INTRODUCTION
Over 6.5 million Canadians live in rural settings.1 Rural Canadians are comparatively less healthy than their urban counterparts, having higher all-cause mortality and a higher burden of obesity, circulatory disease, and trauma.2 The final report of the Collaborative Working Group on the Future of Emergency Medicine found a current and growing staffing shortage in rural emergency departments (ED).3 Despite this shortfall, few medical graduates are choosing rural practice. Data from the Canadian Post-MD Education Registry (CAPER) for physicians who exited post-graduate medical training in 2015 revealed that 11.4% of Canadian College of Family Practice (CCFP) graduates were in rural practice two years later.4 For graduates of Canadian College of Family Practice Emergency Medicine enhanced skills (CCFP-EM) residency training programs, CAPER data shows that 5.3% of the 2015 cohort was in rural practice two years after graduation,5 similar to a University of Toronto survey of previous graduates that showed 6% is in rural practice.Reference Varner, Ovens, Letovsky and Borgundvaag6
In rural Canada, most emergency care is provided by family physicians who practice a broad scope of medicine.Reference Hutten-Czapski, Pitblado and Slade7,Reference Wenghofer, Kam, Timony, Strasser and Sutinen8 Rural physicians practising emergency medicine spend substantially more time in family practice than their urban counterparts.Reference Varner, Ovens, Letovsky and Borgundvaag6 The value of a broad scope practice and generalism has been recognized by both the College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada.9,10 The rural Roadmap for Action specifically highlights the importance of building networks between urban academic and rural communities that foster timely access to consultation and transfer of care, as well as networks that allow for training opportunities for medical students and residents in rural settings.9
Across Canada, academic emergency medicine departments have taken a variety of approaches to engagement with rural hospitals. To date, the largest published engagement effort is the British Columbia Emergency Medicine Network.Reference Christenson11,Reference Abu-Laban, Drebit and Lindstrom12 Their experience suggests the need for broad engagement across all clinical, academic, and operational domains to build successful partnerships.
Building effective clinical networks and engagement between academic departments/divisions of emergency medicine and rural hospitals offer an opportunity to serve the health of rural Canadians. This can potentially be achieved through the support of a broad scope rural generalist practice and by choosing this type of practice more appealing to learners as they consider their eventual practice location. The purpose of the work undertaken by our panel was to make recommendations on how to best build and strengthen these relationships.
METHODS
A panel was convened with physicians from a variety of work environments, including rural physicians and urban physicians. The panel included education-focused physicians involved with formal CCFP-EM residency training, training of physicians in practice, and rotation-based training of medical students and family medicine residents. Collectively, these physicians had leadership roles in both academic and rural practice, as well as experience in building relationships between academic institutions and rural/regional communities.
The panel met by teleconference monthly to review the experiences of panel members in building relationships between academic institutions and rural/regional communities.
The panel developed and administered two surveys, one for physicians working in rural and regional EDs and one for academic department leaders. Ethics approval for the surveys was obtained through the University of Calgary. The survey for academic leaders was distributed through the CAEP Leadership group and generated 11 responses. The survey for rural and regional emergency physicians was initially sent to 13 members of the Society for Rural Physicians of Canada (SRPC) who had agreed to receive the survey. Snowball sampling was encouraged, and the survey link was subsequently posted to the ruralmed listserv by one of the study participants, generating 53 total responses. Free text from the surveys was analyzed by two members of the panel who conducted and coded thematic analysis.
Focused (semi-structured) interviews were conducted with four leaders in the area of connecting academic and rural emergency medicine (one academic department head, two rural medicine leaders, and one rural academic leader from an alternate system in Australia). Open-ended questions were used to delve into the past experiences of these emergency medicine leaders to elucidate potential challenges and “lessons learned.”
Draft recommendations were developed based on these results and presented at the 2018 Academic Symposium of the Canadian Association of Emergency Physicians (CAEP). Feedback from the audience was collected and used to refine the recommendations further.
SUMMARY OF RECOMMENDATIONS
Recommendation 1
The CAEP should engage with other rural stakeholder organizations such as the CFPC and SRPC.
High-level engagement between organizations with a shared interest in rural emergency medicine will foster shared interests, utilize untapped resources, and reveal opportunities for collaboration.
CAEP currently maintains active relationships with both the CFPC and the SRPC. CAEP has also begun the process of tailoring educational course offerings so that courses can be delivered in rural communities at a reasonable cost, as well as design online courses that are accessible in any location.13
Recommendation 2
Engagement efforts require adequate financial and manpower resources.
Large-scale engagement efforts such as the province-wide engagement effort in British Columbia require a significant commitment of finances, human resources, and system resources.
The British Columbia Emergency Medicine Network represents the most comprehensive engagement effort to date in Canada and addressed four key areas: 1) clinical resources; 2) innovation; 3) continuing professional development; and 4) real-time support.Reference Christenson11,Reference Abu-Laban, Drebit and Lindstrom12 Projects of this scale require substantial support to develop, operationalize, and sustain. Smaller-scale or focused projects will equally benefit from estimation and understanding of potential resource requirements at the planning stage to increase the probability of success. As an example, developing rural rotations or training opportunities in emergency medicine training programs requires consideration of financial and resource requirements in the planning phase of development.
