Rural GPs Research Articles

GETTING THE BALANCE RIGHT? GPS WHO CHOSE TO STAY IN RURAL PRACTICE

Despite major challenges to the retention of rural GPs in Australia, little is known about why some rural GPs stay long-term within their communities. A group of rural GPs interviewed as part of another study about 10 years ago were re-interviewed to explore their attitudes to their reasons for staying. Eighteen of the original group of 23 could be contacted and 13 were interviewed. Factors that appeared to promote staying in rural practice were: strong attachment to the community; and practice arrangements that allow for adequate time off-call and for holidays. However, several GPs were stressed and some had considered leaving. The stressors were similar to those identified in earlier research, including overwork and having to send children to boarding school. Personal and professional support arrangements within the community appear to be associated with decisions by rural GPs to remain in practice for substantial periods of time. Retention strategies should focus on facilitation of local integration. Some doctors stay for prolonged periods of time in rural practice, although most leave after a few months or years. The reasons why rural doctors stay have until now not been explored. Rural doctors who stay for prolonged periods of time, defined in this study as 10 or more years, have established personal and professional support networks that have provided protection from the more negative aspects of rural professional life.

Factors associated with rural practice among Australian-trained general practitioners.

To determine the factors associated with general practitioners' current practice location, with particular emphasis on rural location. Observational, retrospective, case-control study using a self-administered questionnaire. Australian general practices in December 2000. 2414 Australian-trained rural and urban GPs. Current urban or rural practice location. For Australia as a whole, rural GPs were more likely to be male (odds ratio [OR], 1.42; 95% CI, 1.17-1.73), Australian-born (OR, 1.95; 95% CI, 1.55-2.45), and to report attending a rural primary school for "some" (OR, 2.21; 95% CI, 1.69-2.89) or "all" (OR, 2.79; 95% CI, 1.94-4.00) of their primary schooling. Rural GPs' partners or spouses were also more likely to report "some" (OR, 2.75; 95% CI, 2.07-3.66) or "all" (OR, 2.86; 95% CI, 2.02-4.05) rural primary schooling. A rural background in both GP and partner produced the highest likelihood of rural practice (OR, 6.28; 95% CI, 4.26-9.25). For individual jurisdictions, a trend towards more rural GPs being men was only significant in Tasmania. In all jurisdictions except Tasmania and the Northern Territory, rural GPs were more likely to be Australian-born. GPs' and their partners' rural background (residence and primary and secondary schooling) influences choice of practice location, with partners' background appearing to exert more influence.

Unity or diversity? Recent developments in the organization of out of hours general medical services in Scotland

The objective of this paper is to describe variations in the different models of out of hours general medical services and identify explanations for variation and the possible influence on patient satisfaction and service costs. A cross-sectional survey of all models of out of hours care was undertaken, including co-operatives, deputizing services, practice rotas and rural general practitioners doing their own cover. Fifteen sites were chosen representing 10 models of care, for more detailed case study; 65 semistructured interviews with key informants were conducted within the case study sites. A postal patient satisfaction questionnaire and an economic analysis were also carried out. Out of hours organizations have developed in response to a complex mix of the population served, geography, resources available and political expediency, leading to considerable structural heterogeneity, even within co-operatives. There was little evidence of formal integration with other services. Only the largest co-operatives showed any evidence of utilizing guidelines/protocols or of providing formal staff training. There were clear differences in the structure of out of hours care in urban and rural areas. Increasing the use of centralized call handling and triage will not address the needs of rural GPs, who would still be required to be available for work. Neither patient satisfaction nor costs varied by model of service provision. The English out of hours review has outlined an integrated model of service provision with consistent standards within an accountability framework. It would appear that only the largest organizations will be in a position to address these standards and that they are likely to be inappropriate to the needs of GPs in rural areas.

