Update on Enhanced Surgical Skills practice

StuI Dr. Stuart Iglesias, Enhanced Surgical Skills (ESS) physician and founding member of the National Working Group on ESS

General practice surgery – also known as Enhanced Surgical Skills (ESS) practice – has long been an essential part of rural healthcare service delivery, especially in British Columbia. ESS GPs currently perform nearly all of the Caesarian sections in rural BC, and – depending on a region’s surgical resources – may additionally perform other procedures such as hernia repairs, tonsillectomies, sterilizations, hand repairs, and appendectomies. The presence of these ESS practitioners in small rural and remote communities has allowed rural patients to remain in their communities and to be close to family, friends, and familiar environments during medical treatment and recovery, reducing expenditures associated with travel to larger centres and overall patient stress.

Although ESS physicians are an essential part of rural healthcare service delivery, there are few people practicing this discipline. Across rural Canada, there are only 125-130 GPs with enhanced surgical skills. Lack of consistent, formalized training in surgical skills has been a significant barrier to building a strong ESS physician workforce until the University of Saskatchewan’s started up a 12-month, rural-focused Enhanced Surgical Skills training program taught by specialists in Prince Albert in 2007. This successful program now graduates two ESS trained GPs per year, and has inspired the formation of a national working group which aims to create a national strategy that maintains the high quality of rural Canada’s surgical and obstetrical services.

Four pillar approach for ESS national strategy

The National Working Group on Enhanced Surgical Skills first convened during the Society of Rural Physicians of Canada’s (SRPC) 2012 Rural and Remote Medical Course in Whistler, BC. Founding group member, Dr. Stuart Iglesias, notes that the Whistler group initially met to discuss how they could nourish the success of the Prince Albert rural ESS training program and “build it into something more robust, more structured, with a lot of buy-in from [surgical practitioners] across Canada.” Over the course of a year, the group developed a national strategy that takes a four pillar approach to building and maintaining high quality of surgical and obstetrical services in rural Canada:

  • development of a national ESS training curriculum that requires candidates to pass an oral and written exam in addition to demonstrating their surgical competency
  • application for ESS to be recognized as a Special Interest Focus Practice (SIFP) interest group within the College of Family Physicians of Canada (CFPC)
  • publication of a joint position paper on ESS with the Canadian Association of General Surgeons (CAGS), the Society of Obstetricians and Gynecologists of Canada (SOGC), the CFPC, and the SRPC
  • proposal for applying the above pillars to influence practice credentialing and privileging processes to be sensitive to rural needs

The National Working Group has made significant strides in three of the four areas of its national strategy: a second draft of the national ESS training curriculum was recently completed in February 2014; the application to recognize ESS as an SIFP was successfully received by the CFPC; and, the support of all groups involved in the authoring of the joint position paper has been obtained.

Work on the position paper has begun but is still “a work in progress,” according to Iglesias. CAGS, SOGC, CFPC, and the SRPC have agreed that the paper must describe the present delivery systems for rural surgical care – which involves a mix of specialist and ESS physicians – and must also address standards of care and measured outcomes “so that rural surgical healthcare will be excellent regardless of who delivers it, or what their training is.”

Dr. Robert Woollard, professor and general practitioner, and a founding member of the National Working Group on ESS Dr. Robert Woollard, professor and general practitioner, and a founding member of the National Working Group on ESS

“The fourth pillar is likely to be the most difficult to achieve” comments Dr. Robert Woollard of RCCbc and UBC’s Department of Family Practice, and also a founding member of the National Working Group on ESS.  “Privileging is in the hands of provincial and regional processes but they often turn to national standards in their decisions. In the absence of clear national policies and standards of training, decisions are often taken, with the best of intention, which are leading to the inappropriate closure of maternity and surgical services to rural citizens across Canada. Insensitivity to the specific needs of rural communities not only compromises care but makes it difficult to imagine a career in ESS. This initiative hopes to contribute to processes and policies that will ensure a vibrant future for ESS and the quality of rural maternity and surgical services as close as possible to where rural Canadians live.”

The proposed national strategy was recently presented to73 ESS physicians attending a CME event in Banff at the end of January 2014. Iglesias reported that the National Working Group spent the evening showing the assembled physicians the results of their work, and getting feedback, suggestions, and buy-in. When asked whether general surgeons were concerned about the ESS development process, Iglesias noted that generalist surgeons were invited to participate and contribute at the Banff CME event, and that there was no divisiveness at all. In fact, the mood was “one of unbridled enthusiasm,” says Iglesias. “In this new iteration of developing policy and programs for rural surgical care, the specialist surgeons have become our partners and colleagues.”

“Most of us were energized by the [Banff CME] event,” observes Iglesias. “The average age in the room was younger than I’ve ever seen, the enthusiasm was greater, and the frustration was lower than in the past. It augurs well for the future of ESS.”

“There really are no controversies out there with the ESS process, just a whole lot of work to be done.”

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