Meeting the health care needs of the country's rural population is increasingly problematical, but at a recent primary care forum hosted by the AAFP's Robert Graham Center, former AAFP President Ted Epperly, M.D., of Boise, Idaho, along with several other speakers, suggested that instituting programs in medical schools and residencies that cross-train family physicians and general surgeons, in conjunction with critical-access hospitals, could result in an enhanced level of care for rural populations.
Former AAFP President Ted Epperly, M.D., of Boise, Idaho, says rural family physicians, general surgeons and critical-access hospitals should work together to coordinate and deliver care for the good of their communities.
Rural areas often lack an adequate supply of primary care physicians and general surgeons, said Epperly during the July 14 forum here. Often family physicians and general surgeons in these areas need to provide coverage for each other and collaborate to ensure rural patients can get the health care they need.
"We have many communities in Idaho in which the family physicians are doing bread-and-butter surgery," said Epperly, one of four speakers to address the forum, which was sponsored by the American Board of Family Medicine. At the same time, general surgeons working in rural areas sometimes are the only source for such primary care services as treating hypertension, diabetes, hyperlipidemia and other conditions that usually fall under the purview of primary care physicians.
"That is not typically how general surgeons train," said Epperly. He noted that developing some sort of combined family medicine/surgical training or combined fellowships could ensure that both family physicians and general surgeons are prepared for conditions in rural settings.
Tom Cogbill, M.D., vice chair of the American Board of Surgery and program director of the surgical residency at Gundersen/Lutheran Medical Center, in LaCrosse, Wis., called for the establishment of a network treatment model consisting of a few family physicians and a general surgeon. "That is the model we use -- family medicine, and then we add a general surgeon in the clinics where there are small, rural hospitals," said Cogbill.
- Speakers at a recent forum noted that rural communities often have an inadequate supply of primary care physicians and general surgeons to meet their populations' health care needs.
- Many times, family physicians provide "bread-and-butter" surgery in rural areas, and general surgeons provide primary care services.
- The nation's medical schools and residency programs should develop programs to cross-train family physicians and general surgeons.
Epperly also noted that the prevailing misperception in America that family physicians only take care of "minor issues" is particularly wrong in rural areas. Although family physicians often are thought of as "outpatient doctors," said Epperly, "the scope of practice it takes to create a family doctor is huge in terms of being able to handle anything from a pregnant woman at her delivery to an end-of-life congestive heart failure patient in the ICU and everything in between."
The scope of practice family physicians cover in their training is already broad, said Epperly. By providing FPs even more comprehensive training in general surgery, rural communities could reap the benefits. "The best definition I have ever heard of a family physician is the type of doctor a community needs," said Epperly.
However, he noted, that means family physicians will "need to morph our skills into the needs of the community. We must have endoscopy skills, including colonoscopies and upper (gastrointestinal) endoscopy, and enhanced obstetrical skills, including (cesarean)-section skills. We must have surgical skills -- preoperative, intraoperative and postoperative -- to assist the general surgeons or to be able to do the general surgery."
According to Epperly, the ultimate goal is teamwork -- the ability to bring physicians and other health care providers together for the good of rural communities. Ideally, family physicians, general surgeons and critical-access hospitals should be virtually connected, making it possible for each to work together when coordinating care.
Family physician Arlene Brown, M.D., of Ruidoso, N.M., also addressed the forum, telling meeting participants that she practices in a small town in the mountains of southern New Mexico that is 200 miles from the nearest Level I trauma center. During the past 29 years, she has worked with 11 different general surgeons and an even greater number of obstetricians.
"I think it is critical that family physicians and general surgeons be trained together to be able to do trauma care," said Brown, who is a former AAFP director. "In a small town, if a school bus runs off a snow-covered mountain road, it is going to be the family physician and the general surgeon who respond. It is absolutely critical that the family physician knows how to do stabilization, intubation or whatever needs to be done."
Brown also said family physicians and general surgeons need to have endoscopy skills. "In our community, our nearest GI physician is one county away," she said. "He covers three counties, a geographical area that extends all the way from the Texas border to my county."
Finally, it is essential that family physicians and surgeons be able to cover for each other in the area of obstetrics, said Brown. "When I first started in my community," she said, "there was one obstetrician, and he and I covered for approximately 200 deliveries that we did in our county for a year."
But, she added, "I knew when my obstetrician was gone, I could call on the (general) surgeon to do operative deliveries in the cases where they were needed." When that general surgeon left, however, incoming general surgeons were less willing to provide that type of backup, said Brown.
Family physician Warren Newton, M.D., chair of the American Board of Family Medicine Board of Directors, stressed the interrelationship between family medicine, general surgery and critical access hospitals. Each has a critical role to play in the health of their respective communities, said Newton, but "Most of us understand that family physicians are the foundation of the physician workforce in rural communities. Fifty to 60 percent of all physicians working in rural areas are family physicians. That percentage increases the more rural you get."
General surgeons also are critical to the health of rural communities, as well as to the economic health of rural hospitals, according to Newton. And rural hospitals are an important part of the mix, he added, noting that "about two-thirds of (rural hospitals) are critical-access hospitals. They are the mainstays of their communities, the first or second (largest) employer in their communities."
But most rural areas have a difficult time recruiting and retaining physicians and other health care professionals, noted Epperly and several other speakers. You have to get the residents out into the rural areas so they fall in love with the area, said Epperly, who is the program director at Family Medicine Residency of Idaho in Boise. Otherwise, it is going to be very hard to get folks to those areas.
For example, said Epperly, his residency program focuses on training family physicians in rural areas. Residents spend their first year training in Boise before being sent out to train for the final two years in rural areas. The program has achieved an 80 percent retention rate for residents staying in rural areas after they graduate.
That type of success can be translated across the country, said Epperly. Every U.S. medical school should have a rural training program for all of their medical students to enhance student knowledge and awareness of the health care issues facing rural America and what can be done to resolve them collaboratively.
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