Skip to main content

International approaches to rural generalist medicine: a scoping review



Contemporary approaches to rural generalist medicine training and models of care are developing internationally as part of an integrated response to common challenges faced by rural and remote health services and policymakers (addressing health inequities, workforce shortages, service sustainability concerns). The aim of this study was to review the literature relevant to rural generalist medicine.


A scoping review was undertaken to answer the broad question ‘What is documented on rural generalist medicine?’ Literature from January 1988 to April 2017 was searched and, after final eligibility filtering (according to established inclusion and exclusion criteria), 102 articles in English language were included for final analysis.


Included papers were analysed and categorised by geographic region, study design and subject themes. The majority of articles (80%) came from Australia/New Zealand and North America, reflecting the relative maturity of programmes supporting rural generalist medicine in those countries. The most common publication type was descriptive opinion pieces (37%), highlighting both a need and an opportunity to undertake and publish more systematic research in this area.

Important themes emerging from the review were:

  • Definition

  • Existing pathways and programmes

  • Scope of practice and service models

  • Enablers and barriers to recruitment and retention

  • Reform recommendations

There were some variations to, or criticisms of, the definition of rural generalist medicine as applied to this review, although this was only true of a small number of included articles. Across remaining themes, there were many similarities and consistent approaches to rural generalist medicine between countries, with some variations reflecting environmental context and programme maturity. This review identified recent literature from countries with emerging interest in rural generalist medicine in response to problematic rural health service delivery.


Supported, coordinated rural generalist medicine programmes are being established or developed in a number of countries as part of an integrated response to rural health and workforce concerns. Findings of this review highlight an opportunity to better share the development and evaluation of best practice models in rural generalist medicine.

Peer Review reports


A rural generalist, for the purpose of this review, is defined as a community physician, primary care physician, general practitioner (GP), or family practitioner/family physician, with ‘recognised skill sets and qualifications, credentialed to provide primary care, hospital, emergency and population health care as well as one or more areas of advanced specialised practice in a rural, remote and/or regional setting’ [1]. This definition is consistent with the Cairns Consensus Statement (May 2014), an international document defining rural generalist medicine (RGM) and its key pillars and supported by representatives of the First World Summit on Rural Generalist Medicine in 2013. The Cairns Consensus Statement describes RGM as ‘the provision of a broad scope of medical care by a doctor in the rural context that encompasses the following:

  • Comprehensive primary care for individuals, families and communities;

  • Hospital in-patient and/or related secondary medical care in the institutional, home or ambulatory setting;

  • Emergency care;

  • Extended and evolving service in one or more areas of focused cognitive and/or procedural practice as required to sustain needed health services locally among a network of colleagues;

  • A population health approach that is relevant to the community;

  • Working as part of a multi-professional and multi-disciplinary team of colleagues, both local and distant, to provide services within a ‘system of care’ that is aligned and responsive to community needs’ [2].

Contemporary RGM must be considered against a backdrop of challenges faced by policymakers, health services and medical educators in addressing ongoing health inequities [3], workforce shortages [4] and service sustainability concerns specific to rural and remote areas around the world [5, 6]. These challenges reflect the paradox of the ‘inverse care law’ and the inequity of access to health care in areas of most need; in this case rural and remote communities [7]. More recently, a number of countries have investigated RGM as part of an integrated solution to these issues, including supported pathways aimed at developing a rural medical workforce skilled in primary health care, public health and advanced specialist care [1, 8]. This emerging international focus on RGM is highlighted by three RGM World Summits since 2013; now a biennial event [2, 9].

RGM has been a feature of medicine in countries with large rural and/or remote areas for a considerable time [8, 10], despite variations in rural generalist titles, nature of training programmes and models of care. However, the commitment to coordinated RGM training is now occurring in a climate of generalist practitioner shortages [11], most prevalent in rural communities and areas of socio-economic disadvantage [12,13,14,15]. Rural workforce shortages have been identified by the World Health Organization (WHO) as a significant barrier to universal, equitable health coverage [16]. Some of the common drivers for these shortages include the increasing trend toward metropolitan-based medical specialisation [17]; feminisation and ageing of the medical workforce; changing work priorities of younger doctors; changing attitudes toward owning a general practice; and, negative perceptions of both rural and general practice [18, 19].

This scoping review aims to capture, analyse and summarise the international state of knowledge relevant to the development and support of RGM training, models of care and clinical practice.


The question ‘what is documented on rural generalist medicine?’ ensured that a broad range of literature was captured in this review. Broad analysis of the scale and scope of available literature is consistent with scoping review methodology and the five stage framework developed by Arksey and O’Malley: establishing the research question, identifying relevant studies, selecting studies to be included, charting data and summarising results [20].

Inclusion and exclusion criteria (Table 1) focused the search results to ensure relevance of findings. Government and education policies aimed at addressing the geographic maldistribution of the medical workforce took a significant shift from the late 1980s and continued during the 1990s [19, 21, 22]. To capture this change, literature from January 1988 to April 2017 was sourced and reviewed.

Table 1 The inclusion/exclusion criteria applied to the screening of the papers for this review

Medical subject headings (MeSH) and Boolean operators were used to narrow, widen and combine literature searches and ensure relevant literature was captured in the search Table 2). This search was supplemented by bibliographic searching and inclusion of grey literature.

Table 2 Search terms and databases

Using these parameters, 2454 articles were initially retrieved in the database searches. The variation in titles and terms within the RGM field may have had some influence on the search results. However, after selecting the relevant articles based on inclusion criteria (Table 1) and removing duplicates, 140 articles were retained for review (Fig. 1). A further 36 articles were identified using Google Scholar. Grey literature obtained through data searches and prior knowledge added another 39 articles (this included 11 websites). A further 17 articles were included as a result of bibliographic searching. Three more articles were included as a result of manual journal searches. Guided by the inclusion and exclusion criteria, a total of 235 studies were identified as relevant to the research topic.