Unity or diversity? Recent developments in the organization of out of hours general medical services in Scotland

The objective of this paper is to describe variations in the different models of out of hours general medical services and identify explanations for variation and the possible influence on patient satisfaction and service costs. A cross-sectional survey of all models of out of hours care was undertaken, including co-operatives, deputizing services, practice rotas and rural general practitioners doing their own cover. Fifteen sites were chosen representing 10 models of care, for more detailed case study; 65 semistructured interviews with key informants were conducted within the case study sites. A postal patient satisfaction questionnaire and an economic analysis were also carried out. Out of hours organizations have developed in response to a complex mix of the population served, geography, resources available and political expediency, leading to considerable structural heterogeneity, even within co-operatives. There was little evidence of formal integration with other services. Only the largest co-operatives showed any evidence of utilizing guidelines/protocols or of providing formal staff training. There were clear differences in the structure of out of hours care in urban and rural areas. Increasing the use of centralized call handling and triage will not address the needs of rural GPs, who would still be required to be available for work. Neither patient satisfaction nor costs varied bymodel of service provision. The English out of hours reviewhas outlined an integrated model of service provision with consistent standards within an accountability framework. It would appear that only the largest organizations will be in a position to address these standards and that they are likely to be inappropriate to the needs of GPs in rural areas.

Maintaining the wellbeing of rural GPs.

Maintaining the wellbeing of rural GPs.

Information technology creeps into rural general practice.

This study looked at the effect of information technology on rural medical practice. Eight GPs in rural medical practice in Victoria were interviewed, and World Wide Web sites were accessed for information relevant to the rural GPs use of information technology. The results indicated that rural GPs are developing their use of information technology according to their needs. The use of information technology is changing the nature of rural medical practice, and bringing more support and information to rural GPs. However, some of the technologies now available are of little perceived use to the GPs, and GPs with good support staff are better able to take advantage of the technology than GPs with little or inadequate support. The findings of this study have implications for policies being implemented to increase the availability of information technology to support rural health care.

Professional and social support networks of rural general practitioners.

This study explored the nature of rural general practitioners' (GPs) professional and personal support networks. A qualitative design was employed, using in-depth interviews with a diverse sample of GPs in rural Queensland. The support network of the rural GPs in this study incorporated the domains of clinical, workforce and social support, with clinical support as the most important domain. There was a preference for face-to-face contact wherever possible. Such contact was particularly important in the process of developing the network and for personal support. Despite this, many network contacts were by telephone out of necessity. There were few notable differences between male and female rural GPs on the issues explored in the present study. General Practitioners' satisfaction with their professional interactions was varied across the sample. The findings suggest that level of satisfaction may be associated with intentions to leave or stay for this group.

Where there is no surgeon: the effect of specialist proximity on general practitioners' referral rates.

To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?). A cross-sectional survey of GP-patient encounters. The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia. A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters. Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments). Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44-0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49-0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury-related and non-cancer-related problems, follow-up presentations, and more than one problem managed at an encounter. Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.

Australian GPs are satisfied with their job: even more so in rural areas

Australia has seen a constriction of the scope of practice and of professional prerogatives for GPs in the 1990s, which is said to have led to lower job satisfaction, particularly for rural GPs. The aim of this study was to determine levels of job satisfaction and mental health in a rural and an urban sample of GPs, and to correlate population and practice characteristics with lower job satisfaction and morale. A postal survey of GP members of two urban and four rural Divisions of General Practice in New South Wales was carried out using the Wall-Cook-Warr scale and the 12-item General Health Questionnaire (GHQ-12). The overall response rate was 74%. Both urban and rural Australian GPs were generally satisfied with their jobs; however, rural GPs had significantly higher job satisfaction scores. The highest levels of satisfaction were recorded for factors denoting autonomy. The lowest ranked factors were hours of work, income and government policy in general practice. GPs without psychological disturbance were significantly more satisfied with their work than those who were disturbed. Lower job satisfaction was significantly associated with urban GPs, GPs who worked full-time and those who used a language other than English during consultations. Poor mental health and working in an urban area were predictive of lower job satisfaction in men, and bulk-billing all patients (i.e. not charging patients a co-payment, but making a consolidated claim to the government funder Medicare) and working full-time were predictive of lower job satisfaction in women. Both urban and rural GPs derive a large measure of satisfaction from their job. In particular, rural GPs are satisfied, especially so with their autonomy. Poor mental health was the strongest predictor of lower job satisfaction. The high percentage of GPs with psychological disturbances raises the problem of their access to appropriate mental health services, in particular in rural areas.

