Rural surgery in “The Great White North”— universal care or universal challenge?

Health care in Canada, for the most part, is under provincial rather than federal jurisdiction. Although the Canada Health Act has flagship criteria and conditions, such as “universality” and “portability,” it rests these definitions on what Canadians perceive as a citizen’s right: Health care access for all.1 This definition includes access to surgical services. Details of traveling a certain distance to receive this care and the specifics of what that care encompasses at each hospital never made it into the act’s fine print.

Figure 1: Geography and population demographics of Canada

Access to timely, affordable, and quality surgical care is an ongoing challenge for Canadians and this challenge is magnified in rural communities, which are defined as locations with populations of less than 10,000 and/or fewer than 150 people per kilometer.2 An estimated 95 percent of the Canadian land mass is considered rural or remote (see Figure 1).2-5 The 20 percent of Canadians who call rural communities home live with the environmental challenges this landscape presents, in addition to the socioeconomic, cultural, and political factors that complicate this situation further. Several factors affect provision of rural surgical services in Canada, including: (1) surgeon training; (2) certification, licensing, privileges, and credentialing; (3) recruitment and retention; (4) rural surgical care delivery models; and (5) recognition of a rural surgery subspecialty within general surgery.

Training general surgeons

To optimize Canadian rural surgery services, training programs must account for certain trends that are increasingly problematic. General surgery residency curriculum has been trending toward subspecialization with subsequent pursuit of postresidency fellowship training categorized by anatomic association (such as hepatobiliary), clinical etiology (such as surgical oncology), a technical approach (such as minimally invasive surgery), or patient demographics (such as pediatric). More than 70 percent of Canadian general surgery residents pursue fellowship training, similar to the 80 percent documented by the American Board of Surgery.6,7

Whereas some surgical educators would argue that fellowships tailor skills in a manner paralleling trends in clinical practice and job postings, others maintain that they have created a shift in perception of skills and expertise. Subspecialization will preferentially benefit the 80 percent of Canadians in urban centers where most, if not all, subspecialty-trained surgeons will practice. Career goals of subspecialization may have heightened the demand for fellowships at the expense of undermining training for future rural surgeons with a different set of exit competencies. Indeed, even large urban hospitals demand well-rounded generalist surgeons who apply this particular expertise for the bulwark of surgical emergencies.

A pervasive concern is that many general surgery residents no longer obtain the skill set that rural, “generalist” general surgeons require.8-10 This situation is illustrated by challenges for residents to acquire particular skill sets. For example, in Canada, nonsurgeon gastroenterologists perform a large volume of endoscopy in teaching centers, which may limit surgery residents’ access to endoscopy training.11 Yet, data from the Canadian Association of General Surgeons (CAGS) shows that the majority of colonoscopies in Canada, especially in rural settings, are completed by general surgeons, necessitating advocacy/position statements to support acquisition of these skills in surgical residency.6 Similarly, although the generalist skill set overlaps with other surgical specialties, the Royal College of Physicians and Surgeons of Canada’s (RCPSC) general surgery training requirements are specific to general surgery and its subspecialties.12 Residents usually have little to no formal training in other surgical specialties. While such “off-service,” nongeneral surgery electives may be requested, such flexibility is usually limited to junior residency years when training focuses on core surgical principles rather than procedural competency.6 This training occurs years before residents establish clinical practice, limiting transition into their rural surgery career.

Although graduating surgery residents have been deemed competent to perform complex subspecialty procedures within a tertiary care team environment, these skills may not transfer to a case-mix with which they are unfamiliar, an isolating environment with no peer support, or a lifestyle not previously experienced.6 Exposure to the spectrum of a rural surgeon’s skill set during training may increase residents’ awareness and likelihood to tackle the unfamiliar path. The RCPSC has recently established a task force known as the Future of General Surgery in the 21st Century to address gaps in generalist surgeon training.

Certification, licensing, privileges, credentialing

Although the RCPSC oversees certification of graduates from Canada’s residency programs, licensing is overseen by each individual province’s College of Physicians and Surgeons.13,14 Licensing guarantees neither privileges nor clinical positions. Clinical privileges are acquired at a local/regional level, and variations in requirements for licenses and privileges may limit portability of a rural surgeon’s diverse skill set. Given the shortage of surgeons willing and able to work in rural—and particularly remote—locations, this jurisdictional barrier can wreak havoc on issues such as locum programs or rural surgeons moving from province to province.

