Health Committee on March 30th, 2010

[The Chair, Conservative, Joy Smith]

Good morning, everyone. We have quorum this morning, so I would ask everyone to gather together so we can start our committee business.

Pursuant to Standing Order 108(2), a study on health human resources, we have with us today, from the Northern Ontario School of Medicine, Dr. Roger Strasser; from the Society of Rural Physicians of Canada, we have Dr. John Wootton; from the Rural Ontario Medical Program, we have Dr. Peter Wells. Welcome to you all. I notice we also have with us Lee Teperman, who is from the Society of Rural Physicians of Canada, and we have Michelle Hunter, who is the manager from the Rural Ontario Medical Program. Welcome as well.

We're going to have five minutes of presentation from each organization, and after that is finished we will go on.

We will begin with the Northern Ontario School of Medicine and Dr. Roger Strasser. Thank you very much.

[Dr. Roger Strasser, Doctor, Northern Ontario School of Medicine]

Thank you very much.

First let me express my appreciation of the committee and for the opportunity to come and be with you today.

When I made some inquiries yesterday as to what you were interested in, in health human resources in rural areas, and I started talking about some of the issues, it kind of felt like I was going to be talking about my life's work.

In my brief introduction, I thought I'd tell you about who I am, introduce the Northern Ontario School of Medicine and the various initiatives we have there, mention my involvement with the World Health Organization and on an international expert panel, and then talk about my experience from previous times in Australia. I come originally from Australia.

Currently, I am the dean of the Northern Ontario School of Medicine, and I've been in that position, in fact, as the founding dean, since 2002. Before I came, there was no Northern Ontario School of Medicine.

Prior to that, I was in Australia. I was the head of the Monash University school of rural health. Monash University is a very large university with a very large medical school in metropolitan Melbourne. Melbourne is a big city like Toronto and Montreal, and I was the head of a rural branch of Monash University school of medicine.

I also was involved as the inaugural chair of an international working party on rural practice for WONCA, the World Organization of Family Doctors.

As I mentioned already, I'm a member of an expert panel advising the World Health Organization on developing recommendations on the retention and recruitment of health workers in rural areas.

I also am an advisor to the World Bank on the scaling up of the training of rural health workers.

I have brought a folder of information on the Northern Ontario School of Medicine. Unfortunately, most of it is in English, so it can't be submitted to the committee, but there's a folder available for each committee member, to look at when you have an opportunity.

The Northern Ontario School of Medicine serves as the faculty of medicine of two universities, Lakehead University in Thunder Bay and Laurentian University in Sudbury. As I imagine you're aware, those two communities are 1,000 kilometres apart. Northern Ontario is geographically vast, the size of Germany and France put together. The school was established with a social accountability mandate. That's a commitment to be responsive to the needs of the people in the communities of northern Ontario. There's also a commitment to innovation.

The education and training activities of the school are based on research evidence that shows three factors are most strongly associated with going into rural practice after education and training. The first is a rural upbringing, that is, having grown up in a rural area. The second factor is positive clinical and educational experiences as part of undergraduate education; that's in the MD program. The third factor is targeted training for rural practice at the post-graduate level--having residency programs that prepare the residents to practise in rural areas. At Northern Ontario School of Medicine, we're doing all of that. We've developed a distinctive model of medical education and health research that we call distributed community engaged learning. We have over 70 different locations across northern Ontario where our students and residents may undertake part of the clinical learning. We have a four-year MD program. The curriculum for that is very much grounded in northern Ontario and really prepares the graduate to have the knowledge and skills he or she needs and the inclination to pursue a medical career in northern Ontario or similar northern rural, remote, aboriginal, and francophone sorts of environments.

We also have residency programs in family medicine and eight major rural college specialties--again, very much with an emphasis on generalism.

We also have an accredited continuing education professional development program, which is largely available using electronic communications, so that many of the sessions are available by video conferencing and webcasting. We make heavy use of electronic communications.

Also, we are involved in education beyond strictly medical education. In the health sciences, we have a dietetic internship program. We're involved in education of physiotherapists and occupational therapists in northern Ontario. In collaboration with the University of Toronto Faculty of Medicine and the Michener Institute in Toronto, we have just established a physician assistant education program in northern Ontario as well.

