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Table 6 Summary of included papers by region

From: International approaches to rural generalist medicine: a scoping review

Author (citation number) Location Year Study design/methods/sample Findings/critique
Asia Pacific
 Basnyat [101] Nepal 2013 Descriptive opinion piece • Outlines main emergency procedures of working in Kalikot District Hospital, including surgery and obstetrics procedures required of the primary care doctors and the resource limitations that they face.
 Matsumoto et al. [98] Japan 2005 Quantitative study—survey • From this survey the only factor relevant to training identified as ‘retention enhancing’ has been family medicine training.
• Authors advocate for an identified rural generalist practitioner training programme with a broad skill base with identified advanced skills (e.g. internal medicine, gastroenterology, general surgery). Obstetrics in rural Japan are however covered by specialists.
 Mavalankar et al. [102] India 2009 Qualitative study—interviews • Shortage of anaesthetists in India—especially in rural areas—and the programme developed to train MOs in LSAS. Highlighted protectionist opposition to the programme.
• 14 surveyed reported the practical training was too short. 5 felt that the training had not sufficiently prepared them. Training programme duration should be extended and that more time spent on practical areas.
 Moore [100] Nepal 2006 Descriptive opinion piece • Overview of critical health needs in Nepal
• Highlights the need for a generalist workforce specific to Nepal, especially in subsistence farmland areas.
Australia/New Zealand
 ACRRM [76] Australia 2002 Literature review and quantitative study—survey • Outlines a decline in the rural procedural workforce and the barriers to practise that have impacted on this decline.
 ACRRM [86] Australia 2002 Position paper • Provides recommendations to address the barriers to procedural practice outlined in the research report.
 ACRRM [25] Australia 2014 Position paper • Identifies key issues, enablers and barriers to establishing streamlined training and education for a career in Rural Generalist Medicine.
• Proposes a national officer position within the Commonwealth Department be established to oversee the integration of national RG pathway. Also has 28 Recommendations for reform to build and support the RG pathway.
 ACRRM [2] Australia 2014 Position paper • Statement with international endorsement of a definition and recommendations for rural generalist medicine. The definition provided involves an integrated model of both primary and secondary care and recommendations are provided under the domains of Recognition, Training Pathways and Research.
 ACRRM, RDAA and ARRWAG [103] Australia 2002 Position paper • Provides recommendations to governments on key rural generalist reform areas.
 AMA [104] Australia 2012 Position paper • Supports enhanced generalist pathways and greater recognition, including RGs.
 AMA [105] Australia 2014 Position paper • Regional Training Networks needed to establish expanded generalist and specialist post graduate training positions in regional/rural areas. At present Rural Generalist and Specialist Training programmes are the only supported programmes addressing regional long-term placement in postgraduate medical training.
 Carson [106] Australia 2009 Descriptive opinion piece • Consider cooperative models of remote (surgical) specialist delivery in the Northern Territory, delivered by appropriately trained generalists in cooperation with and supported by specialists from larger areas.
 Department of Health and Human Services, Tasmania [51] Australia Web link 2016 Programme description • Overview of Tasmanian RG pathway and describes the RMG as ‘a medical practitioner who is trained, mentored and supported on a ‘career superhighway’.
 Department of Health, Victoria [28] Australia 2014 Government report • Provides a definition of a RG and characteristics of the Victorian RG programme.
 Ellis and Philip [84] Australia 2010 Descriptive opinion piece • Describes the need for priority up-skilling generalist clinicians to meet the needs of clients facing mental health emergencies in rural and remote areas.
• Proposes the use of the ‘Mental Health Emergencies’ training programme developed by the Australian Rural Nurses and Midwives based on the success of this programme.
 Glazebrook and Harrison [75] Australia 2006 Literature review • Identifies the barriers to the maintenance of advanced procedural skills for rural generalists.
 Government of South Australia: SA Health [107] Australia Web link 2016 Programme description • Highlights AST training support for GPs in anaesthetics and obstetrics.
 Hays et al. [108] Australia 2005 Qualitative study—interviews • The analysis highlights the differing views between health professionals and rural patients on the quality of care in rural hospitals.
• Patients and families focussed on interpersonal skills whereas health professionals focussed on workforce and technical aspects of care.
• All groups agreed on the need to be able to continue to provide the flexible care and familiar surrounds offered by proceduralists in small rural hospitals.
