Rural doctor shortage

[Star1234]

How do we solve the problem of the doctor shortage in rural areas?

 

Ideas?

[omgwut123]

lol

 

 

 

 

 

 

 

 

 

10char

[aKGDH]

..why is that funny? It is a legitimate question and if you have nothing constructive to say, don't. Could a mod remove such a useless post, please?

 

 

@OP: I believe some incentives could include financial bonuses for doctors who work in the rural areas. As well, there can be programs instituted into most medical school curriculums that emphasize the lack of doctors in rural areas and the significance of this. Elective experiences in rural areas may be offered and encouraged too. The benefits of working in rural areas should also be highlighted and generally, the entire issue should just be brought to the attention of all medical students and those working in the healthcare.

[doctulk]

aKDGH, you have some great ideas there. I have provided health care in a rural area and the pros far outweigh the cons. The experience that you will attain in a rural environment is second to none. In a rural environment the GP or family doc is all of the specialties rolled into one. What a great chance to learn and gain experience that will only benefit you in the long-run as a physician.

 

Great ideas! Thanks!

[terryann]

I believe schools such as NOSM address this issue by selecting premeds most likely to stay in their community...and other schools do. Although, some find it unfair, I think it is a way to deal with shortages in rural areas.

[Star1234]

Great answers guys! Thanks for the input.

 

 

The reason I ask is because I found this practice MMI question recently:

 

Due to the shortage of physical therapists in rural communities, it has been suggested that physical therapy programmes preferentially admit students who are willing to commit to a 2 or 3, year tenure in an under-serviced area upon graduation.

Consider the broad implications of this policy for health and health care costs. For example, do you think the approach will be effective? At what expense? Discuss this issue with the interviewer.

 

 

You could easily apply this situation to physicians too. My question is, will this really work? I mean, can you really FORCE someone to work in a certain area after they've graduated? Realistically speaking, couldn't someone just lie and say they will commit to a 2 or 3 year tenure in an under-serviced area and then when they graduate not?

 

I would figure a better solution would be to provide financial incentives like aKGDH said.....maybe even in the form of bursaries if you agree to do a certain number of years in a rural region. And then if you don't do it, they cancel the bursary, or something along those lines.

[running_girl]

One of the issues that I see happening in the case of a financial incentive, is the possibility of a high turnover of physicians in rural areas. Many medical graduates may go to rural areas to learn and help pay off some of their debt, but what happens when the 2-3 years comes to an end?

Any thoughts?

[Star1234]

Well I guess that's better than not having any doctors up there at all....

 

And maybe after 2-3 years, they'll decide that they actually like working in rural areas and decide to stay....

 

But ya, I guess the best way would be to build med schools in rural areas and give preferential acceptance to people who would be willing to practice rural medicine. I'm still not sure how efficient this process is though. Just because someone is willing to study for 4 years in a rural area doesn't necessarily mean they will stay there. I mean, with the competitiveness of Canadian med admissions these days and premeds willing to go overseas and study in Ireland in the middle of a cow field, I'm sure many people would jump at the opportunity to study in Northern Ontario.

[aKGDH]

Due to the shortage of physical therapists in rural communities, it has been suggested that physical therapy programmes preferentially admit students who are willing to commit to a 2 or 3, year tenure in an under-serviced area upon graduation.

Consider the broad implications of this policy for health and health care costs. For example, do you think the approach will be effective? At what expense? Discuss this issue with the interviewer.

 

 

You could easily apply this situation to physicians too. My question is, will this really work? I mean, can you really FORCE someone to work in a certain area after they've graduated? Realistically speaking, couldn't someone just lie and say they will commit to a 2 or 3 year tenure in an under-serviced area and then when they graduate not?

 

There is something called 'return of services,' which is a legal contract that you must agree to before attending medical school, which essentially binds you to spending x number of years in a certain area, often the region that the medical school is located. If you want out, you must pay a rather large fee. If you do not sign this contract however, you may not attend the medical school.

 

Now to answer your MMI scenario, I think it is important to present both views on the issue of physician shortage. Using return of services and other contracts that legally force you to work in a specified area for a specified time is a good way to ensure that the local region gets an increase in the number of available, working physicians. Without these contracts, a physician trained in one region may very well pursue opportunities elsewhere, particularly in more affluent, urbanized settings, depriving smaller towns, rural districts and remote areas of physicians. A binding contract would essentially force a physician trained in a rural area to remain there for a substantial amount of time, to the effect that although some will still move away after their contract expires, others will settle down and remain there. In other words, it is a temporary solution but effective.

