ANZ J. Surg.

2003;

73

: 232–233

CONTINUING MEDICAL EDUCATION

CONTINUING MEDICAL EDUCATION

MAINTAINING SURGICAL STANDARDS BEYOND THE CITYIN AUSTRALIA

A

NTHONY

G

REEN

Specialist Medical Centre, Atherton, Queensland, Australia

Many Australians, by choice or necessity, live and work in rural Australia. In the past broadly trained general surgeons and appropri-ately trained general practitioner (GP) surgeons provided much of the surgical management. Recently very few rural GPs have beentrained in surgery and there is a shortage of specialist surgeons in many rural parts of Australia. Outreach surgery can assist in theprovision of some surgical services but it is not as effective as an on-site surgical presence. The challenge for the Royal AustralasianCollege of Surgeons Rural Surgical Training Programme is to provide an ongoing supply of well-trained surgeons in general surgeryand the other specialties to provide adequate surgical services to rural Australians. This will be best achieved by having adequatenumbers of surgeons resident in rural areas with appropriate outreach specialist services, and training and support of the proceduralGPs in the smaller centres.

Key words: rural surgery, surgical standards.

Abbreviations

: CPD, continuing professional development; DGRS, Divisional Group of Rural Surgeons; GP, general prac-titioner; RFDS, Royal Flying Doctor Service; RSTP, Rural Surgical Training Programme.

INTRODUCTION

Despite increasing urbanization approximately 25% of Australiansstill live in what is broadly defined as ‘rural Australia’. Many livethere permanently by choice whereas others reside temporarily forreasons of work, holiday or travel. They expect a high standard ofsurgical services and care, particularly for acute problems includ-ing trauma and ongoing serious illnesses such as cancer.

The challenge for surgeons individually in the Royal Aus-tralasian College of Surgeons (RACS) is to provide access to anacceptable, achievable high standard of surgical care.

THE PAST

In days gone by regional areas had broadly trained general sur-geons providing a high standard of overall surgical care withback-up and support from broadly trained or experienced generalpractitioners (GPs). In rural and remote areas, GPs and some-times nurses (with the support of GPs) provided the initial surgi-cal assessment and management.

The Royal Flying Doctor Service (RFDS) provided the ‘mantleof care’ for much of remote Australia and support for clinicnurses and individuals on sheep and cattle stations etc.

The majority of surgical services did not require high technol-ogy or specialist back-up.

THE PRESENT

The last 10–20 years have seen an increase in technical supportrequired for modern surgery with a concomitant tendency to spe-cialization and subspecialization within the specialties and, at

the same time, de-skilling and lack of training for rural GPs inbasic surgery.

In regional towns non-general specialty surgeons may be pro-fessionally isolated if there are only one or two and will haveproblems with excess hours on call, difficulty with continuingprofessional development (CPD) and adequate leave. Thesespecialty surgeons additionally need broader training than theirmetropolitan counterparts as well as increased professionalsupport from their colleagues and specialty societies. In thesmaller regional areas they need support and collaboration withtheir general surgical colleagues.

Within general surgery there is also an increased tendency forsubspecialization (e.g. breast, colorectal surgery). These surgeonsalso need to be broadly trained in the first instance and maintaintheir skills and experience across a broad range of general surgeryover and above their special interest area.

1

It is important that thespecialty societies encourage and support these surgeons andthere is a significant role for the RACS and the Divisional Groupof Rural Surgeons (DGRS) in ensuring this.

In the more rural and remote towns there is an ongoing role forthe general surgeon outside the (metropolitan) scope of generalsurgery. As well as providing emergency care they need skills indiagnosis, initial management and treatment (non-operative andoperative if appropriate) of common conditions across the sur-gical spectrum.

OUTREACH SURGERY

It is a belief of some health administrators and indeed surgicalgroups that the problem with regional surgical services to ruralAustralia can be completely achieved with outreach services frommetropolitan or major regional centres coupled with efficient(and expensive) retrieval services. This will never be true becauseof distances involved, frequent unavailability of aircraft, weatherrestrictions etc.

There is no doubt that outreach services will play a larger rolein the provision of surgical services. This is particularly true withspecialty services (e.g. neurosurgery or paediatric surgery to

A. Green

MB BS, FRACS.

Correspondence: Dr A. Green, Specialist Medical Centre, 47 Jack Street,Atherton, Qld 4883, Australia.Email: ajgreen@tpg.com.au

Accepted for publication 11 November 2002.

SURGICAL STANDARDS 233

regional centres) and in the provision of general surgery to largerrural centres that cannot afford to maintain an adequatelyequipped and staffed surgical service. Outreach services alsohave an important role in providing back-up for 1–2-surgeontowns for professional support, the provision of adequate servicesand time off for the resident surgeons.

The RACS ‘Guidelines for outreach surgery’ recommend thatoutreach services should be of benefit not only to the patients butalso to the on-site medical staff particularly as an educationalexperience. It should not occur in isolation but be delivered incollaboration with the on-site doctors.

