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Let's be honest. Most medical students being trained on the East Coast don't want to practise family medicine. Even fewer want to hang a shingle in rural or remote areas. So where does that leave the recruitment efforts aimed at solving the doctor shortage? What other possible solutions can we explore?
WHAT'S BEING DONE, OR NEEDS TO HAPPEN, TO RECRUIT MORE DOCTORS
Sheila MacLean is one of the most experienced health recruiters in Atlantic Canada.
Shortly before her retirement from P.E.I.’s department of Health and Wellness, the Canadian Association of Staff Physicians Recruiters (CASPR) gave her a lifetime achievement award.
During her career, she recruited nearly 300 doctors. She is currently a recruiting consultant and remains active with the communications committee of CASPR.
Her answer is blunt when asked why medical school graduates are increasingly choosing not to specialize in family medicine in rural communities.
"Nobody in their right mind wants to work 60-80 hours a week. So why should we be expecting physicians to do that?” MacLean said.
She said the health system, which has often relied on a generation of family doctors who brought their work home with them, often lacks flexibility to provide local medical grads with a reasonable work-life balance.
"Nobody in their right mind wants to work 60-80 hours a week. So why should we be expecting physicians to do that?" — Sheila MacLean, recruiting consultant
“Our system says, if you want to be a family doctor here, you've got to take on 2,400-2,700 patients, and you've got to participate in the on-call schedule for family medicine in the hospital,” she said.
MacLean added many residents — often saddled with debt in the hundreds of thousands of dollars — do not see rural family practice as offering competitive pay compared to other specialties in urban areas.
Last spring, only 20.4 per cent of Dalhousie medical residents listed family practice as their first choice of specialty, down from 41.7 per cent in 2014.
At Memorial University, 36.3 per cent of medical residents listed family practice as their first choice, down from 43.9 per cent in 2014.
If national trends are followed, most who choose family practice will remain in urban areas.
According to the Canadian Post-M.D. Education Registry, only 6.2 per cent of Canadian medical school graduates were practising in rural communities in 2017, two years after graduating.
So where does that leave the region’s health-care recruiters?
Many have focused upon drawing physicians from countries whose training is comparable to Canada’s.
Rebecca Gill, manager of Health P.E.I.’s recruitment and retention secretariat, said there are many steps involved in ensuring physicians are a good fit for specific communities.
P.E.I., she noted, has had success in recruiting physicians from South Africa, the U.K. and Ireland.
"There's a lot of work that goes into recruiting the internationally educated medical graduates," Gill said.
"There's an immigration piece to get them to be eligible to work in Canada, but also the (medical) licensing piece, to get them to be eligible to work in Canada."
Gill’s team of five also focuses on helping spouses of potential recruits find employment.
She said P.E.I.’s small size can be advantageous for physicians. Young graduates, who have access to policymakers, can be change-makers in the health-care system.
“You can come here and effect change very quickly in our health system," she said.
Despite its advantages, P.E.I. appears to be barely keeping up with retirements and resignation of family physicians. Over the last two years, the number of family physicians hired by the province has equalled the number of physicians who have departed or retired.
In an “educated guess,” Gill estimated as much as half of the time of staff members is spent on filling locums, in order to allow for personal leaves or vacations.
Some recruiters refer to this as “reactive recruitment.”
"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.” — Tracey Bridger, president of the Newfoundland and Labrador Medical Association
Tracey Bridger, president of the Newfoundland and Labrador Medical Association, believes recruitment should be driven more by the current and future health needs of the population.
“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.
A report released by the NLMA last spring called for the Newfoundland and Labrador government to complete a physician human resource plan that could guide recruitment and retention over a 10-year period.
Cindy Snider, CASPR’s chairperson, believes this should be national priority.
"Having a plan like that in every province would be wonderful. It helps everybody and it helps the medical schools," Snider said.
Some provinces have already begun this work. Gill said P.E.I. is developing a five-year human resource plan. Nova Scotia currently has projections of the number of physicians needed over the next 10 years and has a recruitment strategy in place.
But tracking of basic recruiting data has occurred only relatively recently.
"A lot of provinces don't even record that data," MacLean said, referring to tracking of departures and arrivals of family physicians.
Still, MacLean believes that the recruitment and retention practices of all four Atlantic Canadian provinces are sound. Recruiters often follow up with physicians repeatedly once they have been hired within a community.
