A primer on rural medical politics

Keith MacLellan, MD
Shawville, Que.

CJRM 2001;6(3):205-6.

Many concepts in rural health care have features that go against the grain of some basic tenets of modern medicine. Consider, for example, how inimical the idea of broadly skilled general practitioners is to the current implacable tide of medical sub-specialization. The true medical generalist might be defined as a practitioner not only with broad primary skills but one who is able to carry out any number of defined tasks within the specialty fields. These generalists, who provide thrombolysis, trauma care, anesthesia, appendectomies, cesarean sections, and other "secondary" skills, sustain rural health care as we know it.

But efforts to support these practitioners are whimsical when our entire medical system, politically, administratively, legally and intellectually has accepted and encourages, as do all densely populated nations, the worth of sub-specialization in the "primary/secondary/tertiary care" analysis. The rigid division of responsibilities in this model of urban health care does not translate well to rural Canada and is often an impediment to rural populations accessing proper care. It represents a major reason why rural women are having an increasingly difficult time being able to deliver their babies in their own communities, since obstetrics is treated as "secondary" care, particularly if practised without specialist backup.

An associated fallout of the emphasis on specialization and the abandonment of our historical commitment to the education of medical generalists is the "dumbing down" of primary care, which, by definition, is everything not done by specialists. Acceptance of the intrinsic worth of specialization in this increasingly complicated medical world means that the role of generalists is reduced to "gatekeepers" who can be trained to sort, triage, and coordinate care provided by specialists — a valuable function in a densely populated urban population. The depressing debate over primary care reform centres around the question of how physicians and nurses divide up the tasks of triage, coordination and communication.

So, if a rural organization like the Society of Rural Physicians of Canada (SRPC) were to come along and say, for example — "Canada is a vast country, different from most because of a significant population too geographically distant from secondary and tertiary care to fall within the confines of good medicine and patient convenience that would allow patients to move through the neat levels of care so useful in urban areas" — we would be given a polite audience.

If we then went on to say — "We have documented with the best available evidence that rural women are having an increasingly difficult time delivering babies in their own communities, in part because specialized obstetrical skills including cesarean section capabilities and anesthesia are no longer within the 'primary care' domain" — there would be a general wagging of heads.

If we then followed with — "The provision of specialized skills by generalists in rural areas not only supports all of rural health care but has always existed 'under the carpet' as a mix of international medical graduates with some combination of aberrant licensing and indenture, and supplemented by Canadian graduates with informal, unaccredited training. Furthermore, this system, cobbled together over decades from necessity, can be described and documented as cost-efficient and within the confines of good medicine and patient convenience. This rural health care system of generalists functions on all 3 levels of care (1^o/2^o/3^o) in a flexible and cost-effective manner, with excellent outcomes. But it looks to be dying, and rural populations soon will receive only public health and triage in their communities, with withdrawal of specialized skills by generalists, leading inevitably to the collapse of all other significant care." — there would be more head wagging and a scattering of applause.

But then we would say — "We have come up with a curriculum and a plan, agreed upon by specialist societies and accrediting bodies, that, with the best evidence, will shore up the ability of rural women to have their babies safely in their own communities. We want you, the Canadian political/medical structure, to help implement this plan nationally, but we warn you that it involves generalists being openly supported to function at all 3 levels of care. We challenge you to mobilize the resources of Canada's medical/political system to recognize and support the GP/obstetrician, both for the good of rural populations and also, perhaps, for the revitalization of the entire 'primary care' movement. More such plans in anesthesia, surgery, endoscopy, critical care, psychiatry, etc. are to follow" — and general consternation would ensue. Naturally, the medical system is unable to accommodate changes of benefit to rural populations if those changes threaten the fundamental assumptions of the system.

What follows is a highly personal account of the major "players" in Canadian medical politics who are essential for implementing, for example, the SRPC's policies on rural obstetrics — or any other health policy for rural populations involving broadly skilled generalists — accompanied by reasons why they can't easily accommodate rural health care needs. We will see that the problems are chiefly structural, with a large measure of good old Canadian jurisdictional tensions thrown in.

Two very important premises before beginning: 1) transport and regionalization, while needed, are not the total solution and if implemented wholesale will be deleterious to rural population health; and 2) significant change in rural health care and training must come from the national front.

The first premise is thorny, since transport is often seen as the easy option consistent with the specialization trends of our medical system. There is reasonable evidence, however, that women transported out of rural communities to deliver in a regional centre have worse outcomes than if they were delivered locally by competent staff with proper selection. This is compounded by the inevitabilities of Canadian weather and geography, the myth of a safe, cost-effective, 24-hour, all-weather transport system and the degradation of the local hospital's all around capabilities once it loses obstetrics.

The second premise is more political. A national training program for GP/obstetricians, with training that is both accredited and certified, with portable licensure, with maintenance of competence programs that are fully funded, and with professional support through national medical organizations, is beyond the capabilities of the provincial ministries of health.

But how to implement such a program? This will form the basis of a series of articles on the players in our health care system. At all times we will use rural obstetrics as a lens to focus the issue, but remember that there are many more equivalent health care disciplines that can be used. Remember too that this view comes from a busy rural doctor with no formal training in politics or health administration. It distils what was learned on the fly during 3 years of parttime interaction with our system as the president of the SRPC.

© 2001 Society of Rural Physicians of Canada