Letter to the Editor: Author Response.

Jude Kornelsen raises several issues, almost all of which are focused on rural obstetrics rather than rural general surgery, which was the focus of the proposed training curricula.1 In response to the concerns regarding volume outcomes, the literature we referenced was not limited to complex major surgery, but included hernia repairs and endoscopy, which are largely elective outpatient procedures wherein distance to care would be irrelevant and system issues are minimized, yet a clear signal of volume to outcome is still seen. We agree that time and distance to emergency care is a determinant to outcome and always will be. The effects are not limited to rural environments nor to obstetrical situations. They also apply to fire, security and policing services. Outcomes of cardiac arrest in Canada’s largest city are worse on the upper floors of high-rise buildings than at street level.2 Unless all people live at equidistant locations from emergency services there will always be inequitable outcomes. The important questions are what high-quality services can be sustainably provided in remote communities, by whom and at what cost, and when should we expect the patient or provider to travel to enable health care services. We reiterate that a comprehensive analysis of geographic and demographic parameters that can support sustainable services analogous to that done in Australia would be helpful in depoliticizing the issue. We disagree that the higher cesarean section (C section) rates when performed by general surgeons in the studies referenced are an argument in favour of family physicians providing the service. The optimal rate of C section is still unclear, but a recent major study3 has suggested that maternal and neonatal mortality are minimized at C section rates of 19%, far higher than previous recommendations. We reiterate that quality outcomes are far more important than travel time or distance and should not be compromised for expediency. Outcomes are measured in lifetimes, whereas travel time is measured in hours. We see absolutely no evidence that supports the premise that training family physicians to do hernia repairs, endoscopy or other minor surgery will enhance obstetrical outcomes in remote communities. The proposed surgical curriculum deviates so substantially from standard surgical curricula that we consider it highly unlikely to result in surgical competency. Solutions to obstetrical issues should not compromise the quality of surgical care.