• This study indicates the ongoing need for rural health professionals to be trained in providing procedural medical care in smaller rural hospitals, despite the developing trend to centralise procedural tasks in larger urban areas.
 Health Education and Training Institute (HETI) [26] Australia Web link 2016 Programme description • Provides definition and overview of the NSW RG pathway.
• Supported advanced skills are anaesthetics, obstetrics and ‘advanced skill set’ (Obstetrics and Emergency Medicine).
 HWA [109] Australia 2012 Government report • Overview of the imbalance in the distribution of the specialist vs generalist medical workforce.
• Identifies concerns about the decline in generalists and impact of rural workforce.
• Also identifies the geographic maldistribution across the total medical specialties including general practice.
 HWA [1] Australia 2013 Government report • Background to the need to focus on supporting the RMG pathway. Reform recommendations across six domains.
 HWA [77] Australia 2014 Quantitative study—survey • Shows that over half GP proceduralists in rural Victoria are not using their procedural skills and 32% plan to retire in the next 5 years. Identifies key barriers to practise.
 Humphreys et al. [67] Australia 2003 Quantitative study—survey • Finds that the proportion of GPs providing complex services increases with increasing rurality or remoteness.
 Jones [65] Australia 2014 Descriptive opinion piece • Posits generalism as the domain of all general practitioners, with the changing role of rural based generalists.
• Outlines training programme for rural generalist of the RACGP.
 Kitchener [50] Australia 2013 Descriptive opinion piece • Overview of the challenges and issues arising from the Queensland RGP and argues for regional training providers to address some of the training issues regarding private and public placements.
 Larkins and Evans [73] Australia 2014 Descriptive opinion piece • Advocates policy support for Rural Generalists.
 Lawrance [39] Australia 2007 Literature review • Questions the use of term ‘rural generalism’ in Australia based on the US model of community based training programmes.
• The main application for the term in Australia, then, is to describe a state government (Qld) hospital role. The author claims this is a government definition for a government purpose.
 Lee [38] Australia 2015 Descriptive opinion piece • Provides an historical account of the evolution of generalism and an overview of the different definitions.
• Supports the development of a definition that embraces the diversity of approaches and settings in generalism and argues that a political approach is needed to revive the generalist profession.
 Manahan et al. [23] Australia 2011 Programme description (conference paper) • Background discussion on QRGP and the outcomes of the research into the advanced skills.
• Also raises the concept of the rural generalist as applicable in other jurisdictions, and perhaps in other disciplines.
 Mason [88] Australia 2013 Government (commissioned) report • Proposes a new rural training pathway to support the training of both rural generalist specialists and rural generalist GPs. The proposed model focusses on a regionally coordinated programme from undergraduate through to fellowship.
 McKenzie et al. [110] Australia 2013 Quantitative study—survey • Overall this study of outcomes from advanced rural skills training in Qld has shown that the majority of GPs and Rural Generalists are using their advanced procedural and non-procedural skills but also that there is room for improvement.
• Unlikely that this study is not representative of results of other states and territories.
 Murdoch and Denz-Penhey [74] Australia 2007 Descriptive opinion piece • Argues that main rural medical workforce has to be made up of contextually trained rural generalists.
• Supports an academic discipline of rural and remote medicine supported through medical school, postgraduate councils and colleges
• Needs to be an increased training focus on rural medical generalists from rural student recruitment to established rural career, via undergraduate education, rural pre-vocational postings, and vocational and continuing education.
 Murray and Wronski [87] Australia 2006 Descriptive opinion piece • Describes the need to increase the medical generalist training to develop a workforce that can provide primary and secondary care.
 Nixon et al. [58] New Zealand 2007 Descriptive opinion piece • Describes moves in NZ to establish a professional body for rural hospital generalist doctors and to recognise the role as a scope of practice.
 Northern Territory Government Department of Health [27] Australia 2016 Programme description • Definition of RG—similar to Qld.
• RG pathway offers guaranteed training places, priority rotations and structured mentoring, supervision and support.
• ASTs are anaesthetics, obstetrics and emergency medicine.
• ASTs under development are Internal Medicine, Surgery and Paediatrics.
 Nova Public Policy Pty Ltd. [8] Australia 2010 Government (commissioned) Report • Examines whether the QRGP could potentially be expanded nationally.