Fig. 1
figure 1

Overview of the review process

During the final article selection, more were excluded on the grounds of relevance. In some cases, these articles did focus on ‘generalism’ but not rurality; others focused on the rural health workforce but without reference to generalism as defined in this review (Fig. 1). After final eligibility filtering, 102 articles were included in this review (Fig. 1 and Table 3). Another author reviewed all articles for consensus on inclusion.

Table 3 Sources of retrieved and included papers


Articles included for the final review were identified by geographic origins to enable a comparative analysis of rural generalist medicine data by region (Table 4).

Table 4 Geographic regions of included papers

Articles were also identified by type of article or design (some were combined approaches, explaining the total greater than 102; Table 5). The majority were descriptive opinion articles.

Table 5 Articles by report type

Table 6 contains a summary of each article by region, including the main findings. Data extracted from the articles was coded into key themes, including:

  • Definition of rural generalism

  • Existing pathways and programmes

  • Scopes of practice and service models

  • Enablers and barriers to recruitment and retention

  • Reform Recommendations

Table 6 Summary of included papers by region

The key findings in each theme are summarised below.


The majority of data relevant to the definition of RGM comes from Australia, reflecting a growth of coordinated RGM pathways since 2005. Early developments include the Roma Agreement [23], which underpinned the establishment of the ‘Queensland Rural Generalist Pathway’ (QRGP), an initiative of the state health department [24]. Similar definitions are now found in the literature used by the Australian College for Rural and Remote Medicine (ACRRM) [25]; and in Australian Commonwealth, state and territory government documents [1, 26,27,28]. More recently, ACRRM and the Royal Australian College of General Practitioners have supported a definition of a rural generalist that reflects the Cairns Consensus Statement: a medical practitioner trained to meet the health care needs of rural and remote communities by ‘providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural health team’ [29].

The application of specialised skills by the RGM is a focus of definitions in North America [30,31,32]. However, there are also some variations in the literature from this region. In the United States of America (USA), ‘generalism’ is often used to jointly describe family physicians, general internists and general paediatricians [33,34,35]. In the USA and Australia, there has been some criticism of RGM as defined in this review [36, 37], which focuses mainly on the expansion of family medicine fellowship training into specialised skills [37] or efforts to distinguish and then define generalism by rurality [38, 39].

Pathways and programmes

This theme includes literature relevant to (i) medical school training designed to support and develop RGM and (ii) postgraduate (vocational) pathways and programmes.

Undergraduate medical training

Programmes supporting the development of RGM vary between countries, ranging from mature, government-funded models to new, and emerging programmes. In Australia, a medical student is not obliged to choose their speciality until they enter postgraduate (vocational) training, though there are medical school programmes supporting early-entry rural medical and generalist pathways [40,41,42]. A key example of this is university-based rural clinical schools [21], which emphasise rural recruitment, training in rural areas and rural graduate practice. These programmes have been shown to provide a strong foundation for attracting medical students to rural practice [43].

A Canadian study highlights the role of medical schools and residency training programmes in teaching procedural skills to rural family medicine residents [44]. The University of Washington School of Medicine (USA) established the ‘WAMI’ programme to increase generalist graduates in the region with an emphasis on rural practice [45]. This rural training ‘pipeline’ emphasises community practice training, including the Family Medicine Spokane residency programme, with specialised skills rotations [45, 46].

The Moi University Master of Family Medicine Training Program (Kenya) aims to address a shortage of generalists and prepares family physicians for roles as superintendents in regional hospitals, or as district medical officers [47]. This provides access to comprehensive health care services, especially for rural and underserved communities.

Postgraduate pathways and programmes

Six Australian state and territory governments have funded structured and supported prevocational and vocational RGM training pathways [1]. The QRGP offers postgraduate medical trainees:

  • Advice and support services

  • Access to a range of vocational and quarantined training opportunities

  • Procedural and non-procedural training workshops [24]

The QRGP is supported by an industrial agreement that has enabled salaried senior medical officers with RGM credentials to access a higher salary range equivalent to staff specialists [48]. The QRGP is both a training and employment pathway that is founded on four ‘pillars’: recognition of RGM, practice value, a pathway to vocational practice and responsiveness to workforce redesign [49]. Evaluation of the programme found numerous community, workforce and economic benefits, with a cost analysis showing a 120% return on investment [49]. The evaluation also documented two criticisms of the programme: the restricted capacity for training providers to find rural placements for trainees not on the pathway and the negative impact of the programme on private general practice [49, 50]. Funded vocational RGM pathways now exist in other Australian states [26,27,28, 51, 52].

This degree of government administration, coordination and management of RGM programmes is unique to the Australian context. However, there are training programmes and agreements organised toward similar goals in other countries. Ethiopia’s first training programme in family medicine was established in 2013 [12] with the aim of providing postgraduate training to develop comprehensive-care generalist doctors for underserviced urban and rural areas [12]. A collaboration between the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada (CFPC) developed guidelines for surgical services delivered by family practitioners (FPs) in rural areas [53]. Similarly, a shortage of rural FP anaesthetists led to the development of accreditation standards which also applied to training of FP surgeons and FP obstetricians across rural Canada [54]. Additionally, there was a call to establish a college for rural medicine in Canada to specifically prepare rural generalists with specialised skills [55]. In 2008, the CFPC approved family physicians with special interests and accredited enhanced skills that met the Triple C curriculum standards (‘continuing care centred’ in family medicine) [56]. This was particularly relevant to rural FPs, where these skills were more commonly required [56].

