Remote and rural general practiceBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7166.2 (Published 24 October 1998) Cite this as: BMJ 1998;317:S2-7166
The most challenging job of them all? Self-reliance, good emergency skills, an increasing role for information technology… and the goldfish bowl of village social life. John Gillies on working in the back of beyond
General practice in the United Kingdom has to be adaptable. It has to supply general medical services to communities as diverse as inner city London and the Shetland Isles. Suburban practice shades into rural practice; definitions are complex and often unrewarding to pursue except for academic work.(1) Rural practices are, by definition, in the country but tend to have good, fast transport links to urban areas. Remote practices are those on offshore islands and in areas of low population density with long and tenuous transport links to cities and to district general hospitals. Such areas exist in many parts of Britain, including Devon and Cornwall, Cumbria, Northumberland, Wales, and Scotland.
Remote and rural general practice has had a low profile, partly because it has, on the whole, worked quietly and efficiently, and partly because isolation reduces the visibility of both problems and achievements. There is evidence that remote and rural practices have been disproportionately affected by recent difficulties in recruitment.2
If you are self sufficient in personal and professional terms, if you enjoy outdoor sports and pursuits, relish the natural world in all weathers, enjoy having a high profile in a small community, and have undergone a fairly broad clinical training, then practice in a remote or rural area may be for you.
Every remote practice is unique, but extended clinical skills are always needed. These may include prehospital trauma care, emergency medicine (such as thrombolysis for acute myocardial infarction), intrapartum obstetrics, and minor casualty skills. Many areas have community hospitals that fulfil varying needs from acute medical and maternity care to palliative care. Information technology and telemedicine are rapidly growing in importance. As the number of general practitioners in an area is often small, a management role is often inescapable. Life in remote communities can be lonely for the doctor and his or her partner and family, and having a happy and fulfilled partner who also wants to be in the area is very important. As other professionals may be in short supply, there are often opportunities to take a leading role in community organisations and have a major impact on community development.
The role often suits those (but not only those) who have worked for a time in remote and rural areas of the developing world. They tend to enjoy “hands on” clinical work and have become used to working on their own initiative with limited or distant back up services. Some remote and rural doctors are indigenous to the areas that they serve, and there are still areas of rural Wales and island Scotland where a knowledge of or interest in Welsh or Scottish Gaelic can be of great value, although it is not essential.
Pros and cons of remote practice
Rewards of being an essential, key figure in a small community
Wide range of “hands on” clinical work, including emergencies
Community hospital work in some areas
Growing role of information technology and telemedicine
High quality environment for family life and outdoor interests
Less crime, stable communities
On call commitment can be considerable and inescapable
Continuing professional development often distant and costly
Problems finding locums
Need to keep up to date with a wide range of skills, especially trauma and emergency medicine
Lack of anonymity and choice for doctor and patient
Isolation, difficulties of single handed and small partnerships
Those who need the stimulus and cultural diversity of city life are unlikely to find remote practice a good career choice. Wages are often low in rural areas, and unemployment is high. The country may seem idyllic on a summer day, but rural deprivation and poverty are largely unrecognised and have a considerable impact on the health of rural populations and the workload of practices.
Many practices have a considerable on call commitment (often one in two), and some very remote and island doctors are on call continuously for long periods. Although the number of calls may be small, the general practitioner and community nurse are often the only health professionals immediately available, and a call may be for a minor ailment or for a road traffic accident with trapped casualties 20 miles away. There is a need to keep up to date with rapidly changing developments in a great variety of different specialties, including acute trauma, acute medical care, and information technology. Finding locums with relevant skills and experience, essential in many practices, is often difficult, especially in the summer months of high demand, and compounds the problem of access to postgraduate education.
Other difficulties largely stem from the lack of freedom, for doctor and patient, inherent in living in remote areas. It can be difficult to look after patients who have become close friends, especially during serious illness. Small communities can be claustrophobic and lonely, especially when everyone is a patient. Most are wonderful rumour factories. Anonymity is impossible. If the doctor is unfortunate enough to become ill or have an alcohol or marital problem, then access to confidential medical care can be very difficult. Many remote practices are single handed, and professional isolation is a real problem, although advances in information technology may reduce this. Providing input into health planning at times of major organisational change in the NHS can be constrained by the lack of manpower flexibility. Relationships within small partnerships can be difficult and need constant nurturing to avoid misunderstanding and breakdown.
The yawning chasm between what vocational training can deliver and what the service needs is nowhere wider and deeper than in training for remote practice.(3) So how do you become a general practitioner in a remote area?
Posts that give experience of emergency medicine and trauma are obviously useful, but experience in most clinical areas from dermatology to thrombolysis after myocardial infarction may be of value. Directors of postgraduate general practice education can give advice on what is locally available, and discussion at an early stage is advisable to avoid hospital posts which may not be recognised for training and for advice on an appropriate general practitioner registrar post. To my knowledge, only the Inverness vocational training scheme (see below) has a four year rotation which includes at least six out of a total of 18 months' experience in a rural or remote practice. Further developments in this area are imminent. Some general practitioners successfully move into remote areas after a period in an urban area. Ideally such a move should come after a period of retraining in the extended skills needed for remote practice.
It is unusual to move straight from vocational training to a principal post in a remote area, and some time spent as either a locum or an associate is essential. Associate general practitioners, who have completed general practitioner training,(4) work part time or full time as salaried practitioners in one or two remote single handed practices. These posts provide valuable experience in remote medicine and can let you know whether the lifestyle and the job are for you. Part time and job sharing associate posts are possible.
Dealing with emergencies is a part of the post that many aspiring rural general practitioners find difficult. The British Association for Immediate Care (BASICS) provides courses of uniformly high quality in pre- hospital trauma, resuscitation, and medical emergencies. These are strongly recommended for all doctors who need to respond to emergencies during the course of their work.
The rural doctors group of the Royal College of General Practitioners has now been running for several years. It has published a useful occasional paper on rural general practice(5) and a textbook on rural healthcare is imminent.(6) Members of the group, who are geographically distributed throughout the United Kingdom, can be contacted via the college's website, which also hosts a rural general practitioners discussion forum.
The Institute for Rural Health, which aims to identify and address issues on rural health and disseminate good practice, has an excellent website. The institute has a broad remit, which includes education and continuing professional development for doctors and other rural health professionals, research, and information technology. WONCA (World Organisation of National Colleges, Academies and Academic Institutions of General Practice and Family Medicine) has published a seminal policy document on training for rural practice.(7)
General practice in remote and rural areas can be a rewarding and stimulating career, especially for those doctors who enjoy emergency medicine and trauma and who want to be an integral part of a small community. Developments in information technology are reducing some of the problems of isolation, and there have recently been welcome attempts at addressing the problems of professionals living and working in remote areas.(8) A trial period as a locum or as an associate is essential before making a commitment, however.