Medical recruitment in rural Canada: Marathon breaks the cycle
Michael OReilly
CMAJ 1997;156:1593-6
[ en bref ]
Michael OReilly is a freelance writer living in Marathon, Ont.
© 1997 Michael OReilly
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In brief
Two years ago, the 5500 residents of Marathon, Ont., had 1 overworked physician to look after their medical needs. Today, they have 7 physicians to share the load. In this article Michael OReilly looks at the steps the town took to attract new doctors. It offered a financial incentive and also worked to revitalize its hospital. As Marathon worked to attract new doctors, it also found that a new generation of physicians has much different career aspirations than past generations.
En bref
Il y a deux ans, les 5500 habitants de Marathon (Ontario) bénéficiaient des services d'un médecin surmené qui répondait à leurs besoins médicaux. Aujourd'hui, ils en ont sept. Dans cet article, Michael OReilly analyse les mesures que la ville a prises pour attirer des nouveaux médecins. Elle a offert des incitations financières et modernisé aussi son hôpital. Pendant qu'elle cherchait à attirer des nouveaux médecins, Marathon a constaté aussi que les médecins de la nouvelle génération ont des aspirations professionnelles très différentes de celles des générations précédentes.
A medical renaissance is taking place in a small community on the north shore of Lake Superior. Marathon, Ont., a town with 5500 residents that was once chronically underserviced, now has more doctors than ever. More important than that, it has stopped the revolving door that has affected rural medicine across the country.
Dentist George Macey and hospital board chair Iris Sullivan were instrumental in making Marathon attractive to physicians
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For years Marathon, like many small Canadian communities, had struggled to supply primary health care services. Doctors were hard to come by and even harder to retain. In a 10-year span, no fewer than 75 general practitioners had spent varying amounts of time in the little community.
Through the efforts of community leaders the system limped along, but by the fall of 1995 a slow hemorrhage turned into a gaping wound. In a few short months the town went from 3 permanent physicians to 1. A health care crisis had begun.
"It was day to day," explains Iris Sullivan, board chair at Marathon's Wilson Memorial General Hospital. "We didn't know from one day to the next if we could even call ourselves a hospital because we didn't know if we'd have a doctor. It was so close, we had the rags ready to hang over the 'H' signs on the highway."
A year later, things look radically different. Marathon now boasts 7 family physicians, all working as part of a strong group practice. The local hospital is being renovated and is working toward official accreditation. And the community is now receiving medical residents for 6 months -- something unheard of for a town this size.
The problem develops
Dr. Gordon Hollway is, in many ways, the architect of both Marathon's crisis and its solution. It was Hollway who found himself working alone in the fall of 1995, having just moved back to town after a 7-year absence.
"When I came back I told [the hospital board and fellow physicians] that for my own health, and for the long-term health of the community, I was only going to work [on call at the hospital] 1 day in 4," he explained. "I'd done 1 in 3 when I was here before and got burned out. I knew I couldn't do it, so something had to change."
Hollway had first moved to Marathon in 1987, arriving straight from his residency. He worked for 2 years before hitting the burnout wall. Like many rural practitioners he worked 5 days a week, and was on call 1 day in 3 at the local hospital, 365 days a year.
Of course, this picture of rural medicine is common in Canada today, and is not confined to remote regions like Northern Ontario. Communities within a relatively short distance of major centres like Toronto, Winnipeg or Calgary also struggle to attract and keep doctors.
Hollway responded to the long hours by moving to Nova Scotia -- he is a Dalhousie graduate -- but remained in love, and in touch, with Marathon. By 1995 the pull of the north had become too strong, and he headed back.
"I might get lynched for saying this, but I missed the snow," he joked. "I also missed the adventure. Nova Scotia doesn't have the same frontier feeling that you get here in Marathon."
Unfortunately, the same problems that forced Hollway out of Marathon still existed. There were still too few doctors working far too hard. Hollway stuck to his guns, however, and refused to work more than "1 in 4."
Even when the town's long-serving GP departed, heading for the warmer south, Hollway still refused to take up the slack at the hospital. The crisis Marathon had been putting off for 15 years had finally arrived.
"This was the beginning of the paradigm shift that was needed to get out of the cycle," he explained. "By this time the hospital board had some new faces changed some faces and was in agreement: something had to change."
