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PRESENTATION TO The Standing Senate Committee on Social Affairs,
Science and Technology
MAY
31, 2001
PETER HUTTEN-CZAPSKI, MD phc@srpc.ca
About the Society of Rural Physicians of Canada
The Society of Rural Physicians of Canada (SRPC) is the national voice of Canadian rural physicians. Founded in 1992, the SRPC’s mission is to provide leadership for rural physicians and to promote sustainable conditions and equitable health care for rural communities.
On behalf of its members and the Canadian public, SRPC performs a wide variety of functions, such as developing and advocating health delivery mechanisms, supporting rural doctors and communities in crisis, promoting and delivering rural medical education, encouraging and facilitating research into rural health issues, and fostering communication among rural physicians and other groups with an interest in rural health care.
The SRPC is a voluntary professional organization representing over 1,100 of Canada’s rural physicians and comprising 5 regional divisions spanning the country
Table
of Contents
About the Society of Rural Physicians
of Canada
"Every citizen in Canada should have equal access to health care
regardless of where they live."
There are many health care challenges for Canadians, but none are any
greater than the challenge of providing care for those who live in remote
and sparsely populated regions of this country. The Society of Rural Physicians
of Canada has extensive experience in rural health care analysis.
(1)(2)(3)(4)(5)
The
following will explore some rural trends and offer suggestions on how we
can deal with the issues. In a way, the challenges of Rural Health are
an opportunity as by building a system that can address rural needs in
a fair and equitable manner we will build a system that can address the
needs of all Canadians.
Rural
Health Current Status and Trends
Rural Canada has about 20 percent of the employed Canadian workforce,
31.4 percent of the Canadian population and over 99.8 percent of the nation's
territory. (6)
It is a highly diverse economy and society, from its coastal regions
to its agrarian heartland. Canada's rural natural resources provide employment,
forest products, minerals, oil and gas, food, tax revenue and much of our
foreign exchange. Rural and remote Canada provides an intense cultural
identity for the country as celebrated by our artists.
Rural Canada is growing in population at a half percent annually
(6), and this will accelerate as baby boomers retire to the country
where many of them have their roots.
There are major challenges in rural health care delivery. The chronic
and often critical shortages of physicians, nurses, rehabilitation therapists
and other health care providers are well-known. For instance, while 31
percent of Canadians live in rural areas, only about 17 percent of family
physicians and about four percent of specialists practise there.
(7)
A 1999 study funded by Health Canada projected that our overall supply
of doctors will reduce from 56,775 in 1999 to 52,438 in 2021. Relative
to the population, this means the ratio will fall from 1.82 physicians
per 1000 people in 1999 to 1.39 in 2021 (a 24% decrease).
(8)
It will be worse in rural Canada. Statistical modelling predicted a
decrease of rural physicians from 5,531 in 1998 to 4,529 in 2021. The ratio
of physicians per 1000 population will decrease from an already low 0.79
physicians per 1000 population in 1999 to 0.53 by 2021 (a 33% decrease).
And so the gap between urban and rural grows.
Our existing health system trends will cause accelerated rural attrition
and increasing disparity between rural and urban Canada in terms of access
to physicians.
The
Urban Centric Educational Paradigm
"An important attitudinal problem is that of 'learned helplessness'.
The highest that many new medical graduates aspire to in dealing with medical
problems is being able to assess to which specialist to refer the patient.
Consequently, it is a frightening prospect for them to contemplate rural
practice."
Education is the entry point into the national health human resource
pool. Research shows that training experience in rural medicine is important
and that rural origin applicants are the most likely to practice in rural
settings (10)(11)(12)(13).
The current system of training physicians generally does not take advantage
of that information.
Medical schools preferentially select people from urban neighbourhoods
with an average income of over $80,000 (14),
train them in an urban environment that promotes and emphasises subspecialisation,
research and academia, separate from the larger community. Graduates of
the educational system are thus increasingly interested in subspecialisation
and urban practice. Family medicine training positions are increasingly
unfilled (15), and even those that fill
do not train to the skills needed for rural practice. Only eleven percent
of current medical school graduates choose to practice in rural areas
(16)
Universities have appeared reluctant to take on responsibility for serving
the rural community, however they have a societal obligation to meet the
needs of the population as a whole. This some medical schools do better
than others.
