She’s 60 years old, has had a lung transplant but now has new chest pain.
He has metastatic colon cancer and is contemplating medical assistance in dying.
She is 22, in hospital post-overdose, and is starting Suboxone hoping (as always) for recovery.
He woke up with a cough and will be seen in the Assessment Centre.
She is 19, newly pregnant and needing a first prenatal visit.
What do they have in common? They will all be seen by me today as I cover care from the hospital to the clinic to our small, connected Assessment Centre, and then go on to a home visit before the end of the day.
This is not a “special day.” It’s a day that is much like the one many of my colleagues will have, here and in communities across northern Ontario.
In our community of Marathon, there is funding for six rural general family physicians and we have a small Family Health Team. We have no specialists. Our nearest larger centres are 300 kilometres away to the west (Thunder Bay) and 400 kilometres away to the east (Sault Ste. Marie). Many of our patients cannot easily travel because of poverty, lack of vehicle access, illness, age and the challenges of a twisty, craggy highway that’s a menace in the winter.
So, we work to provide as much care as possible in this community, in our patients’ “medical home.” We talk to specialists on the phone and implement their plans. We send e-consults to get quick answers, and we follow up with our patients to make recommendations.
We deliver babies, manage traumas, treat heart attacks, help people struggling with substance use disorders or experiencing symptoms of COVID-19. We do the clinical work and provide the clinical support for policies to make the system run safely. We train medical students and residents in the hopes that one might come back to work here one day, or in a similar community. We ask questions about care and care improvement, and we try to answer them through research.
And this work – the kind of comprehensive community responsive care that has supported the health of rural systems in northern Ontario for years – is in jeopardy. Today in northern Ontario, according to community-level recruiter information, we need more than 300 physicians. Of those, we need 97 rural generalist family physicians in our small communities. There is an increase in need by 10 physicians since December 2020, mirroring a trend for family physicians across the North.
Currently, the system focus is on keeping Emergency Departments (EDs) open. To that end, locum physicians (fill-in physicians) are brought in to support the ED, though in some places closures are now all but inevitable. But the ED is only one piece – albeit an important piece – of the health-system puzzle.
In some communities, it is impossible for local physicians to stay and keep clinical services afloat. How can one or two clinicians reasonably keep the ED open 24/7 and provide primary care in the clinic? It cannot be done. Cooperation from other northern health units that had to adjust their own schedules was needed to avert a holiday shutdown of the ED in Thessalon’s small hospital. And Thessalon is not alone in its challenge.
We need family physicians in northern Ontario’s rural communities to keep the ED open and keep primary care services in our clinics consistent. We need those same family physicians for patients who need preventive care, management of chronic disease or who are struggling with mental health and substance use issues; we need them for pregnant women and young children; we need them for people who are entering the last chapter of their lives who need palliative and end-of-life care. While some of this can be provided virtually, all of it is better with a consistent family physician, working with a team in the “Patient Medical Home” model of care, providing continuity of care across the spectrum of health and from birth to death.
Without consistent physicians in communities to keep ED’s open and patient services going, patients will travel farther for care, some will not access care in time for emergencies, others won’t access care at all. Some may die.
This kind of comprehensive community responsive care is in jeopardy.
And then there’s this: Without consistent physicians in a community, it becomes harder to retain the nursing staff. The lab staff move on. The administrators find better, easier places to work. Then businesses in our communities will struggle to draw people to their industry or business. Other professionals will leave. The local economy will decline. School enrolment will drop and teachers will leave.
We need not look far to see examples of this kind of decline. In the U.S. over the past decade, 120 hospitals in rural areas have closed, leading almost uniformly to economic decline in the most sparsely populated areas.
If we want a sustainable northern Ontario, then we must understand that local health systems are pillars of infrastructure without which communities will struggle to survive and without which people will suffer.
The solutions are known, but the pandemic has shown we need to reinvigorate our approach. We need to continue to decrease the barriers to training in northern Ontario through medical electives, and we need to expand the Northern Ontario School of Medicine. And then there is an “ecosystem” of support necessary to ensure that clinicians can thrive in rural health-care settings. Foremost, we need to continue to offer the ongoing, funded training and education they need to competently and confidently do the work and we need to support them with new virtual tools to decrease isolation from specialist care. We need to staff our settings to be able to provide care and to teach medical learners. We need to provide financial incentives that reward the complexity and breadth of the clinical work. We need to ensure mentorship of new grads as they transition to practice. And finally, we need to ensure that there is a team of people (nurses, physios, lab techs, personal support workers) to support the breadth of care that people need.
If we are serious about equity in Ontario, then the citizens of rural and northern Ontario must have equitable access to care and to the opportunity to live and die well in their communities, close to those who love them.
If we are serious about post-COVID recovery in our health-care system, then we need to optimize the potential that exists in our small rural health-care systems so that they can provide as much care as possible locally to keep our tertiary centres focused on what they can do.
If we are serious about economic resilience, then we need to understand that it is essential to have community-based, high-functioning health-care systems that enable citizens to access care locally, allow them to live in the best health possible and contribute their fullest potential economically.
If we are serious about any of this, we will commit to ensuring that rural and northern health-care systems are resilient and have the robust and highly trained workforce needed to deliver care where it is needed – in the ED, on the hospital ward, in the primary care clinic and in people’s homes.
We have the solutions in Ontario. We need the will.