Scope of practice and service models

Ideally, scope of practice is tailored to meet community needs and is responsive to a range of factors, including population size, demographics, burden of disease, access to specialist services, geography and socioeconomic status [42]. As the provision of primary health care is common to RGM internationally, the literature on scope of practice is largely focused on the additional, specialised skills provided.

The QRGP supports advanced skills training (AST) in adult internal medicine, Indigenous health, emergency medicine, paediatrics, mental health, obstetrics and gynaecology, anaesthetics and surgery [24]. The procedural skills listed here are common to the scope of practice in other states and territories across Australia and in New Zealand, in particular obstetrics and gynaecology, anaesthetics, emergency medicine and surgery [27, 28, 57, 58].

These procedural skills are also common to RGM in Canada and the USA [59, 60]. In Western European countries, the rural generalist undertakes some procedural tasks, especially in minor surgery [22]. In sub-Saharan Africa, obstetrics, anaesthetics and surgery are common skills for rural family physicians [61, 62]. In South Africa, the generalist in remote areas can also provide orthopaedic care and ENT practice [63, 64].

Whilst core procedural skills are a feature of RGM, there is also evidence of training in non-procedural tasks. The QRGP includes Indigenous health, paediatrics and mental health in the supported ASTs [24]. The Tasmanian Rural Medical Generalist Program has also identified needs in psychiatry, radiology and palliative care [51]. Palliative and elder care is also featured in Canadian RGM training [6, 65].

Discussion on scope of practice extends to models of care, including interaction between generalists and medical specialists, and the quality and safety of comprehensive care. In Canada, there is general agreement between specialist colleges that a generalist approach to procedural services in rural areas is the only feasible solution to rural medical workforce issues [66]. However, there is ongoing interprofessional debate between rural general practice and surgery about role delineation, despite it being uncommon for smaller communities to have surgical services provided by a resident specialist surgeon [66]. Kornelsen et al. (2013) claim that in communities with populations of 5000 to 15 000, surgical services are usually provided by one or more rural GP surgeons, whilst for populations of 15 000 to 25 000 surgical services are usually provided by a specialist surgeon supported by one or more GP surgeons [66]. Australian models of care are similar in that specialised skills practised by the rural generalist increase with complexity with less specialist support as rurality or remoteness increases [67]. In South Africa, there are two opposing views on the model of remote emergency care: (i) stabilisation and transportation of patients to a larger hospital and (ii) support local hospital services where the generalist can treat most cases [63].

The model of care where the generalist provides increasing specialist care proportional to remoteness is also supported by quality and safety outcomes [42]. In Canada, a study comparing caesarean section services provided by rural GPs with those of specialists concludes that rural GPs perform this procedure with an acceptable degree of safety [68]. Rural hospitals in Nova Scotia with less than 100 deliveries a year performed by rural generalists have also shown the lowest perinatal morbidity and mortality rates in the province [69]. Thompson and Iglesias (1998) conclude that there is no evidence to support exclusive skills sets given numerous quality and safety studies demonstrate identical standards for both rural generalists and urban specialists [55].

Enablers and barriers to recruitment and retention

The ability to be trained in, and then practice, specialised skills is considered essential in successful RGM recruitment and retention. The ability to combine procedural work with primary health care is key to much rural recruitment in the Australian context [52, 70]. This, combined with the commencing salary and financial incentives offered under the QRGP, have had a positive impact on rural medical workforce recruitment [49]. In the USA, training programmes producing rural generalist graduates also emphasise comprehensive advanced skills training as key to their success [17, 60]. A study in Canada also showed the larger the range of procedures practised by a family physician, the more satisfied they were in their profession [71].

However, the trend of medical graduates toward highly specialised career choices and corresponding control of hospital-based training posts by specialists are considered threats to RGM in North America [32, 72] and Australia [73]. This also adversely affects the distribution of the overall medical workforce due to the urban-centric focus of speciality practice [73]. There are further systemic barriers for rural generalist practice in Australia, including a lack of appropriate training opportunities and support [74], complexities in maintaining and practising advanced skills, the limited availability of the supporting workforce, working hours and lifestyle factors, perceived medico-legal problems [75, 76], a lack of recognition for the rural generalist role and GPs’ reluctance to resume procedural practice once they had ceased [52, 77].

In the USA, one article identified high liability insurance premiums as a threat to viable smaller rural generalist practices, as well as limited technical facilities and the lack of an appropriate support workforce [78]. In Canada, difficult access to locums, the need for more education and training [79], low confidence in responding to paediatric emergencies and worsening physician shortages [80] are seen as the major barriers to developing the rural generalist workforce. In Europe, the pressures of providing the dual-role of primary care practitioner and specialist in rural communities [81], as well as an increasing centralisation of specialist services to larger centres, are negatively affecting RGM [82]. As a result, fewer rural GPs are practising obstetrics in Europe and it is increasingly rare for those remaining to undertake high-risk obstetric care as routine practice [83].

Reform recommendations

The reform theme can be separated into recommendations from the literature that (i) are focused on training and (ii) have a broader workforce focus.

In Australia, recommendations for training reform include: improving linkages between Commonwealth and State training programmes; increasing support for universities committed to rural generalism; identifying new advanced skills [84]; accelerated vocational pathways into RGM; training and supporting a rural female proceduralist workforce; extending the QRGP training model into other Australian states [85]; and establishing training support networks [42, 86, 87]. The concept of a national RGM training pipeline in Australia is common to many of the training recommendations [1, 74, 88, 89]. Similarly, a USA article supported the concept of a national rural training pipeline that recruits from rural communities, provides rural placements throughout medical school, supports residencies in the rural setting and provides support in rural practice after training [17].

