Meeting the challenge: providing anesthesia services in rural hospitals
A. Wayne Barry, MD, FRCPC
Canadian Medical Association Journal 1995; 153: 1455-1456
Paper reprints of the full text may be obtained from: Dr. A. Wayne Barry, Department of Anesthesia, Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa ON K1Y 4E9; fax 613 761-5209
Although the volume and intensity of surgery done in rural hospitals are not sufficient to support a fully trained staff anesthetist, it is not practicable for all surgical, anesthesia and obstetric services to be provided by specialists in referral centres. As the study reported by Chiasson and Roy in this issue shows (see pages 1447 to 1452 [abstract]), general practitioners (GPs) with limited additional training in anesthesia already play an important role in the provision of these services in rural areas. To ensure that there is a continued supply of physicians prepared to meet the needs of small communities, funding and opportunities for supplemental training in surgery, anesthesia and obstetrics must be made available to GPs.
Même si le volume et la gravité des interventions chirurgicales pratiquées dans les hôpitaux ruraux ne suffisent pas pour justifier d'embaucher à plein temps un anesthésiste qualifié, il n'est pas pratique d'envoyer tous les patients qui en ont besoin recevoir les services de chirurgie, d'anesthésie et d'obstétrique auprès de spécialistes dans d'autres établissements. Comme l'indique l'étude décrite par Chiasson et Roy dans ce numéro (voir pages 1447 à 1452 [résumé]), les omnipraticiens (OP) qui ont reçu une formation supplémentaire limitée en anesthésie jouent déjà un rôle important dans la prestation de ces services en milieu rural. Pour assurer un bassin constant de médecins prêts à répondre aux besoins des petites localités, il faut mettre à la disposition des OP du financement et des possibilités de suivre une formation supplémentaire en chirurgie, en anesthésie et en obstétrique.
The research findings reported by Drs. Patrick M.
Chiasson and Peter D. Roy in this issue (see pages 1447 to 1452 [abstract]) highlight issues in the provision of anesthesia services that deserve our attention. Chiasson and Roy found that in 45 (80%) of the 56 rural hospitals included in their survey that offered surgical services, anesthesia services were provided by general practitioners (GPs) with limited additional training in the field; in 36 (64%) of the responding hospitals anesthesia services were provided exclusively by GPs with additional training. Even though the proportion of anesthesia services provided in Canada by GPs is decreasing as a result of regionalization and improved transport to referral centres, this proportion remains significant. The 1988 CMA report to General Council on the anesthesia training of GPs and family physicians revealed that, in 1986, 25.5% of anesthesia services in Canada were provided by nonspecialists and that 7.0% of family practitioners included anesthesia in their practice.(1) Since then, more specialist anesthetists have become available to provide this service in community hospitals, and some anesthetists practise in more than one hospital.
In the past many GPs provided anesthesia services as part of their practice after little or no formal training and learned their anesthesia skills from other GPs in the hospital where they worked. Physicians in the community welcomed new colleagues to share the call schedule, and hospitals were less concerned about credentials when they granted privileges than they are today. Anesthesia techniques were unsophisticated and lacked scope; generally, one type of anesthetic was given for all procedures.
More recently GPs started to take extra training in anesthesia before beginning practice or returned for training when they recognized a need for this expertise in their community. The current trend is for hospitals to grant anesthesia privileges only to candidates who have had 6 to 12 months of formal training. The 1988 CMA report to General Council recommended that 12 months of anesthesia training in addition to 2 years of family practice residency training be considered reasonable preparation for rural general practice that includes anesthesia procedures.(1) Most anesthesia training programs offer this sort of training. However, funding for these positions is rather limit-ed and may come from a variety of sources, including
the community hospital in which the prospective GP-anesthetist will practise. Although in Ontario many training positions are potentially available, there are only six funded 1-year training positions for GPs who wish to obtain an additional qualification in anesthesia (Dr. Dennis Reid, director, Anesthesia Training Program, University of Ottawa: personal communication, 1995).
Most specialist anesthetists are not interested in working exclusively in a rural hospital, where the volume of work may be low and the proportion of night and weekend call excessive. Given the lack of diagnostic facilities and of intensive medical and nursing care in a rural hospital, the cases treated in this setting will be less intense and complex than those handled in referral centres. Many anesthetists feel that practising in smaller centres does not make the best use of their 4-year residency training. Moreover, they may need to supplement the income from an anesthesia practice in a rural hospital with earnings from general practice or, in some cases, with funding from the hospital. As an alternative to running a full-time rural practice, some prefer to practise anesthesia in a larger hospital and provide occasional or part-time coverage and share emergency call at a rural facility. The financial disincentives to rural practice aside, there are still enough positions in large and medium-sized hospitals to absorb all of the graduates from specialized training in anesthesia.
When rotating internships were permitted in medical training a general licence allowed the physician to supplement work in anesthesia with general practice. Now training is rigidly specialized at an early stage. The medical student who has opted to specialize in anesthesia is not trained to do the work of a GP and, even if it were desirable, is not permitted under the present system to obtain general practice training, nor would he or she be able to obtain a licence for general practice. Thus, rural hospitals would need to provide supplemental funding, and few would be attracted to such an environment. Although relying on GPs with extra training in anesthesia becomes one of the few feasible options, it is my impression that we are not training enough GP-anesthetists to replace those who are approaching retirement. A 1986 CMA survey revealed that more than 25% of GP-anesthetists were over 50 years of age.(2) Each year many applications for 1-year training positions are turned down for want of funding. Some community hospitals are paying for physicians to obtain such training, with the understanding that they will return with this skill to their community.
GPs with training in anesthesia benefit small hospitals in a number of ways. They are proficient in handling airways and ventilation, managing intravenous lines, fluids and transfusions and performing emergency resuscitation. No other area of practice can match the skills developed in anesthesia. Advanced trauma life support courses are valuable, but the skills they teach tend not to be retained unless they are regularly put into practice. For the many GPs who work or take calls in emergencies and obstetrics, basic training in surgery, obstetrics and anesthesia is invaluable. Moreover, obtaining these skills in properly equipped training centres leads to a higher quality of care: graduates will be proficient in the use of specialized monitors and equipment and will be more likely to ensure that the equipment used in their own hospital is safe and up to date.
GPs with training in anesthesia play an important role in providing quality medical care in rural hospitals. Although it has become increasingly rare for medical graduates who have not been streamed through 2-year family practice programs to become GPs, it must be recognized that those graduates who practise in rural areas have special training needs. Funding and opportunities for supplemental training in surgery, obstetrics and anesthesia must be made available. As Chiasson and Roy rightly point out, those who currently provide surgical and anesthesia services in rural hospitals are not being replaced in sufficient numbers to keep up with natural attrition. We need to give more attention to preparing physicians to work in the many and varied rural communities across our country. The CMA recommended in 1988 that provincial jurisdictions provide funding to ensure the viability of family practice programs in anesthesia.(1) That recommendation bears repeating today if we wish to ensure that Canada's rural populations are provided with adequate medical care.
- Report of the Invitational Meetings on the Training of General Practitioners/Family Physicians to provide Anaesthesia Services. Appendix B of Reports to the General Council of the Canadian Medical Association, Canadian Medical Association, Ottawa, 1988
- Canadian Medical Association Physician Resource Questionnaire 1986. [database] Canadian Medical Association, Ottawa, 1986
CMAJ November 15, 1995 (vol 153, no 10)
/ JAMC le 15 novembre 1995 (vol 153, no 10)