Recruiting rural physicians

[Guest MED09]

Hey Everyone,

 

I've been thinking about this issue a lot lately and wondering if anyone has any thoughts on the subject.

 

Although strategies have been put in place to attract physicians to work in rural areas, there seems to be an increasing shortage of doctors in these areas.

 

Does anyone have any thoughts on how physicians could be recruited to rural areas such as Northern Ontario? What about without financial incentives?

[Guest Steve MD09]

I think most med schools believe that people originally from rural communities are fairly likely to return there to practice, so some of them are aiming to attract medical students from these areas.

[Guest happy2bme]

I believe though rural applicants are still a low a percentage% of all applicants, and thusly schools must make rural at least a "considered" option for their urban students.

 

I think Manitoba is making headway in this area. Their clerkship portion for family medicine is mandatory rural, (unless you have extenuating circumstances that require you to stay in the city). Therefore everyone knows when applying to the UofM that this is part of the training they will receive. They also have a "Rural Exposure week". and return for service grants immediately out of med school/residency.

 

I think part of the theory behind this is the fact that most students are either unmarried/attached or attached with the possibity of having children at the age they leave med school. If you go rural and are single, you might hook up with someone in the surrounding rural area making the option of staying once your return for service is over and you are out of your contract. If you have kids and you're rural you may be also under pressure to "not uproot the kids" and may also stay longer than you intended. According to a study or a poll I read, why most rural physicians choose to go rural, financial incentives were at the bottom of the list. So throwing money around as carrots obviously is not the ultimate solution.

[Guest PMD109]

I think lack of rural physicians is the symptom of a larger problem. This problem being that rural canada is shrinking coast to coast. If you come from a rual area think back to high school and then look at how many of your friends are now in a city. Its easily 90% of the peope i know are gone to an urban center. As for fixing the problem well rebuilding rural canada is a huge task......as for recruiting docs...well certain groups in rural areas have recruitment programs and I think those that are agressive tend to convince docs to settle in their communities.

[Guest NurseNathalie]

Even though the issue of recruitment and retention is not only specific to Northern Ontario, since I've had personal experience living there- I'll only comment on that:

 

I beleive that social factors specific to Northern Ontario are major obstacles in successfully recruiting (AND retaining) physicians in our rural areas.

 

From my experience, we had many physicians find their way to northern ontario, with a genuine interest in practicing there... only to find that they could not deal with the social/economic issues of the community- and leaving ...

 

:\

 

Its more than offering a big incentive to recruit physicians from urban areas, hoping they 'make roots and stay'...

 

its even more than training the ppl of northern ontario to become doctors and practice there.. .

 

we have to invest in northern Ontario, so that we stop losing our youth.. we have to make northern ontario a place where businesses want to come- where health practitioners want to live with their families (let alone only physicians!)...

 

I find it very sad (and embarassing for Ontario) that living in Northern Ontario is a negative determinant of health!

 

just my two cents

[Guest Lactic Folly]

There needs to be enough resources/training available so that people will feel comfortable practicing medicine away from the support of a tertiary care centre. Also, the amount of people interested in specializing means that some will be practicing in urban areas by default.

re: happy2me- I thought that it would be less likely for single people to want to go to a rural area, as you can't date your patients..

[Guest mesoderm]

From my experience, we had many physicians find their way to northern ontario, with a genuine interest in practicing there... only to find that they could not deal with the social/economic issues of the community- and leaving ...

 

I've never lived in a rural community, and I'm a little curious, mind if you elaborate on the "social/economic issues" you just mentioned??

[Guest happy2bme]

LOL

Yes I do agree it 's forbidden to date patients!! But I was referring to rural as everything outside a city. Some communities do indeed have one doc only, but many rural communities have a couple . For example a town of 10 000 is still rural but yet may have more than one doc, making part of your community fair game for fostering relationships.

[Guest opiedog]

www.srpc.ca/ruralmed.html This web site might offer some review information for those that are interested.

[Guest satsumargirl]

You know you'd be surprised what is considered rural...Guelph, Cambridge, Pickering, Whitby....not exactly living in a big city but Whitby and Pickering are half an hour from downtown TO, so not exactly in boony land either!