Rural hospital closures and centralisation of many health services
in larger cities mean that rural residents have more difficulties accessing
services. The lack of community services in many smaller centres means
that patients discharged early from hospitals often lack community-based
care. Not to minimise urban difficulties, but residents in rural areas,
small towns and remote locations face many more obstacles to care and those
obstacles tend to be much more formidable.
The fact that a metropolitan hospital offers health care of the highest
standard to its city citizens does not mean that a rural population who
has to travel to it will have the same results. In fact the need to travel
will always produce worse outcomes on a population basis because some will
not travel and others, especially for emergent conditions, will suffer
negative health outcomes due to the inherent risks of travel and the time
it takes.
By example Walter Rosser has pointed out that
Centralization
and Women's Health
The ability to become pregnant is distributed throughout the population
but providers of maternity care are not. Rural physicians, in the absence
of volume to attract specialist midwives or obstetricians have developed
mechanisms that transcend urban classifications of primary and secondary
care. An obstetrically trained GP (18),
with a GP anaesthetist and a trained nursing staff will be able to care
locally for over 98% of women with results equal to that of the city.
(19)
The ability to deliver in your community, however, even if it still
has a hospital, is becoming much less for rural women. Access to maternity
services in southern Ontario is decreasing. (20)
In Northern Ontario the reported number of community hospitals that
have closed their maternity ward has increased 5 fold since 1981. The distances
that women have to travel are increasing. (21)
Studies in the United States (22)(23)(24)and
Norway (25) consistently document significantly
poorer outcomes for communities that lack maternity services, even when
the referral centre is of an excellent calibre. Children of women who are
forced to travel have greater rates of perinatal death and prematurity
and incur higher health care costs.
"There is a trend towards a progressive deterioration in health as
one moves from that area bordering urban centres into the very remote hinterland"-The
Quebec health survey (26)
Health status decreases as one travels to more rural and remote regions.
As an example heart disease is common in northern Ontario. Certain types
of cancer are found among miners and farmers. There are substantially higher
rates of diabetes, respiratory and infectious diseases, as well as violence-related
deaths, in some aboriginal communities. Combined, there is an increase
in mortality in rural regions as evidenced by life span.
The lower life expectancies are not associated with just a few specific
causes; rather, the mortality rates in these regions are higher for most
causes of death. Consistent with other measures of the health of the population,
there is an association with socio-economic factors: life expectancy decreases
as the rate of unemployment increases and the level of education decreases.
The differences between low life expectancy regions and the Canadian
average is over 3 years of life.(27)
This is a striking difference as this is equivalent to the effect of
having a cure for cancer in all regions of Canada except for the rural
ones.
Overall life expectancy is still increasing. It is not clear how much
credit the health care system can take for this or if the rural gap is
closing or widening. It is clear that these rural regions with the most
ill health, and higher rates of long-term disability and chronic illness,
as well as increased mortality have the least access to health services
to alleviate this suffering.
"Telehealth is the delivery of health services at a distance. It
has considerable potential to have either positive or negative impacts
on access to and delivery of rural health services."
While the technology of telehealth changes rapidly, the principles remain
unchanged from the time the first doctor picked up Graham Bell's invention
to talk to another doctor. The potential of telehealth lies in supplementing
the skills and abilities of existing rural health workers to deal with
problems that would otherwise require patients to travel out of the community
to access care. The risk lies in diverting resources so that there is no
local expertise and that now the only way to access needed care is from
outside.
The most common problem with telehealth, however is that fascination
with the technology becomes the focus and the process is made irrelevant.
How much TeleVideo conference equipment sits in rural hospital administrator
offices unused? The first priority with telehealth must be to acknowledge
and respond to local needs and expectations of the rural community and
health care workers. Without this the money is wasted.
Provincial
Rural Incentive Plans
While the existing array of strategies is better than doing nothing,
it has not prevented the sharpening of rural/remote access as a policy
issue. Something different and additional will have to be done in future
if rural/remote access is to be improved.
The vast majority of medical graduates are of urban origin, have been
trained to city standards in metropolitan hospitals, and can make a good
living not far from where they were trained. In Ontario over 90% of the
graduating classes choose to enter urban practice.(29)
The provinces have monetary incentives for physicians to move to rural
and remote areas. Most provinces rely on recruitment incentive programs.
