Additional skills training for rural physicians

Abstract

PROBLEM ADDRESSED

Rural physicians in Alberta identified access to special skills training and upgrading skills as an important practice requirement.

OBJECTIVE OF PROGRAM

The Rural Physician Action Plan in Alberta developed an Enrichment Program to assist physicians practising in rural Alberta communities to upgrade their existing skills or gain new skills. The Enrichment Program aimed to provide a single point of entry to skills training that was individualized and based on the needs of rural physicians.

PROGRAM DESCRIPTION

Two experienced rural physicians were engaged as “skills brokers” to help rural physicians requesting additional skills training or upgrading to find the training they required. Physicians interested in applying for the Enrichment Program consulted one of the brokers. Each applicant was assigned a preceptor. Preceptors confirmed learning objectives with trainees, provided the required training in keeping with agreed-upon learning objectives, and ensured trainees were evaluated at the end of the training.

CONCLUSION

The program has helped rural physicians upgrade their skills and gain new skills. More Alberta rural physicians are now able to pursue additional training and return to practise new skills in their rural and remote communities than in the past.

EDITOR’S KEY POINTS.

• The Rural Physician Action Plan in Alberta is designed to allow rural physicians to upgrade their skills through focused training that will help them further benefit their communities.

• Unique features of the program include the fact that two rural physicians act as “skills brokers,” providing a single point of entry to training for applicants and promoting customized needs-based experiences for them.

• Support from rural physicians’ regional medical directors ensures that the skills are truly needed in the community and that there is appropriate infrastructure, staff, and equipment available for physicians on their return.

POINTS DE REPÈRE DU RÉDACTEUR.

• L’objectif du Plan d’action pour la médecine rurale de l’Alberta est de favoriser l’accès des médecins ruraux à des interventions ciblées susceptibles d’améliorer leurs compétences et de les aider à en faire profiter leurs communautés.

• Parmi les particularités du programme, mentionnons le fait que deux médecins ruraux agissent comme «courtiers en compétences», fournissant aux intéressés une seule voie d’accès à la formation, tout en favorisant des interventions conformes à leurs besoins.

• La participation des directeurs médicaux régionaux de la médecine rurale permet de s’assurer que ces compétences sont vraiment requise dans la communauté et qu’au retour du médecin, l’infrastructure, le personnel et l’équipement adéquat seront disponibles.

When our colleagues in rural medicine resign, retire, or pass away, the rural and remote communities they served often struggle to find doctors with equivalent skills to take their place. Recognizing this, the Alberta government in 1991 created and funded the Rural Physician Action Plan (RPAP), a comprehensive plan for educating, recruiting, and retaining rural physicians. The plan’s purpose is to address the two main issues that affect rural recruitment and retention: professional issues and lifestyle issues.¹ During the last decade, the RPAP has implemented more than a dozen innovative initiatives in an attempt to influence physicians’ decisions regarding moving to and remaining in rural and remote communities in Alberta.²

One of the retention initiatives, the Enrichment Program (EP), assists physicians practising in rural Alberta communities to upgrade their existing skills or gain new skills so they can meet the medical needs of their communities. The EP was developed because Alberta rural physicians identified access to special skills training and upgrading as an important practice requirement. The RPAP steps in to help rural doctors access special skills when these skills are necessary to improve the level of health services in rural communities or regions or to replace existing skills that will be lost because of retirement or other reasons.

More than 150 Alberta rural physicians have taken enrichment training through RPAP since the EP was launched in 1992-1993. Thirteen doctors completed additional skills training in 2004-2005, and 12 are currently in training. Most doctors undertook their training in Alberta, but some physicians have traveled to other provinces (Saskatchewan and British Columbia) to pursue their studies. The EP has helped physicians seek training in many areas, such as emergency medicine, obstetrics, epidemiology, palliative care, regional cancer care, psychotherapeutics, surgery, anesthesia, gastrointestinal medicine, research, and medical education, and at all levels of continuing education. Any doctor practising outside the Calgary Health Region or Capital Health Authority (Edmonton region) is eligible to apply to the EP.

