General Practitioner rural and remote proceduralist services (2018)

RACS recognises that the practice of surgery has advanced significantly over the past twenty years with advances in research, technology and increasing subspecialisation. As a result it is essential to ensure appropriate training, facilities, scope of practice and ongoing support is available for all medical practitioners providing surgical services to the community. This position paper outlines the principles to support collaboration between specialist surgeons and rural and remote general practitioners who undertake surgical procedures to ensure high quality care is delivered to patients in rural and remote communities.

A working group comprising RACS, RACGP and ACRRM was convened by RACS in 2014 to explore the role of rural General Practitioner (GP) proceduralists (surgery), the need, scope of practice and accreditation requirements. This included two surveys from both RACGP and ACRRM of surgical procedures being undertaken by an estimated thirty general practitioners in rural areas of Australia. The surveys highlighted that the majority of procedures being performed by general practitioners included drainage of abscess, excision of skin lesions and caesarean section. In addition to these, proceduralists also indicated that they had performed closed reduction of fractures, dilation and curettage and carpal tunnel surgery as well as a range of other small- to medium- size procedures. Volumes performed are modest.

The teaching of advanced skills in procedural surgery must be supported by appropriately qualified surgeons in their fields of expertise.  Any interventional procedure needs to be performed at a level accepted by peers and the community.  All surgical procedures require regular audit and review. RACS policy on essential surgical skills outlines three levels of skills that RACS recommends for general practice proceduralists and appropriate training levels for the different requirements.

• Patients requiring emergency surgery require prompt diagnosis, resuscitation, stabilisation, and when appropriate, transfer to a centre that is resourced for the surgery required. Truly remote centres (more than four hours air retrieval time) require access to local doctors with these procedural skills.
• Continuing improvement in inter-hospital transfer and transport addresses some of the difficulties associated with transfer of patients from remote hospitals but some areas remain problematic.
• Short stay procedures in regional and some smaller rural centres allow much less dislocation from home for rural patients. Some patients may be suitable for post-operative
• Where Rural GP proceduralists (surgery) are required to support services in regional, rural and remote communities, they need strong linkages with the surgeons and regional and metropolitan hospitals to which they usually liaise.
• Procedural skills need to be service-specific and be considered in the context of the community need as well as the infrastructure available. This includes the physical resources (e.g. hospital or surgery facility) as well as the professional resources such as anaesthesia, internal medicine, nursing and allied health.
• A Rural GP proceduralist (surgery) in a remote location has a close association with the surgeon(s) in the neighbouring centre with full surgical facilities. In New Zealand this collegial relationship is required by the Medical Council in order to practise.
• Supporting surgeon(s) need to be intimately aware of both the skills of the GP and the environment in which he/she practises.
• Where Rural GP proceduralists (surgery) are undertaking extended practice there is a need for the neighbouring surgeon(s) to support the GP with supervision and for peer reviewed audit and continuing professional development within the local regional or metropolitan centre.
• Specialist surgeon(s) are encouraged to visit and undertake appropriate elective operating lists on a regular basis with Rural GP proceduralists (surgery) to further resource and up-skill the resident GP.
• If facilities are inadequate for a specialist surgeon to perform routine elective procedures then the facility would be inappropriate for a GP to be performing the same elective or emergency surgery
• RACS will collaborate regarding surgical curricula and training programs proposed by any other Specialist Medical College. RACS offers to provide guidance in this space, and in the provision of continuing professional development and peer reviewed audit.

Generalists, Generalism and Extended Scope of Practice Policy

Essential Surgical Skills Guideline