The success of these programs is under debate. Proponents will point to
how many new doctors have been attracted. Detractors will point out how
the number of vacancies keeps increasing every year despite rapid escalation
in funding and number of rural incentive programs.(30)
In a way both groups are correct.
These programs have been very successful in attracting physicians, annual
recruitment to rural regions in Quebec has been 12.5% and in BC between
17% and 25%. Few of the doctors stay. BC data shows that attrition in the
smallest BC communities (under 7000 pop) was twice that of communities
over 7,000 and under 30 000 population.(31)
In these communities, most cancer patients outlive the tenure of their
physician (4 years).
And so the gap between urban and rural grows.
Recent attempts in BC, Quebec, Alberta and Ontario have focussed on
structuring and increasing retention payments and/or contract positions
to reduce attrition rates. Although some programs (eg replacement physician
or locum programs) do focus on working conditions, most rely on direct
financial incentive and fail to provide adequate infrastructure support.
With all this suffering and few providers, rural areas by virtue of
necessity have found efficient and effective mechanisms to provide care.
Rural areas have supported collaborative models of health involving patient
self care, nurse practitioners, midwives, and mental health workers. GP's
in these settings work in the hospital and everywhere else, and local or
distant specialists act as consultants and do not provide ongoing primary
care. All this happens for the lowest per capita cost in the system.
These systems are so small that they are subject to attrition of key
personnel. This vulnerability makes the systems fragile. Rural areas need
support for maintenance and expansion of these models where services are
faltering or at risk.
A
Role for the Federal Government
There is a constantly changing landscape in health professional education
systems, hospitals, clinical standards and incentives that occur just outside
the jurisdiction of any given province. Thus it is not surprising that
all provinces have been unable to equitably distribute health human resources
across their own geography. Many have called for a pan Canadian solution.
The rational for a national approach to physician distribution was argued
in 1999 by consultants to the federal and provincial health ministers,
Barer and Stoddart :
Indeed solving one provinces problem by attracting physicians from another
is a zero sum game. This is an opportunity for a novel non-coercive federal
provincial approach whose co-operative synergy will be to every province's
benefit. Before a national approach to the challenges of rural health care
delivery can be implemented, there are national systemic structural changes
required. Three groups, councils, or committees need to be established:
1) A Federal/Provincial "Advisory Committee on Rural Health". This would
be similar to the current Advisory Committee on Health Human Resources
supported by Health Canada. It would be made up of Federal and Provincial
public servants who would report to the combined Federal / Provincial /
Territorial ministers and Deputy Minister's of Health and would be responsible
for co-ordinating and initiating co-operative government solutions to rural
health care.
2) A "Ministerial Council on Rural Health" - This has been announced
but seems stalled. It would be made up of community and health care groups
and would directly advise the Federal Minister of Health on rural health
concerns. The Office of Rural Health of Health Canada would serve as secretariat.
3) A "Rural Medical Forum" made up of the national medical organisations
involved in training, licensing, accreditation and standards. It would
be patterned on the current "Canadian Medical Forum" but would focus only
on rural health care.
All three are essential. One or two is not sufficient nor is simple
modification of existing multifunction structures.
A National Rural Health Strategy could then be implemented, supported
by the three groups mentioned above, funded by a significant recurrent
federal budget and backed by dedicated research and data collection from
CIHR. A NRHS with the structural backup outlined above, besides improving
rural health care, would also be of enormous benefit to the whole system
in such areas as Primary Care Reform
1. That the federal government, in co-operation with the provinces,
reduces the structural barriers to national rural health policy advancement
and form a National Rural Health Strategy that can be implemented
2. That the NRHS initial priorities include
4. That rural health delivery research is adequately funded.
Making do and the status quo are not options. This is an opportunity
for the Federal government to assist the provinces to develop a National
Rural Health Strategy and make a difference.
