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Keeping doctors where we need them


How do we get more doctors to practice in rural communities?  This has been a long standing challenge in Canada — getting physicians to work where we need them — especially in provinces with large rural populations.  Policy makers have created and implemented some promising solutions, but until recently, there has been little evidence on whether or not the solutions are working.

Unfortunately, new research indicates that some programs aimed at retaining doctors in rural areas across the country may not be as successful as we’d hoped.

Almost all provinces and territories in Canada offer “return-for-service” agreements to attract and retain physicians in rural and underserved communities.  Known by many names (including conditional scholarships, return-in-service bursaries, loan forgiveness programs), these agreements provide medical students and post-graduate residents with financial support for a commitment to practice in an underserved community, usually for one year for each year they receive support. Physicians have the option to pay back their funding if they can’t complete their service commitments.

Return-for-service programs are seen as a key tool in addressing physician shortages, so much so that both the Conservatives and the Liberals promised a return-for-service program during the last federal election, and the current federal government is rolling out their own program later this year.

In a study published in Healthcare Policy, my colleagues and I found that most medical trainees who take return-for service agreements in the province of Newfoundland and Labrador complete their service commitments in full. Moreover, return-for-service physicians stayed in these underserved communities for the long term (up to ten years after their required service).  We also found that return-for-service physicians were less likely to leave these communities than their counterparts who did not hold similar agreements.

Sounds pretty good, right?

Except that we also discovered that most physicians who choose to take return-for-service agreements wanted to work in these underserved communities in the first place.

Rather than finding new physicians who were uninterested in working in rural Canada, in Newfoundland and Labrador, these agreements appear to be encouraging already interested physicians to stay the course.

Our study also uncovered another important finding: of the 20% of physicians who defaulted on  some or all of their return-for-service contract obligations, more than half were international medical graduates (IMGs) — physicians who graduated from a medical school outside of Canada.

Why might this be the case?  IMGs are obligated to take a return-for-service agreement in order to obtain a residency position in Canada, which is a necessary step for full licensure.  In other words, their return-for-service commitments aren’t really as ‘optional,’ as with Canadian graduates.  Results from our study suggest that few of these physicians go on to complete their service commitment or pay back their funding.

Using international medical graduates to fill physician shortages in rural communities is nothing new.  In fact, many IMGs start their careers in Canada working under special licenses that allow them to work only in underserved areas.  However, requiring IMGs to take return-for-service agreements will likely do little to stop the revolving door of short-stay physicians in rural communities.  It is a stop gap, not a solution.

In 2013, the federal government introduced its own “return-for-service program” to encourage physicians and nurses to work in underserved communities.  Physicians can qualify for the program’s financial incentive ($8000 student loan remission each year for up to 5 years) if they work in “eligible” communities, defined in the federal program generally as a rural community with a population of 50,000 or less that is not near a large urban center.

Unlike provincially run programs, the federal government’s program does not require physicians to coordinate their “return” community with provincial planners so eligible communities may not necessarily be considered underserved from the local perspective.

Without meaningful coordination, provincial and federal return-for-service programs may end up being counterproductive and do little to resolve the physician shortages they hope to address.

And without meaningful follow up studies, the new federal program, like similarly structured provincial and territorial programs, may look good on paper, but fail to retain doctors in underserviced areas over the long-term.

Problems with physician shortages in rural regions in Canada have existed for a long time.  Isn’t it about time we had a better idea about what actually works?

Maria Mathews is a Professor of Health Policy/Health Care Delivery at Memorial University of Newfoundland.

This blog is republished with the kind permission of our friends at EvidenceNetwork.ca

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15 comments

  1. Tom Closson

    %featured%If most IMGs don’t complete their service commitment or pay back their funding, what are the consequences for them? What does this say about the manner in which the IMG programs are designed?%featured%

    • Dr. J

      From my knowledge, they’re on the hook for the money plus interest plus the costs of recruiting a new physician there. It’s not a small amount of money.

      What’s even more worrisome is the return of service obligation required of foreign-trained residents who match to programs in Canada. If the resident is not up-to-snuff, and fails to pass the certification examinations, the cost of training – in the multiple hundreds of thousands of dollars – is borne by the resident, not the program and not the government. Thus, poor-quality residency programs have every incentive to recruit barely-competent foreign-trained physicians provided they can cover call without any concern for the financial well-being of the foreign-trained physician, the physical well-being of the patients under his or her care, and the professional well-being of medicine itself.

    • Maria Mathews

      In our study, there appeared to be few if any consequences for physicians (IMG or Canadian trained graduates) who didn’t complete their service commitment or paid back their funding – in part because of record keeping. Since we completed our study, the program has revised its requirements and is tracking outcomes closely.

      Rather than just thinking about the way “IMG programs are designed”, we really should be thinking about the best models of care to provide rural residents with high-quality, appropriate and accessible care.

    • Margaret

      Good comment. There have to be serious repercussions.

  2. Dr.X

    I’m a physician from a rural area that wanted to move back there, provided I could obtain training in a competitive field of interest. My community was willing to fund my training.