We have a strong emphasis on interprofessional education. On the research programs at the school, the focus is on addressing research questions, the answer for which makes a difference to the health of the people in communities in northern Ontario. Again, the social accountability mandate really is the guiding light for the development and for all of the activities of the school.

The school admitted our first class--it's a four-year MD program--which had its official opening in 2005. We had our first graduates just last year, in 2009. So it's early days to talk about the outcomes.

In terms of the classes, for each of the intakes so far, roughly 90% of each class are students who have grown up in northern Ontario. Usually between 40% to 50% of the class are from rural and remote areas. We have a proportion of aboriginal medical students each year and francophone medical students. What we do is aim to represent the population distribution of northern Ontario in each class, and we've been fairly successful with that. We've done that in a way that does not sacrifice academic standards, so the grade point average of each class has been of the order of 3.7 on a four-point scale, which is very similar to the other medical schools in Canada.

The first group of students, of course, have now graduated. They're all matched in the first round of the national match into residency programs, and that's the first time that's occurred in Canada for over 10 years--a whole class matched in the first round. I think that's an indication that our students, our graduates, compare very favourably to the students and graduates of other medical schools, because the residency program directors wanted them in their programs. Seventy percent of those graduates are now pursuing mostly rural family medicine residency. To put that into perspective, that's more than double the national average of students going into family medicine residency. In our case, it's mostly rural family medicine. The other 30% of the graduates are mostly undertaking general specialty residency programs.

The early signs are certainly encouraging. The other indicator is that there's a national exam--the Medical Council of Canada exam--and our students, as a whole group, placed number six out of seventeen medical schools, in looking at their scores. In the section on clinical decision-making, they actually had the highest score of all the medical schools in Canada. So we take that as positive indicators of early success, really, for the Northern Ontario School of Medicine.

Just briefly, as I said, I wanted to mention the World Health Organization. We're just in the latter stages of completing guidelines and recommendations that will be presented, I think, to the World Health Assembly in May. There are four categories of these recommendations--I'm one of the members of the expert panel--and once this is finalized, it might be of interest to this committee to receive a copy and to review that document.

[The Chair, Conservative, Joy Smith]

We'd like very much to have that, Dr. Strasser, if you could submit it to us.

[Dr. Roger Strasser]

I can organize that.

[The Chair, Conservative, Joy Smith]

Thank you. I'll make sure all the members have it.

[Dr. Roger Strasser]

I will just give you an idea of the four categories: education, regulation, financial incentives, and personal/professional support. I can tell you more if you'd like to know.

On the last point, just as I said, I'm originally from Australia and was very much involved in developing rural health initiatives in Australia, including the national rural health strategy. Australia was the first country in the world to have a national rural health strategy, and that initiative of having a national rural health strategy I think has had major benefits for Australia in improving the numbers and the skills and the mix in the rural health force in Australia. So that's something I'd encourage this committee to consider.

That's my five minutes.

[The Chair, Conservative, Joy Smith]

I've stretched that a bit, Doctor.

It was very interesting what you had to say, and our guests here on this panel are here for a reason. It helps us a great deal to have your insightful comments, so thank you.

We'll now go to Dr. John Wootton, president-elect for the Society of Rural Physicians of Canada.

[Dr. John Wootton, President-elect, Society of Rural Physicians of Canada]

Thank you very much. I appreciate this opportunity.

I will give my presentation mostly in English, but I can answer your questions in French if you wish me to.

I practice in the Outaouais region, on the Quebec side, about an hour from here. So I am the closest from Ottawa.

The Society of Rural Physicians is a national organization that brings together physicians who share a common style of practice and common challenges across rural Canada and northern Canada. They recognized some years ago that by sharing their stories they were able to have a larger voice than their individual voices in their communities.

What they have been able to articulate are some common themes about the populations they serve. Those of you who represent rural communities will know that Canadians in rural Canada are older than the average, they're engaged in riskier activities, they're more isolated, more sparsely distributed, and therefore more difficult to serve. They're more economically disadvantaged, and those of you familiar with the principles of population health will know that's a major determinant of their health status. And from the cross-sectional studies that have been done, they're in poorer health to begin with and have significant challenges to overcome. Some indicators of well-known risk factors such as smoking and obesity are very present in rural Canada and in some--particularly first nations--communities, they have devastating health consequences.

