Recently some colleagues and I had an opportunity to speak with Steve Paikin on TVO’s The Agenda about practising medicine in Northern Ontario and the significant shortage of physicians here. Paikin asked whether, as one solution, doctors should be forced to work in rural Northern Ontario. My response, and the response of all the panellists, was “no,” that communities need to have physicians who truly want to be there and who can deliver care effectively and with a measure of excellence.
I think the question of “forcing physicians” is the wrong one to ask in the first place.
Instead, the question that we need to be asking is, “How do we support physicians in rural and remote settings so as to ensure equitable access to care for the whole of our province?”
This is a significant challenge and one which I know well, having been in rural family practice in the community of Marathon for the past 21 years.
Northern Ontario, the area defined by the boundaries of the Northeast and Northwest Local Health Integration Network, is huge. It is 80 percent of the province’s land mass—an area greater than France and Germany combined—and is home to only 5.8 percent of the province’s population.
Despite the celebrated work of the Northern Ontario School of Medicine in this territory, the need for full-time family physicians in the rural communities of the Northwest LHIN alone is estimated to be 56. In these communities, family physicians provide primary care, staff the emergency department, provide inpatient and obstetrical care, and in some of the larger rural communities they also provide anaesthesia services to allow patients to have surgery locally. Rural family physicians are also responsible for some system administration. Occasionally, they are supported by one or two local specialists who also work in a particular degree of isolation. Some communities in Northern Ontario have only half of the needed “complement” of family physicians, leaving doctors overworked, and the community dependent on itinerant locum (fill-in) physicians.
And the shortage appears to be getting worse. Over the past three years, the need for locums to cover emergency department shifts in small hospitals has increased 78 percent, according to Health Force Ontario data. In fact, across Northern Ontario last year, almost 800 shifts were filled by the “Emergency Department Locum Program,” a program without whose work, local community hospital ER departments would have had to close for lack of physician coverage. That’s close to 800 times across Northern Ontario that an ER department might have been closed to the community for 12–24 hours.
Health outcomes in Northern Ontario are also worse than in the rest of the province on several measures. Health Quality Ontario’s “Health Equity in Northern Ontario” report states that, “The 800,000 people living in Northern Ontario are more likely to have worse health, poorer access to health care, and die earlier than people in other parts of Ontario.” Life expectancy is almost three years less on average in Northwestern Ontario compared to the province as a whole. While some of that difference is due to the “social determinants of health,” access to a family physician or primary care provider was noted to be significantly less in Northwestern Ontario compared to the provincial average.
So how do we change this? As I said on The Agenda, “forcing” doctors to work in these communities is not the answer. In fact, the question itself reveals part of the problem. Because at its most basic, the notion of being “forced” to go somewhere implies a sort of punishment. That sends, I think, the wrong message about the rewarding, challenging, difficult and profoundly satisfying work that the practice of medicine in rural and remote settings can be.
How do we, then, support rural physicians to serve the communities of Northern Ontario where their service and care is much needed?
In an effort to address this question, in February 2017, a joint task force of the College of Family Physicians of Canada and the Society of Rural Physicians of Canada released the “Rural Road Map for Action,” which recommended 20 actions that we need to take across the whole country to better support equitable access to health care in rural and remote and Indigenous communities.
The report addresses “social accountability” in education, a concept that focuses on preparing learners at the undergraduate and post-graduate levels to serve historically under-served populations. It also points to the fact that education needs to be aligned with workforce planning to ensure that no community is left without reasonable access to family physicians and health care service.
Beyond workforce planning, we need to better enable clinicians to come together in supportive networks of care that decrease professional isolation, improve access and timeliness of transfer of care and ultimately support retention of skilled clinicians.
Building on the work of the Road Map for Action, a renewed conversation has begun in Northern Ontario. On Jan. 24, 2018, the Northeast and Northwest LHINS, Health Force Ontario, and NOSM came together and hosted a day-long event: “Summit North 2018.” Bringing together 125 people—educators, policymakers, administrators, clinicians and community members—from across Northern Ontario, we focused on how to build on the good work done in other areas, like rural Australia, Nova Scotia and British Columbia, and implement the great ideas of local clinicians and citizens.
