The Family Doctor Crisis

I read Alastair Brown’s excellent article on the challenges of the rural physician (“The Cost of Care,” April) with both admiration for Dr. Mihu’s dedication and concern for the future of Canada’s rural doctors. General practitioners in the United Kingdom are the highest paid in Europe, taking home around $100,000 (Cdn.) after tax. The allure of financial comfort, coupled with relatively gentle working hours, makes general practice an enticing proposition for med-school graduates in the UK.

Unfortunately, increasing salaries will not be sufficient to attract Canadian med-school graduates to rural medicine. An additional solution might be to work on the image of the rural physician and family doctor in order to inspire medical students about the work of these generalists and to expose them to it. If medical students in Canada are anything like those in England, many will have a dim view of family doctors, these jacks of all trades and masters of none. Family medicine is not “sexy.” It is seen as old-fashioned and devoid of the glamour that surgery, emergency medicine, and other specialties possess. Because the majority of family physicians work in communities, hospital-based medical students have scant opportunity to be inspired by them. Their understanding of what family doctors actually do, and the role they play in the community, may be limited, or worse, false.

I work outside the field of clinical medicine but have a reasonably clear view of it, and I have often felt that family medicine is undervalued and misunderstood. It suffers from its low-tech image of treating common colds and little old grannies, and gets too little credit for its integral role. A primary vehicle for improving its deteriorating status, I suggest, should be Canada’s medical schools.

Daniel K. Sokol
Researcher in Medical Ethics
Imperial College London
London, United Kingdom

Rural physicians are truly the last “general” practitioners, and their jobs become exponentially more difficult as medical knowledge evolves and the shortage of doctors worsens. The financial pressures described by Alastair Brown have been made worse by skyrocketing medical-school tuition ($16,207 at the University of Toronto this year, set to increase this fall), which has made a $100,000 debt the norm rather than the exception. Financial assistance has barely begun to catch up. As a result, students from rural communities (i.e., those most likely to return there to practise) may be shut out.

Fortunately all is not bleak. In Ontario, new modifications and alternatives to the fee-for-service model are providing incentives for group practice, preventive care, and after-hours care, and they are doing a better job of recognizing the complex needs of elderly patients. And telemedicine, which involves two-way video technology, holds out the promise of reducing the need for travel, thus improving the access people living in remote areas have to specialists.

The pace of change has been slow, but as I prepare to begin residency training in rural family medicine at the University of Western Ontario, I am looking forward to meeting the challenges of helping preserve the “social aspect of medicine.”

Stephen Keleher
Toronto, Ontario

I am finishing my last year of medical school at the University of Toronto and plan to practise rural family medicine. Canada is in desperate need of rural and family physicians. Only 10.3 percent of Canada’s doctors work in rural or remote areas, caring for up to a third of the population. Health Canada’s Ministerial Advisory Council on Rural Health recently stated that “there is a fundamental mismatch between the health care needs of people living in rural Canada and the availability of health care providers and health services.” At last count, Canada was short 1,175 rural doctors.

Research shows that growing up in a rural area and entering medical school with plans to become a family physician are the most important predictors of a doctor practising in a rural area. However, data published in 2002 revealed that students of rural origin are seriously under-represented in Canadian medical schools. Currently only 11 percent of Canadian medical students come from rural backgrounds—one-third as many as would be predicted by demographics.

From 1992 to 2003, the number of Canadian medical students choosing family medicine as a career fell from 44 percent to 25 percent, rising slightly, to 28 percent by 2005.

Extensive efforts have been made across Canada to promote training and practice in rural settings. Ontario reimburses medical students up to $1,500 per month for participating in a rural elective. These efforts are important. Due to the relatively small number of students from rural areas in medical school, urban students must be exposed to the rewards of rural medicine. Physicians raised in urban settings account for two-thirds of new physicians in rural areas.

This past February, students from each of Canada’s seventeen medical schools met in Toronto to discuss the state of family medicine in Canada. They established a Family Medicine Interest Group at each of their respective schools, with the goal of increasing the number of Canadian medical students choosing family medicine. Similarly, another group of Canadian medical students are creating a National Rural Medicine Student Committee and held their first meeting this April at the Society of Rural Physicians of Canada’s annual conference. The University of Toronto has both an Interest Group in Family Medicine and a Rural Health Initiative, and has delegates on both national committees.

While these efforts are encouraging, what is really needed is further primary care reform in order to compensate family physicians and rural physicians adequately. As long as there is a significant pay discrepancy between specialists and family physicians, the shortage of family physicians in Canada will continue.

Canadians deserve access to family physicians. We must continue to encourage federal and provincial governments as well as Health Canada policy-makers to address this fundamental issue.

Jonathan Kerr
Toronto, Ontario

I commend Alastair Brown for discussing the realities of family practice in rural communities, specifically Kinmount, Ontario. As a recently retired physician from neighbouring Minden Hills, I can vouch for the difficulties one meets in such a practice. Patients are often elderly and poor. Communities tend to lack public transportation, which would make follow-up visits easier and more affordable—patients commonly suffer from multiple chronic illnesses. Dr. Mihu and her colleagues nevertheless carry on with great skill and empathy under these conditions.