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Canadian Journal of Rural Medicine
CJRM Summer 2000 / été 2000

Promoting the image of rural medicine -- a neglected dimension

Sam G. Campbell, MB BCh, CCFP(EM)

CJRM 2000;5(3):150-2.


Physicians who successfully serve rural and remote areas are general practitioners with the skills and attitude to potentially manage any degree and volume of illness. They do so with little backup and less than desirable resources. Rural medicine has been touted as the "newest specialty" in medicine.1 I disagree. A clinical specialty evolves by relinquishing certain skills and parts of a large fund of knowledge in order to focus in more detail on a smaller segment of knowledge. Specialists waive much of their claim to being able to practise the skills they relinquished, their forfeiture being compensated for by their heightened skill in the clinical segment that they have chosen.

As a physician's practice becomes more "rural" he or she becomes, by necessity, more self-reliant and less dependent on other physicians or technology to help care for patients. For this reason, rural medicine represents the remnants of "general practice" in its purest form. The newer "specialty" is urban family practice, whose practitioners have relinquished many skills and much of the knowledge that rural physicians have retained.

Being the principal resource for innumerable diverse medical and social issues can afford the rural physician a level of fulfilment and job satisfaction that is unparalleled. It is with this image that I believe rural medicine should be marketed to potential rural recruits. Perhaps the most vital trait that such a candidate should possess is the enthusiasm for independently and effectively carrying out a broad range of clinical duties.

The image of rural medicine has been tarnished by some of our recruitment efforts. Financial incentives, for example, encourage the image of young doctors "doing time in the salt mines" of rural Canada to set themselves up financially before leaving for the comfort of urban practice. Residents or students exposed to this picture see rural physicians working their fingers to the bone, leaving little time to spend with their families or to enjoy the benefits of rural life. Trainees are reminded that physicians who have left rural practice "did their stint in the bush" in order to (for example) buy a house in the city. This perception creates the image of rural medicine as something worth doing only for great financial reward.

I believe that to stabilize the base of rural physicians in Canada we need to look and act earlier in the physician production system. We need to build onto the existing benefits of rural practice to attract physicians, rather than try to compensate for the disadvantages.

Much of the literature on rural hospital staffing talks about the paucity of effective rural training programs in medical school.1-5 Indeed, it is both unrealistic and unfair to expect young family practitioners to function without the support and technology that we have taught them is essential.2 Whereas it is vital to provide future rural physicians with the necessary training at medical school, I am not convinced that "rural" training alone steers physicians in a rural direction. The small proportion of third-year emergency medicine trainees who end up in rural practice attests to this.6,7 Easterbrook and associates8 described a statistically insignificant association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community.

Perhaps it is not the skills that we are teaching to doctors that are most important, but the doctors to whom we are teaching the skills. Certain attributes desirable in rural physicians cannot easily be taught at medical school, and we need to develop ways of identifying physicians or students with these attributes and to foster such attributes in candidates who may be keen but hesitant.

Dr. Peter Newbery, responsible for staffing several small, isolated communities in north western British Columbia for 20 years, has said that the most important characteristic that he looks for when recruiting rural physicians is their attitude. He listed the attributes of keenness, adaptability, flexibility and the ability to work well as a team member. He has found that physicians with the right attitude tend to develop the necessary skills and knowledge whereas those with only skills and knowledge, without the right attitude, don't last. They may make life miserable in the meantime for many members of the existing staff (Personal communication, May 1999).

This does not imply that inadequately trained (but keen) physicians should be unleashed on the rural public in the hope that they will develop the necessary skills. The necessary attitude includes the ability to recognize limitations in skill and knowledge, to safely cope with such limitations appropriately and to develop skills and knowledge in areas that have been identified as lacking.

A network of "scouts" in schools, universities and professional organizations should be enrolled to identify people who show the attributes that would make them thrive in a rural environment (Table 1). Candidates so identified could be encouraged to enter medical school or, if already there, could be steered in a rural direction.

