Krista dowhos HBSc Dr marion maar PhD dr bruce cook MD PhD Disclosures Krista Dowhos Relationships with commercial interests NONE Potential for conflicts of interest ID: 917080
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Slide1
Barriers and facilitators to physician preparedness working in a rural emergency department (ED): a qualitative study
Krista
dowhos
,
HBSc
, Dr.
marion
maar, PhD, dr.
bruce
cook, MD, PhD
Slide2Disclosures
Krista Dowhos
Relationships with commercial interests: NONE
Potential for conflict(s) of interest: NONE
Slide3Background
Slide4First, a question for the audience:
What do you think could make a physician feel
prepared
or comfortable working in a rural emergency department (ED)?
What do you think could make a physician feel unprepared or uncomfortable
working in a rural emergency department (ED)?
Slide5What does the literature say?
Rural EDs in Canada are largely staffed by Family Physicians (FP)
Suggests many Family Physicians (FP) do not feel comfortable in the ED
Gaps in the literatureHow can we better prepare physicians? Family medicine (FM), FM+ EM, 5-yr EM, other
?Facilitators and barriers to preparednessWhat are rural physicians’ views on this issue?Lack of research done in rural Northern Ontario“Family physicians, however, may not be adequately trained in EM… studies have revealed that graduates of Family Medicine training programs do not feel comfortable in the ED environment.”- Canadian Association of Emergency Physicians, ”Rural Emergency Care”
Slide6Objectives of this study
E
xplore the facilitators and barriers to Family Physician preparedness working in a rural emergency department
Recommendations for enhancing physician preparedness
Slide7Methods
Slide8Methods
Design:
Single setting, descriptive qualitative study
Semi-structured interview questionnaireSetting:Rural community Northern Ontario, population <10,000, nearest academic health
centre > 300 km Data gathering:Inclusion criteria - Licensed physicians, worked in community ED in past 12 monthsInterviews audio-recorded, transcribedData analysis:Immersion/crystallization analysis, triangulationNvivoParticipants:10 family physicians 8 male, 2 female; years in practice ranged from 8 months to 25 years; 2 had an extra year in anesthesia, 1 has extra certification in EM
Slide9Results and Discussion
Slide10Key Themes
Slide11Facilitators of Preparedness
1) Culture amongst the emergency physician group
Colleague support
Receptive to calls for help
“…there are a lot of things in medical culture that dissuade us from calling for help… And [colleagues in community] never do that. They're always happy to help.”
Slide12Facilitators of Preparedness
“
…
everybody seems to have taken a particular area that they have developed strength in… it’s
nice to know that if something out of your area that you prefer comes in, you've got these people you can call… I love the fact that we've got good back-up.”“pseudo-specialists”Allows back-up and consultation even with limited specialist care in the community
Slide13Facilitators of Preparedness
2) Skills and attributes of rural emergency physicians
Tolerance
of uncertainty
“You
have to have a basic certain personality type to work in a rural emergency room. I use the word clinical courage. You have to be able to live with more uncertainty
than
even faster paced bigger
center
emergency rooms because you have less
back-up.”
Slide14Facilitators of Preparedness
“As
a rural doc your skill set gets bigger. In the city your skill set tends to
shrink… there are a number of things that you don't do because there are people that do it for you…
Here you sort of have to have a wide variety, a wider skill set”“We've had physicians that operated very well in much larger centers that weren't able to operate here because they needed the trauma guy, the anesthetist, the cardiologist. To do it all themselves just wasn't in them.”Independence
Broad scope of practice
Slide15Facilitators of Preparedness
How did physicians acquire these skills?
Exposure to rural EM during medical education
“I did a lot of rural
rotations… You have to spend time in rural emergency departments and you have to spend time in a lot of different ones… Being in rural setting and having mentors that show you that this is attainable and this is how you get there."
Slide16Barriers to Preparedness
1) Patients exceeding local resources
“You
have to be able and willing to care for a patient that is sicker in a rural department because you don't have the specialists to call
in.”
Lack of specialist back-up
“Its
a little bit scary because we may not see as much trauma, acuity, or we may not have to use critical care skills on a daily basis, but we have to use them semi-regularly. So you really have to have a wide skill set that you may only use two, three, four, or ten times a year
.”