That's the portrait of rural populations, and it's the reason I think this committee is interested in rural health issues. There are major challenges in a country the size of Canada--much as my colleague, Dr. Strasser, discussed about Australia--on how to organize the system and how to give it the appropriate support in order to be able to achieve what is perhaps not best described as equal access, but equitable access, to services.

This requires action at many different levels. If the last 20 years is any indication, there have been actions at different levels, but I would characterize them as being somewhat disconnected and certainly not part of a national rural health strategy. There are elements of a strategy, but they lack the strategy for which they are an element of, if one can put it that way. And one of the things that is required for us to move forward is to identify the critical elements of a national rural health strategy that would allow us to move forward.

There clearly are many players. Many of the levers to improve rural health are economic in nature. Many of them are social or societal. Many are educational. Many of the things are out of the sphere of the health care system. So many government departments are involved.

With respect to access to services from a community level, what I hear most often from communities is a discussion about the challenges of health human resources. In health human resources in Canada--particularly in rural areas--there are shortages at the physician level, there are shortages at the nursing level, and there are shortages in all the other professional levels. Communities are struggling to outbid each other with incentives and the attractiveness with which they present their communities. It's a lose-lose proposition for many rural communities who start off with few resources and are forced to use them as incentives.

That really begs the question for me, because my experience in rural Canada is that if you have a workforce that understands the challenge, that is appropriately trained, that is appropriately exposed, they will work in rural communities willingly. If the model is ever-larger incentives, which are clearly part of the package, they aren't the fundamental thing that will improve things in rural Canada.

We need to pay attention to the messages coming from our communities. We need to understand the kind of health worker we need, we need to understand the kinds of teams we need, and we need to understand how those teams can be trained. If we are to seriously address the issues facing the distribution of this workforce, we need to mandate some organizations to actually have some authority to get the training done at the appropriate level for the long-term solution.

If we continue to depend on individual interest and the size of the incentives, we will be continually faced with putting out fires and band-aid solutions, and we won't have a durable infrastructure that can solve the problem in the long term.

I'd encourage the committee to use the expertise that does exist in rural Canada at many levels. There is a great deal of understanding of their communities and a great willingness to come together to produce recommendations for consideration by the different levels of government. The different levels of government must be encouraged to work together to find solutions that are long term in nature and not stopgap.

The Society of Rural Physicians has been working in this community-focused way for 20 years and will continue to do so. Hopefully we'll be able to provide you with assistance and recommendations as we go along.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Wootton.

Now we'll go to the Rural Ontario Medical Program and Dr. Peter Wells.

[Dr. Peter Wells, Executive Director, Rural Ontario Medical Program]

Good morning. Bonjour.

Thank you to the committee for inviting the three of us to speak to you this morning. It's a privilege and an honour to be able to be here.

What I hope to do in this five minutes is to provide you with a very brief overview of what the rural Ontario medical program is all about and what we do. In the package that you will be receiving perhaps later, because it will need translation, you will find more detail, but I hope to really be able to hit the highlights for you.

Training equals recruitment and retention of physicians. Early on, I try to tell people that there's a take-home point in any presentation I do. This is the take-home point, which Dr. Strasser mentioned earlier but it's worth repeating: after a rural background, training and location of training--both at the undergraduate and the post-graduate levels--are the biggest determinants of where people will elect to practise and set up practice.

That's not something we just made up. There is a large body of research to support that, including the WONCA policy on training for rural practice, published in 1995.

ROMP is an organization that began in 1988. We're located in Collingwood, Ontario, but cover a large area of south central Ontario. We're a training organization for community practice. Our intent is to create generalists who come out into community practice.

It's worth noting the economic impact of that kind of training. One doctor, studies estimate, produces a $500,000 to $1 million impact on the local economy in our communities. That would be true across Canada.

So what is the ROMP vision? We all have to have a vision or an idea of what we're going to do. Certainly our concept is that we want to start in high school, so we send our current trainees into high schools to try to encourage students from more rural settings to consider a health career. That doesn't just include medicine, but the allied health professionals as well.

