"As they trickle in, they trickie out": Recruiting Physicians in h a 1 Ontario

The Department

Sociology and Anthropotogy

Presented in Partial Fu(filme11t of the Requirements

for the Degree of Master of Arts

Concordia University

Montre& Quebec, Canada

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ABSTRACT

"As they trickle in, they tnckle out": Recruiting Physicians in Rural Ontario

J e d e r Ann Perzow

This exploratory study examines the recniitment of rural physicians in Ontario, Canada.

Ernphasis is on the social context Ui which practice location decisions are made, with four

Spheres of Consideration playing a dominant role: &ancial, personal and sociai,

professionai, and educationai. Eleven physicians and medical students were interviewed

regarding the basis for their decisions to practice in mai areas. Their responses were

compared to the major issues regarding recniitment found in the research fiterature. From

a financiai point of view, respondents mentioned the importance of student debt loads and

goverment incentive programs for rural placement. Personal and socid considerations

inchide the special relations between physicians, their niral clients and neighbours, as

weU as their partnedspouse and chilcirea. Professional concerns included the

legitimation of rural practice and more specificaüy, making rurai medicine a specidty.

Educatiod concems refmed to the need for exposure to d issues and conditions in

medicd school. The thesis underscores the specîai characteristics of niral practice and the

Unportance of specinc training directed to its apport. Recommendations for rt.uai

comrrnmities, goveraments, and the medical community are hcluded.

iii

The preparation of a thesis involves a paradoxical process - it is at once a highly

individual process and a community effort. Researching and wnting is a solitary (and

o h isolating) endeavour. Yet the most rewarding aspect of thk process is the

development of original ideas and hypotheses, a process which c a m t suNive without

the input and dedication of the community surroundhg the author. It is to this community

that 1 extmd my profound gratitude and appreciation.

First and foremost, I must th& the members of my cornmittee for providing me

with constant support and inughtful commentaries on my work: 1 am profouncüy grateful

t O my supervisor, Dr. Bili Reimer, whose enthusiasm, p rofessionalism, mentorship, and

tireiess dedication to my work aad academic training have fomed the foundation of my

graduate experience; Dr. Patrice Leclerc whose academic clarity and dedication have

been a constant source of strength and support, and Dr. Neil Gerlach whose thoughtful

consideration and contimied optimism were invaluable. 1 am aiso deeply appreciative for

the guidance and comraderie of the fa cul^ and staff ofthe Department of Sociology and

Anthropology.

This work would not have been possie without the generous assistance ofmy

respondents, to whom 1 extend m . thanks. In addition, 1 wodd iïke to thank Dr. Patty

Vann and the SocÏety ofRural Physiuans for assisting me in reuuituig respondents for

my study.

Thaaks must ais0 go to my dear fiends aad colleagues for oE&g academic and

emotionai support thioughout this process: Jane LeBrun, Kim Matthews, Anna

Woodrow, Hasan Alam, Lyle Robinson, Stephanie Kalisky, Shannon Breedoq LU:

Lautard, and Tom Saldanha. On a more personal note, 1 rnust also thank my family (The

Perzows, Yachnias, Rabhovitches, Jacksons, Rudds, and Doughertys) for loving and

supporting me in aii possible ways before, during, and after this incredible adventure.

Lady, 1 thank my husband and partner Joshua Dougherty, whose love and support has

known no limits and whose belief in me is the cornerstone of ail that 1 endeavow to

undertake.

TABLE OF CONTENTS

1 . Introcfuction

1.1 Contextuhtion of the area of inquiry .......................................... 1

............................................................. 1.2 Theoretical Framework 7

................................................ 1.3 Statement of Research Questions - 8

........................................................................ 1.4 Expectations -9

1.5 Statement ofPurpose ............................................................... 10

1.6 How and why I decided to investigate this subject ............................. I 1

1.7 Defining'Rura17 ................................................................... 1 1

2 . Theoretical Framework

...................................................................... Introduction. -13

........................................................ Spheres of Consideration -16

............................................. Financial Sphere of Consideratio a 22

............................................................. 2.3. I Remuneration 22

....................................................... 2.3.2 Incentive Packages 23

2.3.3 Student Debt .............................................................. 25

.............................................. 2.3.4 Tuition Fees... ........... ... 26

.............................. Personal and Social Sphere of Consideration 27

................................................. 2.4.1 Personal Considerations 28

2.42 Social

Professional

Educational

................................................... Considerations -29

...................................... Sphere of Consideratio e 3 1

Sphere of Consideration.. ......... .. .......................... -34

3 . Methodology

................................................................ 3.1 Research Design -37

3 2 Research Methods ................................................................ -39

................................................................. 3 -3 SampIe Selection -42

........................................................ 3 -4 Cimitations of this study 44

4 . Findhgs and Discussion

4.1 Ficial Sphere of Consideration .............................................. 48

............................................................ 4.1.1 Remuneration. 49

................................. 4.1.2 Financiai Incentives and Student Debt 50

.................................... 4.2. Personal and Social S phere of Consideration 56

................................................. 4.2.1 Personal Considerations 57

................................................... 4.2.2 Social Considerations -60

............................................. 4.3 : Professional Sphere of Consideration 64

.................... 4.3.1 The Doctor-Patient Relationslip in a Rural Setting 64

..................................... 4.3.2 The Broad Scope of Rural Practice 67

................................ 4.3.3 Less Support and More Responsibility 71

............................................ 4.4. Educational S phere of Consideratio a. -73

.................................................................. 4.4.1 Exposure 73

4.4.2 The Profle of Rural Medicine in Medicai School .............,... 77 . * .................................................................... 4.4.3 Trauung 78

................... 4.4.4 Accessibility of Medicd School to Rural Students 81

....................................................... 4.4.5 Early Career Decision Making -82

5 . Recommendations and Conctusions

............................................ F i c i a l Sphere of Consideratio n.. 84

.............................................................. 5 1 Conciusions -84 .. . 5 1.2 Recornmendations for Rurd Commuriltres ..........................es. 87

....* *..........-............ 5 . I -3 Recommendations for Governments ,.... -88

5.1.4 Recommendations for the Medical Corn- ....................... 88

5-1-5 Indications for Further Researcfi ...................................... 88

...................................... PersonaVS ocia Sphere of Consideration 89

5.2.1 Conclusions ............................................................... 89

5.2.2 Recommendations for Rurai Communities ........................... -90

5 .2.3 Recommeodations for Govemments .................................. -90

5.2.4 Recommendations for the Medical Community ....................... 91

5.2.5 Indications for Further Research ...................................... 91

5.3 Professional S phere of Consideratio a. ....................................... -92

5.3.1 Conclusions ............................................................... 92

5.3 . 2 Recommendations for Rural Communities ................ .. ......... -93

................................. 5.3.3 Recommendations for Governments 9 3

5.3.4 Recommendations for the Medical CommUnity ....................... 94

....................................... 5.3.5 ludications for Further Research 95

.......................................... 5.4 Educationai Sphere of Consideratio n. 96

.............................................................. 5.4.1 Conclusions -96

............................ 5.4.2 Recommendations for Rural Communities 97

................................... 5.4.3 Recommendations for Governments 98

....................... 5.4.4 Recommendations for the Medicai Community 98

5.4.5 Indications for Further Researc h ...................................... -98

........................................................................................... References 101

.......................................................................................... Appendix A 112

viii

UST OF TABLES

Table One - Respondent Profles.. . . . . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . . . . . . . . . . . - . . - . - . . . . . . . . . - . . . .43

Cbapter One: Introduction

1.1 Conterhiaiiition of the ana of inqairy

Heakh care in nual Canada is in crisis. Physicians worhg in rural and remote

parts of the country often are overworked and feel underappreciated. As a resuit, many

niral communities are unable to attract and keep physicians and health care in these areas

is not sustainable (OReilIy, 1994).

A great deal of Canadian research and literature eists on airnost every aspect of

heaith: biological, social, emotionai, and spiritual. Howwer, until recently, nval heaith

care has occupied a peripheral position in Canadian medical sociology that mirrors the

marginaiization of rural health care within Canada's medical community. Despite the fact

that Canada's geography is 90% nirai and one-thûd of Canadians live in mal areas, very

Iittle is known outside of the medicai community about the stnrggies and challenges of

Canadian rural heaith care. Furthemore, ody 1 1% of Canadian physicians practice

outside of urban centres (Rourke, 1993) and there are less than half the proportion of

physicians in mal areas as k e are in urban areas @er 1000 population) (Statistics

Canada, 1999). According to the Canadian Medcal Association two problems reiating to

the la& of physicians are: 1) there simply are not enough doctors working in Canada

ri@ now with physician shortages in both d and mban areas 2) there is a

maidistiibutîon ofdoctors who are working here (CMA Task Force, 1999).

As with &an health care, a thorough mtmhction to niral heaith care is time

consuming. The realities of Canadian heaith m e reflect the "interlocking set of ten

provincial and two tenitonail heaith insunince pians" (Health Canada, 1997) that form

what Canadians know as Medicare. This thesis seeks to introduce rural Canadian health

in broad strokes by fonising on one of the largest probtems in rural heakh care: reczuithg

physicians. Whiie the physician is one part ofa health care system, she undoubtedly is

the centrai force in a Western medical mode[.

Reauiting physicians can be chdenging for numerous reasons. However, the

struggie to obtain sustainable heaith care does not end when comruunities recniit

physicians. The next problem with which they are ofien codkonted is that physicians do

not stay in rural areas. For this reason, I had initially intended to focus rny attention on

the retention of nuai physicians. I was unable to do so due to diflicuities in findulg

practicing rural physicians who were willing snd able to participate in this study. In part,

1 was subject to the end resuit ofthe trend that I endeavoured to imrestigate: rurd

physicians are overworked. Retention is an important issue, worthy of study of its own

accord.

lThe creation of an additional temtory d e d Nunam in 1999, has increased the total d e r ofterritorid heaith insurance pians to three.

Physicians practicing in nual communities feel f'nistrated and powerless. They see

a dedine in the pal i ty of rural health care and have littie control over its fate. Rural

commmities have trouble recruiting and retaining docton because ofthe heavy

workload, long hours on-cd, professional isolation, general lifestyle choices, and

because ofthe lack of appropriate recognition that nirai practice gets nom mainsueam,

urban medicine. These problems lead to a high rate of burnout among nual doaors and

consequently high turnover rates in rural communities (SRPC, 1997; OReilly, 1994).

In consideration of the professional and personai isolation, the demanding

worWoad and the lack of teaching about rurai medicine in medicai schools, it is easy to

see why rural commhties oRen have such dif]Eiculty reCIUiting and retaining physicians.

But what is being done about it? Federal and provincial governments have responded to

rural comrmLaities in different ways, but it is the communities themselves and non-

partisan medicai associations that have generated the most positive movement towards an

end to this crisis.

In an effort to combat the problem of niral recruitment and retention, both the

federd and provincial governments have designed programs and imrested a substantiai

amont of money in nual health care. The 1999 Federal Budget aliocated SSOmillion

towards rurai and community health2 (HeaIth Canada, 1999). The Ontario Ministry of

%e Budget did not indicate how the moaey wodd be divided between 'niral' and 'comrmmity.

He& has imrested more than $83 million in rural and Northem health in the province,

close to 80% of which is directed to the recruitment and retention of physicians (Ontario

Ministry of Heaih, 1997: 2). In 1998, Canada's Heaith Minister Man Rock announced

the creation of a new brandi of Health Canada whose prhary interest is rurai health. In

creating this'position, Mr. Rock stated that he wants "to eosure that the views and

concems of nual Canadiam are better refiected in health poiicy and in the health systern7'

(Heaith Canada, 1998). Before then, curai health issues had been absent Eom many

National debates on hedth care. The National Forum on Hedth, released in 1996 by

Health Canada, fails even to acknowledge the struggies of rurai health care.

Because specinc health care policies Vary between provinces and territones, there

are tbirteen distinct sets of policies goveming nirai health in this country. In Quebec,

recent medicai graduates are paid ody 70% of the standard fee-for-seniice rate if they

practice in Montred but are paid up to 1 15% of that same standard rate ifthey practice in

a Northem community (Armstrong, 1994: 27). Additional bontxses also are paid to

pbysicians who practice in designated areas. R h c t i n g billing privileges is proving to be

successhi in NOM Scotia, but the Ministry of Hedth in British Columbia was sied for

their 'Thysician Supply Memen which reduced bikg rates for doctors in urban areas

(The House, 1998).

Forcing physicians to work in nual Canada does not address the real problems in

niral health care. Moreover, it jeopardizes the heahh of& c o m m d e s and places

4

bamers between the nual doctor and the commUnay. Often, both the doctor and the

comrrrrmity may know that the doctors are there against their will. The implications of

this forced labour on the qyality of care that patients receive are not yet known.

Medical associations also provide support and seMces to mal doctors and rural

communities. The Ontario Medical Association (OMA) organizes rural lonims, or relief

statt; for physicians wanting to take some t h e off, whether for a vacation or to attend a

conference. Similady, the OMA sponsors Continuhg Medical Education programs that

are specincdy designed for nual practitioners. Wer programmes, designed to attract

recent medical graduates to rural practice often employ the use oflimited term contracts.

Physicians sign a contract for a 1 to 5 year period. In that time they will receive

substantial cash and in-kind bonuses. When these contracts end, however, there is no

guarantee that the physician will stay in the community. Even comrnunities that are able

to reauit physiQans can have d i f i d t y retaining them

The Wodd Organizsltion of Family Doctors (WONCA) has been instrumental in

detailing the troubles of niral medicine and offiring practicai sohrtions. The Organization

recommends that undergraduate medicai training expose students to nual medicine in

order to attract them to niral practice. In th& publication PoIicy on Training for RMal

Practice (1995), the Organization diScusses the key misperceptions of nuai practice.

They state that:

A number of attitudinai and perceptual barriers have been

identitied as discouraging medical graduates from e n t e ~ g

rural practice.. . .The key misp erception is that rurd practice

is somehow 'second class medicine' (4).

In Canada, the recently formed Society ofRurai Physicians ofcanada (SRPC) has,

among other things integrated the WONCA guidehes into the Canadian heaith care

system. Like the WONCq the Society's members feel that "...education is the key to

sohring the problems of recnlltment and retention of nual physicians" (1997: 29)

Medical schools have started to acknowledge niral medicine. Presentiy, most

Canadian medicd schools provide some wposure to rural medicine for students who are

interesteci, and evduations of those pro- have been positive. The Department of

Famiiy Practice at the University of British Columbia (UBC) initiated a niral training

program in 1982 @hiteside and Mathias, 1996: 1 1 14). An evduation of the program

indicated that "graduates of the UBC rurai training program consider themsehres better

prepared for rural practice than non-pro--trained niral physiaans" (Whiteside and

Mathias, 1996: 1 1 13). Moreover, the evabation suggested that spe&c7 structureci

training was indeed heipful in preparing physicians for rural practice and by extension

&O increased the number of new graduates practicing in rurd areas (1 i20).

1.2 Theoretid Framework

It is important to know what draws physicians to nual practice. Without that

information, it is difficuit to find solutions that are meaniapfiii, appropriate and

sustainable. For a sociologist, it is also important to know the social context in which

those decisions are being made because individual dioice is always afEected by extemal

conditions. Each physician has his or her own reasons for choosing mal practice. While

each choice is indeed personal, physicians approach that choice fiom perspectives that are

influenced by thek social expenences. For example, a recent study by Easterbrook et al.

(1999) suggests that doctors who grow up in rural areas are more likely than doctors who

grow up in urban areas to choose and stay in rural practice. This suggests that the person

who grows up in a rural area is used to the social context of rurd Ee. A person of rural

origin is used to knowing many people in town, and having many people know him, is

accustomed to having limited access to shopping facilities and driving long distances to

reach the nearest urban centre. This familiarity prepares physicians of mai origin for the

personai and social aspects ofbeing a rural doctor. That preparedness, in tum, means that

they are likely to choose rural practice. Physicians who grew up in an urban centre are, at

be* less fâdiar with the day to day experience of k g and working in a d area and

are therefore less prepared. Lack of experience or preparatioo ais0 will inauence a

physician's choice of practice location. This is one example of how social context can

~ u e n c e physician recluitment.

