will have completed their clinical year covering exposure to all hospital-based specialties and most will have experienced rural family practice for at least 4 weeks. We are in the process of organizing a profile of exactly the level of training the students will have. Students are responsible for organizing their elective objectives with their supervisor for subsequent approval by the Dean.

In addition, an interdisciplinary student group, GOSA (Global Outreach Student's Association) of the University of British Columbia is working to make contacts in northern Canada for interdisciplinary projects. Thus, we are looking for specific people in communities who are involved in health care. These people would include public health nurses, First Nations chiefs, teachers and others.

Anyone who is interested or has contacts for us, can reach us at: stephanb@unixg.ubc.ca or etches@unixg.ubc.ca (email) or Attention: Vera Etches or Stephanie Buchanan, Room 3250, LSP, Faculty of Medicine, Vancouver Hospital, University of British Columbia, 910 West 10th Ave., Vancouver BC V5Z 4E3.

Stephanie Buchanan
Vera Etches

University of British Columbia
Vancouver, BC

The Scott Report

A response to Dr. A. Drummond's "Critique of the Scott Report" (CJRM 1998;3[1]:27-32full text]) is both necessary and probably healthy for a proper discussion of the issue of how best to provide emergency care in rural areas. Perhaps because of our respective roles within the Ontario Medical Association (OMA) (Dr. Drummond within the Section of Emergency Medicine and myself as Past-Chair of the Section on Rural Medicine), Dr. Drummond and I have agreed to disagree on several issues, including one that Dr. Drummond refers to in his article.

Dr. Drummond would argue that it is better to demote or close a small rural emergency department because of a perceived failure to reach a "defined minimum standard of emergency care," and instead substitute the dubious principles of regionalization with its paramedics, nurses and helicopters to provide acute care.

I would argue that it is better to strive to maintain the rural emergency department, with its dedicated rural doctors, and recognize that even with support for continuing medical education, locums and the like, we will not be able to meet the lofty standards proposed by some, including those in academic settings, insulated as they are from the real-world situation in rural areas. The reason is simple and well known to all who truly understand rural issues. The rural physician must have expertise in ALL areas of medicine -- internal medicine, surgery, obstetrics, pediatrics, psychiatry, to name a few -- AND emergency medicine. We will never quite achieve specialist level in any of these areas because of the vast amount of knowledge necessary coupled with the relatively low frequency of exposure in rural areas to these problems. We also will never have access to the urban level of technology. However, I am still waiting for evidence to prove that the quality of medicine provided in rural areas is deficient.

It is my contention that when all factors are considered (level of expertise, the personal touch, financial efficiency, the benefits of care close to home, and so on), rural doctors will come out on top every time. Furthermore, continuing developments in technology should allow for even greater improvements in quality care. There is certainly a need for research to confirm these beliefs, but unless Dr. Drummond has evidence, including outcome measurements, to suggest otherwise, it is inappropriate to suggest that rural doctors are offering an inferior level of emergency care. One must also remember that although our volumes may be low, the acuity of our cases remains high and this, combined with the realities of rural life (remember, helicopters do not fly in blizzards), makes it imperative to ensure that well-trained, well-supported, and motivated rural physicians remain active in rural areas.

I would like to respond to several additional points raised in Dr. Drummond's article.

First, Dr. Drummond bemoans the lack of input from "representatives of organized emergency medicine." In fact, Scott acknowledges input from 134 physicians, including physicians such as Drs. Jim Rourke, Ken Babey, Eugene Dagnone (Department of Emergency Medicine, Queen's University), Dennis Psutka (Department of Emerency Medicine, McMaster University) and Alan Drummond himself. I think that Mr. Scott did consult widely, and wisely obtained most of his input from the true experts in rural emergency issues -- rural physicians.

Second, although Dr. Drummond has done a good job of summarizing the history leading up to the Scott Report, unfortunately he did not portray adequately the depth of emotion and tension that finally, after some 5 years of pressure, gave rise to Scott's recommendations. Rural doctors in Ontario were at the breaking point -- the same point that rural doctors in northern British Columbia have reached recently. Scott's advice, although not perfect, provided an excellent, workable solution for some 70 small Ontario hospitals, providing reasonable compensation for emergency work, allowing rural MDs to take time off after a night shift and bringing in outside physicians to help out, usually on weekends and holidays.

Third, I note, with some dismay, Dr. Drummond's recommendation to review the $70/h stipend, because of to the perceived need to "demonstrate cost-effectiveness" and that "the plan has . . . improved the standard . . . of emergency care." The Scott Report received the unanimous endorsement of the OMA Section on Rural Medicine at a well-attended annual meeting in November 1996. It is a cornerstone in the battle for recognition and adequate compensation for rural physicians in Ontario and should act as a precedent for rural situations across the country. For many of us, it represents the first and only "perk" available to compensate for the many hours and degree of dedication provided by rural physicians. It has functioned well as a successful recruitment and retention initiative. How does one evaluate the "cost effectiveness" of these benefits? Unfortunately, there are some who, perhaps for political reasons, would seek to have the Scott sessional payments altered or reversed. I would argue that the Scott recommendations represent a bedrock accomplishment that is sacred to rural doctors and must not be touched (see related article page 149 on Scott in Nova Scotia [Regional Review]).

Of course, it is necessary to address other issues such as reimbursement for rural specialists on call, those who provide obstetrical and anesthesia services in rural areas, and emergency physicians in larger rural hospitals. Some of us within the OMA are working on these very issues, and I urge Dr. Drummond to join us.

C.R.S. Dawes
Box 850
Barry's Bay, Ont.

Rural maternity care

The Society of Obstetricians and Gynaecologists of Canada (SOGC), the College of Family Physicians of Canada (CFPC) and the Society of Rural Physicians of Canada (SRPC) wish to reinforce the support of our 3 organizations for the recently released joint position paper on rural maternity care (CJRM 1998;3[2]:75-89). We believe this paper clearly emphasizes the critical need to preserve and enhance the provision of obstetrical services for the women of rural Canada and their families.

Included as Appendix I with our paper is a list of the SOGC guidelines for obstetrical care. The guideline entitled "Number of Deliveries to Maintain Competence" has been and remains an integral part of the joint position produced by our organizations. It emphasizes the importance of evaluating the competence of those providing obstetrical care, not by the number of deliveries but by other objective measures of competence. In situations where numbers of deliveries will be small, this guideline emphasizes that the small numbers alone should not eliminate health care professionals from caring for pregnant women and delivering their babies. These women must continue to have the opportunity for complete maternity care as close to home as possible.

The example of less than 25 low-risk deliveries per year used in this guideline was not intended to suggest that such numbers should be used as a reference point, below which a physician or other health care professional should be denied privileges to deliver babies. As indicated in the guideline, we maintain that health care professionals with low-volume obstetrical practices should be participating in appropriate and relevant continuing medical education, including the ALSO (Advanced Life Support in Obstetrics) or ALARM (Advanced Labour and Risk Management) courses offered by the CFPC and SOGC.

We encourage the ongoing discussion and application of the recommendations of this joint position paper by all parties involved in maternity care in Canada.

André Lalonde, MD, FRCSC, FSOGC
Executive Vice-President
Society of Obstetricians and
Gynaecologists of Canada

Patricia Vann, MD, CCFP
President
Society of Rural Physicians of Canada

Calvin Gutkin, MD,CCFP (EM), FCFP
Executive Director and Chief
Executive Officer
The College of Family Physicians of Canada