The imperative to improve rural surgical services in Canada

I was recently reminded of the importance of networks that support vital surgical care in remote Canada when a colleague sent me an operation summary for a procedure that I had performed years ago while working in Edmonton. The report detailed definitive surgical management of a high velocity left thoracoabdominal missile wound on a patient who had been shot in Canada’s remote Arctic.  Before transfer to my hospital, the attending doctor, working with his team in his remote hospital, had applied life-saving essential surgical skills to stabilize shock, enabling successful transfer of the patient to my center.  Thanks to the outstanding skill of this surgical first responder physician beginning in his remote community, the patient not only survived but returned back home where he now thrives 20 years later!

Unfortunately, today’s access to timely, affordable and quality surgical care is an increasing challenge for Canadians in rural and remote communities.  Several factors have conspired to affect provision of rural surgical services, including insufficient surgical training, variations in the certification, licensing, privileging and credentialing process, insufficient recruitment and retention and, flawed rural surgical care delivery models (1).

The Royal College of Physicians and Surgeons of Canada recently convened a Task Force to make recommendations that improve the future general surgery workforce in Canada (2), recommendations that will be implemented beginning in 2017.  These formulate a useful framework that can be harnessed to improve the training of generalist general surgeons who require the skill sets which are needed to perform surgical care (including cesarean section) in rural communities.  Moreover, the Society of Rural Physicians of Canada (SRPC) and the College of Family Practitioners of Canada (CFPC) have unveiled a four- pillar national strategy to enhance surgical skills for physicians in rural communities.  One of these pillars is to develop, together with the Canadian Association of General Surgeons and the Society of Obstetricians Gynecologists of Canada, a joint position statement on rural surgical care, including cesarean section.  The objectives of the statement are to describe the present delivery system for rural surgical care, appropriateness for rural practice for general surgeons and family physicians with enhanced surgical skills, to recommend models of collaborative surgical practice and to identify standards of care for all rural surgical providers.  The aim is to ensure sustained ability of well-trained practitioners and networks of teams that provide high quality surgical, obstetrical, anesthetic and emergency surgical services to the citizens of rural Canada.

At the February 2014 Board meeting of CAGS, the provision of rural surgical services was discussed in the context of the new initiatives by the Colleges.  It was agreed by the Board that CAGS should be at the table to participate in a joint position statement and to participate with interest in the development, teaching and evaluation of essential surgical skills for practitioners in remote communities.  Otherwise, CAGS will have minimized influence and limited grounds on which to criticize outcomes in this important area or to celebrate success of future models of care for citizens of rural Canada.  Accordingly, the process of drafting an outline for a joint position paper has begun with input from CAGS from past- CAGS President Garth Warnock (Vancouver) and American College of Surgeons Rural Committee representative Nadine Caron (Prince George).  Additional advice from general surgeons who have expertise in rural surgical service delivery is strongly encouraged and we welcome any interested surgeons to contact us for input into this important document as it is developed to positively impact on delivery and quality of rural surgery.

1. Caron NR , Kennedy CM ,Warnock GL .  Rural Surgery in the” Great White North–Universal Care or Universal Challenge?  Bulletin of the American College of Surgeons volume 98, September 2013, pages 50-56.

2.  Task force of the Royal College of Physicians and Surgeons of Canada .  The Future of General Surgery Training in Canada.  February 2014.