"Everybody, I believe, is doing all the right things," she said.
Other regions in Canada have placed a more long-term focus on health-care staffing issues.
Roger Strasser, founding dean of the Northern Ontario School of Medicine in Thunder Bay, said health authorities in his region have focused efforts on local high schools.
"It's recruiting our own students,” Strasser said.
“We encourage high school students in the Indigenous communities, elementary school students to see a future for themselves which might include health care."
An action plan developed by NOSM also urged rural communities to “collaborate rather than compete” on recruitment and retention efforts.
The doctor shortage has plagued our region for more than two decades. Based on our reporting over the last four weeks, here are three solutions creating a positive impact.
CHALLENGE: Obstacles with doctor licensing
Solution: Atlantic Canada could see regional licensing of doctors
The East Coast could see a streamlining of licensure for doctors before the rest of Canada.
Currently, physicians practising or on locum outside their home province require licensure by the college of physicians and surgeons in the jurisdiction in which they are practising.
Physicians often find the paperwork overly complicated, plus fees vary from $600 in New Brunswick to $1,950 in Nova Scotia and P.E.I.
Dr. Linda Inkpen, registrar of the Newfoundland and Labrador College of Physicians and Surgeons, said the four Atlantic provinces could introduce changes to streamline the process within six months.
“We're pretty close right now to even stripping out the few barriers that we think we can.”
Changes to licensure may require some provinces to pass legislation. But following a recent meeting of Atlantic Canadian premiers in Charlottetown, all four leaders supported the initiative.
Nationally, Inkpen said medical colleges are also discussing the establishment of a national licence for locum physicians.
However, internationally-trained physicians looking to practise in Canada may not see a simplification of their process for licensure.
Dr. Cyril Moyse, registrar of P.E.I.’s College of Physicians and Surgeons, said colleges are finding it increasingly difficult to evaluate the training of physicians from outside of the country.
"We've got no way of knowing what their training programs are like and how to appropriately vet them for public safety," Moyse said.
— Stu Neatby
CHALLENGE: Pay structure might not match population’s needs
Solution: New Brunswick’s blended system provides incentives to take on more seniors, and encourages collaboration
A blended payment model may be helping New Brunswick keep more local doctors.
For over a year, the New Brunswick Medical Society (NBMS) has been overseeing a program in collaboration with the province’s Department of Health. It allows physicians to use a blended capitation model of billing for medical services.
Blended capitation allows for a combination of fee-for-service billing, used by all other Atlantic Canadian provinces, and a per capita funding for a set number of patients. Fee-for-service provides a payment to doctors for every service they provide.
Across the province, 42 physicians have signed up for the project.
Anthony Knight, CEO of the NBMS says new billing practices provide incentives for physicians to take on more seniors as patients and collaborate more with other health professionals.
“Young physicians, early career physicians, are very attracted to this model,” said Knight.
“There’s lots of good evidence to show that a blended payment model encourages doctors to have practices that meet the population’s demands.”
Knight said the billing changes have been implemented as part of the program, known as Family Medicine New Brunswick, which patients choose to opt into.
It allows patients to book appointments with their family physician online, access their health records, and make appointments during nights and weekends.
The program has provided enrolled physicians with free coverage of an electronic medical record system.
Knight said the initiative is still new but he hopes to see the number of physicians enrolled double within the next two years.
“We’ve had residents who’ve completed their training stay in New Brunswick because of this model,” he said.
— Stu Neatby
CHALLENGE: Getting med students to become family doctors
Solution: Getting them to train in rural communities
Last spring, Dalhousie’s School of Medicine saw only 25 per cent of its graduates chose to family medicine.
The results were surprising for staff at the medical school. This was the lowest level of students to go on to family medicine since before 2004, and is a precipitous drop from 2014, when 49 per cent of graduates chose family medicine.
In an e-mail to SaltWire Network, a representative of the faculty of medicine said the university has established a task force to investigate why students are increasingly choosing other specialties.
“We immediately began investigating the factors that led to these results and put resources into a Family Medicine Project Charter whose course is to examine these influencers more deeply,” said Jennifer Lewandowski, a communications advisor for the department.
Lewandowski said the school hopes to encourage 50 per cent of graduating students to pursue family medicine by 2022.
