In preparing to write this article, I wrote to a small group of GP obstetricians (GPOs) and posed the question of what GPO upskilling should involve. To my surprise, I received 86 replies! Ongoing education and skill development is a hot topic. In this article I’ve attempted to reflect some of these views and ideas, while discussing what work as a rural GPO can be like, and the importance of maintaining and developing skills that are needed. There are currently no formal RANZCOG mandated requirements for upskilling in larger centres, although some states and hospitals have varying credentialling criteria for training through short-term placements.
I have spent the last three years working in Nhulunbuy, a mining town of about 3500 people in remote Northern Territory. Rural Generalists provide the medical services for our hospital, and there are normally two or three GPOs. We provide medical care for about 15,000 people living in the East Arnhem region. About 70% of our patients are Aboriginal people, and many live in remote communities. Antenatal care in the communities is mostly provided through Aboriginal Medical Services, and often remotely coordinated and reviewed by our hospital obstetric team. The women we care for typically have complex health needs, particularly due to a high prevalence of diabetes, kidney disease and rheumatic heart disease. As well as the burden of chronic health problems, good antenatal care is challenged by geographic, cultural and social factors. Some women have not seen a doctor in their pregnancy until they present to Nhulunbuy at term for their ‘confinement’.
Our hospital is about 1000km from Darwin by road. We are supported by Careflight, but the limited availability of services as well as the sometimes-challenging weather conditions means that transfer times can be less that optimal. We manage low- to moderate-risk obstetric patients, with fabulous phone support from Royal Darwin Hospital, our referral centre. We help 150–170 women birth locally at our hospital each year and also coordinate the care of about 50 more high-risk women annually, planning for them to birth in Darwin. We also run a level 3 nursery which allows us to keep neonates and their higher risk mothers more often than some other small centres.
The purpose of this background is to paint a picture of the types of care that Diplomates in regional, rural and remote Australia are called on to provide. Sometimes we all have to deal with complex obstetric problems when transfer is not an option. Even though we have relatively small birth numbers to maintain our skills, we can be forced to manage unplanned, complex and high-risk situations, often with only one other GPO to call on for help. Our unit in Nhulunbuy is not alone in this – even those closer to tertiary facilities cannot avoid the unexpected complications or emergencies.
Some of the challenges that our team has had to deal with over the past three years include:
- a clinically unstable woman with a ruptured cornual ectopic with 3L blood loss
- a 27-week preterm birth
- more massive PPHs than I’d like to admit to, with management in the operating theatre, Bakri balloons and recently a B-Lynch suture
- caesarean sections for a fully dilated preterm breech birth, a massive Antepartum haemorrhage at 31 weeks and a transverse lie with ruptured membranes
In my first week of work in Nhulunbuy, I was called on to fly to a remote community to attend a woman at 31 weeks, septic and close to birthing. Because of a cyclone affecting the Darwin area, there was no option to send other paediatric or obstetric doctors. When I arrived with the retrieval nurse, the baby had been born and was being given respiratory support by a GP who worked in that community. The baby’s mother was hypotensive, febrile and was bleeding with a retained placenta. Fortunately, we were able to manage this, using all the uterotonics in the Careflight kit, and performing a manual removal in that clinic, although without optimal pain management.
So how can we prepare ourselves for these situations? Practice scenarios can help, but I believe that clinical attachments in larger centres to upskill or refresh skills are vital to help maintain confidence, technical skills and to provide knowledge of policy changes and research developments. These attachments also enable growth in the communication and connection with the referral centre, which results in a better shared understanding of local systems from both ends. Improved relationships can lead to streamlining of referrals and management, and can ultimately lead to a decreased workload for referral centres and ultimately better patient care. While specific challenging births are unable to be planned during a short placement, time in a larger centre can allow involvement in complex care with a specialist supporting and teaching. Previous experience is always helpful if emergencies have to be managed alone!
In the replies that I received from colleagues, many referred to a perception that GPOs normally manage low-risk births, and so opportunities for involvement in complex deliveries during upskilling terms were lacking or even deemed to be inappropriate and so not facilitated. Some GPOs report positive experiences, though others state experience in performing primary elective caesarean sections was provided, but the more complex situations like third or fourth caesarean sections, or even emergency operative delivery for a failed vaginal birth with full dilation, was managed by a consultant or senior registrar. Some reported not being able to do any more than assist at elective caesarean sections.
The responses that I have received overwhelmingly stated that enabling and expecting GPOs to take primary responsibility for complex deliveries during an upskilling placement was necessary to enable them to grow in their skills and abilities to manage in isolated centres. As well as this, having an opportunity to be involved in a relatively large number of births in a short time is important in reinforcing skills. To enable learning opportunities, being rostered with a senior registrar or consultant is vital. Experience with and learning new elective gynaecological procedures appropriate to the GPO’s hospital is helpful. As well as skill development, the growing ability of GPOs from these placements can help to reduce unnecessary transfers and referrals to the larger hospital.
While upskilling terms are essential, arranging them can be difficult. Leave cover for small hospitals can be hard to arrange, and taking time away from home and family isn’t easy for some GPOs. For Rural Generalist GPOs also needing upskilling in different specialties, arranging time away from their employing hospital for ongoing education is compounded. Shorter, more frequent upskilling posts when within driving distance for a GPO are useful options. Some GPOs struggle to find hospitals willing to support them, especially if larger centres only offer upskilling to those within their catchment area. This can particularly affect doctors working as locums, or those in areas where the referral hospital is unable to provide ongoing training. Lastly, some GPOs reported having to personally pay for an upskilling term in a larger centre, which put them at a financial disadvantage.
Despite these challenges, there are referral centres that take a very active approach to continuing education, with invitations to online departmental teaching and development of relationships. This can be particularly supportive of those GPOs who work as rural generalists involved in different specialties, who have limited time to keep up to date in each of those areas.
Upskilling in larger centres is vital to the maintenance of skillsets. In my view, support by larger centres and FRANZCOG colleagues of Diplomates working in isolated and challenging locations is necessary for ongoing patient safety, good obstetric management and coordinated care of vulnerable women. The provision of clinical attachments needs the recognition and commitment that other onsite training is afforded.