 

Anyway, at U Ottawa all first years have to complete a "week in the country" placement. So they are trying to expose us to rural medicine early on and rural lifestyle.

 

My weekly afternoon placement happens to be about 50 minutes from Ottawa in a small little town that pretty much consists of 2 intersecting streets. And if I were to be a family physician I would probably opt for rural if I could since they get to see pretty much everything....I have seen many things I wouldn`t have if my placement was right in Ottawa...because there is no emerg hospital in this town and most people aren`t going to drive 50 min to get to a hospital unless they really need to.

 

That being said...I probably won`t be a family doc and as a specialist I probably would want to be a in a bigger centre. Also, many of us have spouses/significant others who have jobs that don`t permit living in a rural setting. So likely, the money being spent on me to do this rural placement (gov't is footing most of the bill for us) is wasted...but it is mandatory so, gotta do it.

 

Anyway...this is one strategy, I don`t know how successful it is/will be.

[Guest nova175]

I live in a rural community in Nova Scotia- it is not uncommon for patients to drive an hour to get to their family doctor. The shortage of rural physicians here is a huge problem, especially in the case of an emergency. Farm accidents are so popular, and are most of the time out in the middle of nowhere. I can understand how one would have seen things that they would not have if they were in a urban setting.

[Guest GP2B]

hi nova, i too am from rural ns... and hope to be a rural gp someday. i think that addressing lifestyle issues will be important to recruiting more rural physicians in the future (i.e. arranging locums so that doctors can have some time away or with their families).

[Guest physiology]

UBC has several initiatives as well:

 

1) a family practice COURSE that runs throughout the first 2 years of medical school (often consists of working with family doctors in various settings such as obstetrics, run of the mill urban practices, inner-city practices, addiction medicine, palliative, prisons even).

 

2) a mandatory rural family practice rotation - many graduates have said that this was the best rotation they ever did

 

3) regionalized programs - Island medical program, Northern Medical Program and of course the program based in Vancouver. All 3 programs are distinct, but essentially the same in terms of content and learning.

 

As a result of these initiatives, a high percentage of UBC grads go into family practice. I believe it was around 40% this year and around the same last.

 

Physio

[Guest cracked30]

www.walrusmagazine.com/ar...20/0227258

 

The Cost of Care

 

Thanks to rising costs, the rural doctor is a vanishing breed

 

by Alistair Brown

 

Unable to get a university education in her native Romania, Elena Mihu emigrated to Canada, arriving in 1986. She was alone, with a dental technician's certificate and a hunger for knowledge. In less than ten years, she taught herself English, was accepted into university, and graduated from McMaster University's medical school. She also owed the government $100,000 in student loans and dearly missed the rural life of her childhood. On weekends she and her husband, Jean-Claude, would drive north in search of country property. On one such trip they found both the perfect home and a "Doctor Wanted" notice pinned to the door of the Kinmount township office.

 

The sign was not new. For almost six years there had been no local health services in Kinmount, Ontario—no family doctor, no immediate emergency care, with the nearest hospital some twenty kilometres away. The town, cradled by a long bend of the Burnt River at the edge of the Haliburton Highlands, numbered almost 400 permanent inhabitants. Several thousand more people lived in the immediate townships, and each summer the population increased significantly. If you fell ill here, however, you were on your own.

 

Then suddenly, in 1999, the sign was taken down and a banner welcoming Mihu replaced it. Kinmount, miraculously, had acquired a family physician.

 

Visit any medical school in Canada and ask, "Who plans to practise family medicine?" and too few hands will go up. Having competed with thousands to get into these prestigious schools, and already deeply in debt, most of these ambitious young adults feel they cannot afford to become family doctors in Canada. Without fringe benefits, and after the expenses of renting a clinic, paying for receptionists and nurses, and buying equipment and supplies, a family doctor working forty-hour weeks could expect to take home roughly the salary of a union plumber, auto worker, or skilled bricklayer (around $70,000). But with a few more years of training, medical students can become specialists, virtually guaranteeing them twice the income of a family doctor.

