Time to revisit the skills and competencies required to work in rural general hospitals.

OBJECTIVES: To determine the structure and demographic of medical teams working in Rural General Hospitals (RGHs) in Scotland, and to gain insight into their experiences and determine their opinions on a remote and rural medical training pathway.
DESIGN: Structured face-to-face interviews. Interviews were partially anonymised, and underwent thematic analysis.
SETTING: Medical departments of the six RGHs in Scotland 2018-2019. PARTICIPANTS: 14 medical consultants and 23 junior doctors working in RGHs in Scotland. Inclusion criteria: Present at time of site visit, medical consultant in an RGH or junior doctor working in an RGH who provides care for medical patients. Exclusion criteria: Doctors on leave or off shift. Medical consultants with less than one month of experience in post. Non-medical specialty consultants e.g. surgical or anaesthetic consultants.
RESULTS: Of 21 consultant posts in the RGHs, only eight are filled with resident consultants, the remainder rely on locums. Consultants found working as generalists rewarding and challenging, and juniors found it to be a good training experience. Consultants feel little professional isolation due to modern connectivity. The majority of consultants (12/14) and all junior doctors favour a remote and rural medicine training pathway encompassing a mandatory paediatrics component, and feel this would help with consultant recruitment and retention.
CONCLUSION: RGHs medical departments are reliant on locum consultants. The development of a remote and rural training medical training pathway is endorsed by the current medical teams of RGHs and has the potential to improve medical consultant staffing in RGHs.

Introduction

There are six Rural General Hospitals (RGHs) serving Scotland’s most remote and rural (R&R) populations (Fig 1) [1]. These are NHS hospitals in towns with small populations of over three thousand that require a consultant led service to meet their healthcare needs as they are more than two hours away from larger urban centres [2]. RGHs serve populations of around 20,000–44,000 people (Table 1) [3]. They usually have an emergency department (ED), a single medical ward and a single surgical ward staffed by 8–12 junior doctors, and led by 3–4 substantive surgical, medical, and anaesthetic consultants. Due to the small size their teams must practice as generalists, rather than specialists, providing emergency care and managing chronic diseases to all patients in their locality, including children [4]. Each RGH’s ED triages patients to medicine or surgery, they are then reviewed by a junior doctor, and a medical or surgical consultant is ultimately responsible for their care. In critically ill patient, an anaesthetic consultant is normally involved soon after their arrival in the ED. RGHs can access support from specialist centres by telephone or videolink with options for patient transfer when required. This arrangement is known as the ‘Hub and Spoke model’ with the specialist centre being the hub, and RGHs the spokes. Each of the areas covered by the RGHs have their own primary care team and a local or regional public health team.

Fig 1

Rural general hospitals, and health boards.

(The dotted line shows the 103 mile drive between Raigmore and Caithness General) Source: USGS National Map Viewer.

Table 1

Populations served by RGHs in Scotland [3].

NHS Scotland Health Board	Population Number
NHS Shetland	22,990
NHS Orkney	22,190
NHS Western Isles	26,830
NHS Highland—Caithness1	25,807
NHS Highland—Fort William	22,500
NHS Highland–Oban2	44,000

1 Personal Communication via email with Ross MacKenzie NHS Highland Area Manager West, 2019.

2 Personal Communication via email with Caroline Henderson Local Area Manager, Lorn & Island Hospital, 2019.

Globally, a high proportion of the population live in rural settings [5], and Scotland is no exception with 17% of the population residing in rural areas [6]. Recruitment and retention of healthcare staff in R&R areas has always been challenge to healthcare equity, in the UK and internationally [7-9]. In Scotland this is reflected with high turnover of healthcare staff and a reliance on locums in RGHs [10].

Research into recruitment and retention of healthcare to rural areas has been carried out on regionally, nationally, internationally [11-14]. The rural pipeline model of recruitment and retention suggests that exposure of medical students and trainee doctors to rural settings (through personal connection or via training) increases the likelihood that they will both work and remain in rural areas [15-19].