So we try to start in high school. Certainly in medical school we try to get students out early on, because, again, research suggests that the earlier and longer duration of exposure you have, the more likelihood of success in recruiting to communities. That really sets the foundation and plants the seeds for those students to consider coming back for longer-term rotations later in their clerkship training, and then indeed in their residency training.

To complete that circle we try to make sure we can get those students placed in communities that need their particular services, that they'll be happy. Other speakers have talked about the success of those placements being multi-factoral; it's not just training, but spousal support, and so on. Once we have them located into those communities, we try to recruit them back into a teaching role. So it's a bit of a self-fulfilling circle that we're trying to achieve.

It is important to also note that we're trying to encourage retention by providing clinical teaching. The opportunity to teach allows the connectiveness that will help with retention. So although we're talking about recruitment, I also have to emphasize retention. Retention is a huge factor. Once you have people in the community, how are you going to keep them there? You really want to keep them there. If you start losing the folks you planted there, you're defeating your own purpose. Education and providing continuing medical education are all factors in keeping physicians in the community.

Is our program successful? I want to highlight just a couple of things. In our area of south central Ontario, we have over 1,000 preceptors registered to date. That's a huge resource for us. We have 53 months of learning in place since we began, and 800 community recruits in south central Ontario between 2003 and 2008.

In addition, we work with all six medical schools in Ontario. That requires a fair degree of collaboration. So we're really a collaborative program. We want to partner with schools, and we do indeed partner with all six schools in providing various services for them.

You can ask yourself if training works. I've said it works, but where is the proof? We have done some research to look back on our track record. Again, we have worked with all six medical schools, and obviously some relationships are more long-standing, but they're all certainly successful. In fact, 47% of our trainees practise in rural or underserved areas, so that's really quite remarkable just in and of itself.

In the targeted training programs whereby we locate trainees to a particular community, that post-graduate training in family medicine would last two years, and 85% of our ROMP residents are actually practising in the local area where they trained. That's really quite an outstanding figure. I think it speaks not only to the success we're having but also to the success that programs like the Northern Ontario School of Medicine will have.

I'm going to reiterate that you want to retain those people and those who are already there. Dr. Wootton mentioned how incentives for someone to come to a community are self-defeating. I would echo that in the sense that if you have incentives to recruit somebody to your community, then the physicians who are already there are going to start asking, well, if you're bringing them in and providing them with all the incentives, I've been here for 25 years and what have you done for me? So it can be a very divisive tool, and we would not want to look at this kind of suggestion in health human resource planning.

We do need more research in this area to look at the early careerists and how we can retain them. Are we keeping them? Once we've been successful in placing them—and I've given you some statistics on that—are we able to retain them in that community, and are we getting them back into teaching and providing more training for the students coming behind them?

We have four recommendations for your consideration. First, we're suggesting holding a national conference on interprovincial collaboration of the organizations working in this field. Although the Rural Ontario Medical Program is essentially one of three programs in Ontario, there are sister programs in other provinces, and a national conference would allow us to address common needs across the country and develop a common response. It would also allow us to be able to share best practices so that we're not trying to reinvent the wheel. It may also come up with some practical suggestions, including, for example, the creation of a college of rural medicine. This is an area of federal jurisdiction, so it would be right up your alley, hopefully.

Our second suggestion or recommendation is that the Rural Ontario Medical Program and RPAP, the Alberta Rural Physician Action Plan, our sister organization in Alberta, both collaborate on our registered website called practicaldoc.ca. It's very early days yet. We're just putting together the skeleton, and the meat remains to be put on the bones. It's a portal for national retention. So we envision it being a tool for faculty development, continuing medical education, and research administration. We hope it will be open to all provinces. Most recently, B.C. has expressed an interest in joining our collaborative work. Currently we have no funding for any of this work and are just doing it out of our existing infrastructure. Certainly it is one area that could be looked at.

The third recommendation is for a national learner placement program, and we're envisioning that as interprovincial and international learner placement. For example, within our program, the ministry of health in Ontario funds us to place learners in Ontario from the six medical schools. It does nothing that's not available to students anywhere across Canada or indeed any international medical graduates or Canadian medical students being educated abroad, for example, in Ireland, Australia, etc. So we are continually asked to place learners from outside of Ontario. They may be Ontario residents who want to come back to Ontario but are training in B.C., or they may be people from B.C. who are training in Ontario and want to go back to B.C. We think there is an opportunity for distributing these students around and allowing international medical graduates to come here for training and to see our country, and for interprovincial movement of learners. We think that is important and could be a shared resource.

