Pauline Wilson1 and Kenneth C McHardy2
1
Specialist Registrar in General and Remote & Rural Medicine, Grampian
University Hospitals Trust, Aberdeen
2
Associate Postgraduate Dean, NHS Education for Scotland, Forest Grove House,
Aberdeen
Address
for correspondence: ken.mchardy@nes.scot.nhs.uk
SMJ
2004 49(3): 93-96
Abstract
Objective:
To obtain the views of the current remote and rural consultant physicians with
regards to their opinion on components of an ideal training programme for an
aspirant remote and rural physician.
Design:
A questionnaire was designed to elicit information in three main areas:
experience and training prior to appointment, current pattern of service
provision and opinions on components of an ideal training programme for remote
and rural physicians.
Setting:
Five Scottish rural hospitals in Shetland, Wick, Stornoway, Fort William and
Oban.
Subjects:
Thirteen
consultant physicians based in the five rural hospitals chosen.
Results:
The response rate to the questionnaire was 85%.
All had previous experience in acute general medicine, and most in one of
a variety of subspecialties. Each physician had developed interests and skills
in other branches of medicine following appointment in order to meet local
service needs. Most felt that there was a need for expansion of consultant
numbers in the future, 45% citing the European working time directive as the
major reason. There was an encouraging degree of commonality between the current
consultants as to what they felt should be included in a training programme for
remote and rural physicians.
Conclusion:
There are challenges in meeting training needs for consultant physicians
intending to work in a remote setting. Development of broader-based training
than offered by most current dual training programmes is essential. Only
imaginative approaches to training will produce physicians who are fit for
purpose.
Introduction
Policy
makers, researchers and medical practitioners are becoming increasingly aware of
the challenges involved in meeting the complex health and social needs of remote
and rural populations. The Acute Services Review of 19981 considered
the provision of acute medical services throughout Scotland. This document
highlighted the diverse nature of rural populations and the difficulty of
addressing their healthcare needs. It also recognised the complexities of
providing quality medical services in areas where manpower and economic
stringencies are particularly acute. The Scottish Executive has voiced a strong
interest in the delivery of health care in remote and rural Scotland2.
The coalition’s first programme for government stated that “the Scottish
Executive is committed to working with the NHS to establish managed clinical
networks across rural Scotland to ensure consistent high standard of care and
eliminate professional isolation". The Future Practice report3,
July 2002, considered the challenges of developing and maintaining a Scottish
medical workforce for the future and argued that the National Health Service in
Scotland will only survive if appropriate changes are implemented. This has
particular implications for rural areas. Recruitment and retention of staff,
training pertinent to rural practice and the need to strike the correct balance
between accessibility of services and maintenance of quality and safety are
among the many challenges facing policy makers. The economic vulnerability of
providing high quality specialist services in areas of sparse population and
hence, low volume demand, is self-evident.
There
has been a tendency in the last decade for hospital training programmes to
become focused, specialised and stereotyped at the expense of the more broadly
based experience of trainees in the past. While this approach may be of
considerable benefit in training sub-specialists for secondary and tertiary care
centres, there are concerns regarding its suitability for training hospital
practitioners destined to work in remote and rural areas where a wider
repertoire of, albeit less specialised, skills and roles will be required.
Temple embraces this concept by advocating flexibility in training to
provide "generalists in secondary care and specialists in primary
care"4
In
order to address the need for general medical secondary care in areas of sparse
population, in North East Scotland, we have embarked upon the training of
general physicians with a declared interest in remote and rural practice. Based
on a single certificate programme in General (Internal) Medicine, we are seeking
to adapt certain aspects of consultant physician training to provide the array
of skills and experience most appropriate to the needs of a remote and rural
community. While there is much debate as to the ideal ingredients of such
training, we believe it is of paramount importance to have the views of those
already at the coalface, i.e. those physicians currently working in small
peripheral hospitals. The current study was therefore undertaken to seek the
opinions of Scotland’s remote and rural physicians on what we should include
in our developing programme of training.
Subjects and Methods
In
2001-2 there was an establishment of 13 consultant physician posts based in five
hospitals in rural Scotland. Each hospital fulfills the definition of a
remote hospital5 in that it is a least 75 miles or 90 minutes travel
time away from a major centre, and typically serves a population of 30,000. The
Balfour Hospital in Orkney, while fulfilling these criteria, was excluded, as
there is no resident consultant physician.
