Rural recruits

Innovative rural communities are using the lure of the countryside and perqs to bring new doctors to town

BY RICHARD CHARTERIS

In the hit baseball movie "Field of Dreams," a spectre's whispered "Build it, and they will come" compelled Kevin Costner's character to carve a ball diamond from a corn field. In gratitude, the ghosts of the black-marked, 1919 World Series-throwing Chicago White Sox came to practise and play in rural Iowa.

Some rural and northern communities in Ontario are taking a page from the movie's script in a bid to get doctors to practise, play and stay in their locales, too. They've been forced to as small-town, solo-practice physicians scale back, retire or move to centres where the demands on their time aren't as great, creating health care gaps in a number of locales.

Take Alexandria. In the early '90s, Glengarry Hospital faced having to close its emergency department. The eastern Ontario town's complement of general practitioners (GPs) had dwindled to less than a handful.The two who still did all-night, on-call emergency work sensed they weren't at their best in their family practice office hours following the overnights, says hospital executive director Curt Pristanski. And the fee-for-service pay mandated by the health ministry/Ontario Medical Association fee schedule for ER work was even less attractive on nights when just two or three patients led them from their beds to drive to the hospital.

"To keep the doctors we had from burning out," says Pristanski, "we finally resorted to hiring Cornwall, Montreal and Ottawa doctors for night shift on-call work." To accommodate the doctors, Glengarry renovated some spare space into a small one-bedroom apartment with bathroom, combination kitchenette/living room with a fridge, stove, TV VCR and work desk. "The only thing lacking was carpet," chuckles Pristanski. "Just as well - one of the doctors had a dog with some training problems."

Today, Glengarry has a roster of 14 local and area doctors sharing overnight ER duty, attributable, says Pristanski, to investing in comfort and adequate compensation. Initially the on-call doctors were paid a flat rate of $200 out of the hospital's budget; by 1996 the health ministry was topping up the ER doctors' fee-for-service wages with funds granted through its Underserviced Area Program (UAP).

ER wasn't Glengarry's only problem, though. By the mid-90s, retirements, moves to the U.S. and other factors reduced the town's complement of GPs to two. "We simply needed more family doctors," says Pristanski.

"So we set up a reward program - $1,000 - not for the doctor but the person who found the doctor. We advertised in the local papers, then the wire services picked up on what we were doing and carried the story across the country. So we had lots of publicity, and out of several dozen calls, a quarter came to visit."

Pristanski discovered his candidates had a reluctance to move, though: "Most doctors today want to work in a group practice where they can walk into a clinic setting with a private office, maybe sharing a nurse, a receptionist, exam rooms... They don't want to have to buy all their equipment, rent space - unlike the older solo practitioners, mainly working from home offices."

Again, a solution came from construction - moving some administration offices from beside the ER to an unused obstetrics unit, then reconfiguring the freed space to provide a reception/waiting area, two exam rooms, a bathroom and an office. "For $20,000, which came from the hospital's capital budget, we had a walk-in setting for a doctor who simply had to bring in a secretary or nurse, a computer and day-to-day supplies," says Pristanski. Glengarry's built three more of the units, is considering another, and Alexandria now has six family practice doctors in town along with 24-hour ER service.

Seeley's Bay, about 25 miles northeast of Kingston, took the building route, too. In late 1994 the health of the village's only doctor, a senior citizen, was deteriorating, says area resident Deb McCann. There was concern about attracting a new doctor - especially as the health ministry declined to award the local municipality - Leeds and Landsdowne - UAP status, meaning income would be strictly fee-per-service.

Community members formed a search committee, says McCann, and ultimately two doctors came to the town, attracted in part by all that was done to accommodate them. The doctors share offices in a building put up by a private developer. Leeds and Lansdowne council is picking up their rent for two years. A local direct-mail campaign and charity auction raised close to $40,000, which went toward furnishing and equipping the offices, "so the doctors had little to buy themselves," says McCann.

Seeley's Bay isn't alone in involving community resources. In Ridgetown, local service groups pledged to defray some of the expenses incurred by doctors during university and their internships in exchange for committing to the town for a few years.

And prior to assuming duties in Alexandria, Pristanski worked in Atikokan, west of Thunder Bay. He says the hospital made a special effort to get doctors to do portions of their residency or internship there. "We went on the tour of medical schools that the health ministry organizes each year and focused on the kind of people who we thought would enjoy life there - canoeing, the outdoors. We'd supply a decent apartment, local car dealers chipped in an automobile; the interns received free meals in the cafeteria. On graduation, they were calling us to locate there."