• The conclusion reached is that there are some core principles to the programme that could be adopted in all jurisdictions.
• Includes a broad international literature scan.
 Pashen et al. [42] Australia 2007 Systematic review • Comprehensive research study into a range of key components of rural generalism, including:
• Definitions
• Scopes of practice
• Workforce supply
• Education and training
• Procedural skills
• Funding
• Safety and quality
• Service provision models
• Legislation
• Clinical privileging
 Pereria [57] Australia 2010 Descriptive opinion piece • Dr identifying as a Rural Generalist and the advanced skills practised (general anaesthesia, obstetrics, including forcep and caesarean sections, and in-patient and emergency care).
 Queensland Health [24] Australia 2016 Programme description • QRGP overview. Aims to provide medical graduates with a supported training pathway to a career in rural medicine and rural and remote communities with a medical workforce.
• Defines the RG and lists what the QRGP offers in terms of supported training and quarantined places.
• Links to further details including background and the application process.
 Queensland Health (Ernst and Young) [49] Australia 2013 Government report • Evaluation of the QRGP.
• The study presents the strengths and criticisms of the QRGP to date and a cost analysis base on a return on investment model.
 RDAA [89] Australia 2012 Position paper • Proposes a National Advanced Rural Training Program with a strong focus on principles underpinning a national approach to supporting rural generalist training.
 Rural Health West [52] Australia 2015 Quantitative and Qualitative study—surveys and interviews • The capacity to practise procedural skills was the 4th highest influence on going rural. However, concerns about workload was also a negative factor about going rural.
• Doctors recognised recent efforts to develop a rural generalist pathway but there was a general lack of awareness as to when and how the WA rural generalist practice pathway will be implemented.
 Senate Community Affairs Committee Secretariat [85] Australia 2012 Government report • Examines factors affecting the supply and distribution of health services and medical professionals in rural areas. The Senate Committee stated their strong support for the Queensland RGP and recommends expansion of RG pathways.
 Sen Gupta et al. [111] Australia 2013 Descriptive opinion piece • Responds to the Kitchener article on the QRGP
• Acknowledges unintended consequences for the ‘equilibrium’ in the private sector but argues that 34 of 111 trainees in year 3 or beyond are concurrently or wholly in private practice, the same proportion as the 30% reported in 2011.
 Sen Gupta et al. [48] Australia 2013 Programme Description • Definition provided of rural generalist as an extended medical generalist.
• Background provided to Queensland programme.
• Queensland pathway characterised by both training and employment reform.
 Sondergeld and Nicholas [112] Australia 1998 Quantitative and qualitative study—survey and interviews • Indicates a clear relationship between rural GPs ceasing procedural work and the level of their indemnity premium (a barrier of the time of writing).
 Stratigos and Nichols [4] Australia 2002 Position paper • Reforms priorities for the rural generalist workforce in:
1. Training
2. Indemnity
3. Local facilities and equipment
4. Social and financial issues
5. Retention
6. Continuing Medical Education and Upskilling
• There is no evidence that outreach programmes provide a viable alternative to local procedural practice and therefore can only act as a supplementary workforce. Continuity of care is a key reason for this.
 Tolhurst et al. [70] Australia 2006 Qualitative study—interviews • Explores factors influencing urban background medical students’ interest in rural practice.
• One of the ‘work preference’ results indicated the ability to undertake procedural work in hospitals as well as provide primary GP care as an influencing factor.
 Wainer [113] Australia 2004 Quantitative study—survey • Women make up less than a quarter of the rural general practice workforce and an even smaller percentage of the specialist rural medical workforce. Their experiences are not well articulated in research and policy on rural medical practice.
• The incoming cohort of rural general practitioners has a majority of women.
• Recommendations include linking female medical students with female rural doctors, matching trainees with female mentors, adequate skill development in areas important to rural practice, and ensuring a career path in rural practice.
 Worley et al. [41] Australia 2000 Qualitative study—interviews • Overview of the Parallel Rural Community Curriculum (PRCC).
• PRCC affirmed the potential role of true generalist physicians in undergraduate medical education.
• The students developed a high level of competence in procedural skills and an increased confidence with patients.
North America
 Angle et al. [79] Canada 2009 Qualitative study—secondary analysis of qualitative data • Explored barriers experienced by physicians in providing obstetrical anaesthesia care in Ontario community hospitals that experience low volume deliveries per year.
