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- Abstract
- Introduction
- Shifting Structures in Rural Settings
- Delineation of Clinical Competence
- Emergency Medicine Training
- Conclusion
- References
Abstract
A number of issues underlie the practice of emergency medicine in rural areas, including the preparation and continuing medical education of emergency medicine practitioners.
Many rural practitioners have become specially trained in aspects of secondary care, and most pay considerable attention to skill maintenance.
In past times, the rural doctor was generally not troubled by litigation from patients presenting as emergency cases, but this aspect of practice has changed. Litigation by patients now significantly affects Australian medical practice and vicarious liability often affects hospitals. In seeking to minimise any possible liability, hospitals have adopted a risk management approach, including assessment of the competence of medical practitioners, particularly in procedural skills. In South Australia the process of delineation of clinical privileges for practitioners working in non-teaching hospitals has operated for approximately 15 years. A report commissioned by the South Australian Health Commission in 1996 included emergency medicine as an area of clinical activity requiring delineation of competence.
There is some concern from rural practitioners, who have generally agreed with the delineation of clinical privileges process, about a further mandatory requirement to show skill maintenance in emergency medicine in addition to existing periodic retraining requirements in obstetrics, anaesthesia and surgery. The many costs involved in attending retraining programs include transport, accommodation and registration, opportunity costs associated with absence from practice, and locum costs. These costs must be balanced against the economic benefits of successfully achieving delineation of clinical competence in particular disciplines, and deriving income from practice in those disciplines.
Enforced training programmes in some disciplines cannot be compensated for financially, where the case load in the relevant discipline does not support the costs of the required skill maintenance. As a result, rural hospitals supported by Government must materially support rural practitioners in their education. There are several options but support should be focused on defraying the practitioners’ costs and providing locum relief during absences from practices.
Issues related to smaller case loads do not tend to apply in emergency medicine where most rural practitioners are confronted with a steady stream of cases. However, a lack of substantial training in emergency medicine characterises most medical courses. Increased exposure of medical students to the practice of emergency medicine, together with better debriefing after involvement or observation of practice, should be a key factor in the development and teaching of medical students.
There has been some small progress in developing national uniformity in the teaching and assessment of emergency medicine skills of intending rural practitioners. It is to be hoped that the future rural training mechanisms will be able to deal consistently with emergency medicine under national guidelines.
Introduction
This paper follows the recent articles in Healthcare Review - OnlineTM on rural health in Australia and New Zealand, and will explore some of the infrastructure issues that underlie the practice of emergency medicine in rural areas. Particular emphasis will be placed on the preparation and continuing medical education of emergency medicine practitioners in rural areas. Comments in this paper are based on a long experience in rural practice and an examination of medical practitioners in obstetrics. The writer also has a long involvement in the process of delineation of clinical privileges for hospital practice.
Shifting Structures in Rural Settings
When situated in a region in which it is not possible to use readily accessible referral systems on a frequent and continuing basis, rural doctors require hospitals as a stage on which to practise their craft. However, serious shortages of both rural nurses and rural doctors constitute a major health service provision issue in Australia, as governments battle to construct and endorse an attractive working environment for health professionals. The old environment of a hospital, with a minimum of lay staff, essentially controlled and nurtured by a capable rural doctor in collaboration with a senior nurse or Matron, has largely vanished. This has been replaced by the Health Unit, now controlled by a Chief Executive Officer assisted by what appears to be an excess of non-medical lay staff, and featuring departmentalisation of nursing and clinical practitioners including medical. Medical input into administration is often scant, delivered via a hierarchy, and sometimes not invited. Some would predict that under this system, governments would continue to battle to attract new rural doctors.
It has been argued that clinical work performed within the old system should have been more transparent. Whilst hospital Boards of Management were, and are, often comprised of consumers, thus catering to the consumer need, there has been a call for even greater transparency. Under freedom of information legislation in Australia, there is now open access to hospital case notes for patient and/or their legal advisors.