Integration of primary health care services: perceptions of Australian general practitioners, non-general practitioner health service providers and consumers at the general practice–primary care interface

Introduction. In conjunction with GPs reporting on their own practice experiences, the experiences of non-GP health professionals and consumer representatives working at the primary care–general practice interface provide valuable considerations for exploring concepts for the development of a GP Integration Index relevant to Australian General Practice. Objectives. To identify concepts that GPs, non-GP health service providers and consumer representatives perceive to be important in facilitating a well integrated approach to delivering primary care, and how these are perceived to be occurring in practice. Method. Group discussions about GP integration were elicited using concept mapping with four groups of GPs and seven groups of health professionals and consumer representatives, purposively selected for diversity in demographic location and practice setting from three Australian States. From Victoria, 19 GPs from two different types of practice settings, 12 Consumer Representatives from 10 separate organisations, 17 Hospital Administrators from 16 major public and private hospitals, 18 specialist doctors representing 12 specialist organisations and 13 Community Service Providers. From Queensland, 13 rural GPs and 22 Nurses representing 10 separate nursing groups were selected. From Western Australia, 19 GPs representing a mix of solo practice, group practice and hospital settings, and 40 Allied Health providers representing various private practitioners and hospital and community centre based allied health practitioners. Concept mapping results from the groups were pooled and analysed using a descriptive meta-matrix to identify overarching themes. Results. Eight overarching themes were identified from consolidated concept maps: GP role; quality outcomes; practice management/accessibility; communication and networks; health care system politics; education and knowledge; personal attributes and attitudes; and lifestyle. Within these major themes, clusters of concepts rated as at least ‘important for patient care’ included various non-clinical aspects of primary care delivery. There was emphasis on a patient—centred and holistic care approach. Strongly advocated by all groups was the need for teamwork between GPs and other health care professionals involved in primary care of the patient. Conclusion. The use of concept mapping was successful in ensuring that the breadth of the topic was explored in its entirety among these groups, contributing to the identification of the dimensions of the concept of GP-integration. Findings from these groups will be pooled and subjected to structural equation modelling processes, to develop a general practice integration index relevant to the Australian setting.

Quality assurance and continuing education needs of rural and remote general practitioners: how are they changing?

The Royal Australian College of General Practitioners' (RACGP) 1998 Rural Quality Assurance and Continuing Education (QA & CE) Needs Assessment Project was designed to generate sufficient data to inform strategic planning for rural and remote GPs participating in the College's QA & CE Program. Results indicated that the demand for QA & CE activities has changed over the past 12 years. Three distinct streams of continuing education emerged, where once only one was researched. This reflected a move towards continuing professional development (CPD) rather than purely continuing medical education (CME). However, differences between the CME needs identified suggested that national data could not be reduced to the local level. Data on CME in which rural and remote GPs felt underserviced, proved more useful in relation to other workforce variables such as age, length of service and gender. A broad 'rural set' of CPD topics was established, and the survey yielded information on learning format preferences that will be of use to providers of QA & CE activities for rural GPs across Australia.

Is case conferencing a retention rates winner for rural GPS and mental health workers?

Is case conferencing a retention rates winner for rural GPS and mental health workers?

