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From Education to Sustainability:
A blueprint for addressing physician recruitment and retention in rural and remote Ontario

December, 1998

Demographic Overview

The paper starts with a description of the continuing attrition of rural physicians in Ontario of 10% since 1994. Furthermore there is an acute need for widely trained general surgeons and other rural specialists.

Solutions

Medical Education:

Sustainablity of human resources for rural medical practice will be achieved when medicine attracts a sufficient number of individuals who:

• find rural lifestyles enjoyable and desirable
• find rural medical practice exciting and fulfilling
• find training for rural medical practice available, appropriate and respected

To this end the following recommendations:

• rural high school students be encouraged to apply to medical school
• medical school admissions should be based on national health work force targets and possibly separate rural admission streams
• each university should have a "office of rural medicine" to coordinate rural medical school activity
• all medical students should have access to funded 4
• 6 week rural electives
• undergraduate return to service agreements should be reintroduced
• a minimum of 30% of family medicine training positions be dedicated to rural streaming
• a rural stream for general surgery, obstetrics, pediatrics, internal medicine and psychiatry be established
• rural faculty need a viable academic career path
• competency based programs in advanced skills in anesthesia, surgery, and obstetrics be funded in sufficient numbers to meet projected needs
• reentry training for advanced skills and specialty residencies should be available at salaries commensurate with experience.
• learner driven rural CME needs to be funded

Rural Practice issues

• telemedicine should not take precedence over providing adequate training and support for rural physician
• telephone triage should be coordinated through the local hospital
• fee for service should remain as an option for physicians with rural fee codes and modifiers
• when requested by physicians salary and capitation models should be made available based on a doctor population ratio of 1:862 subject to adjustment for community and physician needs
• Alternate payment plans must reflect and reward clinical work including inpatients, night call, administration, teaching and advanced skill roles.
• rural specialists also require support including "block" remuneration for call
• back before burnout and retirement options need to be made available
• after 25 years service rural physicians should not be required to take overnight call
• family concerns should preclude rural physicians from providing on call more than one night in five.
• spouses and family should be included in medical school and residency placements
• a rural medical family support network should be funded
• generous funded locum positions for rural physicians should be established.

Infrastructure

• six community development officers be established to cover all rural regions
• the "underserviced area program" be replaced with an "Rural and Remote Areas Program" with the mandate to support and recruit an adequate and equitable number of appropriately trained and skilled physicians to provide accessible and quality medical care to all rural residents.
• a rurality index or series of indexes be established to allow for incentives and programs to be applied without "boundary issues" to the spectrum of rural and remote medicine.
  
  "Medical school admission procedures should be based on institutional mission and capacity, and national health work force targets.  The open entry system is obsolete"
  Edinburough declaration of the World Rural Health Conference

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