The battles and benefits of northern health care

Three northern Ontario physicians – Dr. Stephen Cooper, Dr. Sarah Newbery and Dr. Stephen Viherjoki – discuss the challenges, pitfalls and beauty of working and living in rural and remote areas of the province. They share their solutions to improve the lives and health of their patients.

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Spotlight on Health – Battles and Benefits of Northern Health Care

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Georgia Balogiannis: In this podcast the Ontario Medical Association looks at current issues of interest in health care. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association.

In this first episode of a two-part series, Dr. Steven Cooper, Dr. Sarah Newberry and Dr. Steven Viherjoki discuss the health care challenges they face practicing medicine in rural and remote areas in Northern Ontario.

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Dr. Steven Cooper: I live in an outdoor paradise, right? I mean, I just can't believe we don't have physicians banging at the door. And those ones that come here, I mean, and settled down here, are like “I can't believe my good luck at living here.” That natural beauty was very attractive. There's no traffic, there's no traffic lights, there's just nature, right? It doesn't feel like a hardship.

I didn't come here because of the indigenous medicine, but it certainly added a great deal of interest to the community. It's a different culture, it's a different way of looking at the world, and so I've learned a lot from my indigenous patients and my indigenous colleagues about a different approach to life.

Well, when you think about practicing rural practice, one of the neat things about it is it really — all those things you learn in medical school are not wasted. You use them every day. So, I get to spend time on the floor, managing patients on the floor, which is interesting, and then the remainder of the practice is emergency medicine. It's not emergency medicine like it would be at Sunnybrook — not that kind of urgency. Most of them were sort of walk-in type patients, so you'd see in a typical walk-in clinics, but you have time to talk to the patient, listen to them. I find that that combination of primary care and hospital care is what attracts me to the rural practice.

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Dr. Cooper: The North is absolutely underserviced as far as physicians go. And one of the problems you have in a rural practice is, if you lose a physician for any reason and you become short, it becomes much less attractive because nobody wants to come and work in a practice that people are working double time. I think communities get into these sort of terrible vortexes where you lose one and then suddenly you lose two and then nobody wants to come and move in your community because it's a dysfunctional community from a clinical perspective.

The biggest thing is there's no specialists here, and there's no special services. I don't have the opportunity to develop those close relationships with specialists, and I think that would have made me a stronger clinician to have that chance to work with them closely.

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Dr. Cooper: You want a regular physician living in that community that can be part of those communities. Balance between having that personal connection with the community, caring deeply about the community and being part of the community, and understanding the community – we don't want to lose that. So, we need the physicians living in the community but we need to have the support in those areas where having that expertise makes a difference for the patient.

The geographical distances in the North make it uniquely difficult to retain and attract physicians into those communities. And you need a special person that — that wants to go down there.

I wish we had a couple of indigenous physicians living in our community working with us because I think that perspective — that I can never provide — is missing. I think we need to think a little bit harder about how we can do that to make it more attractive to physicians.

If I can do it over again, I don't think I, I — there's not much I'd change. If I was counselling somebody who has a little bit of adventure and wants to have a — a unique experience as a physician and really experience what I think the full what you can be as a doctor, I would encourage them to consider a career in rural practice. You're not going to get that anywhere else, kind of experiences that you have here. And the friendships and the camaraderie among the physicians is fantastic. So, there are many physicians out there who would very much benefit from that kind of experience.

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Dr. Sarah Newberry: My husband and I wanted to go to a rural northern place. And at the time Marathon was funded for four physicians, but they were about to be down to one physician. We came to Marathon on our site visit, and we were met by the physician recruitment committee, and we were shown a stack of burlap sacks and we were told that those were the burlap sacks that would be going over the blue "H" signs on the highway should we not choose to come to Marathon because they actually anticipated not being able to keep the hospital open.

So, I think like many rural communities, our practice is what we would describe as a comprehensive rural generalist practice. The expectation is that we all have a practice within our primary care practice; that we all follow our own inpatients when our patients are hospitalized in our 10-bed hospital; that we all participate in the emergency shift rosters.