Ideally, medical practitioners with personal experience in rural practice should be involved directly in recruitment and selection. Programs with professional nonmedical recruiters or nonphysician community members frequently carry inaccurate perceptions of the real issues faced by physicians in their communities. Recent flyers circulated throughout Canada in an effort to recruit rural physicians to Australia clearly demonstrate the realities of rural practice and appeal to the sense of adventure of potential candidates.9,10 Although this approach is better suited to the recruitment of locums than it is to long-term physicians, it may lure practising physicians out of the "rat race." Nevertheless, locums are always a potential source of full-time practitioners (Table 2).

Although financial compensation for rural practice should be as good as, if not better than, that earned by urban practitioners, incentives designed to entice physicians into rural practice should focus on creating a better lifestyle as the primary attraction. Current working conditions need to be explored with a view to creating circumstances in which physicians would expect to thrive,3,4,6 given sustained job satisfaction and emotional and physical health.

One example of how suitable working conditions can be brought about is by employing 3 physicians, on a salary basis, to serve a patient population that could feasibly be managed by 2 doctors. The one-third extra free time would allow each physician to spend time with his or her family, and to develop, practise and teach the skills that set rural practice apart from urban practice. A lifestyle that would be envied by most urban physicians would not go un-noticed by students and residents.

Skills training, financial incentives, clinical support, CME opportunities, spousal concerns and locum availability remain vital factors in determining the ability to recruit and retain rural practitioners. However, the promotion of a positive image of rural practice and the people to whom the vocation is marketed needs to occupy a more central focus in our efforts to recruit and retain rural physicians.

Conclusions

Financial incentives offer only short-term solutions to the recruitment of rural practitioners. The image of rural medicine should be enhanced by taking steps to improve the lifestyles of rural physicians. Recruitment of potential physicians should not be left until family practice residents graduate;6 potential rural physicians should be sought out and nurtured from the undergraduate level right up to that of experienced non-rural physicians.


Correspondence to: Dr. Sam G. Campbell, Department of Emergency Medicine, New Halifax Infirmary, 1796 Summer St.., Halifax NS B3H 3A7; EMSGC@qe2-hsc.ns.ca

This article has been peer reviewed.

Editor's note: We invite physicians to speak out on issues that concern them. Please send submissions to Suzanne Kingsmill, Managing Editor, CJRM, Box 1086, Shawville QC J0X 2Y0; cjrm@fox.nstn.ca


References
  1. Iglesias S, Thompson J. Shared skill sets: a model for the training and accreditation of rural advanced skills. Can J Rural Med 1998;3(4):217-22.
  2. Loveridge P. Rural practice: Challenging but endangered? A Nova Scotia perspective. Can J Rural Med 1996;1(1):29-31.
  3. Pope ASA, Grams GD, Whiteside CBC, Kazanjian A. Retention of rural physicians: tipping the decision-making scales. Can J Rural Med 1998;3(4):209-16.
  4. Society of Rural Physicians of Canada. Recruitment and retention: consensus of the conference participants, Banff 1996. Can J Rural Med 1997;2(1):28-31.
  5. Scott GWS. Report of the fact finder on the issue of small/rural hospital emergency department physician service. Toronto: The Ontario Ministry of Health, Ontario Hospital Association, Ontario Medical Association; 1995: Mar 22.
  6. Hutten-Czapski P. Rural incentive programs: a failing report card. Can J Rural Med 1998;3(4):242-7.
  7. Chaytors RG, Spooner GR, Moores DG, Woodhead-Lyons SC. Postgraduate training positions. Follow-up survey of third-year residents in family practice. Can Fam Physician 1999;45:88-91.
  8. Easterbrook M, Godwin M, Wilson R, Hodgetts G, Brown G, Pong R, et al. Rural background and clinical rural rotations during medical training: effect on practice location. CMAJ 1999;160(8):1159-63.
  9. Exciting challenges for general practitioners in rural Western Australia. 1996. Available from Western Australia Centre for Remote and Rural Medicine, 328 Stirling Highway, Claremont, 6010, Western Australia.
  10. Escape the winter to Australia! Available from Global Medical Staffing, Ltd., 6915 South 900 East, Salt Lake City, Utah 84047 USA. Available at: www.gmedical.com

© 2000 Society of Rural Physicians of Canada