A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills

Evaluating the scope of rural general surgery in British Columbia

BACKGROUND

Rural general surgeons perform many procedures outside the conventional scope of the specialty. Unique to British Columbia, the Rural Practice Subsidiary Agreement (RSA) formally defines rurality in the province. Our goal is to understand the scope of practice for BC's rural general surgeons and whether it has been affected over time by changing privileging guidelines.

METHODS

Medical Services Plan (MSP) data were collected from 2011 to 2021 for procedures billed by general surgeons in communities defined by the RSA as rural. We categorized codes from the MSP based on surgical specialty. For each community, we calculated the totals for these categories considering what other surgical specialties were present as well as changes over time.

RESULTS

From 2011 to 2021, 222 905 procedures were performed in 23 rural communities in BC. Colonoscopies were the most frequently performed procedure (n = 80 114, 35.9%), followed by colorectal (n = 23 891, 10.7%) and hernia procedures (n = 20 911, 9.4%). The most common unconventional procedures were plastic surgeries (n = 8077, 3.6%). Classification within the RSA did not significantly influence the percentage of unconventional general surgery procedures performed (p = 0.4). When another surgical specialty was present, there was often a decrease in the number of that specialty's procedures performed by general surgeons. Over the past decade, rural general surgeons performed fewer unconventional general surgery procedures (p < 0.001).

CONCLUSION

General surgeons working in rural communities perform a variety of procedures based on resources, community need, and access to other specialists. Over the last decade, this appears to have been influenced by new privileging guidelines. Understanding the scope of rural general surgery can inform training opportunities and, as there is a migration away from rural surgeons performing as many unconventional procedures, can elucidate the implications on patients and communities.

Surgical Task-Sharing in the Western Canadian Arctic: A Networked Model Between Family Physicians with Enhanced Surgical Skills and Specialist Surgeons

Background

With the loss of generalism in the surgical specialties, there has been a move in Canada to train family physicians in enhanced surgical skills (FP-ESS) to address the surgical needs of rural and remote populations. This research project sought to describe one network integrating FP-ESS and specialist surgeons, focusing on the role of FP-ESS and their relationship with specialist surgeons, in the surgical care of the Beaufort Delta Region of the Northwest Territories of Canada.

Methods

Using a participatory approach, semi-structured interviews were conducted with 22 stakeholders within the surgical system. Interviews were transcribed and reviewed, then imported into NVivo 12 for analysis. First-level coding was performed based on both deductive and inductive reasoning in an iterative fashion during interview collection to develop and refine the codebook. This was followed by second-level categorizing.

Results

The FP-ESS physicians provide cesarean section services to maintain a local obstetrics program, to provide gastrointestinal endoscopy, and to provide emergency on-call support, as described by one stakeholder. FP-ESS work together with specialist surgeons through an informal network keeping surgical care as close to home as possible. FP-ESS within this health regions were seen as “a really big gain to the system.”

Conclusions

This study deepens our understanding of rural surgical service delivery, in particular where FP-ESS and specialist surgeons function collaboratively. It also contributes to strengthening rural surgical systems in Canada and therefore to addressing the health gap between rural/remote/indigenous and urban populations.

General surgery in Canada: current scope of practice and future needs

BACKGROUND

The scope of practice of general surgeons in Canada is highly variable. The objective of this study was to examine the demographic characteristics of general surgeons in Canada and compare surgical procedures performed across community sizes and specialties.

METHODS

Data from the Canadian Institute for Health Information's National Physician Database were used to analyze fee-for-service (FFS) care provided by general surgeons and other providers across Canada in 2015/16.

RESULTS

Across 8 Canadian provinces, 1669 general surgeons provided FFS care. The majority of the surgeons worked in communities with more than 100 000 residents (71%), were male (78%), were aged 35-54 years (56%) and were Canadian medical graduates (76%). Only 7% of general surgeons practised in rural areas and 14% in communities with between 10 000 and 50 000 residents. Rural communities were significantly more likely to have surgeons who were international medical graduates or who were older than 65 years. The surgical procedures most commonly performed by general surgeons were hernia repairs, gallbladder and biliary tree surgery, excision of skin tumours, colon and intestine resections and breast surgery. Many general surgeons performed procedures not listed in their Royal College of Physicians and Surgeons of Canada training objectives.

