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RACGP National Rural Faculty Advanced Rural Skills – Definition

There is a growing body of evidence to suggest that general practice in rural and remote communities has characteristics which differentiate it from general practice in other contexts. Compared to prevailing norms in general practice, rural GPs:

• Are more likely to be the sole source of medical advice for communities
• Have high workloads and long hours of practice
• Tend to be on-call for long periods
• Tend to be accorded high local public status with concomitant expectations about personal and social behaviour and less privacy
• Tend to undertake a broader range of minor procedures
• Are more likely to be involved in providing emergency medical treatment
• Participate in a range of public health roles

The particular social, economic, demographic and cultural characteristics of rural communities place special demands on doctors. Doctors need to develop an appreciation of the different lifestyles of various groups in rural communities and their perceptions of the nature of health and illness and the role of doctors. The patterns of morbidity and mortality in many rural communities require general practitioners to adapt and enhance their medical knowledge and skills to provide effective and high quality care. Rural GPs need to demonstrate competence in providing primary health care in the community including the management of a broad range of patient presentations.

Early studies identified the skills required for rural and remote general practice by concentrating on the differences in required competence by rural GPs compared to their urban counterparts. Britt et al (1993), in a comparison of metropolitan and rural general practice in Queensland, NSW and Victoria in 1992 found that rural GPs in small and medium towns undertook more procedural work than metropolitan GPs. Research around the same period in Victoria by Strasser (1992), again comparing rural and non-rural GPs, concurred. Rural GPs are more likely to conduct procedural services eg. Obstetrics (including caesarean section), and major surgery and anaesthetics. Gill et al (1992), in a 1991 survey of all South Australian GPs, found that rural GPs were most likely to use general medicine, local anaesthetic, emergency medicine and paediatrics skills, followed by (in decreasing order) obstetrics, counselling, radiology, orthopaedics, dermatology, general anaesthetics, psychiatry, caesarean section. Similar results were obtained in a Queensland study (Wise et al, 1992). More recently, Lawrance (2001) found that multiskilling, a variety of medicine, and procedural practice, were second and fourth highest in a range of 21 items that characterised rural and remote practice for rural GPs.

As a result of such research, the RACGP curriculum leading to Fellowship of the College extends beyond Fellowship to include various Advanced Rural Skills training curricula leading to the College’s post-FRACGP Fellowship in Advanced Rural General Practice/Graduate Diploma in Rural General Practice. These Advanced Rural Skills curricula have been developed through Joint Consultative Committees with other medical specialist colleges with a professional interest in the medical skills and knowledge concerned. Advanced Rural Skills curricula are currently available in:

Anaesthetics
Obstetrics
Emergency Medicine
Aboriginal Health
Child and Adolescent Health
Mental Health
Surgery
Adult Internal Medicine

Other curricula are in development in areas such as Small Town Rural, Musculoskeletal Medicine, Drug and Alcohol, Palliative Care, Aged Care and Rehabilitation, and Medical Education.

In a general sense, a general practitioner can be said to have attained an Advanced Rural Skills level of practice if they can demonstrate:

• Competence in advanced rural skills to defined curriculum in the skills area(s)
• An assessment process has been undertaken to certify competence
• The use of appropriately equipped facilities and resources
• Involvement of a team of health professionals in the advanced skills practice(s)
• The active engagement of the practitioners in an appropriate skills maintenance program in the relevant procedural area(s)
• A commitment and responsiveness to community health needs, particularly where there is a shortfall in other specialist services which would normally support community need in the advanced skills area

Advanced Procedural Skills

An advanced procedural general practitioner provides non-referred services normally in a hospital theatre, maternity setting or other appropriately equipped facilities, that in other general practice contexts are typically the province of a specific referral based specialty. Most commonly this refers to the fields of Surgery, Obstetrics, Anaesthesia and Emergency Medicine. Since, however, most rural and remote general practitioners need to deliver emergency services at some level, emergency medicine is considered separately.

Elements essential to advanced procedural medicine include a defined curriculum, an assessment process, the use of appropriately equipped facilities and resources, involvement of a team of health professionals and the active engagement of the practitioner in an appropriate skills maintenance program in the relevant procedural areas. As part of this skills program, the GP needs to prepare for the variation in team availability often experienced in rural and remote practice due to workforce shortage.

Advanced Procedural Skills are taken to include:

• Major general surgery (generally performed in operating theatres and excludes simple and complicated flaps and grafts which are already well remunerated under the current Medicare schedule)
• Obstetrics (inc. management of the delivery surgical or non surgical)
• Anaesthesia (inc. general anaesthesia)
• Orthopaedic Surgery (inc. the management of dislocations and fractures requiring major regional or general anaesthesia)
• Radiology (inc. personally performed x-rays, ultrasounds and/or echocardiograms with interpretation of results, not confined to limb x-rays)
• Endoscopy (inc. colonoscopy or gastroscopy)

Emergency Services at an Advanced Rural Skills level

Such general practitioners will typically have access to a hospital with acute care facilities, or be able to provide similar facilities in their practice rooms, from their mode of transport or, indeed, from their doctor’s bag. A checklist of the range of skills normally provided by such a general practitioners is appended. A minimal skills set, however, includes advanced airway tools, IV fluids and defibrillator, trauma management (including suturing and plastering), and a range of medications. A more comprehensive curriculum can be found in the Emergency Medicine Advanced Rural Skills Curriculum endorsed by the JCC Emergency Medicine in 1997.

References

Britt, H., Miles, D.A., Bridges-Webb, C., Neary, S., Charles, J. & Taylor, V. A comparison of country and metropolitan general practice. The Medical Journal of Australia 1993; 159, Supplement 1 November.

Dickinson, J., Hickner, J., Radford, S. 1995. The changing characteristics of rural GPs. Australian Family Physician, 1995; 24 (7):1272-1278

Gill, D. et al 1992. Review of General medical Practice in South Australia, Third Report: Country General Practice. SA Health Commission, Australian Medical Association (SA) & the Royal Australian College of General Practitioners (SA), South Australia.

Kamien, M. 1987. Report of the Ministerial Inquiry into the Recruitment and Retention of Country Doctors in Western Australia. University of Western Australia Department of Community Practice.

Lawrance R. 2001. What symbolises rural and remote general practice: the practitioners’ perspective. Infront Outback papers from the 6 th National Rural Health Conference, NRHA, Canberra.

Strasser, R. 1992. Rural general practice in Victoria: The report from a study of the attitudes of Victorian rural general practitioners to country practice and training. Monash University. 1992

Wise, A.., Hays, R., Craig, M., Adkins, P., Mahoney, M., Nichols, A., Sheehan, M. & Siskind, V. 1992. Vocational training and continuing education for the rural medical practitioner. Queensland Rural Practice Research Group, Queensland.

Appendix: Advanced Rural GP Emergency Medicine Skills

Last Modified: 16 August 2006
Authorised By: National Rural Faculty