Problem being addressed

The RPAP was designed to individualize and customize training for rural physicians to allow them to upgrade their skills while still in practice. In the past, any individual rural physician seeking to expand or upgrade skills had to approach one or both of Alberta’s faculties of medicine to inquire regarding training opportunities. Many physicians did not try or tried and gave up, as they found the process bureaucratic and intimidating. They often felt professionally isolated when faculties also passed judgment on whether the requested training was appropriate for the physician’s community. The rural physicians who successfully sought and found training opportunities often left their rural communities following acquisition of the new skills. The RPAP wanted to help rural doctors pursue further studies and stay in or return to rural Alberta.

Current continuing medical education (CME) programs are usually short-term (1 to 7 days) or long-term and attached to established residency-based training programs, such as anesthesia and emergency medicine. Busy doctors in rural and remote areas can find it difficult to undertake CME activities for various reasons, such as distance from tertiary care centres and faculties of medicine, a lack of networking opportunities, confusing bureaucracy, and problems finding locums.

Objective of the program

In June 1999, the RPAP Coordinating Committee established an Additional Skills Training Working Group to recommend and plan improvements to additional skills training for family medicine residents and enrichment training for practising rural physicians. The Working Group suggested that RPAP create two “skills broker” positions to work with the province’s regional health authorities, the College of Physicians and Surgeons of Alberta (CPSA), the University of Calgary Faculty of Medicine, the University of Alberta Faculty of Medicine and Dentistry, and physicians applying under the EP for additional or advanced skills training.

Program description

Skills brokers: physician advocates for rural physicians.

The RPAP consulted with Alberta’s rural physicians and asked what would work best for them. Physicians wanted the program to be managed by “one of their own” and to be objective-based and not limited to the confines of the two universities. In response, RPAP reformulated the EP. In July 2000, RPAP appointed two Alberta rural family doctors as part-time (0.5 full-time equivalent) skills brokers to act as advocates, brokers, and concierges on behalf of rural physicians seeking enrichment training. One broker would serve the rural physicians of northern Alberta and the other the rural physicians of southern Alberta. The challenge was to develop a program that would please individual rural physicians, satisfy the medical needs of rural communities and the CPSA, and ultimately result in improved retention of rural physicians in Alberta.

The skills brokers aim to make the process of acquiring special skills simple and expeditious for rural physicians. They advocate on behalf of rural doctors and their communities and arrange appropriate, objective-based training programs with any training organization to benefit the physicians and their communities. Skills brokers also act as concierges for practice problems and conflict resolution. In addition, they have the freedom to develop new or special programs and establish liaison with CME providers to enhance educational choices for rural physicians. Any program with regional support and licensing authority approval will be considered.

About two thirds of physicians seeking information from skills brokers about enrichment training later apply for training. Skills brokers streamline the application process and provide RPAP funding for the duration of training. The RPAP gives EP trainees an honorarium of $76 000 per year, prorated over the length of the training ($6333 monthly). If required, and depending upon availability, locums are provided with the assistance of the Alberta Medical Association Rural Locum Program.

New initiatives within the Enrichment Program.

One of the skills brokers’ responsibilities is to identify gaps in training opportunities and design new programs to fill those gaps. One gap identified was emergency medicine skills. The recently developed General Emergency Medicine Skills Program, which uses a combination of multimedia technology and on-site Shock Trauma Air Rescue Service human patient simulators in remote rural hospitals, is one such initiative.

Application process.

Physicians interested in applying for enrichment training consult a RPAP skills broker. The broker sends them an application package (available on-line or by fax or mail) with a request to outline the proposed training and state its purpose and how it will benefit the region. Rural physicians must also supply a list of their training objectives, a curriculum vitae, and details of their work experience. Training must last between 2 and 52 weeks, which need not be consecutive. The broker asks the applicant’s regional medical director, as the representative of the provincial health region, to provide a letter of support for the candidate and agree to provide necessary infrastructure or equipment once the training is complete. (The medical director in each of Alberta’s 9 health regions is responsible for physicians’ privileges and standards of care.) This policy ensures that candidates’ training is appropriate, needed, and supported financially and in principle by the regional authority in which physicians will practise the new skills.

Sometimes acquisition of new skills will lead to a change in privileges. In these instances, RPAP advises applicants to seek the approval of the CPSA for the training program. Liability coverage must also be confirmed.