References
2 The
Society of Rural Physicians of Canada. Comment on "Improving Access to
Needed Medical Services in Rural and Remote Canadian Communities: Recruitment
and Retention Revisited" by Morris L. Barer and Greg L Stoddart The Society
1999 http://www.srpc.ca/librarydocs/Comonbs.PDF
3 Hutten-Czapski
P, Park I, Arif S, Dawes R, Mann R, Rourke J, Henderson B, Kelly L. A fair
share for rural health at the millennium The Society of Rural Physicians
2000 http://www.srpc.ca/librarydocs/ONprogam.htm
4 Hutten-Czapski
P. Primary health care reform - A rural perspective. The Society of Rural
Physicians 2000 http://www.srpc.ca/librarydocs/hsrcpcr.htm
5 O'Neil
D. Response to the Fyke Report. The Society of Rural Physicians 2001http://www.srpc.ca/librarydocs/CentralFyke.html
6 Statistics
Canada Population structure and change in predominantly rural regions The
Daily Jan 16, 2001 Catalogue 21-006 XIE http://www.statcan.ca/english/freepub/21-006-XIE/21-006-XIE00002.pdf
7 The
Canadian Medical Association, physician resources data base, the Association
2000
8 Buske
LM, Yager SN, Adams OB, Marcus L, Lefebvre FA. Rural community development
tools from the medical perspective: A national framework of rurality and
projections for physician workforce supply in rural and remote areas of
Canada. Report to Health Canada April 1999
9 Strasser
R, Rourke J, Anwar I, Naidoo N, Rabinowitz H, McLeod J, Newbery P Policy
on training for Rural Practice. World Organisation of Family Doctors 1995
http://www.wonca.org/working_groups/rural_training/training/WONCAP.htm
10 Easterbrook
M, Marshall G, Wilson R, Hodgetts G, Brown G, Pong R, Najgebauer R: Rural
background and clinical rural rotations during medical training: effect
on practice location CMAJ 1999;160:1159-63http://www.cmaj.ca/cgi/reprint/160/8/1159
11 Rabinowitz
HK; Paynter NP The role of the medical school in rural graduate medical
education: pipeline or control valve? J Rural Health 2000 Summer;16(3):249-53
12 Pathman
DE; Steiner BD; Jones BD; Konrad TR Preparing and retaining rural physicians
through medical education. Acad Med 1999 Jul;74(7):810-20
13 Rolfe
IE; Pearson SA; O'Connell DL; Dickinson JA Finding solutions to the rural
doctor shortage: the roles of selection versus undergraduate medical education
at Newcastle. Aust N Z J Med 1995 Oct;25(5):512-7
14 Harris
R as quoted in Students, university at odds over tuition's effect on med
school class Medical Post 2001; 37(18)
http://www.medicalpost.com/mdlink/english/members/medpost/data/3718/02C.HTM
15 Walker
AG. Medical students across country shun family medicine residencies. Medical
Post 2000; 36(13) http://www.medicalpost.com/mdlink/english/members/medpost/data/3613/02C.HTM
16 Hutten-Czapski
P, Thurber D. Who Makes Canada's Rural Doctors? Can J Rural Med 2002; 7(2):95-100
http://www.cma.ca/cma/staticContent/HTML/N0/l2/cjrm/vol-7/issue-2/0095.htm
17 Rosser,
W. Application of evidence from randomised controlled trials to general
practice. The Lancet 1999; 353: 661-664.
18 Hutten-Czapski
P, Iglesias S; Joint Position paper on training for rural family physicians
in advanced maternity skills and cesarean section Can J Rural Med 1999;
4 (4): 209-225 http://www.cma.ca/cma/staticContent/HTML/N0/l2/cjrm/vol-4/issue-4/0209.htm
authorship correction CJRM 2000;5(1):36
19 Black
DP, Fyfe IM. The safety of obstetric services in small communities in northern
Ontario Can Med Assoc J 1984;130:571-576
20 Rourke
TB. Trends in small hospital obstetric services in Ontario. Can Fam Physician
October 1998, 2117-2124
21 Hutten-Czapski
P; Decline of obstetrical services in northern Ontario. Can J Rural Med
1999; 4 (2): 72-76
22 Larimore
WL, Davis A. Relationship of infant mortality to availability of care in
rural Florida. J Am Board Fam Pract 1995;8(5):392-9.
23 Allen
DI, Kamradt JM. Relationship of infant mortality to the availability of
obstetrical care in Indiana. J Fam Pract 1991;33(6):609-13.
24 Nesbitt
TS, Connell FA, Hart LG, Rosenblatt RA. Access to obstetric care in rural
areas: effect on birth outcomes. Am J Public Health 1990;80(7):814-8.
25 Bakketeig
LS, Hoffman HJ, Sternthal PM. Obstetric service and perinatal mortality
in Norway. Acta Obstet Gynecol Scand Suppl 1978;77:3-19.
