Remote and Rural Medicine (18 Nov 2024)

SPEAKER_01 0:00

Welcome to the Royal College of Physicians Edinburgh Clinical Conversations podcast. Each episode within this podcast series we delve into a different medical topic with an expert speaker to join us. If you want to find more about the Royal College, then please do head over to the RCPE website and have a look at the education stream and see if membership would work for you. It offers a host of educational updates and activities such as the evening medical updates, the Royal College Symposium, and many more. Please don't forget, if you listen to our podcast, to give us a rating on one of the podcast platforms or subscribe so that it can come directly into your podcast stream.

SPEAKER_00 0:42

On Friday, the 24th of January, we'll hold our medical trainees conference at the College in Edinburgh. You can also join online. Organised by the RCPE Trainees and Members Committee, the conference is free for RCPE collegiate, associate and student and foundation members. We'll cover managing medical emergencies, think about cases that have changed our practice, move on to navigating complexity and ambulatory care, and finish with clinical lessons. We'd love to see you there. Book now on the RCPE website.

SPEAKER_02 1:31

My name is Dr. Marilena Gianudi and I am on the Trainee and Members Committee. You will have noticed that today's episode is from both podcast channels, Clinical and Career Conversations, because we have Dr. Neil Shepherd with us, who is a rural emergency physician in Caithness, a locum GP in Orkney, and the training programme director for broad-based training in Scotland. And this episode is going to be on rural medicine. So we don't want to limit you to just either career or clinical conversations. We're going to do a bit of both. So Dr. Shepherd, good morning and welcome. Thank you for joining me. So I think the best place for us to start is by you explaining to our listeners what rural medicine is.

SPEAKER_03 2:17

Yeah, that's a good question. I've found it quite hard to get a good definition of rural medicine from my quick Googling before today. I guess I'd describe it as provision of healthcare in areas that are far from the major centres that we think of. But it can be quite a wide ranging areas in what rural medicine actually is. So that could be district general hospitals in some rural places like the borders in Scotland, rural general hospitals. I work in a rural general hospital. There's six of them in Scotland. They're in Orkney, Shetland, the West Niles, Caithness, where I am, Open and Fort William. And then you get more out there rural medicine. There's lots of outlying islands in Scotland in particular where there's a population of six or seven hundred people with one GP. And that GP is there 24-7, providing all the general practice, but then all the emergency care, there's no ambulance crews on these islands, so they go out to everything as the GP and then transfer people off as required. So you certainly get different levels of rural medicine and different levels of isolation. I have a wee bit of experience in most of them. Hopefully we can share the common challenges across some and how we address them and how we staff them and how we train to work in these areas. The rural general hospitals are broadly the same. The staffings are different slightly depending on the historical basis of how they've been there and their individual staffing challenges. So I work in Caithness General Hospital, which is in WIC, so that's where the local hospital for John O'Groats are about 20 miles away from the far northeast tip of the UK. We cover 30,000 people. We're the same size as a large general practice essentially, but we provide all the hospital required care that we can in that area. So it's a small hospital. We've only got two wards. We've got an acute receiving ward that takes a mix of surgical and medical patients. We've got an AE, we've got a theatre which does daycase theater stuff mainly. We've got an endoscopy suite. And we try our best to keep people local at home when they can. We're as specialised as we need to be as local as we can be just to keep people home and treat them as well as we can.

SPEAKER_02 4:23

Regarding the different types of rural medicine that you mentioned before, how do they differ between themselves? Like how can one prepare to work in such isolated conditions?

SPEAKER_03 4:34

Good question. The generalism is the key thing. So you need to be able to do a decent level of work and clinical acumen for most things while accepting that you're not going to have the same level of input as a specialist would. So to work in these hospitals, most doctors there have actually just followed the standard career pathway and then ended up moving to a rural area and working there. So we have a team of physicians who are actually based in Inverness. Most of our physicians they rotate up on a weekly basis to provide cover to the wards and to participate in the on-call and do the acute take. So these doctors have all just completed training in larger centres in a reasonable-sized district general hospital and then rotates through to come see us and to come work with us. There's other physicians who are based there full-time and their jobs are predominantly rural medicine entirely. And again, they've usually completed a standard training pathway and then moved to the area. It's helpful to have a general background, so acute medics and geriatrics is something that you can apply your hand to most patients. More recently, there's been a big push to help support these areas because staffing is so difficult. You can imagine how difficult it is to recruit to popular places to live like Edinburgh and Glasgow unfilled posts there. There's even more difficulty filling these places where it's quite a challenging place to live. There's quite a lot of isolation, so we have to make the jobs as appealing as possible, whether that be through creative job planning or extra training opportunities, and then we need to support them and help them stay there. One of the excellent new training resources is just launched GMC accreditation in remote and rural acute care. And the first six or seven doctors have just completed that this month. We would expect over the next few years that will get rolled out, and more and more doctors will complete that pathway and get accreditation in providing remote and rural urgent care. It's a program that's mainly open to GEP and career-grade doctors like staff and specialty grades, although consultants can complete it as well. And it's basically designed to give evidence that the doctor who's completed it is able to work in a rural environment, seeing a wide variety of cases, including acute medical take, but also trauma, pediatrics, hubs and guiny, ENT emergencies, the common stuff that you would expect to see in any hospital, but you need to be able to deal with independently without calling a specialist help, as there isn't any in most cases in the rural areas.

