International approaches to rural generalist medicine: a scoping review

The majority of data relevant to the definition of RGM comes from Australia, reflecting a growth of coordinated RGM pathways since 2005. Early developments include the Roma Agreement [23], which underpinned the establishment of the ‘Queensland Rural Generalist Pathway’ (QRGP), an initiative of the state health department [24]. Similar definitions are now found in the literature used by the Australian College for Rural and Remote Medicine (ACRRM) [25]; and in Australian Commonwealth, state and territory government documents [1, 26‐28]. More recently, ACRRM and the Royal Australian College of General Practitioners have supported a definition of a rural generalist that reflects the Cairns Consensus Statement: a medical practitioner trained to meet the health care needs of rural and remote communities by ‘providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural health team’ [29].

The application of specialised skills by the RGM is a focus of definitions in North America [30‐32]. However, there are also some variations in the literature from this region. In the United States of America (USA), ‘generalism’ is often used to jointly describe family physicians, general internists and general paediatricians [33‐35]. In the USA and Australia, there has been some criticism of RGM as defined in this review [36, 37], which focuses mainly on the expansion of family medicine fellowship training into specialised skills [37] or efforts to distinguish and then define generalism by rurality [38, 39].

This theme includes literature relevant to (i) medical school training designed to support and develop RGM and (ii) postgraduate (vocational) pathways and programmes.

Ideally, scope of practice is tailored to meet community needs and is responsive to a range of factors, including population size, demographics, burden of disease, access to specialist services, geography and socioeconomic status [42]. As the provision of primary health care is common to RGM internationally, the literature on scope of practice is largely focused on the additional, specialised skills provided.

The QRGP supports advanced skills training (AST) in adult internal medicine, Indigenous health, emergency medicine, paediatrics, mental health, obstetrics and gynaecology, anaesthetics and surgery [24]. The procedural skills listed here are common to the scope of practice in other states and territories across Australia and in New Zealand, in particular obstetrics and gynaecology, anaesthetics, emergency medicine and surgery [27, 28, 57, 58].

These procedural skills are also common to RGM in Canada and the USA [59, 60]. In Western European countries, the rural generalist undertakes some procedural tasks, especially in minor surgery [22]. In sub-Saharan Africa, obstetrics, anaesthetics and surgery are common skills for rural family physicians [61, 62]. In South Africa, the generalist in remote areas can also provide orthopaedic care and ENT practice [63, 64].

Whilst core procedural skills are a feature of RGM, there is also evidence of training in non-procedural tasks. The QRGP includes Indigenous health, paediatrics and mental health in the supported ASTs [24]. The Tasmanian Rural Medical Generalist Program has also identified needs in psychiatry, radiology and palliative care [51]. Palliative and elder care is also featured in Canadian RGM training [6, 65].

Discussion on scope of practice extends to models of care, including interaction between generalists and medical specialists, and the quality and safety of comprehensive care. In Canada, there is general agreement between specialist colleges that a generalist approach to procedural services in rural areas is the only feasible solution to rural medical workforce issues [66]. However, there is ongoing interprofessional debate between rural general practice and surgery about role delineation, despite it being uncommon for smaller communities to have surgical services provided by a resident specialist surgeon [66]. Kornelsen et al. (2013) claim that in communities with populations of 5000 to 15 000, surgical services are usually provided by one or more rural GP surgeons, whilst for populations of 15 000 to 25 000 surgical services are usually provided by a specialist surgeon supported by one or more GP surgeons [66]. Australian models of care are similar in that specialised skills practised by the rural generalist increase with complexity with less specialist support as rurality or remoteness increases [67]. In South Africa, there are two opposing views on the model of remote emergency care: (i) stabilisation and transportation of patients to a larger hospital and (ii) support local hospital services where the generalist can treat most cases [63].

The model of care where the generalist provides increasing specialist care proportional to remoteness is also supported by quality and safety outcomes [42]. In Canada, a study comparing caesarean section services provided by rural GPs with those of specialists concludes that rural GPs perform this procedure with an acceptable degree of safety [68]. Rural hospitals in Nova Scotia with less than 100 deliveries a year performed by rural generalists have also shown the lowest perinatal morbidity and mortality rates in the province [69]. Thompson and Iglesias (1998) conclude that there is no evidence to support exclusive skills sets given numerous quality and safety studies demonstrate identical standards for both rural generalists and urban specialists [55].