1 propose, in Chapter Two, a theoretical framework that accounts for the idluence

of social context. 1 c d that h e w o r k the Spheres of Consideration and 1 suggest that

practice location decisions are being made within those spheres of consideration. The

four spheres of consideration that I use in tbis thesis are: financial, social-emotional,

professional, and educational.

1.3 Statement of Research Questions

Physicians decide whether to practice in an urban or nual Iocation Logic dictates

that asking physicians about their decision will help us identify solutions to the problem

of physician recniitrnent. Asking rurai doctors about recniitment is the first step to

solving the health care crisis in rural Canada My hquiry is two-pronged. On the one

hanci, 1 will be examining the reasons that physicians and medical students clairn are the

determining Eicton in th& choice of practice location Whiie this is a good start, there is

no way to ve* or confinn that the factors that physicians report as being important are

variables when the time to make the decision arrives. Often, in social science research, we

see a discrepancy between people's perceptions and what they actuaüy do. In order to

glean more information fiom this study, 1 propose the second prong in my approach to

the problem I will identay the social and personal conditions in which those respooses

are &en. In condusion, my research questions are: What issues are cited in the literature

regardhg nual physician recruhent and retention? What issues are cited regarding rurai

recniitment and retention by physiciam and medical students? To what extent are these

8

issues congruent and comprehensive? What is a useful fhmework for research mto mal

recnllrment and retention? What is a usehi fhmework for policy suggestions to improve

the present situation of rural recnritment and retention?

Prior research in the field of mal physician recruitment suggests a number of

structural factors that encourage physicians to locate in rural areas. The following factors

are highlighted in the litetature and 1 expect to h d similar factors idenfified by my

respondents. The respondent:

O feels adequately trained for rural practice

- has adequate professional support

- foresees that he or she will be able to integrate Uito the comm~

- is able to address his or her spouse or partnefs happiness

- feels oppormnites for children (education, cultural, extra-CUmcuIar, etc.)

are adequate

receives financiai compensation beyond standard remuneration

bas interest in and aptitude for al life

has professional aspirations that are adeqyately met

1.5 Statemeat of Purpose

R d medicine, Iargely marginalized by both sociology and medicine, has been in

the spotüght recently, due in large part to the efforts and dedication of rurai people. Issues

conceming mai communities are slowly moving nom the rnargin to the centre. With

some exceptions, the sociological cornmunity in Cauada has been slow to respond to this

area of in& which is ripe for sociologicai analysis. More is pubiished about rural

medicine in medical joumals than in sociological joumals. However, nual medicine also

has been marginalized within the rnedicai comrrmnity and the literature suggests it is

often not taken seriously within the urban-based medical community. In this instance, the

urban biases ofboth sociology and medicine have negated the validity and importance of

rural He.

1 begin to fill that void in order to benefit the sociological and medicd

comrmrnities, as well as the niral communities that stniggle to keep doctoa among them.

My hope is that this work will contriiute to the social activist nature of sociology, wilI

suggest that sociology should not remove itselffkom the subjects under its investigation

and witl inspire a diffèrent seme of social responsibility in social scientists in general. 1

dso hope that the medical communiv will take fiom this research some indications

conceming as role in the marginalization of nnal communities and peoples, and seek to

change. Fdy, 1 hope this work wifi inforrn nual comnfltnities and poücy maken about

potentid sohrtiom to the problem ofphysician recniitment m rurai health m e .

10

1.6 How and why 1 decided to investigate this subject

The need for patients to advocate for themeives bas always interested me and in

thinking of how to apply that advocacy concept to communities, I developed an interest

in community health care. While workhg for a national research initiative organked by

the Canadian Rural Revitalkation Foundation (CRRF) enMeci The New Rural Economy:

Options and Choices (ME), I became more C O ~ S ~ ~ O U S of nual stniggies and triumphs.

Over time 1 saw a ctear link between my interest in community hedth care and the

struggies rurai redents were baviog gening and keeping doctors in their communities.

nie NRE has designated thirty-two sites across Canada to participate in a comparative

study about the econornic and social realities in nual Canada. My work with the NRE has

been a superb academic and personal leamhg expenence, and has sustained rny interest

in and desire to as& nuai communities in the creation of sustainable Mth care in theü

cornrnunities. Through my work with CRRF and the NRE, c o m m w heaith care

moved f?om being an abstract, academic constmct to a tangible social quandary affecthg

the Iives of real people.

D e h g mal for the purposes of this study has been a cornplex ta& Fiduig

definitions ofthe word has not been the problem. The OECD indicates that a community

Ïs coosidered 'd c o d t i e s ' if it has a population density of Iess than 150 per square

11

kilometre (OECD, 1994). 1 hve felt unabIe to use such pe&c definitions for two

reasons. First, to do so would be incongruous with the small but growing body of

fiterature studying rurai medicine- This literature does not define rural in a specific

fashion, refietring not ody to mal but to remote. The exact distinction between the two

is rarely made aIthough some distinctions are implied. The second, and more

consecpential reason for not defining mal in a specinc way stems fkom a

methodological concern, that doing so wouid potentially Limit the pool of respondents

who were willing to participate in this study. 1 decided to dow people to sefidefine

mal. The implications of this decision are fiirther discussed in Chapter Threee3

Tor a more comprehensive discussion of denning niml for the purposes of health, and other, research, see Leduc 1997

Chapter Two: Theoreticai Framework

2.1 Introduction

What issues are cited in the literature regarding nuai physician recnlltment and

retention? What issues are cited regarding rural recruitrnent and retention by physicians

and medical students? To what extent are these issues congruent and comprehensive?

What is a usefui fiamework for research into rural recnritment and retention? What is a

usehi fiamework for poky suggestions to improve the present situation of rural

recruitment and retention? In this chapter, I explore the m e r s to these questions

comrnonly found in the titerature, and deveiop and employ a theoreticai mode1 to assist

with this task.

Much of the literature on and discussion around rural physician recniitment e d s

within the medical comrrrrmity. While this is changing, as researchers in the social

sciences and policy rnakers become increasingiy aware and interested in the various

aspects of nual heaith care, there are severai implications of the origins ofthis research

that must be addressed.

1 consider it a positive thing that the research and discussion in this field were

instigated and for the most part deveioped by the research subjects. Rural physiciw have

been speaking out (formally - in academic research and publicatio~~~, and m f o d y - on

13

internet hserves) for many years. It is essentid that physicians' voices be an integral

part of identifying the problems and suggesting some sohitions.

There are several caveats ofwhich we must beware. The first and perhaps most

obvious is that physicians are not the ody cohort imrolved in this problem; niral

cornrminity mernbers are the ones who are not getting the medical care that they need. It

is ultimately on their behalf that one undertakes research in this field - with a hope and

intention to improve the Iives of rurd Canadians. Likewise, nurses and other medicai

personnel are imrolved. Advances c m and do corne fiorn realizing that uitimately medical

personnel (physicians, nurses, and others) and other comrnunity mernbers share common

goals.

Research conducted by the medical cornmunity is rarely grounded within a

theoreticai fkamework Its full potentiai remains unexpiored until it is placed within a

theoreticd fiamework that cm heIp us better understand why things are the way they are.

My hope is that emp1oyhg a sotiological lem in exploring questions of physician

retention wilt contexiualite the problem in a new and helptiil way.

Sociology cm help us overcome a third caveat. To conduct a thorough and

rigorous d o n ofthis topic, we cannot reiy solely on the explanations d e s d e d in

the medicd Iiterature. Sociologists examine what is not said as w d as what is said and

ask qyestiom tbar hwe not been asked.

14

Although the scope of this thesis is primarily limited to recniitment issues, the

value of addressing retention issues should not be overlooked. Recniting physicians

r-es diffèrent strategies and imrohes different variables than retaining them. While

the two issues are not rnutudy exclusive, there are enough differences between them that

they necessitate individual attention. Many strategies employed by govemments favour

recruitment issues over retention. That is why, despite substantid energy and money

invested, so many comrrmnities remain without physiciaas. It is not enough to ask "How

do we get a physician?", we dso must ask 'Wow do we h e p a physiciaa" The tendency

to codate the recniament and retention, in both theory and practice, hinders efforts to

h d manageable and appropriate solutions. Retention recemly started to be investîgated

independently of recmitment, although Cutchin reports that the two are often codlated

(1 997). He indicates that :

... the best expianation for why we have b e m slow to develop

theones to explain retention is the ongoiag assumption that the

same factors frivolved in locational behavior are at work in

retention. It must be realized, however, that the decision to locate

in a place is not the saine as the dension to remain there. The

decision to locate in a m a i practice sethg occurs largely Eom

outside that setting. The decision to remain takes place from within

the practice setting and arises fiom the strearn of experience there.

(1662)

2.2 Spheres of Consideration

Aithough Cutchin's (1997) work focuses on retention, it is Iikewise helpful in

deveioping a theoretical framework to determine what factors influence physicians to

choose rurai praaice and is the work 6om which 1 take rny theoreticai cue. From his

research invohring mai physicians, Cutchh concludes that the key to physician retention

is in community integratioo. He posits that physicians are more likely to stay in rurd

practice when they feel integrated within the cornmunity. He adds that:

... retention research to date has tended to focus on quantitative

methods and 'factors' of satisfaction detennined fiom the context

of the initiai locationai decision, we must recognize that complex

and dyaamic social relations affect rural physicians and their

decision-making process within the p d d a r rural setting (1672).

In other words, it is not sufncient to identify factors that influence retention, we must also

understand the sociai con= withui which those detisions are being made. To do so,

Cutchin identifies three domains that intluence integration: the physician, the medical

comrminity, and the community-at-large?

An eiaboration on Cutchin's domaias is beyond the scope of this thesis.

16

The use of theoreticai toois in additional works (Pope et al, 1998; Crandail et aL,

1990) marks the iocreased presence of the social scientSc community in informing this

dialogue. Pope et al. (1998) oEer categories that descriie the decision making process,

but do not explain the context of those decisions. They S o m us that physiciaos balance

lifestyle with three conceptual categories in making their decision: comrminity

cornmitment, medical confidence, compensation (broadly defined). They acknowledge

that "[fJor every fiictor judged positive by one physician there is another who sees the

same situation in a dEerent light" (210-1 1) but do not suggest why that might be so. The

spheres that 1 explore in this thesis attempt to speak to that issue.

Crandall et al. (1990) provide conceptuai modeis with which they descnie various

efforts at recnitment and retention. The models are: atFnity models, economic incentive

models, practice characteristics models, and indenture modeis. Afhity Models, they

suggest, are most commonly used and are "...premîsed on the idea that physicians choose

rural practice because they h d it desirable* (26). Economic Incentive Models suggest

that physi&m act "as rationai economic beings" (29) and will work in rural areas

providing that it is cost-effective to do so. Practice Characteristic Models (30) address

non-economic aspects of rural medicine, such as professional support. Finally, Indenture

modeis (3 1) refer to forced service in niral areas.

Crandafl et aL's work beneh literature in this field in two ways. F i Ï t does a

good job of summariring recruitment models. Second, in doing so, the work highlights a

17

number of important factors that innuence d recruitment such as: professionai support

and nzral origin However, the Models that Crandd et ai. employ are ofhited use in

this thesis. The authon fail to provide a critical analysis of the factors that they identify as

being important. For srample, when disnissing Affinity Models they state that

"...recruitment to nual practice occurs ... because the physician is fiom a nual backgromci''

(26). Rural origin is an important factor in both recnritrnent and retention, as 1 discuss in

Section 2.4.1, but the authors do not explain why it is an important factor. The goal ofthis

the& is to explore the underlying social conditions that explain why, in this case, rural

ongin is impmaat.

ReCniitment Iiterature indicates that there are mgny reasons why ma1

cornmunifies have ciiEcu.ity getting and keeping doctors. However, what also becomes

clear is that the reasons one doctor cites as disadvantages of rural practice are the precise

reasons another doctor finds nual practice appealing. As Cutchin (1997) niggests, it is

not enough to sllnply list the reasons why doctors do or do not choose nual practice.

Literature in the field of nual medicine suggests that people have similu reasons for both

decisions.

Many reasons are cited as being responsiile for the Mdty of recruiting and

retaÎning physicians in rural areas. Numerous authors (Conte et al., 1992; Rourke, 1993;

OReilly, 1994; MacLellaii, 1996; CMA, 199%; OMH, 1997; Wrlson, 1999) have

identified the foiIowing fàctors as the main Menges in niral medicine: formd trainmg.,

18

professioaal support, social integration, spouse or partner's happiness, oppominities for

chïldren, financial compensation, interest in and aptitude for rural Me, and professional

aspirations.

Take professional support as an example. There are fewer doctors, specialists, and

diagnostic tools in rural areas. This means that physiuans who are working in a rural

community probably are doing so with l e s professional support than they might have had

in an &an centre. Some physiciaus iden@ this aspect ofrural medicine as a

disadvantage. They do not want to work in an environment with so M e professional

support, and refer to themsehtes as 'isolated' f?om the larger medical community. ûther

physiciam see minimal professional support as an advanîage of nual praaice, enjoy

being challenged, and express appreciation for the 'independent' nature of their practice.

What accounts for the Merence between these two perceptions of the same variable? I

suspect that the answer lies within the social cantext and experiences ofthe physician in

qyestion. While this hypathesis has not yet been explored, 1 suspect that, in this case,

medicai education is related to perception. Physicians trained to work independently are

likely to set this vuiabIe as an advantage whiie physicians trained to depend on other

medical professionals see this variable as a disachantage. In this acample, the contes of

medicai education influences the perception of rurai mediane.

In conchsion, most literature m the field of rurd physiaan recruitrnent identifies

variables that influence recruitment, 1 subrnit that it is insuBiCient tu simply list those

19

variables. In a simple list there is no mechanism to help us understand why these

variables idluence recruitment or how they interact with one another. While each

person's Iife expenences are unique, there are similarities in the context in which these

decisions are made. We need to develop a mecbanism or theoreticai fiamework that will

enable us to understand why and how those variables are important. Drawing on

Cutchia's work, as noted above, I propose that we must identify the social context in

which those variables exist. His domains fonn the basis of how I ident* and understand

sociai context, namely through the examination of spheres of consideration.

Spheres of consideration are interrelated groupings of variables that r e m in both

the üterahire and in my own research. These spheres represent the space where decisions

are made about chooshg rural or urban practice. They also repment the variety of sociai

factors that influence those decisionS. I have identified four spheres of consideration:

financiai, personaVsocial, professional, and educational.' Financiai compensation is the

main variable m the hancial sphere. Comprised of more than salary and incentive

packages, the financiai sphere aiso houses questions of debt and professional aspirations.

F d y consideratiom, such as a spouse or partnefs andlor children's happiness, are

subsumed within the personal and social sphere. Social imegration is similady induded.

me spheres are not meant to be mutually exclusive. Variables, such as finanaal compensation, oftes reappear in more than one sphera Nor is this an exhaustive lisr, but a recommended starting point It is expected that the spheres will change and grow as we corne to understand more ciearly qpestions ofrurai retention

Questions of professional support and aspirations are the main dements in the

prof&oaal sphere, although it does often overlap quite heady with the financiai sphere.

Finally, the educational sphere refêrs to the training and preparatioo for rurai practice that

physicians receive during their formal medical training. As we wüi see, each of these

spheres is influenced by severai différent sources. Govemment programs and policies

inmience the amount ofmoney a physician receives and the kind of support available to

him or her. Communities Vary greatiy in what they can offer to a physician, both in terms

of formal and idormai support. The medical community plays an important role in

t"ning and supporting wai physicians. I wiii examine the role of the govemment,

c o d t y , and medical commWYty in each of the four spheres.

