Health Committee on March 30th, 2010

[Dr. Roger Strasser]

The essential principle is that the best predictor of future behaviour is past behaviour, so we look at grade point average. Any applicant who has a grade point average of more than 3.0 on a four-point scale we will consider. We look for a balanced academic background. If they have a science or math degree, then they have courses in humanities and arts; if they have an arts degree, they have courses in science and math. We don't have any prerequisite courses. We don't use the MCAT, which is an American aptitude test that most of the medical schools in Canada use. We look at their academic score.

They complete a questionnaire, which tells us about where they grew up, where they went to school, and when they had choices in community work and that sort of thing. We also give them what's called a context score. That's really what I think is the answer to your question. If you grew up in northern Ontario, you get the highest score. If you're aboriginal, you get the highest score. If you are francophone, you get the highest score, and so on down.

It's very competitive. We have in the order of 2,000 applications each year for 56 places. That's something like 40:1. We select 400 for interview. Actually, this past weekend in Sudbury and the weekend after Easter in Thunder Bay are the interview weekends. We interview 400. With the interview score plus the other score, we decide who to offer the places to.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Perhaps this is a provincial matter, but I would direct this to Dr. Wootton.

I know that in some of our communities there was a decision recently to change the model of how physicians are remunerated from basically a contractual model to fee-for-service. It certainly caused great upset in that the physicians are choosing to move on. I am wondering if there is, Canada-wide, any general research about the preferred remuneration model in rural and urban settings. Can you make a few comments?

[The Chair, Conservative, Joy Smith]

Be very quick, Dr. Wootton, because we're running out of time.

[Dr. John Wootton]

The quick answer to that is that there is more appetite for a global capitation-type system, because one of the characteristics of rural areas is that volumes are unpredictable. Emergency rooms, for instance, may be quiet or may be overwhelmed from one day to the other.

Just to add a point about the distributed education point, we're in the middle of a Canadian experiment. The increase in medical school enrollment was not because of a recognition of a rural problem. It was in response to a global recognition, finally, that the Barer-Stoddart report got it wrong and that we actually do need more physicians in Canada. But because the universities are strapped for places, it has generated an interest in distributed education. And it's really important that we capitalize on this.

One of the things the federal government could do is find a way to support those areas where distributed education is occurring. They're outside of the traditional university locus, which is well developed, but they are demonstrating that in terms of solving the rural problem, they have results that nobody can match. That's a place we can work.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Wootton.

We'll now go to Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much, Madam Chair.

I want to thank our witnesses for coming today.

I know several of my colleagues are perhaps more interested in provincial initiatives then in what you do. Personally, I take great interest in your initiatives and, specifically, in what the Northern Ontario School of Medicine does. I think the Quebec government has much to learn from the way you manage the school and the actions you took. As you mentioned it, Dr. Strasser, I believe things are starting to move in Quebec. For instance, the department in Chicoutimi and several other Quebec schools are taking measures that are somewhat similar to what you did.

As Mr. Malo mentioned, yesterday we met some people from the Canadian Federation of Medical Students who talked about your school with great admiration.

I would like to know what the comparative retention rates are for physicians working in urban and rural settings. I guess there are major differences that are not only related to the place where the physician was recruited and the location where he got his training. Can you provide us with any data and statistics on the comparative retention rates for these two types of areas?

[The Chair, Conservative, Joy Smith]

Who would like to take that one?

[Dr. Roger Strasser]

When you say two types of areas, you mean the urban and the rural areas?

[Nicolas Dufour, Bloc, Repentigny, QC]

Exactly. Do physicians in rural practice stay both in rural areas and in family medicine as compared to physicians who got their training in an urban setting?

[Dr. Roger Strasser]

Okay. Regarding the first, you have to realize that until very recently, the vast majority of medical students came from the big cities. Only 10% or maybe 11% of a medical school class would come from rural areas, so that most medical students had that city view of the country, which was that it's a nice place to visit, but I wouldn't want to live there. Therefore, most medical students wouldn't think about going into rural practice, and that attitude has tended to be encouraged by the main teachers in the medical schools, who are sub-specialists in big teaching hospitals in the cities. Their view is that the best kind of doctor you can be is a doctor like me, a sub-specialist in a teaching hospital.

