Focus on Alberta

David O'Neil, MD, CCFP
President, Alberta Section of Rural Medicine, Trochu, Alta.
dpo1@agt.net

Can J Rural Med 1996; 1 (2): 87-89

About 40% of Alberta's 2.5 million people live outside our seven cities.[1] Before April 1995 there were 104 rural hospitals, with a total of 3879 acute-care beds, and approximately 540 rural family physicians, nearly all of whom provided emergency department services for 50% of all emergency outpatient visits in the province.[1,2]

The most important of the sweeping new health care legislation introduced since 1995 was consolidation of Alberta's 120 hospital boards into 17 regional health authorities. The budgets given to the new regional boards for the 1995­1996 fiscal year led to the loss of a significant number of rural acute-care beds and the closure of some rural hospitals, sometimes with little input from local physicians.

Many rural physicians in Alberta felt severely marginalized by the political process that led to regionalization and massive fiscal cutbacks in 1995. The shift of control away from local hospital boards and the failure to consult physicians about matters affecting patient care in their communities seem to have been the two key factors leading to the feeling of marginalization.

A limited survey of 702 rural physicians in Alberta conducted by a group of rural physicians in 1995 (which had a 27% response rate) found that 88% of respondents wanted representation by an identifiable body within the Alberta Medical Association (AMA) (http://www.agt.net/public/asrm/amasurv.htm). A similar survey in Ontario also reported that a majority of rural physicians preferred representation by a rural physician organization.[3]

These findings led to the formation of the independent Alberta Section of Rural Medicine (ASRM) at an April 1996 organizational meeting in Banff. The Section has applied to the AMA for formal section status and continues to work for rural physicians in the meantime. The ASRM Web site (http://www.agt.net/public/asrm/ruralama.htm) describes the Section's activities.

Alberta Health began funding a new program in 1990 called the Rural Physician Action Plan (RPAP). RPAP is unique in Canada and is similar to a comprehensive program in western Australia.[4] It has brought together government, universities, regional health authorities, medical organizations and municipal governments and is gradually awakening these groups to the realities of rural medicine.

The Alberta program is administered by a predominantly urban multistakeholder steering committee and is gradually becoming more effective and more comprehensive, reaching into all aspects of rural medicine. In the 1996­1997 fiscal year Alberta Health will increase the budget for RPAP from $1.7 million to $2.8 million.

RPAP is gradually becoming the comprehensive type of program needed to really make a difference for rural communities and their doctors. So far, RPAP has funded a rural locum program through the AMA, education initiatives through the universities, studies of rural physician recruitment and retention, and a program to help communities recruit rural physicians.[5] However, problems remain: there is too little direct representation from practising rural physicians on RPAP's decision-making committees, and some of the funding appears to be going toward projects that only indirectly address the issues.

An independent evaluation of the RPAP, commissioned by the provincial government in 1995 and released earlier this year, is beginning to influence events.[5] The so-called MacDonald Report concluded that RPAP provided good value to the taxpayers but that the effect of many of the initiatives could not be determined, given the context of rapid change throughout the health care system. The report identified important barriers to implementing changes that would improve rural physician recruitment and retention. These barriers included strained relationships between regional health authorities and rural physicians, anxiety about further cutbacks and the fact that a significant number of rural physicians were thinking about leaving the province.

The MacDonald Report made four suggestions to Alberta Health:

• quickly mobilize the regional health authorities to work with rural physicians
• improve funding and working conditions for rural physicians
• separate urban and rural issues
• address competition from recruiters from the United States.

The MacDonald Report identified many of the same issues that the Scott Report did, issues that rural physicians themselves think are important. It remains to be seen whether this evaluation will have any more real impact in Alberta than the Scott Report has had so far in Ontario.

The two faculties of medicine in Alberta continue to evolve toward the comprehensive model of training for rural medicine recommended by WONCA (the World Organization of Family Doctors) and available at http://www.cfpc.ca/carmen/woncapol.htm. RPAP programs at both the University of Calgary (described at http://www.med.ucalgary.ca/saran/) and the University of Alberta (described at http://hippocrates.family.med.ualberta.ca/rpap/rpap.html) have led to rural physician training programs for medical students and residents and enhancement programs for rural physicians in practice. In addition, rural education is available at training sites in rural communities throughout Alberta. RPAP has been a significant factor in improving rural education in Alberta.