The ability to be trained in, and then practice, specialised skills is considered essential in successful RGM recruitment and retention. The ability to combine procedural work with primary health care is key to much rural recruitment in the Australian context [52, 70]. This, combined with the commencing salary and financial incentives offered under the QRGP, have had a positive impact on rural medical workforce recruitment [49]. In the USA, training programmes producing rural generalist graduates also emphasise comprehensive advanced skills training as key to their success [17, 60]. A study in Canada also showed the larger the range of procedures practised by a family physician, the more satisfied they were in their profession [71].

However, the trend of medical graduates toward highly specialised career choices and corresponding control of hospital-based training posts by specialists are considered threats to RGM in North America [32, 72] and Australia [73]. This also adversely affects the distribution of the overall medical workforce due to the urban-centric focus of speciality practice [73]. There are further systemic barriers for rural generalist practice in Australia, including a lack of appropriate training opportunities and support [74], complexities in maintaining and practising advanced skills, the limited availability of the supporting workforce, working hours and lifestyle factors, perceived medico-legal problems [75, 76], a lack of recognition for the rural generalist role and GPs’ reluctance to resume procedural practice once they had ceased [52, 77].

In the USA, one article identified high liability insurance premiums as a threat to viable smaller rural generalist practices, as well as limited technical facilities and the lack of an appropriate support workforce [78]. In Canada, difficult access to locums, the need for more education and training [79], low confidence in responding to paediatric emergencies and worsening physician shortages [80] are seen as the major barriers to developing the rural generalist workforce. In Europe, the pressures of providing the dual-role of primary care practitioner and specialist in rural communities [81], as well as an increasing centralisation of specialist services to larger centres, are negatively affecting RGM [82]. As a result, fewer rural GPs are practising obstetrics in Europe and it is increasingly rare for those remaining to undertake high-risk obstetric care as routine practice [83].

The reform theme can be separated into recommendations from the literature that (i) are focused on training and (ii) have a broader workforce focus.

In Australia, recommendations for training reform include: improving linkages between Commonwealth and State training programmes; increasing support for universities committed to rural generalism; identifying new advanced skills [84]; accelerated vocational pathways into RGM; training and supporting a rural female proceduralist workforce; extending the QRGP training model into other Australian states [85]; and establishing training support networks [42, 86, 87]. The concept of a national RGM training pipeline in Australia is common to many of the training recommendations [1, 74, 88, 89]. Similarly, a USA article supported the concept of a national rural training pipeline that recruits from rural communities, provides rural placements throughout medical school, supports residencies in the rural setting and provides support in rural practice after training [17].

In Canada, the Canadian Medical Association committed to expand the number of rural generalists in training [90] and the Society of Rural Physicians have proposed developing a national rural medicine curriculum to promote the RGM workforce [31]. Other Canadian-based proposals include the establishment of a college for rural medicine [55], an extra training year with focus on procedural and obstetric care skills for family practitioners intending to work rurally [91], expanding and improving enhanced skills training programmes aligned to community need [59, 90, 92] (including advanced maternity care [93], anaesthetics, general surgery [94] and endoscopy [55, 79]).

In Africa, recommendations include increasing the number of rural generalists in training and providing a more structured secondary-care curricula across a broad range of diagnoses and procedural skills [64], similar to Australia and Canada [61, 95]. In South Africa it is recommended that more generalists with specialised skills be trained to position them as the leading health professional in the District Health System [96].

There are also recommendations for new RGM training models in many countries. Recommendations in Kenya include expanding the scope of practice for rural generalists to include emergency surgery [97]. In Japan the authors of one article advocate for the establishment of a rural generalist practitioner training programme with specialised skills, including internal medicine, gastroenterology and general surgery [98].

The literature also contains recommendations for broader workforce policy reform. A New Zealand article outlines efforts made to recognise the RGM role as a specific discipline to advance RGM practice [58]. In Australia, such recommendations include new national funding models that support the RGM pathway [42], workforce strategies aimed at recruitment and retention of rural generalists [48], supporting flexible models of practice ownership [73] and developing a national approach to recognising the rural generalist role [89]. Many of these relate to the broader agenda to develop a national RGM pathway throughout Australia [1, 8, 85] and to establish a specific role in the Commonwealth Government dedicated to this task [25].

The Cairns Consensus Statement contains policy-based recommendations under the domains of ‘Recognition, Training and Research’ for global action in RGM [2]. This is complemented by an earlier WHO recommendation to establish and regulate enhanced scopes of practice (including for Family Medicine) in rural and remote areas [99].