As indicated, this modei aEords the invesrigator an opportunity to understand how

and why decisions are made. This discovery is important for two reasons. First, it dows

us to see tbat recniitment is more than simply a factor of individual choice that is beyond

the influeme of govemment or communityunity Ultimately, it is the doaor who decides

where he or she wiii practice medicine, but we now can see how social context infIuences

the decision We may not have much control over the psychologicai deteminations of an

indMdual doctor but through public policy we can innuence the spheres io which that

doctor makes decisions about his or her practice location that may in tura influence

personai deasion-making.

23 P i n a n d Sphere of Consideration

Financial discussions account for a substantid amornt ofthe dialogue

surrounding rural recniitment. Four issues continue to emerge as important: professionai

rermineration, incentive packages, debt load, and education costs. Remuneration refer s to

the income that a physician receives (exchiding any income acquired through hancial

mcentives) for his or her work and are discussed in Section 2.3.1. Incentive packages,

discussed in Section 2.3 2, refer to the financial bonusw that governments offer

physicians who are willing to work in specinc rural co&ties that have been

designated (by the govement) as underse~ced. Section 2.3.3 addresses the impact bat

student debt has on physician recniitment. Finally, the rishg cos of medical education,

which relates diredy to student debt, is examined in Section 2.3.4.

2.3.1 Remmeration

The current structure for remuneration has been constnicted to be beneficiai to a

doctor practicing in an urban context. The fee-for-se~ce payment method compensates

physicians for each patient visit (for physicai examinations) or for specined services

(sutures, burn treatments, etcetera). Incorne, therefore, is dependent upon the m b e r of

patients that a physich sees in practice. Additionally, physicians are compensated for

on-call hours imspective of whether or not they see a patient whüe on c d . Cmentiy,

physicians in nual areas are paid on the same basis as their urban counterparts. There are

22

some daims that using similar payment methods for nird and urban areas is u n .

because a nual physician has a s d e r population base which resuits in fewer billable

visits for physicians.

S a l q negotiations are on-going betwea nirai physicians and the provincial

government. Mead of recognizing the needs and practical experiences of rural

physicians, and developing and irnplementing a remuneration system which would better

refiect the different work-load of a mal doaor (ie. that they may see fewer patients but

spend more time with each one because the cannot refer the patient elsewhere as easily as

an urban physician cm), rural doctors are forced to operate under a system not

constructed with their needs in mind.

2.3.2 Incentive packages

Fl~lszncial incentives are the preferred "solution" employed by the provincial

governent to encourage physicians to go to rural areas. Not al1 nird areas are eligiile

for incentive packages. The provinaal government tirst identifies those commuaities

which it feels are underserviced. Ody physicians working in those areas are eligicble for

hancial hcenthes. Most incentives programs in Ontario and the rest of Canada work on

a contractuai basis. Physicians are offered money in addition to the standard fée-for-

service and on-caIl remuneration. The Ontario govemment empIoys this technique

fkequently, as do o k provinces. Crandan's (1990) report on international remdment

23

and retention practices notes that the economic incentive model is also popdar in other

countries.

m e the financial incentive model is a popular one, it does not seem to be

effective in keeping physiciaas in rural areas. There is Little empirical data available to

identay the effect ofincentive prognuns on recruhuent rates, but financial bonuses have

not soived the problem of nual physician shortages (Hardy, 1998: 8). Furthemore,

incentives packages are not recommended by most physicians, who see them as being

"out of step" with what is needed to attract and keep physicians in rural areas (Hardy,

1998: 8). Incentive modeis are not widely supported for three reasons.

Fust, incentive packages do not keep physicians in mal areas. Their focus is

recruking, not retaining, physinans. As discussed in Chapter One, b ~ g i n g a physician to

a nual area is not enough ifthat physician Ieaves after a couple of years of service

because the community is then in the same position that it was in initially - doctorless.

C o d e s that have more than one doaor are likewise afFécted by high turnover rates.

Building professional ties and support can be difticuit when your colleagues change on a

regular basis. The breakdown of those professional connections cm lead to a breakdown

in profionai support! Professional support is often indicated as being a variable which

a f f i both physician recmitment and retentioe

Second, there is a great deal of concern about money being the primary factor that

brings a physician into a niral area. Few nual residents, no matter how desperate to have

access to a physician, want a doctor who is in their community only for the money. The

motivation to provide yaiity care to patients does not stem h m financial consideratiom.

Finally, incentive packages give a fdse sense that the problem is being adequately

addressed and dealt with. They mask other issues that need to be addressed such as

student debt and rising W o n costs. Sections 2.3.3 and 2.3.4 demonstrate how all of

these issues are interrelated.

2.3.3 Student Debt

Student debt has oniy recentiy been acknowledged as a factor involved in

recnUtment, Hardy (1998) suggests that student debts make people wary of hesting in a

6Ultimately, whether or not a physician feels that she is professiondy supported in her work may be as mudi perception as rea(ity. The concept of profional support is, to some extent, sociaiiy coIIStntctedd A physician cm work with other docton and still not feei p r o f ~ o d y supported. Likewise, a physician working done may feel adequately supported. Whüe deseMng of fkther attention, an in-depth discussion of this process is beyond the scope ofthis thesis.

nual practice. The concem, he explains, is that physiciafl~ graduate Eom medical school

with substantial debt loads and are primdy concernai with paying back their loans.

Student debts have increased substantially in recent years, due in large part to the rising

tuition costs of medicd schoob.

Because Ontario employs a fee-for-service payment scheme, physicians who see

more patients per day make more money. Rural areas have a smaller population base and

consequently a srnaller patient base than do utban areas. Phyticians with large debts are

not always certain that they wiiI be abte to see enough patients to repay their loans

promptiy. An additional concern when the money guatanteed (as is the case with

incentive packages) is that the physician wili leave the comunity as soon as the debt is

repaid. Increased debt loads and incentive packages together make recntitment unlikely.

2.3.4 Tuition Fees

Tuition costs may help place docs where needed" was the title of a recent article

that appeared in The Mech'caI Pm. - a weekly medicd newspaper (quinn, 1998). The

amcle exptained that the Ontario govemment was considering offering financial aid to

medical snidents who agreed to practice in niral locations in response to c'skyrocketing"

M o n fees. Eminent deregdation of tuition fees for Ontario medical schools couid mean

that fees double in one year, p i a a studcnts in unprecedented &cal crisis.

Tepper and Rourke express concern in the5 recent article that "[tlhe recent and

unprecedented inmeases in mition at most of Canada's medicai schools wül only add to

the problem [ofrecmiting medical students fiom urban areas and not ha* enough rural

students)" (1999: 1173). Tepper and Rourke's concern touches on the question of who

can afEord to go to rnedicai school. Data suggests that students from rurai areas are more

Likeiy to choose and stay in niral praaice than their urban counterparts (Easterbrook et

al., 1999): However, it is not clear that nual students have the same access to medicai

school as urban students, finances and school grades being among the concerns. The

importance of mai ongin in physician retention is discussed in Section 2.4.

In condusion, factors within the financial sphere that are suggested to influence

physician recnîitment are: rununeration, financial compensation, student debc and

medical school tuition fees. In Chapter Four 1 compare these factors with those identified

as important by my respondents.

2.4 Personai and Social Sphere of Consideration

The decision to choose rurai practice involves considerations ofa personal and

social nature. White I have combined both considerations wahm one sphere, I disniss

hem separateiy bdow, in Sections 2.4. I and 2.42. The personal considerations that

'The impact o f d oiigin on mention is M e r discussed in Section 2.6

affect rural retention are: interest in and aptitude for rural We3 rurai origin, spousal

contentment, and oppominites for children. Soual integratioq and the social role of the

r u d physician are included as social considerations that affect rural recruitment.

2.4.1 Persona1 Considerations

What do physicim like about rural practice? A lanrtmsitk report published in

1995 by the Worid Association of F a d y Doctors (WONCA), reported that the

.. .great attraction of rural praaice is the country

environment and lifestyle which is associated with a better

f d y Me in a good place to raise children. .. . Social

satisfactions of nual practice idenaed by rurd doctors

include comrmrnity standing and respect, coupled with a

sense ofbelonging to a stable comiminity, and enjoyment

of outdoor king with many recreationai opportunities

(WONCA, 1995: 9).

The personality and background ofa physician also is a factor in reccuitment.

Accordiiig to a 1999 inter-disuplinary midy published by Easterbrook et ai. in the

CQlltOLiilan MeCaca~Associafion Jouma13 physiciam who were raised in nual commdes

were 2.3 times more Likely to choose a ruraI practice than those h m non-rurai ongins

and 2.5 times more k d y to stay.

An overworked doctor, whether urban or mai, has little time or energy for home

We.* The physician contemplating rural practice may emTision a refaxed lifestyfe and

good quaiity of life but be too busy to take advantage of rural We. There aiso is the

consideration of educational oppomuities for children, and, ofken, there are no job

oppomiaties for the physician's spouse or partner. This is no s m d consideration as two

incornes often are essential for financial Sufvivai. Feelings of social isolation often are

reported (OMH, 1997; Cutchin, 1997; Pope et al., 19%; Wilson, 1999), especiaiiy by the

physician's spouse or partner. Social isolation can be explained partialiy by the confusion

of social d e s that physiciaas confront in rurai practice.

2.4.2 Social Considerations

Physicians generdy occupy weü defined social roles. However, the ruraI

physiùan ocnipies a somewhat different social role than the urban doctor.Western

* The exact distinctions between the life d a mai and urban doctor cannot be generaüzed. Certaiaf, there are tuban doctors who are highly overworked just as there are Mal d o a o ~ who enjoy a relaxed work &onment PresumabIy, there are both similarities and differences between nual and h a n medicine and research is required to detemine th& impact. The concepts raised in this work r d - the iiterature in the field of niral physician recniitment.

medicd practice is predicated upon substantid social distance being placed between a

doctor and bis or her patient. The doctor-patient reiationship is sociaily coi1StNcted to

discourage social interaction between physician and patient. This distance dows the

physician to retain objectivity about the patient and not get emotionaily invohred, which

might @kt his or her treatment decisions. Additiody, this distance serves a

mechanisrn of social control. There is a hierarchy in the traditional doctor-patient

relationship that places the physician in power. In an urban setting, the interactions

between docton and patients are confhed to the physical space of the office. Moreover,

the patients under an individual doctor's care are unlikely to know one another. Such

ngid divisions do not exist in rurai comrnunities. In a mal community, maintahhg

social distance between physicians and thek patients is more difncult because your

patients are also your neighbours and nieads. Mediating the spaces between doctor,

neighbour, and friend is a constant stmggie for rurai practitior~ers.~

The factors in the personai and social sphere of consideration that affect nual

physician recniitment are: interest in and aptitude for niraI üfe, rurd ongin, spousd

contentment, oppomuities for chiidren, and the social role of the rural physiciae

The extent to which a physician is abIe to integrate within the comrminity h which he or she works is important. Cutchin's work on physich satisîaction and retention indicates that socio-cultural integration is a primary &or in bath recruimient and retention (1994, 1996). Aithough important, Cutchin's emphasis on retention, as opposed to recnulfment, places his work outside the scope of this thesis- The extent to which phpicians make practice location deciCsions based on a perception that they wül be abie to htegrate is a question worthy of consideration and research.

2.5 Professiond Sphere of Consideration

The profdon of medicine m e r s between rural and urban areas. These

differences, as discussed below and in Chapter Four, make an important contriiution to

our understandhg of physician recluifment. The doctor-patienî relationship, an integral

part of the medical profession, seems to be less rigid in niral areas than it is in urban

areas. This is so p d y because of the breadth and scope of rural practice. Foi both of

these reasoiis, nual physicians often work with less professional support and more

respoasibility than their urban counterparts.

Rural practice is quite distinct nom urban praaice. In fact, rnany rural heaith care

professionais argue that it should be a specidty unto itself, like cardiology or pediatrics.

The mal practitioner relies on a greater variety of SUS than does the urban physician.

As we have seen, this develops out of necessity - the common urban response of refening

patients elsewhere is not possible for rural doctors. For this reasoq rurai doctors need to

be proficient in many dialects of the language of medicine. They must be pediatricians,

cardiologists, dermatologists, emergency medicine speciaiists and many others. The

Vaciety of cases that the niral doctor sees is fa greater than her utban counterpart

(MacLeiian, 1996; KingmiII, 1997; Pope et al, 1998).

Hospital admission pfieges mark another distinction between rural and urban

medicine. Genedy, urban EMiIy doctors do not a d d their patients to a hospital.

Speciaiïsts, to whom the patient has been refmed by the f d y physician, determine

whether or not the case wanants hospitalization. In contrast, the iow -bers of

specialists in rurai areas necessitates that f d y doctors interact directiy with nearby

hospitais. Obtaining hospital pnvileges often is easier for rural f d y physicians than

urban ones (Henderson, 1996). Because of this expandeci roie, mal tamiy physicians

generaüy foiiow patients through a wider range of their health care experiences.

F d y physicians are "fiont-line" medicai personnel. They are generaiiy the fmt

medicd professional with whom a patient c o d t s with a health-related concem. Wben a

fiimily physician can no longer help the patient with theu partidar health concem, the

patient is referred to a specialist who then assumes Gare of the patient. Rural doctors often

are professionaiiy isolated and support seMces in communities vary. In some cases there

may be full Iaboratory seMces or even a hospital. In other communities, there may be

new, state-of-the-art equipment but no trained perso~el to operate Îî. While in another

community there may be no support staffat d. Rural physicians cannot refer patients to

specialists as easily as &an physicians because there are few specialists in rural areas

(OReiUy, 1994; CM& 1997b; Pope et ai., 1998). Consequentiy7 rurai physiciatts of€en

need to be speciatists as weii as f d y physicians.

The professionai Iâe ofa rurat doctor is dernaadhg in content and in hours. Rural

doaors by necessity offi a wider range of services than their urban colleagues

(WONC4 1995: 13). The heavy workload and o n 4 hours of professional life in rural

32

comrminities can have negative consequemes for personal as wd as professionai

endeavours. Isolation, long hours, and f i f i t e choices deter some physicians tiom

considering niraI practice. For others, however, these are not deterrents, but incentives to

establish a rurai practice:

Rural docton i d e n e a series of key attractions of rural

practice. Fust is the greater variety of practice that often

indudes obstetncs, surgery, anaesthetics and emergency

medicine together with hospital access and care of the

acutely ill. Rural practitioaers are m c h more keiy to be

looking after individuai patients for all of thUr medical

problerns on a continuing basis ... (WONC4 1995: 9).

What is it that makes these factors an advantage to some physicians and a disadvantage to

others? 1 address that question in Chapter Four.

Barer and Stoddart, in a report enntled Improving Accesr to Needed Medical

Services m R d md Remte C d i m Cornmunifies (1999), niggest that sustainable

health care in niral areas may be achieved by integrating non-physician heaith care

professionais into the niral h d t h care model:

The expandeci dep1opent of persorne1 such as muse practitioners,

wÏth training &cient to provide a considerab1e range of primary

care services, enabled by appropriate adjustments on the regdatory

ftont to aUow expanded scopes of practice (e.g. prescnig) offers,

in our view, significant untapped potMtial to address the problems

of access to primary care (33).

The Society of Rural Physicians of Ontario hosted, at their anmal conference in 1998, a

- discussion on nurse practitioners and nual doctoa. Whiie littie exists in the literature

about this topic, the Society seems to be open to the suggestion (SRPC, 1998).

2.6 Edurational Sphere of Consideration

Generally speaking, rural communities have trouble recruiting and retaining

physicians because medical students have not been adequately exposed to and prepared

for the reaiities of rural practice. Nor will they be. says Society of Rural Physiciaas of

Canada president Dr. Keith MacLeUaq "...until rural medicine is recognired as a

discipline7' and given the recognition that it deserves in the broader medicaf community

(KingsmiU, 1997: 141).

