The motivations and experiences of specialists who provide outreach services in rural operating rooms: A survey study from British Columbia.

INTRODUCTION: Outreach care has long been used in Canada to address the lack of access to specialist care in rural settings, but research on the experiences of specialists providing these services is lacking. This descriptive survey study aimed to understand 1) specialists' motivation for engaging in outreach work, (2) their perceptions of the quality of care at their rural outreach hospital, and (3) the supports they receive for their outreach work, in order to create a supportive framework to encourage specialist outreach contributions. METHODS: In July 2022, specialist physicians who provide outreach operating room services at rural hospitals participating in the Rural Surgical and Obstetrical Networks initiative in the province of British Columbia were invited to complete an anonymous survey. RESULTS: 21 of 45 invited outreach specialists completed the survey (47% response rate). Three-quarters of respondents had a surgical specialty. The opportunity to deliver care to underserved patients was the most common motivator for outreach work. Rural hospitals received high ratings from respondents on overall safety and various aspects of communication and teamwork. Postoperative care was a concern for a minority (one-fifth) of respondents, and about half had experienced unnecessary delays between procedures some or most of the time. Generally, respondents felt integrated into rural teams and reported receiving adequate nursing and anesthetic support. The two most common desired additional supports were better/more equipment and space and additional staffing. All 19 respondents not planning to retire soon intended to provide outreach services for at least three more years. CONCLUSION: Specialists providing outreach OR services in small volume rural hospitals in BC usually have altruistic motives for outreach work. For the most part, these specialists have positive experiences in rural hospitals, but they can be better supported through investment in infrastructure and health human resources. Specialists intend to provide outreach services long-term, indicating a stable outreach workforce. More research on the facilitators and barriers of specialist outreach work is needed.

Perinatal Outcomes at Rural Hospitals That Participated in the Rural Surgical and Obstetrical Networks (RSON) of British Columbia (2016-2021).

BACKGROUND: The goal of the Rural Surgical and Obstetrical Networks (RSON) of British Columbia was to support safe and appropriate surgery, operative birth, and perinatal care closer to home for rural communities. Family physicians with enhanced obstetrical and/or surgical skills provide cesarean delivery and family practice anesthetists manage anesthesia for labour pain and operative births at RSON-supported hospitals, with the involvement of a local specialist at one site. OBJECTIVES: The objectives of the study were to: (1) compare perinatal outcomes at hospitals participating in the RSON initiative with outcomes at referral hospitals and (2) examine temporal changes in the proportion of childbearing people who resided in RSON communities and gave birth locally. METHODS: Poisson regression analysis was used to model the effect of hospital type (RSON vs. referral) on perinatal outcomes. We restricted the analysis to singleton births and controlled for differences in maternal characteristics, obstetric history, and pregnancy complications. RESULTS: Childbearing people who gave birth at RSON-supported hospitals (n = 3498) had a 10% lower incidence of adverse maternal-newborn outcomes compared to those who gave birth at referral hospitals (n = 14 772), after controlling for referral bias. We found a small increase (3.2 %) in the proportion of local births over the study period. CONCLUSION: Findings provide evidence that childbearing people can safely give birth at smaller rural hospitals in British Columbia and that investments in rural hospitals contribute to service stability. Stabilizing local birth services in rural communities benefits the whole region because it reduces surgical overload in regional referral centres.

Consensus statement on networks for high-quality rural anesthesia, surgery, and obstetric care in Canada.

