AMA VICDOC SPRING 2021 - Flipbook - Page 37
s the National Rural Generalist Pathway
begins to gather steam, it is imperative to look
at how a rural generalist fits into a complex
system of medical education, credentialing
and continuing professional development (CPD).
If we look at the Collingrove definition of a rural
generalist, that is, a practitioner who is predominantly
a GP but with skills in emergency care and one or
more advanced skill disciplines, we are then forced
to ask the question – how do we prove that these
clinicians are up to the job? How do we ensure that
they meet the standards and ongoing professional
development required to provide quality care to our
rural and remote communities? And how does a
clinical governance professional resolve this issue?
At first glance, one looks at this issue and thinks
the solution is simple – “There’s a diploma for
that!” – the last five years have seen the proliferation
of diplomas from various subspecialty colleges.
These include diploma qualifications in obstetrics,
emergency medicine and prehospital and retrieval
medicine, with upcoming diploma qualifications in
anaesthesia and psychiatry in the works. Each of these
qualifications is renewable and comes with their own
separate college membership and CPD requirements.
Hospital credentialing bodies then proceed to make
the diploma the ‘minimum standard’ for practise in a
given field. So, problem solved!
However, while this solution sounds fantastic on
paper, underlying the concept are issues that demand
and warrant attention.
The first issue is that of grandfathering. How do
you address those already in practise in a particular
field? This is an issue that tends to disproportionately
affect early career doctors (usually 1-10 years postfellowship) who face the prospect of needing to
re-train to do a job they are already doing safely. How
do you manage those with experience and current
CPD but without the piece of paper? If you throw up
roadblocks in this process, a large proportion of newly
minted rural generalists will leave or opt to retrain in
non RG specialties.
The second issue is that of CPD and fees. How
many college memberships should a rural generalist
maintain in order to practise? How many fees should
they have to pay? How many months a year must a
rural generalist spend on CPD for multiple different
organisations at a loss to the community they serve?
The recently-fellowed rural generalist cohort is
large, as it is a relatively new specialty. In a world
where time and case numbers are assumed to be
markers of competence, expectations around CPD
and maintenance of skills dictated from and by
subspecialists in the city quickly become unrealistic.
The end result of this is that these talented rural
generalists opt for two pathways. Many will return
to the centrepiece of rural medicine, which is the
provision of good general practice care. A second
cohort who enjoy working in the hospital setting will
opt to retrain as non-GP specialists in order to avoid
the unrealistic, multiple CPD burdens associated with
a rural generalist skillset. Both of these options are
a loss to rural medicine, as these cohorts of talented
and skilled doctors lose the ability to practice their
full scope as a rural generalist. A combination of poor
clinical governance practise and an obsession with
silos and diploma qualifications leads to them
picking up their bat and ball and moving to
greener pastures elsewhere.
It is important to note, despite all I have said,
that the presence of diploma qualifications is
not necessarily a bad thing. The ability to prove
competency objectively is important and will become
more relevant as rural generalist medicine matures as
The two rural generalist colleges approach this
problem differently, but this is not necessarily to the
detriment of trainees who will enjoy greater choice as
to which pathway to pursue. What is needed urgently
is a discussion amongst our profession about the how
we ensure that those who practise safely are not left
out. It is time that we consider alternatives such as a
competency-based framework as opposed to time in
an accredited subspecialty position as the sole criteria
for determining who is safe to practise.
If we fail to do this, and instead opt for
misunderstanding to drive the process, we stand to
lose our pioneering generations of rural generalists
forever. We simply cannot and must not allow this
to happen any longer. Rural and remote Australia
VI CD O C SPRI N G 202 1