 

No wonder family medicine is an increasingly unpopular option, especially if it means having to move to a community that cannot provide a job for your spouse or decent schools for your kids. Reside in a Canadian city and you will be lucky to have a family doctor. Move to the suburbs and you can spend years waiting to join a local clinic. Live in rural Canada and there is a good chance that an emergency ward in a distant city will be all your children will ever know. In 2004, almost five million Canadians did not have a family doctor, and in Ontario, according to the Ministry of Health, there are 138 communities facing a critical lack of physicians.

 

While our attention was focused elsewhere—on long waiting periods for surgery and spiralling hospital costs—the bedrock of our medical system was eroding. A report by the Society of Rural Physicians of Canada shows that between 1994 and 2000, the number of family doctors practising outside our largest cities declined by 15 percent. Furthermore, a 2004 report by the College of Family Physicians of Canada stated that up to 3,800 physicians were expected to retire over the next two years, among them some 1,400 family doctors. Are we seeing the last of those general practitioners committed to the complete welfare of familiar patients, and, if so, do we truly understand what we are losing?

 

Remember when I was so sick after the flu... remember when I first got chemo... remember when Wayne died?" So starts a conversation between patient and doctor. We ask our physicians not just to cure what ails us but also to bear witness to our lives. The very presence of a doctor in our community means that society cares. The absence can only imply that it does not.

 

Usually a doctor new to a rural community must buy an existing practice and clinic but Kinmount had neither to sell. Instead the community rented the old township building from the county and, through years of fundraising, saved enough money to renovate and equip the building to a doctor's specifications. They could now offer this to Mihu as her clinic. They could also offer her a population of roughly 4,000 underserved residents. However, this hunger placed a huge pressure on any doctor coming into the county. Would Mihu burn out before she could make a difference?

 

For decades Kinmount residents had listened to politicians promising better health care. Now that they had found a doctor, many in the community assumed that there would be government support waiting for her. They were wrong. While the official opening of the new clinic made a nice photo op for local and provincial politicians, after that Mihu was essentially left to sink or swim. She had to build the vital networks of emergency care and regional specialists, while her husband returned to his schoolbooks to create a viable business plan for the new clinic. There were no recent models to follow. It had been decades since a doctor had opened a new practice in rural Ontario.

 

 

 

Rural GPs quickly discover that they are not just physicians, but small-business owners as well. After signing a simple fee-for-service contract with the Ontario Health Insurance Plan (ohip), Mihu was expected to organize an office, hire staff, and pay for insurance, syringes, Q-tips, and all the other tools of her trade before opening for business. Office hours were up to her.

 

What she could not do was set fees. All Ontario physicians must observe the Schedule of Benefits laid down by the Health Insurance Act. Billing is closely monitored by government auditors and mistakes are quickly censured. But neither medical school nor Jean-Claude's business degree had trained the couple to easily decipher this 688-page document. For the first few months both worried that they had either billed incorrectly or failed to bill when permissible.

 

It is easy to see why such a contract encourages doctors to hurry patients through their office. Turn up at a clinic with a nasty cough, sprained neck, or unpleasant rash and you become a Code A005, the bread and butter of the doctor's income, and are worth $56.10 to your physician. Depending on the complexity of your symptoms and your doctor's ability to hustle you from the office before you try to squeeze in a few new complaints, the appointment will take about eighteen minutes. That the quick removal of a plantar wart (Z103) can be billed at roughly this same amount represents a key flaw in the system. It is easier to itemize a simple medical procedure than a life-saving diagnosis. In the fee-for-service economy, primary care is nearly always short-changed. However thorough or cursory your doctor may be, a general examination can only be billed at $27.30, a house-call at $41.75. A simple birth is worth $395.75; a death certificate costs $17.75.

