Recruiting Canadian Family Physicians One

Recruiting Canadian Family Physicians One of the most significant problems for individuals and communities in rural areas in Canada is access to health care.

Some even say that it is the most serious of all social and communal problems in rural Canada, "The most serious problem for residents of rural and remote areas is access to health care." (Nagarajan, 2004) Primary and specialist care are frequently lacking and emergency services and existing services are secondarily challenged by this lack of access, so much so that there has been a recent trend in hospital closures that is simply making the situation even worse than before.

Recently, there has been widespread closure of rural hospitals in some provinces, such as Saskatchewan, with serious consequences to the local residents. A telling observation found in the Report is that the 1993 closure of 53 rural hospitals in Saskatchewan was followed by an increase in the perinatal death rate in affected areas.

Even if one may not directly have caused the other, the Report notes that this finding "is concerning." (Nagarajan, 2004) Over the last 20-30 years there has been an attempt, mostly through physician training infrastructure to recruit and potentially retain primary practice physicians and even specialists for service in rural areas. Primary care is even lacking in its development in rural areas even though it is acknowledged as essential and needs support.

(Starfield, Shi, & Macinko, 2005) the lack of fundamental support is one of the biggest reasons why primary care doctors choose not to locate practice in rural areas despite years of slow but fundamental development of such networks. (Hutchison, Abelson, & Lavis, 2001) Manitoba in particular shows a serious lack of specialist access in any but the most urban of health care delivery systems. While the standardized visit ratios for generalists were not dissimilar between the Winnipeg and non-Winnipeg PSAs (p = 0.61), we found large urban/rural differences in the use of specialists.

All nine Winnipeg areas (including both the relatively affluent suburban neighborhoods and the relatively poor inner core) had specialist use ratios (1.25 -- 1.65) that were significantly higher than any other Manitoba area (0.80 -- 1.09). (Reid, Roos, MacWilliam, Frohlich, & Black, 2002) So, in short there was some difference between primary care access a=in the urban/rural split but they were significantly different in access to specialist care, in areas as crucial as cardiac and surgery. It is clear that Canada is not alone in this plight, as the U.S.

is also seriously concerned about this issue, yet the U.S. lacks a federally organized and funded central health payment system and therefore Canada should be ahead, yet it is not. (Grumbach, Vranizan, & Bindman, 1997) (Rabinowitz, Diamond, Markham, & Hazelwood, 1999) These issues are persistent despite the language of the Canadian Health act or the good intentions of many; …the Canada Health Act (CHA) provision that reasonable access to insured health services be provided to all Canadians under uniform terms and conditions.

The Report points out, however, that in the real world, CHA notwithstanding, rural and remote area residents can have access only to a small range of service providers, and if they have to seek more specialized care they must travel long distances and incur additional expenses, which are not fully reimbursed. During some parts of the year, travel may be impossible due to weather conditions, leading to poor health outcomes.

(Nagarajan, 2004) Without such support there will continue to be a serious rift between the ideal of the Canadian medical system and the reality of it. Having defined the seriousness of the problem this work will then go on to critique the literature surrounding the issue and discuss the fundamental development of real solutions to the problem.

Critique of Literature The fundamental assumption of building recruitment of rural physicians around new graduate recruitment is that the newly trained physician is more likely to be in a state of transition and might be more willing to locate to a rural area while those who have been in practice for some time are likely rooted and unlikely to relocate. Yet, this attempt has been only marginally successful, and some would say a complete failure.

"Despite its intention to recruit family medicine graduates to rural areas and to obstetrics, the University of Calgary residency training program was not successful in recruiting physicians to these areas.

The program likely needs to re-examine the effectiveness of current approaches." (Lu, Hakes, Bai, Tolhurst, & Dickinson, 2008) The Kirby Panel Report compiled in 2002 really shows the extent of the problem, with regard to both rural health care access and rural health and standard of living issues, including education levels (generally lower), regional demographics (disproportionate youth and aboriginal populations), employment levels (generally lower) and general remote rural regional decline (with close in rural development on the rise) of the various rural regions of Canada.

(Nagarajan, 2004) All of these factors are fundamental to the landscape definitions and the lifestyle of rural Canada. What is most important is that healthcare access is disproportionate and real and perceived opportunities are limited, despite the fact that a large portion of the population lives in rural areas 20%-38% depending on the source of the estimate and the calculation standards.

(Jutzi, Vogt, Drever, & Nisker, 2009) (Rourke, 2005) Jutzi, Vogt, Drever and Nisker also point out that the kinds of recruitment systems that actually work include those that take the holistic reasons for a physician to choose or not choose to practice in a rural area into consideration. (2009) Medical students are influenced by both lifestyle and financial factors when considering rural practice. Although rural recruiters appear to recognize both factors, their incentive programs are primarily financial.

(Jutzi, Vogt, Drever, & Nisker, 2009) Recruiters then note that they are limited in what they can provide, and issues such as family support, good schools employment opportunities for partners are simply not within the scope of their work. They are then left with simple financial incentives which sometimes work and sometimes do not, and again are limited in scope and scale.