The Scottish Government has tried to improve recruitment and retention of doctors to R&R areas, evidenced by numerous connected initiatives over the last two decades, however the continued reliance on locum consultants at RGHs suggests these have not be as successful as intended [1, 4, 20]. Currently, only two of the five Scottish medical schools having formal links with RGHs [21, 22]. Moreover, only a minority of Scotland’s junior doctors are exposed to RGHs during training [23]. Students at the remaining Scottish medical schools have created “Remote and Rural Medicine” Facebook groups suggesting an unmet interest [24-26]. Some Scottish remote and rural training pathways, in surgery and general practice (family medicine), have been developed in recent years which has been shown to impacted recruitment positively in some areas [27-31]. Currently, there is no R&R medical training pathway in Scotland to train hospital generalists.

Other nations facing the same challenge of ensuring healthcare equity across R&R areas, have been more successful. Canada and Australia each have national faculties of remote and rural medicine that advocate for recruitment from rural communities, provide training courses for R&R healthcare staff and undertake research into remote and rural healthcare [32, 33]. Australia has an academic open source journal “Rural and Remote Health” [34]. The USA and New Zealand also have R&R healthcare training courses [35-37].

It is against this background, namely the difficulty in recruitment and retention to medical teams at RGHs and the absence of a R&R medicine training pathway, that we have chosen to study the structure and demographic of medical teams working in RGHs, gain insight into their experience of their role, and determine their opinions on a R&R medical training pathway.

Methods

We designed questionnaires to be delivered to medical consultants and junior doctors working in each of the six RGHs in Scotland. Their aim was to gather information on demographic, previous training, experience of their role and ideas surrounding a R&R medicine training pathway.

Responses were gathered using structured face-to-face interviews between the interviewer and participant only, utilising open-questions to maximise responses, with no limit on interview duration. Separate questionnaires were designed for the medical consultants and junior doctors, in order to reflect the different roles and tenure of the two groups. The term junior doctor is used to describe all doctors below consultant grade, whether in a training programme or not.

These questionnaires were reviewed by members of the Remote and Rural Steering Group of the Royal College of Physicians of Edinburgh (RCPE) to provide feedback on both structure and content before being piloted locally in Gilbert Bain Hospital, Shetland. The final questionnaires used for the study can be viewed in S1 Appendix.

One of us (CD) visited all six RGHs between October 2018 and February 2019. CD was employed as a junior doctor working in an RGH at the time of interview, introducing potential bias in the data collection. All participants were aware of this before interview, and the questionnaire was followed in each interview to mitigate this bias.

Visits were arranged in advance by email or telephone. As many medical doctors as possible were interviewed at each site. Medical doctors on leave or off shift were excluded. A few doctors (n = 2) chose not to participate. We only interviewed locum consultants if they had more than one month’s experience working at R&R sites. Junior doctors were interviewed regardless of the team they belonged to as they all cross-covered medicine and surgery when working out of hours.

Each interviewee was given a “Participant Information Sheet” detailing the projects aims, and there we no repeat interviews conducted. Participants signed a consent form before interview, and interviews were recorded on a password encrypted recording device. Data was stored in accordance with the GDPR.

The narrative responses were recorded, transcribed and partially anonymised, retaining only the job role of the interviewee and their hospital, they were not returned to participants for comment or correction. Thematic analysis was then performed by author CD using the method of Braun and Clarke, with consultant responses and junior doctor responses analysed separately [38]. Participants were sent a pre-submission draft of the manuscript to provide feedback on findings.

Ethical approval

The Health Research Authority Decision tool was used during the design of this research and determined that research approval was not needed. Additionally, contact was made with the NHS Grampian Quality improvement and Assurance team who advised that ethical approval was not required.