Sarah MacKinnon is a second-year resident in the University of Ottawa medical school's Northeastern Ontario Residency and Electives family medicine program. Based out of Sudbury, residents and interns travel as far south as Huntsville and "as far north, east and west as they can send us," says MacKinnon, who's currently doing a cardiology rotation in Sault Ste. Marie. She's also worked in Little Current, Huntsville, Sioux Lookout, North Bay, Mattawa and along James Bay and plans to stay in the rural north when she sets up her practice.

Raised in Penetanguishine, she says she came to admire the role of the small town doctors who did emergency work, obstetrics, on call and maintained their family practice.

A problem in attracting Ontario doctors to rural medicine, says MacKinnon, is that most do their internship and residency in big city hospitals where the province's medical schools are located. "They have specialist backup on short notice," says MacKinnon. "Working in a rural area can be intimidating if you're used to that. For some interns and residents, that's enough of a barrier right there. One of the most important skills you learn by working in a small centre is coming to the understanding of how much you can do yourself and when to cry wolf."

MacKinnon believes some of the alternative payment programs, if administered correctly by the health ministry and the OMA, could offer real solutions to recruitment and retainment in rural and northern Ontario. MacKinnon says it's not a case of doctors wanting to make a killing, "It's that they're paid enough so that enough doctors are willing to locate to these communities and prevent those who are there from burning out," coping with heavy patient loads in addition to on call and ER work.

Lynn Bury, executive secretary, Professional Association of Interns and Residents in Ontario (PAIRO), says the health ministry has had $36.4 million available for the last 18 months for such alternative payment programs as contract remuneration, but that only about $5 million has been dispersed. "There are communities that really need fast-track implementation of these plans," she says. PAIRO, which negotiates working conditions and remuneration for its membership, also helps communities with intern and doctor placements.

"Rural or northern life isn't necessarily for everyone," says MacKinnon, "but if you begin selling even high school students on the virtues of practising medicine there, you'll be helping in the long term. Lifestyle could be a huge selling point," whether its being able to go cross-country skiing before going to the ER for the evening or throwing a canoe in the river right after office hours.

© copyright 1998 Agricultural Publishing Company Limited.

New recruits

Two of Alexandria's new GPs contacted by Farm & Country couldn't be happier.

For Montreal native Robert Adams, who attended medical school in Grenada, interned in New York City, and practised in Nova Scotia before coming to Glengarry, Alexandria was an opportunity to be close to his family, work bilingually and have a practice that "deals with all the aspects of medicine that you could imagine." He describes his weekly on call and his ER shifts on top of his GP responsibilities as "as much as I want."

London native Christine Millman, a McMaster grad, spent a lot of time in rural Middlesex while she was growing up. She worked in Mount Brydges as a resident, did an elective in Exeter, and never considered anything but a rural practice.

Still, Alexandria's incentives had a lot to do with her locating there just over two years ago, "because I really wasn't looking anywhere east of Toronto.

"Coming out of medical school, the last thing you want to be concerned about is setting up an office, buying all the equipment, hiring, payroll. I wanted to be practising medicine, not running a business, which," she laughs, "I admit I'm doing any way with the help of some idiot-proof business software that has 24-hour, 1-800 help. But it was so easy for me walk in, hire a wonderful secretary-nurse and get going."

If she had any mild trepidation about coming to Glengarry, says Millman, it was about being on her own in emergency. "But I was assured there's plenty of help here. I know I can call any of my colleagues if I need a hand."

Election issue?

Ron Bonnett, Ontario Federation of Agriculture rural affairs committee executive representative, says rural health "could be an interesting issue in the next election."

Beyond recruiting, retaining and paying rural doctors adequately, Bonnett says there should be some concern about creating "two levels of care and services - good for those municipalities with a large tax base and inadequate for those that don't."

Bonnett, from Bruce Mines, Algoma district, cites as an example the downloading of ambulance services, which last January began a two-year transition from provincial to municipal control. He wonders whether all municipalities will be able to keep up to date on equipment and training. "That becomes even more important," says Bonnett, "as some rural hospitals lose their status as emergency facilities.

"Farmers have to have access to excellent immediate response personnel that can stabilize an accident victim until such time as he or she can be transferred."

Berwick cash cropper and rural affairs committee member John van Turnhout puts health in context with other "declining services" in rural areas - schools and banks. Ironically, sums up Bonnett, banking and health care are two of the areas city people moving to the country in retirement have probably come to expect excellence in: "We're going to see more of that retirement pattern, so rural care is of long-term concern," to both the urban and non-urban population.

© copyright 1998 Agricultural Publishing Company Limited.


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