Focus on Newfoundland and Labrador
Conleth O'Maonaigh, MB BCh, MPH, MICGP
Chief of Staff, Fogo Island Hospital, Fogo, Nfld.
conleth@morgan.ucs.mun.ca
Can J Rural Med vol 2 (2):73
© 1997 Society of Rural Physicians of Canada
review of the current state of rural medicine in Newfoundland and Labrador requires some reference to recent events that have had a direct impact on all rural physicians. Given the nature of the province's geography, this includes the majority of doctors working outside St. John's (population greater than 100 000) and Corner Brook (population 30 000). Thirty percent of Newfoundland's population of approximately 568 000 lives in St. John's and adjoining communities. Others live in 13 communities of population sizes greater than 5000, and the rest are scattered around the province in 379 communities of variable remoteness.[1] A significant amount of medical care, both primary and above, is thus being provided by rural physicians in clinics and small cottage hospitals. Small wonder, then, that any alteration in medical services, including funding, has a direct impact on medical care in rural areas.
There is a sense of fatigue, resignation and disillusionment among many rural doctors, particularly those who have served in outport communities for a long time. This sense was exacerbated by events in 1993, when the provincial government passed legislation restricting the mobility of physicians.[2] At the same time it established the Needs Assessment Committee (NAC), which was foisted on the medical establishment with the cooperation, if not the collusion, of the Newfoundland and Labrador Medical Association (NLMA). Its existence and restrictive powers were supposed to be of 6 months' duration and it was meant to monitor the new regulation that restricted the mobility of physicians and new graduates. A 50% billing rate was introduced for any physician who established a new practice in St. John's. In effect, this was a slap in the face to all rural doctors and prevented any from relocating if they so wished, regardless of the years they had served in the outports. The intention of these changes was to encourage physicians to set up practice in rural areas, where the need for medical doctors was acute. Four years later this "temporary" measure is still in effect. This, despite the fact that there is no evidence that it resulted in any influx of physicians into rural areas. The NLMA is no longer cooperating with the NAC in its activities.
Contemporaneous with the establishment of the NAC, the provincial government, through the Joint Management Committee (JMC), created the Physician Resource Advisory Group (PRAG).[3] Their mandate was to "develop a long-term plan for the management of physicians' resources in Newfoundland and Labrador." The committee had representation from the NLMA, the Department of Health, the Newfoundland Hospital and Nursing Home Association, the medical school, the Newfoundland Medical Board, the Newfoundland Association of Interns and Residents, and the medical student body. Over the course of 18 months the committee members did a comprehensive review of medical services and physician distribution in the province to determine the appropriate number of physicians required to deliver the services and where and how they should be distributed. Their report was presented to the Ministry of Health in November 1994, by which time the restrictions placed on mobility were to be lifted, as the minister proceeded to act on the contents of the PRAG report.
For those of us used to living in the real world it came as no surprise to find the NAC restriction extended and to see that, despite the laudable and intelligent recommendations of the PRAG report, the Ministry of Health has yet to implement or act on the PRAG report in any substantial way. The report was comprehensive and, if acted on, would have improved the lot of rural physicians in the province significantly.
Instead, the state of rural medical services in Newfoundland continued to decay. Problems of physician turnover and retention and recruitment, specifically in the salaried physician body (which constitutes approximately 300 doctors, the majority of whom make up the core of rural physicians' supply), continued to plague rural areas. The government yet again responded to the increasing problems of rural medicine in a truly Canadian way: it commissioned another report in 1996. This report was a review of the rural salaried system and was carried out by Dr. Peter Roberts,[4] who had extensive experience with the salaried system from his work with the Grenfell Association. Until quite recently, this body delivered all medical services to coastal Labrador and the northern peninsula of the province. Roberts thus had intimate experience with the problems of rural physicians. His report was submitted to the Ministry of Health in July 1996. Its contents reflect many of the PRAG recommendations as they pertain to rural doctors, their workload, their call responsibility and their remuneration. So far the minister has made no reference as to what will be done with this report.
In the autumn of 1996 the Salaried Physicians Negotiating Committee, which negotiates for all salaried rural doctors, entered into negotiations with the Newfoundland and Labrador Health Care Association (NLHCA). These negotiations collapsed in November when it became apparent that of the two purse-string holders, the Medical Care Plan (MCP) was adamant that it had no new money to inject into the salaried system and the government had no intention of finding any. This intransigent response was made with full knowledge of the fact that rural medical services have been recognized as being dysfunctional and that the province's rural physicians are the lowest paid doctors in the country.[4]
As with all trends emanating from the mainland, Newfoundland will not be found wanting. True to the current paradigm of less being more, Newfoundland has restructured its health care boards and reduced the number from 31 to 8. Inevitably this means centralization, although it is called regionalization. These boards are of course larger and may prove unwieldy. Since all of them are working under a fixed 3-year budget and since it appears that a good number are already overextended, the inevitable trimming and cutting have begun. As with even the leanest pork roast, the trimming always begins at the periphery. The consequence of this has been the reduction of activity in many of the smaller and less remote rural facilities. Some of them have been downgraded to ambulatory services with holding beds only.
