Advanced skills in rural Canada

CJRM 1999;4(3):160-3

• Conference goals
• Speakers
• Panel
• Questions for breakout groups
• Answers by breakout groups
• Next steps – Summary of the wrap-up discussion from the floor

Conference goals

• Document the need for advanced skills in rural Canada.
• Review the appropriateness of the practice of advanced skills by rural generalists.
• Review present Canadian training programs.
• Explore models for advanced skills training.
• Promote specialist­family physician dialogue.
• Recommend solutions for professional isolation, maintenance of competence and CME.
• Explore the need for a national consensus conference on advanced skills for rural family physicians.

[Contents]

Jill Strachan (Manager, Health Human Resources, Canadian Institute for Health Information [CIHI]) and Stuart Iglesias (Rural Family Physician) — "Utilization of Advanced Skills in Rural Canada." Jill and Stu explained how they used CIHI databases in an attempt to measure the numbers of rural general practitioners performing advanced procedures in rural Canada. The data showed large variations regionally in the number of GP surgeons and anesthetists, and showed that foreign-trained graduates contribute significantly to the pool of generalist rural physicians performing these skills in Canada. They also found evidence of advanced skills training in Canada that was not covered by any standards but might be training rural physicians effectively for a variety of advanced skills outside recognized training programs — the so-called "underground." Comments from the audience pointed out problems with the data, which the investigators hope to resolve with more complete data sets.

Jim Thompson (Associate Professor, Division of Emergency Medicine, Dalhousie University) — "A Model for Sharing Advanced Skills in Rural Medicine." Jim presented the model he and Stuart Iglesias described (Iglesias S, Thompson JM. Shared skill sets: a model for the training and accreditation of rural advanced skills. Can J Rural Med 1998;3(4):217-22), which could be used to develop training, accreditation and quality assurance programs for generalists performing advanced skills. The shared skill-set model says that generalists should select patients appropriately and perform an advanced skill equally as well as a specialist. The model assumes that generalists are experts in knowing when to perform the procedure and when to refer the patient.

Steven Gray (Medical Consultant, British Columbia Ministry of Health) — "A Provincial Government Viewpoint." Steven reviewed data and concepts regarding the use of advanced skills by generalists in rural communities. He expressed the view that physician shortages were due to a maldistribution of an adequate number of physicians. He gave the opinion that improved educational and training opportunities would not solve the rural recruitment problem.

Paul Rainsberry (Director of Education, CFPC) — "Current Training Programs in Advanced Skills." Paul reviewed existing training programs for family physicians who wish to learn advanced skills in Canada. There are problems with existing training programs because they are either not covered by a national training standard or produce graduates who end up staying in urban communities, particularly Emergency Medicine. He provided a vision for how training and certification could be improved and proposed a certifiable "third year" of training in advanced skills for rural physicians.

[Contents]

Peter Newbery (President-Elect of the CFPC), Stuart Iglesias, Ruth Wilson (Chair, Department of Family Medicine, Queen's University), George Goldsand (Associate Dean, Postgraduate Medical Education, University of Alberta), Stephen Gray and Larry Ohlhauser (Registrar, College of Physicians and Surgeons of Alberta).

Reconciling community needs and the need for a national training program in advanced skills for rural family physicians

Peter outlined the many-faceted problems inherent in developing and implementing training programs for rural advanced skills programs, and suggested solutions for discussion. George outlined the history of how Alberta's hospitals responded to the need for training rural family physicians in advanced skills training. He spoke of the need for competing groups to speak with and not about each other; the importance of balancing viewpoints; the need to determine need; the definition of "rural;" and the problem of deciding whose needs would be served. He urged that national, portable, accredited programs be developed for deans to implement. Larry said the first step should be to define the "ends" (healthy, happy patients) and that the "means" (appropriate physicians performing appropriate procedures in appropriate places) will follow. Trying to define the means first would slow the process excessively. He felt that an effort to develop a national program for funding rural advanced skills training positions would fail owing to the complexities of administering and funding such a program. He encouraged use of existing accrediting bodies for national accreditation of local training programs. He suggested a focus on developing data to document inflow and outflow of patients among communities and the cost to communities for the dispersal of advanced skills capability. Ruth called for an agreement on national standards for accreditation and development of a professional "home" for rural family physicians who practise advanced skills. She gave a university perspective on the realities of using limited residency positions for this training. Steve polled the audience and by a show of hands found that many thought that funding for training for advanced skills would contribute significantly to resolving the problems of access to advanced skills by rural communities.

[Contents]

Common for all groups

1. What is the most appropriate delivery system for anesthesia, operative delivery, and general surgical services in rural Canada?
2. Should training programs be standardized and national, or should we encourage considerable regional variation?

One additional question for each group

3. How would you design a prototype program to train rural family physicians in advanced skills?
4. How large a training system do we need?
5. How should training programs provide for maintenance of competence activities of its graduates?
6. Are return-of-service contracts appropriate for advanced skills training?

[Contents]

1. What is the most appropriate delivery system for anesthesia, operative obstetric delivery and general surgical services in rural Canada?

The most appropriate delivery system would train Canadian physicians to be sensitive to community needs and would be competency-based. No single system fits all regions without modification. Any system must be sustainable.

It was generally felt that international medical graduates (IMGs) have a role in the current provision of advanced skills in rural Canada. The long-term sustainability of this source of rural physicians is not guaranteed.