Outreach surgical services should not encourage the de-skilling of local practitioners or decrease the viability of theirpractices. The presence of capable doctors, GPs and surgeons ‘onthe ground’ must be the goal, assuming adequate facilities and anadequate population in the region.

THE WAY FORWARD

The RACS Rural Surgical Training Programme (RSTP) is fullysubscribed in general surgery and is now expanding to includeorthopaedics. More needs to be done in other specialty groups.This will allow a shift away from the almost completely metro-centric training that was available particularly in the specialtyareas, and engender in trainees a desire to spend at least a portionof their professional life in a regional or rural area. Six out of thefirst seven ‘graduates’ of the RSTP have gone to rural positions.

Similarly the RACS Rural Continuing Medical Education (CME)and Locum Service has made it easier for rural surgeons to maintaintheir personal standards and competency and meet the CPD require-ments of the College. The sense of professional isolation should bedecreasing. Audit activities and peer review are achievable

2,3

andthere is an increasing role for the RACS in facilitating this.

The RACS similarly has a role in making sure that both humanand physical resources meet minimum requirements for the pro-vision of surgical services within hospitals.

The Rural Secretariat with the College provides a focus forthe integration of the monitoring of surgical services and stand-ards throughout rural Australia (including the limited Indigenousservices that are being provided). It is in the position to foreseevacancies that will arise and identify other gaps in the surgicalservices. It is well placed to provide the link between ruraltrainees and succession planning in rural surgery. The ProvincialSurgeons of Australia provides an annual, rurally based, CPD/training meeting for trainees and surgeons with excellent net-working opportunities.

Current expectations of Australian Fellows and the expensivefacilities that are required for a surgeon to practise in the 21stcentury mean that the future of single-surgeon towns is precari-ous. There are, however, a number of remote areas within Aus-tralia with a current population that warrant an on-site specialistsurgeon. Apart from encouraging Fellows (and their families) tospend perhaps a limited time in these areas, other creative waysand means need to be explored to provide these services. Forexample a major metropolitan hospital may ‘adopt’ a rural hos-pital and provide an ongoing series of locums, as occurs inWhyalla, South Australia. Similarly the Flying Surgical Service

in Queensland provides one model with the provision of surgicalservices over a vast geographical area. It is, however, expensive,difficult to staff, and requires updating.

Some specialty elective procedures are suitable to be doneusing ‘mobile surgery’ vans visiting a rural centre on a regularbasis, (e.g. extra-corporeal shock wave lithotripsy/cystoscopies,insertion of grommets or cataract surgery). It may be expensiveand requires a surgeon being available.

Overseas-trained surgeons are often willing to spend severalyears in a rural or remote town and are often appropriately quali-fied. The College now has a streamlined system to assess (andperhaps further train) these doctors who can then provide theirservices to true ‘areas of need’.

RURAL GENERAL PRACTITIONER SURGERY

The provision of first-line surgical services in most rural townswill continue to rely on adequately trained GPs, some of whomwill want to develop further expertise in surgery. A survey of 78rural centres (with a population >5000) across Australia showedthat 53% had GP surgeons (15% had a specialist surgeon);35% of centres (population >10 000) had no specialist surgeon(R Stiles, unpubl. data, 2001).

The College has an ongoing role with the Royal AustralianCollege of General Practitioners and the Australian College ofRural and Remote Medicine in helping these doctors achieveinitial training and ongoing CPD. It is important that these GPshave close working relationships with their appropriate regionalsurgeons for clinical and educational support.

CONCLUSION

The maintenance of high-standard surgical services to rural andregional Australia first requires that these services actuallyexist in an adequate way. A variety of methods can achievethis: surgically trained GPs, overseas trained surgeons and,most importantly, an ongoing output of appropriately trainedAustralian fellows with the desire and skills to live and work innon-metropolitan centres.

Outreach services are important in the absence of on-site serv-ices but they must support and not weaken local services.

The RACS and particularly the DGRS have a monitoring andcoordination role in (i) overviewing the actual planning and pro-vision of services (in conjunction with the relevant health author-ities); and (ii) supporting individual surgeons in maintaining theirprofessional standards and monitoring hospital standards, therebyenabling the provision of high-quality surgical care.

REFERENCES

1. Tulloh B, Clifforth S, Miller I. Caseload in rural general surgicalpractice: Implications for training.

ANZ J. Surg.

2001;

71

:215–17.

2. Tulloh B, Goldsworthy M. Breast management: A rural perspec-tive.

Med. J. Aust.

1997;

166

: 26–9.3. Birks DM, Gunn IF, Birks RG, Strasse RP. Colorectal Surgery in

Rural Australia. SCARS; a surgeon-based audit of workload andstandards.

ANZ J. Surg.

2001;

71

: 154–8.