At the same time many solo salaried practices continue despite the recognition that these physicians work untenable call hours and are often professionally isolated. In both the comprehensive PRAG report and a report commissioned by the JMC on the role of the family physician in Newfoundland and Labrador,1 strong recommendations were made to consolidate solo practices in rural areas. Very few boards have acted to do so because of the possibility of community resistance to the loss of facilities. In many situations, solo positions are staffed by a series of short-term locums delivering an intermittent medical service. Once again the will to act on these recommendations has been deferred, pending ... yes ... another report! A medical consultant currently is undertaking a medical service review of the whole province in order to assist with medical manpower planning. This is to be completed by Mar. 31, 1997, thus doing in 12 weeks what the PRAG had taken 18 months to do. It is no coincidence that the joint management agreement between the government and the NLMA expires on the same date.
From this litany of events it is little wonder that any efforts that are made to enhance the status of rural medicine are increasingly viewed as an elaborate form of lip service. However, there have been some major attempts to raise the profile of rural medicine (both in the public eye and that of the student body) over the past number of years. The Memorial University Medical School, through the Working Group of Rural Medicine, has run a rural medical forum in the fall for the past 5 years. This has been a venue for rural doctors, administrators, students and faculty to discuss (possibly ad nauseum) the problems and unique qualities of rural medicine. The inevitable list of recommendations that result from these gatherings year after year would not be considered new, novel or unreasonable by any rural physician.
In 1995, as a result of the medical school retreat, major proposals to revamp the whole undergraduate curriculum were made with the intention of placing a greater emphasis on rural medicine and of exposing students more fully to it, in the hope and possibly the belief that this would encourage more to choose it as a career path. At present, first-year medical students spend 2 weeks and clinical clerks spend 1 month of their clerkship in a rural site. Dr. Ian Bowmer, the new dean of medicine, who took over in 1995, is exploring the possibility of using telemedicine technology to allow rural preceptors to be active teachers in the university setting. Also, the possibility of more rural academic sites throughout the province is being explored. To evaluate the success of the medical school in acting on the recommendations arising from the retreat a monitoring committee has been established. One rural family doctor sits on this committee of 5.
In May 1996 the Faculty of Medicine established the Office of Rural Medicine. Its brief is to:
- develop programs to recruit physicians to rural areas of the province. Programs have been developed for high school students, medical students and postgraduates.
- oversee the various bursary programs that have been introduced over the past number of years. The success or failure of these will be evaluated as the first group of bursary residents finishes in June 1997.
- take on the responsibility of developing appropriate continuing medical education for rural physicians.
The medical school has yet to develop any comprehensive program to offer advanced skills to rural physicians or graduates from the family practice residency program, specifically in areas of rural surgery and obstetrics and gynecology.
In the summer of 1996, the NLMA established a rural physicians committee, which hopes to bring to the NLMA board issues of direct concern to rural MDs. The committee recently produced a survey of international medical graduates, working in Newfoundland (many of whom worked in rural areas). Results revealed a significant level of dissatisfaction with the current status quo. Of note is that 47% of respondents indicated that rural medicine was not their primary choice of work (Survey of international medical graduates. Rural Physicians Section, Newfoundland and Labrador Medical Association: unpublished data, 1997 Feb.). Many of these international medical graduates, have great difficulty in obtaining full licence, either in this province or in the rest of Canada, and some are constrained to work in rural areas because of their limited mobility (see also the discussion of this topic in RuralMed, page 92).
Currently, the Newfoundland Medical Board is planning to issue guidelines on continuity of care and the availability of physicians to their patients. It is also issuing guidelines on the responsibility of the on-call physician. The intent is to ensure that physicians provide coverage for their patients. The impact may be to constrain rural physicians to unreasonable call hours, if locums cannot be found.
Finally, the 1998 annual meeting of the Society of Rural Physicians of Canada is being planned for Newfoundland: mark your calendar now!
References
- Patey P, Harvey N, King S, Moulton W. The role of the family physician in Newfoundland and Labrador. Report of the Joint Management Committee on the Role of the Family Physician. 1995 May.
- Physicians & Fees Regulations, Nfld Reg 50/93. Amendment to section 4.
- Reid I, Hogan TG, White G, Ludlow N, Robbins C, Young R, et al. Report of the Physician Resource Advisory Group to the Newfoundland Ministry of Health. 1994 Nov.
- Roberts P. Salaried physician service. "Making it better." Report to the Newfoundland Ministry of Health. 1996 July.