General practitioners' opinion of a new psychiatry of old age service

AbstractObjective: To evaluate the reaction of local general practitioners to a new psychiatry of old age service 10 months following its inception.Method: An anonymous questionnaire was sent to all GPs in the catchment area of the Service. Questions asked the opinion of GPs on structure and process of the Service, and also asked for suggestions as to how the Service could patients did not have any reservations about being seen by a psychiatrist, but 72% of rural GPs felt the location of the service base (in the city) was a problem.Conclusion: The results of the study suggest that GPs are reasonably satisfied with the initial service offered by the new specialty. Future service developments must address issues highlighted such as access to the service for patients living outside the city, improving the inpatient facilities for patients with a functional mental illness, and improving communication with GPs.

Management of childhood gastroenteritis in the community.

To examine general practitioners' (GPs') management of childhood gastroenteritis and their perceptions about barriers to optimal management in the community. Cross-sectional postal survey in which GPs' self-reported practices were assessed by a paediatric gastroenterologist for compliance with published guidelines. Hunter region of NSW, mid 1994. All 422 urban and rural GPs practising in the Hunter region were sent questionnaires; 289 (243 urban and 46 rural) GPs responded. Nearly all GPs (97%) recommended clear fluids in the management of childhood gastroenteritis, with 195 (67%) recommending oral electrolyte solution. Management practices were assessed as: optimal, 170 GPs (59%); acceptable, 33 GPs (11%); inappropriate or potentially dangerous, 38 GPs (13%); and too vague to classify, 48 GPs (17%). Multiple logistic regression analysis showed that better management strategies were associated with being younger and practising in rural areas. GPs perceived the main barriers to effective management of gastroenteritis were: inadequate parenting skills, 131 GPs (45%); lack of parental understanding about the illness, 118 GPs (41%); other social problems, 67 GPs (23%); parental anxiety, 57 GPs (20%); and conflicting advice given by others, 42 GPs (15%). Only 33 GPs (11%) identified the taste and 16 (6%) the cost of oral electrolyte solution as major barriers. Most GPs reported management of gastroenteritis was acceptable, although not necessarily optimal. GPs need to ensure that parents fully understand the nature of their child's illness and their recommendations for management at home.

Barriers to effective primary health care for adolescents.

To assess general practitioners' (GPs') perceptions of barriers in the health care system that hinder provision of effective adolescent health care; and to assess the training needs of GPs for a future education program in adolescent health issues. Retrospective questionnaire survey. A 66-item questionnaire was mailed during May and June 1995 to a random stratified sample of 997 rural and urban Victorian GPs. A Practice Assessment Task enabling respondents to fulfil Royal Australian College of General Practitioners' quality assurance requirements was mailed on return of completed questionnaires if requested. The response rate was 72.4%. After adjusting for stratified sampling, 77% (95% confidence interval [CI], 73%-81%) of respondents favoured individual Medicare cards for adolescents from the age of 16. Thirty-eight per cent (95% CI, 34%-43%) were less willing to charge for longer consultations because they feared Health Insurance Commission (HIC) investigation. Most respondents indicated that their undergraduate training in adolescent mental health issues was inadequate and 64% (95% CI, 61%-68%) found it difficult to obtain advice about complex mental health problems. An interest in continuing medical education in adolescent health issues was expressed by 82% (95% CI, 79%-86%) of respondents. Individual Medicare cards should be automatically issued to adolescents from the age of 16 to improve their ability to access health care. Revision of the Medicare rebate system and clarification of HIC's investigative functions may improve GP's effectiveness in adolescent consultations. Undergraduate medical and GP training should include curriculum relevant to adolescent health care.

Evaluation of GPs' medical knowledge by a decision support system

This paper deals with the EValuator which is a multipurpose DSS. EV can be applied by creators of automated disease and therapy models to get insight into knowledge necessary for diagnosis and treatment of diseases. GPs, trainees/interns, hospital clinicians, and students can test their medical knowledge with EV. If necessary, EV offers decision support. In a functionality test, EV was used by GPs to assess their knowledge of thyroid disorders. Test conclusions referred to the GPs' level of medical knowledge of thyroid disorders, differences in EV usage by urban and rural GPs, use of thyroid disorder indices and the GPs' commendations that EV is capable of providing automated decision support to medical professionals in daily practice, and that it can very well be used in the education of students and in GP refresher courses.

