THE RURAL MEDICINE CONUNDRUM: STEPS IN THE RIGHT DIRECTION, AND THE DIFFICULT ROAD AHEAD
Goldis Chami. UBCMJ 2012 3(2):29-30.
The global shortage of rural physicians is one that hits home for many people living in rural and remote areas of British Columbia. An aging Canadian population requiring more care, coupled with many rural physicians retiring, has put stress on healthcare systems which are already stretched to their limit. The result has been physician shortages in communities such as Burns Lake and Fort St. James, the latter having to temporarily close its hospital emergency room in March 2012, because while it previously had five physicians working in the town, it now only has one.
At the root of the problem is the recruitment and retention of physicians to rural areas, especially those who can be considered “generalists.” According to the Society of Rural Physicians of Canada, “with subspecialists and high technology of large cities distant, country doctors (…) require a broad spectrum of clinical skills.”1
For many years, federal and provincial governments have offered incentives to encourage physicians to practice in rural areas.1 These have included student debt relief for new graduates who decide to practice rurally,2 mandating that international medical graduates complete a return of service contract in a rural area after completing residency,3 and providing improved payment and practice models.2
There are also programs in place to support existing rural physicians, since the demands of rural practice can sometimes make it difficult to take time off from work and can lead to burnout. In British Columbia, locum placement programs allow for rural family physicians and specialists to take time off from their practices for vacations, continuing medical education, or for personal reasons.
Motivated by research demonstrating that medical students who come from rural areas are more likely to return to rural and remote areas to practice,4,5 governments and medical schools have turned their focus to students to address the problem. The process of cultivating rural physicians has been termed the ‘rural pipeline,6 and involves providing rural high school students with exposure to careers in medicine, recruiting, and admitting rural students to medical schools, and providing adequate exposure to rural practice opportunities during medical training.
As such, a number of Canadian medical schools have developed high school outreach programs. According to the Schulich School of Medicine, “early exposure to the practice of medicine can help influence students career plans, ultimately increasing their chance of successfully entering medical school.”7 Secondary school students are taught how to deliver babies using a simulator, learn to read x-rays, and practice applying casts. At Memorial University, the MedQuest high school outreach program may be one of the reasons why greater than 30 percent of its medical students hail from small towns, compared to only 11 percent of students at other Canadian schools.8
Peter Newbery, a family physician in Hazelton, British Columbia, and a pioneer in the efforts to increase rural physicians in Canada, tells the UBCMJ that one way that Canadian schools are aiming to increase the number of rural medical applicants is by broadening the socioeconomic distribution of medical students. He explains that traditionally medical schools have admitted students who engage in time-consuming and sometimes expensive extracurricular activities that help distinguish them as well-rounded applicants. Schools have since realized that they may have been, in turn, rejecting a First Nations student whose summer holidays had been spent on a fishing boat so that his or her family could feed themselves for the next year. He says that medical schools are therefore broadening their approach to selections so that they “value those students who may not have the high profile achievements but who have been doing equally significant things.”
In British Columbia and other provinces, rural training programs are popping up as “satellite campuses” of a number of medical schools. The Northern Ontario School of Medicine has main campuses in Thunder Bay and Sudbury with multiple teaching sites distributed across Northern Ontario. Memorial University’s Family Medicine Residency Program has another site in Goose Bay, Labrador, allowing residents the option to do a considerable chunk of their training up North. Dr. Geoff Payne, the Assistant Dean for Education and Research of the University of British Columbia’s Northern Medical Program, says that there is very much the belief that, Distributed medical training–where physicians live, learn and establish strong roots in these communities– presents one of the most promising prospects of meaningful and long-term engagement and service of medical professionals in underserved areas.9
As Canadian provinces and medical schools work together to roll out many of these initiatives, the question remains whether they will be effective. In many cases it is too early to tell, such as with high school outreach initiatives, which will only produce rural physicians many years down the line. Indeed, as Newbery states, “the issue of providing rural medical services is a complicated one, with many players and many perspectives” and schools and provinces alike can only hope that their efforts will pay off.
1. Joint Standing Committee on Rural Issues. (January 2011). Rural Programs: A guide for the rural physician programs in British Columbia. British Columbia Medical Association and Province of British Columbia.
2. Wilson DR, Woodhead-Lyons SC, and Moores DG. (1998). Alberta’s Rural Physician Action Plan: an integrated approach to education, recruitment and retention. CMAJ 158(3): 351-355.
3. Health Human Resources Policy Branch. (November 2007). Guidelines for Return of Service (ROS) for International Medical Graduates (IMGs), Repatriation Program and Registration through Practice Assessment. Ontario Ministry of Health and Long-Term Care.
4. Rolfe IE, Pearson SA, and O’Connell DL (1995). Finding solutions to the rural doctor shortage: The roles of selection versus undergraduate medical education at Newcastle. Aust NZ J Med 25(5): 512–517.
5. Laven G and Wilkinson D. (2003). Rural doctors and rural backgrounds: How strong is the evidence? A systematic review. Aust J Rural Health 22(6): 277–284.
6. Henry J.A., Edwards B.J. and Crotty B. (2009). Why do medical graduates choose rural careers? Rural and Remote Health 9: 1083.
7. Schulich School of Medicine & Dentistry: MedQUEST. Available from: http://www.schulich.uwo.ca/swomen/medquest. Accessed on: July 3, 2012.
8. Rourke J. (2010). How can medical schools contribute to the education, recruitment and retention of rural physicians in their region? Bull World Health Organ 88(5): 395-396.
9. Presnell, D. Medicine Matters: Distributed Medical Education in BC blog [Internet]. Vancouver (BC). Re: Doctor shortage in northern B.C. ongoing concern; 2012 Mar 27 cited 2012 July 3. Available from: http://blogs.ubc.ca/ medicinematters/2012/03/27/re-doctor-shortage-in-northern-b-c-ongoingconcern-by-kelly-sinoski-vancouver-sun-march-17-2012