Results

The six rural general hospitals each have funding for between 3 and 4 medical consultant (Table 2). Five of the 6 employ medical consultants who undertake all of their clinical work locally at their RGH, and live in the surrounding area. Failure to recruit to these posts is common, and vacancies are covered by locums. Shetland, Orkney, Fort William and Oban all have permanent medical consultants, but also depend on locum consultants (Table 2). The Western Isles hospital in the Outer Hebrides is staffed by 3 regular locum consultants, one of whom is always on site.

Table 2

Medical teams and interviewees in rural general hospitals.

Hospital	Number of consultant posts	Resident Consultants	Number of consultants interviewed	Number of Junior Posts	Number of juniors interviewed
Gilbert Bain Hospital, Shetland	4	2	3	12	4
Balfour Hospital, Orkney	3	1	3	8	2
Belford Hospital, Fort William	3	2	2	9	5
Lorn and Islands Hospital, Oban	4	3	2	10	4
Western Isles Hospital, Outer Hebrides	3	01	1	12	5
Caithness General Hospital, Wick	4	02	3	10	3
TOTAL	21	8	14	61	23

1 Three regular locums, at least one of whom is always on site.

2 Five medical consultants who rotate on a regular basis from Raigmore Hospital, Inverness.

The Caithness General Hospital in Wick has adopted a rotational model of medical consultant staffing (Table 2). Five medical consultants split their clinical time between their specialist work at Raigmore Hospital in Inverness (the hub) and generalist work in Caithness (the spoke). Each undertakes four days on call every fifth week in Caithness while the rest of their clinical time is spent in Inverness where they live (Fig 1). Weekends and any vacancies in the medical consultant rota are covered by locums.

Medical consultants

One of us (CD) interviewed 12 male and 2 female consultants. Two were under 40 years of age, five were 40–49 years of age, four were 50–59 years old and three were over 60 years of age. All but one had been raised in an R&R area and/or had previous experience working in a R&R area before taking up their posts. Only 2 of the 14 had spent their entire consultant career in a RGH. Thirteen of the 14 had trained in GIM, but only two had created an R&R training pathway for themselves. Their other specialist interests were diverse as shown in Table 3.

Table 3

Consultants interviewed.

Hospital and Interviewee	Previous R&R	GIM	Specialty	Consultancy (years)	Current post (years)
Shetland 1	Y	Y	Diabetes	19	5
Shetland 2	Y	N	Cardiology	11	1
Shetland 3	Y	Y	R&R1	14	14
Orkney 1	Y	Y	Acute	5	1
Orkney 2	Y	Y	Respiratory	13	4
Orkney 3	Y	Y	Nephrology	21	4
Fort William 1	Y	Y	GP	6	102
Fort William 2	Y	Y	Gastro	26	26
Oban 1	Y	Y	Diabetes	25	1
Oban 2	N	Y	Nephrology	18	1
Western Isles 1	Y	Y	None	9	4
Caithness 1	Y	Y	None	20	15
Caithness 2	Y	Y	R&R1	7	4
Caithness 3	Y	Y	Acute	3	3

1Specialist interest in Remote and Rural. During their specialist training each of these consultants had an individual agreement with their deanery to undertake extra training outside the scope of their speciality (e.g. Psychiatry for 6 months) to allow them to practice more effectively as a generalist in the future.

2Underwent Caesar Route to specialist accreditation in General Internal Medicine, initially being under supervision in their role whilst gaining consultant qualification.