Recommendation 3
Training opportunities are an important method of building and strengthening collaborative relationships.
Training opportunities, including the opportunity for practising physicians to participate in exchanges in both directions between rural and academic practices, as well as distributive training to medical students and residents, is an opportunity to build and strengthen relationships.
The two most frequently suggested methods of strengthening relationships, as identified by rural and regional emergency physicians, were having urban physicians visit or work in a rural emergency department (21%) and increasing the presence of trainees in rural EDs (13%). Through narrative comments within the surveys, both urban physicians and rural physicians expressed interest in opportunities to work or shadow in each other's environments, without the undue burden of paperwork, as an important method of increasing understanding and engagement. Increasing opportunities for trainees to work in rural EDs were also identified as an important strategy.
Recommendation 4
The current operational interface between the academic emergency medicine department and the EDs in the catchment area must be understood, with gaps addressed as part of building and strengthening relationships.
Operational challenges and limitations (distance, remoteness, time allotment, human resource limitations, breadth of clinical responsibility, and practice differences) were identified as the most significant barrier in creating connections between urban/academic and rural/regional EDs (64% of respondents).
Rural and urban academic hospitals regularly interact around patients at the operational level. This operational interface is important and cannot be separated from that of the academic relationship. This is captured in a quote from one of the respondents; “We often experience push back from our current tertiary centre when we transfer our patients to their facility whether it be to the emergency department [ED], ICU [intensive care unit], etc. So there are barriers currently, and I do not know what they are.”
Recommendation 5
Initial engagement should be around projects with a common value for both the academic and rural/regional partners to foster and build positive working relationships.
Rural/regional physicians identified joint academic rounds, journal clubs, educational outreach, and shared continuing medical education (CME) as high-value items.
Academic activities occurred in all academic departments and were identified as occurring in some of the rural/regional departments: grand rounds (37%), journal clubs (17%), and departmental CME (35%). Leadership connections were also highlighted in survey free text as an area of high value for initial engagement. Identification of projects of common value and interest may represent opportunities for early engagement and building positive working relationships.
Recommendation 6
Academic departments should be encouraged to partner with rural scholars (including researchers, quality assurance/quality improvement, and educational scholars), who should receive financial and academic support that is similar to urban scholars.
Survey data showed that 35% of rural/regional physicians rated increasing the potential for rural scholarly opportunities as an important or very important potential benefit of increased engagement with academic emergency medicine departments. Only 5% of the departments surveyed reported having current participation in scholarly work, thus identifying this as a potential area for engagement and growth.
Although active interest in scholarship may represent a minority of rural/regional physicians, the gap between stated importance and current participation represents an important growth opportunity. Text-based comments from the survey identify validation of decision support tools in the rural environment and quality improvement initiatives as potential targets for joint scholarly work. Such joint scholarly work requires the support of both academic and rural participants.
Recommendation 7
Academic departments seeking to build or strengthen relationships with rural and regional departments should consider successful examples from elsewhere in the country and local culture, barriers, and opportunities specific to their own geographical region.
Meaningful relationships can be fostered by continuous engagement if both urban academic and regional/rural EDs develop an understanding of each other's practice setting and challenges.
The survey data demonstrated rural and regional physicians perceive that urban academic departments underappreciate the unique challenges and differences of a rural emergency medicine practice.
According to a rural survey participant, “Academic emergency departments have very little and limited knowledge of what happens in rural emergency departments and of the myriad challenges and resource limitations we have. They also have absolutely no idea of the staff limits we have either.”
Even within a single health region, the resources, staffing, and local challenges may be variable among rural hospitals. In building and strengthening these relationships, it is advisable to be aware of similar efforts across the country and the lessons learned, but there must also be an awareness that local context is highly variable and an important consideration in building these relationships.
CONCLUSION
Building and strengthening the relationship between an academic department or division of emergency medicine and rural/regional EDs is an important part of providing access to high-quality emergency medical care to all Canadians. The British Columbia Emergency Network provides an example of a large-scale project.Reference Christenson11,Reference Abu-Laban, Drebit and Lindstrom12 Opportunities for mutually beneficial projects, training opportunities, and scholarship can promote a shared understanding, along with the development of improved processes of care and strengthening the emergency care system for patients. As the current interface between academic and rural hospitals is primarily operational, initial efforts should focus on these issues to address concerns and establish common ground. Although there is variability across Canada in current local ED cultures, opportunities, and potential barriers, the recommendations presented will help academic departments build and strengthen relationships with rural and regional EDs.
Acknowledgements
The panel gratefully acknowledges the in-kind support of the panel members, CAEP administrative staff, and the University of Calgary Department of Emergency Medicine research group.
Competing interests
No conflicts of interest or financial disclosures were identified by any of the panel members.