By then both Hollway and other community leaders in Marathon could see that more than a Bank-Aid solution was needed, so the town set about rebuilding its medical infrastructure from scratch.
Led by a local dentist, Dr. George Macey, a Doctor Crisis Coalition was formed. The aim, as Macey explained, was to attack the root causes of the problem, not just the symptoms. "Recruitment was never a problem -- we knew how to find docs, but what we couldn't do was keep them. We had to understand why our physicians left, and then had to find ways to change that."
All the right people
Mayor Don McKay says Marathon offers physicians a warm welcome
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This group brought together representatives from all sectors of Marathon -- people like Mayor Don McKay, hospital chair Sullivan and major industry, union and community leaders.
As Macey put it: "We had all the right people."
Together, the town began to rebuild a health care infrastructure that had been ignored for too long. The first job: dealing with the problems that were driving physicians away. Macey said these fell into 3 areas: quality-of-life issues, finances and professional support.
One solution was to bring in additional doctors, but to do this the coalition had to convince the Ministry of Health to increase the number of doctors allowed to practise in Marathon, so it began to build a political case for change. Using a recently released report on rural medicine as a basis for action, the coalition began lobbying to change provincial policy.
After much effort, including a community-wide letter-writing campaign, the ministry saw things Marathon's way and increased the town's medical complement to 5 physicians. "We were not just flailing aimlessly as in the past," said Sullivan. "We had a plan and followed through. Our letter-writing campaign was so effective the health minister [Jim Wilson] asked us to tell people to stop -- he was getting that many letters."
The lobbying not only led to an increase in the number of physicians but also paved the way for Marathon to become the first Ontario town to use an APP -- alternative payment plan. The details are still being worked out between the ministry and the coalition, but it was the town's political action that established the possibility of an APP.
"The APP, the quality of life, the sessional fees for emergency work and Gord's [Hollway] concept of a group practice -- these were the only things we could really offer prospective doctors," said Macey. "If we had the money we would have bribed them, but we didn't so we had to do something different."
While Macey's group was working on the politicians, Sullivan was leading the effort to improve the local hospital. It had suffered from the same neglect as physician services in the area, and Hollway said it was a major recruiting "liability."
The hospital board hired a temporary chief executive officer to restructure the 25-year-old facility. This led to changes in the hospital's administration, some significant cost savings and a joint management agreement with a neighbouring facility.
At the municipal level, Mayor McKay convinced the town to kick in $10 000 for each new doctor and to provide inexpensive housing. Finally, when all this was in place, the coalition went looking for MDs.
By this time, Marathon's fame had spread. Drs. Ruby and Steve Klassen had just graduated from McMaster University's Health North Program, based at Lakehead University in Thunder Bay, Ont. They had heard of the town's efforts, and of Hollway's stand over on-call services.
The idea of a rural practice appealed to the Klassens, but they did not want the typical small-town work environment. "We wanted to go to a place where we didn't have to kill ourselves working," said Dr. Steve Klassen.
They had heard how Hollway had refused to be on call more than 1 day in 4, and that he was setting up a family group practice. They contacted the town, and received a warm welcome. The support from the coalition members, along with Hollway's general philosophy, were enough to convince this husband-and-wife team to move to Marathon.
"This was great news," said Hollway. "But then we got word there were 2 more couples interested in coming here. This was a real mind-bender for us. No one ever conceived that we'd get up to our designation, let alone go beyond it."
In the span of 8 months the town went from having 1 permanent physician to the prospect of having 7. Hollway had some concerns this might, in fact, be too many. He remembered a time during his earlier stint in Marathon when 2 doctors left because they did not think they were getting enough work.
"After meeting them, however, I quickly realized that this was a different group of professionals, with very different expectations about hours of work and community involvement."
With the arrival of the new doctors in September 1996, Marathon was taken off the critical list for health services. Six months later the prospects remain bright. Ironically, the biggest problem facing the town involves its overachievement: it is now considered overserviced by the Ministry of Health.
This fact is making it difficult to negotiate an APP for Marathon, so as Dr. Eliseo Orrantia, another new arrival, said, much work has yet to be done. But something fundamental has changed in Marathon, because basic physician services are no longer in doubt.
Over time the faces and details will change, but residents of Marathon can, finally, rest assured that when they need to see a doctor, medical services will be available.
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