RURAL GENERALIST PATHWAY ACTION RESEARCH 2008

Dr Kim Pedlow & Meg Ritchie

Paediatric Module for Geraldton

Our Intention

• Create a team of specialist paediatrician, rural generalist with special interest paediatrics (RGSIP), junior doctor and paediatric nurses

• To offer a paediatric training module in Geraldton as part of the rural generalist pathway

• Integrate service delivery with junior doctor training

• Cement strong links with Princess Margaret Hospital

Vote of Thanks to Supporters

• Combined Universities Centre for Rural Health, Geraldton• RCSWA Professor Campbell Murdoch, Harriet Denz-Penhey • WACHS, medical director of the Midwest health area Dr Fraser Moss• Rural Health West Viv Duggin• Paediatricians Dr Jehangir and Dr Whiting• Rural generalists with interest in paediatrics/obstetrics doctors Ray Borcherds

and (Richard) Mornia Teariki-Tautea, Aru Moodley• Senior nursing staff at Geraldton Regional Hospital (GRH)

Local Need

• Ample clinical demand– 750 deliveries yearly– 2,000 ED presentations yearly <2yo– Many of our ED doctors are not paediatric trained

• One overworked specialist paediatrician

Local Capacity

• Supportive local environment including doctors, nurses, allied health, public and private hospital, local university system, Rural Clinical School WA, Midwest GP Network

• Model of shared care between specialists and generalists is well established in obstetrics, anaesthetics, general medicine

• Specialists supportive of the model and prepared to transfer their “mantle of authority” to generalists

• Generalists with paediatric capacity • High-speed internet access

Credentialing

• Remember. If you see one country town you have seen … One country town

• The local health service must decide on the scope of practice for various clinicians whether they be RGSIP, paediatricians, nursing staff or junior doctors, NOT CENTRAL HEALTH DEPARTMENT

Fiscal and Credentialing Arrangements

• Need flexibility

• Payment for education and service delivery to RGSIP or paediatrician for rostered days on

• Extra retainer for an overarching lead clinician/educator role for the specialist paediatrician

RDAA Specialist Committee

THE VALUE OF LOCAL SPECIALIST MEDICAL SERVICES TO RURAL AND REMOTE COMMUNITIES IN AUSTRALIA

• 2005 the Rural Specialists Group of the Rural Doctors’ Association of Australia position paper “A sustainable specialist workforce in rural Australia”

• They emphasised the importance of the GP/specialist interface and the vital role of GPs

• PROBLEM The anticipated reduction in specialist services

• SOLUTION Create teams of specialists and rural generalists to provide services

Difficulties in the Specialist/GP Relationship RDAA

“While there are examples of this relationship (working) from many places, it is not as widespread or as common as it could be”

Methods of remuneration affect service provision

RDAA• Another issue is the tension between practitioners especially where there is a fee for service

arrangement

• This discourages collegiality

• Where the specialist acts as leader of a team of RGSIPs, the issue of remuneration becomes critical

• The absence of flexible working models is sometimes a disincentive to specialists wishing to provide services in the country

City specialists earn moreRDAA

• Disparity exists between metropolitan and rural specialists, who need to maintain a degree of generalisation

• Medicare rewards specialist procedural skills, not generalist skills

Progress to October 2008RGSIP

• New post of procedural paediatrics under 16 yo has been created at GRH• Supported unanimously by a forum of the rural regional directors and

subsequently the clinical directors• Approved by local director, local and central credentialing committees• Waiting for the business case to be accepted by the regional manager• Sunday 19th October I was on call for obstetrics and covered for our

paediatrician at GRH

Training Post – Y2 Y3

• My intention is that this post will be owned by the GRH………we are looking for partners

• WACHS application to become a primary allocation centre is stalling in the committee stages due to opposition from DIT and medical student reps

• Application to the GP training scheme WAGPET has been unsuccessful for 2009• Does not fit well into PGPPP nor community residency terms• May well be suitable for specialist paediatric training post• Why not interstate partners and applicants?

Increased Burden

• Concerns regarding the extra time commitment needed from specialist paediatrician/RGSIP to supervise junior doctors dissipate as the length of stay of the junior doctor increases

• Research tells us that one month is the generally accepted break even time for this process

Draft Roster for PGY2/3

• Morning – Wards/neonates/available for emergency department at GRH– Supervisor/teacher to be either specialist paediatrician or RGSIP

• Afternoon– Community practices either specialist or RGSIP

• Child health clinic, Aboriginal medical service

• Outreach clinics to Carnarvon, Meekatharra, Mt Magnet, Aboriginal communities

Teaching Curriculum

• Would need to cater for the requirements of

– Rural generalist pathway (WA, Queensland, elsewhere?)

– For RGSIP – ACRRM and the RACGP

– Paediatric specialist training pathway for the FRACP

– The Diploma of Child Health………but this would fall well short of our minimum competency requirements

IT

• We shall provide excellent IT support

• Each junior doctor gets:

– PDA with the following guidelines: ACRRM, eTG, MIMS, Bright Futures from AAP, Primary clinical care manual 2005

– Desktop computer access including the above plus ACRRM, RACGP, KEMH/PMH guidelines, HDWA Ciao online, Nelson’s Paediatrics

The student perspective

• Brainstorming session of Geraldton RCS students in March and October 2008

Issues

• Accreditation of training posts• Appropriate timing of the placement – PGY2? PGY3?• Coordination of education in a rural setting while being away from the major centres

for training• Training and development of preceptors• Overlapping roles – ACRRM, RACGP, specialist colleges, WAGPET, WACHS/RHW, RGP• Future employment – security, sustainability• How would this affect RCS students in Geraldton?

Strengths of Geraldton

• Exposure to paediatric cases in a variety of health care settings• Hospitals – breadth of both public and private• Availability of specialists and generalists• Team approach including allied health input• “Apprentice model”• Supportive local environment with availability of facilities within close

proximity• Presence of support organisations – Midwest Division of GP, RCSWA, CUCRH

Barriers

• Away from family and supports in the city, employment for spouse?• Enough teaching for the junior doctor? - reassurance required that the

doctor will not just be an extra service provider for the town• Breadth of responsibility• The quantity of paediatrics – guaranteed a large quantity of clinical

experience in Perth versus potential quiet periods in Geraldton• What will this placement count towards? What job prospects are there?

How to overcome the barriers

• Provide support – through education, clinical experience and in the community

• Ensure adequate IT support• Realistic workload and good supervision• Have the backing of specialist colleges and other organisations• Regular up-skilling sessions provided with PMH and others• Provide a structured pathway towards future training and employment

options

Questions?