Health Committee on March 30th, 2010

[Dr. Roger Strasser]

To add to that, I think it is important to look at a type of “whole systems” approach, to look at the various elements and have incentives that support not only doctors but the whole health team, because that's what is needed in rural communities.

There are a couple of limitations with the kinds of specific incentives you're talking about. One, particularly when the initiative is taken by the community, is that some communities have more resources than others, and often the communities that are more remote and have the least resources have the least capacity really to provide the incentives. A systems approach that ensures that there is comparability across the communities is important. Sometimes that can be quite distorted.

Another is that when the incentive time runs out, there is a tendency for the physicians to decide that they're not going to stay in the community any longer. There was a crisis in a town called Geraldton in northwestern Ontario a few years ago when incentive payments for five physicians ran out and they all left, more or less at the same time.

The solution to this is not just about how the incentives are provided, although certainly retention incentives and rewarding the polyvalence of the practitioners who provide the full round of services—I would call it extended generalism in English—is important. There's a community element to this. It's really important for the community to recognize their role in hosting the doctor, and in fact the whole family. And for other health professionals it's the same sort of thing. When a doctor or a nurse comes to a community, it's actually a whole family. The incentives need to ensure that the needs of the spouse and the children are covered as well, so that the physician becomes a member of the community and wants to stay because of feeling part of the community. That's another systems element that's very important to assist retention as well as recruitment.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Strasser.

We'll now go to Mr. Brown.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Madam Chair.

I have some questions for the Rural Ontario Medical Program. Michelle and Peter, it's great to see you here. I've had the pleasure of attending some of the PAIRO tours that you're involved in. My colleague, Ms. Bennett, has spoken to one of your conferences before. Certainly you have a great reputation for helping get doctors into the community in underserviced areas.

I want to understand the setting right now in underserviced Ontario before I get into what some of the possible solutions are. I spoke to our physician recruiter in Simcoe County, and I understand that in Barrie alone, under the changes with incentive grants, we're going to have 17 doctors who no longer get incentive grants—that's 17 doctors in our community, taking patients, playing a vital role.

I understand that this change is going to make it remarkably more difficult for many parts of Ontario to recruit doctors. I understand there is an incentive grant of $40,000 that is on the precipice of being gone, and a $15,000 incentive grant. Could you share with the committee how these changes by the provincial Ontario government are going to affect recruitment in Ontario?

[The Chair, Conservative, Joy Smith]

Who would like to start?

Dr. Wells.

[Dr. Peter Wells]

I'll start. Then I'll turn it over to Michelle.

The program you are referring to is the underserviced area program, UAP. The intent of the program is to try to allow communities some funding to be able to provide for recruitment. That is being reallocated, in essence, and it's fairly complicated. I don't know that we necessarily need to go into the details here, but when you're looking at trying to provide incentives, I would take a whole systems approach, much like Dr. Strasser, and say we need to support undergraduate medicine, which in Ontario is not supported very well. Medical students, who are paying high tuition and so on, are not supported in coming out to do part of their education, and the research suggests the earlier and longer, the better your success rate, in providing communities with some infrastructure support directly to be able to support clinical teaching activities in all aspects. Allied health professionals as well as doctors are important.

Michelle is better able to answer your direct question about the program.

[Michelle Hunter, Manager, Rural Ontario Medical Program]

Thank you.

If you are looking at the programs that are currently running in communities such as Barrie, or if you look to the west, to Kitchener--Waterloo, down into southwestern Ontario or southeastern Ontario, they are going to be losing their incentive grants. The free tuition program will collapse on April 2. Those moneys have been reallocated into alternative funding programs hitting more rural and remote communities.

I would refer to Dr. Wootton's comments on whether it is a matter of geography or it is an incentives program better focused on responsibility. The polyvalence they have mentioned is probably the program you are looking at. You are looking at supporting physicians with a broader scope of practice. If that is rewarded, then these communities have the opportunity to recruit and sustain physicians.