In Canada, the Canadian Medical Association committed to expand the number of rural generalists in training [90] and the Society of Rural Physicians have proposed developing a national rural medicine curriculum to promote the RGM workforce [31]. Other Canadian-based proposals include the establishment of a college for rural medicine [55], an extra training year with focus on procedural and obstetric care skills for family practitioners intending to work rurally [91], expanding and improving enhanced skills training programmes aligned to community need [59, 90, 92] (including advanced maternity care [93], anaesthetics, general surgery [94] and endoscopy [55, 79]).

In Africa, recommendations include increasing the number of rural generalists in training and providing a more structured secondary-care curricula across a broad range of diagnoses and procedural skills [64], similar to Australia and Canada [61, 95]. In South Africa it is recommended that more generalists with specialised skills be trained to position them as the leading health professional in the District Health System [96].

There are also recommendations for new RGM training models in many countries. Recommendations in Kenya include expanding the scope of practice for rural generalists to include emergency surgery [97]. In Japan the authors of one article advocate for the establishment of a rural generalist practitioner training programme with specialised skills, including internal medicine, gastroenterology and general surgery [98].

The literature also contains recommendations for broader workforce policy reform. A New Zealand article outlines efforts made to recognise the RGM role as a specific discipline to advance RGM practice [58]. In Australia, such recommendations include new national funding models that support the RGM pathway [42], workforce strategies aimed at recruitment and retention of rural generalists [48], supporting flexible models of practice ownership [73] and developing a national approach to recognising the rural generalist role [89]. Many of these relate to the broader agenda to develop a national RGM pathway throughout Australia [1, 8, 85] and to establish a specific role in the Commonwealth Government dedicated to this task [25].

The Cairns Consensus Statement contains policy-based recommendations under the domains of ‘Recognition, Training and Research’ for global action in RGM [2]. This is complemented by an earlier WHO recommendation to establish and regulate enhanced scopes of practice (including for Family Medicine) in rural and remote areas [99].


The effort to develop an internationally agreed definition of RGM and priorities for action through the Cairns Consensus Statement provides an opportunity to review global approaches relevant to RGM [2]. This is further underpinned by international health care planning, including the WHO Workforce 2030 Strategy, which aims to correct workforce supply, maldistribution and the imbalance of specialists to generalists [16].

This review found a significant body of literature relevant to the subject of RGM. However, the majority of this originates from Australia, New Zealand and North America (82 out of 102 articles). This reflects the relative maturity of, and funding allocated to, coordinated RGM programmes and pathways in these regions. The smaller volume of literature from lower-middle income countries and/or lesser developed programmes reflects a need for increasing research, support and evidence to evaluate and progress their RGM training pathways and programme design.

What literature was available from these lower income countries or those with less developed programmes does show the extent of emerging interest in RGM. Thigiti et al. (2011) describe the potential to expand the Kenyan ‘Master of Family Medicine’ training programme into Uganda and Rwanda [47] and the developing family physician role in Ethiopia, which will likely provide emergency surgical and obstetric services for those practising rurally [12]. The need for a role with procedural skills, especially in emergency medicine, obstetrics and fracture management, has also been identified in rural Nepal [100, 101], whilst in India, a trial to train rural Medical Officers in Life Saving Anaesthetic Skills was recommended for extension in response to a shortage of rural anaesthetists [102]. There are also some known early RGM programmes, including in Papua New Guinea and the Cook Islands, and some discussions occurring around RGM models in Fiji, Tonga and Zimbabwe. At the World Summit on Rural Generalist Medicine in 2017, Japan also launched its Rural Generalist programme.

This review also identified recommendations to coordinate national RGM pathways within Australia, Canada and the USA, which illustrates the need for ongoing improvements in countries where there are established programmes. Reflections on the literature identifying such improvements could also present valuable learnings for emerging programmes as they continue to build RGM models matched to local needs. Future research on commonalities and contextual differences between RGM programmes internationally (in both high and low income settings) could further understanding of best practice in RGM policy, training and delivery.

Descriptive opinion pieces were the most common form of article identified in this review (40 in total), highlighting the lack of high quality research evidence on RGM. This supports the need for more research to improve the quality of RGM-relevant data as programmes continue to develop internationally in response to ongoing rural health and health workforce needs.


Developing RGM training programmes and models of practice can be a key strategy in improving health care and outcomes in rural communities around the world. This review has synthesised literature relevant to RGM, its development and implementation internationally. Whilst the majority of articles originate from Australia, Canada and the USA, there is also literature emerging from countries such as Japan, Kenya, Uganda, Rwanda, Ethiopia and India. Efforts to coordinate and strengthen RGM pathways as a response to both workforce shortages and health needs in rural and remote areas internationally are now being shared through forums such as the biennial World Summit on Rural Generalist Medicine. Scale-up of high-quality research and publication of evidence related to RGM is now required to support best practice outcomes as this momentum continues to build.



Australian College of Rural and Remote Medicine


Family practitioner


General practitioner


Queensland Rural Generalist Pathway


Rural generalist medicine


World Health Organization


  1. Health Workforce Australia: Rural Medical Generalist DRAFT National Framework. 2013.

    Google Scholar 

  2. Australian College of Rural and Remote Medicine. Cairns Consensus Statement on Rural Generalist Medicine: improved health for rural communities through accessible, high quality healthcare: Australian College of Rural and Remote Medicine; 2014.