Canadim medical schools, traditionaii~. teach urban students (ORdy, 1994;

Tepper and Roudce, 1999; Wüson, 1999) urban medicine. Most medical students are

nom urban areas due in part to the structurai and political disadvantages that niral

students face in acc- to educatiod senrices and other determinants of career choice

(Tepper and Rourke, 1999) . For this reason, some argue that more niral students should

be admitteci to medical school no matter what it takes to get them there (WONCA, 1995;

3 4

Easterbrook). m e there is no guarantee that a student will choose and stay in a rurd

practice simply because she is nom a d commuDityy rural origin is positively

correlated to both recruitment and retention (Easterbrook, 1999).

Another important factor to consider is the medical school and its faculty.

Traditional medicai curricuia are urbanly biased and most docton teaching medicine,

whether in the classroorn or in the hospital, are urban docton: "Most of this training

[undergraduate medicai education] takes place in city hospitals where the emphasis is

technology, the benents of the city and of specidkation ... It is a very urban-centred

approach and many graduates are biinkered when it cornes to appreciating what happens

outside the doors of those University hospitals." (John Wootton in Wilson, 1999) Rural

mediane has not been visible in Canadian medical schools. This is of great consequence

in view of what we know about processes of sociaiization and p rofess io~ t ion . The

lack ofrole models and menton for aspiring rurai physicians indicates to medical

studems that rural practice is not a viable option. Funhermore, medicd students are behg

forced to decide very early in their training what direction they want to fouow. Early

career decision-making affects where people decide to pradce (Tepper and Rourke,

1999: 1 173) and nual medicine ioses out when people make th& career choice before a

rurai practice has been presented as an option.

Medicd schools have staaed to ackaowiedge rurai medi& Presenty, most

Canadiari medical schoois provide some exposure to nnaI medicine for shidems who are

35

interested, and duations of those programs have been positive (Rabinowitz et al., 1999;

Moores et al., 1998; CMA, 199%). The Department ofFamily Practice at the University

of British Cohimbia (UBC) iuitiated a rural training program in 1982 (Whiteside and

Mathias, 1996: 1 1 14). A recent evahiation of the pro- indicated that "graduates of the

UBC niral training program consider themselves better prepared for mal practice than

non-program-trained rural physicians" (Whiteside and Mathias, 1996: 1 1 13). Moreover,

the evaluation suggested that specific, m u m e c i training was indeed helpfui in preparing

physicians for nual practice and by extension also increased the number of new graduates

practicing in nual areas (1 120). Rourke (1996) ako acknowledges the importance of

training p h y s i n ~ to work in nual areas, and adds that rural doctors should have play a

role as teachers in rnedicd school.

The reasons why physiaans choose to praaice in rural locations are numerous

and varied. In this chapter, 1 have presented the variables commody identified as being

important to physician recniitment. 1 propose the implementation of a theoretical modd

to best understand the social context in which those variables operate. Four Spheres of

Consideration (hanu& sociallpersonal, profession& and educational) provide us with a

more thorough tmderstaudiag of the factors involved in rurai phytician recniitment. In the

foliowing chaptq 1 explore the methodology used to obtain ori@ data about physicim

remritment,

Chapter Three: Methodology

Section 3.1 Research Design

Due to Merences in health care policy between provinces and the requirernents of

this M . A Thesis, it is not feasble for me to include rurd physicians in all provinces. To do

so would mean including 13 (one for each province and tenitory) dEerent health care

policies which is beyond the scope of this project. Additionaliy, had 1 inteMewed

respondents fiom across the country, it would be difncuIt to compare the results because

heah care systerns mer. Differences are partidariy abundant in the ways in which

Werent provincial govements have addressed and tried to resolve the problem of

physician retention in mal areas. Because of the diffidty in c r e a ~ g a national picture due

to provincial variations the task then was to choose one province as a focus for my research

As I was not confident in my abiiity to conthict in-depth intemiews in French 1 iooked

outside my home province.

1 chose Ontario for three reasom. First, Ontario boasts the largest population base of

any province. My pool of potentid respondents was s d to begin with and Ontario's large

general population indicated tbat there might be more rural physiciaus than in provinces with

d e r populations. Second, 1 was f à m i k with the conditions of the Ontario health care

system, F i y , Ontario is home to many professional and research-based organizations that

were able to provide substantid support to the project in terms of access to physicians and

exkahg data

Glven the s d body of both fiterature and research (particularly sociological) in

Canadian mai heaith, this project is largely exploratory in nature. In order to gain the most

amount of information fkom respondents, quantitative data collection was accomplished

using the survey method. Interviews provided me with the best option for exploratory

research because they are interactive in a way that d e d questionnaires are not.

Furthemore, they ailow the inte~ewer to be more responsive to the in t e~ew subject.

Additiondy, my respondent pool is made up of particularly busy people, and 1 nispected

that my response rate would be greater with interviews.

More specific~y, 1 designed an interview guide (Appendix A) constructed of both

open and closed questions. Although 1 had severai hypothesis in mind in constnicting the

intecview guide, 1 decided to foilow a general format of loosely structureci, open questions.

The reason for this was that although 1 had sevaal hypotheses in mind whiie constructing

the inttMew guide, 1 did not want to inchde questions that wouid be Ieadmg for the

respondent. 1 wanted to know ifrespondents would report the same factors, and had to Ieave

them room tu reply as they desired. 1 was able to glean more specinc idormation through

the use of probes. Open questions permit respondents room to answer cornplex questions.

As this research deah with an extremeiy cornplex issue, open questions were the most

appropriate. Because 1 was looking for thoughts and opinions, I wanted to be certain that

38

respondents fdt they were engaging in a non-hostile dialogue, with them as the primary

speakers. as opposed to a fonnaI, stmctured interview session.

Due to the geographical distance between myselfand the respondents, as weii as the

distances between respondents traveIling to meet with each respondent for face-to-face

interviews was not feasible. 1 decided instead to condua telephone inte~ews. This allowed

me to engage in a type of intemiew similar to fice-to-face without additional travelling coas.

Whiie 1 was unable to enlist visual observation as a technique in the interview, 1 was able to

complete the interviews faster because 1 was using the telephone. FinalIy. telephone

inte~ews were more cornrenient for the respondents who, as medicai professionals, are

subject to last mimite changes of schedule that cm be more easily accommodated in

telephone than in face-to-face intemiews, particularly when extensive travelling is involved.

3.2 Research Methods

Making contact with potentid respondems was problematic at the beginning of my

research for several reasons. Fint, I was not based in the same province as my respondents.

Second, 1 am not in the rnedicai comrrmnity. I initidy had hoped to be able to interview

respondents in predesignated comrminàies in Ontario. Doing so wouid have enabled me to

coordinate my research with the on-going research project of the New Rural Economy

(NRE). 1 set about obtaining the names ofthe doctors in those coiflIllltnities fiom a directo y

that is pubIisbed annudy Listmg all licensed medical praaitioners in Canada I discovered

39

that due to the high tunover rate of physicians in rural areas, by the t h e 1 was able to

identiQ who was workhg in a particular communky, they were no longer there.

Furthemore, the entire pool ofpotential respondents was s d L O and I wouid not have been

able to interview enough respondents ifeven one or two were uawilling to participate in the

Consequdy, 1 eniisted the assistance of the Society of Rural Physicians of Canada

( S m ) and a decision was made to access potentid respondents through the SRPC listserv

(RuralMed). The listserv has approxhately 500 members, and dthough there are not strict

d e s about who can join (meanin8 that of those 500 participants, not ail are rural physiciaos)

it was the best option for hding respondents. In totaI, 1 posted two calls for participation on

the server explainhg who 1 was and what my research was about. Interested parties were

asked to contact me via e d or through phone, fax, or written mail. AU respondents made

initial contact via email and all contact, apart from the actual interview, was made through

emaiL A mutualIy agreed upon time was then set for the interview. In 4 cases, the respondent

did not answer the phone when 1 called at the designated the. In those cases I left messages

saying that 1 wodd c d back in 15 or 20 mimites. When I cailed again, aU but 1 respondent

'OAccording to the Society of Rural Physicians of Canada, there were 1044 ruraI f d y physicbs in Ontario in 1999 ( W C , 2000).

picked up the phone. In those cases where the respondent did not answer on the second

attempt, 1 left a message asking to reschedule via emaü."

In addition to postulg a c d for participation on RuralMed, 1 enlisted the snowbaii

technique to W e r expand my respondent List. This technique was ineffective. In totai, I was

able to remit one more respondent because of a contact that 1 was given. 1 did not hear

anything £tom those respondents who said that they wouid p a s dong rny coordinates to

kiends and/or colleagues.

Respondents were advised that the inte~ews wouid last approximately 30 minutes,

which was an accurate estimation. Most of the respondents were at home duriig the

interview. Two respondents participated in the interview from th& place of work. The

majority of the in te~ews took place in the evening, during the week.

*%me are methodologicai implications to my use of RuralMd as the primary access point to my respondents. These implications are discussed in detail in section 3.4 of this thesis.

Section 3 3 Sampie Seleetion

Of the eieven respondents, f i e were at some stage of th& undergraduate medical

training, three were complethg theV residency and an additional three were generai

practitioners. Seven respondents were female and four were d e . The youngest respondent

was bom in 1977 and the eldest was born in 1958. Five respondents were manieci, one was

engaged to be mmied and the rest were single. Only two respondents had children.

Ody one respondmt was currently practicing medicine in a nual location but ail but

one of the respondents expressed an intention to praaice in a rural area in the future (witbh

the next five yean). Six of the respondents had lbed in a mal area prior to their

undergraduate medical training.

AU the respondents in this study were in Ontario, although 1 also talked to MDs Eom

other provinces, as web as one Nurse Practitioner. 1 had decided not to tum away

respondems since 1 füt that they wouid be able to add to my overall knowledge about the

subject material and might know someone in Ontario, but 1 indicated that I wodd not be able

to use the data d e e d fiom their inte~ews directiy in my thesis. Table 1 shows a

breakdown of respondents by various demographic characteristics.

Table One: Respondent Profdes

PIansto p d c e in a d

location

h d c r

M

F

F

F

F

F

M

M

F

F

M

tegories - ugraddergraduate Fam MD = fw Qctm

M d d Statw

Ma~icd

-t

tngaged

sinde

m d c d

siagie

Marricd

Mam'cd

single

married

siagie

(&os h u a i ) :

Chiiden

no

no

no

no

C 3

no

no

3

no

no

no

A. $0-19

Prof=-onai s@e

nsident

W a d

w a d

F m MD

FmMD

ugrad

nsidtnt

Fm MD

ugrad

&dent

iio2rin

999 B. $20

Cturcntly i a R d

A m

no

no

110

Not d y

no

no

no

Y==

no

no

no

000-49 999

Hasqcnt h e i n Rurai bcfm

no

Y- 18 ycars

Ycs, 20 Y-

Ycs, 3 y- for

wotk

Yw, 2 year!? for

wo*

Ycs, 18 Y-

no

no

no

yes, for work

no

C. $50 0004

3.4 Limitations of this study

1 made every effort to design and implement as rigorous a research design as possible.

However, a number of limitations to this research need to be addressed. They cm be

categorized in the followhg marner: limitations rdt ing nom the use of RuratMed and

ernaii, limitations in sample base and size.

As mentioned in section 3.2, there are several implications of using the RuralMed

iistserv as the primary source for hding respondents. A number of the problems stem fkom

my use of emaii as a prirnary source. Fust, 1 did not a& for proof that these people were who

they said they were and indeed self-presentation on the internet is a problem. However, my

feeling was that an individual wouid have to go to great trouble to participate in this

î n t e ~ e w ifthey were not involved in the dehery of heaith care as the questions were

specinc to that profkon. Second, and more important, the sample fiom which 1 drew my

respondents was not random and therefore not necessarily generaüzable to a broader

population. However, this is acceptable for an exploratory study as one of my goals is to

highiight various f o m offiirther research. The people who are subsmiers to RuralMed are

probably more keiy than others to be interested in and proactive about rural health issues.

As a r d t , they may not be representative of the larger population of nual physicians.

Again, this affects the extent to which my research can be generaiized to a larger population,

Respondents were responsitbe for making i . d contact ifthey were interesteci &er reading

the prospectus of my study. A c c d g individuaI respondents would have been preferable

44

since it may have increased my response rate. Most conespondence, including the initial c d

for participants, was made through email which potentialky limits respondents to those with

access to emaiL This is particulariy problematic if snowballllig doesn't work, and most of

my respondents found me through this cd. Emaü seems to be widely used among mal

doctors who are isolated to Werent degrees so the e f f i of the problem may be somewhat

neutralized.

Another Limitation of my research is my small sample sue. Several factors explain

why 1 have such a mal1 sample size. F i the pool of potentid respondents is smd. [fit

were not, there would be no cause for me to undertake this research in the fist place. The

size of my potentid respondent pool reflects the shortage of rural physicians in Ontario and

the rest of the country. Second, the pool of rural physicians is highly volatile. The high and

rapid turnover rate of rural doctors complicates the process of fincihg people willing to

participate in research. Those who are interested are busy, and it was difFcdt for them to

find time to speak with me. k s , the third factor iduencing my sample size was the

availability of people who were interested in participating. Finally, aithough 1 attempted to

employ a snowbd sampliag technique to increase my sample size, it yielded only a few

more respondents.

The implications of a small sample are numerous. As a r d t of the small generd

pool fkom which to select respondents, 1 was forced into a non-random sampk. As we& I

codd not impose strict dennitions of niraI and remote, but haci, rather, to reiy on the

45

definition of the respondent. Both factors compromise the extent to wbich 1 am able to

generaiize fhdings to a broader population. However, generalizability is not as important in

the context of an exploratory snidy as it wouid be in a study with different motives.

In addition to the size of the sample, the demographic characteristics of the

respondents yielded some limitations. Fust, only one of my respondents was curredy

practicing in a mai location WhiIe most others were planning to start practicing rurdy, and

some already had, iî would have been advantageous to hear fiom more people who currently

were working in a rural setting. Second, the majonty of respondents were at the beginning

of their medical careers which limiteci the amount of practical experience that they couid

have to share.

Defining rurai was equdy problematic. Ln the spint of an exploratory snidy, I

decided not to enforce a rigid definition for feu of limiting rny potential pool of respondents

too drasticdy. 1 was concemed that potentiai respondents might not be able to categorize

their community according to a rigid set of standards. However, I have Ioosely foUowed the

definition of 'd as suggested by the Organization for Economic Cooperaûon and

Dwelopment (OECD) who consider that a region is "rural" ifmore than halfthe people there

live in communities with a population de* of fewer than 150 persons per square küometre

(Health Canada).

Fmdy, as 1 have worked on this project, the stmgpies of nual Canadians vis a vis

their health care &as moved into foms and become a hot topic. It is diflinilt to stay abreast

o f d the changes in policy and the efforts being made to solve the problem whiie conduchg

this research. For this reason, by the time this work is hished it is possible that some claims

or suggestions made in this thesis will have aiready been addressed in other work.

Nonetheless, the problem at hand is a complex one that requûes extensive contemplation and

discussion if sustainable solutions are to be found,

Chapter Four: Findings and Discussion

Section 4.1: Fimancial Sphere of Consideration

As discussed in Chapter Two, physician cetmitment fiterahire highlights four

interrelateci components within the hancial sphere. According to that body of fiterature, the

p r h w y factors of concem to nual docton in this sphere are: remuneration, financial

incentives, debt, and tuition fees. Negotiations between physicians (as represented by the

Ontario Medical Association) and the provincial goverment seem to be never-endhg which

indicates that remuneration is a topic that concerns many physicians. For that reason, 1 expect

that my respondents wiU identify remuneration as being an important factor in their decision

to choose nual practice. Aithough financiai incentives are widely used to recnllt and retain

physicians, their use has not sohred problems of rural remitment and retention in rurai

Ontario. 1 do not expect my respondents to report that they find financial incentives an

important factor in recruitment. m e debt has ody recedy appeared as a recntitment factor

in the literature, 1 expect that the high proportion of medical students and residents in my

sample wili mean that debt is something that concems rny respondents. For the same reason,

1 expect that nution fees will be of concem to moa respondents.