Thematic analysis of consultant interviews

Theme 1: Generalist medicine

Consultants said they enjoyed the generalist aspect of their clinical practice, managing patients presenting with a broad range of acute and chronic diseases. This breadth was colourfully defined by one consultant as “if you can’t put a knife in it, and she isn’t about to deliver it’s medicine and you deal with it”. Their role was often contrasted with previous roles held within their speciality to highlight dealing regularly with unfamiliarity. Whilst this was satisfying, it was also a source of stress and challenge, and required regular advice from colleagues elsewhere in other specialties. The importance of finding a balance between, “giving things a go” and awareness of ones limitations,

“It is proper general medicine, its challenging and refreshing”

Consultant 2

“It makes you very humble when you are in a position when you don’t know, and it makes you feel like a junior doctor again when you are talking to a colleague in another speciality who knows more than you”

Consultant 4

Working in small regular teams was considered a positive aspect of the role, allowing the development of deeper bonds with local colleagues. Several consultants commented that as the majority of junior doctors they worked with were at an early stage in their career, and there are no “middle grades” (specialist trainees below consultant grade) it can create more work, particularly supervising procedures.

Theme 2: Professional isolation

Consultants spoke of the ease with which technology connected them to specialists and other information sources. Two factors did however occasionally contribute to professional isolation: a lack of understanding from colleagues at hub centres about the role and challenges of RGHs (generally considered to be a rare occurrence) and difficulty attending educational meetings that related to their specialty. On call commitments are higher at RGHs than at larger centres, and the travel time to Continued Professional Development (CPD) events is longer, making it inherently difficult to attend. Several consultants commented, that a richness and enjoyment in CPDs is lost when doing them online rather than in person. Consultants who rotated between Caithness and Raigmore did not experience feelings of professional isolation.

“A willingness to realise you are isolated, and a willingness to do something about it is important”

Consultant 2

Theme 3: Training pathways

Most consultants (12/14) felt there should be a R&R medicine training pathway though some were concerned that it might deter otherwise competent medical consultants from applying and/or limit career options for a new consultant. There was no clear consensus, however, on how such a R&R medicine training pathway might be configured. Two options were proposed:

Trainees undertake General Internal Medicine training with a specialist interest in Remote and Rural medicine.

A post Completion Certificate of Training (CCT) syllabus of R&R skills and competencies could be completed by individuals if not already achieved during training and not already covered by the skills and competencies of consultants already in post.

Training experiences that were cited as most useful were acute takes; seeing a breadth of different pathologies, being responsible for a large number of patients and leading a team. It was felt that it would not be possible to see the volume of patients required for adequate training at R&R sites and therefore that the majority of training would need to occur at Hub centres.

Theme 4: Paediatrics

Provision of care for paediatric patients was a particular source of stress and concern for consultants working in RGHs, even with remote support from specialist paediatric units. This was because of limited exposure to paediatrics in medical training programmes but initial responsibility for paediatric care presenting to the emergency department. Often medical consultants had voluntarily undertaken paediatric resuscitation courses, and in emergencies the RGHs anaesthetic consultants usually assisted. Only the Western Isles hospital has locum consultant paediatricians on site. All agreed that some form of training in paediatrics was an essential requirement for a remote and rural training pathway.

“I am not a paediatrician, but I’m expected to be able to manage the first stages of a paediatric emergency”

Consultant 5

Junior doctors

We interviewed 12 male and 11 female junior doctors. Twenty one were 20–29 years of age, one was 30–39 years of age, and one was 40–49 years of age. Twelve of the juniors had been raised in an R&R area, enjoyed a previous R&R placement in medical school, or belonged to an R&R student society. Fifteen juniors were in training posts and eight were in locum posts. Seven trainees and seven locums applied specifically to work in an R&R area. Fifteen juniors said they were interested in working in R&R areas in the future (Table 4).

Table 4

Junior doctors interviewed.