OBJECTIVE: To describe the essential components of well-resourced and high-functioning multidisciplinary networks that support high-quality anesthesia, surgery, and maternity care for rural Canadians, delivered as close to home as possible. COMPOSITION OF THE COMMITTEE: A volunteer Writers' Group was drawn from the Society of Obstetricians and Gynaecologists of Canada, the Society of Rural Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Canadian Association of General Surgeons, the College of Family Physicians of Canada, and the Association of Canadian University Departments of Anesthesia. METHODS: A collaborative effort over the past several years among the professional stakeholders has culminated in this consensus statement on networked care designed to integrate and support a specialist and non-specialist, urban and rural, anesthesia, surgery, and maternity work force into high-functioning networks based on the best available evidence. REPORT: Surgical and maternity triage needs to be embedded within networks to address the tensions between sustainable regional programs and local access to care. Safety and quality must be demonstrated to be equivalent across similar patients and procedures, regardless of network site. Triage of patients across multiple sites is a quality outcome metric requiring continuous iterative scrutiny. Clinical coaching between rural and regional centres can be helpful in building and sustaining high-functioning networks. Maintenance of quality and the provision of continuing professional development in low-volume settings represent a mutual value proposition. CONCLUSION: The trusting relationships that are foundational to successful networks are built through clinical coaching, continuing professional development, and quality improvement. Currently, a collaborative effort in British Columbia is delivering a provincial program-Rural Surgical Obstetrical Networks-built on the principles and supporting evidence described in this consensus statement.

A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills.

SUMMARY: Rural western Canada relies heavily on family physicians with enhanced surgical skills (ESS) for surgical services. The recent decision by the College of Family Physicians of Canada (CFPC) to recognize ESS as a "community of practice" section offers a potential home akin to family practice anesthesia and emergency medicine. To our knowledge, however, a skill set for ESS in Canada has never been described formally. In this paper the Curriculum Committee of the National ESS Working Group proposes a generic curriculum for the training and evaluation of the ESS skill set.

GP Surgeons' Experiences of Training in British Columbia and Alberta: A Case Study of Enhanced Skills for Rural Primary Care providers.

INTRODUCTION: There has been a steady erosion of family physicians with enhanced surgical skills providing care for rural residents. This has been largely due to the lack of formal training avenues and continuing medical education (CME) opportunities afforded to those interested, and attrition of those currently practicing. METHODS: A qualitative study was undertaken using an exploratory policy framework to guide the collection of in-depth interview data on GP surgeons' training experiences. A purposive sample of GP surgeons currently practicing in rural BC and Alberta communities yielded interviews with 62 participants in person and an additional 8 by telephone. Interviews were audio recorded and transcribed then subjected to a process analysis. RESULTS: Participants thematically identified motivations for acquiring advanced skills training, resources required (primarily in the area of solid mentorship), the most efficacious context for a training program (structured), and differences in mentorship between obstetricians and general surgeons. CONCLUSION: Mentors and role models were the most salient influencing factor in the trajectory of training for the participants in this study. Mentorship between specialists and generalists was constrained at times by inter-professional tensions and was accomplished more successfully within a curriculum-based, structured environment as opposed to a learner-responsive training environment.

Rural patients' experiences accessing surgery in British Columbia.

BACKGROUND: More than 33% of Canadians live in rural areas. The vulnerability of rural surgical patients makes them particularly sensitive to barriers to accessing health care. This study aims to describe rural patients' experiences accessing local nonspecialist, family physician-surgeon care and regional specialist surgical care when no local surgical care was available. METHODS: We conducted a qualitative pilot study of self-selected patients. Interviews were analyzed using a modified Delphi technique and NVivo qualitative software. RESULTS: The needs of rural surgical patients were reflective of Maslow's hierarchy of needs: physiologic, safety and security, community belonging and self-esteem/self-actualization. Rural patients expressed a strong desire for individualized care in a familiar environment. When such care was not available, patients found it difficult to meet even basic physiologic needs. Maternity patients and marginalized populations were particularly vulnerable. CONCLUSION: Rural patients seem to prefer individualized care in a familiar environment to address more of their qualitative emotional, psychological and cultural needs rather than only the physiologic needs of surgery. Larger studies are needed to delineate more clearly the qualitative aspects of surgical care.

Rural surgery in British Columbia: is there anybody out there?

