Thank you. That's a very important problem considering the size of our country. Having centres of excellence is one thing, but having access for the whole community and the whole province is very important.
I think there are basically the frontline providers. We have to mention the family physicians, who will be the ones who have to be educated to recognize the possibility of endometriosis, to initiate first-line treatment and then to really promptly make a referral once the first-line treatment doesn't work. I think there's a huge education piece on that side. We're trying hard. We put an article in the CMAJ; we do CME events; we reach out in various ways to family practice meetings, but more has to be done.
Once that first-line provider has referred someone, you need the gynecology expert in the local area. Now, many communities in rural areas do have gynecologists, but they also have to have their skills upgraded to a certain degree so they know the proper chain of treatments and when to refer. There's a certain subset of patients who need a referral for treatment in tertiary care centres. Those are the ones who are going to have quite severe endometriosis, with invasive disease and the challenging surgeries that require that kind of expertise or those who have chronic persistent pain who really need that holistic, interdisciplinary, multi-faceted approach. If the general gynecologist is clear on that and knows what works in that setting and who to refer, then having access to those centres becomes a bit more efficient.