 

However, it may also be argued that these contracts are infringing upon physician's freedom to move. If initially one school binds their physicians to their local region, why should not all medical schools do the same? Eventually, most physicians will be unable to find work other than the city where they had attended medical school and the entire system becomes segregated, closed and disjointed. This is not a goal of the Canadian health care system, particularly since the reform calls for better collaboration amongst health care workers and institutions, rather than isolation. Simply, limiting physicians' freedom to move in order to ameliorate the lack of physicians will not provide a permanent, long-term solution.

 

As a conclusion, I think it is important to emphasize the significance of a long-term solution as well as to stress the importance of allowing physicians to exercise their freedoms (your interviewers are mostly all doctors and would not want to hear about how doctors must be 'forced' to do things against their will!). It may help to propose some short-term solutions as well, so as to make it clear that you understand that the shortage of physicians in rural areas is an important and pressing matter.

[orange123]

There is something called 'return of services,' which is a legal contract that you must agree to before attending medical school, which essentially binds you to spending x number of years in a certain area, often the region that the medical school is located. If you want out, you must pay a rather large fee. If you do not sign this contract however, you may not attend the medical school....

 

 

All good points. However, just wanted to bring to your attention that the return of service must be signed at the time of residency. Not while in medical school (If I'm not mistaken). Does anyone know for sheezy?

[Star1234]

I found this:

 

http://www.health.gov.on.ca/english/providers/project/img/serv_agreem.html#4

 

So apparently the 'return of service' agreement is only for internationally trained med students wanting to do a residency here? Or has any med school in Canada actually implemented this for their graduates?

[terryann]

The physician shortage could be resolved easily, by stating that each new medical graduate upon graduating from residency must provide 1 year of service in an underserviced area. Being medical school in Canada,are partially funded by the government, I believe that they would have the right to do this. This would result in underserviced rural areas having doctors; although, they would have a high turn over rate.

On the flip side, we live in a democratic country, would go against our right to freedom and choice.

In stating the above, I still believe the best solution is schools like NOSM who favour people from their area, it is a known fact tht people like familiarity and like to live close to family and friends. I would think the adcom committee at schools that have a mandate to service their rural areas would be well educated as to how to determine if a premed is genuine.

To say, is this fair to all premeds..I say yes, because at the end of the day, the problem of shortage of doctors in rural areas has to be addressed and that was the sole purpose for schools such as NSOM being built.

[orange123]

I found this:

 

http://www.health.gov.on.ca/english/providers/project/img/serv_agreem.html#4

 

So apparently the 'return of service' agreement is only for internationally trained med students wanting to do a residency here? Or has any med school in Canada actually implemented this for their graduates?

 

Ahh, yes, true dat! IMGs have to def sign a ROS. But for Cdn graduates, this requirement is not necessary. We can practice anywhere in Cda. Thanks for bringing it to my attention It's coming back to me now.

[aKGDH]

I thought Saskatchewan required it.

 

http://www.health.gov.sk.ca/grants-physicians

 

If one province requires it, why shouldn't others? Everyone wants their own physicians, instead of training them and then having them move elsewhere.

 

I might also point out that Saskatchewan offers a monetary incentive for physicians to move to their province and practice.

 

 

 

Edit:

 

http://www.gov.mb.ca/health/msrfap/

 

"Manitoba’s medical graduates are the foundation of the future of healthcare in this province. Recognizing the important contribution of locally trained physicians in providing high-quality health services that meet the needs of Manitobans, the Government of Manitoba established the Medical Student/Resident Financial Assistance Program (MSRFAP) for eligible medical undergraduates and medical residents in May 2001."

 

What are my requirements after receiving this financial assistance?

- To commence the Return of Service (ROS) commitment within 90 days of program completion as per the agreement. This is full-time practice (minimum 35 hours a week) for 12 consecutive months in Manitoba. 3rd year undergraduate applicants must repay Return of Service in a rural area (excluding Winnipeg).

- To repay the full amount of the financial assistance received, plus interest accrued from the date the financial assistance was first provided if ROS commitment is not fulfilled.

 

 

This financial assistance program + ROS is not mandatory however.

[aKGDH]

I would think the adcom committee at schools that have a mandate to service their rural areas would be well educated as to how to determine if a premed is genuine.

You would not want to actually say this during your interview. It is almost putting down the current system and the capabilities of your interviewers, which is never good.