OBJECTIVE: To document surgical procedures performed in British Columbia between 1996 and 2001 at rural hospital sites with no resident specialist surgeons and to define the scope of practice of general practitioner (GP)-surgeons at these small-volume surgical sites. METHODS: We obtained data from published information available in the medical directories for British Columbia and from the Population Utilization Rates and Referrals For Easy Comparative Tables database (versions 6.0 and 9.0) to conduct a retrospective study of all rural BC hospitals with surgical programs that had no resident specialist surgeon and relied on GP-surgeons for emergency surgical care between 1996 and 2001. We studied surgical programs at the 12 hospitals that met inclusion criteria and interviewed the physician or nurse responsible for the program. Outcomes were measured in terms of the types and volumes of surgical procedures (elective and emergency) from 1996 to 2001, including itinerant surgery. RESULTS: On average, 2690 surgical procedures were performed annually at the 12 hospitals included in the study. Endoscopy, hand surgery, cesarean section, herniorrhaphy, tonsillectomy and dilation and curettage (D&C) were among the top elective and emergency procedures. For each hospital, between 8 and 26 procedures of hand surgery, cesarean section, herniorrhaphy, D&C and appendectomy were performed each year. In the 12 communities studied, 19% of all surgery was emergency and 81% elective. There was significant overlap in the types of emergency and elective procedures. GP-surgeons carried out most of the emergency procedures, which nonetheless accounted for a small portion of their surgical work. CONCLUSION: GP-surgeons still perform a significant number of emergency and elective surgical procedures in rural BC hospitals. This study defines useful procedures for GP-surgeons in communities without the population base to sustain a resident specialist surgeon. This information can be used to structure training programs for GP-surgeons that will adequately meet the needs of rural communities.

Delivery models of rural surgical services in British Columbia (1996-2005): are general practitioner-surgeons still part of the picture?

OBJECTIVE: To define the models of surgical service delivery in rural communities that rely solely on general practitioner (GP)-surgeons for emergency care, to examine how they have changed over the past decade and to identify some effects on communities that have lost their local surgical program. METHODS: We undertook a retrospective study using the Population Utilization Rates and Referrals For Easy Comparative Tables database (versions 6.0 and 9.0) and telephone interviews to hospitals that we identified. We included all hospitals in rural British Columbia with surgical programs that had no resident specialist surgeon and that relied on general practitioner-surgeons (GP-surgeons) for emergency surgical care. We examined surgical program characteristics, community size, distance from referral centre, role of itinerant surgery, where GPs were trained, their age and years of experience and referral rates for appendectomies and obstetrics. RESULTS: Changes over the past decade include a decrease in the total number of GP-surgeons operating in these communities, more itinerant surgery and the loss of 3 of 12 programs. GP-surgeons are older, are usually foreign-trained and have more than 5 years of experience. Communities with no local program or that rely on solo practitioners refer more emergencies out of the community and do less maternity care than those with more than a single GP-surgeon. CONCLUSION: GP-surgeons still play an integral role in the provision of emergency and elective surgical services in rural communities without the population base to sustain resident specialist surgeons. As GP-surgeons retire and surgical programs close, there is no accredited training program to replace them. More outcome comparisons between procedures performed by GP-surgeons and general surgeons are needed, as is the creation of a nationally accredited training program to replace these practitioners as they retire.

The relationship of preschool and early school age attachment to mother-child interaction.

This article focuses on the description and meaning of attachment relationships and their relation to patterns of caregiver-child interaction. Concepts fundamental to coding separation-reunion behavior in older children (J. Cassidy & R. S. Marvin, 1992; M. Main & J. Cassidy, 1988) are discussed and then applied to delineating the distinct patterns characterizing secure, avoidant, dependent, and disorganized/controlling at preschool and school age. A scale for rating the quality and relationship structure of adult-child interaction is described. Analyses comparing the interactive patterns of 121 mother-child (ages 5-7 years) dyads revealed a significant difference among the 4 attachment groups and specifically distinguished disorganized/controlling dyads. The study validates current school age attachment measures as well as a new taxonomy suitable for further research in naturalistic or clinical settings.