Generalism & Rural Health

Importance of Generalism in Rural Health Responsiveness 

Rural healthcare is different from urban and suburban models of care, primarily because of the defining elements of rural and remote communities, including low population density and distance from other communities. The overarching reality of rural healthcare is that it is more generalist in nature as rural populations are not large enough to support specialist and subspecialist models of care. The Royal College of Physicians and Surgeons of Canada defines Generalism as “breadth of practice […] and collaboration with the larger health care team in order to respond to patient and community needs.”⁵⁵ Rural health practitioners can thrive when they expand their scope of practice and are able to respond to a broader range of health problems. This is true for general surgeons and internists as much as for family doctors and nurses.

Rural communities also create an ideal context for physicians and nurses to acquire and practice enhanced skills. These enhanced skills include generalists with experience in maternity, surgical, anaesthesia, cancer, and newborn care, among a host of other skills. The Canadian Journal of Rural Medicine publishes a regular series titled “The Occasional […] Procedure”.⁵⁶ The procedures within the series include dislocated shoulder reductions, removing a nasal foreign body, or repairing a lacerated nail bed, among others and can be used as a resource for rural physicians seeking to enhance their generalist skills.

A publication led by Jill Konkin (2020) in BMJ Open argues that rural healthcare access challenges can be addressed by better transport.⁵⁷ For instance, helicopters and air ambulances can be made available and ready to deploy and save patients when life or limb is threatened, and surface travel alternatives can be made available to address less pressing situations. While access to transport can theoretically mitigate some rural health emergencies, weather and uncontrollable circumstances all too often leave local providers to manage with the contingencies. Therefore, availability and accessibility to local care provided by generalists with enhanced skills and supported by virtual care support is now seen as essential.

Local generalists interact with local patients more frequently due to their broad scope of practice, which enables them to create strong relationships with the community they serve as well as put them in a position to provide effective education for health-related climate resilience. They can also identify the most prominent risks and avoidable morbidities through examining the lifestyle, primary industry, climate risks, major age groups, and underlying health problems of their community and prepare the local healthcare system accordingly. As such, generalists can be framed as “front line witnesses to the social dimensions of health, critical to access to the health system and key to long-term health outcomes.”^58-60

Generalism in Medical School Curricula

Despite its importance in not only rural healthcare but the entire healthcare system, generalism often goes unrecognized over specialist practice in medical education. While mandatory clinical rotations expose students to various branches of specialism, generalism is not highly regarded in the halls of medical education and academia. As a result, the current curricula not only decrease students’ awareness but also interest in rural generalist practice. Providing positive experiences in rural settings during undergraduate education is one of the driving forces for encouraging professional entry into rural practice. Further, increasing exposure to generalist practice can foster interest in the field amongst future physicians.⁶¹

As the only institution in the province of BC that currently educates physicians, the University of British Columbia (UBC) has a responsibility to produce generalist physicians who are trained to meet the needs of rural and remote BC. One of the ways in which the province trains rural practitioners is through the UBC Medicine Northern Medical Program (NMP), in partnership with the University of Northern British Columbia (UNBC). The program provides opportunities for students to gain rural perspectives through exposure to regional hospitals, Indigenous health centres, and smaller healthcare facilities.⁶² For example, the FNHA, the Northern Health Authorities, the NMP and the Health Arts Research Centre established the First Nations Community Education Program. This program allows students to closely engage with northern Indigenous communities to develop cultural competence and understanding of Indigenous health and provides an opportunity for cultural exchange while increasing primary care access for Indigenous populations.⁶³ Other sites of UBC Faculty of Medicine undergraduate education include the Vancouver Island and Southern Medical Programs.

Increasing Environmental Literacy in HealthCare

Eco-medical literacy is “the ability to access, understand, integrate and use information about the health-related ecological effects of climate change to deliver and improve medical services.”⁶⁴ Physicians must enhance their environmental literacy to strengthen their natural leadership role in influencing the health system towards responding to climate change and ecosystem disruption. To empower and equip physicians in responding to climate change-related health outcomes, education is essential throughout medical training including in undergraduate programs, residency training, and continuing professional development. For example, climate change awareness and environmental literacy can be incorporated to meet the objectives of existing undergraduate curricula.⁶⁴ Climate change and health can be seen as an integration of major educational fields such as public health, clinical practice, pathophysiology, and statistics.

Climate-related health outcomes can be embedded into case-based learning where students are presented with individual or community level situations where health is impacted by climate change, and encouraged to discuss potential preventive and remedial approaches.⁶⁵ For instance, the Health and Environment Adaptive Response Task Force (HEART) was established in 2016 by the Canadian Federation of Medical Students (CFMS) to increase awareness of climate change and environmental health.⁶⁶ The CFMS HEART has developed 12 core competencies concerning climate change and planetary health education to incorporate in all Canadian medical school curricula. These include displacement of vulnerable populations, changing infectious disease burdens, emergency disaster risk, and Indigenous health.⁶⁷ The first evaluation of its curricula was conducted in 2019 by students and faculty members.⁶⁸ Findings revealed a clear push from students and faculty for the continued integration of planetary health into the curriculum which supports the need for national standardization of climate and environmental-related education within Canadian medical schools.

Some of the current barriers to advancing environmental literacy within rural healthcare education include an overloaded curriculum, the prioritization of traditional learning objectives, a lack of developmental resources and climate change expertise, dismissive attitudes towards the relevance of sustainability in clinical practice, and an underlying bias towards reductionist approaches of care.^64,65,69 Overcoming these challenges will require collective action across healthcare education systems. The Education for Sustainable Healthcare (ESH) curricula suggests three integrated strategies for driving meaningful change: adopting a systems-thinking approach, engaging with stakeholders through storytelling, and transforming vision into reality.⁷⁰ These practices will further equip health care providers in becoming adaptive leaders for planetary health action.

Incorporating Indigenous Cultural Practice

Knowledge of local traditions is also important in providing holistic generalist care. With a generalist philosophy guiding the provision of community-centred service, there is potential to explore innovative ways to promote the population’s wellbeing. Learning from and incorporating Indigenous traditional healing is an example of such an approach.⁷¹ This includes healing circles, ceremonies, and traditional diets and medicines.⁷² The Canadian Cancer Society and the FNHA recognize cultural practice as beneficial for mental wellness and restoring balance to Indigenous communities, reaping superior long-term outcomes for patients. These Indigenous cultural practices should be acknowledged and respected independently from the biomedical paradigm of Western medicine. Traditional practices can strengthen the connection between communities, their environment, and local health services and should be looked upon by general practitioners as a method of culturally sensitive and wholistic care.^71,72