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Rural Practice
BMA: Healthcare in a rural settingPostgraduate trainingRural and remote practices can provide a broader range of services than those in urban areas. Research in Australia has found that, in general, the proportion of GPs providing a broader range of services increases with increasing rurality or remoteness.48 Rural GPs are often the first port of call for a wide range of health needs, and may be exposed to health problems for which they may not have received sufficient training and support. Those health problems that practitioners in rural/remote areas may need experience and knowledge of are highlighted below
In addition, patients in rural areas may present practitioners with health problems that are particular to rural areas or more prevalent in rural areas. For example, certain health problems are more prevalent in farming communities
In the secondary sector, there is a similar need for consultants working in such areas to provide a broader range of services. The surgical skills needed by surgeons in rural areas may vary with location. For example, consultants in Shetland and Orkney need to carry out caesarean sections, while those in Fort William need skills in mountain trauma. Surgeons also need generalist skills to deal with a complex case mix. Healthcare professionals in rural/remote areas therefore need to develop a greater range of skills than those in urban areas. Remote and Rural Areas Resource Initiative (RARARI) in conjunction with Skills for Health has recently explored the skills used by rural healthcare. Skills for rural healthcare teamsIn the UK, RARARI has worked with Skills for Health, the Scottish Executive and relevant NHS health boards and organisations to provide an improved understanding of the activities that make up healthcare in rural communities. Skills for Health has categorised the skills and competencies that are needed by rural healthcare teams. Identifying these skills will assist workforce planning and inform the education and training of staff at all stages of their career.
Postgraduate training programmes should be provided which reflect the generalist skills required in rural areas by different healthcare professionals. This would help to provide professionals with the confidence and encouragement to choose rural practice. Primary and secondary care in rural areas can provide opportunities to expose trainees to a variety of situations and experiences, and thereby increase knowledge of generalist skills. A period spent in general practice would give all trainee specialists experience of the holistic, generalist and continuous care delivered in general practice. Most patients treated in hospital are referred from general practice, most return to a community setting, and 80 to 90 per cent of all healthcare episodes are dealt with in general practice. An improved mutual understanding of the skills, knowledge, experience and roles of GPs and other specialists would be helpful. Modernising Medical Careers offers the opportunity to broaden the experience of trainees within the general practice setting. The second foundation year (the equivalent of the current senior house officer training) will focus on the management of acutely ill patients as well as the acquisition of key generic skills. One aim of this training period is to foster a better understanding of the relationship between primary and secondary care, by providing a greater number of experiences in, and knowledge of, general practice. It is desirable that the choice to spend time in a rural practice as part of this training should be offered and encouraged. RecommendationPostgraduate training programmes should use the opportunities provided in rural primary and secondary care to teach generalist skills to healthcare professionals (including surgeons) during their basic training.
Rural Healthcare Report [BMA Members]
WONCAPostgraduate Vocational TrainingRural family physicians generally provide a wider range of services than do their metropolitan counterparts. Consequently, there is a need for specific residency training programs for rural practice which prepare new medical graduates for a career in the country. Wherever possible, training for rural practice should occur in the rural setting based at regional rural hospitals and rural family practices. In addition to standard training for family practice, rural practice vocational training requires specific emphasis on: hands-on learning of procedural skills; the spectrum of illnesses in rural and remote communities; the sociology and psychology of rural and remote communities; and professional and personal aspects of living and working in small rural communities. Training positions for advanced rural practice skills in emergency medicine, anaesthesia, surgery, procedural obstetrics and others, need to be developed and appropriately funded. Depending on the intensity of the training program, such training may involve one to two years of additional training time over and above basic family medicine training. Consideration should be given to recognition for rural vocational training in the form of certification in rural medicine. The opportunity to take some training in other countries can broaden experience and help develop new approaches to medical practice, medical education, and health care delivery. Source: WONCA Training for Rural Practice
American Academy of Family PhysiciansFamily practice in rural communitiesFamily practice is the specialty most likely to be found in rural communities. Family physicians constitute nearly 90 percent of all primary care rural physicians' and are the only source of medical care in many remote rural communities. The low population density that characterizes rural areas often cannot support the practices of physicians in the narrower subspecialties. Rural family practice presents an exciting and challenging opportunity for family physicians. Instead of being hemmed in by restrictions in highly competitive urban settings, the rural family physician has an opportunity to practice a broad scope of family medicine. Limits are usually based only on the physician's training, experience and demonstrated abilities. The economic turf wars of urban communities are also usually absent in rural areas' Most rural family physicians express a high degree of satisfaction with rural practice, even in the smallest communities' Among the many reasons for satisfaction expressed by rural family physicians is the feeling that their services are essential to their communities and deeply appreciated by the people they serve. Satisfied rural family physicians often cite their ability to provide continuing and comprehensive care to a broad mix of individuals and families from