General practitioner obstetric practice in rural and remote Western Australia.

The objective of this study was to examine the practice of obstetrics by general practitioners in rural and remote areas of Western Australia (WA). A questionnaire was mailed to all rural and remote GPs in June, 1994. The response rate was 67%. Questionnaires asked GPs to self-report how many deliveries they had performed in the previous year and how many of those deliveries were by Caesarean section or assisted by forceps or ventouse. Comparisons were made with perinatal statistics for the entire State of WA. GPs reported an average of 28 deliveries per year. The Caesarean section rate of 8% was lower than the rate of 21% for all WA in 1993. Ventouse was used more often than forceps to assist the delivery of a baby. Intervention rates for ventouse, forceps and Caesarean section were lower in rural and remote areas of WA than the State as a whole; there was also less use of epidural analgesia. More than half of these GPs currently practising obstetrics hold the Dip RACOG or DRCOG. Medical indemnity is an increasing issue for many GPs. For 6 of the 7 country health regions, close to 80% of women deliver within the health region in which they reside.

Retrieval Principles for Rural GPs

ABSTRACT: The isolated rural general practitioner will, from time to time, be faced with a critically ill patient or medical emergency which requires a higher level of care than can be provided locally. These patients need to be resuscitated, stabilised and transferred to another centre and therefore may need to be escorted by medical personnel. Retrieval services aim to provide a level of expertise and equipment which can be taken to the patient so that management of the patient is optimised prior to transport and continued during transport.The medical retrieval teams which operate from Sydney are: • Westpac Surf Life Saving Association, based at Prince Henry Hospital; • NRMA Careflight, based at Westmead Hospital, and • neonatal teams from Royal Alexandra Hospital for Children and Prince of Wales Children's Hospital. These teams utilise helicopters provided by NRMA Careflight. SLSA and Childflight and fixed wing aircraft from NSW Air Ambulance. Road ambulance retrievals are also provided within the metropolitan area.Country areas in NSW are serviced by retrieval teams from Base Hospitals such as Orange Base Hospital and Tamworth Base Hospital. These services arc primarily by road, but distance sometimes necessitates the use of fixed or rotary wing aircraft.This paper aims to discuss stabilisation of patients prior to transport. There is nothing more daunting than to have strange medical personnel descend on your local hospital and seemingly ‘take over’. Nursing and medical staff who have been caring for the patient, in many cases for hours, may feel pushed aside and not understand why certain things are done to their patient. This discussion will hopefully shed some light on the mysterious ‘transport environment’ so that personnel at the referring hospital can help prepare the patient appropriately and understand the needs of the retrieval team.

Rural access line: a tool for Improving communication between rural GPs and hospital specialists in Western Australia

Rural access line: a tool for Improving communication between rural GPs and hospital specialists in Western Australia

How Can We Attract More Doctors to the Country?

ABSTRACT: Drawing on findings from an extensive survey of rural general practitioners in Victoria, this article explores proposals for improving the recruitment, training and retention of rural doctors. The study which included metropolitan comparison groups achieved a 75 per cent response rate, providing information representative of most GPs in Victoria. Main barriers to entering rural practice identified by rural doctors were spouse problems; lack of skills; city background and training; ignorance of country practice; lack of self confidence; and inadequate remuneration. Negative attitudes towards the country and general practice plus ‘learned helplessness’ picked up in medical school were rated by rural doctors as being of significant importance. Of 14 suggestions for improving recruitment, training and retention of rural GPs the following were rated as top priority; substantial clinical experience in rural hospitals and practices; reciprocal links between the country and medical schools; extra financial reward for isolated rural practice; establishment of Rural Medical Education Centres; and a program to meet the needs of the rural practitioner's spouse.