Hospital	Previous R&R	Stage of training1	Applied to work R&R	Future interest R&R
Shetland 2	N	Locum FY2 (3)	Y	Y
Shetland 3	N	Locum FY2 (3)	Y	N
Shetland 1	Y	Locum FY2 (3)	Y	Y
Shetland 4	Y	FY2	N	N
Orkney 1	Y	Locum FY2 (4)	Y	Y
Orkney 2	Y	Locum FY2 (4)	Y	Y
Fort William 1	N	FY1	N	N
Fort William 2	N	GPST1	Y	Y
Fort William 3	Y	FY1	Y	Y
Fort William 4	Y	Locum FY2 (3)	Y	N
Fort William 5	N	FY2	N	N
Oban 1	Y	GPST1	Y	Y
Oban 2	Y	FY2	Y	Y
Oban 3	N	FY1	N	N
Oban 4	N	FY1	Y	N
Western Isles 1	Y	GPST1	Y	Y
Western Isles 2	N	FY2	N	Y
Western Isles 3	Y	FY2	Y	Y
Western Isles 4	N	CST1	N	N
Western Isles 5	Y	FY2	N	Y
Caithness 1	N	FY2	N	N
Caithness 2	N	Locum CMT2	Y	N
Caithness 3	Y	Locum FY2 (4)	N	Y

R&R = Remote and Rural; FY1 = Foundation year 1; FY2 = Foundation Year 2.

GPST1 = General Practice Specialty Trainee 1; CST1 = Core Surgical Trainee 1.

1Number of years since qualification is denoted in brackets for junior doctors in locum posts.

Each of the six rural general hospitals have funding for between 8 and 12 junior doctors and offer a mixture of training and non-training posts. The most senior of these are core trainees in medicine and surgery. There are no registrars at any of the six RGHs (Table 4). All junior doctors, except FY1s, contribute to the on call rota. The exception was the Western Isles where junior doctors do not undertake night shifts, which are provided by an A&E specialist, a paediatrician, and specialist nurses.

Thematic analysis of junior doctor interviews

Juniors also found working as a generalist a useful and enjoyable learning experience. They saw a breadth of pathology, grew in confidence as they learned how to manage patients at night with limited access to tests, and were “encouraged to think like registrars” as they discussed queries directly with consultants whenever needed. Some juniors missed having “middle grades” whom they could approach for advice as they had done in larger centres.

“You get to do a lot more clinically, you don’t get this hands on experience in a less remote setting”

Junior Doctor 3

Some juniors found working in the Emergency Department difficult. Of note they felt supported when dealing with major cases, as they would get consultant help, but several reported struggling with “minor injuries” due to lack of formal emergency department training.

“I don’t like dealing with minors in A&E, I’m unsure of what to do, but it can feel too small to ask for help so I have to spend a lot of time looking it up……….. And I’m slow at suturing”

Junior 6

All of the juniors enjoyed working in small teams amongst a relatively small population, as they established better relationships with their colleagues and regular patients. The team sizes meant the rota was less flexible, which could lead to issues regarding leave and attending training courses.

“You get to know you patient better and your colleagues better”

Junior Doctor 10

Theme 2: Training pathways

All juniors believed there should be a training pathway for consultants in R&R medicine and that this would improve recruitment. Their view was that the training pathway should follow general medical training and that R&R medicine should be an independent specialism. They felt the pathway should be “more general” than other medical training pathways, but weren’t sure how this might be achieved and other than paediatric training, no specific examples were given of what should be in the pathway. This may reflect that all juniors interviewed had not undertaken any speciality training as they were in the first few years of their career.

Theme 3: Paediatrics

Juniors found seeing paediatric patients stressful, normally due to limited paediatric training. Training in paediatrics was mentioned by each junior as something that would be a vital part of a remote and rural training pathway.

“I find seeing the paediatric cases in A&E difficult”

Junior doctor 11

Discussion

The main findings of our study are: that failure to recruit to medical consultant posts in Scottish RGHs is common with frequent use of locums to cover vacancies; that medical consultants’ specialist interests are diverse; and that consultants enjoy the generalist aspect of their clinical practice but do occasionally experience feelings of professional isolation. Most felt there should be a Scottish R&R medicine training pathway and that some form of training in paediatrics was an essential requirement, though there was no clear consensus on how such a training pathway might be configured. Juniors also found working as a generalist a useful learning experience and grew in confidence as they learned how to manage patients at night with limited access to tests. All agreed that training in paediatrics should be a vital part of a remote and rural training pathway.