SPEAKER_02 6:53

How does that training differ from your typical GP training then? Is it longer so that you have more time to become independent in these, or do you have more rotations? What's the difference?

SPEAKER_03 7:04

The standard GP pathway is three years post-FY2, and the remote and rural track GP training is the same. It's still three years post-FY2. Although for a GP to be appointed to work in these hospital generalist roles, you would need to do more training beyond that. There's a few options. Some doctors who enter the working of the hospital route as a GP have often completed many years in another specialty. For example, if someone's been a medical registrar for several years and switches to GP training, they've got an excellent skill set and they'd be able to slot in pretty easily into the roles. Alternatively, if they've got less experience in the hospital background, there's a GP Rural Fellowship in Scotland, which is based in some of the smaller rural general hospitals. And that's for people with a CCT in general practice who need to increase their skills and knowledge in certain hospital-based areas. And that's a year-long programme. The new accreditation pathway is designed to complement that. So during the fellowship, we'd be expected to gain sign-off in managing various medical emergencies, surgical emergencies, etc. And then you could hopefully get accreditation approved at the end of that fellowship. So you can bolt on fellowships on top of your CCT at the end of general practice training. There's one way to get into it, if you wanted to put it from a GP perspective. You could also do that from a physician perspective. There's a new push in NHS Highland in particular to train physicians to work not only in the district general hospitals but also in the rural general hospitals. In Inverness I put a lot of effort into creating training programmes which enable the trainees to stay in NHS Highland for the vast majority of their training and also provide them the skills to work in isolation in these smaller hospitals so that when they see CT they can spend some of their time in Inverness in the larger site and then rotate to the smaller hospitals to provide consulting cover there. And they're excellent because they've got that link, they can get them transferred very quickly, they know how the systems work. They've got the excellent links with the larger hospital sites. So if somebody's complicated, they know who to phone, they know if you some call for endocrine or for urology or whatever, and they know the pathways to get that sorted, and they're phoning their friends who they work with regularly. So our rotational modeling works very well. Physicians are out for a week as part of their rotation from the larger site, they can easily interact with the specialist in mode to assistant sites and gain advice. And if they're sick enough to require transfer, they know where they're going, they can understand how to get there as efficiently as possible.

SPEAKER_02 9:13

How do you deal with the uncertainty and the lack, I guess, of having a big team around you when you are working in these remote sites, even if it's not, you know, in one of the rural hospitals that you mentioned, but when you're a GP on one of the remote islands, how can you do that? I can't imagine going to work without knowing there's a big team around me, and if I have a problem, I can ask for help straight away.

SPEAKER_03 9:38

How do you trade for that? That's a good question. You take the opportunity to learn as much as you can before you do it. So there's other support courses for GPs in this role. There's Basic Scotland in Scotland who provide a pre-hospital emergency care course, a two or three-day course, which most GPs working in these rural areas will do and they'll do regularly, not only to maintain the skills in managing acute problems, but also to network with other rural clinicians. And they're provided with an emergency bag, completion of that, a sandpiper bag, which is funded through a charity, the Sandpiper Trust, that provides them with the kit they need to manage emergencies while they're waiting for, for example, an air ambulance to come and retrieve the patient. It also takes a certain type of person, I think, to work in these roles, you need to be comfortable managing uncertainty. You know, for the rural island GPs, it'll take them a couple of days to get a blood result back in some cases, because they've got to put the bloods on a boat and the way they go, and then they get the result the next day. You've got to be comfortable managing uncertainty and confident in your clinical acumen, your basic examination and your history that you're lacking the results and the investigations to confirm diagnosis, at least in the immediate term. We try our best to support each other. There's a system that was become in Orkney. Amongst all the rural island GPs, they have a weekly meeting on teams. They'll catch up and discuss challenging cases and write peer support. Although you're isolated, you're aware there's other people in the same boat on their island, and you can share learning and knowledge and difficult cases if you need to. Also, there's a monthly meeting of all the rural general hospitals where we also share interesting cases as a ground round, you know, two small hospitals have a ground round individually, but we all dial into one. And again, it's nice to hear that other places have the same problems with the same logistics and transfers and pediatrics, you know, if there's no pediatrician. And we can share learning and tips and ideas on how to manage these patients with the lack of resources or the less resources that we have.

