Ireland’s first Established Professor of Rural and Remote Medicine, Prof Robert Scully, speaks to Niamh Cahill about the importance of medical generalist roles in primary and secondary healthcare
Earlier this year the University of Galway announced the appointment of Prof Robert Scully as Ireland’s first Established Professor of Rural and Remote Medicine.
Providing primary healthcare to Ireland’s remote communities remains a major challenge.
The University has described the role as a “landmark appointment”, which it says is aimed at tackling doctor shortages in the west and strengthening medical training.
Speaking to the Medical Independent (MI), Prof Scully recalled his time as a rural emergency physician on the Isle of Skye off the west coast of Scotland and how this impacted his career.
“That was fabulous. It was the best job in medicine because we were true generalists,” said Prof Scully, who trained as a GP.
“We ran a small rural hospital and we saw all sorts of patients there. This model is very common in Canada and Australia. We used GPs to provide an enhanced service – sure, we needed additional training, and we all did additional training in various disciplines like anaesthetics and acute medicine and emergency medicine.”
After two years in the role, the Kildare native continued to work in Scotland as a rural GP with an extended role in emergency medicine for five years.
“Then, for many years, I worked on the Scottish Graduate Entry Medical Programme where I was Deputy Director based at the University of St Andrews…. The Scottish NHS is also struggling for generalists across primary and secondary care. They have a programme there now that’s well established that sought to address that workforce crisis by sending students out to rural hospitals around Scotland and into rural general practice to help impact their eventual career decisions.”
It is this work in Scotland that Prof Scully will emulate in his position at the University of Galway, as it prepares to launch a four-year graduate entry medical programme focused on rural and regional healthcare needs.
It is planned that 48 students on the programme will be placed in rural, community-based postings when the course begins.
“All entrants to the programme will be graduates of a certain grade, usually a 2:1 honours degree and most programmes take people from any background,” he outlined. “There is good evidence that people from a non-science background start to outperform people with a science background after a couple of years.”
It is hoped the programme will start in September 2027 and its first graduates will receive their primary medical qualification by the summer of 2031.
“One way to think about the curriculum is that we will be focused on the common and the dangerous [illnesses/conditions], as opposed to learning about esoteric concepts. I remember learning about things in medical school that I never encountered in my career. Whereas I didn’t learn much about measles or migraine and more common conditions.”
Curriculum
He said the new curriculum would be shaped by the principles of medical generalism, with an emphasis on community settings, in addition to hospitals.
“A lot of medical education in Ireland relies on large city hospitals and, unsurprisingly, graduates see those role models throughout their training. And then it’s unsurprising they want to choose those careers because that’s where they spent their time and that’s what they aspire to become. Whereas there is good international evidence that shows if you expose students to generalist role models during their training, particularly in rural and remote locations, and particularly if you do it longitudinally, where they go out and spend a decent chunk of time with these people, that’s more likely to affect their eventual career decision.
“These graduates will be free to pursue any branch of medicine. They can go and be a neurosurgeon if they want, or a GP, or whatever they like. The evidence is that if they’re exposed to a curriculum that’s orientated in a certain way, they are more likely to want to enter generalist careers, which is exactly what the Irish health service, in particular in the west, needs.”
Healthcare services in rural areas globally, not just in Ireland, are facing similar challenges, Prof Scully told MI.
Throughout his career, Prof Scully has found the experience of treating undifferentiated patients in both emergency medicine and general practice fulfilling.
But he noted some studies show that students view generalist roles as lacking in intellectual challenge.
He referred to the By choice – not by chance report from the UK (more widely known as the Wass Report, after Prof Val Wass, who chaired the taskforce which wrote the document). This report found that students perceive general practice as intellectually under-stimulating.
“That’s both surprising and concerning to me because for me the most intellectually stimulating part of medicine is seeing people with difficult to diagnose or undifferentiated problems. We need to work hard to demonstrate that this is actually very intellectually stimulating to students so that they might consider those careers.”
The long-held belief that general practice is somehow less worthy a pursuit than other specialties has an impact on student career choices, Prof Scully argued.
“That’s in the research and it’s called the ‘hidden curriculum’. And that’s actually the most significant factor, that this sways students from thinking about careers in general practice. We really need to work hard with our secondary care colleagues to address that. We are all important for the provision of healthcare services in this country. We all play a role and each role should be equally respected. I don’t know why general practice is seen as inferior by some but, for some reason, it is.”
Shortages
The reasons why doctor shortages are a particular problem for rural areas are both complex and multifaceted, he stressed.
“I think one thing is, rural GPs, they’re often in smaller practices and they don’t have the physical space to have students. They’re often very busy and not in a large group practice with colleagues that can cover for each other. Therefore, students don’t get to spend a significant amount of time in rural general practice relative to urban general practice. That’s one problem. That’s probably also true of our hospital colleagues, say Mayo [University Hospital] for example; they have very onerous on-call arrangements. They might be on-call every couple of nights, but in large city hospitals, such as University Hospital Galway, there might be several clinicians on every on-call rota so the on-call is less onerous and frees them up with more time for teaching and research… there are multiple other aspects.”
Rural proofing
In order to tackle the challenges that exist, he argued that a concept known as ‘rural proofing’ is required.
“This is a concept that highlights that, in order to solve problems like health workforce deficits in rural areas, you have to have a multi-agency, multi-dimensional approach to the solutions. For example, when I worked on the Isle of Skye, I couldn’t get accommodation there when moving because any accommodation was let out to holidaymakers…. This shows that what we need is Government departments to work together to prioritise accommodation for critical workers that maintain rural sustainability,” he said.
Another issue is professional isolation. “Studies show that when you are professionally isolated that brings a lot of pressure and the pinch point is around holidays…. I don’t think any doctor minds working hard, but if they can’t get a week off here and there, you burnout.”
Perennial recruitment challenges in rural healthcare ultimately lead to health inequity across regions, Prof Scully added.
This is why exposing students to generalist role models in hospital and community services is so important, he said. These are the people that will ultimately help “rebrand rural careers” and improve and sustain healthcare services in remote areas.
Leave a Reply
You must be logged in to post a comment.