Rural practice: Challenging but endangered? A Nova Scotia perspective
Can J Rural Med 1996; 1(1); 29
The professional challenge and satisfaction of rural practice is entirely different from those of urban practice. I deal with some 300 new hospital in-patients a year, all with acute medical problems such as pneumonia, stroke, ischemic heart disease and malignant disease. I must know a varied range of technical procedures, and most of those procedures are never done by urban family doctors. Patients with chronic medical problems, such as diabetes and rheumatoid arthritis, are handled by me, with assistance from specialists if necessary. Medicine in rural areas truly is comprehensive and continuing care.
However, over the last 10 years in the rural community where I live the number of family physicians has dropped 40%, and we now have more than 3000 people for every rural doctor. At least 5000 of the 30 000 inhabitants are unable to get any primary medical care other than episodic crisis intervention from the hospital's emergency department. And I know we are not alone.
What has gone wrong?
There always has been a gulf between the rural and urban populations of Canada. With increasing urbanization the gulf has widened. Rural values are not given much consideration by politicians until some controversy erupts, such as gun control.
Many medical schools share this indifference to the rural population and bear a heavy responsibility for the present crisis. Rural residents are underrepresented as entrants to medical schools, and the pattern of practice that encourages patient management as a series of interventions by subspecialists is not conducive to turning out rural doctors. Whereas most specialists of my generation or older had experience outside teaching hospitals, in rural communities this is often no longer the case. The inevitable result has been a deterioration in understanding the problems of rural practice.
This deterioration is not confined to general practice. In Nova Scotia we are faced with an impending crisis in the provision of surgical services in outlying areas that is every bit as troublesome as the crisis in the delivery of rural general practice.
The perception that academic centres currently view rural practice and rural practitioners as second-rate is widespread amongst my peers. I have sat on the board of directors of the Medical Society of Nova Scotia (MSNS) for more than a decade and have listened to such gratuitous comments as: "We are going to graduate so many doctors that they will have nowhere to go other than the rural areas" or "These fellows wouldn't be out there if they could make a living anywhere else." And these are the printable ones.
Another more recent disincentive is the current obsession about sexual harassment of patients. Blanket proscriptions of social relationships with anyone who might have been or might become a patient, when this group includes the entire population for a 50-mile radius, don't reflect the reality of rural living and could deter a single doctor who would otherwise have been interested in rural practice.
Current incentive programs
Almost all rural incentive programs target new entrants to rural areas. This process has a number of limitations, not the least of which is the encouragement of recently qualified physicians to come to an area, earn a high income through maximizing fee-for-service payments, and then return to an urban environment as soon as possible. The remaining physicians are then left to deal with the outgoing doctors' patients. The population is not well served either: the incoming physician is often there to "mine" the district rather than to nurture and develop it.
Many incentive programs don't bring short-term recruits to an area. The MSNS has had such a program for 2 years, with two full-time staff people. As of Mar. 6, 1996, it has placed only two physicians, balancing out two who are leaving underserviced areas. The amount of money expended could have, among other things, funded full scholarships for five rural residents to enter medical school.
Why is there such apathy and indifference?
The MSNS is recognized as the sole bargaining agent for physicians in the province (except interns and residents), and dues to this organization have been compulsory since the mid-'80s. The Society has never had a majority vote of the membership to confirm this status, and has only once had a vote to ratify a contract with the government. The Society is seen as neither representative nor accountable by most rural physicians. Even though rural physicians have, on occasion, been presidents or officers of the Society, they don't serve long enough to overcome vested urban interests and the inertia of the Society's bureaucracy. The recently formed section of rural practice has had every one of its proposed incentives vetoed by the section of general practice, which is dominated by urban interests.
About two-thirds of the province's physicians live within 20 miles of Halifax, and the Society has never dealt with underrepresentation for those from remote areas who have difficulty getting to Society meetings. Neither has the Society been able to deal with the ultimate Achilles' heel of our health care system: that the demand for care has outstripped the ability of the public purse to pay for it. Financial constraints do determine the numbers and kinds of physicians and where they practise.
Where can we go from here?
The problems of present-day rural medicine appear overwhelming. Over the last year scarcely a week has gone by in this province without reports of yet another physician leaving rural practice. How can the remaining 70 or so physicians in the province's rural areas ensure that their interests are looked after in the current difficult climate?
It should be clear that the key to survival of rural practice is the adoption of sustainable working conditions and adequate remuneration. Recruiting programs that do not address this are, at best, temporary solutions and are doomed to ultimate failure. There have been a number of studies of the problems of rural medicine, such as Ontario's Scott Report.[1] Many of the remedies proposed in this report are directly applicable to all rural areas in the country.
We can have some influence over our own destiny. We do not need anyone's permission to develop guidelines regarding acceptable hours on call. If a community has too few physicians to provide 24-hour coverage it is not the responsibility of these physicians to burn themselves out and destroy their family life. If such coverage is thought to be in the public interest, the community and its politicians should get together to provide funding and an infrastructure. For example, no rural physician should be expected to work more than 72 hours a week, this being a one-in-four rota.
When the Canadian Medical Protective Association states that fatigue is not a defence for a malpractice action, but that a physician is responsible for continuity of care even if this means being on call for 14 successive days,[2] we can and should take issue with this.
We should also take issue with hospital administrators who expect unreasonable hours of service from their medical staff. It is inconceivable that in 1996 we have to argue about hours of work that were banned by the first factory act in Great Britain in 1832. We can support our colleagues who refuse to work under these conditions, and we can publicize and blacklist the institutions that expect it.
We can also compile objective ratings for our rural communities. It is important for a potential recruit to know the quality of education service, whether the municipal government is supportive of rural medicine, and the attitude of the local hospital administrator. Such information is rarely presented honestly on initial visits. In the present climate this would be a powerful bargaining tool.
Long-term solutions
We need to address all the stages -- from the time a person makes the decision to enter medicine to the time he or she decides to enter rural practice. We need to attract more rural residents to medical school; therefore, even the quality of science education in our high schools needs to be addressed.
At the university level, funding should be linked to the provision of a balanced mix of graduates appropriate to the communities' needs. All medical graduates and all university teachers having direct contact with students and residents should have rural practice exposure. A family medicine department that does not have even one full-time staff member with significant rural experience cannot be expected to give a realistic view of rural medicine to its students.
Funding mechanisms need immediate reform because further across-the-board cuts in fee schedules will destroy the present service in this province. Pure fee-for-service has not served rural doctors well and has resulted in a penalty for looking after the sickest people. This is hardly a good basis for public policy. Fee-for-service has no provision for such things as isolation, degree of clinical responsibility, difficulties getting to a big centre for continuing medical education and locum coverage.
After more than 20 years in practice in rural Nova Scotia and after having been heavily involved in the MSNS I am becoming convinced that the biggest problem of rural practice is not government but the lack of effective representation by our medical societies. It may be impossible to reform these bodies from within, and governments seem ready to impose what they perceive to be solutions. Survival of rural medicine may well depend on direct negotiation with governments and replacement of our present bargaining agents.
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