Aust. J. Rural Health (2003) 11, 96–98

Blackwell Science, Ltd10.1046/j.1038-5282.2002.00460.xOriginal Article

WANTED: TRAINEES FOR RURAL PRACTICE

David Topps,1 James Rourke2 and Peter Newbery2

1Department of Family Medicine, University of Calgary, UCMC Sunridge and 2College of Family Physicians of Canada, Missisauga, Ontario, Canada

ABSTRACT: To address the increasing need for rural health practitioners, Canada is trying various methods ofmedical education, including community based residency streams, additional skills training and teamwork models.This paper discusses some of the factors that may affect the effectiveness of these methods.

KEY WORDS: manpower, medical education, rural health.

INTRODUCTION

‘Where have all the students gone?’ to paraphrase PeteSeeger. Off to more rewarding specialties, according tostatistics released by the Canadian Residency MatchingService (CaRMS). Unfortunately, the pastures are not‘greener’ and the decision works hardship on our ruralcommunities. From November to January, medical studentsfrom across the country throw their hats into a collectivering, applying for residency training positions via CaRMS.The past 4 years have seen a steady decline in the numbersapplying to family medicine programs as a first careerchoice, which is causing considerable concern, especiallywith the predicted increase in the need for generalists asmany of our colleagues head towards retirement. The numberof applicants who specified family medicine as their firstcareer choice fell 20% from 406 in 1997 to 327 in 2001.1

There are several possible reasons for this decline ininterest and there is much speculation while we awaitdetailed analysis of surveys conducted in the past year.Chief among the causes for students’ concern seems tobe the FUD Factor – ‘fear, uncertainty and doubt’ – aboutthe future directions of general practice. Primary Carereform, capitalised by its proponents as a new ideology, iscertainly necessary with current spiralling health care

costs, but the direction in which such reform will take usis hardly clear. Will we all be placed on salary? Are we tobe replaced by Nurse Practitioners? Students see theaggravations and anxieties generated in their mentors bysuch huge paradigm shifts and sensibly wish to avoidsuch turmoil. In practical terms, it is extremely unlikelythat general practitioners will become an undesirablecommodity, but students seek to avoid being on the bleed-ing edge by retreating to the perceived safety of specialtydomains. This trend is perhaps fuelled by the students’sense that they do not wish to be ‘mere GPs’ and the fearthat rural general practice is in the ‘too hard basket’.2

Data from Wright suggests that these perceptions arisefrom the predominance of exposure to specialists in theirearly years of training.2 This should readily be addressedby the steps being taken at many schools to involve familyphysicians in all levels of the undergraduate curriculum.

The increasing technological capabilities of our med-ical world run in stark contrast to what most people stillwant of their doctor. As Everett Koop pointed out, thepublic still wants their grandfather’s family physician,with an MRI scanner. Rural doctors perhaps still mostclosely personify what our College espouses as the fullyrounded generalist physician and yet they are increas-ingly challenged by rising public expectations to be con-tinuously available, constantly vigilant and consummatelyinformed.

As a means to train more doctors for rural practice,rural community-based training programs, which provide‘immersion’ in rural life and practice, are blossoming allover the country. They now account for 13% of available

Correspondence: Dr David Topps, Assistant Professor,Department of Family Medicine, University of Calgary, UCMCSunridge, 3465 26AvNE Calgary AB, Canada, T1Y 6L4. Email:topps@ucalgary.ca

Accepted for publication January 2002.

TRAINEES FOR RURAL PRACTICE 97

positions in family medicine. However, we should beaiming for a target of 40% of trainees to enter rural prac-tice if we are to keep up at all with the needs of ruralcommunities.3 Sadly, the increasing availability of thesepositions is not matched by an increase in student interest;many of these places go initially unmatched in theCaRMS process and are perhaps being filled with candid-ates whose rural penchant is somewhat lacking.4

Medical schools that have developed a rural-orientatedundergraduate curriculum, however, are seeing increasingnumbers of their students choose rural family medicineprograms in the CaRMS match. Medical school enrolmentis currently being increased by approximately 25%.Much of this enrolment is being tied to commitments toincreased rural and regional medical education. Thisexpansion also includes the building of a new NorthernOntario Rural Medical School and an expansion of theUniversity of British Columbia medical school, to linkwith a northern University, which will provide a furthernorthern and rural focus to medical education.

There does appear to be increasing interest in special-ising within the realm of family medicine. Our urban col-leagues are increasingly moving towards limiting theirscope of practice in one way or another. Reimbursementrealities force many physicians to be more selective inwhat they will provide as services for their patients; thisluxury of selectivity is largely an urban phenomenon.Rural communities still rely on rural ‘docs’ to do itall. Even in rural communities, however, fewer would do‘everything’ than in previous years. There is a trend forphysicians to be somewhat more selective and perhapsdo GP anaesthesia and emergency, while others doobstetrics and emergency in addition to their familypractice. Many express interest in enhancing their practiceswith additional skills; this certainly keeps up the levelof interest and personal satisfaction, but it doesbring to mind a splendid eye-opening moment when acolleague was being radio interviewed about why he wasseeking additional skills training:

‘… So you’re doing this training at your own expense sothat you can provide more skills for your patients …’,‘Yes …’

‘… So that you will be even more valuable in yourcommunity …’, ‘Er, yes …’

‘… So that you’ll be called in even more often than youare now?’, ‘Umm, I guess so …’