Specialists should be trained for and encouraged to work in rural communities. But the size of the community and the capabilities of the support infrastructure required for them are significant limitations for specialists to live in rural areas. The specialist resource has the same requirements for on-call frequency and lifestyle as for other health care providers in rural communities. Mixed GP/specialist teams sharing an advanced skill set might be an appropriate option in some communities. Specialist/GP teams would permit a sustainable lifestyle for the specialist if the specialist's skill set could be shared among the GPs. Itinerant service by specialists provides useful service but can erode local skill sets by replacing them.

Provision of advanced skills by local GPs enhances recruitment and retention. This also enhances overall maintenance of physician and nursing capability in the rural community. The loss of local advanced skill provision by GPs can result in the loss of even basic physician services as other physicians become dissatisfied and leave.

The Canadian Association of General Surgeons (CAGS) feels that the degree of need for local advanced surgical skills has not been adequately determined. Regionalization of specialty services has not yet been adequately explored. The Royal College of Physicians and Surgeons of Canada (RCPSC), the CAGS and other specialist training programs need to re-examine the training of specialists for practice in rural and regional centres.

Centralization of advanced skills into urban centres in all Canadian regions was rejected by most of the groups. It might be appropriate for selected regions. Analysis of regionalization should include the hidden costs of transportation and other costs.

2. How can we reconcile the advantages of a nationally accredited portable training system with the need to preserve a training system flexible to meet the variety of rural needs?

The two are not mutually exclusive. All groups called for a national standard with regional/local flexibility. A good national program has to be flexible to allow for teaching by generalists as well as specialists and to meet the needs of learners and communities. National standards would permit portability of advanced skills.

3. How would you design a prototype program to train rural family physicians in advanced skills?

There was support for 3 models: a third year, an augmented 2-year program and a modular program that would account for individual community and learner needs.

The program can be built on the existing system at the 16 medical schools but geographically should not be limited to urban university campuses. Teachers should include urban specialists and rural generalists and specialists. Training could be delivered away from urban university centres geographically, but specialists need to participate in the training program.

Programs could be modular to meet the needs of both learners and communities. Duration of training should be flexible based on competency. The concept of "mastery," variable rates of learning and previous experience should be taken into account. Availability of volume in the chosen teaching environment would also influence the training time.

Content of training would also be modular to meet the community needs and the infrastructure appropriate for and available to rural practice. The concept of combining the content of different skill sets should be encouraged. CIHI data presented revealed that FPs with more than one special skill-set are already prevalent and seem to be an important element of sustainable rural practice in many communities.

The model requires an external evaluation process in addition to the opinions of local preceptors. This evaluation needs to be "shoulder to shoulder" and governed by national standards.

It was not clear who would take the lead — the RCPSC or the CFPC; this was thought not to be important as long as there is a national standard. Advice from specialty societies should be invited. Those colleges would address the issue of program length using evidence-based, and not empirical, guidelines.

The RCPSC uses a model whereby it accredits local training programs, and the individual is awarded a certificate of training. It was felt that the accrediting body should be national and that it could be one or both of the CFPC / RCPSC. It was felt that the programs should probably be the property of Family/Rural Medicine, but specialist departments should be key participants and the program should fall within their academic responsibility.

4. How large a training system do we need?

The answer to this was not clear. There should be a few centres of rural excellence that would administer the programs. These would not need to be in urban university centres, but the universities would be a resource for the rural-based programs.

It might be possible to contract to provide training internationally if volume at an appropriate centre within Canada is a problem.

5. How should training programs provide for the maintenance of competence (MOC) of its graduates?

There was agreement on the need for MOC. Currently too much MOC is reactive rather than proactive, but proactive MOC is burdensome to generalists who have to keep up in many areas. Virtual reality training or evaluation might be a viable future option. In-community peer assessments by regional referral specialists would be mutually beneficial to both the rural generalist and the specialist. There should be a yearly CME/continuing professional development requirement of 25 hours. Periodic audit by rurally aware certified specialists was suggested. There was no clear consensus on which of the 2 colleges should control the MOC process.

The need for continuous quality improvement and outcome measurement was raised.

6. Are return-of-service contracts appropriate for advanced skills training?

Return-of-service contracts were controversial, but they could be mutually beneficial. They might promote recruitment. These contracts might cast rural practice as second-class. There should be no such requirement for residents or re-entry physicians. Contracts could be used in some circumstances if there was extra funding to support a trainee's family or provide a locum, because a contract would be mutually beneficial. There should be a positive incentive on the physician's return, such as infrastructure support for providing the learned skill, and remunerative reward for using the advanced skill.

[Contents]

1. It was the consensus of the floor that the presidents of the SRPC, CFPC and RCPSC form a working group to move the issue of advanced skills toward a national consensus conference.

   1.1	Planning for a national consensus conference on advanced skills should include the Association of Canadian Medical Colleges (ACMC).
   1.2	The SRPC will meet separately with the Canadian Anaesthetists' Society (CAS) to further discuss training for advanced skills in rural Canada.

2. Further research is required in a number of areas, including but not limited to:

   2.1	Document the programs, preceptors and sites currently providing training in advanced skills in Canada for rural physicians.
   2.2	Find out why GP anesthetists often seem to give up their anesthesia skills after a few years.
   2.3	Expand the CIHI data on the current use of advanced skills by rural physicians to include physicians funded by other means than fee-for-service.

Hosted by the Society of Rural Physicians of Canada and the College of Family Physicians of Canada.

© 1999 Society of Rural Physicians of Canada