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Forget that it’s about doctors. Forget that it’s even about health care. To health-care advocates in towns like Crapaud, P.E.I., Digby, N.S., or Lewisporte, N.L., it’s nothing less than a struggle to save their communities. Part Three of our Deep Dive into doctor shortages delves into grassroots efforts to attract family physicians and considers a possible prescription from doctors themselves.
Longtime physician Henk Visser had that many patients in Crapaud, P.E.I., prior to his retirement in 2017.
The Concerned Citizens Coalition in Lewisporte, N.L., has been working to establish a new clinic for seven years.
That’s the number people in western Nova Scotia without a family doctor.
THE BATTLE FOR RURAL CARE
For the first time in more than 150 years, Crapaud, P.E.I., is without a family doctor.
In the fall of 2017, the only family physician, Dr. Joey Giordani, abruptly announced he would be relocating his practice to Cornwall. Six months later, he would close his practice completely. Patients were informed by a notice posted at his clinic.
Crapaud, located between Charlottetown and the Confederation Bridge, has long acted as a service and health-care hub for towns on the island’s south shore, including Victoria, Bonshaw, Albany, Tryon and even Borden-Carleton.
That fall, a meeting drew more than 200 from these communities to the Crapaud Community Hall. People were motivated. Some, such as Victoria-by-the-Sea councillor Pat Smith, felt the survival of their communities was at stake.
"Rural Prince Edward Island is under threat as it is right now, losing services and population,” Smith told CBC news.
“I think a healthy robust health-care system in the area is absolutely essential for a healthy, robust community.”
Crapaud’s story is one of many examples of rural communities struggling to fill gaps caused by lack of physicians. With less than 10 per cent of Canadian family doctors practising in rural areas and tens of thousands from East Coast towns without a doctor, communities are banding together to try and make something happen.
From the meeting in Crapaud, the South Shore Health and Wellness Committee was born. Its mandate included things one might expect a health authority to do.
"We decided we had to make a not-for-profit organization that could advocate for health-care services and try and recruit," said secretary Lisa Gallant.
The group also committed to fundraising for supplies for a permanent clinic. It has generated $20,000. By January 2018, it opened a walk-in clinic at the pharmacy.
Gallant owns that dispensary. She decided, in a “leap of faith,” to donate the space. Her business later bankrolled a renovation so it could be used by a future physician. She and her employees have made do with a reduced workspace.
“My staff has given up their kitchen, my staff has given up their stockroom,” Gallant said.
“We can't go on like this. We're building the facility hoping that government will come on board.”
Health P.E.I. has agreed to fund a nurse practitioner to staff the clinic. Recruitment of a doctor has proven elusive.
It’s not for lack of trying. The group has canvassed local doctors, medical residents and posted notices at Dalhousie and Memorial universities. It has offered free gym and curling club memberships, as well as a year of free rent in the clinic.
"The issue, as I see it, is that government recruitment and retention has us lumped in with Charlottetown,” Gallant suggested.
When given the choice, most physicians have opted for the bigger centre, she said.
Lewisporte, N.L., has a similar story. The town of 3,400 serves as a regional hub.
And like Crapaud, hundreds gathered to address a doctor shortage in 2011. Residents, from Lewisporte and surrounding towns, formed the Concerned Citizens Coalition, and have worked at establishing a new clinic for seven years.
As of now, it has been built, sharing a building with a local pharmacy. But there’s still no doctor staffing it.
"Right now, we have a state-of-the art medical clinic with nobody in it. We succeeded in getting that land there. We succeeded in getting a private developer," said Walter Dawe of the Concerned Citizens Coalition.
“We don’t know what’s wrong.”
The Central Health Authority hasn’t been able to recruit a doctor for the clinic, although general physician recruitment efforts in Lewisporte have been successful compared to some rural towns. Still, two physicians left last summer.
"Everyone feels that somewhere else in the province is getting all the resources." — Chris Parsons, Nova Scotia Health Coalition
In Nova Scotia, communities have taken a different approach towards health-care staffing shortages.
Digby is among the hardest hit of communities along Nova Scotia’s South Shore. Only one doctor serves the town of more than 2,000.