  3. Health Workforce Australia. National Rural and Remote Workforce Innovation and Reform Strategy: Australian Government; 2013.

  4. Stratigos S, Nichols A. Procedural Rural Medicine: Strategies Towards Solutions. Rural Doctors Association of Australia, College of Rural and Remote Medicine; 2002.

  5. Levack PA, Levack ID. Medical practice on Tristan da Cunha--the remotest island community in the world. J R Coll Physicians Edinb. 2013;43:290–3.

    Article  CAS  Google Scholar 

  6. Imrie K, Weston W, Kennedy M. Generalism in postgraduate. Med Educ. 2011.

  7. Watt G. The inverse care law today. Lancet. 2002;360:252–4.

    Article  Google Scholar 

  8. NOVA Public Policy P/L. Review of the Queensland Health Rural Generalist Pathway (RGP) model to examine whether there is the potential to expand the model nationally; 2010.

  9. International Conferences []. Accessed 2015.

  10. Duns G. Challenges and rewards--a career as a generalist. Aust Fam Physician. 2013;42:439.

    PubMed  Google Scholar 

  11. Ono T, Schoenstein M, Buchan J. In: OECD Health Working Papers DfE, Labour and Social Affairs, Health Committee, editor. Geographic Imbalances in Doctor Supply and Policy Responses: OECD Publishing; 2014.

  12. Philpott J, Cornelson B, Derbew M, Haq C, Kvach E, Mekasha A, Rouleau K, Tefera G, Wondimagegn D, Wilson L, Yigeremu M. The dawn of family medicine in Ethiopia. Fam Med. 2014;46:685–90.

    PubMed  Google Scholar 

  13. Monjok E, Essien EJ, Smesny A, Okpokam SN. A training need for rural primary care in Nigeria. J Obstet Gynaecol. 2010;30:833–5.

    Article  CAS  Google Scholar 

  14. Holst J. Rethinking medical training in Germany towards rural health care. Primary Health Care: Open Access. 2015;5:1–6.

    Google Scholar 

  15. Hussain R, Maple M, Hunter SV, Mapedzahama V, Reddy P. The Fly-in Fly-out and Drive-in and Drive-out model of health care service provision for rural and remote Australia: benefits and disadvantages. Rural Remote Health. 2015;15:1–7.

    CAS  Google Scholar 

  16. World Health Organization: Global strategy on human resources for health: Workforce 2030. 2016.

    Google Scholar 

  17. Hart G. Health care workforce supply in underserved rural areas of the United States. In 5th International Medical Workforce Conference. Sydney: National Rural Health Association, Washington DC; 2000.

  18. de Klerk B. President’s message. Generalism is dead: long live generalism. Can J Rural Med. 2013;18:121.

    PubMed  Google Scholar 

  19. Battye K, White C, Cronin S, Bond N, Mitchell C. Solutions to the provision of primary care to rural and remote communities in Queensland. Health Workforce Queensland; 2005.

  20. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19–32.

    Article  Google Scholar 

  21. Lyle DM, Barclay LM. Securing a rural health workforce for the next generation of rural Australians. MJA. 2015;1:469.

    Article  Google Scholar 

  22. Boerma WGW, Groenewegen PP, Van Der Zee J. General Practice in urban and rural Europe: curative services. Soc Sci Med. 1998;47:445–53.

  23. Manahan D, Sen Gupta T, Lennox D, Taylor N, Rowan C, Hanson D, McKenzie A, Telfer J, Browning L. The rural generalist: a new generation of health professionals providing the rural medical workforce the bush needs. In: Proceedings of the 11th National Rural Health Conference; 2011.

    Google Scholar 

  24. Rural Generalist Pathway []. Accessed 2016.

  25. Australian College of Rural and Remote Medicine. The Rural Way: implementation of a National Rural Generalist Pathway. Australian College of Rural and Remote Medicine; 2014.

  26. Rural Generalist Training Program []. Accessed 2016.

  27. Rural Medical Generalist Pathways in the Northern Territory []. Accessed 2016.

  28. Rural Generalist Pathways Victoria. 2018. [].

  29. The Collingrove Agreement []. Accessed 2018.

  30. MacLellan K. Generalism and rural Canada. Can J Rural Med. 2006;11:177.

    PubMed  Google Scholar 

  31. de Klerk B. SRPC report on the first World Summit on Rural Generalist Medicine... Society of Rural Physicians of Canada. Can J Rural Med. 2014;19:34.

    PubMed  Google Scholar 

  32. Williams PT. Twenty-year trends in the Ohio generalist physician workforce. J Fam Pract. 1998;47:434–9.

    CAS  PubMed  Google Scholar 

  33. Williams PT, Whitcomb M, Harris R. Generalist physicians in nonmetropolitan counties in Ohio. Arch Fam Med. 1994;3:425–8.

    Article  CAS  Google Scholar 

  34. Wartman SA, Wilson M, Kahn N. The generalist health care workforce: issues and goals. J Gen Intern Med. 1994;9:S7–13.

    Article  CAS  Google Scholar 

  35. Colwill JM, Cultice M. The future supply of family physicians: implications for rural America. Health Affairs. 2003;22:190–8.

    Article  Google Scholar 

  36. Handford C, Hennen B. The gentle radical: ten reflections on Ian McWhinney, generalism, and family medicine today. Can Fam Physician. 2014;60:20–3.

    PubMed  PubMed Central  Google Scholar 

  37. Baugh J, Harmon GE, Bosscher DB, Averill WC, Glazer JL. Saving generalist medicine... Dr. James Glazer’s editorial “Specialization in family medicine education: abandoning our generalist roots” (February 2007). Fam Pract Manag. 2007;14:11–2.

