Rural General Practitioners Research Articles

Growing the pool of rural general practitioners.

The critical importance of primary health care in maintaining a healthy population is well established internationally. Nevertheless, general practitioner care is not always easily accessible for some patients in Australia, particularly in rural regions. This is partly due to an insufficient number of medical graduates entering and being retained in the rural general practitioner workforce. Key elements of international and national programs designed to address this shortfall are discussed and include the use of entry requirements that preferentially select for applicants from a rural residence background, and immersion of medical students for a large share, or entire duration, of their training in rural communities. In addition, other factors that can influence decisions to enter and stay in rural practice are discussed.

Outpatient Management of Oligosymptomatic Patients with respiratory infection in the era of SARS-CoV-2: Experience from rural German general practitioners

BackgroundCovid-19 is causing a pandemic and forces physicians to restructure their work. We want to share our experience in the outpatient management of potentially-infected patients with special consideration of altered national test strategies during the crisis.MethodsWe analysed patients with respiratory symptoms reporting to our three rural general practitioner (GP) offices in North Rhine-Westphalia, Germany, from 27.01–20.04.2020 (n = 489 from a total of 6090 patients). A history of symptoms was taken at the doorstep following a specific questionnaire. Patients with respiratory symptoms were examined in a separated isolation area, while the others were allowed to enter the office. We applied the first recommended algorithm of the German Robert Koch Institute (RKI) to test suspected patients and compared our results with an adapted, more liberal version of the RKI, which is currently applied in Germany.ResultsEighty patients (16.36%, mean age: 47.03 years+ − 18.08) were sent to a nasopharyngeal smear. Five patients (6.25%) proved to be positive, four of whom had established risk factors for COVID-19. Overall, the most common symptoms were cough (83.75%), sore throat (71.25%), as well as myalgia and fatigue (66.25%). The most common diagnoses were rhinopharyngitis (37.22%) and acute bronchitis (30.27%). A sore throat was more common in positively-tested patients (80% vs. 12%). Applying the first RKI test strategy yielded 6.25% of positive tests (n = 80), while the more liberal later RKI recommendation would have achieved 1.36% positive tests from 369 patients. No positive test was missed by applying the conservative strategy. None of our employees called in sick during this period, which emphasises the efficacy and safety of our screening methods.ConclusionA clinical distinction between ordinary respiratory infections and COVID-19 is not possible in a low-prevalence population. Our model to prevent unprotected physical contact, screen patients in front of the office with protective equipment, and examine respiratory infections in separated areas works in the GP setting without overt health risks for employees. Thus, this approach should be used as a GP standard to uphold patient care without major health risks for the personnel. Large multi-centre studies are necessary to work out the most suitable test strategy.

Regional differences in the patient population of general practices in northern Germany: results of a mixed-methods study

ObjectivesThe aim of our study was to explore patient types in general practitioner (GP) practices and to quantify the regional differences of the frequencies of these patient types in northern...

Development and preliminary validation of the competency model for rural general practitioner in China.

BackgroundThere is a shortage of rural general practitioners (GPs) in China. Training programs have been initiated to meet the needs of GP workforce in the rural areas; however, there is an absence of validated tool to assess their competencies.ObjectiveThis study aimed to develop a competency model for rural general practitioner (CMRGP) after training in China and to examine its validity and reliability.MethodsA multistage process was adopted to develop the CMRGP comprised literature review, panel discussion and expert consultation, and the initial version of CMRGP was reduced from 10 domains and 77 items to 7 domains and 54 items. A pilot study was conducted among 202 rural GPs for the psychometric evaluation and application of the initial version of CMRGP, in which a questionnaire on the importance of items and self-evaluation was completed by the GPs.ResultsIn the pilot study, 132 completed questionnaires (65.3%) were returned. Acceptability and face validity of the CMRGP were supported by high importance scores of the items, in which 52 out of 54 items achieved score higher than 4.00 (possible score from 0 to 5). Factor analysis supported the construct validity. After the modification, the final version of CMRGP contained 6 domains and 47 items. Good reliability was supported by internal consistency reliability (Cronbach’s α was 0.98) and split-half reliability (Spearman–Brown coefficient was 0.99).ConclusionsThe CMRGP demonstrated good reliability and validity. Pilot study showed its potential for application in the rural general practice and training program.

