Is rural medicine a discipline?
Suzanne Kingsmill, BA, MSc
Shawville, Que.
Can J Rural Med vol 2 (2):141
© 1997 Society of Rural Physicians of Canada
- "The SRPC feels no true and lasting progress will be made until rural medicine is considered a discipline." Dr. Keith MacLellan
- "No one has a definitive answer yet and it must be discussed further." Dr Nick Busing
- "Rural doctors carry a high level of clinical responsibility and provide a broad range of services in an isolated area.... Doctors who practise in rural areas know their practice is different." Dr. Judith Kazimirski
- "Rural practice requires skills not usually needed in urban practice." Dr. Roger Strasser
- "One of our concerns is that discipline has another side to it ... it has an exclusionary characteristic -- if you are not part of the inner circle you are somehow excluded.... I prefer to think of rural medicine as a matter of perspective, point-of-view and focus."
Dr. Hugh Scott
- "Rural physicians want it as a discipline to gain professional, public and political attention and support."Dr. Roger Strasser
- "There is a lot of similarity between rural medicine and [the discipline of] emergency medicine ... there is compelling evidence that rural medicine is a discipline. Both have been around a long time, both are defined by overall practice, both are specialities of breadth and cover a full range of human illness and injury."
Dr. Garth Dickinson
- "If everytime one is annoyed with the national college one goes off and forms another national college that isn't very helpful." Dr. Hugh Scott
- "There are no clear conclusions today but there is opportunity and willingness to build on this.... A longer gestation period is needed.... We are not ready to rupture the membranes and let this baby be born."
Dr. Judith Kazimirski
Is rural medicine a discipline?
The face of family medicine in our urban areas has changed as more and more specialists have cropped up, resulting in family physicians referring patients for problems they were once trained to handle themselves. But rural Canada has few specialists and, with transport an issue, rural GPs must do many procedures their urban colleagues cannot, such as insert chest tubes or arterial lines, to name but a few.
Does this make rural medicine a discipline? The Society of Rural Physicians of Canada (SRPC) thinks so and invited Dr. Judith Kazimirski, president of the Canadian Medical Association, to moderate a discussion of this question at its annual policy convention in Banff this past April. The panel of speakers convened for this discussion consisted of Dr. Roger Strasser, director of the Monash University Centre for Rural Health, Moe, Australia; Dr. Nick Busing, president of the College of Family Physicans of Canada; Dr. Hugh Scott, executive director of the Royal College of Physicians and Surgeons of Canada; and Dr. Garth Dickinson, president of the Canadian Association of Emergency Physicians.
That the question is being asked at all reveals the depth of the frustration felt by rural doctors to get the attention, funding and resources they need to provide quality care, without burnout, to a quarter of Canada's population scattered over more than three-quarters of its land base. Those who hold the power to make the decisions -- the governments, the medical associations, the universities -- are all urban based, and rural doctors routinely feel left out of the equation.
Dr. Keith MacLellan, SRPC president, opened the discussion by saying that the current urban-based policy of centralizing medical services into the cities, which threatens rural medicine, "is OK for Belgium but it's a little different for northern Newfoundland." Centralizing medical services away from rural areas in a country the size of Canada assumes there is a fail-safe, all-weather mode of transport. There isn't and "rural hospitals can't be scaled back like a rheostat," he says. "Lose a rural surgeon and you lose obstetrics and then women can't deliver [in their communities]. Lose one doctor and you could lose 24-hour ER coverage."
Rural Canada is too big to become a satellite community of urban Canada. The answer lies not in centralization and mythical M.A.S.H.-like transport teams patrolling rural Canada but in training and recruiting and funding the personnel to do the job without burnout, so that rural residents don't have to seek health care far from home. This can't be accomplished until rural medicine is recognized as a discipline, says MacLellan.
Dr. Roger Strasser, one of the world's few professors of rural medicine, says rural medicine enjoys far more recognition in Australia than it does in Canada. Strasser sees 4 criteria for rural medicine becoming a discipline: the formation of an academic body (Australia has 2), an intellectually rigorous training program, its own literature describing a unique field, and recognition by outsiders and other associations. "If rural medicine doesn't qualify [as a discipline] it is well on the way in Australia," and the reason, he says, that rural doctors want it recognized is threefold: status, recognition of what we do and resources.
Dr. Nick Busing is not unsympathetic to the problems of rural medicine, but he says "Urban, suburban and rural are just different versions of family medicine.... Maybe different skills are used but the overall focus is the same." He also says, "There is nothing intrinsically rational in the way medical specialities are defined.... What defines a specialty is its focus rather than a unique knowledge or skill." He adds that whereas rural doctors may have a set of skills that are applied differently, the insertion of chest tubes, for example, is not a discipline or different. He suggests altering features of medical training so that rural doctors get what they need, but "We don't want to undo core family medicine [training]. We need to add to the core to meet the needs of rural physicians. We need to train more in context." He feels this can't be done in 2 years and that a third year of training would be needed. "My view is that we must modify the curriculum with additional skills training" and address other issues besides training to help rural medicine, for example, locum support, access to specialists, continuing medical education and so on.
According to Dr. Hugh Scott, the Royal College has recognized 53 specialities, and there are those who think this is too many. In addition, he said there are another 64 mentioned often enough that they could be argued to be disciplines, for example, orthopods limited to hand surgery or small digits, or doctors limited to HIV. "It is obvious that whatever they are certified as, they may become narrower in focus or broader as they continue on their career path." He feels that the question is premature and that "We should watch and evolve and with that evolution comes responsibility for all of us to exchange and find ways to develop the new skills we need depending upon circumstances." He says the college is open to re-entry positions and additional skills training as part of the solution.
Dr. Kazimirski suggested that the SRPC has a role to play here. "This group here today must lead as unilateral ad hoc government solutions are not acceptable," she says.
But according to Dr. Keith MacLellan the fledgling SRPC is a voluntary organization with no outside funding other than memberships and that the rural conference, this panel discussion and the rural critical care workshops were planned on the fly between patient visits. "We would like an integrated inclusive approach" to the problems threatening rural medicine, he says, but at the moment there is not enough funding to do what everyone is suggesting. He says Australia has 35 million dollars injected annually into rural medicine, but the money has created a lot of "fiefdoms protecting their turf.... We would like to avoid that type of split." He says that when more money is available for rural medicine, "I hope we have a structure in place to accommodate and work in an integrative way with the college."
Not surprisingly the discussion ended in a draw with Dickinson, Strasser and MacLellan agreeing that rural medicine is a discipline and Busing, Scott and Kazimirski reserving judgment. All agreed, however, that rural medicine needs help -- more resources, more funding and better training -- if rural residents and rural doctors are to be well served in an era in which more and more Canadians are leaving cities to live the country life.