4.11 Remuneration

1 suspected that my respondents would cite remuneration as being a factor in th&

decision to choose niral practice. That hypothesis was not supported by the r d t s of my

research. None of my respondents said that remuneration was an important consideration in

their decision to stay in or leave rural practice, although one respoadent did feei strongly that

niral physicians should be paid more than urban physicians. In total, ody four respondents

spoke about remuneration, although d respondents expressed opinions about financiai

incentive programs, which I disntss below.

Respondent Two, a 25 year old female medical student who grew up in a rurai area,

was the only person to express stroag feelings about remuneration. She feit that

"...physiciaas are highIy educated and highly skilied people and ... their pay should reflect

that". She also felt that rurd physiciaiis should receive additional incorne because they work

with less professionai support and are requked to perform more medical tasks than urbm

physicians: "If 1 see a sore throat in the city it's not reaüy much Merent from seeing a sore

throat in the country but the practice profile ri the country] is very dserent [rhan in the

city]". 1 discuss issues surroundhg "practice pronles" later in this section

Three other respondents acpressed that medicine pays weU no matter where you

practice. Respondent One, a 3 1 year oId male resident, said: "doaors make a lot of money

in town or out oftown". Respondent Sk a 28 year old f d e medicai student, said: 'Woney

49

isn't a big motivation for me being in medicine in the fkst place" and that "...medicine

anywhere is pretty well paid". Respondent Nine, a 30 year old female medical student agreed

that remuneration was "...good pretty m c h anywhere you go".

There are two possible exphnations why rny hypothesis was not supported. First,

perhaps the physicians and medicd students with whom 1 spoke felt that they were (or wouid

be, in the case of medical -dents) weli paid and that remuneration was aot a factor in their

decision to choose niral practice. This could change as students actuaiiy start their practice.

The second possible explanation is that 1 did not ask the right questions. 1 suspect that the

nrst expianation is more accurate than the second. My respondents felt that physicians are

paid w d for what they do regardes of whether they work in a rural or urban settiag and

that others factors, both positive and negative, eventuaüy outweigh any monetary

considerations Financial remuneration, at Ieast for my respondents, is not of prirnary

importance when making decisions about practice location

4.12 Finamcial Incentives and Student Deb t

Financial incentives are often used to make rurai practice seem more entichg to

potential mai physicians. Three respondents (Respondents Two, Fie, and Eight) felt that

hancial incetrtives were good tbings. Two of them (Respondents Two, and Eight) agreed

that financiai incentives were needed to atîract and keep physicians in niral areas.

Respondent Eigbt, a 42 year oId male f d y physician, acknowledged that financial

50

incentives are now the n o m He feIt that they were needed to ccIeveI the playing fieldn

between rural and urban medicine. Respondent Two, who felt strongIy that physicians should

be wd paid due to their skiIL and training, fdt that f?nancial incentives were necessary. She

added that "...in an ideal world there shouid be no Werence between practicing medicine

in the city and practicing medicine in the country but we don? Iive in an ideal world,

and. ..the reality is that ... you have to pay them more".

Respondent Fie, a 36 year old femaie f d y physiciaq felt that financiai incentives

were '%vonderfiil". When asked ifthey infiuenced her decision, she said: "1 don? know if

uimienced is the rîght word, but ifyou're going to put pluses and minuses on things it would

be a plus". Respondent Five also indicated that the financial incentive she was offered in

exchange for spendhg some time in a rural setting sparked her interest in mal medicine. It

is i n t e r d g to note that the respondents who felt that incentives were positive and helpflll

also indicated that the reason why is because rural medicine had characteristics that re@ed

compensation, such as lack of professional support and demanding workload. AU other

respondents felt differently about h c i d incentives.

R d the words used by Respondent Eight when discussing financial incentives. He

felt that fhancial incentives were important because they 'level the playiog field" between

nual and h a n practice. His use of the term "Ievel the playing field" implies that there is an

inherent merence between niral and urban medicine that must be acknowledged. The

ideologicai premk behind fÏnancial incentives is that Rual practice is a chore or bad

SI

situation that physicians shouid be compensated for enduring. Using financial incentives in

this way creates and propagates an image of mral medicine as being undesirable - money

is the only thing that can convince physicians to be in rural practice. This is why financial

incentives are not a sustainable sohition for nual medicine. Furthemore, 1 suspect that

hmcial incentives negatively inthience people's perceptions of rural medicine's value.

Although she admitted that the hancial incentives were nice, they did not mothate her

decision making in t e m of practice location.

The remaining respondents did not feel, as did Respondents Two and Eight, that

hancial incentives need to compensate mrai physicians. Six people fek that financial

incentives were only short term solutions to the problem of rurai recruitment. Both

Respondent Nine and Respondent Ten, a 27 year old f e d e resident. identîfied financiai

incentives as being a short-terni advantage to rural practice because the additional income

would help newly graduated students deal with the massive debt that they had accumdated

throughout their studies. Respondent One, who had spent time during his medical training

in a Mai setting and planned to move to a rural practice, said:

... when you see the &dent I w n b d m that people are graâuating

with right now, any type offinancial incentive at the beginning of a

person's praaice makes a huge difference. I don't know about the

long term...l think people might go initially for the money, and if

they stay, they stay for other reasons, such as continuity of care, or

because they can practice a wider ranger of medicine, or [because]

they like lMng in a rurai ara as opposed to a large &y. Once people

have paid off thur loaas and are looking at their hes in the Iong-

term, the extra 20% [offered by a hancial incentive package] isn't

that big a factor [in their decision to stay in or leave rural

pradce] ... financial incentives are a huge factor at the beginning ofa

person's career to offsetsfutiknt Zmdebt but [they are] not important

beyond that (emphasis added).

Respondent S k who stated that money did not motivate her to choose medicine as a career,

said "[a financial incentive] doesn't impress me a whole lot, it's reassuring that there wiii be

reasonable prograrns in phce so 1 will be able to pay my I o m back, that is an issue for

studentsn (emphasis added). Financiai incentives might not convince people to choose nual

medicine if they were not interesteci in it for another reason, but financial incentives can

make niral pradice a more viable option for students carrying a large debt. Respondent

Tbree fdt k t financiai incentives are a bonus but would not influence her decision She

conceded that they might make a merence for someone with a debt to repay. Respondent

N i e summarizeci the situation by saying: "Student debt loads are getting so unbearable tbat

people are looking for a quicker means to get out of a bad situation ".

This discussion about financiai Ïncentives highüghts another important aspect of the

financiai sphere which is the impact that debt has on practice location Respondent Four, a

36 year old f d e fiun@ physician r e d e d that "men 1 was a medicd student] t was an

enonnous amount of debt to go into anb.itjust puts your focus di onmoney, and everything

becornes about money, and I'm not sure that's redy hdthy." Respondent Two said: The

truth of the matter is that large debt loads force or redirect the stream of -dents away fiom

f d y practice into higher paying specialties and f d y pradtioners are more likely to

practice in a rural setting in the h t place". Respondent Three believed that debt increases

the likelihood that a student wiIi choose to move to the United States in order to make money

faster to pay off loans.

Debt can represent a coercive way to get students into rural areas. Respondent Six

dso expressed concem about forcing or coerchg people into rurai areas:

The bottom iine is that the only good rural health care that you're

going to get is from people who want to be there, and if people are

there because tbey were forced to be there or ... they were so

bancidly strapped that they felt their ody option was to do this

program then 1 don't think they're gonna provide great health care.

Respondent Four was @ad that she did not receive any hanciai compensation for the time

she spent in a niral comnninity. She was "...happy to have the fkeedorn to go there by choice

rather than 'owing the ' [because of having signed a contract]. She aiso says that T h e

money is a nice benefit, but 1 am not comrinced that you're going to get the people you want

if you're just gishg money, and I think people who are interested and see the dniw of this

kind of practice will go so long as the compensation is fair...I thmk protechg time and

Lifestyle M i s more important." Respondent Nie afso agreed that physicians need to be

going to niral areas by their own choice.

The responses nom rny respondents suggest that there are many factors in the

financial sphere that influence practice location. However, it is interesthg to note that my

respondents did not place importance on hancial compensation. The primary concern,

financiaily, was to be debt-fiee. Four of the seven respondents who said that incentive

packages were important only to pay off loans were students and another two were residents,

thereby supporthg my hypothesis that the students in my sample would be partidarly

concerned with issues of debt. Financial considerations play a part I the decision making

of physicians, but the respondents in my study were not mofivated by money.

There seems to be, based on the fiterature, a perception that mal physicians place a

lot of weighr on h c i a l considerations when decision-making about practice location.

Mostiy, that consideration is perceived to be about being compensated for the hardships of

mrai practice. However, my respondents were not soleiy concemed with being compensated

financidy for their work in rural areas. While money was important, particdady to those

respondents concerned with paying back loans, it done was a key variable in th& decision

about practice location. The reason for the discrepaacy between what 1 expected to find and

what I did fhd is this: Rural physiciaas are concemed about money, but without

understanding the context for that concem, we assume that they just want more ofit and that

ifthey don? get enough, they won? go to rtuai areas. Once placed withm a contact, we see

55

that the reason people are concemed about money is because tuition fees are rising resuiting

in increased debt for medical students. These physicians are essentiaily forced to focus on

money due to the debts that they m s t repay upon graduation That is not to Say that the

physicians and students with whom 1 spoke do not feel compensated for their work. hdeed,

they expect to fed compensated by the quality of interaction that they have with their

patients and that outweighs questions of remuneration. Traditional Literature in this field

gives us a false understanding of the financial sphere. This k of grave consequence

conside~g that the financial sphere is the one most focused on by government policies.

Understanding the social context of the &anciai sphere sheds iight on the reasons

why decisions are made in the financiai sphere. As we have examined this sphere in the

literature and through practical research, we see the interrelationship offinanciai incentives,

debt and tuition fees and how they combine to influence decision making. We also, in

understanding this relationship, are in a better position to suggest changes that might

improve recruitment rates of physicians in rural Ornario.

Seetion 4.2: Penonal and Social Sphere of Consideration

RecnUtment iiterature, as discussed in Chapter Two, identifies several factors that

beiong to the persunai and social sphere of consideration, Personal considerations indude:

a prefnence for living in a niral uea, and rurai origh Not ail ofmy respondents are of rurai

ongin, although all are interesteci in niral rnedicme. 1 expea that they wiU have an interest

56

in a rurai l i f i l e . Social considerations include: social isolation and la& of anonymity mie

to the social roIe that a physicim occupies in a rural c o d t y . 1 q e c t that my kdings

wül &or the literature with respect to anonymity and social isolation

Section 42.1 Personal Considerations

Fie respondents reporteci that they were initially interested in nual practice because

they sought a nual lifestyle. Rural lifestyle was defined by: outdoor actMties and recreation

(n=5), safety (ne), no cornmuthg (n=2). These h e respondents were interested in

practicing mally before it was presented as an option in medical school. Respondent Two

said:

Living in a rural area is probabiy one of the most important things,

it's one ofmy maui goals, 1 want my kids to gmw up without having

to worry about cars and bad people and 1 want them to be able to

swixn in the lake when they feel Wre it and skate on the ice in the

d e r and that kind of thing

Respondents whose social conte* included the srperîence of Gviog in a niral area,

perceived the characteristics of rurai living as positive. M e r characteristics that have been

identified as negatiw in the literature were eithex not mentioned or were outweighed by the

advanfages. For exampIe, Respondent Three, a medicai student, acknowIedged that people

are concemed about the opportunities available for children in nuaI areas. HaMig grown up

in a mal area, she suggested that people supplement th& children's education with specialty

camps, iike one for music if the music program at the child's achool is not adeqyate. I

suspect that people who grew up in rural areas are more kely to problem-solve and find

solutions rather than people Eom urban areas who would see that as an obstacle.

Another factor mentioned in the iiterature is mal origie Recaii that in Chapter Two

I indicated that recent snidies suggest that physicians who are fiom rural areas tend to stay

longer in rural practice. I found support for this claim in my study. For example, Respondent

One suggested that:

"[the solution to rural physician shortages] starts with recruiting into

medical school. The more we try to get people into medical school

who are boni and raised in niral areas, the more we'ii keep people out

there in the long term, I've met very few people fiom Toronto who

will stay long term in rurai because it's just too different, the lifestyfe

becomes dependent on city amenities, pretty huge change to rural

area"

Respondent Four also said that people ftom rural areas are the best candidates for rurd

practice. Neither wexe fiom a rurd area, but both intendeci to pursue rurai practice.

Respondent Nme, who had intended to pursue a niral practice but changed her mind beçause

of ber partner's employment restrictions, was not fiom a nual area eithw. She started

medicai school with an interest in undersewiced populations and had good expexiences

working in rural areas. Respondent Ten, who aiso grew up in an urban area, did not start

medical school with an interest in rural medicine. Her interest was sparked by a six-month

mal i n t d p in famiiy medicine: "1 was surprised that 1 enjoyed t because 1 had done a

f d y [mediane] rotation in an urban area and hadn't enjoyed it as much. It was both a job

and a setting that suited my personabty". Clearly these respondents' urban backgrounds has

not prevented thw interest in nual practice.

Ifmai origin is so important, how is it that my respondents fiom urban areas express

the same interest in rural medicine as do my rural ongin respondents? Once again, the

answer lies in the social context. 1 propose that rural origin is a fmor in retention because

it prepares physicians for k g in the social world of a rival community. Many people, rural

and urbaq enjoy outdoor actMties, but the intimacy of social interaction in srnaiier t o m s

can be daunting for an unprepared physician. Further research is needed to determine why

mai origin is so important. If1 am correct in my proposition, the solution lies in exposing

and preparing medical school for the social and personal reakies of living in rural areas. A

physiciaa's personalay (as weii as his or her f d y ) rnust be predisposed to k g in a mai

area, but personalities are flexiile when &en a chance.

As is expressed ni the Iiterature, respondents reported that among the most

disadvantageous aspects o f d medicine were challenges relating to f d y - The primary

concem among this grouping was finding employment opportunities for the physician's

spouse or significant other. Respondent Nine, a student had intended to pursue a career in

59

rurai medicine, but decided aga& it because her fiancé's work necessitates that he h e in

an urban setting.

Other fdy-reIated concems revolved around educational and recreational activities

for children. Respondent Fie, a f a d y physi- who is preparing to return to rural practice,

noted that she and her family will not stay in a community ifit does not meet her childreds

educationai needs. Concem for a spouse or partnefs happiness ako Wuences physician

practice location Respondent Six observed that it can be hard to negotiate between one

partner who wants to Live in a rural area and another who does not. In her expenence, the

partner with rural interests is usuaiiy the one to compromise: "...a just seems too cruel to

drag your urban based partner out into the country where they can't do mything". From an

h@oricaf perspective, the consideration of spousal happiness is a fairy new one. Today,

increasing numbers of couples iive in two-incorne househoids and both partners must be able

to work. As Respondent One noted, "In 1965 nrral doctors were unmarried ... males who

couid go anywhere and ifthey did have a wife, she didn't work."

Section 4.2.2 Social Considerations

Another problem that physicians cite as being a deterrent nom niral practice is the

Iack of anonymity that physic=iiins Etce. Respondent Ten said: T o u almost become like a

ceiebrity in a small tom". To îlhstrate her point, she telis a story about meeting with an

unmarri& male physician with whom she hoped to work They met for lunch in the d

60

tom in which he lived and worked. She was aware thoughout th& meal that people were

watchmg and talkuig about them Before long, she explaine4 ruraour had spread that the

unmrried tom doctor had a girIfnend. It is a common stereotype that people living in rural

towns know everything about ali the other people h g in the t o m This stereotype seems

to take on another dimension when the person being taiked about occupies a highiy visible

social role such as town doctor.