The
nature and purpose of the study was explained to each of the consultants by
means of a letter which included a questionnaire designed to elicit information
in three main areas: experience and training prior to appointment, current
patterns of service provision and opinions on components of an ideal training
programme for an aspirant remote and rural consultant physician. The items in
the last section were based upon the current curriculum documents of the Joint
Committee on Higher Medical Training relating to 12 subspecialty programmes
(Cardiology, Dermatology, Diabetes & Endocrinology, Gastroenterology,
Geriatrics, Haematology, Clinical Oncology, Palliative Care, Neurology,
Nephrology, Respiratory Medicine and Rheumatology). In addition, current support
of paediatric services by physicians was addressed.
Following
the initial letter, the consultants were contacted by telephone, whereupon each
was given the option of completing the questionnaire over the telephone or by
returning the completed forms by post.
Results
All
thirteen consultants working in rural Scotland were successfully contacted.
Seven completed the questionnaire by telephone while the remaining six agreed to
complete and return paper copies. Only four of these questionnaires were, in
fact, returned. The remaining two consultants, despite further telephone
contact, did not return the questionnaire. The two non-responders were working
in different locations; one was in a locum appointment.
Previous
training and general issues
The
correspondents had been medical graduates for 15 to 35 years (mean 24 years),
eight from medical schools within the United Kingdom (2 in Scotland). All had
experience in acute general medicine prior to appointment. Most, however also
regarded themselves as having been trained in a medical subspecialty in
addition: three geriatricians, two gastroenterologists, and one each who had
been trained in nephrology, respiratory medicine, rehabilitation and cardiology.
Two of the consultants described themselves as general physicians. Each
consultant had had to develop interests or skills in other branches of medicine
following appointment to meet local service needs. All highlighted the
difficulties that isolation brings in terms of professional interaction and
attendance at continuing professional development meetings in larger centres.
Ten
of the eleven consultants currently felt that there was a need for expansion of
consultant numbers, five citing the European Working Time Directive as the main
reason. While none expressed concerns in managing acute unselected medical
emergencies or general medical out-patient clinics, three felt challenged by
aspects of chronic disease management and no fewer than seven felt that a
physician with an interest in diabetes would be a useful addition to their
respective clinical teams.
Cardiology
None
of the five areas had a visiting cardiology service. All the consultants had
direct access to exercise tolerance testing and 90% were directly involved in
reporting of these. Six of 11 were skilled in echocardiography, most having
learned this once in post, and could use this in the emergency setting. One
hospital relied on a visiting technician for echocardiography and had to
transfer patients requiring emergency investigation to the nearest Cardiology
unit some 105 miles away. Nine of the eleven
consultants felt that echocardiology was a skill that should be part of general
training for a remote and rural physician. Other cardiology skills felt
important for a remote and rural physician to have were that of management of
cardiogenic shock and temporary pacing.
Dermatology
Four
of the five centres have visiting dermatologist. Stornoway does not have a
visiting dermatologist but does have tele-medicine links with the tertiary
referral centre. Skin biopsy is generally undertaken by local surgeons or
visiting dermatologists, although 36% would do punch biopsies. Recognition of
skin manifestations of systemic disease was felt to be an important skill for a
remote doctor. The improvement in tele-dermatology links was also highlighted by
some as a particular way forward.
Diabetes
and Endocrinology
All
of the five centres have dedicated diabetic clinics with support staff present.
Stornoway has a visiting diabetologists. All eleven consultants have been
involved in the care of the diabetic patient during surgical procedures and some
had involvement of diabetes management in pregnancy. Seven (63%) felt that they
needed someone locally to head up and develop diabetic care. Another aspect of
care highlighted was that a shared care scheme should be developed with an
endocrinologist for the management of patients with complex endocrine
conditions. Six of the eleven (55%) highlighted the need for the trainee to
develop skills in chronic disease management in the context of diabetic service
provision.