all socioeconomic backgrounds.2 In addition to the opportunity to practice the full range of family medicine, there are numerous other professional benefits to rural practice, such as close relationships with colleagues and the community hospital. Today's rural practices are increasingly characterized by innovative practice arrangements. This makes it possible to share the workload through call schedules and coverage, thus enabling rural physicians - even in remote areas - to practice the type of sophisticated family medicine for which they have been trained, as well as to maintain close links with professionals and facilities within and outside of the immediate community. Furthermore, arrangements for salaried practice) often sought by new residency graduates, are becoming much more prevalent in rural areas. Changes in the health care organization and delivery system are making rural practice more attractive to family physicians. Satisfaction levels from those practicing in rural areas continue to increase. 3 Federal and state governments have enacted policies supporting placement of family physicians in rural areas. In addition, federal policies have been instituted to support rural hospitals as stabilizing factors in rural communities. Improved funding opportunities allow for new-start community health centers. There are regional and state support programs for recruitment and locum tenens. Communication technology (e.g., teleconferencing, telemedicine) allows for improved ease of practice and reduced professional isolation. The Federal Communications Commission's Universal Services Fund supports telemedicine technology in rural practices. However, training family physicians for rural practice continues to be a challenge. Results from surveys conducted by the AAFP indicate that the clinical practices of rural family physicians differ from those of their urban colleagues. For example, rural family physicians are more likely to provide routine and high-risk obstetric care, to perform major and minor surgery, to reduce and cast fractures, and to perform gastrointestinal endoscopies. Primary care in the rural setting also includes a stronger emphasis on emergency care and the stabilization and transportation of patients with medical emergencies and trauma.4 Strategies to promote rural family practiceA number of strategies have been implemented over the last 20 years by family practice residency programs and federal and state governments to promote rural family practice among new physicians. Rural residency tracks have been developed to prepare students for rural family medicine. Residents complete the first year of training in an urban-based program and the last 2 years in a rural community. Among the 474 family medicine residency programs in this country, 29 have established separately accredited rural training tracks, and 143 programs offer a fellowship in rural medicine. Residents in rural training tracks often participate in preceptorships in a rural primary care environment where they learn what it means to be a rural family physician. They acquire the skills necessary to diagnose and manage health problems unique to rural areas. In addition, they learn surgical skills necessary for rural practice, as surgery in rural hospitals is significantly different than in large urban hospitals. Rural family physicians are often the surgical assistant at the table, or must provide large portions of postoperative care. Surveys of graduates of rural residency tracks place 76 percent of respondents in a rural community, and 61 percent in federally designated health professional shortage areas' Thirty-nine percent were near their hometown and 45 percent were near the community in which they completed residency training. Ninety-four percent reported that their rural training was adequate or better. 5 The quality of rural training programs can be measured by the curricular elements offered that are critical for rural training; that the training program has a stated mission for rural practice education; and that the training program employs faculty members with specific experience in rural practice and training. Requisite skills and curricular elements necessary for rural family physiciansRecently, family practice residency directors, educators, and private family practitioners were surveyed regarding requisite skills for a successful rural family physician. The results indicate that certain curricular elements should be emphasized for residents anticipating practice in rural or medically isolated communities. The educational needs for rural family physicians differ strongly from their urban counterparts. These elements are as follows: I. First-hand rural training experience Residency training in family practice involves rotations through many different specialties. Variations exist between programs with regard to the amount of time spent with individual specialties. In addition, programs offer second- and third-year residents the opportunity to plan an elective curriculum (generally three to six months out of the total 36-month residency) to acquire specific practice skills. The following information should help both residents and program directors design elective time that optimally prepares residents for rural practice. Experience should be obtained in the following areas: 1. Hands-on rural training A. At least a two-month rotation in a rural family practice setting.
If possible, ongoing exposure to a rural A. Occupational health: B. Women's health D. Trauma and emergency care
A. Professional and personal time management SummaryResidents interested in rural family practice should periodically review their training and discuss their career plans with residency program faculty and directors. Physicians in rural private practice can also provide valuable education and career planning assistance. In addition, residency programs should develop rural curricular elements in concert with rural family physicians to ensure adequate training electives for residents. These special considerations for specific curricular needs have been developed by members of the American Academy of Family Physician's Commission on Education and Committee on Rural Health. For more information, contact the AAFP at 800-274-2237, or www.aafp.org.
Source: AAFP Family Medicine Graduate Medical Education Training For Rural Practice (Position Paper)
Society of Teachers of Family Medicine Rural Interest GroupRural Issues Skills and Skill Knowledge Enhancement for Rural Practice Trauma and Emergency Care Occupational Health Critical Care Surgery and Procedural Skills Musculoskeletal Medicine and Sports Medicine Geriatrics Child's Health Behavioral Medicine Community-Oriented Primary Care
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