 

Also, I wouldn't offhandedly remark that the problem is 'easily solved.' If it were, it wouldn't currently be a problem. Offer opinions, but be humble.

[medisforme]

@OP: I believe some incentives could include financial bonuses for doctors who work in the rural areas. As well, there can be programs instituted into most medical school curriculums that emphasize the lack of doctors in rural areas and the significance of this. Elective experiences in rural areas may be offered and encouraged too. The benefits of working in rural areas should also be highlighted and generally, the entire issue should just be brought to the attention of all medical students and those working in the healthcare.

 

All of this is already being done. Rural physicians are being paid a lot more for their services and medical schools (at least out west) are highlighting the benefits of working in rural areas.

ie. at UBC before students start their clinical rotations they have to do a one month practicum in a rural setting with a family physician. They have also set up a satellite campus medical school in Prince George at UNBC to train those who want to go into rural medicine.

Highlighting rural medicine at medical school is quite new and so it will take some time to see how effective it is. As for financial incentives for rural physicians; if this actually worked we would have solved the rural shortage long ago.

[Star1234]

I thought Saskatchewan required it.

 

http://www.health.gov.sk.ca/grants-physicians

 

If one province requires it, why shouldn't others? Everyone wants their own physicians, instead of training them and then having them move elsewhere.

 

I might also point out that Saskatchewan offers a monetary incentive for physicians to move to their province and practice.

 

 

 

Edit:

 

http://www.gov.mb.ca/health/msrfap/

 

"Manitoba’s medical graduates are the foundation of the future of healthcare in this province. Recognizing the important contribution of locally trained physicians in providing high-quality health services that meet the needs of Manitobans, the Government of Manitoba established the Medical Student/Resident Financial Assistance Program (MSRFAP) for eligible medical undergraduates and medical residents in May 2001."

 

What are my requirements after receiving this financial assistance?

- To commence the Return of Service (ROS) commitment within 90 days of program completion as per the agreement. This is full-time practice (minimum 35 hours a week) for 12 consecutive months in Manitoba. 3rd year undergraduate applicants must repay Return of Service in a rural area (excluding Winnipeg).

- To repay the full amount of the financial assistance received, plus interest accrued from the date the financial assistance was first provided if ROS commitment is not fulfilled.

 

 

This financial assistance program + ROS is not mandatory however.

 

Apparently they also give out bursaries in Alberta (and probably other provinces too....this was just the first one I found) to people who are willing to dedicate a certain amount of time in rural areas after they graduate.

 

http://www.rpap.ab.ca/medical_students/financial_support/student_bursary.html

 

 

I guess these are all financial incentives for those that want them. So instead of FORCING medical graduates to practice in a certain area, those that are willing to do so apply for grants/bursaries in exchange for 'return of service' in underprivileged areas. Seems like a good compromise to me.....

[cnb88]

Great answers guys! Thanks for the input.

 

 

The reason I ask is because I found this practice MMI question recently:

 

Due to the shortage of physical therapists in rural communities, it has been suggested that physical therapy programmes preferentially admit students who are willing to commit to a 2 or 3, year tenure in an under-serviced area upon graduation.

Consider the broad implications of this policy for health and health care costs. For example, do you think the approach will be effective? At what expense? Discuss this issue with the interviewer.

 

The physician shortage could be resolved easily, by stating that each new medical graduate upon graduating from residency must provide 1 year of service in an underserviced area. Being medical school in Canada,are partially funded by the government, I believe that they would have the right to do this. This would result in underserviced rural areas having doctors; although, they would have a high turn over rate.

On the flip side, we live in a democratic country, would go against our right to freedom and choice.

In stating the above, I still believe the best solution is schools like NOSM who favour people from their area, it is a known fact tht people like familiarity and like to live close to family and friends. I would think the adcom committee at schools that have a mandate to service their rural areas would be well educated as to how to determine if a premed is genuine.

To say, is this fair to all premeds..I say yes, because at the end of the day, the problem of shortage of doctors in rural areas has to be addressed and that was the sole purpose for schools such as NSOM being built.

 

I used to live in a rural area, and while yes, there is a severe doctor shortage (where I was living (not a northern area either) if you phoned the doc because you were really sick, they would tell you, "ok... we have an opening... 3 months from now" (that's ok... I'll either be dead or better by then). Also, if you did manage to get an appointment it was a guaranteed 2 hour wait from the time you were supposed to be in), I can't see how you can "force" someone to move to any area.