(Jutzi, Vogt, Drever, & Nisker, 2009) Recruitment of individuals new to physician training from rural areas has also been a focus of both research and intent with regard to the global issue, as this strategy serves a bi-fold purpose, i.e. increasing real opportunity in rural areas for education and employment and second to recruit individuals who have a tie to the rural system.

Studies in Canada and elsewhere indicate that rural physicians are up to 5 times more likely than their urban counterparts to come from a rural background.5 -- 17 a recent study in Ontario found that one-third of rural physicians came from a rural background.6 Woloschuk and Tarrant18 reported that Canadian clerkship students of rural origin were significantly more likely than their peers raised in urban areas to indicate that they planned to do rural locums and to practise in rural communities.

(Rourke, 2005) This hometown draw is only relevant when individuals find incentive to return to their rural roots in combination with actual real medical practicum opportunity. Individuals must be supported by allowing the creation of a system where experience can be gained and individuals might say, trade off to do practicum service in a more urban setting and then return to the rural setting when adequate experience has been gained. New doctors commonly stress the need for better practicum opportunities as one of the biggest reasons for practicing in urban settings.

(Rourke, 2005) Recommendations and Discussion Probably the most comprehensive lists of recommendations for change is that offered by Curran & Rourke who then go on to analyse the impetus and effectiveness of such changes.

In short the reasons that physicians do not choose to practice in rural areas are categorized into two areas, that which is within the control of the insitution and that which is not (possibly to be supplimentary addressed by recruiters); Rural student recruitment, admissions policies, rural-oriented medical curriculum, rural practice learning experiences, faculty values and attitudes, and advanced procedural skills training are areas which the medical school has direct control of and which have been shown to influence the likelihood of medical students entering rural primary care practice.

(Curran & Rourke, 2004) As one can see the literature has detailed several possible recommendations for the development of better rural health care access not the least of which is the sense that statistically and really speaking the recruitment of candidates from rural settings seems to be the most telling success marker for improving the situation. Physicians who were raised in rural communities were 2.3 times more likely than those from nonrural communities to choose to practise in a rural community immediately after graduation (95% confidence interval 1.43 -- 3.69, p = 0.001).

They were also 2.5 times more likely to still be in rural practice at the time of the survey (95% confidence interval 1.53 -- 4.01, p = 0.001). There was no association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community.

(Easterbrook, et al., 1999) Rourke goes on to discuss his recommendations for increasing the number of rural sourced students to medical training programs, the most important of which is changing the admissions one that more adequately recruits rural candidates: Changes to admissions process Objective • to admit a fair and equitable number of students of rural original to medical school Recommended strategies • Include rural physicians and rural community members on admissions policy and process committees • Include rural physicians and rural community members as interviewers • Ensure that students of rural origin are not disadvantaged by the admissions process • Apply a rural adjustment factor to grade point averages and MCAT scores • Set targets for rural enrolment (Rourke, 2005) All of these strategies to increase enrollment of rural candidates in medical training programs seem logical as the need to recruit people that have ties to rural communities and are presumably committed to returning to their rural roots is significant.

People from a given region are more likely than others to be aware of the specific cultural and social systems already in play in any given community and are more aware of what might need to be changed in any given system. (Rourke, 2005) the U.S.

has had some success in recruitment and retention programs similar to the recommended actions of the Calgary example above and utilizing some of the recommendations of Rourke and others regarding recruitment from rural areas and retention through support and incentive, but again like Canada progress is short and limited.

(Rabinowitz, Diamond, Markham, & Hazelwood, 1999) Rabinowitz, Diamond, Markham, & Hazelwood actually offer a significant model example of a recruitment program at a university in Pennsylvania, where they have slowly but surely been able to influence the numbers or recruited and retained family physicians in the immediate surrounding rural area to the university program. (1999) Yet, all this marginal success begs the question that the recommended idea of recruiting already practicing physicians with experience and confidence is also not a viable solution. It is clear that every complicated problem requires multiple solutions.

In the Calgary residency program, mentioned above even those individuals recruited from and doing practicum in rural areas often chose not to settle in urban areas in the short and long run as they perceived medical support as limited in those areas and sought greater skill set learning opportunities and then often chose to stay for family and financial reasons.

(Lu, Hakes, Bai, Tolhurst, & Dickinson, 2008) the institutions that are seeking to help solve these problems with recruitment might consider that the population they might be successful with is the existing physician population, rather than new recruits.

The recruitment might be more challenging, as these are not students present at clinical every day, but it might also be pointed out that physicians who have been practicing longer might have more resources to relocate, might have more fundamental desire to make a lifestyle change and most importantly may feel as if they are supported by experience and the already strong network they have developed as physicians in urban areas.

This paradigm shift might make the possibility of solving this problem, in part more logical as one of the biggest reasons new physicians site for not choosing rural practice is perceived lack of medical support. Whereas older physicians may feel confident in their practicum skills and feel comfortable using remote or tele-networking to obtain advice and treatment support from already established colleagues. (Grumbach, Vranizan, & Bindman, 1997) Summary The development of and strengthening of programs associated with improving.