The example I would give is that there are probably at least 2,500 medical students in Ontario, many of them vying for distributed medical training sites. As the medical schools are ramping up their acceptance of medical students because of societal pressures, then we need to get those students placed.

The fourth recommendation is to hold a health ministers conference on funding for community education, recruitment, and retention. You could support the administration of that conference.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much, Dr. Wells.

We're now going to go into the seven-minute Q and A, but we will be dispersing at 10:30 for in camera committee business.

There's going to be shared time between Dr. Duncan and Ms. Murray. Ms. Murray is first.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you, Madam Chair.

I'm very interested in the overlaps or cooperation between those working on the issues of aboriginal health and rural health. At our last committee meeting we had a row of experts giving testimony about the aboriginal aspect. So when you are giving us health statistics for rural areas, do the data include aboriginals in the rural areas?

Regarding the issues of recruitment and retention you're talking about, I am curious whether you see recruitment and retention of health human resources for aboriginal communities as a subset of your work, or are these two areas treated as separate areas of study and analysis and recommendation?

I note that among the four main initiatives of the pan-Canadian health human resources strategy, one is health human resource projects, but there isn't a rural component to those initiatives. I'm trying to get a sense of this. Are they completely separate in terms of the fundamentals you're addressing, or how can the work on the aboriginal side be combined or complemented with that on the rural side so that it's more effective overall? Your comments on that would be welcome.

[Dr. John Wootton]

I'll just make a first comment.

Roger is working in a more northern area than I am, but I have worked in Sioux Lookout in his area. Fundamentally, from a health human resources perspective, I think there's a great deal of similarity. There are a lot of physicians and nurses who move from isolated communities in the north to rural communities farther south. They don't go as far south as Toronto, but coming south for them is a big change.

However, in terms of the specifics and content of the two, it's quite different. The Society of Rural Physicians is collaborating with a first nations physician group to produce a textbook on northern health, because so many aspects of it are different in terms of specifics. So it's a subset on the clinical side.

On the training side, it's probably not. The main characteristic of physicians who work in rural Canada is the level of responsibility they take on. They're isolated, but they can be just as isolated here in Shawville in a snow storm as they can be up north if the planes can't fly.

So in terms of the infrastructure and the training level, there's a great deal of similarity. However, when you branch out into individual communities, things start to be quite different.

[Dr. Roger Strasser]

The first comment to make in looking at the health status statistics is that if you remove the aboriginal health statistics the data still shows that the health status of people in rural and remote areas is worse than the general population. When you ask what's behind it, sometimes there's an assumption that it's the poor state of aboriginal health in rural areas that drags down the whole picture. That's not the case.

There are specific issues, and John mentioned some of those, around lifestyle and the occupations of people in rural areas and so on, that contribute to the health statistics of people in rural and remote areas. They overlap with aboriginal...but they are distinct from the factors that contribute to the poor state of aboriginal health in this country.

I'm not sure who you spoke to last time, but those who have an interest in aboriginal health will tell you that there are as many aboriginal people living in urban and semi-rural areas as there are in rural and remote parts of the country. Aboriginal health is not just about rural and remote; it's also about urban and metropolitan.

Having said that, in northern Ontario we have over 100 first nations. They are amongst the most socially and educationally disadvantaged communities, and certainly in terms of health status, amongst the worst in the country.

In northern Ontario, with our social accountability mandate, we have a focus on aboriginal health and aboriginal issues. There are a number of elements to that. We are working very hard at developing and continuing strong relationships with aboriginal organizations, people, and communities. We have aboriginal people on our board of directors, involved in the governance of the school. We have aboriginal people involved in all aspects of the development and delivery of our curriculum and the running of the school, including elders who are members of our senior leadership group. We have aboriginal people who are our learners, medical students, and residents. In fact in our first intake of students, 11% of the class were aboriginal medical students, the highest percentage ever in a medical class in Canada.

We have a strong focus on aboriginal issues and aboriginal health, with the intent that our students and graduates have an understanding of the history, tradition, culture, social, and health issues of aboriginal people and that they are responsive to that. We have a thread that runs through our whole curriculum on aboriginal health. In the first year our students have four weeks where they're living and learning in aboriginal communities. That's an immersion experience for them, where they're really learning from the community.