 

Let's look at a situation like this: You are married and have a child that is... 7... you finish med school and are required to move to a rural area. Your husband (or wife) has a good job and likes where you are living now. Your child has some difficulties learning. If you were required to move to a smaller area, your significant other would have to quit their job and find a new one (if they could in the small town- depending on what they do, they may not be able to). Your child is in a whole new school. Problem is, rural areas may not have the proper tools/people that can help your child succeed. It also would be extremely hard for any parent/spouse to just up and leave their child/significant other for 3 years.

 

Also, from the rural town's point of view, could you imagine having to get a new doc every 2-3 years (and that's assuming that there would be few enough rural areas for there to be a new doc coming into the area as the other was leaving)? There would be very little stability. Part of the importance of having a family doctor is having someone that knows your history and that you can trust (with literally your life). If I absolutely love Dr. A, but his time is up in 2 years and Dr. B comes in, and I think he is an arrogant idiot that doesn't know anything, am I really going to go to the doctor when I need it and, for that matter, am I going to follow Dr. B's advice to the letter?

 

I think the best solution is to have rotations in a rural setting (so that everyone can experience it, and so that you can have more people realize that they actually really actually like it) for a month or so. As well, I think we should train more Nurse Practitioners so that they can also be in those rural areas (under the guidance of a couple docs in the area). Lastly, I think if there were certain drugs a pharmacist could "dispense" without a prescription (ie Mr. Smith has been asthmatic all his life and needs an inhaler, but needs to go to the doc every few months to get his prescription renewed. If the pharmacist can essentially just give it to him, and Mr. Smith could maybe only be required to get checked out once a year instead of every couple months) it would help allieviate the problems in rural areas. Obviously there is a need for more rural doctors, but I don't think you can force all med graduates to have to work for a certain length of time, both for their sake, and for the rural areas'.

 

(Also, I hate how many small towns in rural AB "advertise" in South African countries. South African countries need to retain their own doctors, they don't need AB towns "poaching" their doctors.)

[aKGDH]

@cnb88

 

 

I think you brought up some excellent points. As you mentioned and I totally agree, one of the huge disadvantages of return of services is the high turnover rate of physicians in rural areas, which is not constructive for the community, as there is a lack of stability.

 

I also agree with your view that specifically in rural regions, more power should be given to pharmacists and nurses, such that they may fulfill the role of the general practitioner...This is a controversial situation though and may prove to be disadvantangeous for physicians in other parts (urbanized) of Canada.

 

Thanks for your input!

[Star1234]

Let's look at a situation like this: You are married and have a child that is... 7... you finish med school and are required to move to a rural area. Your husband (or wife) has a good job and likes where you are living now. Your child has some difficulties learning. If you were required to move to a smaller area, your significant other would have to quit their job and find a new one (if they could in the small town- depending on what they do, they may not be able to). Your child is in a whole new school. Problem is, rural areas may not have the proper tools/people that can help your child succeed. It also would be extremely hard for any parent/spouse to just up and leave their child/significant other for 3 years.

 

 

Funny that you mention that because the CMA recently cited educational opportunities for their children and job opportunities for spouses/partners as 2 of the top reasons why physicians move from rural communities to the city.

 

http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/CMA_Bulletin/2009/bulletinjun23_en.pdf

 

Very informative discussion guys. Thanks to those who have contributed so far

[keith_015]

I for one can speak of initiatives in the US as I have been accepted there, principally for rural purposes.

 

I have been accepted to one school which has a rural dedicated program for 10 students, in which I will be 1 should I decide to go. The premise is that you do your regular years in the city and do you clerkship in a rural community which I believe is 6,000 strong. In this case, the school has affiliated with a large regional medical center so while clerking, students will get a real feel for rural medicine. Some rotations will have to be done in the city, but for the most part, all clinical is rural. The school has invested mega money into this rural program, building a dedicated building at the hospital site. I asked the director of the program if he had trouble getting funding from the state and he said the money for the 10 spots is coming from the school's budget (in which other programs were trimmed to come up with the money) and no money was coming from the state. There are other schools that I have seen in the US which use this format for training and admit only those students interested in doing rural medicine into these spots.

 

I interviewed at a second US school with a special application format for students interested in rural med. The program itself is primarily in the city; however, due to the large number of affiliated hospitals, doing rotations in rural areas is primarily up to you as to how much exposure you would like, although the "rural" areas are to me pretty large cities. There is no hitch to this program other than you must do at least one 3rd year rotation away from the city, and it is expected that you do a residency in a rural related specialty and practice rurally.