    PubMed  Google Scholar 

  38. Lee KH. A historical perspective of the barriers to generalism. Aust Fam Physician. 2015;44:154–8.

    PubMed  Google Scholar 

  39. Lawrance R. NRF: rural generalism or rural general practice? Aust J Rural Health. 2007;15:391–3.

    Article  Google Scholar 

  40. Sen Gupta T, Murray R, Hays R, Woolley T. James Cook University MBBS graduate intentions and intern destinations: a comparative study with other Queensland and Australian medical schools. Rural Remote Health. 2013;13:1–10.

    Article  Google Scholar 

  41. Worley P, Silagy C, Prideaux D, Newble D, Jones A. The parallel rural community curriculum: an integrated clinical curriculum based in rural general practice. Med Educ. 2000;34:558–65.

    Article  CAS  Google Scholar 

  42. Pashen D, Murray R, Chater B, Sheedy V, White C, Eriksson L, De La Rue S, Du Rietz M. The expanding role of the rural generalist in Australia - a systematic review. Brisbane: Australian College of Rural and Remote Medicine; 2007.

    Google Scholar 

  43. Greenhill JA, Walker J, Playford D. Outcomes of Australian rural clinical schools: a decade of success building the rural medical workforce through the education and training continuum. Rural Remote Health. 2015;15:2991.

    PubMed  Google Scholar 

  44. Crutcher RA, Szafran O, Woloschuk W, Chaytors RG, Topps DA, Humphries PWA, Norton PG. Where Canadian Family Physicians Learn Procedural Skills. Residency Education. 2005;37:491–5.

  45. Ramsey PG, Coombs JB, Hunt DD, Marshall SG, Wenrich MD. From concept to culture: the WWAMI program at the University of Washington School of Medicine. Acad Med. 2001;76:765–75.

    Article  CAS  Google Scholar 

  46. Maudlin RK, Newkirk GR. Family Medicine Spokane Rural Training Track: 24 years of rural-based graduate medical education. Fam Med. 2010;42:723–8.

    PubMed  Google Scholar 

  47. Thigiti J, Heres W, Van Den Hombergh P, Jurgens E, Wendte H. Human resources for health crises in rural Africa: the contribution of family medicine in providing answers. Trop Med Int Health. 2011;16:41.

    Google Scholar 

  48. Sen Gupta TK, Manahan DL, Lennox DR, Taylor NL. The Queensland Health Rural Generalist Pathway: providing a medical workforce for the bush. Rural & Remote Health. 2013;13:1–10.

    Article  Google Scholar 

  49. Ernst & Young. Evaluation and Investigative Study of the Queensland Rural Generalist Program: Queensland Health, Office of Rural and Remote Health; 2013.

  50. Kitchener S. Rural Generalism and the Queensland Health pathway - implications for rural clinical supervisors, placements and rural medical education providers. Rural & Remote Health. 2013;13:1–7.

    Google Scholar 

  51. The Tasmanian Rural Medical Generalist Pathway Program []. Accessed 2016.

  52. Rural Health West. Finding My Place: Factors Influencing the Attraction and Retention of Doctors in Rural Western Australia. In Feedback from Rural Doctors, vol. 1. Rural Health West; 2015.

  53. Inglis FG. Surgical care in rural Canada: training and planning for the future. Can Med Assoc J. 1995;15:1453–4.

  54. Lockyer J, Norton P. An analysis of the development of a successful medical collaboration to create and sustain family physician anaesthesiology capacity in rural Canada. Aust J Rural Health. 2005;13:178–82.

    Article  Google Scholar 

  55. Thompson J, Iglesias S. Shared skill sets: a model for the training and accreditation of rural advanced skills. Can J Rural Med. 1998;3:217–22.

    Google Scholar 

  56. Gutkin C. Focusing on generalism. Can Fam Physician. 2012;58:351–2.

    PubMed  PubMed Central  Google Scholar 

  57. Pereria G. Rural generalist. Aust Fam Physician. 2010;39:459.

  58. Nixon G, Blattner K, Dawson J, Fearnley D, Gardiner S, Hoskin S, Kashyap B, Naicker K, Nieuwoudt B, Skinner A, et al. Rural hospital medicine in New Zealand: Vocational registration and the recognition of a new scope of practice. N Z Med J. 2007;120:1–5.

  59. Soles J. President’s message. Rural generalism. Can J Rural Med. 2015;20:5.

    PubMed  Google Scholar 

  60. Geyman JP, Hart LG, Norris TE, Coombs JB, Lishner DM. Educating generalist physicians for rural practice: how are we doing? J Rural Health. 2000;16:56–80.

    Article  CAS  Google Scholar 

  61. Reid SJ, Mash R, Downing RV, Moosa S. Perspectives on key principles of generalist medical practice in public service in sub-Saharan Africa: a qualitative study. BMC Fam Pract. 2011;12:67.

    Article  Google Scholar 

  62. Reid SJ, Chabikuli N, Jaques PH, Fehrsen GS. The procedural skills of rural hospital doctors. S Afr Med J. 1999;89:769–74.

    CAS  PubMed  Google Scholar 

  63. Ellis C. Training general practitioners for very remote areas. Med Teach. 2008;30:809–11.

    Article  Google Scholar 

  64. Hill PV. Procedural skills in rural practice - a practice profile. S Afr Fam Pract. 1995;16:674–7.

    Google Scholar 

  65. Jones FR. Generalists rule OK! 2014.

    Google Scholar 

  66. Kornelsen J, Iglesias S, Humber N, Caron N, Grzybowski S. The Experience of GP Surgeons in Western Canada: The Influence of Interprofessional Relationships in Training and Practice. Journal of Research in Interprofessional Practice and Education. 2013;3:43–61.

