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THE DOCTOR SHORTAGE IN RURAL REMOTE COMMUNITIES
By Suzanne Forcese
The Canada Health Act (CHA) sets out the primary objective of Canadian health care policy, which is "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers". However, for many Canadians this remains an issue. Canadians without a family doctor understand how challenging this problem is. For Canadians in rural and remote areas, the problem is more serious. Geographical, environmental and organizational forces result in difficulties of accessing health care.
According to the Canadian Foundation for Healthcare Improvement, a not-for-profit organization, funded by Health Canada, rural Canadians constitute 22% of the population. Fewer than 10% of physicians and 2% of specialists work in these areas. While Canada as a whole averages 1 doctor per 450 residents, this ratio can be as low as 1 in 3,000 in some remote areas. Adding to this difficulty, residents of rural and remote communities often have greater healthcare needs than their urban counterparts, experiencing higher rates of chronic disease, traumatic incidents, and poorer mental health. Increased urbanization and centralization of medical services have further stressed the situation. Disparities in Indigenous Health and access to care for Indigenous people in rural Canada are even more pronounced. This suggests that according to CHA, these Canadians must be served better.
WaterToday spoke with Dr. Nadin Gilroy. Dr. Gilroy leads a double life. She is a palliative care specialist in Winnipeg. Every other week, Dr. Gilroy boards a plane to Norway House, 300 km north of Lake Winnipeg, on the bank of the eastern channel of Nelson River. This has become her second home where she has practised broad spectrum medicine. She has done this for the last 7 years – and she loves it. "I am part of a core team of 10. We split into 2 groups and alternate weeks. It is the only way it works."
Dr. Gilroy explains that she soon realized the demands of working in a remote community would lead to burn-out. She and her team came up with the solution of dividing into the 2 groups and for the team it has resulted in the longevity of continuous care. "It took a lot of advocating to get to this in place." Regional Health Authorities have a different perspective than the actual physicians, nurses, practitioners and patients Dr. Gilroy suggested.
,br> "The First Nations people have so much to offer. They could contribute so much to the way the system could evolve, if only they could be heard." Dr. Gilroy adds that so many of her patients are still feeling victimized by colonization and it has taken a lot of effort and advocacy on the part of the team to overcome this. "That is why it is so important to have continuity with our patients. It also allows us to be part of the community and experience the riches of their culture."
Although Norway House is not as remote as many northern communities, most patients from the catchment area have to travel 12 hours by bus and take a ferry for a visit to the doctor. Their issues are always more complex than the patients in urban areas. "Added to that, we don't have the resources that an urban centre has." In urgent cases either the doctor has to fly to the patient or the patient has to be flown in to a larger centre.
WT discovered that in some provinces this fly-in option works well but in others not. Sometimes a patient can be flown into a hospital for urgent care but when it is time for the patient to leave, there is difficulty obtaining the return flight. When hospital beds are at a premium this poses a serious concern and contributes to doctor burn-out.
While Dr. Gilroy and her team enjoy northern rural living and culture for every other week of the year, attracting physicians to practise in rural remote Canada is not for everyone. Several barriers contribute to the difficulty these areas have in retaining physicians, including a heavy workload, professional isolation and limited career options. Personal considerations are also important, including fewer educational opportunities for the doctors' children and limited cultural and religious resources. Employment and social opportunities available for spouses may also be inadequate, further hindering long-term retention in remote areas.
While all these barriers play a role in poor retention rates, there are ways in which retention can be improved. Research suggests (Canadian Journal of Rural Medicine) "by exposing urban students to rural life and learning experiences interest in rural practice may develop. Encouraging individuals who are already from rural areas to apply to med school (currently only about 11% of medical students are from rural and remote areas) could improve retention rates. By promoting student outreach and financial support for rural students, rural recruitment and retention could be vastly improved."
The Northern Ontario School of Medicine (NOSM) has that vision. NOSM is the only Canadian medical school with a joint initiative between 2 universities - Laurentian University in Sudbury and Lakehead University in Thunder Bay. Providing training across a geographic expanse of 800,000 sq. km the school offers exposure to rural, remote, Indigenous and Francophone communities. By the time the MD program is completed, the average NOSM student will have spent nearly 40% of his or her time studying in Aboriginal and small rural communities in Northern Ontario. In fact, the entire geography of Northern Ontario is considered NOSM's campus. To date 526 MDs have graduated from the School. NOSM's MD class has 91% of its learners from Northern Ontario, including 7% Indigenous and 22% Francophone medical students. 62% of NOSM graduates go into mostly rural family medicine compared to the Canadian average of 38%.
Although work still needs to be done in the recruiting department there is a a cadre of physicians who are ready, willing and able to travel to remote areas of Canada if only the system would allow it. This is something that would appeal to early and late career physicians according to Dr. Ruth Wilson of the Society of Rural Physicians of Canada. Dr. Wilson would like to see a special national locum licence designation that would allow doctors to practice in all provinces and territories as ‘trusted travellers'. As it stands, every province and territory has its own licensure.
Dr. Wilson also feels much more could be done with distance technology. "Much more could be done with tele-medicine." Certainly it would eliminate a good deal of the distance travel.
Another approach to recruiting students into the Faculty of Medicine has been adapted by the University of Alberta in Edmonton.
The University of Alberta is eliminating a quota system that caps the number of Indigenous students admitted to its medical school. For the past 30 years the medical school program held 5 spots per academic year for Indigenous students as long as they met eligibility requirements. Recruiting and supporting Indigenous students is a priority to bring forward "the understanding of the vital role Indigenous medical professionals have in making important contributions to the health-care system broadly and among Indigenous peoples specifically". (Dr. Tibetha Kemble, Director of the Division of community Engagement's Indigenous health Initiatives Program (IHIP). Kemble is advocating for other medical schools across Canada to make similar admission changes.
The challenges of delivering continuing care in First Nations communities remain. Indigenous health outcomes tend to be poorer than the Canadian average. The underlying factors are complex and include historical and inter-generational trauma attributed to colonialism and discriminatory policies.
Indigenous Services Canada reports: "Significant gaps remain in the overall health status of Indigenous peoples compared to non-Indigenous Canadians. For Indigenous peoples increased ownership, control and management of health services are the foundation for closing the gaps that exist in health outcomes between indigenous and non-indigenous Canadians."
We are indeed a country with a lot of geography. To span that geography and clear the structural hurdles in providing adequate health care to the population that is sparsely spread across the northern reaches there is much to accomplish. The steps being taken in recruitment and education are a beginning. The awareness of the deficiencies is providing an awareness of the solutions that need to be met.
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