Because of the rise of consumerism, and consequently medico-legal issues related to hospital care, hospitals have become aware of risk management strategies which can be employed to minimise the likelihood of costly and time consuming legal processes which often lead either to litigation or near miss litigation. In the writer’s view the development of these strategies is unfortunate, but necessary. Whether it will result in sensible outcomes is another matter. Established medical practitioners will understand that medicine is an imperfect science, practised with some art by imperfect practitioners on imperfect patients. Recent decisions handed down by the courts suggest that the degree of perfection in medical practice required by consumers and their lawyers cannot be guaranteed under current the medical practice. However, because changes to the law, especially tort law, must come from Parliament, advised by senior lawyers within the Crown Law office, doctors situated in a relatively minor group in society have little ability to influence the process. This ability is influenced by doctors’ group and social profile set against the other groups and lobbyists which are involved in submissions to legislative change. It is beyond the scope of this paper to establish a commentary on whether this situation will eventually benefit the entire population or only sections of it.
There are probably few areas in medical practice in which the outcomes are less guaranteed than in the practice of emergency medicine. Strasser, in a recent edition of this Journal, comments on the wish of rural people to be saved when they are seriously ill [ 1 ]. In past times, the rural doctor was generally not troubled by litigation from seriously ill patients presenting as emergency cases, but this aspect of practice has changed. Litigation by patients now significantly affects Australian medical practice, with New South Wales said to show the highest incidence of litigation outside the US.
When litigation occurs, there are usually a number of targets. In the process of litigation, vicarious liability often affects hospitals. As mentioned above, hospitals have therefore sought to minimise any possible liability, and in doing so have adopted a risk management approach. Part of this approach has involved assessment of the competence of medical practitioners, particularly in procedural skills. Hospitals also have a vested interest in the competence of medical practitioners at emergency medicine. However, the practice of emergency medicine involves not only the performance of procedures. Emergency medicine is now recognised as a discrete medical discipline.
So where does this leave rural doctors? There is good evidence to indicate that one of the attractions of rural practice is the opportunity to practise secondary care. Indeed, many rural practitioners have become specially trained in aspects of secondary care, and the majority of these, in the author’s experience, pay considerable attention to skill maintenance. They often become integrally involved in a skill maintenance process that focuses on their skills and also on the hospital infrastructures necessary to the practice of these skills. They often become indignant when they are not included in hospital decisions about equipment purchase and protocol development.
Delineation of Clinical Competence
In South Australia the process of delineation of clinical privileges for practitioners working in non-teaching hospitals has operated for approximately 15 years. It was negotiated with the medical profession using an argument that suggested the delineation process should be grasped and nurtured by the profession before other players became involved. Notwithstanding apprehension from some of the profession, the process has spread throughout South Australia and it is now conducted on a regional basis. There has been some inconsistency between the seven South Australian regions in establishing and maintaining this process. This was identified in a report commissioned by the South Australian Health Commission in 1996 . This report recommended streamlining the process of delineation of clinical privileges and that attention be paid to particular steps in the process [ 2 ].
The report included emergency medicine as an area of clinical activity requiring delineation of competence. This comment has caused considerable discussion amongst rural practitioners, who have generally agreed with the delineation of clinical privileges process. Already required to maintain their skills by visible periodic retraining in obstetrics, anaesthesia and surgery, they are concerned about a further mandatory requirement to show skill maintenance in emergency medicine.
These practitioners’ concerns are not unfounded. There are many costs involved in attending retraining programs. These costs include transport, accommodation and registration, as well as lost opportunity costs associated with absence from their practices such as earnings lost. There are also costs associated with the practice remaining open, which include fixed costs, staff costs and locum costs. These costs must be balanced against the economic benefits of successfully achieving delineation of clinical competence in particular disciplines, and deriving income from practice in those disciplines.
The costs of practising obstetrics have been the subject of considerable discussion in Australia over the past five years. The principal concern is the cost of medical indemnity insurance, which despite the interest which a practitioner might exhibit in the craft of obstetrics, must be offset by their earnings. Many rural doctors consider the professional satisfaction arising from practice barely compensates for the low earnings from rural obstetric practice. In 1994, it was calculated that a general practitioner in Victoria needed to deliver 13.5 obstetric cases before making a financial profit, after paying the costs of an obstetric practice [ 3 ].
These financial issues, compounded by the fact that attendance at skill maintenance courses is mandatory, mean that rural hospitals supported by Government must materially support rural practitioners in their educational efforts, particularly those focused on achieving the required standards for delineation of clinical competence. This could be done in several ways but the main thrust of support should be towards defraying the practitioners’ costs and providing locum relief for them during absences from their practices.