According to data from the Canadian Resident Matching Service, between 2014 and 2018, the percentage of Dalhousie residents who listed family medicine as their first choice dropped from 41.7 per cent in 2014 to 20.4 per cent in 2018.
Conversely, the Memorial University Faculty of Medicine has largely maintained its rate of student graduates who choose family medicine. The school saw 41 per cent of graduates match to family medicine in 2018. In 2014, 42 per cent chose family medicine.
Dr. Kathy Stringer, MUN’s chair of family medicine, said they place a strong emphasis on encouraging students to practise in rural communities. The school attempts to recruit students from rural areas in hopes they will go back and practice in their home region.
“Right from first year … our medical students have exposure to family physicians in their offices,” Stringer said.
In the third year, students spend eight weeks in a rural community as part of a core family medicine rotation.
Stringer said there is strong evidence that students who receive their training in rural regions tend to practise in these communities after graduating.
But she added work needs to be done at the high school level to encourage teenagers from rural communities to consider a career in health care.
“It has to be an approach that starts way before we get them,” Stringer said.
— Stu Neatby
TECHNOLOGY MIGHT BRING FUTURE SOLUTIONS, BUT THAT'S OF NO USE NOW
I went to see my family doctor after three days of feeling ridiculously tired.
He examined me while listening to me describe my symptoms.
“I don’t think the tiredness is too serious. Get more sleep,” he said. “But I’m concerned about something else.”
He had discovered an extremely large lump on my neck, just above the collar bone.
The doctor promptly referred me to an ear, nose and throat specialist who removed a benign tumour a few months later.
I consider myself really, really lucky.
But with an estimated 175,000 Atlantic Canadians without a family doctor, I’m wondering how many lumps — or high blood pressure, concerning moles, pneumonias, cancers, etc. — are not getting the attention they require.
Over the past four weeks, SaltWire Network has taken an in-depth look at doctor shortages in Atlantic Canada.
The team — Stu Neatby, Jen Taplin, Glen Whiffen and Nancy King — has endeavoured to outline the scope of the issue and how it affects people, especially those who have been marginalized in society.
They’ve also looked into the fixes being tried by individuals, communities, doctors’ unions, health authorities, medical schools, and more.
Despite those collective efforts, the doctor shortage continues, and is all-too frighteningly real for those without a physician.
There are glimmers of hope for patients, as with the Cape Breton program where paramedics triage during home visits, and there’s the success of the blended pay structure in New Brunswick.
There’s also the promise of technology — numerous wearable devices for monitoring health are on the market and their effectiveness will only improve. (Suggestion: don’t rely on a device until it’s tried and trusted.)
And expect more health authorities to implement technological advances. Telehealth is already a reality across the region, with new initiatives underway, and there are other things coming.
For instance, on Feb. 12, a BBC article explored a report on how technology will change England’s health-care staff.
The research was conducted by Dr. Eric Topol, an American health expert.
His prediction: in a decade, it’s likely patients will stay at home and rarely see family doctors or have out-patient appointments.
Many, the article explained, “will manage their own long-term conditions, for example high blood pressure and lung disease, with wearable devices and sensors, which will be much more effective than occasional appointments with a doctor.”
That’s obviously a futuristic, and for some, a controversial prediction.
Still, emerging technologies will undoubtedly change primary care and, if the health system in England or anywhere else adopts such innovations successfully, other decision-makers will follow suit.
These advances are years away, of course, and of no use to people currently without a family doctor.
While our Deep Dive did not identify a clear remedy for the doctor shortage, it shows that a considerable amount of work is being done to attract physicians and deliver primary care to Atlantic Canadians.
Hopefully those efforts will pay off and people will get the care they need, and worrying things — like a strange lump in the neck — will be addressed in a timely manner.
— Steve Bartlett, senior managing editor
P.S. If you have a symptom that’s worrying you and you don’t have a family physician, go to a walk-in clinic if one is available, or to the nearest emergency room, and have it checked out.
The chair of the Canadian Association of Staff Physician Recruiters says a human resource plan to guide recruitment and retention over the next 10 years should be a national priority.
6.2 PER CENT
A Canadian Post-M.E. Education Registry report shows 6.2 per cent of medical school grads practice in rural communities.
DOCTORS COME AND GO
Between 2015-2017, New Brunswick attracted 49 physicians, while during that same period, Nova Scotia and P.E.I. lost six total.
— Source: Health P.E.I., N.S. Health Authority, NB Department of Health