Gastroenterology
No
visiting gastroenterologist serves these areas. Five of the consultants (45%)
have skills in upper GI endoscopy and two (18%) in colonoscopy. Views on the
inclusion of these skills in a training programme differed. A broad spectrum of
views existed with regards to liver biopsy. Seven of the eleven (63%)
consultants have performed liver biopsies in the past, however, at present only
two (18%) are happy to continue doing this locally. The two who were happy to do
this procedure locally were only happy to do so under ultrasound guidance. The
reason cited for the changed in practice were that of not having enough exposure
to keep the skill and the advances made in radiology that made it safer to do
the procedure under radiological guidance. All of the centres have access to
abdominal ultrasound.
Care
of the Elderly
Four
of the five hospitals have wards/beds dedicated to the care of the elderly.
Three centres have a care of the elderly physician. Being able to work as part
of a multidisciplinary team and discharge planning skills were highlighted as
important to for a trainee to develop.
Haematology,
Oncology and Palliative Care
The
management of haematological and oncological patients is becoming increasingly
specialised with regards to certain aspects of disease management. Three of the
five centres have joint care initiatives with Specialist units. This allows
certain chemotherapy regimes to be delivered locally and reduced the need for
patient travel. The development of local chemotherapy liaison nursing service
has been beneficial to the delivery of quality care to the oncology patient.
Skills in the management of the neutropenic patient were felt to an essential.
Three of the eleven felt that the skill of bone marrow biopsy may be beneficial
and the management and investigation of the anaemic patient was seen by all to
be a core skill.
The
delivery of palliative care should be of a high standard independent of where an
individual lives. The development of the Macmillan nursing service has helped in
this regard. In most centres the care of the dying patient is community lead
with the general practitioner leading the team. Pain management issues and an
understanding of the range of therapies available was felt to be important by
all of the eleven consultants. Specific training was felt necessary in this
field of medicine by ten of the eleven. Pain clinics are held in one of the five
centres and are headed up by an anaesthetist.
Neurology
Three
of the five hospitals have local access to CT scanning with reporting performed
by radiologists in a tertiary referral centre. One of the five hospitals has a
visiting neurologist. All eleven consultants highlighted a need for
understanding of chronic disease management of conditions such as multiple
sclerosis, Parkinson's disease and stroke. It was felt that the initial
diagnosis and management of complex neurology should be primarily carried out
under the care of a neurologist. It was then felt that joint care schemes could
then be arranged for these patients. Keeping up to date with the issues
regarding the care of the stroke patient was highlighted. It has to be
remembered that not all of the stroke patients are imaged, as the service is not
available in all the centres. Guidelines on who to image were deemed important.
It was highlighted that as more tertiary referral centres have designated stroke
units and rehabilitation units the trainee should make sure that during their
training they are exposed to the care and management of the stroke patients.
Renal
medicine
The
only centre with facilities for on site haemodialysis has a trained nephrologist.
The remaining four hospitals have individuals in the community on chronic
ambulatory peritoneal dialysis (CAPD). Specialists in a tertiary centre mainly
manage these patients but local input is necessary in the event of intercurrent
illness. The majority were agreed that understanding and experience of managing
CAPD and acute renal failure were essential for the remote and rural physician.
Respiratory
medicine
Three
of the five centres have local access to bronchoscopy. Four consultants do
bronchoscopy although only one is a trained respiratory physician, the remainder
having learned the skill to fulfil a local service need. The general view was,
however, that bronchoscopy would not be an essential or useful skill for a
prospective remote and rural physician. All centres have the facility for formal
pulmonary function testing with all physicians doing their own reporting. Each
felt that training in interpretation of pulmonary function tests would be
beneficial. Pleural aspiration and biopsy, and insertion of chest drains were
felt to be core skills.
Rheumatology
Three
of the hospitals have a visiting rheumatology service. All physicians
highlighted the need for an understanding of the disease-modifying drugs and of
chronic management of patients with rheumatological problems. Joint aspiration
and injection were felt to be useful skills although in some centres these
procedures may be shared with surgical colleagues.
Paediatrics
None
of the five hospitals have a paediatrician with inpatients responsibilities
although three localities have a community paediatrician. All of the physicians
had concerns about the provision of paediatric care. All are expected to deal
with paediatric emergency admissions but none has had formal paediatric
training. Stabilisation and transfer of the very sick child appeared to be a
combined duty between the physician, anaesthetist and the tertiary referral
centre’s response team. The physicians were in agreement that training in
advanced paediatric life support should be an essential part of training.