These include but go beyond remuneration, and some that were discussed at Summit North included:
- creating more formal clinical care networks among rural clinicians and specialists
- formalizing mentorship for new-to-practice physicians
- creating collaborative relationships for community recruitment not just within communities, but across communities
- creating a regional rural locum pool familiar with the needs of the population and the realities of rural practice that can support local community physicians
- ensuring access to enhanced skills training for physicians in a timely way based on the needs of the community
Most exciting to me is that at the end of Summit North, a commitment was made to create a task force to implement strategies that will improve the workforce situation in Northern Ontario with the ultimate goal of more equitable access to care and improved health outcomes for communities there.
I look forward to a day when we don’t talk about “forcing” physicians to work in our small communities. Rather I look to the day when we can identify and support capable, competent family physicians who can feel confident that their work is valued, that their needs are understood and addressed meaningfully, and that they can trust that when it is time to move to a new chapter in their professional and personal lives, there will be a lineup of physicians ready to take their place.
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I live in Northern Ontario that has a population of between 10,000 to 11,000 people. we have a Family Health practice, but a substantial number of residents do not have a Family GP and are on a waitlist, there is Tele-Health but there still remains a wait-list for even this service. The apparent problem is that the Government has stated that there are enough enrolled Doctors on the roster for our city. How can that be if there are numerous “Doctors” on that list that are at retirement age or even some of them are way past
‘retirement” age and none are accepting new patients!! How is this acceptable?
I am self taught in many areas of microbiology and diagnostic medicine. Acedemically trained in triage medicine…sutures etc.
But no formal training.
I am willing to be relocated to a remote Northern community, if given a salary and moving expenses.
Trained in sterilization and disinfectants.
Not fearful of risks.
I am also trained in many trades, can build and repair.
Contact me if you are interested.
I live in Fenelon falls Ontario. I can’t get a doctor. I have a child with autism who gets sensory overload being driven in a car for a long time. I can’t afford to live anywhere else. I have neighbours who are seniors who can’t drive or get the care either. We do have pharmacies and and small town walk in clinics, but there not legally allowed to give out many of the types of prescription renewals required. This needs to change. These people should have a right to hand out renewals. And online doctors should have a right as well. Even if they have to work with 3rd party doctors to make this happen. I hope Canadians really do protest and take things in the right direction. I agree forcing a doctor to move somewhere isn’t the solution though.
The approach to selling the beauty, lifestyle and community sense of northern Ontario and what it has to offer, strikes me as significant. I used to work in the region for some time as a health inspector with the TBDHU in an area ranging from Nipigon to Manitouwadge – primarily working out of Library building adjacent Wilson Memorial when in Marathon. I used to look forward to remote work outside of TB; what a beautiful existence. I was recently admitted to medical school abroad. Securing the funds to complete can be trying, at best. The process has been informative, however. Some answers regarding obtaining otherwise limited residencies could possibly be addressed through northern community involvement, as well as potential contractual agreements relative funding. There are also many brilliant physicians from other nations who reside in Canada and would love to have the opportunity to contribute but work in other fields to get through. Wonder if tapping into the pool of persons challenging the Canadian Medical Exam may provide some answers. Just thoughts.
Cpso is refusing to obey the law that requires it to ensure patients have access to adequate numbers of doctors. Its Registrar of 17 years recently resigned saying that it is headed for a disaster and is on the verge of elimination.
Will you contact your MPP to hasten the elimination in order to relieve the suffering of patients who are waiting for access to the health care system?
Thanks for your insightful article.
I haven’t had a doctor for almost 10 years because i was on a waiting list. I received letters telling me that they were still looking. I became an alcoholic in those 10 years and struggled for help. The emergency room laughed at me. I had a breakdown and went back, asking for help. I was sent home with no help again. Finally i was given a doctor who had just opened. He hasn’t helped me at all. When i see him he tells me everything that is wrong with me and says that I have to live with it. Says that the anti depressants i took probably did damage but he doesnt know… Oh and also my liver is ok but maybe not.
I think that choosing medical students that were raised in rural Ontario will more likely produce physicians who will return to these communities. I also think that requiring rural rotations during medical school training in all disciplines will make graduates more aware of the multiple benefits of rural practice. Finally medical school training needs to have less emphasis on technology which is not readily available in the rural areas. New graduates often now feel ill prepared to work and diagnose in areas void of these services and thus are far less likely to set up practice there.