Skills brokers also organize assessment of competence at university centres for international medical graduates who wish to qualify for privileges in such disciplines as anesthesia, surgery, psychiatry, and obstetrics, before entering practice in rural centres.

Preceptors.

Each applicant is assigned a preceptor who confirms learning objectives with the trainee, provides the required training in keeping with agreed-upon learning objectives, and ensures the trainee is evaluated at the end of the training. Preceptors currently receive an honorarium of $1000 per month.

Evaluation.

Critics of recruitment and retention initiatives have argued that they fail to provide measurable objectives and controls to compare outcomes.² Few studies to date have determined whether the EP has increased retention of rural physicians, although an August 2000 external evaluation of the EP indicated that the program had done so.

The RPAP wants to know whether the EP meets individual rural physicians’ needs for CME, helps retain physicians in rural Alberta, and maintains rural medicine skills at the community level. Skills brokers need to know whether the application process is simple and easily accessible. The RPAP has, therefore, commenced the Physicians’ Rural Enrichment Program Study to determine whether goals are being met and whether rural retention has improved. This study, using matched physician controls to compare retention, is also evaluating whether individual trainees’ objectives and preceptors’ and communities’ needs have been met. Surveys exploring these issues are sent out at 1 month, 1 year, 3 years, and 5 years after training is completed.

Discussion

Retention initiatives in Canada and beyond.

Alberta’s rural physicians have been fortunate because their provincial government has generously funded a comprehensive RPAP for more than a decade. While other countries and provinces also have initiatives to improve recruitment and retention of rural physicians, the RPAP often pioneers new initiatives. Rural physicians in other Canadian provinces (Saskatchewan, British Columbia) and other countries (New Zealand, Australia, United Kingdom) have already expressed considerable interest in using the RPAP’s EP as a template for similar programs.

In British Columbia, the Physician Recruitment and Retention Program provides enhanced funding for CME and support for advanced practice and postgraduate training. British Columbia’s Rural Health Office also has a 10-year human resource plan addressing critical skills and staffing levels for underserved areas. Ontario has several rural physician supply and retention initiatives, including a physician re-entry program. The Manitoba Action Plan for Rural Physician Retention, run by the Manitoba Department of Health since December 2000, aims to restructure rural CME to provide advanced skills training programs that will help rural physicians to acquire the knowledge and skills needed to meet the health needs of their communities.

None of these programs, however, has dedicated rural physician coordinators. Other programs also lack the flexibility to pursue training outside the province or to allow episodic training weekly and monthly. No other program for rural physicians has considered the ability to do research a skill of sufficient value to fund. The EP is truly individualized for the benefit of physicians and the regions they serve.

Limitations of the EP.

The RPAP’s skills brokers work very closely with rural physicians seeking special skills training. They have learned first-hand how difficult it can be for individual physicians to find and apply for educational opportunities quickly and simply and then to gain new privileges once training is completed. For instance, the application process proceeds much more smoothly when RPAP has a champion in the educational facility to act as a liaison. It has also become apparent that it is wise for applicants seeking privileges to apply to the licensing authority for approval of their training before they commence the training rather than after they have completed it. Some procedural skills training, such as for tonsillectomy, have been difficult to organize because surgeons do not consider this skill necessary for rural physicians.

The skills brokers travel frequently to Alberta’s rural communities and still find that, despite extensive advertising, some physicians know little about RPAP or the EP. More must be done to inform physicians of the scope of RPAP’s programs.

Conclusion

The RPAP’s EP, through its skills brokers, provides individualized training and support to Alberta’s rural physicians. Brokers not only provide a seamless single point of entry into existing programs, but also have the freedom to develop new programs to fill perceived gaps in rural doctors’ knowledge and skills.

Biography

Dr Gorsche and Dr Hnatuik are skills brokers for Alberta’s Rural Physician Action Plan. Dr Gorsche, a Clinical Associate Professor in the Departments of Family Medicine and Community Health Sciences in the Faculty of Medicine at the University of Calgary, practises in High River, Alta. Dr Hnatuik, Area Clinical Director of the East Central Health Region, lives in Camrose, Alta.