Rural Canadians often experience disparities in health care which are unique to their environment, including a shortage of physicians in emergency room (ER) departments, and difficulty accessing specific health care services.
To better meet the health care needs of patients in rural settings, health care providers are establishing networks between urban academic emergency departments and their rural and regional counterparts.
A recent symposium paper, co-authored by researchers such as principal investigator Dr. Aaron Johnston, the Director of Distributed Learning and Rural Initiatives at the University of Calgary, and Dr. Yasmine Mawji, an assistant professor at U of T’s Faculty of Medicine, looked into ways to build and consolidate these relationships.
The co-authors identified some of the logistical benefits of a network between urban academic and rural communities, including more timely access to consultation, the facilitation of transfer of care, and opportunities for training medical students and residents in rural environments.
The study surveyed health practitioners working in rural emergency departments and academic department leaders. A panel of leaders from both rural and urban settings convened over the course of eight months to propose seven recommendations on ways to consolidate and build these relationships.
According to the survey’s respondents, there seems to be a lapse in how urban practitioners understand and perceive the unique challenges of the rural environment. For example, rural physicians often have difficulties accessing specialists for advice by phone.
The study identified the significance of providing training opportunities for physicians, medical students, and residents in rural emergency departments in order to address the gaps in understanding. Both urban and rural physicians expressed interest in opportunities to shadow and work in the others’ environment.
The link between rural hospitals and universities
The relationship between the rural hospitals and universities must therefore be predicated on mutual understanding and learning, according to the co-authors. It is not recommended for universities to disseminate knowledge, which not only patronizes the rural constituency, but also fails to appreciate that the academic and operational approaches are two sides of the same coin.
“At the time of recruitment and admission to medical school, we need to provide opportunities… in the kind of areas we hope that people will work in,” said Johnston to The Varsity.
Training opportunities not only prepare individuals for rural communities through experiential learning, but this active involvement in medical education also stabilizes workforce communities. Communities involved in teaching medical trainees have more stable workforces over time, partly because some of these same trainees will be colleagues in the future.
There are challenges, however, to providing medical students with training opportunities. “We need to address issues of hidden bias or [the] hidden curriculum… that might dissuade people who are interested [in] or predisposed to a rural career from pursuing [it],” said Johnston.
The term ‘hidden curriculum’ refers to an implicit set of values that may impact care. To address this issue, he recommended providing exit surveys to graduate students which examine its impact on their educational and medical experiences.
Examples of the hidden curriculum include the idea that doctors may “never admit to not knowing something,” and the emphasis in many ERs to minimize wait times, which could lead to behaviours that reduce the quality of patient care.
What academic divisions can learn from rural departments
Engagement between rural departments and academic divisions also provides opportunities for mutual learning and teaching, and practitioners in rural settings can also teach other practitioners about the concepts and significance of generalism and clinical courage.
Clinical courage is the concept that practitioners are sometimes pushed to the limits of their training in order to meet the patient’s needs. Because of staff shortages and limited resources in rural environments, this concept is often applicable to everyday practice for rural physicians.
Johnston explained that it “is an idea that means working at the edge… [because] you’re really the only doctors there.” In a larger environment of health care, practitioners do not often consider this situation.
In fact, family physicians in rural communities across the country practice a broader scope of medicine, which even includes providing emergency care because of the shortage of ER physicians.
Rural physicians can also teach other environments and communities about resource stewardship, since these areas often have limited access to the labs and diagnostic testing that urban communities have, yet still manage to provide exceptional care.
On the flip side, physicians, trainees, and medical students can also gain additional skills from academic institutions in areas of palliative care, for example, or the ER, as there is an appreciation for adaptability or being able to meet the needs of the patient population by acquiring and updating an individual’s skills.
Looking outside Ontario
So, what does this mean for Ontario? The study recommended modelling future relationships between academic institutions and rural regions after successful models, like the British Columbia Emergency Medicine Network, which links the province’s emergency physicians and BC-relevant clinical resources initiated in September 2017.
The network encourages peers and colleagues to support one another and share knowledge and information in order to better serve patients. Its rural component is embodied in the network’s Rural Working Group, which provides a rural perspective on the clinical resources that the network offers. Where and when necessary, rural members review and update resources.
But there are challenges to building this kind of network, according to Johnston. Firstly, it takes time to build relationships, so the potential for successful results won’t be immediate or instant. Its infrastructure also requires significant amounts of money, resources, and manpower.
The BC Emergency Medicine Network works because it was intentionally built with specific goals in mind. Leaders travelled to rural communities to get a sense of what the community wanted and what the relationships between the community and the health care profession should look like.
By listening to the constituents, namely the physicians who use the resources, the BC Emergency Medicine Network has been successful, as it is equipped with knowledge of the needs of the health care communities.
Building a similar network elsewhere
To build a similar network elsewhere, Johnston recommends a web-like network rather than a “hub-and-spoke” model, in which the academic institution is in the middle and everything else is connected to it. While it may be more difficult to build a web-like network, Johnston noted it is important because it allows for the interconnection of nodes in different ways.
The Supplemental Emergency Medicine Experience (SEME) is a program that offers three months of clinical immersion in emergency medicine for physicians from rural environments, and was launched to address a staffing shortage of physicians working in ER departments in smaller and rural communities.
By providing family physicians with training, SEME hopes to aid in the acquisition of skills that are necessary for these physicians to practice emergency medicine in their rural communities. The program’s success is attributed to the collaborative network between U of T’s teaching hospital sites, the Rural Ontario Medical Program’s teaching sites, and many faculty members.
The program measures its success in the sustainability of family physicians in rural communities in emergency medicine. According to exit surveys, most respondents have still been providing care in emergency departments in rural communities one to five years after program completion.
“It’s rewarding to have them speak back to us [about] how much they feel the program has improved their confidence to practice emergency medicine and [their] interest to practice emergency medicine. We receive emails in terms of how they’ve been able to use the program in their day-to-day practice,” remarked Mawji, who is also SEME’s program director.
A great challenge for SEME, however, has been attracting physicians from northern Ontario, since it is difficult for some to leave their practice for such a long period of time. With the renewal of the program, Mawji hopes to create a satellite program in Thunder Bay. Hopefully, providing training opportunities closer to home may increase the recruitment of rural physicians into the program.
Physicians like Johnston and Mawji are taking action to improve the health care outcomes of rural communities, and the future seems promising for successive generations and how they can get involved with improving equitable health care for all.