I think it's important to understand that in rural and remote areas the aboriginal communities and their health issues are very much a part of the big picture of rural and remote health issues, but there are also specific dimensions that are cultural, historical and so on, that affect aboriginal people and communities.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Strasser.

Monsieur Malo.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you, Madam Chair.

Yesterday, along with my colleague Mr. Dufour and the leader of the Bloc Québécois, Gilles Duceppe, I talked to a number of medical students. In our discussions, one of them told us that most places set aside for aboriginal students in medical schools remain unused.

I would simply like to know your position in this regard, particularly Dr. Strasser. I understand that the system established at the Northern Ontario School of Medicine works. I think the places set aside for aboriginal students are being used. I would like to have your comments on this.

With your permission, Madam Chair, I will now ask my second question. Dr. Strasser talked about his involvement with an international panel on the practice of medicine in rural areas. I would like to have more details on what is being done in that regard elsewhere in the world.

[Dr. Roger Strasser]

Thank you for the question.

The first question was about designated places set aside for aboriginal people to be medical students. Essentially, as we were starting to develop the plan for our medical school, there was heated debate amongst the aboriginal people themselves about whether we should have designated seats put aside for aboriginal people. There were those who said, “Well, unless there are designated seats, our people won't get into medical school.” Others said, “No, we shouldn't do that, because it gives the impression that these aboriginal students are getting in through the back door and the standards are lower, and that creates a stigma for them.”

The approach we have at Northern Ontario School of Medicine is a sort of middle ground. We have a class size of 56 students each year, and two seats are set aside for aboriginal students. But we see that as a floor, not a ceiling, and we've never had as few as two students in a class. We have a target approach and aim to reflect the population distribution of northern Ontario in each class. So we've been successful in having somewhere between three and six aboriginal people in the class, which then translates to between 5% and 11% of the class.

Other medical schools, as you've heard, have designated seats and they're not necessarily filled. That's partly because there needs to be an active process to encourage aboriginal people to want to apply to become medical students in that school. So we have an aboriginal admissions stream. We actually start in the elementary schools to encourage students to think about becoming doctors and health professions in the future.

When our medical students are in those first nations communities, they go into the schools and talk about themselves, university, medical school, and so on. We have a high school program where aboriginal students come in and spend a week. It's a summer science camp. They spend a week on the university campus making the connection between the science they study at high school and health. Thanks to television, in recent years we've had a CSI theme, and this has been very popular with the students.

So you have to work hard to encourage aboriginal students to see themselves as potentially future physicians, to study and get the grades, and to fund their way into medical school. You have to look at the whole picture and develop a pipeline, a pathway of aboriginal people into medical school.

Your second question, as I understood it, is that you'd like to know more about the World Health Organization report. I'm an expert panel member giving advice on that. This report has a focus on the retention and recruitment of health workers in rural and remote areas worldwide. As I said, there are four categories of recommendations. The first one is education, and there are five recommendations. The first is to recruit students from rural backgrounds.

The second is to establish medical and health science schools outside of major cities, similar to the Northern Ontario School of Medicine and the success we've had. There are other examples around the world of medical schools and health science schools that have been established in rural areas, or at least in locations that are not in metropolitan and major urban areas.

The third recommendation is that all students should have clinical experience in rural settings--do clinical rotations in the rural clinical setting.

The fourth is that the curriculum should include a focus on rural health and rural practice. There is a defined set of knowledge and skills that rural practitioners require. Dr. Wootton mentioned before that rural practitioners are extended generalists, so it's important that all medical students develop the knowledge and understanding that a special skill set goes with being a rural practitioner, and help them to understand that, with a potential future career in mind.

The fifth recommendation in education is continued education and professional development to help rural practitioners keep up to date and maintain and update their skills while they're in practice. As you can imagine, in a small community it's hard to get away from the community to access education. You have to get a locum, travel, and so on. So providing education that's tailored to the needs of the practitioners, and accessible, usually using alternate communications, is a great benefit.

So that covers that recommendation.

