A Marathon session: A town's MDs develop a philosophy to call their own

Michael OReilly

CMAJ 1998;158:1516-7

© 1998 Michael OReilly

• Letter: Marathon's success

Last June CMAJ described how Marathon — a remote town in Northern Ontario — had gone from medical rags to riches in just over a year (CMAJ 1997;156:1593-6 [full text/en bref]). Once chronically underserviced in terms of physician services, this community of 5500 people went from a single overworked doctor to a group practice of 7 physicians. The change involved far more than numbers, however. The Marathon solution was built on a philosophy of physician sustainability and long-term retention, not just recruitment. The change was designed to ensure that the town could finally get off the roller-coaster ride that saw more than 75 doctors come — and go — during the previous 10 years. A year after its initial report, CMAJ returned to see if the Marathon experiment was still working.

This means that many of the services that would have meant a 400-km road trip to Thunder Bay are now being provided in Marathon. Perhaps more importantly, the principles of regular follow-up and a continuum of care have become more than a pipe dream for the first time in years.

The most important change, however, is in the community's attitude. After years of living with crisis-mode medicine, the people of Marathon are actually beginning to believe that there will always be a doctor around when they need one.

The success of the Marathon Family Practice pleases its founder, Dr. Gordon Hollway. This is especially true given that the practice has just survived the loss of 2 of its original members. "We made lots of noise about how we've created a new philosophy that will survive individual faces and will be attractive to other doctors out there," said Hollway. "Now we had to put our money where our mouth was, so to speak, and find out it if was all true."

As Hollway proudly points out, it does appear to be true. The group's members had little trouble finding 2 new physicians to replace the departing colleagues — at one point they were holding discussions with 10 interested physicians. This stands in stark contrast to recent years, when advertisements for new doctors often went unanswered for months.

In selecting the 2 new physicians, Hollway said the group picked doctors who were "a fit" with the group's philosophy. There were a couple of calls from physicians looking for "the Northern Ontario gold mine," remarked Hollway, but after hearing the job description they quickly decided that Marathon was not for them. "We want people who are looking for a life, not just a well-paying job."

The recent history of health care in rural and remote parts of Canada can be summed up in 2 words: ongoing crisis. As they moved from Band-Aid solution to Band-Aid solution, towns like Marathon offered a case study of these problems. The focus was always on the here and now, not on long-term solutions or sustainability. The result: physicians who did arrive would burn themselves out in a few months or years, and patient care always suffered.

Hollway and his colleagues are changing this by trying to build a rural practice that is healthy for doctors and good for the patients they serve. The Marathon physicians believe their practice is sustainable over the long run and can actually attract physicians to the north instead of coercing them, à la certain provincial recruitment policies.

"The message here is that you have to take a much longer and harder look at the whole structure of medical services in your community," he explained. "It's not as easy as a signing bonus or a low-rent house: communities have got to build something that lets doctors have an attractive lifestyle."

Hollway always points out that the solution to Canada's rural medical-services problem is not more money, but more doctors. Seven physicians in Marathon seems about right, he said, because the number ensures that no one is on 24-hour call more than 1 day in 5. It also allows the group to deal with holidays, CME and extended leaves for sabbatical work or family time.

Another part of the equation involved changing the way the community used services such as the hospital emergency department. As in many other smaller communities, Marathonians had come to regard the emergency room as the only guaranteed way to see a doctor, and they began using it like a walk-in clinic.

In the past year, Marathon's doctors have set about changing these attitudes. By training nurses in effective triage techniques and empowering them to treat patients who fall within their skill sets, they have reduced the demand on physician time. Hollway said the results have been significant.

"We call a night with no phone calls a 'no-hitter.' Before the triage system I think I had one no-hitter in a year. Now I've had 2 in the last month, so something has certainly changed."

One thing that has not changed is the way doctors are paid. Despite much effort, the Marathon Family Practice still operates under the standard fee-for-service system. Under the leadership of Dr. Michael Sylvester, however, the group is negotiating with the Ontario Ministry of Health to sign a globally funded group practice (GFGP) agreement.

This would provide a global budget for medical services offered within the community and put remuneration on a par with the group's philosophy. Unfortunately, philosophy and money don't always mix. Months of discussion have failed to produce an agreement that is acceptable to physicians in Marathon and nearly everywhere else in Northern Ontario. Despite political rhetoric, only one GFGP agreement has been signed here.

This disturbs Hollway and Dr. George Macey, a local dentist who leads Marathon's Physician Retention Coalition. Macey is concerned that the provincial government may spoil what Marathon has built. According to Macey and Sylvester, the government's current GFGP offer is based on a minimum number of doctors, not a sustainable number, and accepting this type of agreement would inevitably mean a return to crisis.

"I sold [the Marathon doctors] on the idea of a GFGP," Macey said. "We've got to have a change in public policy so that it supports the idea of sustainability or we are going to lose what we've gained."

Despite the ongoing political wrangling, Hollway said the Marathon practice is thriving, so much so that it will be offering 8 months of resident training this year. This is quite a feat for a place that could barely keep its own hospital open just 2 years earlier.

The group plans to continue expanding specialty services, and is looking forward to the completion of renovations at the local hospital. This was made possible through a successful fund-raising campaign that brought in $1.8 million.

So the future does, indeed, look bright for physician services in Marathon, Ont. There will be continued challenges with regard to politics and the recruitment of female physicians, but as Hollway says, these problems are a walk in the park compared with the town's recent medical crises.

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