• Difficulties were greatest for FP/GP anaesthetists in rural communities due to lack of locums, the need for relevant CME, and worsening physician shortages threatening the provision of services in some rural hospitals.
• Need for increased numbers of FP/GP anaesthetists and the development of formal funded networks for knowledge transfer between academic and community hospitals as means of providing supports.
 Aubrey-Bassler et al. [68] Canada 2007 Quantitative data analysis • Authors concluded that these GPs performed caesarean sections with an acceptable degree of safety compared with specialists.
 Avery et al. [114] Canada 2014 Descriptive opinion piece • The authors express their concern about the Privileging Standards Project and the methodology involved in the project to establish a minimum number of procedures to maintain currency.
• The unintended consequence of this project could be the departure of rural generalists with skills from British Columbia with advanced skills in surgery, anaesthesia, emergency, and maternity care.
 Baker et al. [115] USA 2010 Quantitative study—survey • Results identified a broad range of advanced skills practised by rural Family Practitioners in Idaho including obstetrics, Colonoscopy, Emergency room coverage and mental health services.
 Bronstein [78] USA 1992 Quantitative study—survey and data analysis • This analysis distinguishes between counties with larger populations and counties with smaller populations.
• Rural generalist physicians were more likely than rural specialists to have at least two of the components required to maintain obstetrics services. However more of these physicians than any other group left obstetrics over this period.
• Specialists entered markets where generalists used to practise, driving the generalists to more rural areas or out of obstetrics practice altogether.
 Crutcher et al. [44] Canada 2005 Quantitative study—survey • This study examines where Canadian family medicine graduates learned to do the procedures they perform. The findings reinforce the important role that medical schools and residency training programmes play in teaching procedural skills to family medicine residents.
• They also show that rural family physicians perform a greater volume of procedures than those in urban practices.
 De Klerk [18] Canada 2013 Descriptive opinion piece • Generalism has given way to medical specialisation in Canada (and many other countries) over the past 60 years and this does not serve the dispersed Canadian population well.
• The Society of Rural Physicians is advocating for a countrywide rural curriculum in medical schools to produce a well-trained doctor with the necessary knowledge and skills to pursue a career in rural medicine.
 De Klerk [31] Canada 2014 Descriptive opinion piece • Describes the recommendations of the Cairns Consensus Statement from the First World Summit on Rural Generalist Medicine.
• Rural generalist medicine embraces the Triple C principles of The College of Family Physicians of Canada: competency-based curriculum of comprehensive care, focused on continuity of education and patient care, and centred in family medicine.
 Evans et al. [116] USA 2015 Systematic review • Review of studies of rural colonoscopy to determine speciality types providing rural colonoscopy and the quality of these procedures.
• Concludes that rural generalist physicians can safely and effectively perform colonoscopies.
 Geyman et al. [60] USA 2000 Literature review • This review was performed to discover what has been learned from various initiatives taken by pre-doctoral and graduate medical education programmes to encourage choice and preparation for rural medical practice.
• Family practice the predominant speciality upon which small rural health systems need to be based.
• Rural physicians need to have procedural skills in emergency medicine, surgery, obstetrics and perhaps anaesthesia; be skilled in community medicine, have computer and business skills; and also be attuned to team and group practice.
 Gordon Chaytors et al. [91] Canada 2001 Quantitative study—survey • More family practice graduates in rural areas performing almost all types of obstetrical care
• Relatively more female than male family physicians, regardless of practice location, provide obstetrical care, including obstetrical procedures.
• Recommends that curriculum for the training of Family Practitioners that intend to go rural should include more procedural and obstetric care.
 Gutkin [56] Canada 2012 Descriptive opinion piece • Canadian Family Physician College (CFPC) decision in 2008 to approve Family Physician with Special Interest or Focused Practice (SIFP) to accredit enhanced skills that meet the Triple C curriculum standards.
• The need for SIFP was particularly relevant to rural family physicians with a strong need to meet needs of their communities.
 Hart [17] USA 2000 Quantitative analysis and literature review (conference paper) • Focus on the supply, distribution and training of generalists into rural areas, with mention of the importance of advanced skills training in developing rural generalists equipped to undertake the range of care required.
• Also looks at current programmes aimed at producing a rural medical workforce and concludes that the current attempts to ensure an adequate supply of providers in underserved areas is proving problematic.