More quickly, the other recommendations include, under regulations, an enhanced guide for practice, recognizing that rural practitioners, whether they're nurses, doctors, pharmacists, or physiotherapists, are actually extended generalists, and the regulations recognizing and supporting that, in terms of the legislation.

Another recommendation is supporting different types of health workers. These include nurse practitioners—“physician assistants” is the language used in Canada. There is demonstrated value in having a spectrum of different types of health workers providing care in rural areas.

Compulsory service is another. In some countries, new graduates are required to do one or two years of service in a rural area. This has been shown to enhance both retention and recruitment.

Also recommended are financial supports in the way of subsidy during education, with a return of service requirements. There are programs like this in Canada as well. Financial incentives are mostly around bonuses for staying in rural practice and supports for setting up as rural practitioners. There is a series of those.

The last group is personal and professional support, ensuring, in terms of living conditions, that the rural practitioners have good places to live, that they have a safe and supported work environment, that they're supported by the system and by specialists in the urban areas—outreach support.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Strasser.

I'm sorry to interrupt you; you'll have a chance. We've gone way over, and some people will miss out on their questions. I've gone over on everybody.

So if you could just pick up on that—

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

Can we table the WHO...?

[The Chair, Conservative, Joy Smith]

Excuse me. We'll now go to—

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

Madam Chair, in regard to the WHO report that Dr. Strasser was walking us through, can we make sure it's tabled?

[The Chair, Conservative, Joy Smith]

Could we do that, Dr. Strasser?

Thank you so much.

Thank you, Dr. Bennett.

We'll now go to Ms. Hughes.

[Carol Hughes, NDP, Algoma—Manitoulin—Kapuskasing, ON]

Thank you very much. I'm glad to see you all here.

I'm from a rural area. I represent Algoma—Manitoulin—Kapuskasing, and I was at the graduation class of the Northern Ontario School of Medicine. I am a very close friend of and deal a lot with Dr. Maurianne Reade, who provides residential training in Mindemoya. I'm glad we're seeing the input from you here today.

You talked about incentives; just about every one of you touched base on that issue. There are pluses to incentives, but there are the negatives as well. The NDP put forward a proposal that would encourage doctors to go into the rural areas by helping them pay off some of their loans if they would commit to staying. This is a good thing in a way, because it would get doctors there; however, it doesn't deal with the issue of whether, once the incentive is paid out, they would leave or stay.

The other thing we've talked about as well is the opportunity for the government to ensure, if there are some disparities with respect to staffing in the hospitals, that in areas with fewer than 30,000 residents there be at least one nurse practitioner put in. I think we actually need somewhat more, but that is something we saw as a need.

Staffing is a big issue. You've touched base with respect to some of the suggestions you're making in moving this forward. The Canadian Federation of Medical Students was here yesterday. They talked about the downfall of incentives, but also about the impact of having grants so that there are incentives for students and about how to get more of the rural students there, because normally they're the ones who will stay.

Could you provide us with some feedback on that and maybe indicate some of the downfalls you're seeing—what's working, what's really not working, and where government should come in?

[The Chair, Conservative, Joy Smith]

Who would like to take that question?

Dr. Wootton.

[Dr. John Wootton]

I can speak from the experience in Quebec.

The incentive structure that works best, in my mind, is one that is tied to the characteristics of the practice. In other words, the major thing that distinguishes a rural physician from his urban colleague is—and the word is best in French—la polyvalence de la pratique: the fact that the physician is responsible for patients who are sick in hospital and who may be in the intensive care unit, or they may be obstetrical patients; the physician will also have an office practice and may be on duty in the emergency room and have to deal with trauma.

It's the broad range of responsibility and the training required to get there that justifies a differential. This is better than pure geography, because if people have an incentive program that is based purely on geography, it carries a negative connotation that the community does not have other things to provide and that therefore they need an incentive just to change their geographical location.

Many countries have the same level of responsibility incentives for other health professionals. I believe in Australia the rural nurses have incentives to establish in rural areas. This is lacking in Canada, because a lot of the enhanced responsibility that rural nurses or rural pharmacists have is not recognized by their negotiating bodies, and there really isn't a structure for this.

The effect of incentives has to be recognized throughout the whole career of the physician. Big lump sums up front, as was mentioned, cause division within the community when long-established physicians see themselves not being recognized.