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Canadian Journal of Rural Medicine
../../../ 1998

The future of rural health: Comprehensive care or triage?

Stuart Iglesias, MD
Hinton, Alta.

CJRM 1999;4(1):32-3


Correspondence to: Dr. Stuart Iglesias, Box 5202, Hinton AB T7V 1X4; fax 403 865-5444

This paper has been peer reviewed.

© 1999 Society of Rural Physicians of Canada


Historically, community hospitals have provided comprehensive care to rural Canada. Strategically located close to smaller neighbouring communities and far from urban centres, they have offered a full range of essential surgical, obstetrical and anesthetic services. Within these hospitals rural family physicians with advanced skills have sustained the system of rural health care as we know it. Can we imagine the alternative as we witness the erosion of these skills?

How important are advanced skills?

In rural western Canada, general practitioners provide surgical services in 87% of the hospitals, and 16% of hospitals rely exclusively on general-practitioner surgeons.1 Thirty percent of all appendectomies are performed by general-practitioner surgeons.1 In Canada in 1991, 4884 cesarean sections were performed by family physicians, virtually all in rural Canada. This represents 7% of all cesarean sections done.2

In rural British Columbia, general-practitioner anesthetists represent 97% of anesthesia personnel in hospitals having fewer than 50 beds and 88% in hospitals having 50 to 99 beds.3 Canada's general-practitioner anesthetists, practising almost exclusively in rural Canada, provide 20% of all anesthetics in Canada.4

Who provides these services?

Rural Canada has relied heavily on the graduates of foreign medical schools to provide advanced procedural care to its citizens. Approximately one-half of Canada's rural general-practitioner surgeons and one-third of general-practitioner anesthetists have been trained elsewhere.1 Of these foreign graduates, the largest group were trained in South Africa, the next largest group were trained in the United Kingdom.1 These physicians represent 2 distinct populations: some are family physicians who received extra training to acquire advanced skills; the others were trained as specialists, but the Royal College of Physicians and Surgeons of Canada does not recognize their specialty certificates. Nonetheless they chose to stay and combine a limited procedural practice with a family practice in rural Canada.

What would we do without these foreign graduates?

The door through which these rural physicians immigrated has now largely been closed. Faced with important human rights issues, the provincial licensing bodies decided a few years ago that the preferential recognition of equivalency in training between Canada and the United Kingdom, South Africa and some other Commonwealth countries would be discontinued. Graduates of these foreign medical schools are no longer eligible to practise medicine in Canada. [This decision by the licensing bodies should not be confused with the decision by the Royal College to stop recognizing the equivalency of specialty training in these countries. Immigration by foreign specialists intending to practise their specialties is an urban issue, with these physicians filling niche roles, such as in the transplant programs, which are located in urban areas.]

Where is the Canadian supply?

Clearly, rural Canada will not attract Canadian-trained specialist physicians prepared to provide advanced skills. The specialties of anesthesia, general surgery and obstetrics are facing their own serious supply problems. For the most part, the graduates of these programs are not interested in working in a community hospital. The volume and complexity of cases is low and the proportion of night and weekend call is excessive. It is often necessary for them to supplement their income with earnings from a general practice. Moreover, a specialty service in rural Canada, with limited nursing and technical support, is often inappropriate. From a purely fiscal viewpoint, a laparoscopic bowel program to attract a specialist general surgeon is a very expensive way to provide the community with essential surgical services, such as appendectomy and cesarean section.

So, if there is to be a Canadian solution to the provision of advanced procedural care in the rural setting, it will have to be provided by rural family physicians trained in Canadian programs. The brightest hope is in anesthesia. Canada has a long history of training family physicians in anesthesia, which is why we are less reliant on foreign graduates for anesthesia services (one third) than we are for surgical services (one half).1 However, several of the training positions have remained unfilled in recent years. The problem is multifactorial. The decision, made without any evidence to support it, to change the training program from 6 to 12 months has set the bar too high.4 Without adequate provision for continuing medical education, maintenance of competence programs and professional support, the graduates endure a significant degree of professional isolation. The general malaise in rural medicine is amplified by the additional responsibilities of providing coverage for advanced skills to a community hospital. Without recognition and remuneration, and without creative provision for off-call interludes, there will be diminished interest by rural physicians in acquiring anesthesia training and other advanced skills. We also face increased attrition rates amongst rural physicians currently in practice.

The situation with Canadian training programs in general surgery and operative obstetrics is more discouraging. The only training programs for general-practitioner surgery are at the University of Alberta and the University of British Columbia. These are very new and small, producing a maximum of 2 graduates each from the 12-month program each year. Both universities offer similar programs, as do a few others, to teach cesarean section skills to rural family physicians. Again, the numbers are small. There also exists, in operative obstetrics, an underground, informal training program whereby applicants, standing "shoulder to shoulder." with their preceptor, acquire a special one-time only training arrangement.

Physicians working for the United Church of Canada on the west coast have been trained in this manner for years. Naturally, all of the difficulties faced by anesthesia graduates — continuing medical education, maintenance of competence, professional isolation, burnout — are endured by the few Canadian graduates in obstetrics and general surgery.

What is the future without advanced procedural care?

The availability within community hospitals of rural family physicians with advanced skills in anesthesia, operative obstetrics and general surgery has sustained rural medical care as we know it. The opportunities and the responsibilities to provide care for seriously ill or injured patients affords teams of physicians, nurses and support staff the opportunity to practise teamwork and to maintain their skills and confidence. When these same professionals are deprived of essential anesthetic and surgical services, and are required to transfer ill patients for definitive care, they lose both the ability and the inclination to care for anything but reasonably well patients. Their communities will not attract physicians with ambitions to provide comprehensive care. Rural medicine will face the prospect of providing ambulatory care, triage, transport services, and not much more.


References
  1. Chaisson PM, Roy PD. Role of the general practitioner in the delivery of surgical anesthesia services in rural western Canada. CMAJ 1995;153(10):1447-52.
  2. Health Information Division, Policy and Consultation Branch. Medical Care Data Base (MCDB). Ottawa: Health Canada; March 1995.
  3. Lubin S. Family practice anesthesia in British Columbia. Can Fam Physician 1987;33:1607-12.
  4. Report of the Invitational Meetings on Training of General Practitioners/Family Physicians to Provide Anesthesia Services. In: Proceedings of the 121st annual meeting, including the transactions of the General Council, Vancouver, British Columbia, August 22­24, 1988. Ottawa: The Canadian Medical Association; 1988. Appendix "B."