Respondent Seven explained the dificuity associated with the role ofnual doctor:

"if you're the oniy physician in town you're singied out in a way and it's off en ciifficuit to

get away fiom your work enwonment - everybody in the community sees you as a

physician. People expect you to be a physician whenever they see you". In other words, there

is no chance to take on the role of neighbour or feiîow citizen because the physician role is

so penrasive. Respondent Seven explained that it is ".. .challenging to never be able to leave

that role [of physician]. You are aiways the doctor and never the guy next dooi'. Respondent

One had similar experiences to share: "... when you're the doctor and you're out at the

grocery store you can get cornered and asked questions about lab tests or what not."

Recd the discussion in Chapter Two about the doctor-patient rdationship and how

it is different in in mal setbg. In an urban setting, physicians and their patients rarely see

one another outside ofthe doctor's office. In niral areas, physician's patients are also their

fiends and neighboun.

AU of my respondents commented during the interview that the doctor-patient

relationship is different in rural settings than it is in urban settings. Feelings were mixed

about the potentiai advantagle or disadvantage ofthe merence. Respondent Four commented

that "[olne of the things that happens in a small place is that you ... see people at work, you

bump into them at the grocery store...".

While the majority of respondents spoke favourably of the more imrolved relationship

that mal physicians have with their patients, Respondents Two and Six expressed ambiguity

about the relationships. Respondent Two said "...you might be treating people who are yow

fiends and neighbours and that can be tricky". Yet another Respondent, number Four,

accepted that fact as an integrai component of ruraI practice: "Treating people you know is

just part of the package, and that ifyou are not cornfortable with that, then rural practice may

not be for you".

A more involved rdationship between doctors and their patients is accentuated by the

very visible role that the rural physician ocnipies within a community. The high status of the

physician role can be isolating The professional isoiatioa that was identified as being among

the most challenging aspects of rural practice, is minored by the sense of persona1 isolation

that some rurai physicians experience. Respondent Six shared this:

C[t is] not just the professional isolation [that c m be s c q ] but the

personaI isolation is reaIIy Eghtening especially for people who have

nwer hed in a small town, and even for those who have, to go back

as the doctor, one of the higher statuses in town, ifs a different life

you're living than when you're just in high school. It's a whole, sort

of, social change that 1 think cm be reaily isolatkg.

In addition to being a "higher statusy' role, the local physician can also suffer nom

lack of anonymity which can be hard. Respondent Five reported that a nual physician can

end up feeling that "...you7re in a fishbowl because you work and socialize with the same

people". They noted that physicians are watched in a way that other residents are not

It is interesting to note that there seems to be some contradiction in terms of isolation

and lack of anonymity. On the one han& physicians report that they feel isolated from the

corn- in which they practice. They feel, as Respondent Six expresse4 that they are in

(or are perceived to be in) a higher social class than other residents. As a redt , they feel

isolated. At the same tirne, however, physicians report that they d e r ftom a lack of

anonymity in nuai areas. In other words, they are not isolated enough. While this may appear

to be a contradiction, in fact it is not. It is, however, an interesting commentary on the

personal and social sphere that nirai physicians may experîence. Perhaps the very reason that

they feel isolated is because they are such public figures occupying prestigious social roles.

My respondents reports echo the literature as discussed in Chapter Two.

SirnirarIy, physicims must be prepared to deai with a more familiar relationship with

patients than they are used to in uhan areas. Medicd schools train physicians to work in

d a n areas and within a compatible doctor-patient relationship. The distance pIaced between

doctors and patients rarely exists in niral areas and physicians must therefore be trained

accordingiy.

Section 4.3: Professional Sphere of Consideration

Characteristics of the rurai doctor-patient relationship as discussed in Section 4.2.2

are also relevant to the professionai sphere of consideration. Ln the sociaVpersonai sphere,

the impact of the doctor-patient relationship is seen in the social isolation and lack of

anonymity tint the physician may feel. The social role of 'nual physician' k a ciifficuit one

to leave at the office - it seems to follow m a l physicians through dI of their social

interactions. Likewise, the breadth and scope of rurai practice is Iarger thaa urban practice.

I expect my respondents to indicate that rural medicine is distinct fiom urban practice. As

they are aiI interested in rural medicine, 1 expect that they wiIi perceive those distinctions to

be positive characteristics.

4.3.1 The Doctor-Patient Reiationship in a Rural Setting

W~Rbin the professional sphere, the impact of the doctor-patient relationship is

slightiy different Ln this sphere, we are more coacerned with the power dynamic imrohred

m this relatioaship as weil as the impact that tbis power dynamic has on both the quality of

patient «ire and the satisfaction and lidfibnent that rural physicians get fiom their practice.

64

I propose that the power dynamic is different in niral medicine than it is in urban medicine

because ofthe more familiar nature of the relationship between doctor and patient. Does this

imply that the doctor-patient relationship in a rural setting is more egaiitarian? I suggest that

it does. Furthermore, I suggest that the quaiity of care that patients receive is better when the

doctor-patient relationship is less power &en.

Respondent One agrees that patients in rural areas benefit fiom a f d a r relationship

with their doctor:

I think people, whether they reaiize it or not ...g et better care in

s d e r centres, because the big merence [in a rurd area as opposed

to an urban area] is that you tend to see the same doctor each t h e

[that] you're cared for ....[a a larger centre care tends to be more

âagmented because t's easier to go out and p a s the problern on to

a specialist or [to mother] heaith care worker.

He eiaborated by telling a story about a patient who went to see hÏs famiy doctor for a minor

surgical treatment. In an urban centre, Respondent One expiained, the f d y doctor would

have referred the patient to a specialist - in this case a surgeon - but there was no one nearby

to whom he couid referthe patient. Instead, he agreed to pedbm the procedure but spent the

evming before leanüog how to do it.

Whüe Respondent Two acknowledged that knowing your patients as fKends and

neighbows cm be ''tricky'' she &O indicated that it can improve the quality of care that they

receive: "...a person's social, psychologicai and emotionai background cootntbutes to their

heaith, if you know [what that background is then] you're in a better situation to help them

decide how to manage theh heaith properiy".

Respondents reported that rural practice would be more sati@ng than urban practice

because of the more familiar relationship that they would have with their patients. This claim

was based on their rotations and electives in rural settings. Respondent Niue identified that

diifference as an advaotage to nuai practice:

[the rural physician is ] more Likely to know patients on a persona1

Ievei and not just professon ai.... the relatioaship seems to extend

outside ... the chic, so it seems a lot richer. ..[As a r d t of this

relationship,] people reaiiy know their docton as people in a

comprehemive sense, they feel that this person knows them weU

[and] seem more content with the quality of care they get.

I was unable to ascertain why some physicians felt that a more Familiar relationship

was positive and why some felt t was negative. If1 had to hazard a guess, I would Say that

those physicians who see that as a positive t b g are less concemed with maintaining the

traditional medical power structure (which places doetors at the top and patients at the

bottom) tban those who express discodort with having a more famüiar relationship with

the^ patients. The distinction aho seems to lie in whether or not a physician feels that he is

part of the commumty (as does Respondent Eight, who has been working and h g in the

same community for sixteen years) or feels iike an outsider - someone who is "living in a

fishbowl" to use the words of Respondent Five.

Although 1 did not see this in the iiterature, through my respondents I bave developed

an understanding that the hierarchy of rural mediane is very different firom urban medicine,

and that d doaors see that as a good thing. Respondent Four commented that "[olne of

the thiags that happens in a small place is that you ... see people at work, you bump into them

at the grocery store...". The relationship between a rurai phpician and his or her patient is

less likely to be limited to soldy a professional one, as is the nom in urban centres, because

both parties are iikeIy to have occasion to interact socidy in addition to their professionai

interaction. The social distance between physicians and patients in mal areas is therefore

smaller than in urban areas. In Section 4.2,I discussed the implications of this relationship

on the personal and social sphere. There are also implications of this Merent relationship

in the professional sphere as it influences physician satisfaction and feelings of fulfillment

provided by rhat relatiodip.

4.3.2 The Broad Scope of Rurai Practice

My respondents reported that one of the most important fiictors scplaining thek

interest in nnal medicine that was that nual medicine offered practice characteristics that

67

urbau medicine did not. AU of my respondmts expressed a belief that family medicine has

an expanded role Ï n a rurai setting because rurai physicians are imrohred in a greater capaQfl

in their patient's medical care and overaii welI-being. Rurai practice, they said, is broader

thanurbaa praaice because the rurai physician works without speciatist back-up. As a remit,

nual physiciaas are invohred in more stages of their patients heakh care than urban

physicians. Rural physicians, for example, are more likeiy than urban physicians to have

hospital admitting privileges. Respondent Eight (a male) said that this ailowed him to foflow

his patients fiom the office into the hospitai and back into the office again. The scope of mai

practice is broader than urban practice and therefore niral physicians are able to be more

iavoIved in thei. patient's care. Respondents used the words rewarding, challenghg,

interesting, comprehensive, and varied to descnie rurai praaice. Respondent S k said:

"[A niral community is] a place where you can sort of be the true

well-rounded physician..the old-fashioned doctor where you really

get to deal with a whole variety of things, see a variety of things, and

I think it's one of the best situations in which to get to know your

patients as a whole and not just see a d part of them. 1 think that

there's a lot of oppominity for variety throughout your career, more

than there couid be in a city."

Respondent Four expressed a similar sentiment when she noted that rurai practice enabled

her to "...becorne the doctor that 1 went to medical school to ben.

CLeuIy, my respondents feel that they benefit fiom the expanded role that they play

in their patient's medicd experiences. This is also identi6ed in the literature as king an

advantage of rurai practice. 1s it also an advantage of being a rurai patient? Do nual patients

receive a higher quaiity of care than urban patients because their f d y physician knows

them better and accompanies them M e r in their medical encounters? Doctor-patient

relationships have been the abject of study and andysis for a long time, however this aspect

of rurai health care requires M e r investigatiod2. Two of my respondents Mt that nual

patients oaen did receive better care. Care is less fkagmented when a d e r number of

physicians are overseeing a patient's treatment. Respondent Eight used the tenu "cradle to

grave" to refer to the longitudinal aspect of rurai medicine.

Interestingi~~ whiie ali respondents said that the broad scope of rurd praaice was

a positive thing, three also indicated that it was intimidating. The respondents who expressed

intimidation were ail medical students which suggests that there may be a relationship

between experience and confidence, which wouid be reasonabIe. Whiie some respondents

indicated that the professional independence or isolation can be a good thing othen notes

that it can be a scary thing. Respondent Six said: "Medicine is an apprenticeship, you are

constantiy learning nom people who are above you and around you. The thought of sort of

tmcking out to this two-doctor t o m is terriQing because we're aiways in training

nThe impact of the doctor-patient relatioliship on the quality of nrral health care is a subject worthy ofimrestigation. h i e to the M e d scope of this work I am unfiortunately unable to address the topic M e r at this tirne.

surrounded by other people .... It's redy scary to thllik of going off and doigg evuything on

your own". Respondent Nie added: "It's very amiety provoking to be out there treating

patients on your own 1 think a lot of us have been brought up more on the system of

collaboration rather than iodividuality".

Respondent Nine cleariy summarized yet another distinction between rural and urban

medicine. Smicturaily, Western medicine îs based on a "system of coilaboration" in which

docton are trained in specific areas of expertise. FamiIy doctors, trained as generalists, act

as front-line personnel in the medical system. Due to a lack of speciahed knowledge, one

of their jobs (in an urban centre) is to refer patients to specialists. Rural f d y physiciaps

often work in an independent system because there are few other health care speciaIists with

whom they can collaborate. Therefore, they require a more extensive body of knowledge

than urban f d y practitioners. Rural fiimily physicians need to be tmined as generaiists, and

they dso need training in sorne key speciaities.13 Clearly, if we continue to train physicians

who are able to oniy work within a coiiaborative mode4 we will never have enough doctors

to work competentiy in rurai areas. Physician training for rural doctors mst reflect these

differences in rurd practice.

Wetermining which speciaities shouid be inciuded is a task bener lefk to niral physicians, who know tfieir own tra8iing needs .

4.3.3 Less Support and More Responsibüity

Io Chapter Two, the broad scope and independent nature of niral pradce, descnied

earlier as an advantage by ail of my respondents, is also desaibed as a disadvantage of rural

practice because it resuits in greater respomiility being placed on the shouiden of nual

physicians. The tendency for nird physickm to have more responsiîiIity with less support

than urban physicians was the main disadvantage reported by all of my respondents. For

example, they cited that the number of hours worked per week tends to be high, and getting

time off for vacations or Continuhg Medical Education (CME) is difncuit. Respondent One

noted: "...you are busier than you want to be and it is really hard not to be". On-cd

Eequency cm be high, and Respondent Two claimed that it is often untenable. Another

respondent noted that it is "harder to set Limits" in a nual area because there is no one else

to take your place. Respondents also indicated that there can be a lack ofprofessional support

in rural areas. Lack of specialty back-up, limited access to lab tests and diaeostic tools make

rurai practice more chdenging than urban where ali of those facilities are r e d y available.

These challenges can be severe, particuiarly if, as Respondent N i e stated, "you [the rurai

physician] are unsure of your skiiis". How can physicians become more sure of their skills?

Part ofthe answer to that guestion emerges in the Educational Sphere of Consideration when

it cornes to exposure and training.

Being isolated and without back-up has also meant to some respondents that

engaging in CME has been diflicuit. However, Respondent Eight has found that improved

71

communications technology, such as the Internet, have made accessing CME programs

easier. Any training that requires travelling, however, remains difficult to manage. Because

most teaching centres are atnliated with urban hospitals, incorporathg an academic

component into a rurai practice is auother challenge. Respondent Five, who is planning on

rewning to a mal practice f?om her current position in an urban setting explahed: "[what]

I wiiI miss more than mything is the regdents, the teachiag, the academic part. There is very

M e opportuniv [for] teaching and positions in mal settings. That's the hardest thing to

leaven.

As 1 suspected, my respondents mirrored the fiterature in their thoughts and concerns

within this sp here. Rural medicine, they felt, is distinct fiom urban because the doctor-patient

relatioaship is more famüiar, the breadth and scope of rural p h c e is greater in niral

practice; nuai physicians operate with more respoosi'biiity and less support than urban

physicians. 1 was also correct in expecting that those differences would be perceived as

positive attributes to my respondents. Not surprisingiy, nobody mentioned incorporahg

other ideas like training other people to provide basic rnedicai services. Social control is an

important part of the profkon of medicine and I anticipated that few people, ifany, would

volunteer to open the doon to outsiders.

Section 4.4: Educational Sphere of Consideration

Within the Educational Sphere of Consideration, six questions emerge as idluential

on rural recnùtment. First, how is exposure important for people who end up pradchg in

nual areas as weil as for those who never do?. Second, what profiie does rurai medicine bave

in medicai schoois? Tbird, does medical school train students adequateiy for niral practice?

Fourth, who are the students in medicai schools? Fiifth, what is the impact of early career

decision making on d retention? F S y , examining CME: what oppominites exist for

education after medical school?

In the iiterature, exposure to rural medicine during undergraduate medical training

is emphasized as an important factor in niral recniitment. The types of exposure rnost

commody refened to are rurd ele&es and rotations. Both imrolve the medical student or

resident spending time (a few weeks to a few months) working with or shadowing a rural

physician in his or her practice. E l d e s and rotations give the snident a chance to see what

nual practice is redy like and dows them to expesience working and living in different

c o d t i e s . 1 suspect that my respondents will report that being exposed to nrral medicine

early in medicd training influences practice locatioa AII of my respondents have an interest

in rurd medicine and 1 suspect that they aü had d y exposine to niral m medical schooL

Swen respondents (Two, Three, Four, F N ~ , S k Seven, and Nine) reported that

exposure to a rural medical setting during their medical training had launched their interest

in nual practice. Of those seven people, three were from rural areas and four were fiom

urban areas. The most common exposure ocaured d u ~ g undergraduate medicd training

and consisted of rural electhes or rotations. As undergraduate students, they went to nird

comrnunities to work alongside the communities' practichg physicians. The time period

lasted anywhere fi-om several weeks to six rnonths. m e r respondents reported that they had

spent rime in a nual community during their residency training.

