In the aftermath of the First World War, an American trio (Donaldson, Young and Lewis) wrote a hit song bemoaning the out-migration of large numbers of returning veterans, many of them young farmers, from their rural homes to the ‘big’ cities. It posited the age-old question: “How ya goin’ to keep them down on the farm after they’ve seen Paree?” This question continues to confound rural areas world-wide, and today can be asked of health care professionals, especially physicians.
Prince Edward Island is not immune to this phenomenon, as reflected in the shortage of physicians in its rural communities. Unlike many other provinces, P.E.I. is small enough to do something about it. I am tired of people continually complaining about our rural health care, or lack thereof, but offering no practical solutions to the problem. I don’t claim to have all the answers, but after spending nearly 50 years in the health care system, I have some suggestions.
Physician recruitment and retention are two facets of the same challenge. First you have to find potential candidates, then you have to convince them to relocate to where you have the greatest need and for which they seem to be reasonably suited. Next you have to facilitate the licensing process, then you have to keep them long enough to justify the cost of your efforts. Sounds pretty straight forward, doesn’t it?
Alas, the devil is in the details. Experience suggests that physicians who have grown up in rural communities are more likely to return to and remain there than those who have lived most of their lives in urban environments. This doesn’t apply as much to immigrating international physicians who are seduced by economic opportunity and understand that spending time in rural Canada is the price they must pay to qualify for a permanent license, usually before moving on to a more urban setting. Unfortunately, most medical schools in Canada are located in larger cities, and most of the medical students’ role models are urban physicians. Attempts to establish medical schools in more isolated areas have met with mixed success.
The painful reality is that the average Canadian medical trainee accumulates a crippling debt load and feels a great deal of pressure to get out from under it. This financial pressure is often compounded by the acquisition of a spouse, partner and children along the way. Therefore, it shouldn’t come as a surprise that many graduating physicians prioritize lifestyle when it comes to picking a specialty career, and that their final choice is less and less often family practice. Even well-established urban family physicians are finding it more difficult to make a living as younger colleagues continue to shun rural practice and elect to compete with them for a relatively fixed supply of patients. I don’t expect that dynamic to change any time in the foreseeable future.
If we are going to provide reasonable medical care to relatively isolated populations, change is essential and a whole bunch of players, including patients, will need to cooperate. Startup costs will be significant and will be shouldered by the populace, probably through additional taxation. We only have limited ways to convince physicians to work in rural P.E.I., either we grow our own and contract with them to work in rural communities or we compete with the rest of the world for a diminishing supply of primary care physicians. The latter is a chump’s game which we will lose in the long run. Besides, it seems immoral to lure a scarce resource from another location where the need is just as great and the investment equally high. Identifying promising local candidates who might become doctors must begin in high school, where they start making career decisions.
Desmond Colohan, MD is a retired physician, former chief coroner for P.E.I. and a former medical director with Health P.E.I. with a keen interest in responsible public health policy.