Addressing rural physician shortages in Canadian primary care

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)

Summary

The development of and strengthening of programs associated with improving the recruitment and retention of physicians in rural Canada is absolutely essential to the development of a system that has an ideal more in line with its reality. The recommendations that are found within the literature and are supported by experiential data within it offer a host of recommendations that could go a long way in improving the situation of health care access in rural Canada. Given that 20-38% of the population resides in rural areas the need to provide equitable care according to the intent of the Canada Health Act is absolutely fundamental to the success of the health care system overall.

The proposed solutions in the literature include but are not limited to recruitment of medical school candidates from rural areas, who will presumably return to such areas when in practice, and improved medical school curriculum that will have the duel effect of focusing on rural practicum issues and most importantly provide greater orientation to advanced procedural skills that students may feel they will miss out on if they practice in a rural area and may feel they need to feel confident in doing so. In addition I added a secondary recruitment strategy that will allow recruitment of already practicing physicians who may be at an advantage financially, socially and practically to enter into a contracted engagement in a rural area. Like many of the authors here the use of strategies that both improve the situation on the educational level and improve the recruitment strategies private recruiters might use to bring care providers to rural areas are important to a long-term solution for this enduring problem.

Resources

Curran, V., & Rourke, J. (2004). The role of medical education in the recruitment and retention of rural physicians. Medical Teacher, 26 (3), 265-272.

Easterbrook, M., Godwin, M., Wilson, R., Hodgetts, G., Brown, G., Pong, R., et al. (1999). Rural background and clinical rural rotations during medical training: effect on practice location. Canadian Medical Association Journal, 160 (8), 1159-1163.

Grumbach, K., Vranizan, K., & Bindman, a.B. (1997). Physician Supply AndAccess to Care in Urban Communities. Health Affairs, 16 (1), 71-86.

Hutchison, B., Abelson, J., & Lavis, J. (2001). Primary Care in Canada: So Much Innovation, So Little Change. Primary Care, 20 (3), 116-131.

Jutzi, L., Vogt, K., Drever, E., & Nisker, J. (2009). Recruiting medical students to rural practice: Perspectives of medical students and rural recruiters. Canadian Family Physician, 55, 72-73.e4.

Lu, D.J., Hakes, J., Bai, M., Tolhurst, H., & Dickinson, J.A. (2008). Rural intentions: Factors affecting the career choices of family medicine graduates. Canadian Family Physician, 54, 1016-1017.e5.

Nagarajan, K.V. (2004). Rural and remote community health care in Canada: beyond the Kirby Panel Report, the Romanow Report and the federal budget of 2003. Canadian Journal of Rural Medicine, 9 (4), 245-251.

Rabinowitz, H.K., Diamond, J.J., Markham, F.W., & Hazelwood, C.E. (1999). A Program to Increase the Number of Family Physicians in Rural and Underserved Areas Impact After 22 Years. Journal of American Medicine, 281 (3), 255-260.

Reid, R.J., Roos, N.P., MacWilliam, L., Frohlich, N., & Black, C. (2002). Assessing Population Health Care Need Using a Claims-based ACG Morbidity Measure: A Validation Analysis in the Province of Manitoba. Health Services Research, 13 (5), 1345-1365.

Rourke, J.T. (2005). Strategies to increase the enrolment of students of rural origin in medical school: recommendations from the Society of Rural Physicians of Canada. Canadian Medical Association Journal, 172 (1), 62-65.

Starfield, B., Shi, L., & Macinko, J. (2005). Contributions of Primary Care to Helath Systems and Health. The Milbank Quarterly, 83 (3), 457-502.