Res pondent S even was one person whose interest in rural medicine was develo ped

due to his experience in an elective. Respondent Three noted that:

... it was really interesthg to watch that first group of students go out

into rural areas because a lot of them reaiIy weren't lookhg forward

to it, [they were] w o n d e ~ g 'What am 1 gohg to do there for 2

weeks?', Y s this going to be a h g ? ' , 'Oh my gosh look at where

bey sent me' sort of thùlg. The fact that it was rnandatory, I thllik,

reaily annoyed quite a lot of them But when they came back nom

their two weeks it seemed to me, 1 didn't hem any negative

comments. It seemed to me that everyone enjoyed themselves

immensdy. l4

'This qpotation fiom Respondent Sevm leads us to wonder why levels of recniitment are stilI low astudents are enjoying their experiences in niral areas. Further research is r+ed in order to adequatdy answer that question

Respondent Four, who grew up in a suburban neighborhood, dso found that working in a

niral area der her first year of medical school was very important. She was i n f o d y

exposed to niral medicine in medicai school through classmates who were fkom mai areas.

R d medicine had no formai presence in her medical school at the t h e that she was a

student there, in the eariy 1990's. She summarized the importance of eariy exposure by

saying: "lfnobody ever tells you that [mal ~edicine] is something you can do, then you're

never going to consider, so there are some people w ho are lost before the game even starts".

Four of my respondents felt that exposure to rural medicine is advantageous to those

people who wili never practice in a rural area for two reasons. First, shidents who go to rural

areas seem to have a more hands-on experience than they do in urban areas. in other words,

the student Ieams more and is an active participant rather than a passive spectator. Recaii

what Respondent Two said:." ... medical students who go into rural areas have very good

experiences, they do more, see more, participate more, and generally leam a lot more than

[they do] in [urban) centres where they're at the bottom of the totem pole". Respondent

Three had positive expenences m nual areas: ".A was excellent, the teaching and hands-on

experience were always excellent".

Earlier in this chapter, 1 discussed that the dobor-patient dynamic in rural areas

represents a different hierarchy ofpower than is usuaiIy seen in tirban areas. This hierarchicai

difference emerged fiom comments f?om some ofthe medical students wah whom 1 spoke

75

about the a d m g e s of behg a medical student in rurai areas. Two respondents, both

medical students, noted that doing a rotation or elective in a nual area as a medical student

presented advantages over urban-based Locations because students are more likely to have

more hands-on experience in a rural settïng than they are in an urban setting. Respondent

Two commented that "...medical students who go into rural areas have very good

expenences, they do more, see more, participate more, and generdy leam a lot more than

[they do] in [urban] centres where they're at the bononi of the totempole. You're right there

in a rural setting" [emphasis added]. Respondent Three said that mal practice is "an

excellent venue learning as you get to do a lot of hands-on work" as opposed to urban

settings where the amount of hands-on work is limited.

Second, exposure leads to a greater understanding and respect of nird medicine and

works towards changing the negative perception of it that some people have. Respondent

Fie explained: "once people are exposed they develop more respea for the system [of nual

medicine] as a whole". Respondent Four feels that it may be even more important for people

who will never practice in rurai areas to be exposed to m a l practice:

I've had people say [to me],'Oh, 1 went somewhere like that [a niral

area] when 1 was in training, oh my god ...' I'rn so glad I'm not

there..l'mjust so pleased ifs not me out there' and that's fine, that

persons never going to work m a nnal area But ifthey can be nice to

somebody who's working in a nual area, thaî cotmts just as much

4.4.2 The ProfiIe of Rural Medicine in Medicd Schoot

The respondents quoted above beiieve that there is a misrepresentation of rural

medicine among r n q people in the medical wodd. It is for this reason that they feel

exposhg riU medicd students to mal medicine is so important. How is nual medicine

represented in medical school? What kind of profle does it have? 1s there a bias agaimt

niral medicine? What we are taking about here is the distinction between formal exposure

and informal exposure. Formal scposure may take shape as rural elective progtams or

lectures. Formai exposure is what is most often tatked about in the literature. It influences

the conte* in which medical students make decisions about their practice because it presents

mai medicine as an option that some people might not have thought of on their own. In this

way, most of the formaf exposure that medicai shidents receive is positive. Informai

exposure is not quite as clear cut. It may be, as was the case for Respondent Four, other

students in the class. Or, it may be the attitude that facuity members express when

Respondents indicated an interest in niral medicine. It m y ais0 be seen in the degree of

diflicuity or ease with which information about rurai medicine can obtained by mident.

Respondent Five fdt that there was an urban bias at her Ontario medical school and

that it was evident in the nanow definhion offamüy medicine that they employ: "The famiy

doctors that we see are urban famüy doctors and that is very different fkorn [d f d y

medicine]. We do get some perspective of patients in those areas but you never have a

chance to see what it's Jike as a physician in those areas" (she works with the Queen's rural

77

outreach pro- to change that). Respondent Niue was in the nrst class of her medical

school to be exposed to rural medicine. She noted that the way nual is sometùnes portrayed

@es it a negative image. Respondent Ten feds strongiy that the training that medical

shidents receive does not support rural medicine: "Part of the reason you don? have

physicians jumping to go out into rural settbgs is because they're not being trained to do

that". People who pusnie an education in niral medicine (through eleaives for example) do

so ". . .despite the training [in medical school], not because of the training". She fdt that her

medical school did a poorjob of providing her with menton. She desczibed a lecture that she

attended early (1st year) in her education where the key speaker denounced mal medicine.

She finished by saying that

... there are eager people lin medicd schools] who want to be the kind

of doctor that this province needs, and a lot of us are turned off by

what happens in the universities and in the training. I guess it's just

assumed that we [doctors] ail have the training and that we just wak

out [of nual practice] ... 1 almost feel like there's this portrayai of us

as these seffish people that all jus want to stay in the ciq and work

fÏve hours a day.

4.4.3 Training

Part of the reason why exposing students to the possiility of nual practice is

important is because it helps to prepare them for the parûcular demands that a ntraI physieian

faces. I suspect that the perception ofpreparation is positiveiy associateci with confÏdence

leveis. Some respondents said that they feIt prepared by their medical training and others did

not. Respondent Eighf for example, reported that he had done an additional year of training

in a rurai area and as a resdt did feel prepared for rural practice. He has noticed, however7

that medicai schools do not seem to be training people for what the will have to be doing as

mai physiuans:

Family Mediane programs are doing a poor job of p r e p a ~ g

[students for nual practice]. They finish residency and think that they

can practice in a rurai se* until they come out here and find out

what we do, and then they can't do it because they don't have the

skilis. They've been trained to practice in an urban setting.

Among those who did feet prepared, Respondent One admitted that he felt

"reasonably prepared" by his undergraduate and residency training. However, he added that

"I've corne out [of medicd schoof] feeling there are a few skiUs that 1 just haven't

developed". He added that he hoped to develop those skills on the job. Respondent Three did

not feel prepared, although she noted that she was in the Iast year before a c&cuium change

that incorporated more rural exposure. She noticed that the group following hers (who had

benefitted nom the dm change) tended to have a more positive outiook on ruraI

practice than did her immediate cohorts. Respondent Ten does not feeI that current training

programs prepare aspiring physiMans for acute case or, subsequently, for rurai practice. She

noted that her school did a poor job of providing mentors for students who were interested

in rurd medicine- Respondent Four reporteci that the medical schooI that she atteaded did not

provide direct exposure to rurai medicine, however she did get some exposure from some

ofthe other students in her class who were fiom rural areas. Respondent Six expresseci that

the reputation that the medical school that she is cunently attending has for beùig rurayt

oriented is not entirely deserved. Respondent Seven reported having more trouble than he

had anticipated trying to get some skills for rurai medicine in an urbm residency program.

Respondent Two summarized what she felt medicai schools should be doing to prepare

aspiring rurai physicians: "...training for rural medicine has to entail being trained for what

you wili be doing ...[ medical schools] need to get people prepared for an environment that

is maybe more hostile and Iess supportive".

Not all respondents agreed that it was even the role of medical schools to provide

training specifïc to rurai or urban settings. Respondent Five stated that exposure to nual

medicine, as opposed to training, is what a medical school can do. She was exposed to d

medicine in her undergraduate studies, but did not fed that she had the same exposure during

her residency training: 9 don't think that it necessarily did [provide rurai exposure], but 1

think you can do a lot with a residency program ifyou have the foresight to know that that's

what you want and you create it within in". Respondent Seven s h e d ber belief that

undergradtuate medicai trainmg is too generai to be considerd preparation for mai or urban-

based practice.

Recall the importance of nual O on physician retention. Rural origin is an

important consideration in this sphere as weil because we need to examine not ody what is

happening in medical schools, but who the medical students are who are behg iduenced.

Respondent One feels that the way to improve ruraI retention is to get nirally-raised

people into medical schools. Urbanites are unl.keIy to stay, he says, because the ciifference

between rural and urban is too great and the change is too much to bear. Respondent Two

dso feels that nirai origïn is important: 'My expenence and the experience of other rural

students is that [medicine] is not an option, it's just not sornething really thought about by

mai students ...if you're a smart kid fiom a rural area you go into Education". Why would

nual students fed Iess hciïned to pursue a weer in medicine than urban students? Because

medicine is so urbady biased?

Respondent Three expressed concern about tuition deregdation and the impact that

it wodd have on admissions:

... one of the things that it's going to do, in my opinion, it's going to

bias admissions towards saidents fkom urban areas to begin with. If

you are starhg to bias your pool of appiicanf~. ..towards people fiom

wealthy fhdies and from urban areas, I think you're goma have Iess

success in getting those urban raised people to consider rurai practice

and to stay in rural practke.

Are high school students in rural areas at a disadvantage compared to urban high

school students? Do mal high school students receive a poorer quality of education than

urban students? Respondent Three, a medicd student who went through the nird high school

system believes that "education is what you make of i f . She adds, however, that "...most of

the physicians I've met, and a lot of my classrnates, doubt that the mal education system is

very good". She was not sure what caused the bias. As I reporteci in Section 4.2.1, she

suggested that education cm eady be supplemented by summer programs, like specialty

music camps.

Respondent Six thinks that "...mal kids in high school need to know that medicine

is a great career and that it is totally attainable. the support systems need to be in place to

make that me, they shouldn't ... have to be rich, they should be weU supporteci by their

communities and by the greater community of Canada"

4.4.5 Earty Career Decision Making

Two respondents stated that the pressure onmedicai students to make decisions about

their careers eady in th& training is disadvantageous to rurd medicine. Respondent Four

said "[m]ore and more people are behg forced to make decisions eady on in theh medical

school training - it's crazy, medical students are having to get research papers published in

order to get into the residency [program] that they want and 1 think that is really going to

have a negative impact on people's abilities to do electives in nual places." Respondent Six

expressed concern about the implication of early career decision making on rural

recruitment :

... even by second year [of medical school] we feel the pressure [to

decide on a career path]. To pick rural medicine at that point [*in fist

year] is a pretty big thing to ask someone to do. People are having to

make decisions too early, and it's really hurting rurd Canada.

Cbapter Fie: Condusions and Recommendations

Hedth care in rural Canada is in crisis. Rural c o ~ t i e s struggie to remit and to

retain physiaans. Whüe the recruitment and retention of niral physicians are problems facing

the entire country, this thesis has focused on the province of Ontario. In Chapter Two, 1

ideatified the factors commonly reported as king important to physician recnlltment. 1

ingoduced a theoretical fiamework cded Spheres of Consideration that clarifies the social

context in which those factors exist. In Chapter Three, 1 discussed the methodology

employed in obtainiog my data. Telephone in te~ews with five undergraduate medical

students, three resideats, and three docton M e r iaformed the discussion in Chapter Four.

In this chapter 1 offer my conclusions and recommendations for mal communities,

govemments, the medicd comrminity, and for m e r research.

5.1 Financiai Sphere of Consideration

5.1.1 Conclusions

In Chapter Two 1 introduced literature on remuneration, hanciai incentivees, debt,

and tuition and discussed how they influence Mal physician recrnitment. In Chapter Four

I compared my hdings fiom Chapter Two with the hdings nom my intemiews.The results

of my study indicate that phyScians who choose Mal praaice do so because they are dram

to its practice cfiaracteristics, not because of the remuneration or financiai incentives that

84

they receivel? Many current efforts employed to remedy the crisis in niral health care

overemphasize the importance of this sphere which is why the proposed sohitioos do not

work. Physicimtns are mostiy concerned with the hancial sphere if they are students and

carrying a debt and are concerned with paying it off as soon as possible. Furthermore, 1

suggest that financial incentives portray nual medicine as an undesirable form of medical

practice and that this portrayal is detrimental to recruitment as weil as the general practice

of rurai medicine.

Based on news reports, t seems as though physicians generaiiy express a feeling that

their pay should refiect the yean of forma1 training they receive before being Iicensed to

practice medicine. Ody one of the respondents in this study expressed a similar sentiment.

Others felt that medical practices pay weU regardles of whether you are in a rurai or urbaa

location. Finantial considerations were not high on their list of reasons why they would or

would not stay in a rural cornmunity. Two questions ernerge about the role that rnoney pIays

in recniiting physicians to work in rural communities. News reports often refer to saiary

negotiations between doctors and govemment. It seems that the respondents in th& study do

not share the concems of their coileagues. Could that be mer* due to the srnail sample sue?

In part, it is. My sample, as 1 âiscuss in Chapter Three, consists mostiy of medical students

and residents. Perhaps salary concems emerge later in a physician's carrer as being

URecall that due to my d sample, 1 cannot generalize my fïndings to the broader wal medicai community.

important- However, it was a medicd shident who was the only respondeat to mention the

importance of paying doctors well.

Firuincial incentive packages have not sohred the shortage of physiciaos in xurai areas.

According to the respondents of this study, they do not a#ract the nght kind ofphysician to

niral practice. Whiie there is nothhg wrong with compensating physicians who work in rurai

parts of Canada, ninent efforts and poiicies direct the wrong message at the wrong people.

The people towards whom the message is directed are those physicians who are interested

ody in the finaaciai benefits of the practice of medicine. Rural practice requires a high level

of couunitment from its practitioner. Rurai medicine in Canada is portrayed as a convenient

stopping point for physicians wanting to pay off their debts and get on with their hes. Not

aii physicians who are attracted by incentive packages are interested soleIy in the money.

Respondent Five's interest in nird medicine was sparked in part by the financiai

compensation that she received. However, by not acknowledging and providing for the more

serious considerations of rurai practice, even those physicians whose interest is sparked will

lose thek motivation. Incentive packages are a place to start. The danger is that they have

been used in isolation fiom any other effort.

Resources, in this case financiai, are fùmeiied into people who are not going to stay

in ruai areas. 1 propose that those resoufces be redirected towards creating sustainable

worhg conditions for physiciatls who are genuineiy wmmitted to rurai practice. Incentive

packages can be used, but must be used as part of a iarger package and not in isolation. Two

86

aspects of the financial sphere of consideration reqpke M e r attention The rishg cost of

a medical education will exacerbate ment physician shortages. Likewise, the deregdation

oftuition fees wili reinforce an image of medical education as being for the wealthy and eke

members of soûety.