  67. Humphreys JS, Jones JA, Jones MP, Mildenhall D, P.R. M, Chater B, Rosenthal DR, Maxfield NM, Adena MA. The influence of geographical location on the complexity of rural general practice activities. MJA. 2003;179:416–20.

  68. Aubrey-Bassler K, Newbery S, Kelly L, Weaver B, Wilson S. Maternal outcomes of cesarean sections: do generalists' patients have different outcomes than specialists' patients? Can Fam Physician. 2007;53:2132–8.

    PubMed  PubMed Central  Google Scholar 

  69. Hutten-Czapski P. Life on Mars: practising obstetrics without an obstetrician [Editorial]. Can J Rural Med. 1998;3:69.

    Google Scholar 

  70. Tolhurst HM, Adams J, Stewart SM. An exploration of when urban background medical students become interested in rural practice. Rural Remote Health. 2006;6:452.

    PubMed  Google Scholar 

  71. Rivet C, Ryan B, Stewart M. Hands On: Is there an asociation between doing procedures and job satisfaction? Can Fam Physician. 2007;53:92–93.e5

  72. Urbina C, Hickey M, McHarney-Brown C, Duban S, Kaufman A. Innovative generalist programs: academic health care centers respond to the shortage of generalist physicians. J Gen Intern Med. 1994;9:S81–9.

    Article  CAS  Google Scholar 

  73. Larkins S, Evans R. Greater support for generalism in rural and regional Australia. Aust Fam Physician. 2014;43:487–90.

    PubMed  Google Scholar 

  74. Murdoch J, Denz-Penhey H. John Flynn meets James Mackenzie: developing the discipline of rural and remote medicine in Australia. Rural Remote Health. 2007;7:726.

    CAS  PubMed  Google Scholar 

  75. Glazebrook RM, Harrison SL. Obstacles to maintenance of advanced procedural skills for rural and remote medical practitioners in Australia. Rural Remote Health. 2006;6:1–14.

  76. Australian College of Rural and Remote Medicine. Barriers to the maintenance of procedural skills in rural and remote medicine and Factors influencing the relocation of rural proceduralists. In ACRRM Research Projects. Australian College of Rural and Remote Medicine; 2002

  77. Health Workforce Australia: The GP proceduralist (maternity services) workforce in rural Victoria: future demand analysis; 2014.

    Google Scholar 

  78. Bronstein JM. Entrance and exit of obstetrics providers in rural Alabama. J Rural Health. 1992;8:114–20.

    Article  CAS  Google Scholar 

  79. Angle P, Kurtz Landy C, Murthy Y, Cino P. Key issues and barriers to obstetrical anesthesia care in Ontario community hospitals with fewer than 2,000 deliveries annually. Can J Anesth. 2009;56:667–77.

    Article  Google Scholar 

  80. Lew E, Fagnan LJ, Mattek N, Mahler J, Lowe RA. Emergency Department Coverage by Primary Care Physicians in a Rural Practice-Based Research Network: Incentives, Confidence and Training. J Rural Health. 2009;25:189–93.

    Article  Google Scholar 

  81. Iversen L, Farmer JC, Hannaford PC. Workload pressures in rural general practice: a qualitative investigation. Scand J Prim Health Care. 2002;20:139–44.

    Article  Google Scholar 

  82. Tucker J, Hundley V, Kiger A, Bryers H, Caldow J, Farmer J, Harris F, Ireland J, van Teijlingen E. Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training. Qual Saf Health Care. 2005;14:34–40.

    Article  CAS  Google Scholar 

  83. Wiegers TA. General practitioners and their role in maternity care. Health Policy. 2003;66:51.

    Article  CAS  Google Scholar 

  84. Ellis IK, Philip T. Improving the skills of rural and remote generalists to manage mental health emergencies. Rural Remote Health. 2010;10:1503.

    PubMed  Google Scholar 

  85. Senate Community Affairs Committee Secretariat. In: Australia Co, editor. The factors affecting the supply of health services and medical professionals in rural areas. Canberra: Senate Printing Unit, Parliament House; 2012.

    Google Scholar 

  86. Australian College of Rural and Remote Medicine. Training and support for procedural practice in rural and remote medicine: solutions paper: Australian College of Rural and Remote Medicine; 2002.

  87. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Australia. 2006;185:37–8.

    PubMed  Google Scholar 

  88. Mason J. Review of Australian government health workforce programs; 2013.

    Google Scholar 

  89. Rural Doctors Association of Australia: A national advanced rural training program: discussion paper. 2012.

    Google Scholar 

  90. Jong M. President's message: Need for a national rural health strategy. Can J Rural Med. 2007;12:205.

  91. Gordon Chaytors R, Szafran O, Crutcher RA. Rural-Urban and Gender Difference in Procedures Performed by Family Practice Residency Graduates. Fam Med. 2001;33:766–71.

  92. Wootton J. Who will provide secondary care in rural Canada? Can J Rural Med. 2007;12:67.

  93. Miller KJ, Couchie C, Ehman W, Graves L, Grzybowski S, Medves J. Rural maternity care. J Obstet Gynaecol Can. 2012;34:984–1000.

    Article  Google Scholar 

  94. Oberai A, Solomon A, Kassaye E, Kebede B. Learning from our Ethiopian colleagues: operative obstetrics for the generalist. Can J Rural Med. 2014;19:108–10.