Salvation Expectations of Patients of Medicine, Complementary and Alternative Medicine and Religion

Health and holistic quality of life, physical and emotional needs, somatic and spiritual aspects contain a comprehensive promise of healing. The aim of the current study is to measure the expectations of patients of medicine, alternative medicine and religion related to health and illness. The survey was carried out among 103 patients of a rural general practitioner from May to June 2013 and among 103 patients of the outpatient department for endocrinology and metabolic disease of the Jena University Hospital in 2013. All patients were asked by one interviewer (HM) on fears in relation to health/illness and expectations of help for its own life, medicine, alternative medicine and religion. The biggest fear of patients is “being in need of help of others.” There is no significant difference between religious and non-religious patients. Overall, the expectations of medicine were significantly higher in all sectors than in alternative medicine or religion. Comparing alternative medicine and religion, the expectations of alternative medicine were significantly higher excluding consolation and inner peace. The expectations for medicine in general and for the physician are very high and comprehensive and go beyond diagnosis and realization of therapies. Patients expect hope, guidance, support, comfort, inner peace and advice most from medicine. This results in considerable challenges for the physician, especially in a healthcare system with limited resources and without suitable offers. There is an urgent need to integrate these requirements into daily routine.

An exploration of the experiences of GP registrar supervisors in small rural communities: a qualitative study

BackgroundIn Australia registrar training to become a general practitioner (GP) involves three to four years of supervised learning with at least 50% of GP registrars training wholly in rural areas. In particular rural over regional GP placements are important for developing future GPs with broader skills because the rural scope of practice is wider. Having enough GP supervisors in smaller rural communities is essential such training. We aimed to explore what makes rural GPs’ based outside of major regional centres, participate in supervising or not, their experiences of supervising, and impact of their practice context.MethodsSemi-structured interviews were undertaken with 25 GPs based in rural Tasmania (outside of major regions - Hobart and Launceston), in towns of < 25,000 population, to explore the GPs’ professional backgrounds, their experiences of supervising GP registrars, their practice context and their decisions about supervising GP registrars or not. Thematic analysis was undertaken; key ideas, concepts and experiences were identified and then reviewed and further refined to core themes.ResultsSupervising was perceived to positively impact on quality of clinical care, reduce busy-ness and improve patient access to primary care. It was energising for GPs working in rural contexts. Rural GPs noted business factors impacted the decision to participate in supervision and the experience of participating: including uncertainty and discontinuity of registrar supply (rotational training systems), registrar competence and generating income.ConclusionsSupervising is strongly positive for rural GPs and related to job satisfaction but increasing supervision capacity in rural areas may depend on better policies to assure continuity of rural registrars as well as policies and systems that enable viable supervision models tailored to the context.

Faculties to Support General Practitioners Working Rurally at Broader Scope: A National Cross-Sectional Study of Their Value.

Strategies are urgently needed to foster rural general practitioners (GPs) with the skills and professional support required to adequately address healthcare needs in smaller, often isolated communities. Australia has uniquely developed two national-scale faculties that target rural practice: the Fellowship in Advanced Rural General Practice (FARGP) and the Fellowship of the Australian College of Rural and Remote Medicine (FACRRM). This study evaluates the benefit of rural faculties for supporting GPs practicing rurally and at a broader scope. Data came from an annual national survey of Australian doctors from 2008 and 2017, providing a cross-sectional design. Work location (rurality) and scope of practice were compared between FACRRM and FARGP members, as well as standard non-members. FACRRMs mostly worked rurally (75–84%, odds ratio (OR) 8.7, 5.8–13.1), including in smaller rural communities (<15,000 population) (41–54%, OR 3.5, 2.3–5.3). FARGPs also mostly worked in rural communities (56–67%, OR 4.2, 2.2–7.8), but fewer in smaller communities (25–41%, OR 1.1, 0.5–2.5). Both FACRRMs and FARGPs were more likely to use advanced skills, especially procedural skills. GPs with fellowship of a rural faculty were associated with significantly improved geographic distribution and expanded scope, compared with standard GPs. Given their strong outcomes, expanding rural faculties is likely to be a critical strategy to building and sustaining a general practice workforce that meets the needs of rural communities.