RGHs currently offer one of two models of consultant led care. Five hospitals (Shetland, Orkney, Oban, Fort William and Western Isles) have attempted to staff their medical units with consultants who live locally and embed themselves in their local communities. This has only been partially successful as evidenced by the fact that all five currently require locum consultants to fill gaps. One RGH (Wick) rotates permanent medical consultant from the hub in Inverness to the spoke in Caithness on a weekly basis but still relies on locum consultant cover at weekends. It is our view that what may work well in one hospital may not be suitable or appropriate in another. Rotating between Inverness and Caithness may remove feelings of professional isolation, but may lead to challenges in continuity of care and may be a less than ideal solution for the three island RGHs.

Health care equity is a guiding principle of the NHS [39]. The delivery of generalist secondary care medical services to remote and rural areas of Scotland needs initiatives that work. Central to this discussion must be the creation of a training pathway(s) that encourages doctors to consider a career in a RGH. Thematic analysis suggested two possibilities: either that trainees undertake Remote and Rural medicine as a specialist interest, or a post CCT syllabus of R&R skills and competencies mapped to the needs of individuals and the skill set of the team they are joining. While we recognise that there will always be social and demographic factors such as distance from family and friends that deter some doctors from working in RGHs we believe that the creation of a medical remote and rural training pathway(s) is a pragmatic solution to the workforce challenges faced by RGHs [17, 40–42]. Recruitment to this pathway could focus on doctors with remote and rural exposure, as is the case for no fewer than 13 of 14 consultants interviewed, supporting the rural pipeline model of recruitment.

We are not the first to suggest that remote and rural medicine should have its own training pathway in Scotland. Wilson and McHardy, in their review of remote and rural training in Scotland in 2001–2, noted the tendency of hospital training programmes to prepare sub-specialists for secondary and specialist care centres, rather than training generalists who might work in remote and rural areas where a wider repertoire of less specialised skills and roles are necessary. They went on to list the skills and competencies that might be required of a training programme for remote and rural medical consultants [43].

Now may be the time to form this training pathway. The established remote and rural training pathways in general practice (family medicine) and surgery provide local examples, and give the potential for collaboration [28, 31, 44]. The Scottish Executive, UK government, and the UK General Medical Council have all recognised the issue of staffing R&R areas and made recommendations about the training needs of generalists [45-47]. while other nations provide researched models of R&R training pathways and their impact on recruitment, with evidence of collaboration that Scotland could emulate [48-55].

In conclusion, Rural General Hospitals are vital to the provision of good healthcare across Scotland. Their medical units evidently need new approaches to recruitment and retention of consultant staff. The development of a remote and rural medicine training pathway(s) would aid recruitment by creating a clear route for interested junior doctors and consultants to follow, and would prepare them to meet the needs of the people who live in remote and rural areas. This would follow the trajectory taken by other nations with more robust remote and rural healthcare systems [54, 55]. Much has changed since Wilson and McHardy published their 2004 recommendation [43]. All six of the RGHs now have their own CT scanners, and telemedine and guidelines are the rule rather than the exception, but the fundamental issue of the training of generalist medical consultants remains. We believe it is time to follow the surgeons and general practitioners, and our international colleagues, and clarify the skills and competencies required of a generalist medical consultant. This is a necessary step to ensure healthcare equity throughout Scotland.

Consultant and trainee questionnaires.

(DOCX)

Click here for additional data file.

(PDF)

Click here for additional data file.

4 May 2020

PONE-D-20-06347

Time to revisit the skills and competencies required to work in Rural General Hospitals

PLOS ONE

Dear Dr Doyle,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript addresses an important topic for rural and remote health care not just in Scotland but in many countries. Both reviewers have highlighted the importance of situating the work in a broader context, particularly given the international audience of the journal. In addition reviewer 2 has provide some suggestions for enriching the analysis of the results and I invite you to consider these comments in revising the work.