 

Kinmount's new waiting room was filling quickly. While men were initially reluctant to see a woman doctor, by the fourth month Mihu had almost reached her goal of 2,000 patients and had to start a waiting list. Outside office hours she would visit those too ill to attend the clinic. On weekends she plowed through the endless paperwork involved in coordinating the referral of patients sent to distant specialists. Despite the Kinmount Health Committee's efforts to protect their doctor, Mihu was working a sixty-hour week. For the first few years she did not take holidays or dare to be ill.

 

Even more stressful was the lack of professional support in the region. Over the last decade the decline of rural family physicians has been precipitous, but the collapse of rural specialists has been catastrophic. Only 3 percent of Canada's obstetricians, gynecologists, and psychiatrists, 2 percent of emergency doctors, and 1 percent of pediatricians are located in small towns or rural areas. Other disciplines are often not represented at all.

 

There is no easy answer to the situation faced by doctors such as Dr. Mihu. The Ontario Ministry of Health, in attempting to help, has urged family doctors to limit each appointment to a single series of symptoms. But many of Mihu's patients drive in from distant communities, or are forced to bring ailing family members with them, so it is hard to enforce this policy. Yet Dr. Mihu can only bill for providing a single service.

 

 

 

According to the last official census, between 1996 and 2001 Canada's rural population declined by 286,000 people. Some losses can be more devastating to small towns than others. When doctors desert a community, a whole chain of events is set in motion. The pharmacy immediately closes and parents with medically frail children make plans to leave. In the city, seniors who were thinking of retiring to bucolic spots think again and buy a condo or retire to Florida. With a shrinking population, the local school has to close, and workers with families request to be posted elsewhere. Soon Main Street is empty and the bank shuts its branch office. All this happened in Kinmount before Mihu arrived. As my neighbour in Kinmount, Tom, used to say, "We're waiting for them to roll up the road any day now."

 

With a newly installed Conservative government elected largely by suburban, small-town, and rural constituents, one would hope that the systemic problems facing rural medicine might now receive more attention. But there is every chance that a Stephen Harper-led government will view Dr. Mihu and Kinmount as an exemplar, not an exception to the growing rule requiring state intervention.

 

Stubborn and conservative, Kinmount expects very little from Queen's Park or Ottawa. This makes the residents doubly grateful for the care of their doctor. Her presence in Kinmount has brought a new vitality to the whole community. The town is suddenly full of retirees while parents have stopped worrying about bringing up their children so far from city hospitals. For the first time, a program to beautify the town has been put in place, and pots of flowers line the main street and park. An annual walk-for-health was launched; much of the community turned out to celebrate Mihu's first year and donated another $10,000 dollars to the clinic. Despite letters from American headhunters offering her positions that would pay substantially more than her present income, Elena and Jean-Claude have no intention of leaving. They are in love with rural Ontario and Canada's medical system.

 

 

 

Dr. Mihu's office is full of light. Outside her window the pines of the Ontario Shield have been cut back to let in the sunshine and her patients blink to readjust their eyes after being in the darker waiting room. In many ways Dr. Mihu is the doctor all of us would love to have—caring, dedicated, and knowledgeable. But what is a Dr. Mihu worth to us? How do you put a price on the improved quality of life of a whole community?

 

Nostalgia for her rural childhood and gratitude for the opportunities Canada offered her still colour Elena's life. But few of the students in our medical schools, whether born in Hanoi, Montreal, or small-town Canada, have such altruistic dreams. The provinces may eradicate some of the present barriers against foreign-trained physicians working here, increase enrolment at our medical schools, give bonuses to those willing to practise in rural areas, even develop new medical schools outside the large urban centres. But in the end most medical students will be guided by economic reality, and Elena Mihu, like most family doctors in Canada, will remain grievously underpaid.

 

While a nation with access to primary care is healthier, happier, and more productive, the social aspect of medicine has been largely forgotten, and a doctor's familiar bedside manner replaced by the prescription of quick remedies. It is a comfort to know that there are still physicians like Dr. Mihu in Canada, doctors who know us personally and care about our welfare. But perhaps under the current system we just cannot afford this comfort.

 

 

Alastair Brown recently made a film about Dr. Mihu and her patients, A Country Doctor, for the National Film Board. He has a cottage in Kinmount.