End-of-life care in rural and regional Australia: Patients', carers' and general practitioners' expectations of the role of general practice, and the degree to which they were met.

The study objective was to explore the characteristics of rural general practice which exemplify optimal end-of-life (EOL) care from the perspective of people diagnosed with cancer, their informal carers and general practitioners (GPs); and the extent to which consumers perceived that actual EOL care addressed these characteristics. Semi-structured telephone interviews were conducted with six people diagnosed with cancer, three informal carers and four GPs in rural and regional Australia. Using a social constructionist approach, thematic analysis was undertaken. Seven characteristics were perceived to be essential for optimal EOL care: (1) commitment and availability, (2) building of therapeutic relationships, (3) effective communication, (4) psychosocial support, (5) proficient symptom management, (6) care coordination and (7) recognition of the needs of carers. Most GPs consistently addressed these characteristics. Comprehensive EOL care that meets the needs of people dying with cancer is not beyond the resources of rural and regional GPs and communities.

How does small group continuing medical education (CME) impact on practice for rural GPs and their patients, a mixed-methods study

ABSTRACT Studies which report outcomes of continuing medical education (CME) interventions for rural general practitioners (GPs) are limited. This mixed methods study recruited GPs from four CME small group learning (SGL) tutor groups based in different rural locations in the Republic of Ireland. A two-hour teaching module on deprescribing in older patients was devised and implemented. Assessment of educational outcomes was via questionnaires, prescribing audits and qualitative focus groups. All GPs (n = 43) in these CME-SGL groups agreed to participate, 27 of whom (63%) self-identified as being in rural practice. Rural GPs were more likely to be male (56%), in practice for longer (19 years), and attending CME for longer (13 years). The questionnaires indicated learning outcomes were achieved knowledge increased immediately after the education, and was maintained 6 months later. Twenty-four GPs completed audits involving 191 patients. Of these, 152 (79.6%) were de-prescribed medication. In the qualitative focus groups, GPs reported sharing experiences with their peers during CME-SGL helped them to improve patient care and ensured that clinical practice is more consistent across the group. For rural GPs, CME-SGL involving discussion of cases and the practical implementation of guidelines, associated with audit, can lead to changes in patient care.

General practitioner knowledge and practice in relation to unintended pregnancy in the Grampians region of Victoria, Australia.

Abortion has been legal in the Australian state of Victoria since 2008 and medical termination of pregnancy (MTOP) available since 2012. While these developments were expected to improve Victorian rural women's access to abortion, this has not been borne out in practice. General practitioners (GPs), particularly in rural areas, are women's first point of contact when faced with an unintended pregnancy. The objective of this study was to understand rural GPs' knowledge and practice in relation to unintended pregnancy and referral for abortion, using the Grampians region of Victoria as a case study. Parts of this region, like other rural and regional areas, experience teenage pregnancy rates double the national average and more than four times that of major cities, and access to abortion services is known to be limited. Findings from the study will inform rural health service development to improve rural women's access to abortion. This article reports on the findings from a mixed methods study which explored GP knowledge, understanding and practice in relation to unintended pregnancy services in seven local government areas in the Grampians. Data were collected between April and August 2017. GPs from all practices in this region were invited to participate. A total of 84 GPs were approached, 23 (27%) completed the survey and, of these, five also took part in a semi-structured telephone interview. The quantitative survey data were analysed descriptively while the open-ended survey responses and qualitative interviews were analysed thematically. Of the GPs surveyed, 38% indicated that they 'refer to a colleague due to a conscientious objection' when women present with an unintended pregnancy. No GP always discussed telehealth medical abortion with women and only 27% said that they 'always' discussed medical abortion with women. A range of views were expressed about the adequacy and location of services, with the majority indicating services in the region were limited or inadequate. Interviews with GPs who had conscientious objections to abortion indicated that 'conscientious objection' occurred in different forms and included a range of behaviours. Rural GPs who were interested in becoming MTOP providers faced barriers such as lack of access to timely ultrasounds and surgical backup. The results indicate high levels of conscientious objection and wide variation in knowledge of services. In addition, the provision of tele-abortion and medical abortion is extremely limited in this region, even while these are considered ideal ways to address rural access to abortion. It is likely the promise of tele-abortion is far from fulfilled in the Grampians region and possibly in other rural areas in Victoria. There is a need to improve GPs' knowledge of available services and adherence to legal and professional obligations, and there are clear opportunities to achieve this, with all interview participants expressing strong support for the prevention of unintended pregnancy, and many highlighting the need for good support for women up until the point of termination.