SPEAKER_02 11:20

Speaking of resources, what are the things that you feel or that you've noticed that you don't have access to, which in an ideal world you would want to have access to?

SPEAKER_03 11:33

In an ideal world, we want everything, don't we? To give Caithness as an example of where I work. We have X-ray, we've got CDE, we've got ultrasound in hours, and we've got a lab which can do all the basic lab tests on site. Things like TSH and HBO and Cs get sent away, but you can get a good set of blood and extra investigations at the time. The big problem we have is staffing these departments and the rotor for them is very much not a full shift, it's an on-call service. So nine to five, Monday to Friday, you can get an X-ray, you can get CT, you can get some blood tests done without any bother. After 5 pm and all through the weekend, the lab service and the radiographers are on call from home and you've got to call them in. So if you have somebody who presents acutely short of breath or with an acute stroke, you can be waiting up to an hour to get an X-ray or CT done. Same with trauma. And that's the one thing that we find very tricky. And the other thing that you need to be aware of is if you call the radiographer in at two in the morning, they get six hours off the next day as part of their contract or four hours off. Calling them in at two in the morning when you don't need them means they have to cancel their ultrasound lifts they're doing the next day. So you're very much aware of the limited resources. You have to balance the impact of calling them in as of hours with the requirement of you provide effective and safe care. Quite rightly, the standards that we're judged by are the standards that anyone else in the larger house world's judged by, and we can't misdiagnose a CCF as a pneumonia because we didn't call X-ray. It's really tricky to get that level of when you should call people in, when you shouldn't, and what you can do in the meantime. We're trying to learn point-of-care ultrasound, I think that'll be incredibly useful in these kinds of situations, especially when you're waiting for the sonographer or the bicycle or ever to come in. Problem with that is you need somebody to train you. And if there's no one on site to train you, you'll have to go wait to train and then roll that out. So that's something we're working on. I've just done the fousick heart echocardiography qualification, so I'm hoping that once I've been scanning for a bit, I can then start rolling that out to others. Get some scans done while we're waiting for the Allied Health to come in. Echo's the other thing, actually. That's one of the reasons I did it. We have a visiting synograph for service. They used to come up two days every three weeks. They now come up a bit more often. So you'd end up with patients who haven't probably got heart failure, but you can't get Echo to diagnose them. It's the limited resources which really makes it challenging. You've got to rely a bit more on your clinical skills and also on the tests you have available. We can get a BNP, but it takes two days.

SPEAKER_02 13:52

But I guess in a way, that's good for actually building your clinical skills and working on your differential diagnoses because whilst I appreciate the limitations that working like that gives, I think we almost can sometimes practice in too much of a defensive manner where we don't dare treat anything until we have the diagnosis and we run, you know, five or ten different tests. Whereas actually if we go back down to the basics, then you're taking the history, you're examining the patient, and most of the time that will help.

SPEAKER_03 14:23

I guess you need to commit a bit sooner. Especially if someone's sick, you can't wait for their test to come back because he might be waiting, you know, they'll they'll be getting worse as you're watching them, waiting for X-ray to come in. Perhaps you're a bit more careful with your examination if you know it's going to take a long time for a test to come in and confirm it. Equally, the one challenge, especially in that regard, is for our junior doctors. So in the night shift, they're in the hospital on their own. They're the only member of the medical team in the hospital covering the emergency department and the wards. And they're often a level, maybe FY3, FY4, so they've finished their FY training there a couple of years after that at GP trainees or clinical development fellows, and we don't have a middle grade tier rotor. There's no ST3 or above. So we've got these relatively inexperienced doctors on their own in the hospital with limited investigations available to them. And the vast majority of them really enjoy it. It sounds incredibly daunting, and it is when they start, but they find that they learn to make decisions, they learn to be careful with their examinations, to be thorough. They also learn when to phone for help. We've got a much lower threshold for them phoning us or on call to get advice and support than other sites. One of the challenges with rural medicine is the senior tier rotor get interrupted quite frequently when they're on call. You don't have an ST7 on site to cover up all the medical challenges for that the junior doctors put up so the senior doctor tier have more frequent interruptions to support junior doctors that things are safe and also to help them learn and develop their clinical acumen and their decision-making abilities. And I think a rural rotation is the perfect place to do that. I would encourage anyone who wants to improve their decision-making skills to come to a rural site and work in rural medicine. We often get very good feedback from our trainees in particular for the clinical skills that they learn and the decision-making abilities they pick up.

