Rural and remote medicine: comes of age

Is Rural and Remote Medicine now a distinct discipline? In a May 1995 article for the Australian Family Physician, Professor Roger Strasser posed this question and from his findings concluded that ‘if it had not already achieved this status, it was well on its way’. Some eight years hence, with the author himself now leading a Canadian medical school dedicated to the field, it's timely to revisit the question. Rural and remote medicine has been practised for generations. In today's medical world, however, arranged as it is into disciplinary silos, each with their own organisational apparatus, undefined practice risks disenfranchisement from the engines of research and training. To save it from becoming a dying art, practitioners have sought to define and nurture their distinct form of practice and, through their efforts rural and remote medicine, became a recognised academic field. To resolve the issue of whether this emergent field constituted a discipline, Strasser's analysis drawing upon the work of McWhinney and Gray,1 applied the following determining criteria: A dedicated academic body formed by its practitioners. An intellectually rigorous training program. A distinct body of literature by practitioners. Recognition by wider society. With respect to the first criterion, at the time of writing, initial attempts at establishing a dedicated disciplinary organisation within the General Practice specialty were underway. Since then, the Australian College of Rural and Remote Medicine (ACRRM) was formed; an autonomous professional body entirely dedicated to rural and remote medicine with almost 2000 rural doctor members. Similar organisations have been established overseas including in England, Scotland, Ireland, Canada and the United States of America. On the second criterion, by 1995 the movement had developed advanced rural training posts and was attempting to articulate these to a dedicated rural training pathway. In 2003, dedicated training in the specialty of rural and remote medicine is available from prevocational through to advanced levels. On the third criterion, the Australian Journal of Rural Health was only in its infancy in 1995. Now in its 11th year, along with the many similar publications overseas, it is testament to the depth and the endurance of scholarship in this field. In recent years a proliferation of international organisations, publications and scientific forums have facilitated cross-pollination of ideas, pooling of experience, and crystallisation of common international themes and consolidated the corpus of knowledge in the discipline. In terms of external recognition major inroads have been made since 1995. The discipline is now an integral part of the Australian medical syllabus, with all schools offering some rural component, augmented by the University Department of Rural Health Royal Clinical School network now attached to every school. There are medical schools in Australia and many overseas specialising in the area, including in Canada, USA and Norway. Medical colleges are engaging in a range of collaborative initiatives with ACRRM such as the Joint Consultative Committees (JCC). Government actively seeks the involvement of ACRRM as an arbiter of the discipline in the development and implementation of relevant policy and initiatives and has a dedicated rural health strategy. Strasser's criteria being well satisfied, it is worth further considering whether rural and remote medicine stands alone as an independent discipline. Rural and remote medical practice is not merely an agglomeration of general practice and other select medical specialties and allied health proficiencies. The context of relative professional isolation, rural culture, demographics and epidemiology, and the practicalities of service provision without the ready access to resources, technologies and specialist personnel available in cities, combine to create a distinct practice paradigm, requiring a distinct body of investigation. McWhinney proposes that for a discipline to be truly independent, there should be some research questions that can only be addressed from inside the discipline.1 Given the specific context of the rural and remote services the capacity to consider models of care provision from a whole-of-health-sector perspective and incorporate the full range of medical and other scientific disciplines as required, rural and remote medicine is uniquely qualified to address many of the key issues. For example, devising interdisciplinary models of rural medical care or, addressing rural emergency procedural medicine issues. A final and more pertinent question is whether rural and remote medicine as a discipline can contribute meaningfully to the corpus of human knowledge and to humanity's advancement. Much has already been gained from the investigation, evaluation and exchange of ideas that has been made possible through the rural and remote medicine movement and much more can still be achieved. Better training strategies for workforce development and retention have emerged. We have been able to draw upon international experience on frameworks for safe ‘rural’ practice and when to refer in fields such as obstetrics. New teamwork models for rural patient care, such as teleconsulting and specialty upskilling have been explored and evaluated. A rural health syllabus has been compiled and articulated into training programs, providing the basis for preservation and transfer of acquired disciplinary expertise. Finally, international disciplinary statements on humanitarian issues have been made possible, such as the Melbourne Manifesto developed by the WONCA Rural Health Group, addressing doctor provision in developing countries. Rural and remote medicine has come of age it has acquired the features commensurate with even the most pedantic definition of what constitutes a discipline; but more importantly, its consolidation enables its practitioners around the world to provide something greater than the sum of their individual efforts for the advancement of rural communities.

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