We fully support the decision to improve the self-regulation of our profession and the resultant reassurance of the public about doctors' efficacy. We offer some thoughts on how the provincial Privileging Standards Project might be made more relevant and effective, moving from permissive to criteria-based privileging, for rural medicine. We also anticipate unintended consequences from the project's reliance on numbers--loss of maternity, anesthesia, surgery, and emergency services in rural BC.

Currency
A practitioner begins his or her career with a currency capital account--large on training and education and low on experience. The account is sustained by procedural experience, CPD, team-based care, and measured outcomes of practice examined in local and regional continuous quality improvement systems. Some procedures, all complex and requiring extensive support, show evidence that volume thresholds are, indeed, a prerequisite for good outcomes. Examples are cardiac and thoracic surgery.[1,2] For procedures that are performed in rural BC, there is no evidence that there is any minimum volume to sustain either currency or competency.[3] Unfortunately, the methodology chosen by the provincial Privileging Standards Project to find a number seems to belong more to gaming theory than it does to evidence-based medicine and is unlikely to be helpful is assessing competency or currency.

Competency
Privileging must clearly be linked to competency. Is currency (in the absence of clear statements about competency) being used as a surrogate for competency? The literature on competency and the avoidance of medical error directs us to the importance of systems--in particular, continuous quality improvement systems, including measured outcomes, risk identification, and risk management protocols.[4] Outcomes are formally assessed in protected discussion, directing improvement strategies. Currency, in a low-volume generalist model, does not belong exclusively to an individual practitioner. Rather, it must be examined within the context of a program of care as typically delivered in a rural setting. It is this theme of team currency and competence that is foundational to programs like MORE-OB and the CARE Course.

Unintended consequence: Loss of medical services
We fear that an unintended consequence of the adoption of volume thresholds as markers of currency and competency will be the departure from rural BC of physicians with advanced skills in surgery, anesthesia, emergency, and maternity care. Indeed, this has already happened. 

These practitioners of procedural care work within a generalist model, which validates their low volumes.[5] The provincial Privileging Standards Project proposes to replace this model with one in which the tracking of their procedure volumes would identify them as outliers. As everyone is aware, it is difficult to recruit and retain physicians with both the appropriate advanced skills and the inclination to practise in rural BC. Volume thresholds and identification as an outlier will cause physicians to further avoid these work environments. 

There is a substantial body of evidence confirming that small volume rural outcomes are as good or better when compared to higher volume programs.[3,6,7] Equally important, there are no studies that document poorer outcomes for these programs. Collectively, maternity, surgery, anesthesia, and emergency medicine services stabilize rural health. In their absence, the literature describes a cascade effect where, ultimately, affected communities lose services.[8-10] A privileging project designed to improve a specialist problem in diagnostic imaging cannot be effectively transplanted to generalist rural medicine.

References

1. Hannan EL, Racz M, Kavey RE, et al. Pediatric cardiac surgery: The effect of hospital and surgeon volume on in-hospital mortality. Pediatrics 1998;101:963-969.
2. Dimick JB, Pronovost PJ, Cowan JA, et al. Surgical volume and quality of care for esophageal resection: Do high-volume hospitals have fewer complications? Ann Thorac Surg 2003;75:337-341.
3. Iglesias S, Hutten-Czapski P. Joint position paper on training for rural family practitioners in advanced maternity skills and cesarean section. Can J Rural Med 1999;4:209-216.
4. Kritchevsky SB, Simmons BP. Continuous quality improvement. Concepts and applications for physician care. JAMA 1991;266:1817-1823.
5. World Rural Conference on Generalism, Australian College of Rural and Remote Medicine. Cairns consensus statement on rural generalist medicine. 2013. [self-published document]. Accessed 13 August 2014. http://rccbc.ca/CairnsConsensus [16].
6. Hays RB, Evans RJ, Veitch C. The quality of procedural rural medical practice in Australia. Rural Remote Health 2005;5:474.
7. Krones R, Radford P, Cunningham C, et al. Thrombolysis for acute ST elevation myocardial infarction: A pilot study comparing results from GP led small rural health emergency departments with results from a physician led sub-regional emergency department. Rural Remote Health 2012;12:2013.
8. Bindman AB, Keane D, Lurie N. A public hospital closes. Impact on patients' access to care and health status. JAMA 1990;264:2899-2904.
9. Society of Rural Physicians of Canada. Rural Hospital Service Closures. 2009. Accessed 6 August 2014. www.srpc.ca/PDF/H_closures_2009.pdf [17].
10. Holmes GM, Slifkin RT, Randolph RK, et al. The effect of rural hospital closures on community economic health. Health Serv Res 2006;41:467-485.

Additional reading
The group's position paper, Provincial Privileging Project concerns, is available at www.rccbc.ca/PPP [18].

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Dr Avery is a rural physician in Port McNeill and executive director of the Rural Coordination Centre of BC (RCCbc). Dr Boyd is a rural physician in Nelson and lead of the provincial Rural Obstetrics Network. Dr Iglesias is a rural physician in Bella Bella and lead of the provincial Enhanced Surgical Skills Network. Dr Johnston is a rural physician in Oliver and associate director of RCCbc. Dr Klein is a Vancouver physician and researcher with a focus on maternal health. Dr Ruddiman is a rural physician in Oliver and co-chair of the Joint Standing Committee on Rural Issues. Dr Woollard is a Vancouver physician and leader in fostering the development of social accountability within medical schools.