We would appreciate receiving your revised manuscript by Jun 18 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This study presents original research results that do not appear to have been published elsewhere. The analysis is appropriate for this qualitative study and is described in sufficient detail. Conclusions are presented appropriately and supported by the data. The article is intelligibly written in clear English. The appropriate ethics decision tool and consultation determined that research ethics approval the was not needed. The article appears to adheres to appropriate reporting guidelines of the standard for data availability. The abstract concisely describes the paper.

The introduction is clear, however for an international audience it would be helpful to provide more detail about the context, specifically what other doctors are part of the healthcare team at the rural general hospitals that were studied. The literature review is appropriate for this Scottish paper, but for an international audience could be expanded to include broader references to rural generalist practice in rural general hospitals in other comparable international settings.

The method is clearly described including identification of potential bias.

The results are clearly presented and form the basis of an excellent discussion

Reviewer #2: Thank you for the opportunity to review this paper. It is on the important topic of equity between rural/remote and urban populations with respect to medical care in Scotland. However it shows remarkably little insight into the large volume of publications from elsewhere in the world around this topic. In Australia, the a College of Rural and Remote Medicine (ACRRM) which does exactly as they have recommended has been in existence for more than two decades. Remote medical schools have existed in Canada and the US for 30 years with the mandate of producing a rural medical workforce, with evidence that they do so. The Rural and Remote Health journal, also based in Australia, has a list of relevant publications on this topic – plus more that could be found in a medline search. The present paper would be greatly enriched by considering this literature, and how care is provided elsewhere in the world where are populations are thousands, not hundreds, of kilometres far from city centres.

The method was suitable, and the themes not unexpected, however, the data appear not to be as rich as would be expected. With respect to the consultants, how does a general physician deal with road accidents requiring emergency surgery for example? How do they manage critical care? How do they ensure appropriate immunisation schedules for infants? Do they provide obstetric care, particularly for obstetric emergencies? These scenarios are surely commonplace in remote practice, and one would assume that some depth of what “generalism” meant should have come up in the interviews. For example how does an endocrinologist with 19 years’ experience deal with stroke in an elderly person, or a 21-year qualified Neurologist deal with sceptic diabetic ulcers?

The same could be said of the junior doctor interviews. If they are managing nights in a hospital without resident consultants, who do they call when the case management is entirely out of their competency? How to they feel about this? Is that why they think a new specialisation is needed? What do they think should be in it? I doubt that paediatrics difficulties is all they encounter!

I would suggest that the authors read the literature, and enlarge the scope of their interviews, and resubmit a new manuscript. I highly recommend that they do so, because they are correct in thinking this is an important area to research and publish in with insights into the local conditions pertaining in Scotland.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Professor James Rourke, Honorary Research Professor and former Dean of Medicine, Memorial University of Newfoundland, Society of Rural Physicians of Canada co-chair of Rural Road Map Implementation Committee

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

19 Aug 2020

Dear Reviewers,

Thank you for taking the time to read and review our manuscript. We have found your comments extremely helpful and feel our revised manuscript is a much more interesting piece of work as a result.

There have been two major changes to the paper. The first is to make the paper more readable to an international audience by expanding our description of Scottish Rural General Hospitals (RGHs) and discussing remote and rural healthcare internationally.

The second major change is clarification of our exclusion criteria and expanding our thematic analysis section to give more detail from interviewees.

Below is are more detailed responses to specific comments (reviewers comments are in bold italics)

The introduction is clear, however for an international audience it would be helpful to provide more detail about the context, specifically what other doctors are part of the healthcare team at the rural general hospitals that were studied.

In our introduction, we have expanded the first paragraph describing the Rural General Hospitals (RGHs). We have added detail about how patients are managed in the emergency department, the role of anaesthetic and surgical consultants, and the wider healthcare infrastructure in the areas covered by RGHs (primary care and public health). We feel these changes have added clarity, particularly for international readers.