Tackling rural health inequities from the ground up

New Zealand rural health is in crisis. Many rural general practices are closing their doors or relying heavily on short-term locums. There was public outrage when general practices in Northland closed their books, but this is what more of rural New Zealand will face if swift and ongoing action is not taken. In the Royal New Zealand College of General Practitioners 2018 survey, 39% of rural respondents worked in a practice with an unfilled vacancy, and 36% of rural general practitioners intended to retire in one to five years. In addition, it showed that rural general practitioners are more likely to do on-call and unpaid work than their urban counterparts.

What type of automated external defibrillators (AEDs) do primary care doctors want?

Purpose of the study: The purpose of this study is to ascertain what type of AEDs General Practitioners (GPs), who had previously been supplied and used AEDs, would prefer as replacements for existing defibrillators. Previous studies have identified AEDs as the most suitable defibrillators for GPs. 1 Colquhoun M. Resuscitation by primary care doctors. Resuscitation. 2006; 70: 229-237 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar , 2 Masterson S. Wright P. Dowling J. Swann D. Bury G. Murphy A. Out-of-hospital cardiac arrest (OHCA) survival in rural Northwest Ireland: 17 years’ experience. Emergency Medical Journal. 2011; 28: 437-438 Google Scholar , 3 Bury G. Headon M. Egan M. Dowling J. Cardiac Arrest management in general practice in Ireland: a 5-year cross-sectional study. BMJ Open. 2013; 3: e002563https://doi.org/10.1136/bmjopen-2013-002563 Crossref Scopus (17) Google Scholar This study aims to focus on the type of AEDs required by GPs in advance of a phased replacement of AEDs primarily to rural GPs in the North West region of Ireland.

End-of-life care in rural general practice: how best to support commitment and meet challenges?

BackgroundFew studies have specifically assessed the scope, nature and challenges of palliative and end-of-life care in rural general practice. These knowledge gaps limit the development of evidence-based policies and services for patients in the last months of life. This study aimed to explore the perspectives of general practitioners (GPs) and other stakeholders on rural GPs’ involvement and challenges in providing palliative and end-of-life care in regional Australia.MethodsA qualitative study involving five focus groups with 26 GPs based in rural/regional Western Australia together with 15 individual telephone interviews with four GPs and 11 other stakeholders involved in end-of-life care across Australia.ResultsThe rural GPs’ central role in end-of-life care was recognized by the majority of participants but multiple challenges were also identified. Some challenges were comparable to those found in urban settings but others were more pronounced, including resource limitations and lack of training. Inappropriate payment models discouraged GPs’ involvement in some aspects of end-of-life care, such as case conferences and home visits. Compared to GPs in urban settings, those in rural/regional communities often reported closer doctor-patient relationships and better care integration and collaboration. These positive aspects of care could be further developed to enhance service provision. Our study highlighted the importance of regular interactions with other professionals and patients in providing end-of-life care, but many GPs and other stakeholders found such interactions more challenging than the more “technical” aspects of care.ConclusionsRural/regional GPs appear to be disproportionately affected by inappropriate payment models and limited resources, but may benefit from closer doctor-patient relationships and better care integration and collaboration relative to urban GPs. Systematic collection of empirical data on GP management at end-of-life is required to build on these strengths and address the challenges.

What are the current 'top five' perceived educational needs of Irish general practitioners?