Medical students everywhere are ambitious high achievers, and they want to be the best kind of physician they can be, so they aspire to be teaching hospital sub-specialists. So the system has been sort of self-perpetuating in its encouragement of medical students, whether they come from the urban or the rural areas, to want to become teaching hospital sub-specialists.

Northern Ontario School of Medicine is still almost brand new, and there are other examples of rural-based medical schools in other countries around the world. Their success rate for recruitment and retention of their graduates in rural areas is very impressive. There are two medical schools in the Philippines from which over 90% of the graduates continue to practise in rural remote areas in parts of the country where most people have very limited services--electricity and water and that kind of stuff. The Philippines is a country that most medical graduates leave the day they graduate. They go to the United States and practise in the United States.

I think there's strong evidence that, as I said, recruiting from rural areas, providing the education in the rural setting, supporting training at the residency level, and then providing support in terms of education and the other incentives and so on that I've mentioned actually provide for recruitment and retention in rural areas. In northern Ontario, before the existence of the Northern Ontario School of Medicine, since the early 1990s, there have been family medicine residency programs in the northwest and the northeast. Over 60% of the doctors who have trained in those programs since the early 1990s are still practising in northern Ontario.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Strasser.

We'll now go to Mrs. Davidson.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thank you very much, Madam Chair.

Thank you very much for your testimony here this morning. It's certainly been helpful and very interesting.

One thing I would like to know from each of you is what your definition of rural is, how you determine that. I would also like you to speak on the opportunities that rural Canada can reap from interprofessional interaction, whether we're talking about doctors, nurse practitioners, physician assistants, or our laboratory, imaging, physiotherapy, and occupational therapy people, and whether there are opportunities there for rural and remote areas in Canada. I'll just leave those two to start with.

[The Chair, Conservative, Joy Smith]

Dr. Wootton, do you want to start?

[Dr. John Wootton]

As far as the definition of rural goes, I would strongly encourage you to steer away from trying to completely understand it, because it's a moving target. If you are a researcher, you need sort of a Statistics Canada definition. If you're a health planner, you need more a style of practice definition. If you're a geographer, the simplest....

When we at the Society of Rural Physicians were first distributing our journal, we sent it to every address that had zeros in its postal code. Some of those were addresses of cottages belonging to people who were working in Toronto. The most useful definition and the hardest one to get to has to do with what I referred to earlier as physicians who have a comparable level of responsibility. That's very hard to tease out from geography or from population size.

As the physician workforce shrinks, a lot of communities find their physicians taking on more and more responsibility, and therefore becoming rural in a sense, although nothing around them has changed. But I think the philosophy of the Society of Rural Physicians' definition is the one that works the best. Some people are clearly rural by virtue of their geography. On the other hand, a physician who works in Whitehorse and who is merely doing psychotherapy in his office does not have the same responsibility as a physician in the same community who may be doing obstetrics and emergency room work, etc.

[Dr. Roger Strasser]

I was the first chair of rural health in Australia, so I got asked that question a lot around the world. I would say that rural is a bit like beauty or pornography: it's in the eye of the beholder. It's very much a mindset, more or less, as John has said. You then do have to, for different purposes, construct definitions according to what you're looking at. I'd agree with what Dr. Wootton said, that if you're looking at rural health service and rural practitioners, rural practitioners are extended generalists who provide a wide range of services and carry a higher level of clinical responsibility in relative professional isolation. That's true whether you're talking about family doctors, or surgeons, or internists, or pharmacists, or nurses, or nurse practitioners, or physiotherapists. I think that's a useful working definition if you're looking at health human resources.

In terms of interprofessional care and interprofessional education, my observation is that in the cities there's a lot of talk about teamwork and interprofessional collaboration. In the rural areas, particularly the small communities, it actually happens much more often. It's born out of necessity; there aren't enough health care providers. The rural practitioners live in the community they serve, so they're part of the community and they work very well together to meet the needs of the community they serve.