 Hutten-Czapski [69] Canada 1998 Descriptive opinion piece • Describes some of political activity around rural obstetrics in Canada as provided by family physicians, despite increasing evidence of safe outcomes.
 Hutten-Czapski [117] Canada 2015 Descriptive opinion piece • Argues that using statistics to support any argument that low volume obstetric care in rural areas provided by generalists equates to low quality is not supported by research.
• Low-volume obstetrics has been found to be at least as safe as obstetrics practiced in big centres.
 Iglesias and Hutten-Czapski [118] Canada 1999 Descriptive opinion piece, including a literature review • Advocates for an integrated advanced maternity care training programme for rural family physicians as a way of continuing to provide rural services in Canada in a time of a rapid decline in the availability of rural maternity services.
 Imrie et al. [6] Canada 2011 Literature review • In recent years some family physicians have integrated additional competencies into the development of focused practices in family medicine, including areas such as emergency medicine, palliative care, elder care and rural care.
• It is also stated that generalism is not just a rural and remote practice but that it is important also in urban settings.
 Inglis [53] Canada 1995 Descriptive opinion piece • Describes the work being undertaken by a collaboration between Colleges to develop an agreed set of guidelines for the provision of surgical services delivered by GPs in rural areas. The guidelines were intended to enable the development of a training curriculum for rural surgery for GPs.
 Jong [90] Canada 2007 Descriptive opinion piece • Small communities in Canada cannot sustain narrowly focused specialists. Instead more generalists and more rural doctors with broad and enhanced skills are required. Commitment was made in 2007 by the Canadian Medical Association to address the scarcity of generalist FP/GPs and generalist specialists and to improve access to enhanced skill sets training.
 Kornelsen et al. [66] Canada 2013 Qualitative study—interviews • One of the solutions to doctor shortages in rural Canada is to promote the use of general practitioner surgeons (GPS). This is under threat however due to the due to the lack of interprofessional support garnered in education and practice.
• Interprofessional conflict with professional boundary issues between surgeons and GPSs has prevented the increased update of the GPS role in rural Canada.
• For populations of 5000–15 000, surgical services are provided locally by one or more GPS. For populations of 15 000–25 000, there is usually a specialist surgeon supported by one or more GPS (‘mixed’ model).
 Lew et al. [80] USA 2009 Quantitative study—survey • In rural areas EDs are often staffed by primary care physicians, rather than emergency medicine trained specialists.
• More than one third of the respondent physicians currently covering the ED reported that they derive greater than 40% of their income from working in it.
• Respondents covering ED expressed low confidence in dealing with paediatric emergencies and highlighted a need for more training in this area.
 Lockyer and Norton [54] Canada 2005 Descriptive opinion piece • The authors document the process involved in creating a collaborative, intersectoral approach to developing the Standards for Accreditation of Residency Training Programs arising from the need to resolve the FPA immediate needs but also has application to the support and development of FP Surgeons and FP Obstetricians across rural Canada.
 MacLellan [30] Canada 2006 Descriptive opinion piece • Provides a view of the rural generalist as constantly moving along the spectrum between specialisation and integration.
• Argues that rural Canada needs the generalist with defined competencies, constantly fluctuating between the primary, secondary and tertiary levels of care.
 Maudlin and Newkirk [46] USA 2010 Descriptive opinion piece • Overview of Family Medicine Spokane (FMS, established as a collaborative effort by the University of Washington School of Medicine (UWSOM), four Eastern Washington community hospitals in Spokane, and the Spokane County Medical Society.
• Of the 235 graduates of the FMS, 49% practice rurally (defined as a community of less than 25 000 population located more than 25 miles from a town larger than 25 000).
• To increase the number of graduates going rural, the FMS Rural Training Track (FMSRTT) in Colville, was approved as an ‘experimental pathway’ of FMS.
• Of the 35 graduates of the FMSRTT, 77% practice in rural communities.
 Meyer et al. [119] USA 2000 Quantitative data analysis • Generalists were more likely to have performed a simple diagnostic procedure, perform the procedure for diagnostic and screening purposes and perform them in rural areas.
• Generalists often perform less complex gastrointestinal endoscopies.
 Miller et al. [93] Canada 2012 Position paper and a literature review • Provides an overview of current information on issues in maternity care relevant to rural populations.