26 Pampalon,
R. Health discrepancies in rural areas in Quebec. Social Science and Medicine
1991; 33: 355-360.
27 Statistics
Canada "Life Expectancy" Health Reports, Winter 1999, Vol. 11, No. 3 Statistics
Canada, Catalogue 82-003
28 World
Organisation of Family Doctors. Using Information Technology to Improve
Rural Health Care The Organisation 1998
29 McKendry
R. Physicians for Ontario : Too Many? Too Few? For 2000 and Beyond Ontario
Ministry of Health and Long-Term Care, December 1999 http://www.gov.on.ca/health/english/pub/ministry/mckendry/mckendry.html
30 Hutten-Czapski
P; Rural incentive programs: a failing report card. Can J Rural Med 1998;
3(4): 242-247.
31 Thommasen
HV. Physician retention and recruitment outside urban British Columbia
BC Medical Journal 2000;42(6): 304-308.
http://www.bcma.org/BCMJ/August2000/PhysicianRetention.asp
32 Barer
and Stoddart Sept 16th 1999, Improving Access to Needed Medical Services
in Rural and Remote Canadian Communities: Recruitment and Retention Revisited.
THE
STATE OF RURAL HEALTHCARE
Rural Health Current Status and Trends
1
Increasing Urban Rural Gap 1
The Urban Centric Educational Paradigm
2
Increasing Centralization 2
Centralization and Women's Health
3
Health Status 3
Telehealth 4
Provincial Rural Incentive Plans 4
Improving Rural Health 5
A Role for the Federal Government
5
Recommendations 6
Conclusion 6
- Mr. Justice Emmet Hall
-WONCA Policy on Training for Rural Practice 1995
(9)
"The geographical context in which health care is delivered in a
country such as Canada, with widely scattered small communities far from
major medical centres, creates unique problems for the application of medical
evidence. Although there may be good evidence that the quality of life
of elderly people can be improved by palliative radiotherapy, the practicality
of a frail 85-year-old travelling several hundred kilometres to the nearest
radiotherapy centre must also be considered.... Thus, the geographical
context of the situation affects decisions about treatment, even though
good quality evidence may be available to support a specific course of
action." (17)
-WONCA Using Information Technology to Improve Rural Health Care
(28)
-Barer and Stoddart 1999
Improving
Rural Health
Standby
funding for on Call
Locum
SupportIncentive
for Remote
Rural Signing
Bonus
Reentry
Training for Rural MDs
Rural Contract
Positions
BC
1998
1995
yes
Some
Alberta
1998
1992
1996
1996
Saskatchewan
1998
yes
1979
1995
1984
Manitoba
1997
yes
yes
yes
2000
1996
Ontario
1995
1998
1996
1969
1997
1996
Quebec
1996
some
1982
1982
yes
New Brunswick
1999
yes
yes
yes
PEI
2000
2000
Nova Scotia
1996
1995
2000
1995
Newfoundland
2000
yes
many
Notes:
The date, when available, refers to the first introduction of a provincial
program in that category
Program details
are summarized at http://srpc.ca/regions.html
"It seems important to reinforce the idea that such a restructuring
would need to be pan-Canadian if it is to be expected to provide an effective
remedy to the problems of rural and remote communities. Absent such cross-country
agreement, provinces and territories would likely be faced with whipsawing
and increased migration between jurisdictions." (32)
3. That federal funding for telehealth becomes contingent on tailoring
programs by local rural analysis of health care needs amenable to telehealth
support.
1 Babey
K, Barrett S, Bury L, Dawes R, Gaind S, Galea S, Hutten-Czapski P. Mann
R, Park I, Pong P, Rourke J, Tepper J, Thoburn M, Whiteside C; From education
to sustainability - a blueprint for addressing physician recruitment and
retention in rural and remote Ontario. SRPC - Ontario and PAIRO December
1998 http://www.srpc.ca/librarydocs/toc.html
http://www.cma.ca/cma/staticContent/HTML/N0/l2/cjrm/vol-4/issue-2/0072.htm
http://www.statcan.ca/english/indepth/82-003/feature/hr1999_v11n3_win_a01.pdf
http://www.cma.ca/cma/staticContent/HTML/N0/l2/cjrm/vol-3/issue-4/0242.htm