Physician workload: the rural perspective
CMAJ 1998; 158:1010-1
See response from: N.P. Roos and P. Kirk
The article "Needs-based planning: the case of Manitoba" (CMAJ 1997;157[9]:1215-21 [full text / résumé]), by Dr. Noralou P. Roos and colleagues, suggests an interesting alternative to doctorpatient population ratios in determining requirements for physician supply. It fails, however, to recognize rural medicine as a distinct discipline and makes unwarranted assumptions about the interchangeability of rural and urban family physicians.
The first problem concerns use of the ambulatory visit, defined as a visit to an office, walk-in clinic, home or emergency department, as a unit of workload, without considering the intensity of the visit. The number of patient visits per physician may give a good estimate of income, but it is a poor estimate of workload.
The second problem is in attributing the workload of emergency department visits. The authors do not include emergency physicians in the definition of a generalist physician, although they include emergency department visits in their definition of ambulatory visit. Rural generalist physicians provide almost all emergency services in their communities, but the authors do not make clear the number of emergency department patients treated solely by generalists in the urban environment.
The third problem is the lack of any consideration of the specialist functions performed by rural physicians and the proportion of their workload relating to functions that would not normally be done by an urban generalist. In my community (where no physician has specialist certification) we routinely provide complete medical care for uncomplicated myocardial infarction, appendicitis, trauma and major psychiatric disease (among other conditions) and perform obstetric and gynecological procedures (including cesarean section) and anesthesia. We also perform many outpatient procedures, including biopsy and minor operations, that are seldom performed by urban GPs.
The authors' inability to appreciate the distinctiveness of rural practice is made clear by their statement that 16 000 visits to Winnipeg physicians by residents of the North would have required 4.6 physicians in the North, but only 2.8 Winnipeg physicians "because of their higher workload." The implication is that visits to urban and rural physicians are equally intense and that Winnipeg physicians could perform the same functions, seemingly more efficiently. They would not and likely could not. One might consider what proportion of those 16 000 visits ended with a specialist referral that would not have occurred had the patient seen a rural physician.
Solving the maldistribution of physicians is not simply a matter of shifting urban family physicians to a rural environment. Physicians need additional training to feel comfortable in a rural setting. Ten years ago this would have meant a rotating internship plus additional training in obstetrics, anesthesia or surgery. It now means a 2-year residency in family practice with a rural stream, plus an additional year in a specialty. Only 2 of the 7 authors of this study are physicians, and it is unclear if either of them has experience as a rural practitioner. Researchers who plan to make comparisons between urban and rural family practice should seek the participation or advice of those who know the differences.
Gordon B. Hutchinson, MD, PhD
100 Mile House, BC
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