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.