Training in advanced skills for rural family physicians is being developed in Alberta. Both universities train residents in 1-year programs for anesthesia and emergency medicine. The University of Calgary has just developed a 3rd-year program in surgical and obstetric skills intended for graduates of a 2-year family medicine residency program and plans to welcome the first resident to the program in 1997. The University of Alberta has run a 3rd-year advanced skills program in surgery and obstetrics since 1992.

Granting credentials for procedural privileges is a major issue of contention in rural Alberta. Some rural physicians have felt that their ability to introduce new procedural skills to rural communities has been unfairly restricted, which in turn has restricted access to appropriate care for patients. The new regional health authorities are starting to give patient care privileges to rural physicians. In regions where there are both urban and rural physicians this process is leading to debates between urban specialists and rural family physicians about privileges to perform various procedures. The debates seem to be based on contradictory perceptions that each group has about quality patient care, appropriate access to health care and competition for limited resources.

A large number of acute-care beds have been taken out of both the urban and rural sectors of Alberta's health care system. The impact of this change is still unclear, but we have heard reports that rural physicians are having to keep more acutely ill patients in rural hospitals with fewer resources because urban specialists cannot take them, and urban specialists are less able to transfer patients back to rural hospitals than in the past, because there are fewer rural beds.

The cutbacks and regionalization process have led to problems in recruiting and retaining rural family physicians. Uncertainty, exclusion from decision-making, hospital closures and reduced funding have led to physician departures, and a significant number of the Alberta family medicine residents who completed their residencies last year departed for the United States. International medical graduates have been licensed under special legislative provisions to fill some of the vacant rural positions in several regional health authorities.

The Society of Rural Physicians of Canada (SRPC) is well represented in Alberta, and several Alberta physicians are active in the organization. The University of Calgary hosted the SRPC's national conference in Banff in April 1996 and looks forward to doing the same in 1997 under the leadership of Dr. Cathy Scrimshaw of Pincher Creek. Dr. Hal Irvine of Sundre maintains the SRPC Web site (http://www.gretmar.com/srp/home.html). The SRPC's resources and programs have been instrumental in advancing rural medicine in Alberta.

The Alberta Chapter of the College of Family Physicians of Canada (CFPC) increasingly promotes rural physician issues. Dr. David Topps of Airdrie is moderator of CaRMeN (http://www.cfpc.ca/carmen/), the CFPC-sponsored rural physician Internet email list. Dr. Robert Wedel of Taber, past president of the Alberta Chapter of the CFPC, is an active proponent of rural medicine in Alberta.

Rural physicians in Alberta are now looking forward to a productive time of stability and renewed development after the storm of change in 1995. The many RPAP and rural physician initiatives underway in Alberta demonstrate that there is a will to ensure that the people of rural Alberta continue to have access to good local health care. Improved recognition of the role that rural physicians must play in all of these initiatives will be a key factor in their success.

References

1. Thompson JM, McNair N. Health care reform and emergency out-patient use of rural hospitals in Alberta, Canada. J Emerg Med 1995;13(3):415-21.
2. Alberta Medical Association (AMA). Working paper of the task force on physician resources. Edmonton: AMA, 1993.
3. Babey K. Focus on Ontario. Can J Rural Med 1996;1(1):27-8 (Also available in electronic form at /cjrm/vol-1/0027.htm)
4. Western Australia Centre for Remote and Rural Medicine. Annual report and accounts. Perth, Australia: University of Western Australia, 1996.
5. CA MacDonald & Associates. Evaluation of the rural physician action plan. Edmonton: Alberta Health, 1996.
6. Scott GWS. Report of the fact finder on the issue of small/rural hospital emergency department physician service. Toronto: Ontario Ministry of Health, Ontario Hospital Association, Ontario Medical Association, 1995.