CONCLUSION

Canadian general surgeons provide a wide array of surgical services, and practice patterns vary by community size. Surgeons practising in rural and small communities require proficiency in skills not routinely taught in general surgery residency. Opportunities to acquire these skills should be available in training to prepare surgeons to meet the care needs of Canadians.

Evaluation of the Spring Seedling Project-Zhaotong Program: A study of a novel continuing medical education program for rural doctors in China

Objective

To evaluate the effectiveness of the Spring Seedling Project‐Zhaotong program, a novel continuing medical education program, to improve the knowledge and skills of rural doctors in China.

Design

An uncontrolled single‐group pre‐ and post‐intervention design based on quantitative and qualitative methods.

Setting

Zhaotong is a prefecture‐level city located in Yunnan, China.

Participants

A total of 1866 country doctors practising in Zhaotong were enrolled.

Interventions

The Zhaotong program consisted of three stages: remote education, workshops conducted in Zhaotong and field training in Shanghai.

Main outcome measures

The effectiveness of the remote education and Zhaotong workshop stages was assessed based on differences between pre‐ and post‐training test scores. Qualitative comments were collected to assess the experience of country doctors following the Shanghai field training stage.

Results

In total, 1866 country doctors (46.9% males; mean age: 38.2 ± 9.2 years) participated in the program. The average score of the post‐training test was higher than that of the pre‐training test, both online (P < .001) and offline (P < .001). In regard to the Zhaotong workshops, with the exception of incisions/suturing, the average scores of cardiopulmonary resuscitation, gynaecological examinations and child growth/development were improved after training (P < .001). Qualitative analysis showed that Shanghai field training enhanced understanding of general practice, with the majority of country doctors indicating that they would apply what they learned in daily practice.

Conclusion

This study introduced an comprehensive form of continuing medical education for rural doctors in Zhaotong and proved the effectiveness of this program and also provided a reference point for the future development of continuing medical education.

Delivery of essential surgery by family physicians

Primary health care provides the framework for delivering the socially-informed, comprehensive and patient-centred care underlying robust health-care systems and is, therefore, central to achieving universal health coverage. Family physicians are best placed to embody primary health care’s dual focus on community and population health because they are often employed in rural or district hospitals with limited human resources, particularly a lack of specialists. Here we want to illustrate how additional training for family physicians, the key clinicians in primary care, can play a critical role in reducing disparities in access to surgical, obstetric and anaesthesia care in low- and middle-income countries and in rural or remote settings. Examples are given of how training programmes can be developed in low-resource settings to equip family physicians with life-saving surgical skills and of how family physicians in high-income countries can be trained in the surgical skills essential for working overseas in low-income settings. Policy-makers should promote surgical practice among family physicians by supporting family medicine programmes that include additional surgical skills training and by expanding opportunities and incentives for family physicians to serve in rural areas. Moreover, national surgical plans should include a primary health care strategy for surgical care and, globally, family physicians should be considered in discussions of surgical care. Finally, surgeons, anaesthesiologists, obstetricians and family physicians should be encouraged to collaborate in ensuring that all patients, regardless of place of residence, receive safe and timely surgical care.

Family medicine residents in central Saudi Arabia. How much do they know and how confident are they in performing minor surgical procedures?

OBJECTIVES

To explore the knowledge, practice, barriers and reported self-confidence of family medicine (FM) residents in Riyadh, Kingdom of Saudi Arabia, in performing minor surgical procedures (MSP).

METHODS

A cross-sectional study was conducted by distributing questionnaires to 267 family medicine residents in Riyadh, Kingdom of Saudi Arabia between May and July 2016. The questionnaire includes 7 categories with 71 questions about: knowledge, interest, experience and confidence in performing different MSPs, prior training in MSPs, perceived barriers to performing MSPs and ways to improve basic surgical skills.