After the departure of three doctors in 2016, the Digby Area Health Coalition (DAHC) formed. It raised money for social science researchers to produce a report diagnosing local health-care challenges. The researchers tracked down the departed doctors and asked why they left. The Nova Scotia Health Authority had not conducted exit interviews.
"They described a kind of switch and bait. You come here under certain offers and possibilities for your career when you land in a place like Digby. When you get here, what you thought you were getting into was not what you bargained for,” said Tony Kelly, coordinator for the DAHC.
Kelly said the departed physicians became burnt out because of a lack of support.
"At the end of the day, they were all thoroughly exhausted as young people.”
It’s the type of story Chris Parsons of the Nova Scotia Health Coalition hears a lot. He believes these stories are feeding a sense of regional alienation in rural communities.
"Everyone feels that somewhere else in the province is getting all the resources. There's a real sense in our communities that the battle for health care in a place like Shelburne or Digby is the battle for saving the community. If you can't fix the health-care problem, then the town can't survive."
The town of Crapaud, P.E.I., is without a doctor for the first time in its 150-year history.
“Fee-for-service is good because it incentivizes volume. But it's also bad because it incentivizes volume," says Tim Holland of Doctors Nova Scotia about the current model used to pay physicians in his province.
According to the Canadian Institute for Health Information, the gross clinical payments per East Coast physician during 2015-2016 were (by province): $262,164 in Nova Scotia, $290,457 in New Brunswick, $275,781 in Newfoundland and Labrador, and $366,934 in Prince Edward Island.
FIX BILLING STRUCTURE, RECRUITMENT AND RETENTION, SAY DOCTORS
Physicians in Nova Scotia and Newfoundland and Labrador have diagnosed some causes and possible solutions to their health-care woes.
According to the Canadian Institute of Health Information, Nova Scotia doctors are among the lowest paid in Canada and are the lowest paid in Atlantic Canada.
Tim Holland of Doctors Nova Scotia believes the billing system used in the province has made it harder for the region to retain family physicians.
"Anecdotally, we hear all the time from physicians who cite compensation as a major issue for leaving Nova Scotia to other areas," Holland said.
Nova Scotia uses a fee-for-service model of billing, which provides physicians with compensation for each service they provide.
“Fee-for-service is good because it incentivizes volume. But it's also bad because it incentivizes volume," Holland said.
"It sets up practices to do the one-problem-one-visit family medicine"
The billing system does not incentivize doctors to collaborate with other health professionals or to focus on preventative care, Holland said.
Holland believes the province should use a blended capitation model of billing, which mixes fee-for-service and capitation.
Capitation billing provides compensation for a physician’s total roster of patients, based on the expected care they will receive.
Ontario physicians currently use the blended capitation model and New Brunswick, British Columbia and Alberta have recently moved to this model as well.
"With the blended capitation model, if you can keep them healthy, you have the incentive to access that mental-health social worker, because that helps keep them healthy and frees up time to do other things," Holland said.
Prince Edward Island and Newfoundland and Labrador both use a fee-for-service billing model, although physicians may also be salaried.
A report released last spring by the Newfoundland and Labrador Medical Association, the Newfoundland and Labrador College of Family Physicians and the Memorial University Faculty of Medicine recommended the adoption of a blended billing system.
The report noted Newfoundland and Labrador had the highest net out-migration of family physicians among provinces in 2016. Physicians in the province also tended to be the most dissatisfied in terms of the balance between their personal life and professional commitments.
“Currently, there is no provincial physician human resource plan that identifies the appropriate number and placement of family physicians to meet the province’s current and future primary health-care needs,” the report noted.
“Around the province, a lot of time and effort is spent on filling critical and immediate gaps as opposed to planning for the long-term." — Newfoundland and Labrador Medical Association president Tracey Bridger
Newfoundland and Labrador Medical Association president Dr. Tracey Bridger believes the province needs to take a long-term view of recruitment and retention.
“Around the province, a lot of time and effort is spent on filling critical and immediate gaps as opposed to planning for the long term. They're just trying to fill a position or just get locum after locum,” Bridger said.
“It was very clear to us that a more robust recruitment program, that has a co-ordinated system-wide design, would go a long way to address a lot of these things, especially in rural areas."
Bridger said she was unclear whether human resources staff conducted exit interviews with doctors who leave the region in order to determine the reasons for their departure. She also believes staff often prioritize finding locums over long-term, permanent physicians.