Fellows of the Royal College of Surgeons of Canada (FRCS[C]) may apply for clinical privileges anywhere in Canada and subsequently establish surgical practice where they are needed and resources are available. In contrast, international medical graduates (IMGs) undergo a more complex process.13 Depending on the country in which their training was conducted and previous professional experience, IMGs may practice in Canada by repeating none, part, or all of their surgical training before qualifying to take the Canadian examinations. If they completed training at a FRCS(C)-accredited foreign residency program, they may practice before completing the requisite examinations and other requirements for full provincial license, but such opportunities are almost exclusively in rural, northern, and underserviced communities. Rural Canadians initially benefit from these IMGs, but unfortunately, relatively low retention rates are the typical result, and once these individuals pass their examinations, the rest of Canada opens their doors fully to them.15,16

The scope of rural surgery in Canada has more breadth than depth. While a range of emergent procedures from other specialties is anticipated, the scope of general surgery is at risk. With the subspecialization trend, turf wars diversify as general surgeons with fellowship training expect referral patterns to shift accordingly. If this movement occurs, procedures specific to the generalist general surgeon will shrink further, as has historically been observed with the establishment of other surgical specialties (personal communication with co-author Dr. Warnock and Kenneth A. Harris, MD, FRCS(C), director of education for the RCPSC, May 13, 2013).

The scope of rural surgery may be further constrained by hospital and operative teams’ lack of capacity to deal with anesthetic or technology demands.10,17 Operative volume of a rural surgeon is already limited by the catchment area they serve, but these additional pressures must be considered given the ongoing volume-outcome debate and credentialing bodies proposing “numbers” of procedures rather than competency outcomes.17 Rural surgeons struggle to validate the services they provide while the push for regionalization attached to this complex volume-outcome debate looms.10 This issue is not simply about hospital and surgeon volume, but training and case-mix of the entire surgical health care team, including anesthesiologists, nurses, and other allied health care professionals.

Recruitment and retention

The number of general surgeons in Canada and the province of British Columbia (BC) (5.0 and 4.0 per 100,000, respectively) is lower than health care experts estimate is necessary to provide adequate services (9.4–9.8/100,000).18-20 Health care facilities in rural Canada struggle more to both recruit and retain specialists. Growing evidence demonstrates that where residents complete their medical education and surgical training and where they were raised strongly predict where they will choose to practice.10,19,21,22

The University of BC’s distributed medical school in northern BC, the Northern Medical Program (NMP), was developed in response to this knowledge gained from medical education research.23 Since its inception in 2004, the program has graduated 160 students, 10 of whom chose general surgery training. One aim of the NMP is to expose trainees to life and medicine in rural and northern communities so as to enhance their interest in these professional environments. The first class of surgical trainees with NMP roots graduated in June 2013, and the potential impact on rural surgical services of these and future NMP graduates is anxiously awaited.

Canadian rural surgical services—which is often associated with northern and/or remote geography—have lifestyle implications, including environmental, social, and cultural, to name a few. Government and university programs attempt to address the chronic issue of recruitment and retention. The table below demonstrates a list of programs created over the years for recruitment and retention of specialists in northern BC.24

Programs for recruitment and retention of surgeons to British Columbia’s rural communities

Program name* Program description Funding available
Rural Retention Program An incentive program to enhance the supply and stability of physician services in rural communities $0–$31,365/position/year
Rural Continuing Medical Education (RCME) Provides funding for CME to support the maintenance of skills and credentials required for rural practice $0–$7,800/year
Recruitment Incentive Fund Provides an incentive to physicians recruited to fill vacancies in rural communities $5,000–$20,000/position
Recruitment Contingency Fund Provides financial assistance to rural communities to help with recruitment expenses when filling a vacancy is, or is expected to be, difficult $0–$15,000/position
Isolation Allowance Fund Assists physicians who provide services in eligible rural communities with fewer than four physicians $8,121–$104,571/community/year
Northern and Isolation Travel Assistance Outreach Program Provides compensation to physicians traveling to rural communities to provide services “closer to home” Travel and lodging expenses reimbursedTravel time honorarium: $500–$1,500/physician
Rural Specialist Locum Program Assists with facilitating locum coverage for rural specialists (regarding CME, vacation time, and so on) $1,200/dayTravel honorarium (MSP): $1,000
Rural Education Action Plan (REAP)
Undergraduate Rural Participation Program
Assists third- and fourth-year medical students pursuing rural training opportunities $250/week$800 for travel
REAP
Undergraduate Teacher’s Stipend
Provides compensation for physicians training medical students in rural communities $450/week (maximum eight weeks)
REAP
Specialty Training Bursary Program
Assists residents in training intending to practice in rural communities $25,000/year bursary (maximum two years)
* Funded by British Columbia Provincial Ministry of Health.
† Funds based on degree of isolation, expected difficulty of recruitment, and number of years practicing in a rural community. Specific details are not described.
‡ Funded by the British Columbia Ministry of Health and the University of British Columbia.
 