 

So in terms of improving rural med, I think:

 

1) Admit students who can truly show they are committed rurally. The first school had a special interview cycle at the rural and city facility as well as a questionnaire about your level of rurality and needs for immediacy to a city. The other required reference letters from "community leaders" stating that the applicant is committed to rural practice.

 

2) Start programs where as much of a clerkship as possible is enclosed within a rural area. If urban applicants are willing to take a risk and do training at such a facility, perhaps there perception of rural life and medicine may become favourable.

 

3) Get more affiliation with rural centers for hosting clerkships. There are enough smaller communities, especially in Ontario who could likely host a few clerks at a time.

 

4) Mandate that students do one full rotation in a rural center.

 

In the end financial incentives like return for service do have many caveats. Like many have previously mentioned, musical chairs 2-3 years at a time isn't a long term solution. If gov'ts are going to dole out money for programs like that, they should reinvest the money into producing more medical students dedicated to rural practice a la point 1 I made above. I certainly don't need a payout for wanting to practice rurally.

 

Finally, exposure is critical for ANYBODY who hasn't lived rurally. There are misconceptions abound from urban people. How can you judge a brand new car by looking at it but not test driving it? If more urban people saw the perks first hand to living and working in a small town, potentially more would be willing to give it a try. My gf is so urban mindset because she's never spent significant time beyond the city. If our future is to be together it is a must that I practice rurally, but in compromise, I would likely live within 1hr's (or slightly more) drive to a major city. She has been to my hometown a few times and didn't have really any issues, yet settling of course can be a scary time. I myself admit that I'd like to be rural, yet not remote. Oh...and that's another misconception...rural does not have to mean remote! Finally, the way my gf sometimes talks is that she has watched too many movies where bad things happen in small towns. Its like she believes towns don't have policemen or that they are all corrupt and do whatever they want to. Too many misconceptions.

[orange123]

.... Oh...and that's another misconception...rural does not have to mean remote!...

 

Does rural mean underserviced then? I wonder if we can find a listing of all the underserviced areas in Cda?

[orange123]

Does rural mean underserviced then? I wonder if we can find a listing of all the underserviced areas in Cda?

 

here's an ON ministry of health website that stipulates that underserviced areas (in the north) are as follows: Northern Ontario is defined as the territorial districts of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Rainy River, Sudbury, Thunder Bay and Timiskaming.

 

http://www.health.gov.on.ca/english/providers/program/uap/guidelines/grantprog_phys.html

 

 

Doesn't seem to say much about Southern Ontario though.

[keith_015]

Does rural mean underserviced then? I wonder if we can find a listing of all the underserviced areas in Cda?

 

Rural does NOT have to mean underserviced. In the US per example, they have a designation called an HPSA (High Priority Shortage Area) in which you can get more info at http://bhpr.hrsa.gov/shortage/ . It includes all counties regardless of population. There is a set criteria. If you are interested in a certain area, look up a county map for a state and match up the map to the list to see if it is HPSA designated. Some state agencies have maps to indicate which counties (rural and urban) are underserved.

 

As for Canada, I found Ontario's Underserviced list. You may have to comb through each province's Ministry of Health website to find a list. I'm sure most have one accessible.

 

For Family Med: http://www.health.gov.on.ca/english/providers/program/uap/listof_areas/gp_ladau.pdf

 

For specialties: http://www.health.gov.on.ca/english/providers/program/uap/listof_areas/specialist_ladau.pdf

[orange123]

Rural does NOT have to mean underserviced. In the US per example, they have a designation called an HPSA (High Priority Shortage Area) in which you can get more info at http://bhpr.hrsa.gov/shortage/ . It includes all counties regardless of population. There is a set criteria. If you are interested in a certain area, look up a county map for a state and match up the map to the list to see if it is HPSA designated. Some state agencies have maps to indicate which counties (rural and urban) are underserved.

 

As for Canada, I found Ontario's Underserviced list. You may have to comb through each province's Ministry of Health website to find a list. I'm sure most have one accessible.

 

For Family Med: http://www.health.gov.on.ca/english/providers/program/uap/listof_areas/gp_ladau.pdf

 

For specialties: http://www.health.gov.on.ca/english/providers/program/uap/listof_areas/specialist_ladau.pdf

 

 

Oh wow. Thanks Keith There's a wealth of information there.