    I was told by the CaRMS matching authorities that CMGs cannot secure community funding for post-graduate training, and cannot use such funding for residency transfers. All of the money has to come from the Provincial Ministries of Health for post-graduate training specifically, and once a resident uses it up, its gone. Only after a resident finishes and practices for a while can they secure community funding for return-of-service obligations.

    Doesn’t the above situation waste a lot of time and money? Had I the patience to retrain, I would be wasting 5 years of public post-graduate funding since my initial residency training would no longer be used for anything, not to mention 5 years of my time would be gone, and society would be down one independent physician for 5 years more than expected. That’s an awful lot of waste. Yet that is the system we have.

    I abhor the fact that though I was willing to train in another field – one that is in high need, I might add – and was happy to practice in a rural area with that training, I was stopped because of bureaucratic inanity.

    Keep in mind that Saudi nationals often have their government pay for residency training positions, for them to return to KSA. Why can’t Canadians do the same?

    • Maria Mathews

      you raise an interesting issue around the need to coordinate Health Human Resource production (in this case physicians) with health system needs. The recent RCPSC report on specialist unemployment highlights some of these challenges.

  3. Scott wooder

    Dr Mathews, it’s really interesting that return of service agreements do not seem to work. Do you have any evidence informed suggestions about what does work?

    • Maria Mathews

      Check out

      Wilson NW, Couper ID, De Vries E, Reid S, Fish T Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professional to rural and remote areas. Rural and Remote Health, 2009 1060 1-21

      and this oldie but a goldie:

      Barer ML, Wood L, Schneider DG Towards Improved Access to Medical Services For Relatively Underserved Populations: Canadian Approaches, Foreign Lessons. Vancouver: Centre for Health Services and Policy Research, The University of British Columbia 1999. HHRU 99-3.

      • andreas

        Thanks Maria. For folks who can’t easily access the articles and/or have the time to read them, what are their main recommendations?

  4. Eve Pury

    A very interesting article and evidence to back it up. %featured%The question I think then really becomes how do we select medical school candidates who will select and be happy with rural medicine as a career. Instead of providing extrinsic motivators (return of service agreements) we need to identify those who are intrinsically motivated for the job. %featured%Asking medical school candidates directly if they are interested isn’t good enough (because they might not have the experience to know) but identify qualities that would make them well suited (flexibility, adaptability, interest in generalist fields, comfort with unknown). Furthermore, evidence does exist to suggest that those who grew up rurally are more likely to practice rurally so we should be desperately and aggressively recruiting from these locations as well as creating mentorship programs for even younger (junior/high school age) students to generate interest and realistic opportunities to pursue medicine as a career.

    Anecdotally, having just finished a 5 month longitudinal integrated clerkship in a ruraI setting, I have to imagine that positive experiences at the medical school level can also shape a career but haven’t reviewed the data.

    Thanks for addressing this very important issue.

    • Dr. Anon

      Generalist fields aren’t the only ones that are in need in rural areas. All of the press seems to go to family medicine, but in my opinion the current training structure and stature of the field work against it in every way. %featured%As a physician from a rural area, I can say that I was entirely turned off by the bard-like function, politics, stature, and career finality of family medicine and would never consider it, even though that was my initial career plan going in. However, I would certainly practice in some of the rurally-needed specialties provided I could get trained.%featured%

      Return-of-service agreements only work if the product at the end (the residency training) is worth it. For IMGs it can be, since its the only way into the Canadian system. Once they obtain it, they leave because living as a cultural outsider in a small community is hard.

      For most Canadian graduates, return-of-service agreements are not useful, particularly for non-competitive specialties like psychiatry and family medicine. Such contracts will only do what you suggest in your article: give a bonus to docs already planning on practicing in those fields in rural areas. It won’t entice anyone else.

      If you want to see return-of-service agreements work, make them for competitive specialties like dermatology, plastics, emergency etc. Then you’ll see more domestic interest.

    • Maria Mathews

      You’re right – having a rural background is one of the strongest predictors for working in a rural area and a number of medical schools make it a priority to encourage rural students to pursue health careers. A number of medical schools offer programs to introduce and support students from rural (and other underserved) communities – but few of these programs have been rigorously evaluated. While rural back ground in itself is important, studies from Australia and the US (check out articles by Pathman) show that it’s multi-pronged approaches – those that address the many reasons physicians move to and remain in these communities – that show the most promise

  5. John Philpott

    Great article.
    CanAm Physician Recruiting has been stating these facts for almost 20yrs. The only real solution is to hire a professional firm, such as CanAm, who has the ability to screen physicians both Canadians and IMGS and match them with the best possible opportunities which meet their professional and social needs.
    Local Hospital or even provincial based recruiters cannot provide the National and Global options than CanAm can and do provide. Physicians are no different than anyone else, they wonder if there are better options elsewhere and they seek the perfect place to live. The truth is that there is no perfect place to live and work but at CanAn we layout all the options and as a result we have the highest retention rates in the country.

    • Don Corbiss

      This sounds suspiciously like an advertisement for CanAm Recruiting. The mods should remove it (unless they don’t mind providing a free advertising billboard, in which case I’ll be back with some really good offers)

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