• Importance of collaborative practice models in rural and remote maternity care, including GP surgeons (with obstetrics) and GP anaesthetists, with support from enhanced roles for nurses and nurse practitioners.
• Recommendations include expanding advanced skills training, including in caesarean section and obstetrical anaesthesia services for family physicians.
 Oberai et al. [94] Canada 2014 Descriptive opinion piece • In rural Canada, family physicians are the main providers of maternity care.
• However, fewer Canadian generalists are skilled in advanced maternity care. There has been a high rate of attrition among physicians who provide maternity care in rural areas.
• If rural maternity care is to continue in Canada, rural practitioners will need training in advanced maternity care.
 Ramsey et al. [45] USA 2001 Descriptive opinion piece • Evolution of the University of Washington School of Medicine (UWSOM) to increase generalist physicians in the region with an emphasis on rural practice.
• Known as the WAMI programme after the first 4 participating states (Washington, Alaska, Montana and Idaho) and also now includes Wyoming. The WAMI programme is a rural training pipeline from undergraduate to residency with an emphasis on community practice training, including the Family Medicine Spokane (FMS) residency programme.
 Rivet et al. [71] Canada 2007 Quantitative study—secondary analysis of a population survey • The range of procedures done by family physicians was significantly linked to job satisfaction. The larger the range of procedures, the more satisfied the physician. Rural physicians were also more satisfied than urban.
 Sisler et al. [120] Canada 2013 Quantitative study—survey • Overview of GP Oncologists.
• Whist this is not a strictly rural vocation, the role of FPs with focused practices is particularly critical in rural Canada.
 Soles [59] Canada 2015 Descriptive opinion piece • Highlights the move away from generalism and its impact on rural communities in Canada.
• Supports the principles of rural generalism in the Cairns Consensus Statement in addressing rural community need.
 Thompson and Iglesias [55] Canada 1998 Descriptive opinion piece • Describes a proposed model of shared skill sets for the teaching and evaluation of rural generalist physicians with advanced skills.
• Also raises the possibility of the establishment of a college for rural medicine in Canada as a way of preparing rural generalists with the advanced skills needed in rural areas.
• Describes the need for FPs to identify skills set needed for RG advanced scopes of practice. Areas where some work has been done includes O&G and Anaesthetics. More needs to be done on areas of general \surgery and endoscopy.
 Urbina et al. [72] USA 1994 Descriptive opinion piece • The authors discuss both the problem and various existing innovative strategies to prepare a generalist medical workforce (in family practice, internal medicine and paediatrics) with a strong focus on rural.
• This article also describes the subspeciality domination of hospital based graduate medical education and the impact of that on generalist training.
 Wetmore et al. [121] Canada 2005 Quantitative study—survey • The objective of this study was to create a list of core and enhanced procedures suitable for family medicine training.
• Sixty-five core procedures and 15 enhanced procedures were identified.
 Williams [32] USA 1998 Quantitative data analysis • Rural generalist family physician practices require different skills, are faster paced and demand more time and must deal with higher burdens of illness compared with urban practices. The higher level of hospital intensive care and obstetrical privileges and greater use of procedures by rural family physicians support these observations.
• The rural family physician workforce however has continued to decline, whilst the urban rates increased.
 Wootton [92] Canada 2007 Descriptive opinion piece • Rural physicians should be able to provide the required secondary care and also primary care in rural areas. At present, primary care is treated in education and training programmes as the main focus and this makes the advanced skills training an ad hoc add on.
Africa
 De Villiers [96] South Africa 2004 Descriptive opinion piece • Circumstances in South Africa call for a well-trained generalist that also includes practical/procedural clinical skills regarded by some as the domain of other specialties. The FP should be positioned as the key professional in the District Health System.
 Downing [97] Kenya 2008 Descriptive opinion piece • Family medicine cannot just be primary care providers and the priority for physicians in Kenya is on being good generalists—which requires not only inpatient care but practising emergency surgery.
 Ellis [63] Tristan da Cunha 2008 Descriptive opinion piece • Examples of practice and skills requirements provides insight into the scopes of practice required of a rural generalist in remote areas (Tristan da Cunha).
 Hill [64] South Africa 1995 Descriptive opinion piece • Describes the procedural activity in the town of Kokstad—a town of 25 000 people.
• Argues that primary care is not enough to attract new doctors and in state based hospitals, they need to have additional procedural skills, which makes the role more attractive.