Limited exposure to high acuity cases
Slide17Barriers to Preparedness
2) Limited
access to CME
“Often
you have to travel to [nearest academic centre]… So it does take some time away from your practice and your family…”“We don't get a lot of formal CME in [community].”Lack of local CME opportunitiesTravel requirements
Slide18Recommendations
Plus-one in EM or 5-year EM
not
necessary for rural EMMany different paths to preparing for rural EM
“It would be impractical from a human resources perspective for everyone to get an emergency medicine degree.”“I don’t think you need a plus one…You get your plus-one if you don't feel comfortable, so that you get the experience you want.”
Slide19Recommendations
Exposure to rural EM during FM residency training
Promote
independence and broad scope
Slide20Recommendations
ER Mentorship Program
Funded by ministry of Health
FM graduates work alongside rural emergency physician for 4 months (32 hrs/mo.) (mentor and mentee are both paid)
Complete autonomy but mentor available to review/helpVery “secret”, passed one by word of mouth. Info not easily accessible online. Can take up to 4 months to be approvedProgram needs to be publicized and process needs to be streamlined!!http://www.health.gov.on.ca/en/news/bulletin/2011/docs/hb_20110517.pdf
Slide21Conclusion
Physicians in this community prepared for work in rural ED
Unique skill set and ?personality required
Importance of local CME Future researchOther rural communities in Northern Ontario
Slide22Acknowledgements
All physicians who participated
Supervisors Dr. Cook, MD, PhD and Dr. Maar, PhD
Physician recruiter
Slide23Resources
Canadian Association of Emergency Physicians (2016) “Rural Emergency Care”.
http://caep.ca/advocacy/romanow-commission/rural-emergency-care
Soles, J., (2016) “Who provides most of emergency care in Canada?” Canadian Journal of Rural Medicine, 21(1), 5. Peterson, L., et al (2008) “Nonemergency medicine-trained physician coverage in rural emergency departments” National Rural Health Association: Workforce Issues. 183-188.Thompson
JM, Irvine H, Von Hollen B, Peters M (1991) “Triage system for rural hospital emergency services”. Canadian Family Physician 37:1252-1266Thompson JM, McNair N. Health care reform and emergency outpatient use of rural hospitals in Alberta, Canada. J Emerg Med 1995;13(3):415-421. UBC Rural Continuing Professional Development Program (2015) “Rural Emergency Medicine Needs Assessment – Final Report”. http://ubccpd.ca/rural/researchHenderson, K. (2006) “TelEmergency: Distance Emergency Care in Rural Emergency Departments Using Nurse Practitioners”. Journal of Emergency Nursing 32(5), 388-393. Williams, J. M., (2001) “Emergency Medical Care in Rural America” Annals of Emergency Medicine, 38(3), 323-327 Starks, H., Trinidad, S., (2007) “Choose your method: a comparison of phenomenology, discourse analysis, and grounded theory” Qualitative Health Research 17(10, 1372-1380
Slide24Extra slides – Additional Information
Slide25What is qualitative research?
In simple terms, it answers the
“how?”
and ”why?”A quantitative study might answer the question: “What percentage of family physicians feel report feeling prepared to work in a rural ED after a 2-year family medicine residency?”
A qualitative study might answer the questions: “What made those family physicians feel prepared/unprepared?”, “What changes can be made that will enhance family physicians sense of preparedness to work in this environment?”“Qualitative research methods enable health sciences researchers to delve into questions of meaning, examine institutional and social practices and processes, identify barriers and facilitators to change, and discover the reasons for the success or failure of interventions.”
Slide26What is qualitative research?
How do we go about answering these questions?
phenomenology = one of three main approaches to answering a qualitative research questionGoal: to describe the meaning of the lived experience of a phenomenon
Sampling: those who have experienced the phenomenon of interestData collection: Descriptive interview - participant describes experience and interviewer probes for detail/clarityAnalysis: Researcher identifies descriptions of the phenomenon, groups the descriptions into discrete categories; and then describes the “essence” or core themes of the experience
Slide27Approaches in qualitative research
Slide28Lit Review
Search engines:
PubMed,
QxMD-Read, ClinicalKeyKey words: rural emergency medicine, rural emergency department, emergency physician preparedness, Northern Ontario emergency medicine