Discussion
Development of appropriate training programmes for prospective hospital physicians in remote and rural Scotland is no less important than recruitment and retention of such staff. Those physicians already working in such posts were ready and willing to offer their input and showed an encouraging degree of consensus in the opinions which they provided on both the need for a tailored training programme, and the major components thereof. Patterns of service delivery in the different hospitals studied have evolved somewhat differently depending on the prior training of the incumbents and local complementary provision of services. Several physicians have had to acquire skills which had not been part of their post-graduate training and while provision should always acknowledge the need for such additional (initial and ongoing) training, it would be sensible to consider inclusion of a broader base of skills in the curriculum. Furthermore, many will have had highly specialised training in areas of practice which may not be sufficiently prevalent in peripheral hospitals to permit retention of viable skills and expertise. The current system of dual training in General (Internal) Medicine and a specialty is apt to both under develop the broad-based skills essential in remote and rural practice while overdeveloping skills within the other specialty. The flexibility in training programmes advocated by Temple3 recognises this problematic imbalance in emphasis.
Our
findings highlight the particular example of paediatrics which is no more than a
very minor part of most higher subspecialty training programmes, but is a
service which physicians are commonly required to provide in remote locations.
There
have been recent suggestions that the early years of higher specialty training
may in future be directed towards the award of a ‘general’ certificate of
completion of specialist training prior to
subspecialty training6. This may herald a move towards a more broadly
based approach to training ‘junior’ specialist physicians and could also
delay the stage at which a trainee had to make a final decision on whether or
not to proceed from general specialist to subspecialist. This, in turn, may
encourage trainee physicians to consider general medical options, including
remote and rural practice in career planning. The issue remains, however, of how
best to adapt the current arrangements for higher training in general medicine
to embrace the specific needs of remote and rural practice.
The
conclusion in the Acute Services Review7 that the need for a
specialised remote and rural physician training programme would not be viable
due to the small numbers requiring such training is perhaps too readily
subscribing to the view that standardisation is all in training.
The very existence of smaller peripheral communities and the need to make
provision for their healthcare requirements already demands innovative and
atypical solutions. Training of staff to work in these areas must be similarly
imaginative in producing physicians who are fit for purpose ‘by design’
rather than following a stereotypical training path more appropriate for the
large hospital environment. Concern about the limited need for a continuous
supply of remote and rural trainees is overstated1. Changes in
working conditions are already leading to requirement for larger teams to
provide continuous clinical cover. In any event, there is no absolute
requirement for every training post to be compulsorily continuous for it to be
either viable or ideal.
Potential
innovations in health service provision must also be borne in mind in developing
new models of training. The increasing contribution of tele-medicine will mean
that the application of this technology must be included in training.
The extent to which it is likely to impact on how specific services are
provided is not yet known but it may radically alter how some types of clinical
challenge will be handled in peripheral locations and the scope of networking
with colleagues in larger centres. This too could have attendant implications
for a putative training curriculum.
In
conclusion, we believe that the current study supports the need for adapting
current general medical training programmes for the type of physician required
to staff our remote and rural hospitals in Scotland. Several suggestions made by
the current incumbents have sufficient commonality to encourage a degree of
confidence in a curriculum better suited to the needs of both the trainee and
the community which she/he aspires to serve. Just as the remote and rural
physician has particular requirements to be mutli-skilled and adaptable, so too
must the available training be broadly based and imaginative.
Acknowledgements
We
are grateful to the remote and rural physicians of Scotland for their
enthusiastic participation in this study and to Professor Gillian Needham,
Postgraduate Dean, North Scotland for supporting our efforts in developing this
training programme.
References
1.
The Scottish Executive. Acute Review 5. June 1998. Chapter 13
2.
Personal correspondence. Scottish Liberal Democrats. May 2001
3.
The Scottish Executive. Future Practice- A Review of the Scottish Medical
Workforce. July 2002. Chapter 2.2
4.
The Scottish Executive. Future Practice- A Review of the Scottish Medical
Workforce. July 2002. Chapter 2.2 (point 52)
5.
The Scottish Executive. Acute Review 5. June 1998. Chapter 13 (point 313)
6.
The Scottish Executive. Unfinished Business. Proposals for Reform of the Senior
House Officer Grade. August
2002.
7. The Scottish Executive. Acute Review 5. June 1998. Chapter 13 (point 335)