Editorial

Abstract

In last year's editorial, Professor Ian Wronski, then President of ACRRM, set out the criteria on which we were asserting the speciality status of Rural and Remote Medicine. This was based on the work of Professor Roger Strasser,1 developing on the work of McWhinney, who identified four determining criteria of whether an area of academic endeavour constitutes a distinct discipline Formation of a dedicated academic body by a reasonable number of its practitioners; An intellectually rigorous training program; Emergence of a body of disciplinary literature by the its practitioners, and; Recognition outside the discipline, especially by other disciplines, universities and society (i.e. government). What has happened since then? The College remains and grows stronger with over 1700 members and many other students and doctors associated with programs. Our training program is now recognised by General Practice Education and Training (GPET) and is incorporated in its contract with Government. We have developed significant and innovative programs in obstetric and emergency ultrasound, radiology, dermatology and population health, to mention but a few. Rigorous criteria for fellowship that acknowledge the diversity of paths to Rural and Remote Medicine and recognise training and experience have been developed. Our examination process is being finalised. The disciplinary literature is becoming exponentially stronger. Only this year the Handbook of Rural Medicine has been published and other publications join the groundbreaking work of the Australian Journal of Rural Health.2 Universities and regional training providers have increasingly embraced the discipline with innovative programs. Rural Medical school training models building on the groundbreaking work of Professor Paul Worley have spread rapidly across the rural landscape with repeated reports of these young doctors-to-be requesting to stay on for an extra year or staying for their residency. Australian universities have appointed the worlds first chairs of rural medicine. On 16 April 2004, ACRRM submitted its application to the Australian Medical School for recognition of Rural and Remote Medicine as a speciality. It contains 93 pages of tightly crafted argument with 242 core references to our discipline. The argument is simple – like many disciplines, ours is dictated very much by context. Emergency medicine exists because of emergency rooms, obstetrics because of childbirth and rural medicine because of rurality. These contextual characteristics of rurality determine many aspects of our discipline. The isolation calls for a different form of risk management that selects for the better of two difficult options – to keep and treat or to send. The characteristics of rural illness present special challenges from melioidosis to leptospirosis, from farm accidents to high speed motor vehicle accidents on lonely roads. Our large indigenous populations demand special attention and skills. Our patient's stoic attitude can often result in late presentation and advanced disease. Rural doctors provide much needed skills outside the normal bounds of medicine, acting as advocate and conciliator, friend and counsellor, public health adviser and individual health trainer. In this milieu, although the presenting complaint may be often essentially the same the rural practitioner needs a deeper range of skill across many areas to fulfil their duties to the patient and their community.3 There is not the discretionary option of treat or refer, but a real need to provide a wide range of services locally. The Rural Doctors Association Viable Models report demonstrated that both in the office and hospital, rural doctors had to take a greater responsibility.4 This is not just the ability to work in unsupervised practice, but to work in a practice without the comfort of a range of specialists close at hand. This is self supporting network of generalists each with there own broad range of skills. This is the only way that rural areas can obtain high quality care. As the Australian Medical Workforce Advisory Committee (AMWAC) acknowledged in 2000: In small rural centres, other rural areas and remote areas, the majority of day-to-day medical care in the hospital and non-hospital setting is provided by GPs. This includes primary care, in-patient care and most procedural care (obstetrics, anaesthetics, operative obstetrics, general surgery, trauma, medical emergency and other matters such as endoscopy and radiology). These GPs are also likely to be providing non-clinical medical services, including in public and population health, administration including hospital administration, and activities associated with running Divisions of General Practice. There is also a wider expectation on the individual doctor by the community to act as health advocate and more generally take a leadership role in the community.5 The only point of difference that I would have with AMWAC on this is that these are not GPs – these are specialists in Rural and Remote Medicine.