"For some people, very little is spent on actually recruiting permanent people and retaining the people they have, because they're just busy trying to recruit locums," she said.
This could be an opportunity for collaboration between health authorities throughout the Atlantic region, Bridger said. All four provinces compete with one another to attract health-care staff.
“It would be good, say for example, even to have a (regional) locuming program,” Bridger said.
SaltWire has reached out to health authorities from all four Atlantic provinces to find out about practices undertaken to recruit and retain health-care staff.
COMMUNITY-LED GRASSROOTS RESPONSES TACKLING THE ISSUE FROM ALL ANGLES
Paramedics to the rescue
SYDNEY, N.S.—Nova Scotia has quietly begun operating a community-based paramedic program out of the Cape Breton Regional Hospital.
It’s designed to ease the pressure on emergency departments by sending paramedics out on community calls.
Three of the top five reasons people in the region rely on emergency health relate to primary care, such as wellness checks — something that would traditionally be handled by a family doctor.
The program began operating Dec. 17. After its first weeks are reviewed, the initiative is expected to expand to Glace Bay.
As of Jan. 24, 14 patients were referred to the program. That resulted in 33 in-person visits from paramedics and two virtual visits by registered nurses to support patients after release from hospital.
The program is focused on supporting patients being discharged from hospital, frequent users of emergency health and those with chronic disease.
The project is expected to cost $900,000 a year and is part of the redevelopment of the region’s health-care system.
— Nancy King, reporting for The Cape Breton Post
Interest in a new med school
SYDNEY, N.S. — A proposal by a psychiatrist that Cape Breton University (CBU) open its own school of medicine to help address the doctor shortage struck a chord with people weary of ongoing doctor shortages and emergency department closures.
The idea, put forward by Dr. Kerry Ann Murray in a Cape Breton Post article, attracted thousands of readers and many comments.
CBU has previously undertaken creative ways of launching nursing and teaching training programs. It partnered with St. Francis Xavier University for the former before earning its own nursing program and delivered Memorial’s teacher education curriculum before gaining approval for its own degree offering.
So, the idea of starting a medical program similar to one launched in 2005 in Northern Ontario caught readers’ imaginations.
“Having our own medical school class at CBU and an expanded selection of residency spots, including specialties, allows for the majority of training to be done on the island and increases the rate of retention of future graduates,” Murray said.
“It also adds to the pool of clinicians in training who are able to help current staff physicians carry the heavy burden in an overstressed system.”
There are two med schools in Atlantic Canada — one at Dalhousie in Halifax and another Memorial in St. John’s. In 2018, those schools admitted a total of 192 students to the programs.
— Nancy King, reporting for The Cape Breton Post
Social cuts put added pressure on system: advocate
HALIFAX, N.S. — Chris Parsons, co-ordinator for the Nova Scotia Health Coalition, believes seemingly unrelated decisions are contributing to the erosion of health-care staffing.
He suggests long-term cuts to other social programs that help the poor and marginalized, such as public housing and social assistance rates, have also brought about increased “diseases of despair,” like depression and substance abuses.
"People can't access the social services they need to prevent themselves from getting sick.
"Part of the problem is we have all these cascading problems that start elsewhere in society. They just end up having to be dealt with in the health-care system as the last line of defence."
— Stu Neatby, , reporting for The Chronicle Herald
FROM THE FILES
People have been talking about doctor shortages throughout Atlantic Canada for years. Here’s a sample of some earlier coverage.
"Based on what we see coming into the walk-in clinic and the hospital, there are more and more people in the distressing situation of not having a family doctor. And that's distressing to the doctors, as well.”
Dr. Murdo Ferguson, in a Truro News story, Nov. 29, 2018
CLOSE TO HOME
"It's a scary thought, not having a family doctor … I didn't really understand that until it happened.”
Nicole Deagle, in a Charlottetown Guardian Story, Feb. 26, 2018
NO ONE AVAILABLE
“At the meeting, I asked the board if we could get a doctor to do locum to take Dr. Parsons' place until a doctor or nurse practitioner is found. The answer that I got was there is a shortage of doctors and no one to do locums.”
Dave Kane, in a letter to The Corner Brook Western Star, April 18, 2017