An additional part of our time has been seeing patients from our shared practice who have COVID-related symptoms and need to be assessed. We are all expected to go on transports if we have people who are critically ill or injured and we can't access the appropriate level of paramedics, or if Ornge isn't able to come and we need to send patients by land, then we participate in transport medicine as well.

We have transfers out almost every day, because we're 300 kilometres from our nearest tertiary centre. Even for people who have to go out for CT scans, MRIs —if there’re in-patients who require that, they often have to go with a health care provider. Typically, they go with nurses, but occasionally we have to delay transfers because we don't have the staff. Most of the transfers that physicians attend are traumas, critically ill patients, or obstetrical patients who need to be transferred in labour. That's 300 kilometres away to be seen in hospital or by specialists in Thunder Bay.

Rural communities are realistic in our expectations, we'll never do cardiac surgery here, we're not going to have an angiogram angioplasty program. But I think communities should expect adequate access to rural generalists who have the time and the capacity to be able to provide excellent care within the limitations of the resources of that community.

Simplicity, I think, is a huge advantage to rural practice. When we are working at that top end of our scope, and have the time to do that well, it's deeply satisfying work. But the geographic challenge of distance to diagnostic imaging and specialty services? That's a — another layer of complexity to the work that we do that is a challenge.

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Dr. Newberry: The number of communities now facing challenges with recruitment and retention of physicians is greater than it was even in 2017, when we identified that this was a growing challenge. When we look broadly across the North at the need for physicians, things are worse than they were because the magnitude of the work that we're asking that small group of physicians to do is becoming quite unbearable. And for some physicians, they are not seeing a way out except to leave the community, that it's just becoming increasingly unsustainable.

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Dr. Steven Viherjoki: I wanted to be a doctor since I was knee high, and I'm six-foot-six now. Basically, it was my plan my whole life. I'm a big outdoors person and hunting and fishing are part of my life, and I live on a beautiful house on a lake with a great view. I wanted to be able to move around, do procedures, and it's harder in a big centre.

Not everyone is comfortable having very little clinical backup, so if you are in a emergency room as a family doctor, if you're the kind of person who needs surgeons and specialists and specialist anaesthesia, or respiratory therapists, you can't come here. This is a place where you have to have clinical courage, you have to be willing to do things that are on the edge of a scope or push yourself beyond the average boundaries of the type of practice that we do. You don't have a choice — patients are going to suffer otherwise.

And then there's transport issues. So, we have issues getting patients to us and our patients to other doctors. Bad weather, bad roads — do you want to send someone to a specialist in Thunder Bay where the — the drive there might be more dangerous than the condition that you're sending them for? So, we consider those things.

We're chronically understaffed and chronically maximally utilized. So, we really are on the edge of a cliff all of the time. If one person leaves unexpectedly and we can't recruit soon enough, the whole group suffers and then we're at risk of losing multiple people to burnout or being unwell. We're hundreds of jobs short in the region, so we're barely keeping up with retirements.

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Dr. Viherjoki: This is not an easy adjustment. This is a different kind of world. The lifestyle is very different. You need a partner or you need family or you need a really strong love of hunting or fishing or something outside here. You're not going to the theatre. You're not going to fancy restaurants. That's not happening here.

I think it's going to be some combination of incentives. I think it's going to be development of local models of responsibility where we can put resources and dollars to local needs. We need to be able to make priority decisions locally. And then we also have to develop pipelines of care to get to the specialists in Thunder Bay and then to sub-specialists down south if we need them. I think we need to have specific programs designed to support rural generalism and to reflect the fact that generalist rural practice is different than family medicine elsewhere in the province.

We don't need huge amounts of new equipment, what we need is to be able to have more of us to provide the care to the people we need. Until we get rural generalism

better supported, until we have more graduates, until we solve that transport issue, I don't think we can get to that — that whole piece.

The key for us is keen bodies who want to live here. I think it all — it all rolls down to that, and once that happens then the lifestyle works itself out, the transport issues become less bothersome because now you're going to spread that load among more physicians. Burnout goes away because you can take time and not suffer from taking time away from your practice. It's kind of the linchpin. We have to sort out all those different little pieces, but the main goal has to be the bodies.

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Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.

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