Rural surgical care delivery models

An intuitive model that addresses mounting concerns regarding the need for rural surgical services is regionalization of resource-intense subspecialty services, such as pediatric, transplant, and so on, with the vital balance of a supportive network for rural surgeons to maximize the spectrum and volume of care they can provide. This support historically was limited to patient transfer requiring costly land, water, or air transport; delayed care; risks of transport; and the emotional and physical effects on patients that occur when they are transferred away from their community and support systems. A responsive delivery model requires use of innovative resources in telehealth and electronic health records (EHRs).

BC’s Northern Health Authority (NHA) exemplifies rural Canada in its vast geography (600,000 km2) with its population density less than 0.5 persons/km2 (see Figure 1) The NHA implemented telehealth for consultations, operative preparation, and follow-up for patients who require a broad spectrum of specialty care available only in regionalized and tertiary care centers. Telehealth ensures patients can receive care closer to home.25 Hospital and clinical care costs in Canada are covered under the public insurance plan, but unless the situation is classified as urgent or emergent, travel costs are the patient’s responsibility.1 The telehealth network decreases travel requirements. Figure 2  demonstrates the evolution of telehealth in BC’s NHA with surgical care in the development stage of use (personal communication and Figure 2 production: Frank Flood, BC NHA regional manager, Telehealth, August 15, 2013).

Figure 2: Growth and evolution of Telehealth in British Columbia’s Northern Health Authority

Canada’s remote North West Territories (NWT) also present vast distances across which health professionals must communicate. Physicians there have enhanced on-site and telehealth care via digitized networked EHRs, which house patient databases, laboratory results, decision support vehicles, archived radiologic images, and reports. Now estimated to support most NWT residents, these EHRs and associated telehealth partners permit rapid access to consultative expertise from surgeons in referral centers and facilitate surgical decision making in locations without on-site surgical care.26 Cost savings are significant because a $10,000 (one-way) MedEvac flight for consultation may be supplanted with a $150 video consultation, often permitting patients to stay safely within their community.

Rural surgical care in Canada is provided by a heterogeneous, passionate group of physicians, including general surgeons and family physicians who perform specific procedures, including, but not limited to, caesarian sections.17 Historical terminology of “general practice surgeon” (GPS) is morphing into “Family Physician with Enhanced Surgical Skills” (FP-ESS), with a proposed formal curriculum submitted to the Canadian College of Family Practice in September 2012. Novel engagement with CAGS includes plans for a collaborative position paper on FP-ESS, a concept often skirted due to professional politics. With multiple studies on outcomes and quality of care of GPS supporting the limited but important role our FP colleagues provide for rural communities, the general surgery profession is overdue for discussions with these colleagues.27-34 In Canada, if general surgeons do not play an active role in the development, teaching, and evaluation of the ESS field, they will have minimized influence and limited grounds on which to criticize its outcome or celebrate its success. Rural surgeons can contribute a gold mine of knowledge that textbooks seldom capture.

The subspecialty of rural surgery

It might seem odd that “rural” is an accepted adjective for a surgeon but is not accompanied by the kind of fellowship training that characterizes other subspecialties. Rural surgery demands a unique skill set. This reality must be addressed to ensure surgeons’ skills match their home addresses. Core surgical principles are mastered in residency, but the specific skill set is based on the case-mix for which residents train, including the environment in which they gain these skills and who teaches them.

One solution is flexible general surgery residency programs that provide trainees with rotations targeting procedural competencies within the scope of other specialties in their senior residency years rather than limiting them to, or targeting, subspecialty rotations. Another option is to create rural surgery fellowships, which would provide an additional year of training to give surgeons exposure to the skills and lifestyle associated with rural practice. The RCPSC is giving consideration to both options, which were discussed at a summit meeting in May 2013. Rotations in rural locations may also increase understanding among future surgeons in tertiary care centers of their rural colleagues’ requests for patient transfer, and of the challenges facing rural, remote, and northern Canada.

Conclusion

General surgery is evolving in Canada. Although the established subspecialty trend is accepted, rural surgical care is acknowledged as a discipline to be optimized and preserved so that Canada’s surgical delivery matches the country’s demographics and geography: Yet another canary in the coal mine of a universal health care system.


Acknowledgements
The authors would like to acknowledge F. Flood, BC Northern Health Authority Regional Manager, Telehealth, for sharing his expertise in the evolving Telehealth services of the NHA.


References

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