Authors' objectives:

This investigative report profiles the rural and northern communities of the Province and the physicians who work there. The data in this study cover the period from 1992/93-2001/02, although most time trend comparisons focus on 1996/97 and 2001/02. This report provides a variety of perspectives about the physicians including their location of training, demographic profile and overall numbers in relation to the population they are serving. The report also documents different government policies used to influence physician recruitment and retention during the study period.

The report offers several new approaches to the study of Health Human Resources (HHR) and rural issues. It offers a definition of "rural" based on number and type of physician rather than traditional measures such as population size or geographic distance. The report applies a new measurement tool for assessing workforce stability called the "turnover index". Finally, it defines community catchment areas based on utilization of Emergency Department (ED) services.

Authors' results and conclusions: Key findings This report identifies almost 100 rural communities with hospitals and an even greater number of small affiliated towns. These communities have diverse population sizes and are located throughout the Province at varying distances from their nearest urban centres. The communities in the North were typically the most isolated and at a much greater distance from the next level of care (e.g., tertiary care). Rural economies had a heavy reliance on natural resource use with forestry and mining activities common in northern areas and agricultural-related industry in southern areas. In 2001/02, the 14% of Ontario general practitioners and family physicians (GP/FPs) and 2.5% of Ontario specialists who were practising in rural areas cared for almost 20% of the Ontario population. Most of these rural GP/FPs and specialists lived in the southern parts of the Province. Urban areas had a higher number of physicians per 100,000 population in both 1996/97 and 2001/02 for both family physicians and specialists. However, northern rural areas had higher physician to population ratios than southern rural areas, and the ratio in the north rose significantly between 1996/97 and 2001/02 to almost reach parity with urban areas. Rural GP/FPs were more likely to be less than five years in practice, while their urban counterparts were more likely to be female and trained outside of Canada. Among rural family physicians, those in the Northwestern Ontario District Health Council (DHC) area were much more likely to be more recent graduates and female. A greater proportion of rural specialists had been in practice more than 30 years compared to all other settings. Rural areas had the highest levels of turnover compared to all other settings for both specialists and GP/FPs. This was true for the periods 1993-1996 and 1997-2001. Two of the northern DHC areas (Northwestern Ontario and Algoma-Cochrane-Manitoulin-Sudbury) had the highest consistent rates of turnover among all DHCs. This speaks to the relative instability of the physician workforce in these areas. Physicians showed a preference for practising near the location of their medical school training. The southwestern part of the Province that does not have a medical school relied heavily on international medical graduates (IMGs), particularly for rural specialists, while the northern areas drew heavily on those graduating from medical schools outside of Ontario. Among Ontario medical schools, the University of Toronto trained approximately twice as many rural physicians than any of the other four schools - a finding that may relate to the historically larger class size of the Toronto school. These patterns occurred in the context of numerous government policies aimed at improving the recruitment and retention of physicians to rural, and particularly northern rural, areas. Representing an investment of millions of dollars, these programs fall loosely into four categories: alternative models of care; promotion of rural/northern medicine; financial incentives or disincentives; and, educational programs for future physicians.

Authors' recommendations: Implications 1. The rural South is facing greater challenges than the rural North. While the physician to population ratio for GP/FPs in the North is approaching that of urban centres, the ratio for rural communities in the south lags well behind. Policymakers may want to consider extending some of the recruitment tools traditionally available in the north into other rural areas of clear need. This needs to be done while recognizing the historically greater challenges of physician supply in the north. 2. Location of training is important. This study confirms that medical school location is strongly related to practice location, albeit more for rural GP/FPs than for rural specialists. This suggests that recent policy decisions to establish the Northern Ontario School of Medicine and a Windsor campus of the University of Western Ontario may help improve rural GP/FP supply in those regions of the Province. 3. Uniqueness of the large northern centres. The five large northern centres play an important role in northern health care delivery. The vast majority of the northern specialist physician population is located there. Also, these communities have profiles (demographic, turnover levels, physician to population ratios) that are typically different from both urban and rural communities. While not eligible for many of the targeted rural programs, issues such as their geographic location and broader clinical scope can lead to problems with physician recruitment and retention. Programs specifically addressing these five centres, with enough flexibility to reflect the differences among them, may be helpful. 4. Physician workforce strategies. There has been a wide range of initiatives. However, the fact that many of these are focused more on recruitment than on retention may be contributing to higher turnover rates in northern and rural communities. More research needs to be done to identify ways of reducing turnover. 5. Role of IMGs. The evidence in this study suggests that rural communities have had some success in attracting specialist IMGs. If policymakers want to increase rural specialist supply, then one important source could be IMGs. However, IMGs are a relatively less important source for rural GP/FP supply. To increase the supply of GP/FPs, policymakers may wish to consider other means, such as providing more domestic training of rural physicians. Alternatively, policymakers could make changes to existing IMG entry programs to better tailor them to bringing IMGs to rural areas. 6. Rural specialists are diminishing in numbers. The number of rural specialists is small and declining. Furthermore, rural specialists tend to be older and many are approaching retirement age. If this trend continues, then the model of care that provides rural physicians with local access to specialist back-up may gradually disappear. Policymakers may allow this trend to continue and expect local residents to travel to larger centres or try to provide resources locally through innovations such as telemedicine. To reverse the current trend, policymakers may either aim to bring in more IMGs to rural areas as noted above, or develop other policies such as training specialists for, and in, rural areas. 7. Role of alternate payment models for primary care. The increase in the numbers of both young and female family physicians in areas where new alternate payment models have been introduced suggests that these new models of remuneration may be important recruitment tools. Governments should consider expanding these successful models to other rural areas. 8. New tools for HHR research. This report offers researchers new approaches for the collection of needed data, including an HHR based definition of rural, a measure of workforce stability called the "turnover index", and a definition of catchment population utilizing local ED services. 9. Future directions. Future research should consider the issue of recruitment and retention of providers other than physicians, such as nurses, nurse practitioners, and health therapists and other allied health professionals. HHR research, rural and otherwise, should incorporate the calculation of full-time equivalency and scope of practice.

Authors' methods: Overview

Project Status: Completed

URL for project: http://www.ices.on.ca/file/Physician_Services_in_Rural_and_Northern_Ontario.pdf

Year Published: 2006

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Institute for Clinical Evaluative Sciences

Contact Address: Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, G-Wing, Toronto ON, Canada, M5N 3M5. Tel: 416-480-4055; Fax: 416-480-6048

Contact Name: info@ices.on.ca

Contact Email: info@ices.on.ca

Copyright: Institute for Clinical Evaluative Sciences (ICES)