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Thought leader: Can one size fit all? Family medicine training and rural healthcare (Prof. Ian Couper)
Can one size fit all? - Family medicine training and rural healthcare
Ian Couper
Director: Centre for Rural Health, University of the Witwatersrand, Johannesburg
Introduction
In September 2003, the Medical and Dental Professions Board of the Health Professions Council took the decision regarding the future of family medicine in South Africa that, inter alia, “rural medicine should be seen as a specific discipline within the domain of family medicine, and comply with regulations developed for family medicine.” Therefore, rural medicine is seen to be part of family medicine. What are the implications of this view?
First and foremost it places a major responsibility on family medicine in South Africa to address the difficulties and dilemmas inherent to differences between traditional or urban family practice and rural medical practice directly, and the training implications thereof. Part of this responsibility is to ensure that there is appropriate training for rural practice within family medicine training in South Africa.
Beyond that there is an implied responsibility of care – family medicine must shoulder some of the responsibility of caring for rural people and ensuring their needs are met by trained graduates. The discipline of family medicine also needs to take leadership, with rural doctors and other rural health workers, in advocating for the needs of rural people and for the development of rural healthcare, even when this is uncomfortable, because it means that, to achieve equity, there is skewing of resources of all kinds towards rural practice.
It needs to be clear that rural medicine is not the same as family medicine, and family medicine is not rural medicine. They are linked and intertwined partners, but they are not the same thing. To consider them to be the same will dilute the need for advocacy and special attention to rural issues, or may lead to the disenchantment of urban family practitioners and many others who cannot identify with rural medicine, just as there are many rural doctors who cannot see the relevance of family medicine for their situation – which needs to change.
How do we define these different entities? By family medicine we traditionally understand the specialist discipline of general practice or primary medical care. Rural medicine is generalist practice in a particular context whose demands require predominantly extended procedural and public health skills (see below).
To understand this relationship better, it is more useful and appropriate to define family medicine as the medical speciality responsible for general practice, primary care, rural medicine and district health. However, achieving this as a functional reality is still a long way off. So we need to understand the present solution and the challenges it offers in terms of training especially to move towards this goal.
Rural medicine versus family medicine
What then are the overlaps between family medicine and rural medicine, and their differences?
The fundamental principles of family medicine are surely the key areas of overlap. In other words the rural medical practitioner and the family physician share the following:
- Clinical method. They both need to be skilled clinicians, and to apply clinical reasoning and decision-making appropriate to primary care and the context.
- The focus on the consultation. The interaction with the patient, and most importantly the patient with undifferentiated or ongoing problems, in the primary level doctor-patient consultation is core to practice.
- Primary care. Both operate fully within the realm of primary care, and are the clinical specialists in primary care, whether in an urban or rural context.
- The primacy of the doctor-patient relationship. The understanding of the patient as a person, and the implications this has for relationship and for continuity of care area also shared.
- Community-based: Both work at a community level, and understand their patients in the context of a family and community.
It is these fundamental principles that make rural medicine part of the discipline of family medicine.
An urban family practitioner is a key resource to a defined population. However, this population is often very difficult to define, and there may be a host of competing practitioners functioning as resources to the same population. In rural areas, the population served is usually more defined, and there are less likely to be other practitioners.
Not only are there fewer medical practitioners, but fewer health workers of all kinds in rural areas. Therefore, team work is important to both, but the nature of this team work is different. The urban practitioner is more likely to have access to a full range of professionals and to refer to and interact with them on a regular basis in terms of ensuring optimum care for his or her patients. The rural practitioner is more likely to be dependent on the team to fulfil all the needs of the patient, because the patient load makes it impossible for him or her to deal with the range of problems, yet less likely to have all members of the team available. This then necessitates a blurring of roles and greater interdisciplinary working, with gaps being filled by any team member who is available. Great interaction and understanding for better shared care and shared workload is essential. It also means that in the rural context, continuity is often through the team rather than with the individual.
There are also a number of areas in which rural medical practitioners go further than traditional family practitioners. Firstly, they need to take the patients further, in terms of their clinical reasoning and management of patients. Because there is less access to secondary and tertiary care, this requires highly developed clinical acumen to make appropriate referral decisions at the appropriate time, while providing affordable and accessible care to a patient. For example, a rural practitioner may treat all the way to discharge and follow up a patient with severe malaria, which would not be the case in an urban context. Yet arrange earlier onward referral of a patient with a high-risk pregnancy because of the difficulties of transport should an untoward event happen. Secondly, they are usually required to perform a wider range and a higher level of procedural activities, because of this lack of access to higher levels of care. In fact, a fundamental difference is that the rural medical practitioner is engaged in secondary care in addition to his or her primary care responsibility, thus working comfortably in a hospital context and performing the full range of procedures expected in a district hospital. Thirdly, the extension of the scope of practice is not just in the clinical realm but into other areas, especially in the public health domain, both in the sense of involvement in health system management and in terms of involvement in “community health” – preventive and promotive care at a community level, rather than only at an individual level. This is very much what community orientated primary care is about, and, while it is recognised that there are many urban examples of this, this is a typical element of rural practice.
In other words, the rural medical practitioner is more likely to require multitasking in the way he or she operates. A medical manager in a rural context, who should ideally be trained as a family physician, will be required not only to exercise leadership within the management team but also clinical leadership in terms of procedural skills, care of patients, etc.
This is a consequence of many factors, but the numbers issue is a key one. The number of doctors present and the absence of specialists place greater demands and expectations on rural medical practitioners. Training has to take this into account, both in terms of how such practitioners are prepared but also how training can occur in such a context of high demand.
It is accepted that there is a difference between private and public rural practice. Although this article focuses mainly on public sector rural practice, the difference is usually not as great as it is in the city. Private general practitioners in rural areas are more likely to be involved in giving additional service in the public sector through hospital sessions, forensic clinical work, emergency calls, etc. In other words there is, potentially at least, much greater integration of the public and private sectors in rural practice, with great similarities in practice style and great opportunities for working together.
Can family medicine training equip doctors for rural practice?
A key question is whether someone trained in family medicine can fit into and practise in rural medicine. The principles are core as noted above, and allow the family physician to operate conceptually within the rural environment. Therefore, the family physician has the potential and ability to function in this context, but will generally be lacking in a range of skills, including procedural and community orientated skills. It is true that any change in practice requires the development for a new set of skills, but there would have to a very specific and focused process to acquire the skills for rural practice when there has been no exposure and training in this regard.
In other words, the family physician is multipotential and capable, but will need more training. The concept of gaining additional skills in particular areas for specific types of practice is not unique to rural practice. It is expected that all family physicians should be able to offer palliative care; though some will need to do diplomas in palliative medicine, and may even decide to do a degree such the MPhil in Palliative Medicine.
The area of HIV medicine is similar: HIV/Aids care is very much the realm of family physicians, but there are those who have particular expertise in this regard and many may want to acquire an additional qualification to give them the full range of skills and knowledge to care for HIV patients. In both cases, there may also be non-family physicians – internists or paediatricians perhaps – who also study further in these areas, but it does not negate the fact that they fall within the broad domain of family practice.
Therefore it is quite conceivable – in fact, desirable – for additional specific training to be available for rural practice, such as a Postgraduate Diploma in Rural Medicine which involves advanced procedural training, or a Postgraduate Diploma in Rural Health, focusing on more public health aspects. The Wits Centre for Rural Health for example offers a Masters in Public Health in the field of Rural Health. The Rural Doctors Association of Southern Africa (RuDASA) has proposed that rural medicine become a subspeciality of family medicine.