I loved this article. What an insightful perspective.
Thank you for this article, I had just been speaking to my cousin about her application for a role in a Northern Community that would see her and partner (Social Worker) moving to the area as well, so this article was timely for me. While of course creating a scenario where competent physicians are excited to move to Northern communities and practice is ideal (see this article for some great ideas ideas http://www.cbc.ca/news/canada/nova-scotia/physician-recruitment-goderich-ontario-success-1.4538925), I think it would also be important to support individuals from the communities to become physicians through policies and support for individuals (students!) and remove barriers that may inhibit them from striving for these roles. The same way concerted effort is being put on enabling girls to enter into STEM education and careers we could support Northern residents to enter into the medical field.
Such an important issue, so thanks for writing about it Sarah. When I lived in the US, I worked for the Hawaii State Department of Health as the Primary Care and Rural Health Coordinator. One of my jobs involved working with designated “Health Professional Shortages Areas” and the US National Health Service Corps, which offers loan repayment to physicians and dentists in exchange for living and practicing in rural and remote communities. https://nhsc.hrsa.gov/loanrepayment/ In Hawaii, this often meant working with Native Hawaiian people on the neighbour islands. Physician friends participated in this program, and some stayed in these communities long after fulfilling their commitment because they found the work fulfilling, the patients appreciative, and the lifestyle enticing. I believe the Government of Canada has an FP and nurse loan forgiveness program too, but with relatively low rates of debt relief. Is loan forgiveness the right incentive to attract the right people? Is the debt relieve level sufficient to be attractive? Is this a good way to recruit physicians, or does it lead to churn and instability for patients when physicians leave?
I am no expert with delivering care in rural areas but here is a potentially fresh idea. If we can’t get physicians to come to Northern Ontario, could we create a model where physicians from other regions/areas have a more consistent presence from a distance? Locally, citizens currently living in these rural communities could get trained to be physician assistants or some other similar role. Then enabled through technology, physicians could remotely supervise the work of these physician assistants who are physically living in the rural communities. Although physically in another region, a physician could be consistently delivering/overseeing care of patients in these rural communities. This will allow them to form that relationship with the patients a locum that constantly changes is unable to do. By training local citizens to be physician assistants, this also creates jobs and economic prosperity, which has other benefits. Locals are also known by others in the community so would be more trusted.
Thanks for your comment Sherman! The model that you are describing is used currently in small remote Northern communities where NP’s are the main health care provider and family physicians support the NP from a distance and visit the community, generally monthly. The US makes extensive use of PA’s for remote primary care delivery in models that work well. Technology can definitely be used to support “physician extenders” in caring for the people of rural and remote communities. The challenge I think is that for patients to be able to maximize the care that they receive in their communities, they need physicians. For managing the complex, multimorbity patients, providing inpatient care, running the ER, providing obstetrical care, anaesthesia, etc, there is a valuable role for physicians. I agree with you that we should be encouraging PA’s and NP’s (and in a “grow your own” model encouraging local citizens to take up these roles). Excellent team based care can absolutely be a support for rural family physicians and knowing that there are strong teams would likely make the opportunity of rural practice more attractive. Thanks again for sharing your thoughts!
you might be interested in this episode of freakonomics: http://freakonomics.com/podcast/nurses-to-the-rescue/
Using disparaging terms such as “physician extenders” is not helpful. I wonder if you were to further familiarize yourself with the role if your ourlook would change. We depend on our docs, no question they are invaluable. But NP/PA’s are a solution that is often not sufficiently considered.
I’m a rural NP.
https://health.usnews.com/wellness/health-buzz/articles/2018-03-02/study-more-nurse-practitioners-practice-in-low-income-areas
Money.
If a doctor gets paid the same to work in isolated Northern Ontario as they do in Toronto, they’ll 99% of the time choose Toronto.
I have seen the incentive packages offered to physicians for Northern work, and are not substantial, encompassing an extra week of pay per year. Most people would rather have the week off if they’re going to be isolated.
Living in isolated communities is for a very particular type of person, and unfortunately, that type is rarely ever interested in practicing medicine at all.
Doctors are square pegs and the rural communities are round holes. They don’t fit, and forcing them in breaks both. The only tenable solution is money, as hard as that is to accept.