SPEAKER_02 16:02

Rural medicine, I appreciate geography makes a big difference to be able to be classed as rural medicine, but are there any other areas of the UK that would have a similar training pathway as you do up in Scotland, or is that limited just to Scotland?

SPEAKER_03 16:18

The new accreditation that's come out from the GMC is run by NHS Education for Scotland, although it's a GMC accreditation, so you can do it anywhere. There's a doctor in Cumbria, Dr. Stuart Maitland Nib, who's the lead of the University Department of Remote and Rural Medicine at the University of Lancashire in Northern England, has also been awarded the accreditation. So there is a very strong rural medicine community in that part of England. There's large areas of rural Wales where there's doctors working well beyond the scope of their original training with limited resources. And Northern Ireland too.Anywhere where you're I guess you're more than an hour's drive from your local District General Hospital, there'll be clinicians who are working with limited resources and more geographical isolation. And I guess the further away you go, the harder the job gets or the more challenging it gets.

SPEAKER_02 17:03

What do you enjoy the most about this aspect of your job? Because we started at the beginning and I gave you three job titles, but if we just focus on this one, what do you enjoy the most about it?

SPEAKER_03 17:14

I like the clinical medicine and the helping trainees, I think, and training trainees in rural medicine. I really enjoy being part of the acute take, seeing the patients when they come in, taking the history, making a diagnosis, starting a treatment plan, and using the resources we have as effectively as we can. I think that's the bread and butter of medicine, isn't it? And that's the part I enjoy the most. I also really like supporting our trainees when they start and seeing them develop. We've had a couple of doctors who came as FY2s, who then stayed as a locum or stayed as a CDF. Several doctors who spent a couple of years with us before moving on, and you can really see their clinical skills and their acumen and their knowledge and their confidence develop. People who come in are actually quite nervous or apprehensive can leave our hospital a couple of years later with excellent clinical skills. I think that's the same in any rural hospital where the doctors have to develop and have to develop these skills and the vast majority thrive on it and leave as much better clinicians. I think that's absolutely the most rewarding part of the job. And there's a lot of people in these rural sites who are very keen on clinical education and training and supporting because we recognize that we're not that appealing a place for a lot of people to live. A lot of the people who rotate through us generally see our name as part of their rotation. You know, if you're given six jobs over a couple of years and they'll be like, that's the one that they're understandably not looking forward to because it's far away from their friends and family and they've got to leave their flat and come and stay in hospital accommodation for a few months. So we try our best to support them, and I think that can definitely be the most rewarding part of the job.

SPEAKER_02 18:36

Do you think you need to have a particular skill set or particular personality traits to be able to do the job well? Or do you think that it's something that with experience and time most of us would be able to do?

SPEAKER_03 18:52

I think anybody in medicine could do it. Some will maybe enjoy it more than others. There's different personality types, as we've talked about earlier, with tolerating uncertainty and you know limited resources, but we're all very good at learning. We're all very structured individuals, you know. I guess we've all completed undergraduates and then got into higher training. I don't think there's any reason why anybody couldn't do the job. Like every job's parts of it appeal to some people and parts of it don't. We all end up eventually doing something that we're appropriate for, we like and we're good at. I often tell my trainees that of my university group in 2007, I think my good mates have ended up in jobs that they wanted to do eventually. Some took a bit of a roundabout course to get there. And I think the only way to find out if you'd enjoy it, if you're good at it, is to try it. That's part of the reason why we were really keen to have trainees come through. We're always pushing for university students, undergraduates, FY1s, FY2s, GP trainees, locums to come and spend a bit of time in a rural site, see if they like it, and then think about how they could train, including time in larger centres, to gain the skills that they can only learn there. And if we get a few thousand through over many years through all the rural sites, we take as many students and elective students and trainees as we possibly can. The more we come through, some will come back to work in these areas.

SPEAKER_02 19:57

And I know in preparation for this podcast we discussed about whether it would be appropriate to maybe talk about a couple of cases that you've seen. And given how small the area is, we possibly wouldn't be able to protect patient confidentiality the way we would if we were talking about a patient in London or Leeds, for example. Do you mind if we maybe talk about are the majority of the patients that you see do they come in with medical problems or do you see a lot of trauma or is there a lot of pediatrics?