Doctors' continuing medical educational and professional development (CME and CPD) needs are known to be strongly influenced by national and local contextual characteristics. A crucial step in the development of effective education and training programmes is the assessment of learner needs. A national needs assessment was conducted among general practitioners (GPs) in the Republic of Ireland who attended continuing medical education small group learning meetings (CME-SGL) in late 2017. Doctors completed a self-administered anonymous three-page questionnaire which gathered demographic data and asked them to choose their 'top five' perceived educational needs from separate lists of topics for CME and CPD. There were 1669 responses (98% of monthly attendance). The topics most commonly identified as a priority for further CME were prescribing (updates/therapeutics), elderly medicine, management of common chronic conditions, dermatology, and patient safety/medical error. The most commonly selected CPD topics were applying evidence-based guidelines to practice, appraising performance/conducting practice audits, coping with change, and managing risk and legal medicine. There was no difference between urban and rural practice settings regarding the most commonly chosen topics in each category; however, more rural GPs selected pre-hospital/emergency care as one of their 'top five'. Our findings identified priority areas where CME and CPD for GPs in Ireland should focus. The topics selected may reflect the changing nature of general practice, which increasingly requires delivery of care to an ageing population with more multi-morbidity and chronic disease management, while trying to apply evidence-based medicine and consider patient safety issues. CME/CPD programmes need to adapt accordingly.

Post-diagnosis skin cancer follow-up in rural general practice: A mixed-method study.

The literature reveals a lack of consensus on recommendations for follow-up of skin cancer in general practice for all types of skin cancer. The objective of this paper was to evaluate post-treatment surveillance practices for both melanotic and non-melanotic skin cancers (NMSC) by general practitioners (GPs) in regional Victoria, and to identify challenges in follow-up for skin cancers in rural areas. A mixed-method study involving a survey and semi-structured interviews with GPs and registrars in Gippsland was carried out in 2015. The survey of 65 participants showed that 69% (45/65) followed up NMSC opportunistically, while 66% (43/65) reported using a structured follow-up practice for melanoma. Six practitioners from the interviews identified the patient's level of education, time constraints, practitioner accessibility and specialists' availability as some common challenges in follow-up. We recommend that rural GPs review follow-up strategies for all skin cancers, through the establishment of guidelines and a recall system.

Does locally delivered small group continuing medical education (CME) meet the learning needs of rural general practitioners?

ABSTRACTThe World Health Organisation policy of improving retention of rural health care practitioners recommended that continuing medical education (CME) programmes addressing their needs should be accessible and delivered where they live and work. This cross-sectional study involved a self-administered anonymous questionnaire completed by GPs attending CME small groups (CME-SGL) in Ireland. All GPs attending CME-SGL in a one-month period were invited to complete the questionnaire which examined demographic details, distance to travel to educational meetings/nearest regional hospital, barriers to accessing continuing education, whether CME-SGL met their educational needs, morale and professional isolation.A total of 1,686 responses were collected, of which 332 (19.6%) were from rural GPs. Of these, 289 (87%) reported that their educational needs were fully or mostly met by attending CME-SGL. Compared to urban doctors, rural GPs had further to travel to CME-SGL meetings, were further from the nearest regional hospital, and reported increased barriers to accessing continuing education. Rural GPs reported lower morale and greater levels of professional isolation. Despite considerable barriers to accessing continuing education, rural GPs reported that CME-SGL meets their educational needs. Future research should focus on the potential positive impact this may have on professional isolation and morale.

Factors related to rural general practitioners supervising general practice registrars in Australia: A national cross-sectional study.

General practice training in Australia is uniquely structured to allow half of all registrars to train in rural areas, in order to increase rural workforce development and access to rural primary care. There is, however, limited national-scale information about rural general practice supervisors who underpin the capacity for rural general practice training. The objective of this research was to explore the factors related to rural general practitioners (GPs) supervising general practice registrars. Results were obtained using multivariate analysis of the 2016 Medicine in Australia: Balancing Employment and Life survey data. Overall, 57.8% of rural GPs were supervising registrars. Supervising was strongly related to being Australian-trained, working in a larger practice, andsupervising medical students andinterns. Rural supervising capacity could be increased through supporting GPs in smaller practices to engage in supervision and maintaining the strong involvement of GPs in larger practices. Other important factors may include a greater number of Australian-trained graduates working in rural general practice and increased support for international medical graduates to Fellow and feel confident to supervise.

Lived experiences and insights into the advantages important to rural recruitment and retention of general practitioners.