[Patrick Brown, Conservative, Barrie, ON]

I understand there have also been negative changes to the return of service agreement in the sense that we have a significant interest in foreign doctors and foreign accreditation. I understand that with the changes, which I suspect will come April 2, a foreign-trained doctor doing his return of service could have done it in Simcoe County. Now it's going to be a free-for-all anywhere in Ontario, other than Ottawa and Toronto, so it'll be increasingly difficult for small towns and rural areas to get return of service contracts, because now they can go a few minutes north of Toronto.

Is that something we should be concerned about for rural and small town Ontario?

[Michelle Hunter]

The return of service contracts exist now for the international medical graduates who receive residency spots. They are asked to comply with the standards. Ontario has changed those so now they can go to Hamilton or Oakville, different boroughs of Toronto, and even to London, Ontario. They can do their return of service there.

It will have an impact on Barrie and on northern Ontario. The international medical graduates will stay closer to their cultural groups, so where are the return of service contracts for the folks who are paying tuition in Ontario and then in family practice residencies? Where are they doing their return of service contracts? If they choose to do one, they will take funding that will send them fairly far afield into northern and rural Ontario.

[Patrick Brown, Conservative, Barrie, ON]

That is my concern. Both of these changes are going to prove very onerous for parts of Ontario that are underserviced. It is an unfortunate development that I hope will be rectified.

I wanted to get into what I think is a solution. I believe from the testimony we've heard before that the solution lies in more residency spots. I know you play a role in the training, and I wanted to hear from you what it would cost if we were going to see a program across the country to open up more residency spots. What are the costs of training and residency for a medical student? I understand it is a two-year term. What would the cost be for those two years?

One thing I heard earlier this year when we had the College of Physicians and Surgeons in was that we had this list of 700 or 800 people for 175 residency spots every year. I forget what it was. We're turning down all these potential doctors because of the lack of residency spots, so the solution must be in putting in more residency spots, but I suppose there is a significant cost to that. What is that cost?

[The Chair, Conservative, Joy Smith]

Who would like to try to answer that one?

Dr. Strasser.

[Patrick Brown, Conservative, Barrie, ON]

What is the cost to your organization for residency?

[Dr. Roger Strasser]

The first thing to say is that there are more than enough residency positions for Canadian medical graduates, MD graduates from Canadian medical schools, across the country. In fact, in all provinces there is the opportunity for international medical graduates to find their way into the system and become residents and practising physicians in Canada.

Answering the question about cost is quite difficult and complicated because there are various elements to the costs, and generally they're funded through different pathways and not put together into a total package of cost. There are clearly differences in providing the training in the concentrated population centres like Toronto, where you have a critical mass nearby, compared to in the sparsely populated areas in northern Ontario.

[The Chair, Conservative, Joy Smith]

Mr. Brown, your time is up. I'm sorry, I gave you extra time.

We're now going into the second round of five-minute questions and answers, and if you have shared time, I do have to watch the clock. Be mindful of your colleagues, if you can.

We'll start with Dr. Bennett and Dr. Duncan. Who wants to start first?

[Carolyn Bennett, Liberal, St. Paul's, ON]

I'll start. We'll do the questions and then you can answer together.

Dr. Strasser, in Australia the locum system is pretty well developed. I just went and worked for Locums Australia Pty Ltd., and they sent me wherever they wanted. Also, with the Australian Medical Association....

In terms of the CME piece and looking after families, one of the things I heard was that physicians need to be able to know that they can of course get out with their families, and if they're the only game in town, that's pretty hard to do. Is there something we could do to make that better organized? Is there anything we would have to do in terms of licences across provinces such that somebody could do a locum in northern Manitoba with an Ontario licence? How would you organize that? Is there something you would like to give us that we could put in our report?

Kirsty.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Thank you, Madam Chair, and thank you to all of you for coming and for your important work.

I'm really concerned about the disparity between rural and urban areas. I found that rural Canadians have the highest death rates from causes such as circulatory disease, injury, respiratory disease, and suicide, compared with their urban counterparts. If we look, 21% of Canadians live in rural areas, yet 9.4% of physicians work in rural and remote areas.