RESULTS

The response rate was 71.9%. Residents had a mean knowledge score of 15.75% and a mean interest score of 10.4 out of 12. Out of 23 MSPs surveyed, residents had performed a mean average of 9.18. The mean of residents' confidence scores was 26.6 out of 63. The most common barrier to performing MSPs was a lack of training (n=115; 59.9%), while the least common barrier was a lack of interest (n=113; 58.9%). Participants consider intensive education to be the the most effective way to improve their performance, while increasing the duration of some rotations found to be the least effective way for improvement.

CONCLUSION

A majority of FM residents were interested in MSP, but had low perceived knowledge, low reported confidence and infrequent practice. Family medicine programs should provide continuous standardized training by a qualified and interested trainer within the FM setting.

Learners' experiences of an enhanced surgical skills training program for family physicians

BACKGROUND

Family Physicians with Enhanced Surgical Skills (FPESS) have sustained rural operative care, including local access to caesarean section, in many communities across rural Canada and internationally. The contemporary role of FPESS within the health system, however, has not been without challenges. The 12-month Prince Albert Enhanced Surgical Skills (ESS) program intakes two learners a year and is one of only two accredited programs in Canada offering a scope of surgical practice beyond operative delivery.

METHODS

This paper highlights the results of an evaluation of graduates' experiences of training and the post-training environment. Graduates were practicing in Western and Northern Canada after completing the ESS training program, specifically in British Columbia, Alberta, Manitoba, and the Northwest Territories.

RESULTS

Findings suggest the overall success of the program in meeting learners' needs. There was a close match between the training curriculum and post-training practice.

CONCLUSION

The findings from the post training experience suggest that sustainability of ESS is linked to 1) creating pathways to privileges between the ESS community and the Health Authorities, 2) building functional and trusting relationships with surgical specialists, and 3) creating a web of accessible effective rurally appropriate surgical Continuing Professional Development (CDP). Ongoing CPD is identified as essential in increasing the comfort of FPESS.

Building Rural Surgical Networks: An Evidence-Based Approach to Service Delivery and Evaluation

Formalized rural health service delivery networks are emerging as an over-arching response to the attrition of rural surgical and maternity services in Canada. In effective networks, there is strong collaborative leadership, form follows function, core network elements are identified and site-specific variations are accommodated to meet the surgical needs of the population in each geographic catchment. The network catchment must reflect the natural alliances that already exist among health professionals, policy makers, health administrators, academic institutions and communities. Although each key stakeholder plays a key role in determining success, value is added through the synergistic interplay of all participants.

Why Canada needs networks to provide rural surgical care, including family doctors with essential surgical skills

SUMMARY

Time is long overdue for action to improve rural surgical services in Canada. In this issue of CJS, a proposed curriculum for the provision of enhanced surgical skills (ESS) to rural family physicians offers an opportunity to fortify a seamless network of high-quality surgical care for rural Canada. It is supported and enhanced by the best available evidence and measured advice from specialists and generalists alike. Publication of this curriculum proposal provides for essential dialogue with general surgeons. We discuss why we must play an active role in the development, teaching and evaluation of ESS, or we will have minimal influence and limited grounds on which to criticize its outcome or celebrate the opportunity of success it promises.

GPs with enhanced surgical skills: a questionable solution for remote surgical services

SUMMARY

The Canadian College of Family Physicians recently decided to recognize family physicians with enhanced surgical skills (ESS) and has proposed a 1-year curriculum of surgical training. The purpose of this initiative is to bring or enhance surgical services to remote and underserviced areas. We feel that this proposed curriculum is overly ambitious and unrealistic and that it is unlikely to produce surgeons, or a system, capable of delivering high-quality surgical services. The convergence of a new training curriculum for general surgeons, coupled with the current oversupply of surgeons, provide an alternate pathway to meet the needs of these communities. A long-term solution will also require alternate funding models, a sophisticated and coordinated national locum service and a national review of the population and infrastructure requirements necessary for both sustainable resident surgical services and surgical outreach services.