• Hill proposes more structured secondary care training programmes for generalists in procedural skills as in Australia and Canada.
 Howe et al. [95] South Africa 2013 Descriptive opinion piece • The authors argue that expert family physician generalists are required to support primary health care as well as to provide care at the district hospital.
• District hospitals, especially in rural areas, require family physicians with an extended range of skills in hospital care.
• The challenge therefore for family medicine training programmes is to maximise the number of future family physicians and to re-orientate and ‘up skill’ the existing doctors for their new roles in a reengineered primary care.
 Levack and Levack [5] Tristan da Cunha 2013 Descriptive opinion piece • Focus on the health workforce needs of a remote island, Tristan da Cunha.
 Monjok et al. [13] Nigeria 2010 Descriptive opinion piece • Proposes a short obstetric-training programme for generalist medical officers to increase the number of skilled birth attendants in both rural and peripheral health facilities in Nigeria.
 Philpott et al. [12] Ethiopia 2014 Descriptive opinion piece • Ethiopia’s first training programme in family medicine was launched on February 4, 2013, at the Addis Ababa University, College of Health Sciences, School of Medicine. GPs have been an important part of the health system for decades but until now there has been no postgraduate training programme for generalist physicians. The family medicine programme aims to provide such training, so that its graduates will be highly skilled comprehensive-care doctors for urban and rural areas of Ethiopia who choose generalism as a lifelong career choice.
• Family physicians working in rural areas may act as consultants to other health care workers, may have greater community and public health roles, and will be able to provide emergency surgical and obstetrical services.
 Reid et al. [62] South Africa 1999 Quantitative data analysis and qualitative study—interviews (focus groups) • Defines the role and scope of the rural generalist in South Africa as extremely wide and is often called upon to perform clinical activities ranging from primary care to emergency surgical procedures, as well as leadership roles.
• Training in South Africa needs to capture the specific skills of the generalist and when the rural generalist needs to refer on for specialist care.
• Indicates the need for well-planned support strategies for doctors in rural hospitals at a distance from specialist support.
 Reid et al. [61] Africa 2011 Qualitative study—interviews • In Sub-Saharan Africa family physicians and generalist medical officers are likely to need more surgical, anaesthetic and procedural skills to provide services at the district hospital, as well as skills in consulting, mentoring and teaching to support the front line primary care workers.
• Curricula should ensure that clinical training is sufficiently comprehensive to ensure competency across a broad range of diagnoses and procedures.
 Thigiti et al. [47] Kenya 2011 Programme description (conference paper) • Overview of the Kenyan Moi University Master of Family Medicine Training Program, which aimed to address the lack of generalists in Kenya and prepares family physicians for their role as Superintendents in peripheral hospitals or as District Medical Officers.
• This programme is increasing access to health care, especially for rural and poor underserved communities and is expanding into Uganda and Rwanda.
Europe
 Boerma et al. [22] Europe 1998 Quantitative study—survey • Procedural tasks were greater for rural GPs and for those practising at greater distance from the nearest hospital. However this was only true of western European countries and where the GP was self-employed.
• The authors also identify studies that further show that in the United Kingdom and Netherlands, rural GPs undertake more procedures than their urban counterparts.
 Iversen et al. [81] United Kingdom 2002 Qualitative study—interviews • Pressures of rural GPs having to deal with anything and everything (such as minor surgery, accident and emergency work and dispensing), due to small practice teams and considerable distance from general hospital services
 Tucker et al. [82] Scotland 2005 Quantitative and qualitative study—survey and interviews • Medical workforce issues and falling birth rates are driving centralisation of acute obstetric and neonatal services in the United Kingdom, further limiting geographical access for remote and rural populations. Some general practitioners in this study noted that, because they no longer obtained much obstetric experience, any intrapartum care in community settings was increasingly undertaken by midwives.
 Wiegers [83] Europe 2003 Descriptive opinion piece • In Europe the role of GPs or Family physicians in obstetrics has been in steady decline and do not get involved in high-risk obstetrical care at all.
International
 WHO [99] International paper 2010 Position paper • There is evidence to show that enhanced scopes of practice leads to increased job satisfaction. This resulted in recommendation B1: Introduce and regulate enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction, thereby assisting recruitment and retention.
• Advanced procedural skills training can enhance the confidence of family medicine residents in rural areas and improve their competence.