Part 2 of a three-part series
It used to be common place for residents of rural B.C. to have basic surgical procedures done at their local hospital, but as more and more small-town operating rooms close their doors, patients have to travel longer distances to get care.
The centralization of surgery isn't new nor is it unique to this province, but proponents of rural health care are making the case that it's a trend that needs to be stopped or even reversed to provide better care to those living in small town - including communities in northern B.C.
General surgeon Dr. Nadine Caron is among a group of specialists and general practitioners who believe that giving certain family doctors extra training - known as enhanced surgical skills (ESS) - is an important step in keeping rural care local.
"GPs in Canada do surgery is some places, in certain circumstances, with appropriate training and it has been proven to work," she said.
ESS doctors are part of a surgical continuum, which Caron said also includes specialist general surgeons and subspecialists. Each group on that continuum has a different skill set and provides a different type of service to patients.
Caron was part of a national working group that helped put together a standardized curriculum to train ESS physicians on a suite of skills that can be done in smaller hospitals. Currently a program exists in Prince Albert, Sask., which trains two family physicians a year on a variety of skills like hand surgery and Caesarean sections.
The ESS graduates work in rural operating rooms, often alongside general practitioners who are trained to deliver anesthesia as well as operating room nurses and other specialists.
Yet despite ongoing efforts to train ESS doctors, operating rooms in small communities continue to close their doors.
The reasons for the demise of rural surgery are varied. Dr. Stu Iglesias, the ESS lead for the Rural Co-Ordinatation Centre of B.C. said technology has played a big role in the centralization of care.
The rise in the use of dialogistic imaging equipment, like CAT scans, in planning surgery means smaller communities can't keep up. Advanced surgical techniques also allow for precise procedures that are minimally invasive, but require extra equipment and special training to complete.
"These are high capital cost, technical changes in surgery so it has been difficult for these small communities to keep up with the technology and even keep up with the training," he said.
Northern B.C. used to get many of its GP surgeon-trained physicians from South Africa where basic surgical procedures including c-sections were part of the training for family doctors in that country, according to Northern Health medical lead for perinatal programs Dr. Brian Galliford. But changes to licensing and certification requirements in Canada as well as training programs in South Africa have eliminated that option, leaving Canadian-trained ESS physicians to fill the void.
The Prince Albert program has been running for six years now and Caron said the formalized program is important to give both the medical community and the general public the confidence that the appropriate training is being done.
"It's one of the fundamental questions that has always been raised - how can someone perform a procedure a general surgeon has trained for five or six years and an ESS surgeon has trained for one year," Caron said. "I think it's going to be really important to ensure we don't shy away from that question but that we we're very comfortable that we can say that given the proper training, the focused curriculum, the focused training, the ongoing [continuing medical education], the ongoing mentorship, the collegial support, always have a place to transfer a patient that the [ultimate] outcome of that is going to be an ESS surgeon with the skills to provide an important service to their community."
ESS physicians aren't the only ones doing surgery in rural hospitals. Often specialists from larger centres visit the smaller hospitals because it gives them access to more operating room time and means their patients don't have to travel as far to get treatment.
Dr. Bret Batchelor, a recent graduate of the Prince Albert ESS program who works in Vanderhoof said the ear, nose and throat, orthopedic and plastic surgeons from Prince George who routinely visit St. John Hospital benefit both local patients and rural physicians.
"It's a great way to actually meet these doctors that we're constantly referring patients to and meet face-to-face," he said. "In other rural centres you might constantly refer patient to specialists and never meet them for years on end."
The specialist visits also give Batchelor and the other ESS doctors in Vanderhoof the chance to assist on different procedures when required.
"At the end of the day it improves patient care because you're increasing the communication lines between the referring doctor and the doctor being referred to," Batchelor said.
It's not just patients who are better served by having some surgery closer to home, Iglesias said communities come out as big winners as well. It becomes much easier to recruit high-ranking private sector employees in natural resource industries if they know that their local hospital can do some types of surgery - especially c-sections.
"We've created communities that you might be able to die in but you can't be born in anymore," he said.
The demise of family doctors who can do surgery also imperils the future of GP anesthetists, since the two often work in tandem. Caron said losing anesthetists can also hurt the level of care provided in rural settings because those doctors have specialized training on airway management that can be crucial in an emergency situation.
National organizations representing surgeons, gynecologists and obstetricians and rural family physicians are working together to develop a policy paper on the crisis facing rural surgical care and what can be done to fix it. Iglesias said he hopes the paper will "serve as a springboard" to get the issue onto the agenda of health care decision makers in government.
Currently, Iglesias said the fight is to keep the rural operating programs that are still in existence alive.
"I know of no instance where a surgical service that has ever closed that has ever come back," he said. "We're really looking at trying to keep the ones that haven't closed yet going."
Caron agreed, noting the situation is perilous in many understaffed rural operating rooms.
"The first thing is to maintain [our rural surgical services] because it's such a crisis that at any given time everything is on the bubble," she said. "One physician leaves, one physician gets sick and [that community's] entire system collapses."
Given time and political will, Batchelor is more optimistic that rural surgical crisis can not only be stabilized, but it can also grow. He'd like to see a plan in place where governments and health authorities target certain communities that are the right size and are in the right proximity to other towns and build a rural surgical program,
"There wouldn't be enough volume for each of the specific towns to have an operating room, but to have one that's within 45 minutes of any of those centres is really very important," he said.