My questions are these. To what extent are the health disparities between rural and urban Canadians the result of the shortage? And what does it mean in terms of, for example, emergency care, surgical care, and treatment following?

[The Chair, Conservative, Joy Smith]

Who would like to start? You have three minutes.

Dr. Strasser.

[Dr. Roger Strasser]

Maybe I'll start. To the question about rural practitioners and locums, it's true there is, I would say, a very well-developed system in Australia. Part of the system in Australia is that rural practitioners have more or less automatic funding to attend programs to upgrade their skills--the CMEs, continuing medical education. So they have relatively well-organized support to get locums, to be able to leave their community and go and do the training. They receive funding from the federal government to cover the cost of undertaking that training. So that's a good example of something you could learn from elsewhere.

On the issue of the lower rural health status and the maldistribution of the workforce, access is the rural health issue. That's the same the world over. Certainly reduced access is one of the factors that contributes to the poorer health status in rural areas, but it's only one of the factors. The social determinants of health, as a whole package, affect the health of people in rural areas just like elsewhere.

[The Chair, Conservative, Joy Smith]

Who else would like to continue?

Dr. Wootton.

[Dr. John Wootton]

With reference to the locum licence, the Society of Rural Physicians has long lobbied for a mechanism for locum licence. A rural physician's best replacement is another rural physician, and it's not true that every community is in crisis across the country at the same time. For physicians a change is often as good as a holiday, and many are very interested in seeing other parts of the country, but when it involves buying a licence for an entire year.... For me to cross over to Renfrew to do a locum 20 kilometres away would be a logistical nightmare.

Hopefully AIT is lowering the interprovincial barriers. One aspect of it that could be looked at specifically is a mechanism to allow locum licences and some organization to manage it.

[The Chair, Conservative, Joy Smith]

We only have about 30 seconds left. Are there any other comments you'd like to make on that, Dr. Wells?

[Dr. Peter Wells]

I'd like to support the comments about lowering the interprovincial barriers, both from an educational point of view and a locum point of view. For people to be effective teachers, they need locums to do CME, and trainees need the flexibility of being able to train in different parts of the country.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Wells.

We'll now go to Ms. McLeod.

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

Thank you, Madam Chair, and I'd like to thank all the presenters for some very valuable information.

I would like to start with the university and the training of our medical students. I believe there are 17 medical schools. You talked about two within Ontario. I know we have UNBC. These are all relatively new programs. Are there any other rural educational universities in the country?

[Dr. Roger Strasser]

There are 17 medical schools in Canada, of which Northern Ontario School of Medicine is number 17. It is the only new medical school established in Canada in over 30 years. That said, there has been expansion in medical school class size in every province, and in many cases satellite campuses have been established.

You mentioned British Columbia; they were just a year ahead of us, actually. They established a collaboration between UBC and UNBC--the University of Northern British Columbia in Prince George--and also the University of Victoria, so the students there are UBC students doing the UBC curriculum, but almost all of their four years of education take place in northern B.C. or on Vancouver Island.

There have been similar developments in Quebec. An example is the Université de Sherbrooke, which collaborates with the Université du Québec in Chicoutimi. Across in New Brunswick there's Moncton, and there are other Quebec schools. There's Trois-Rivières with the Université de Montréal, and so on. It's a pattern across the country for established medical schools to put satellite campuses in place in rural regional areas. The program the students follow is identical to, or very close to, the program in the urban area.

The Northern Ontario School of Medicine is the only new school established in a rural area with a program curriculum that is really designed in and for the rural setting.

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

It is a relatively new venture to have many of our medical students trained either by satellite or in a northern setting, and hopefully we're going to see some real results. It sounds as though we're heading in a really positive way with the choices these students are making.

You indicated that in the university you're responsible for, a very high percentage of people grew up in a rural area. I know getting into a medical school is very competitive, so do you just allot extra points within your admission process to people who come from rural communities? How have you managed to create such a high percentage of students who grew up in rural communities?