International approaches to rural generalist medicine: a scoping review

Background 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. Methods 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. Results 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. Conclusions 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.


Background
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 multidisciplinary 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.

Methods
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.
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.
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.
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.

Results
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).
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 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 The key findings in each theme are summarised below.

Definition
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                   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, governmentfunded 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 [26-28, 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].

Discussion
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.

Conclusion
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.