Despite existing studies in this field, community factors behind recruiting and retaining rural general practitioners (GPs) are not fully understood. To address this issue, the Community Apgar Questionnaire (CAQ) was developed to extend the understanding of communities' assets and capabilities that impact GP recruitment and retention. However, more in-depth insights are vital to develop a comprehensive approach. This mixed methods study was administered using face-to-face structured interviews with a total of 40 health service representatives. All interviews lasted 35-40 minutes and were audio-taped. Qualitative data were generated from the extended responses to the structured questions of the CAQ and later transcribed. Thematic analysis was conducted in relation to explanations, elaborations, and relevant strategic approaches to improving workforce retention. The qualitative findings illuminated the most important advantages of recruiting and retaining GPs were linked to medical support, hospital and community support, and economic factors, while the challenges were related to geographic factors. The underlying reasons for and nature of those advantages and challenges reinforce that health professionals' decisions to stay or leave are complex and multifactorial. The originality of the study rests on the administration of the CAQ accompanied by the opportunity for participants to provide extended responses, which gives critical insights into the complexities of rural recruitment and retention. As such, the results confirm the need for a flexible multifaceted response to improving rural GP workforce and informs decision-making in terms of addressing workforce issues within the scope of available resources and capacity.

Job satisfaction and stressors for working in out-of-hours care \u2013 a pilot study with general practitioners in a rural area of Germany

BackgroundChallenging work environment, high workload, and increasing physician shortages characterize current rural general practice in Germany and in most European Countries. These factors extend into Out-Of-Hours Care (OOHC). However, little research about potential stressors for general practitioners (GPs) in OOHC settings is available. This pilot study aimed to evaluate workload, different elements of job satisfaction and stressors for GPs in OOHC and to analyze whether these aspects are associated with overall job satisfaction.MethodsCross-sectional survey with a sample of 320 GPs who are working in OOHC was used to measure workload in OOHC, job satisfaction (using the Warr-Cook-Wall scale) and stressors with the effort-reward imbalance questionnaire. In order to assess associations between workload, job satisfaction and stressors at work we performed descriptive analyses as well as multivariable regression analyses.ResultsThe response rate was 40.9%. Over 80% agreed that OOHC was perceived as a stressor and 79% agreed that less OOHC improved job satisfaction. Only 42% of our sample were satisfied with their overall job satisfaction. The regression analysis showed that the modification of current OOHC organization was significantly associated with overall job satisfaction.ConclusionsOur results suggest that OOHC in the current form is a relevant stressor in daily work of rural GPs in Germany and one of the reasons for a decreasing overall job satisfaction. Strategic changes such as the implementation of structural reforms e.g. reducing frequency of OOHC duties for each GP and improving continuing professional development options related to OOHC are needed to address current workload challenges experienced by GPs providing OOHC in Germany.

Rural and Remote General Practitioners’ Perceptions of Psychologists

ObjectiveAs the first professional contact for most Australians with mental health concerns, general practitioners (GPs) are often considered the “gateway” to accessing psychologists. Understanding GPs’ views of psychologists is therefore of great importance to the profession. GPs serve a particularly important role in mental health in rural and remote areas given the lack of other services; however there has been limited research investigating the relationship between psychologists and GPs in rural areas. This study aimed to investigate rural GPs’ perceptions of rural psychologists.MethodSemi‐structured qualitative telephone and in‐person interviews were conducted with 13 GPs working in rural and remote South Australia. Data were analysed thematically.ResultsThree main themes were identified: Psychologists are useful/helpful; working with psychologists can be challenging; and psychologists are not well understood. Rural GPs held mostly positive views about psychologists and their value in providing professional support and reducing GP workloads. However, GPs’ understanding of psychologists’ training and expertise varied considerably, with most reporting gaps in their knowledge. Challenges included limited access to psychologists and communication barriers. Communication was considered to be enhanced by co‐locating psychology services within the GP practice, which was also considered to be a valuable educational opportunity for GPs.ConclusionWhile rural GPs held largely positive views of psychologists, they may require further support in understanding what psychologists can offer and promoting psychology to their patients. Results may assist in improving communication between rural psychologists and GPs and inform strategies to improve rural GPs’ understanding of psychologists’ skills and training.