Specialists’ care and the needs of the north

Rheumatologist Dr. Saara Rawn and psychiatrist Dr. Jack Haggarty discuss the need for more specialists in the north, how the shortage is impacting patients and what it will take to get them there.

Transcript

Spotlight on Health – Specialists' Care and the Needs of the North

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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.

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Balogiannis: In this second episode of a two-part series, Northern Ontario Doctor Saara Rawn, a rheumatologist, and Jack Haggerty, a psychiatrist, discuss the need for more specialists in the North and the incentives to get them there.

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Dr. Saara Rawn: I'm originally from Bruce Mines, which is about 45 minutes away from Sault Ste. Marie. I had always intended to come back, and so I'm happy that I was able to open a practice here; I'm happy with my decision to practice in Sault Ste. Marie, the patients are very grateful by and large. Right now, Sault Ste. Marie is the mecca for rheumatology in Northern Ontario because we have two and then plus a visiting rheumatologist who's been coming up for decades.

There's supposed to be one rheumatologist per 70,000 population. Outside of the GTA, there's a huge crisis because there's not enough rheumatologists anywhere, and it got to the point where I was getting 40 urgent consults plus regular consults a day, which is not sustainable. I see about seven new consults a day and that backlog was too large. Both of us, our waitlist is almost a year.

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Dr. Rawn: I think our overall burden is higher than the rest of the province for a few reasons. So, you have higher amounts of inflammatory arthritis in the Indigenous community. We're having a big influx of people retiring here, because it's cheaper, and so you have a lot of more elderly patients with comorbidities who already have inflammatory conditions.

In the Sault, another major gap is they don't have a chronic pain service. We're already at the point where it's critical. A ton of people in the North are not getting the care they need. I had a patient today tell me that they feel that care in the North is like living in a third world country. There's so much waiting, there are certain services that are just not available and you have to travel and not everybody can travel.

I've expanded my scope to realise that there's only a finite amount of time in the day and that if I want to improve the care in the North, it's not just seeing the population that's in front of me.

We're trying to set up a model for Manitoulin and Sudbury’s surrounding area where you have four rheumatologists who work with nurse practitioners on the ground. We recognize that it takes many, many years to train a rheumatologist and then there's only a certain percentage that actually leave the GTA. So, we have to look at these alternate models of care in order to provide better care for the North.

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Dr. Rawn: There is a dichotomy in care. There is a ton of need. We definitely need more physicians and specialists. If you have people who grew up in the North, have family in the North, have ties to the North or, like, remote rural communities, you have a greater success of having those people choose to practice in the North.

If we could expand the number of internal medicine training spots as well. So, at least getting them into the system, aware of the huge need and the appreciation, but also aware of all the perks that Northern Ontario has.

A lot of jobs are now virtual and you don't have to come into the workplace. I think we have to tap into that a little bit. And we do have flights and you can travel around the world from here. You can still own a house and you can afford to live. We need you.

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Dr. Jack Haggerty: I did five years of family medicine and actually came to Thunder Bay in the early 90s. I remember as a resident thinking, forget cardiology, this is where the underserved population is existing, you know? Psychiatry was certainly an area of not only unmet need, but untapped — and in Northern Ontario is a fascinating field. So, it's been a wonderful 24 years of a career here and challenging, certainly, but certainly the rewards have more than made up for any of the challenges of the work here.

So, our work is always precarious. I think our service numbers, while they have improved, the expectations of care have really significantly changed. Mental health and psychiatry is an extension of a broader system. It's the nurse, the nurse practitioner, the social worker, the community elder that has knowledge and respect for both the traditional knowledge of an Indigenous skill and practises as well as the value of when does Western medications for psychosis offer value.

And that kind of bridging really gets impossible in some communities. Luckily, we have a tremendous primary care system. And you got to give credit to the family physicians that are comfortable with serious and troubling addictions and mental health.

They're fantastic partners to work with, and a lot of very dedicated people. But there's a limit to that without that additional professional group of the counsellors, social workers, case management workers. So, I think that's probably a part of our system that's certainly most evident in mental health, in part because it's diffused within our communities. Right. Mental health does not bypass any household. I think the extension of that work is really critical to not ignore.

Where we, I think, we fall down is the elective assessments. Historically, psychiatrists have had three to six-month waits of assessment of a patient who's not urgently in need. But boy, it's a real challenge to shorten access, because people want individuals seen quickly. I certainly think the unspoken gaps are the counselling, the community delivery, and the coordination at that level, I think, is often a forgotten part of the service mandate.

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Dr. Haggerty: We are going from 2.4 down to 1.4 child psychiatrists in an area that services a quarter of a million people the size of France. Well, does that sound fair? We essentially have had one to two child psychiatrists for — mostly one — for most of my career that I've been here. We're used to having one child psychiatrist in an area where there should be five or six.

We have had limited access to a psychiatrist with additional addictions training. When you have one and you lose one, you lose 100 percent. We are having deaths, we — we had 14 deaths within the previous month from opioid overdoses.

We are carrying a substantial burden in our community. If you're always managing a stovetop that's between eight and 10 on, temperature-wise, sometimes you don't catch up. And I think these kinds of, you know, hot button issues strain the system and the opioid crises is uniquely concentrated in our population.

So, we have challenges ahead. We have probably 50 to 60 percent of our group within the next five to seven years would be eligible to retire.

We're still short 20 psychiatrists in Northern Ontario. Most trainees in psychiatry tend to be urban, because the largest programs are in urban Ontario or in Canada, so to move to a place in which they've never been, to move to a place in which they may not have the familiar accoutrements, that's one part of it.

The training sites are now being more distributed, so the North Bay, Sault Ste. Marie, Thunder Bay, and we're hoping soon again Sudbury will be a trainee site. So, we're optimistic on recruitment, but there has continued to be a shortage in both depth and breadth of services.

And we've also recently lost to retirement, as well as relocation, five psychiatrists in the last two months, and seven within the last year. Well, when you lose seven and, and you only start off with 22 to 25, that's a significant effect on your service planning.

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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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