[Dr. Peter Wells]

I would echo what's been said before. You can look at crazy definitions of rural as the number of Tim Hortons you have and set a level of that. But I really think it is a moving target and probably not worthwhile trying to pin down.

In terms of your question about teamwork, I think in Ontario there are several models of that. Primary care reform has been in place in Ontario for several years. It offers a blended income model where it can be fee-for-service and capitation, which seems to work quite well. There are several different models physicians can choose from, depending on their style of practice. With that is the opportunity to have a family health team, which allows you to partner with allied health colleagues to provide service. I agree with Dr. Strasser that in the rural area it's used much more effectively just because of necessity, and the reality is that primary care workers, who are the ones who access the family health teams, are having huge demands on them. They don't have the resources, multiple layers of specialists, to refer to. So the family health team helps them deliver very comprehensive care to a larger variety of patients and a larger number of patients.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Wells.

For the last question we'll now go to Dr. Duncan.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Thanks, Madam Chair.

I would like to come back to what I asked before, but I'm going to ask a few questions beforehand.

My question is, what do you see as the federal government's role in bringing a rural lens to health care issues? What are your asks? What would you like to see happen?

[The Chair, Conservative, Joy Smith]

Who'd like to answer that?

Dr. Wootton.

[Dr. John Wootton]

One of the things that was mentioned earlier was that we need a mechanism to bring all the stakeholders together, from the community level up through the various professions, to generate the recommendations that have the broadest consensus possible that we can bring to whatever level of government is the appropriate one for the recommendation. I think there isn't an opportunity for this to be solved simply at one level; it has to be solved at many levels.

[Dr. Roger Strasser]

Just to reinforce that point, I would suggest the development of a national rural health strategy would be a very helpful way to go. I've seen in Australia the leadership from the federal government, which has really improved the quality and the access to health care in rural and remote areas. I can see the same success happening here in Canada.

I would suggest a stepping stone to developing such a national rural health strategy would be to hold a national rural health conference. That's actually how it started in Australia. The first national rural health conference in Australia brought together stakeholders from across the country and developed the first national rural health strategy, and then there have been lots of developments since then. I would recommend a national rural health conference as the basis for developing a national rural health strategy.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

I'd like to know again what impact the shortage of health professionals means for emergency medicine and surgical care, for example, understanding that this is a widespread worldwide problem, understanding the social determinants of health. Practically, what does it mean in rural areas?

[Dr. Roger Strasser]

Based on research that I've done over a number of years, I would say that people everywhere--city, country, anywhere--have a security need. They need to know that if they're unlucky enough to be seriously ill or injured, the system is there to save them.

In the urban areas that's a given. There are emergency departments and ambulances going backwards and forwards and so on, so the focus on health concerns is elsewhere. In the remote and rural areas, the people there know they can't take for granted that they have a hospital with an emergency department and the services they need. So that's a major preoccupation.

The research we've done shows that in order to ensure that people have the services they need, you really need to focus on that safety net and how that's provided in their community. There are many different ways of doing that.

We did a major study in Australia looking at 22 different remote communities and how they had their health services organized, and there were many different ones. There were a number of key elements. A key element that might be surprising was community participation. Where the services worked best there was a community representative organization that had a responsibility for the ongoing development of the health service, for recruiting health practitioners and supporting them, and there are all the things I said about the family, etc. But a key component is active community participation.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

I appreciate that.

How does that effect, for example, rural Newfoundland, where they've closed one hospital and it's an hour-and-a-half drive by ambulance to get to the next hospital, and you have an internist who is covering everything from hematology-oncology to general surgery?

[Dr. Roger Strasser]

That's a very good question.

Certainly modern developments in communication and transportation have improved the situation. For example, using telehealth, telemedicine, and real-time video conference linking helps to improve access to care in remote settings. However, in that life threatening situation there is the golden hour, and what's important is that in the community you have health practitioners who have the training, the skills, and the support to be able to save people's lives. And then they're supported by the system, using telehealth, transportation, and so on to transport maybe to a larger centre for care.

I think it's a serious concern in the example you gave, in a community where it's more than a hour and a half to the next centre, to lose that urgent care emergency response capability.