The availability of opportunities for skill maintenance also requires examination. Most practitioners wish to maximise the educational opportunity from their attachment to a teaching hospital. The time spent away from their practices not only represents lost earnings, but also poor educational opportunity if the educational inputs are neither sound nor appropriate. In recent years many Australian rural practitioners have regarded early management of severe trauma, as specifically taught in early management of severe trauma (EMST) courses, as a desirable goal. Access to these courses can be difficult for rural practitioners wishing to attend, because specialist trainees in surgery, anaesthetics and emergency medicine must also attend and places are limited. Fortunately, in some rural areas, graduates of these courses have been diligent and deserve praise for conducting "mini EMST" courses to improve emergency medicine skills at the local level.
Some teaching hospitals and, more particularly, emergency medicine teachers deserve credit for recognising the lack of training opportunities, and for their efforts in creating short courses, which enable rural practitioners to attend teaching hospitals either for a structured learning programme or in a supernumerary position. The effectiveness of these supernumerary positions depends on the caseload that is processed by a hospital department, particularly Accident and Emergency, and on the ability of the visiting practitioner to achieve the position of a "hands on" involved spectator.
As outlined above, many rural practitioners are concerned that enforced training programmes in some disciplines cannot be compensated for financially, and that the total case load in the relevant discipline may not financially support the costs of the skill maintenance that is required.
This situation is different in the practice of emergency medicine. Most rural practitioners are confronted with a steady stream of emergency medicine cases. The issue of caseload sufficient to allow continuing use of skills does not generally apply. Even the most remotely situated rural doctor must learn to stabilise patients effectively, and to establish liaison with secondary and tertiary referral centres. These centres are naturally interested in establishing effective systems of transfer and retrieval of patients. There is also information which suggests that good emergency care practised in rural areas can affect the final health outcomes for and the financial expenditure of transferred patients.
Emergency Medicine Training
Analysis of this information invites further examination of the continuum of emergency medicine training that is required to boost confidence and skill levels in the medical workforce.
In medical practice it is always necessary to be careful not to "run before one can walk". That problem always concerns medical students and their teachers. It is probably a factor in the lack of substantial training in emergency medicine that characterises most medical courses. However the graded exposure of medical students to the practice of emergency medicine, together with better debriefing after involvement or observation of practice, should be a key factor in the development and teaching of medical students.
The training of early graduates in post graduate years 1 and 2 (PGY1 and PGY2) also requires examination. Current medical graduates face a constant problem balancing the service versus the teaching components of their hospital employment. There is frequent criticism of the "black hole" of the PGY1 and PGY2 that results in poor appreciation of emergency medicine skills after hospital practice. The placing PGY1 and PGY2 positions outside the hospital in rural areas may assist younger practitioners to understand some of the principles of this type of practice, providing that their teaching is consistent with current practice. However, in general terms, it is suggested that these trainees require a considerable amount of effort in order to raise confidence levels in emergency medicine after emerging from hospital training.
Similarly, the vocational training of rural practitioners requires that good skills in emergency medicine be learned. In this regard, involvement of the trainee in an EMST course or its equivalent and achievement of proficiency in an emergency medicine curriculum are likely to be requirements for completion of Advanced Rural Skills Training Posts in Surgery, Anaesthesia, and Emergency Medicine
In Australia the rural medical workforce currently relies on locums to provide adequate numbers of practitioners. The credentialling of locum practitioners is often a difficult issue; uncertainties regarding experience, training and current abilities must be balanced against the pressing need for locum practitioners in the rural medical workforce. Committees engaged in the delineation process are required to act with due diligence in checking the information supplied by locums and an effective liaison between delineation committees and locum providers can be of mutual assistance to both parties. An antagonistic relationship creates unwanted work, and predicates against best management practices. Finally, it is helpful if rapid teaching responses can be made when intending locums require skill assessment or augmentation prior to their placement. This is particularly useful for overseas-trained practitioners.
Conclusion
This article covers a range of issues relating to the practice of emergency medicine, especially in rural hospitals. There has been some small progress in developing national uniformity in the teaching and assessment of emergency medicine skills of intending rural practitioners, and therefore skill maintenance and clinical privilege delineation is carried out on a state by state basis. It is to be hoped that the future rural training mechanisms will be able to deal consistently with emergency medicine under national guidelines.
- Strasser R. Teams in rural health. Rural health in New Zealand and Australia - part 2. Healthcare Review - OnlineTM 4(1); December 1999 / January 2000
- Credentialling of medical staff, Qual-Med Pty Ltd, Report comissioned by the South Australian Health Commission, 1996
- Dixon A, personal communication