Notwithstanding this seeming masochism, there isincreasing interest among our rural GPs to expand theirskill sets. Great progress has been made by the Society ofRural Physicians of Canada (SRPC) and the College ofFamily Physicians of Canada (CFPC) in forging allianceswith other specialty groups to promote the acquisition andmaintenance of additional skills. Foremost among thesejoint ventures is that with the Society of Obstetricians andGynecologists of Canada (SOGC)5 and, more recently,with the Canadian Anaesthesiologists’ Society (CAS).6

Such collaborative measures greatly enhance therelevance of our training programs to rural practice.Interestingly, with the anaesthetists’ group, recentmeetings have made much progress on issues that have beenhitherto ignored, such as maintenance of competence,professional isolation and portable licensing. Pivotal tothe progress made with these groups is the recognition thatassessment and certification should be truly competency-based and not grounded on some arbitrary number basedon cases seen or time spent. Former suspicions of turfprotection by various bodies seem to be evaporating,perhaps fuelled by the realisation that there are too few ofus in all groups, therefore plenty of turf for everyone.

Unfortunately, governments and health regions are notalways entirely supportive of our bringing additional skillsto a community: they tend to see this as merely anotherfactor increasing the size of their expenditures. Resourcerestrictions, both in manpower and in technological tools,are often used as a means of cost control but this tendencydoes appear to be decreasing in many areas.

While we are on the subject of money, reimbursementmechanisms remain a stumbling block in promoting thespread of additional skills for rural ‘docs’. It is noteworthythat additional skills training is most popular in areaswhere physicians can see the most obvious payback andimprove their ‘earning density’ (more intense work, moremoney, shorter time interval), for example, in emergencymedicine and anaesthesia. Fee-for-service can be bene-ficial for encouraging some of these services but does notrecognise many of the additional skilful tasks that rural

What is already known: Rural practice isunderserviced and does not attract enough interestedtrainees. This decline appears to be increasing.

What this paper adds: Cultural immersionthrough training programs based in rural commu-nities, providing additional skills training that isrelevant to rural needs and greater teamwork amongrural healthcare providers will address the shortfall.

98 D. TOPPS ET AL .

‘docs’ are called upon to perform such as co-ordination ofservices, triage, resource management: the old case of‘praxis pays better than gnosis’ or ‘our hands are worthmore than our heads’. There is a groundswell of interesthere in alternative payment plans and blended fundingmechanisms. These may do a better job of compensatingfor these unrecognised chores.

Co-ordination functions and teamwork will undoubt-edly play an increasing part in the role of future physi-cians. Manpower planners predict that the physicianshortage will only worsen over the next 15years, requiringus to work more closely with our nursing and nurse practi-tioner colleagues.7 This is not a role that we have beentrained for at all, as management skills do not featureon any medical school curriculum. Doctors tend to beindividualists, especially rural ‘docs’ who perhapsmigrate away from the tentacles of bureaucracy and theconstricting grasp of inflexible administrative structures.

In the 20th century, most rural doctors owned theirown office and paid their own staff. This century’s graduatesare far more likely to be attracted to group practice clinicsthat have excellent clinical staff and technology supportfunded by communities/governments. Many of the oldercurrent rural family doctors are also interested in explor-ing alternative payment models that would facilitate thistransition and provide a sustainable incentive for ruralpractice and perhaps even allow for more shared carewith other complementary health providers such as nursepractitioners. For example, many rural physicians nowprovide emergency services on a salary rather than on afee-for-service basis. It is still too early to see whetherprimary care reform, which proposes replacing fee-for-service with a capitation type system, will actually take offin Canada and be a ‘boom or bust’ for rural health care.

There is some concern with the apparent desire of cer-tain government departments towards replacing lost ruralGPs with nurse practitioners. Without going anywherenear the issues of scope of practice, workload, etc., simplearithmetic damns this course of action to irrelevancebecause of the marked disparity between the number ofbodies needed and the number that could possibly be

trained. The one bright light is that, just as with groups ofgeneralist and specialist physicians who are working moreclosely together, physicians are much more accepting ofthe skills that their nursing colleagues can bring to thetable. As we alluded to in the above discussion, there isgoing to be far more turf out there than mowers to cut it –we will need all the hands we can get.

On the whole, there appears to be an increasing desireon the part of all groups to work towards solutions to theproblems of looming rural manpower shortages, with manynew initiatives and collaborative ventures, much of whichrevolve around improvements in medical education. Howthese will all pan out remains to be seen but the mostpowerful factor is undoubtedly the willingness to work inconcert towards the common goal of providing an effect-ive, efficient and educated health care team in all ourrural communities.

REFERENCES

1 CaRMS Match statistical data, 2001. http://www.carms.ca/stats /stats_index.htm

2 Wright B, Bradley J, Scott I. Does the first two years ofmedical school influence medical students career choice infamily medicine? Family Medicine Forum, 2001.

3 Rourke J, Newbery P, Topps D. Training an adequatenumber of rural family physicians (Editorial). CanadianFamily Physician 2000; 46: 1252–1255.

4 Topps D, Crutcher R, Norton P, Topps M. The RuralityIndex – are we selecting the ‘best’ students? Fifth WONCAWorld Rural Health Conference, 2002.

5 Obstetrical Committee of College of Family Physicians ofCanada. Position Paper on Training for Family Practitionersin Cesarean Section and other Advanced Maternity CareSkills. Canadian Family Physician, 1999.

6 Anon. Meeting on Competency Assessment and Maintenanceof Competency in GP Anesthesia, November 2001. Kanan-askis, Alberta: Health Canada and Alberta Rural PhysicianAction Plan, 2001.

7 Roos NP, Bradley JE, Fransoo R, Shanahan M. How manyphysicians does Canada need to care for our aging popula-tion? CMAJ 1998; 158: 1275–1284.