In August, the Yellowknife Health and Social Services Board assumed the overhead and operating costs of the city's 4 medical clinics — an expense estimated to consume 40% of the 18 physicians' gross incomes.

The health board then offered the doctors a contract with salary, incentives and benefits that total as much as $285 000 annually (see sidebar). By making the move, the NWT hopes to to achieve some of the same stability it acquired by putting the 40 physicians practising outside Yellowknife on contract.

"We were up against the wall," Dr. David King, president of the Northwest Territories Medical Association, says of the recruiting situation.

Yellowknife, which has 17 000 residents, was down to only 14 physicians in the summer of 1999, and until recently the territory has depended on locums to provide up to half of its physician workforce.

According to the Society of Rural Physicians of Canada (SRPC), the number of rural physicians in Canada declined by 15% between 1994 and 1998. A CMA report to Health Canada in April 1999 pointed out that even in the unlikely event that nothing changes, the rural physician supply will drop by 18% in the next 21 years.

But Dr. John Wootton, executive director of Health Canada's Rural Health Office, says salaries and incentives alone aren't enough. Just look at Quebec, he says, which has had salaried physicians in its community clinics for 20 years and yet still has a shortfall. Wootton points to the need for technological links and a consistent level of infrastructure, including diagnostic, therapeutic and transportation tools, for all rural areas. The key to recruitment and retention, Wootton says, is flexibility to address local needs.

Dr. David O'Neil, the SRPC president, agrees. "Every rural area has different needs and different distances to tertiary services or cultural resources." Sometimes all that's needed is a transportation allowance or a turn-key office. Other times, the physicians need everything from housing to spousal-employment assistance. He admits, though, that alternative payment plans are particularly useful when patient volume is unpredictable or low.

Salaries and other financial incentives are the cornerstone of most rural recruitment and retention plans across Canada. For example, Prince Edward Island's new rural physicians get a $20 000 moving grant for providing a 2-year commitment. This summer, Quebec began offering fee-for-service bonuses of 15% to 30% (depending on years of service) and 40% bonuses to specialists. Ontario offers a range of incentives, including salaries and bonuses of $25 000. Saskatchewan physicians are offered salaries of up to $140 000 to start, plus benefits such as subsidized housing and a practice-establishment grant of $18 000.

But Alberta is ahead of everyone by a decade, says O'Neil, who practises in Trochu, Alta. It offers paid locums, CME, enrichment training, bonuses for on-call work, and more. "You have to make the environment attractive for them," O'Neil says. Next year, Alberta will also offer incentives to 40 medical students to enter a 2-year rural residency program.

Meanwhile, British Columbia may have the most work to do on rural initiatives. This summer, rural physicians in some areas withdrew services and resigned hospital privileges to protest antiquated equipment, inconsistent on-call rates for specialists and the lack of incentives to lure much-needed physicians.

At its annual meeting in Saskatoon in August, the CMA adopted a policy to ensure "reasonable access to uniform, high quality medical care" in rural and remote areas. It contains 28 recommendations touching on the training, compensation, and work and lifestyle issues of these physicians.