    PubMed  Google Scholar 

  95. Howe AC, Mash RJ, Hugo JF. Developing generalism in the South African context. S Afr Med J. 2013;103:899–900.

    Article  Google Scholar 

  96. de Villiers PJT, Editor in Chief,: Family medicine as a new specialty in South Africa. South Afr Fam Pract 2004, 46:3.

  97. Downing J. To the Editor. African Family Medicine. 2008:10.

    Article  Google Scholar 

  98. Matsumoto M, Obayama M, Inoue K, Kajii E. Factors associated with rural doctors’ intention to continue a rural career: a survey of 3072 doctors in Japan. Aust J Rural Health. 2005;13:219–25.

    Article  Google Scholar 

  99. World Health Organizatio. Increasing access to health workers in remote and rural areas through improved retention. In Global policy recommendations. WHO Press: World Health Organization; 2010.

  100. Moore M. Opportunities and challenges for GPs in the developing world. Aust Fam Physician. 2006;35:531–2.

    PubMed  Google Scholar 

  101. Basnyat A. Primary care in a rural set up in Nepal: perspectives of a generalist. J Family Med Prim Care. 2013;2:218–21.

    Article  Google Scholar 

  102. Mavalankar D, Callahan K, Sriram V, Singh P, Desai A. Where there is no anesthetist - increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors. Int J Gynecol Obstet. 2009;107:283–8.

    Article  Google Scholar 

  103. Australian College of Rural and Remote Medicine. Hobart symposium: procedural rural medicine recommendations: ACRRM; 2002.

  104. Australian Medical Association. Position statement: fostering generalism in the medical workforce: AMA; 2012.

  105. Regional Training Networks []. Accessed 2014.

  106. Carson PJ. Providing specialist services in Australia across barriers of distance and culture. World J Surg. 2009;33:1562–7.

    Article  Google Scholar 

  107. Road to Rural GP Program []. Accessed 2016.

  108. Hays RB, Veitch C, Evans RJ. The determinants of quality in procedural rural medical care. Rural Remote Health. 2005;5:473.

    PubMed  Google Scholar 

  109. Health Workforce Australia. Health Workforce 2025 - Doctors, Nurses and Midwives. vol. 1. Australian Government; 2012.

  110. McKenzie A, Beaton N, Hollins J, Jukka C, Hollins A. Advanced rural skills training: are recently qualified GPs using their procedural skills? Rural Remote Health. 2013;13:2159.

  111. Sen Gupta TK, Manahan DL, Lennox DR, Taylor NL. Comment on: Rural Generalism and the Queensland Health pathway--implications for rural clinical supervisors, placements and rural medical education providers... Kitchener S. Rural Generalism and the Queensland Health pathway – implications for rural clinical supervisors, placements and rural medical education providers. (RURAL REMOTE HEALTH), 2013 Apr-Jun; 13 (2): 1-7. Rural & Remote Health. 2013;13:1–2.

    Article  Google Scholar 

  112. Sondergeld S, Nicholas A. Rural Proceduralists: an endangered species. Report of the Queensland rural indemnity study, 1997. Aust J Rural Health. 1998;6:126–31.

    Article  CAS  Google Scholar 

  113. Wainer J. Work of female rural doctors. Aust J Rural Health. 2004;12:49–53.

    Article  Google Scholar 

  114. Avery G, Boyd J, Ruddiman A, Woollard R. Provincial Privileging Standards Project. MBC Medical Journal. 2014;56:326–7.

  115. Baker E, Schmitz D, Epperly T, Nukui A, Moffat Miller C. Rural Idaho family physicians’ scope of practice. J Rural Health. 2010;26:85–9.

    Article  Google Scholar 

  116. Evans DV, Cole AM, Norris TE. Colonoscopy in rural communities: a systematic review of the frequency and quality. Rural Remote Health. 2015;15:3057.

    CAS  PubMed  Google Scholar 

  117. Hutten-Czapski P. Attacking generalism: using numbers when your argument is weak. Can J Rural Med. 2015;20:3–3.

    PubMed  Google Scholar 

  118. Iglesias S, Hutten-Czapski P. Joint position paper on training for rural family practitioners in advanced maternity skills and cesarean section. Can J Rural Health. 1999;4:209–6.

  119. Meyer GS, Cheng EY, Elting J. Differences between generalists and specialists in characteristics of patients receiving gastrointestinal procedures. J Gen Intern Med. 2000;15:188–94.

    Article  CAS  Google Scholar 

  120. Sisler JJ, DeCarolis M, Robinson D, Sivananthan G. Family physicians who have focused practices in oncology: results of a national survey. Can Fam Physician. 2013;59:e290–7.

    PubMed  PubMed Central  Google Scholar 

  121. Wetmore SJ, Rivet C, Tepper J, Tatemichi S, Donoff M, Rainsberry P. Defining core procedure skills for Canadian family medicine training. Can Fam Physician. 2005;51:1364–5.

    PubMed  Google Scholar 

Download references


We would like to acknowledge Professor Jane Farmer and Professor Amanda Kenny for their initial support and advice in the drafting of this Scoping Review.


No funding has been sourced in the development of this research report.

Availability of data and materials

Original articles identified and scoping review materials available from authors on request.

Author information

Authors and Affiliations



NS analysed and interpreted the literature and drafted the manuscript. RE reviewed the included and excluded articles for accuracy. All authors contributed to editing and read and approved the final manuscript.

Corresponding author

Correspondence to Nicholas Schubert.

Ethics declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schubert, N., Evans, R., Battye, K. et al. International approaches to rural generalist medicine: a scoping review. Hum Resour Health 16, 62 (2018).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Rural
  • Remote
  • Medicine
  • Generalism
  • Primary health care