SPEAKER_03 20:29

I appreciate that this will depend on where you're working and the patient population there, but is it the majority medicine and trauma or my job's in the emergency department, mainly in the small rural hospital. And I think from previously when I was training and working in larger departments, we say basically the same mix of stuff, but in smaller numbers. So we'll have 10 or 11,000 patients through the department in a year, whereas some larger sites will have ten times that or more. The mix is the same. The one thing about rural hospitals is actually the mix is better because you don't have the specialty services covering up all the other stuff. So if someone has a STEMI, for example, in a rural area, they don't go straight to the cath lab, they come to us and we thrombolise them and then we send them to the cath lab, which is two hours away or more. The same stroke we'll see an acute stroke with thrombolise them. There's no thrombic immune service, unfortunately, that covers us at the moment. It's still being established and it's very much on a case-by-case basis if it's possible or not. And then pediatrics forms a large part of our work, I think as it does in any emergency department that would take PEATS. And we don't have any pediatricians here, so we spend a lot of time on the phone to PETs in the nearest DGH discussing patients and we try our best to manage them without transferring them if we at all can avoid it. The other big challenge we have is sick people. So we don't have a level two or level three unit in our hospital. We can provide ward level care. We've got a few enhanced monitoring beds where we put our sicker patients. But if someone needs genuine level two support, or certainly our level, you know, ICU level three support, we need to move them out. And sometimes moving a level three patient is much easier. then moving a level two patient out. There's an excellent retrieval service in Scotland called the Emergency Medical Retrieval Service, or Scott Star. If we have a patient who's intubated, they will come and pick them up for us, find a bed in ITU and take them there. And they're also really good at giving phone advice, so if we've got someone who's critically ill, they can give us advice on what to do. We've got local anaesthetists as well who by the nature of their job do a lot of critical care. We can provide short-term critical care to patients before they move out. The tricky ones are the level two patients, the DKAs or whatever with with lots of pumps running. The ambulance service won't take a pump that's running and the retrieval service won't take someone quite rightly who's not needing their level of resource. So we usually have to send a nurse or two down with the patient to manage the pump so we lose them for six hours or eight hours while they go down and then come back again. The rurality also makes these patients harder to manage in that you've got to be aware of the resource you use. An overdose is a good example. If somebody takes a big overdose and comes in semi-conscious in a larger hospital it's often easiest just to intubate them, put them on an ICU, wake them up tomorrow and send them home. We can't really do that because by the time you intubate them, transfer them down the road that you know it's pretty much time to wake them up by the time they get there. So you need to be aware of the resource that you're going to use when you intubate someone and I suspect we're probably a little less interventionalist in terms of intubating a patient. If someone's sitting around about GCS 7 or 8, we may sit on them slightly longer than we would in a larger centre because of the resource implications of intubating them and transferring them. You need to involve your local seat involve the retrieval service, you need to speak to ICU elsewhere and make sure that everyone's on board with it. But you know we try not to manage patients any differently than if they were in a larger centre. But the realities are you know the resources aren't there. We can't just put them on an ICU. So how do you best manage them without tying up a helicopter in the north of Scotland for 12 hours that could be doing something else? They're the kind of cases like any other department the bread and butter stuff is you know geriatrics, you know, people whose social care package no longer supports their ability or people who've had a minor illness who've got many other comorbidities and it just knocks them off a bit and they need to come in for some rehabilitation. And to manage their acute illness we've got lots of people who are waiting care packages to go home again and you know we're just like any other hospital really but more fun to work in.

SPEAKER_02 24:04

I'll put the link to the GMC accreditation on the footnotes of this podcast so all our listeners can have a read in their own time. I think I've reached the end of my question, so I don't know if you have any final comments for anyone listening other than how amazing rural medicine obviously is agenda is to come and recruit people so if anyone wants the job come let me know.

SPEAKER_03 24:24

I would just encourage everyone to consider it either taste in rural medicine or a rotation through as a student and reassure you if you see the name of an isolated rural hospital because often the clinical experience and exposure can be excellent and we hope that you'll leave us a better doctor than when you started.

SPEAKER_02 24:38

I'm kind of regretting not having one now although I don't know if I would be rural sponsor maybe post CPT thank you so much for your time. Thank you for explaining everything so well and hopefully we've gathered a few more rural medics from our listeners thank you so much. Pleasure Marilyn thanks for inviting me the TNMC podcast Career Conversations supports medical students and trainees with career guidance and progression as well as professional development we wish to recommend our Demystifying PACES podcast series on career conversations. As some of you may know in late 2023 MRCP UK updated the PACE's exam format so we developed this new series to support PACE's candidates. Our episodes cover exam organization, calibration, every PACE station including key changes and candidate perspectives