The literature review is appropriate for this Scottish paper, but for an international audience could be expanded to include broader references to rural generalist practice in rural general hospitals in other comparable international settings.

However it shows remarkably little insight into the large volume of publications from elsewhere in the world around this topic. …The present paper would be greatly enriched by considering this literature, and how care is provided elsewhere in the world where are populations are thousands, not hundreds, of kilometres far from city centres.

We have made changes throughout the paper to discuss remote and rural healthcare internationally, and feel this has enriched the paper. In the introduction, we discuss how Scotland is not unique in needing to provide healthcare in remote and rural settings to ensure healthcare equity, and describe how other nations have succeeded. In the discussion, we re-iterate that other nations provide an example of remote and rural healthcare that Scotland can follow, and cite researched examples in Australia and Canada showing the impact of training on recruitment and retention.

Throughout the manuscript, we have tried to be more mindful towards international readers, who are unlikely to be familiar with the idiosyncrasies of the NHS in remote and rural Scotland. We have summarised a paragraph in the introduction that mentioned numerous Scottish government policy papers, and throughout have tried to use healthcare related terms that will be understood internationally.

The method was suitable, and the themes not unexpected, however, the data appear not to be as rich as would be expected. With respect to the consultants, how does a general physician deal with road accidents requiring emergency surgery for example? How do they manage critical care? How do they ensure appropriate immunisation schedules for infants? Do they provide obstetric care, particularly for obstetric emergencies? These scenarios are surely commonplace in remote practice, and one would assume that some depth of what “generalism” meant should have come up in the interviews. For example how does an endocrinologist with 19 years’ experience deal with stroke in an elderly person, or a 21-year qualified Neurologist deal with sceptic diabetic ulcers?

The same could be said of the junior doctor interviews. If they are managing nights in a hospital without resident consultants, who do they call when the case management is entirely out of their competency? How to they feel about this? Is that why they think a new specialisation is needed? What do they think should be in it? I doubt that paediatrics difficulties is all they encounter!

This was a helpful comment, as our original manuscript did not include much detail on how the RGHs operate, particularly between the different teams of doctors. We have added to the introduction about the management of major cases, and that there are primary care and public health teams covering these areas who co-ordinate immunisations. We have also tried to clarify that we only interviewed medical consultants, not surgical or anaesthetic consultants, and have explicitly added this to the exclusion criteria. Medical consultants would have little involvement in obstetric care and road accidents at RGHs, the surgical and anaesthetic teams would manage this.

We have expanded the thematic analysis sections. We have added detail about how some consultants described “generalism” as a concept. Some of the lack of richness, may be due to the questions we asked. The consultants did not go into details of cases outside their specialties, but discussed this concept generally.

For the junior doctor thematic analysis, we have expanded the difficulties they encounter, namely that they struggle with “minor injuries” in the ED due to lack of previous experience, and with having no “middle grade” doctors to go to for advice.

While all of the juniors felt there should be a remote and rural medical training pathway, none gave details except that paediatrics should be included. This may reflect that they are all within the first few years of their career, and have not undergone any specialism training. Additionally, the juniors interviewed have only worked in RGHs for a number of months, and may not have reflected as deeply as the consultants on the need for such a pathway.

Thank you for your consideration, we hope this is a clear response to your helpful comments.

Sincerely,

Authors of manuscript

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

23 Sep 2020

Time to revisit the skills and competencies required to work in Rural General Hospitals

PONE-D-20-06347R1

Dear Dr. Doyle,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for your responses to reviewer comments and manuscript revisions. These have satisfactorily addressed the comments.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Dr James Rourke, Professor Emeritus and former Dean of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada

29 Sep 2020

PONE-D-20-06347R1

Time to revisit the skills and competencies required to work in Rural General Hospitals

Dear Dr. Doyle:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr Jenny Wilkinson

Academic Editor

PLOS ONE