Findy, a note about compensation. Compensation can be made in more than

fiaancial ways. Clearly, the respondents with whom 1 spoke support the notion put forth by

Pope et al. (1998) that we need to rethink the definition of the word. Both the literature and

the interviews 1 conducted demonstrate that physicians who stay in rural practice feel that

the benefits outweigh the drawbacks. They do not express a need for compensation, for they

are rewarded by the work itself. Reducing niral practice to a question of compensation

betrays its unique and appreciable characteristics.

5.1.2 Recommendations for Rural Communities

Communities should not expect financiai incentives to single-handediy solve theû

' recruimient problems. They must ensure that the doctor they recruit has interests in niral

medicine beyond financiai gain A percentage of the money that is mendy ear-marked for

recruitment mi& for example, be used to sponsor their students' medical school

&cation.

5.1.3 Recommendations for Governments

As 1 indicate throughout this thesis, the impact of the financial sphere on nual

recniitment is over-emphhd. Financial incentives are likeiy a permanent component of

niral physician recniitment. However, coercive measures are unacceptable and reflect a

negative and damaging perception of niral medicine. Provincial and federal governments

should re-imrest the tirne, money and energy that is currently directed at this sphere in other

spheres as indicated below. Govemments should work with medicai c o d t y to regulate

tuition and decrease student debt. Likewise, governments should make debt easier to hanàie

for students by, for example, gMng them longer to pay it back interest-ftee.

5.1.4 Recommendations for the M e d i d Community

Accordiug to the resuits of my study, nual physicians feel adequately remmerated

for their work. As a result 1 can make no specific recommendation to the medical comunity

with respect to this sphere of consideration

5.1 J Indications for Further Research

The use of iïmncial incentives is widespread in this, and other, countries. Do

f i n a n a incentives work to keep doctors in nual ateas? 1 suggest, as do rny respondents, that

they do not However, research is needed to more adequateiy amver this qyestioa

88

In this thesis 1 suggest that the message portrayed through the fiequent use of

financiai incentives is that rurai practice is a burden and the only way that physicians would

work in rural areas is if they are paid a lot of money. 1 suspect that physicians with little or

no experience of mai medicine wiIi be infiuenced by this negative image. Research is

needed to explore the ideological message of financial incentives as well as to explore

implications of that message. - the impact of financial incentives: how are they working?

what is the ideological message?

5.2 PersonaVSocial Sphere of Consideration

5.2.1 Conclusions

In many ways, this is the sphere with the largest obstacles because it cornes down to

personal preference - personality. Rural practice is different from urban practice, as the

Iiterature suggests and my respondents concur. Ultimately, it takes a person who enjo ys those

Werences to choose mal practice. The personality of the physician must match the

HestyIe. But more than that, in most cases the personality of the physician's spouse or

partner and children mst &O match the lifésty1e. This brings us back to the idea that we

must r d medical students 6om d areas since they will be predisposed towards rural

Iife because they are EMiliar with R Social integration plays a trernendous role in the

devdopment ofthis c~mpatibility~ Taking on a hi&-profle social role in a small CO&

can be t h g for those physicians who are not prepared for playhg a centrai role in the

social dyoamics ofa smali town.

5.2.2 Recommendations for Rural Comrnunities

Rural communities play a role in the social integration of physicians. Community

members must be active participants in facilitahg this integration. Likewise, community

members must be prepared for the arrivai of a new physician. They mst understand that a

physician needs to leave behind her professional role when not worklig. 1nd'~chiai nirai

commulzities should work in tandem with the medical community to develop guidelines so

as not to overtax a new physician.

When r d t i n g physicians, nual communities mst dso think of the physician's

spouse or partner and familes. Are there empIoyment opportunities for the spouse or

partner? What educationai oppommities aÛst for children? When a comtlTunity reaches out

to a physicim, f ' e s musr be included.

5 . 2 Recommendations for Governments

Rural physicians are concerned about adable faalites in rurai communities and

govemments can provide fimds to support CO- deveiopment projects. Some examples

of important resources for the commUIUty are: schools, camps, intemet access, hiharies, and

youth programmes.

53.4 Recommendations for the Medicai Commanitg

The medicd community should work with curai communities to help them explore

their needs and expectations of physicians. They shodd dso work together to determine

appropriate boudaries so that the physician will maintain a sense of p h c y . To do so, a

liaison officer shodd be appointeci at the Ontario Medical Association to work with rural

communities, individuai docton and the medicai community

5.2.5 Indications for Further Research

How does the social rote ofdoctor diffa between nual and urban comrnunities? What

are the social and persod implications of a change in that role? How do doctors relate with

other medicd persomel? How do docton and medicd personnel relate to members of the

community? These are research questions that shouid be addressed.

5.3 Professional Sphere of Consideration

5 . 1 Conclusions

One of the reasons that 1 interviewed so few praaicing rural physicians is because

they were too busy to speak with me. The initial response that I had to my request for

participants was good. People were interested, but it was difncult to find a time that was

cornrenient to do the interview. Rural physiciaas tend to have very demanding and somewhat

unpredictable scheduies, so even ifwe made an appointment there wodd be no guarantee

that an emergency of some son would not aise and impede even our vety best efforts to

connect. He& schedules are one chacteristic of the profile of m a l praaice. Another

profile characteristic of rurai medicine is that it is distinct from urban practice. The difference

between urban and mal medicine is seen prirnarily in: the broad scope of nual praaice, the

lack of support that rural physicians face, and the nature of the doctor-patient relationship.

Rural hd th care mst take its place as a viable specialty of f d y medicine and medicai

students interested in pursuing a career in niral health must be trained accordingiy.

Professional isolation is a great concem among my respondents, as it is in the

literature. However, this is a good scample ofhow physicians cari see the same situation very

difrently depending on their experience and perspective. Most of my respondents viewed

the isolation as independence. Contrary to being overwheiming, they saw it as a chaüenge.

I propose that physicians who féel confident in th& medicai skills will be more open to that

92

challenge. Confidence, 1 beheve, develops fiom experience and training. Therefore,

physicians who are trained for the specific rigours of rurd medicine will feel more confident

of their SlùUs.

Part of the unique and distinctive nature that my respondents spoke of is that rurai

practice is more varied and interested. They also spoke of a different, more intimate,

relationship with their patients than urban doctors have. Does this imply that rurai doctors

care for their patients dinerentiy? When rural residents get care, is it of a higher qualiv?

5.3.2 Recommendations for Rural Communities

The suggestion made by Barer and Stoddart (as discussed in Chapter Two) that the

practice of basic medicai services be opened to other people is one that 1 address fidy in

Section 5 -3 -4. That recommendation obviously has implications for rurai communities.

Under such a modei, nuai citizens wiU be responsible for providing basic services. Doing

so requires a great deai of organization and training that requires, above di, dedication on

the part of interested community mernbers.

5.3.3 Recommendations for Govenrments

Govemments must stop ai i coercive mwwres, inchichg forced service and

restnctùig b i h g numbers. Not ody do coercive measures faii to sohre the Fdisis of rurai

93

recruitment, thqr exacerbate the problem by enforcing a negative stereotype of rurai

medicine that is inaccurate. This thesis is predicated on the assumption that the physician

must be the centre ofany heaith care model. That assumption may need to be chaiienged in

order to create sustainable rural health care solutions. Ifphysician recruitment contirmes to

be a problem, will we not be forced to adjust that mode1 to make room for other heaith care

workers? What is the most appropriate and beneficiai role for nurse practitioaers to play in

a rural health model? Might openhg up licensing to other medical p e r s 0 4 be required?

What aspects of the physiciaos' current role may be supplemented by other heaith care

professionais? The application and impact ofthese changes warrant substantial investigation.

5.3.4 Recommendations for the Medical Community

Nowhere is the medical community's role in solving the crisis in rural heaith care

more evident than in the professionai sphere of consideration. The medicine that is taught

and practiced in Ontario, and the rest of the country, has an urban bias that is detrimentai to

the health ofrurai Canadians. R d medicine must be acknowledged as a specialty of f d y

practice. Making niral medicme a sub-specialty wiIi validate its differences thereby changing

its negative image. SpecialiPng m a i medicine wili also make room for changes in medical

education. Students who are interesteci in nird practice need to feel confident in more skilis

than do students ptusuing an urban practice. They must be trained to work in rural settings.

Additionally, rurai physicians work within a doctor-patient reiationship that is more f d a r

than its urban counterpart. Rural physicians have a fUer knowiedge of th& patients) are

94

Likeiy to know th& patients better than urban docton because they know them in various

capacities and not just as a patient. Rural physicians can and shodd be prepared to deal with

those ciiffierences.

5.3.5 Indications for Further Research

Many rural physicians (or aspiring wal physicians) beiieve that the quaiity of care

that people receive in rural settings is better than the care that people receive in urban

settings. Two reasons explain this perception. F i rurai care is less hgmented. Rural

physicians seem to folIow their patients through a broader speanim of their health care

experiences than do urban physiaans. Second, the doctor-patient relationship in a nual area

is not limited to a professional one. Doctors and patients interact sociaüy and therefore know

one another better than they might in an urban setting. One hypothesis worth exploring is

that hedth care in rurai areas is harder to get, but that when people do get it, it is better

because it is more personalired care than they wodd get in an urban centre. If rural care is

better then does that not have implications for the way that care is structured in urban

centres? Does that mean that city dwellers shodd have the kind of relationship with their

f d y doctor that people in nual areas do?

As mentioned in Section 5.3.4, the profile of rural medicine within the broader

medicai conmm&y needs to be changeci. There is a bias against niral medicine, and the main

thing we can do to change that bias is to make niral medicine a specialty There needs to be

95

more research done to investigate how this could happa and what the obstacles are that

prevent it nom happening

5.4 Educational Sphere of Consideration

5.4.1 Conclusions

EarIy exposure to mal practice was important for my respondents, as it is argued in

much of the literature. Threatening that atposure is the pressure on medicd students to make

major career decisions very early in thek trainiag. My respondents added somethllig that I

did not corne across in the literature. Early exposure, some said, was aiso beneficial for

students who wouid never practice in a rurai area. Might this indicate that the process of

professionaIization diers somewhat between regions? As medicai students complete their

education, they leam the scientific d e s that govem the art and practice of medicine. They

also learn the n o m that govem the profession ofmedicine. For example, medical students

leam that they must be emotiondy detached from their patients. In urban areas, medical

midents compete with one another to gain experience. Leaming is often by watching. In niral

areas, according to my respondents, students are brought into the Înner-circle with the

attendmg physician, Leaming is by watching and doing. In short, the type of training that

occurs in a niral area dafers fkom training in urban centres because students are more

bohred. That implies that the hierarchy within the physician's world is Iess pronounced and

rigid in mrat areas.

Physiciam ofrurai origin, as has been discussed severai times in this chapter and this

thesis, are more likeIy to stay in rurai practice than are their urban counterparts. 1 suggest

some reasons why this may be so in Seaion 5.2.1. If nirai hi& school students are to be

recniited for medical schooi, they need fht to see medical school as a viable option. 1

recommend below that mal communities, governments and the medicai community work

together to reach those students.

Youth out-migration is a huge problem in many rural cornmunities. One of the main

reasons that youth cite for Ieaving th& communities is that there are no jobs available for

them. Perhaps if more mai students saw medicine as a viable career choice, we could work

towards solving both problems of youth out-migration and niral physician recruitment.

5.4.2 Recommendations for Rural Cornmunities

Exposing rurai high school students to the possibility of practicing medicine and

preparing them to do so should be the mandate of rurai comrnunities. rinviting physiciaos to

speak to hi& school students, taking students on medical tours, and other special events

support the goal of exposing and preparing students for a career in medicine. C o r n r i e s

should work with goveniments and the medical community to achieve these goals.

5.4.3 Recommendations for Govemments

Govements should work with rural c o m m ~ e s and the medical community to

encourage rurai high school students to pursue a career in mal medicine. Funding and

organkational support can be provided for exchanges between high school students and

physicians.

5.4.4 Recommendations for the Medical Community

Medical schools should recruit medical students fiom mai areas and they should

adequately train the students that they do have. Early exposure to rural medicine in medicai

school is important and medical schoois mua ensure that aU students have the opportunity

to consider a career in rural practice. Creating that oppominity also means that the pressure

on students to make major deusions eariy in their education mst be eased. These steps are

the nrst in ensuring that the urban bias in medicd schools be addressed and changed.

Physîcians hained in a social context that is hostile to mal medicine wiii be iikewise hostile.

5.4.5 Indications for Further Research

1s the process ofprofeSSionaIization in nrral areas different than the process in urban

areas? What are the implications ofa posinbe difference? What barriers, ifany, stand in the

way of niral high school students who wish to pursue a career m nrral medicine? How can

98

medical school be made accessliie to these students? What impact will that have on rurai

recruitment? All of these qyestioos emerge &om my research as worthy of imrestigatio~ I

suggest, in Section 5.4.1, that encouraging rural youth to pursue a career in medicine may

be a step towards solving problems of youth out-migration in addition to improving rural

physician recruitment. The existence and impact of this re1atiooship also warrants

hestigatioe

Five research puestioas guided my research: What issues are cited in the Literature

regarding rural physician recruitment and retention? What issues are cited regarding rural

recruitment and retention by physicians and medicd students? To what extent are these

issues congruent and comprehensive? What is a usem hmework for research into rural

recruitment and retention? What is a usefbl fiamework for policy suggestions to improve the

present situation of rural recruitment and retention? This chapter has been devoted to

answering those questions within the context of four Spheres of Consideration.

Underlying many of the struggles and concerns expressed by my respondents is a

question of the Iepitimaq, perceived or otherwise, of rural medicine within the dominslnt

medid structure. Rural medicine must be legitimized ifphysicians are to see ruraI practice

as a viable career choice. Wrtfiout that legitimacy, rud medicine will not be able to occupy

enough space in medical schools to adequately prepare physicians for rural practice. As an

expforato ry study, this thesis has raised many questions that await fiuther imrestigatioa

Health care was a dominant topic ofdiscussion in the most recent Canadian electio~

Among the topics being debated by party leaders and the Canadians public was the question:

'What is the fiture of Medicare in Canada?'. Many Canadians are concemed that our

Medicare system is deteriorathg into a two-tier system, a system where money shortens

waiting tiines for tests and essentid medical procedures. This thesis has demonstrated that

a two-tier heaith care systern already does exist in Canada While we fight off the

implernentation of a fUiaaciaiIy-based two-tier system, a geographicdy based two-tier

system has aiready replaced the universality of 'our' Medicare. The Canadian health care

system is in crisis, how much longer will it take for us to respond?

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APPENDIX A: INTERVIEW GUIDE

Heiio, this is J e d e r Penow. Thank you again for agreeing to speak with me. Before we

continue, I'd iike to know ifyou would mind i f1 tape record this conversation. (That will

make it easier for me to reflect on your comments). [Start tape now] As you know, I am

doing research for my Master's Thesis on the retention of physiciaas in nual Ontario. The

inte~ew shouid last roughiy 30 minutes. 1 wül first read through a consent form with

yoy to satisfy the requirements of my ethics cornmittee. Then we'll go through a few

questions and end with some basic demographic information. Does that sound okay?

Ptease feei ftee to stop me at any point Xyou have any questions or coacems.

CONSENT FORM TO PARTICIPATE IN RESEARCH

I agree to participate in a program of research being conducted by Jennifer Penow as part

of her Master's Degree under the supervision of Dr. Bill Reimer of the Department of

Sociology and Anthropology at Concordia University-

A PURPOSE

I have been mformed that the purpose of the research is to explore the factors that

improve the retention rata of physicians m mal Ontario.

112

B. PROCEDURES

I hwe beea informeci that this research wiü be conducteci via telephone interview during

which time 1 d be asked questions about my personal feelings regardhg medicd

practice. I understand that the inte~ew is expected to last 30 minutes, although I may

extend that tirne i f1 wish.

C, CONDITTONS OF PARTICIPATION

O 1 understand that 1 am fiee to withdraw my consent and discontinue my

participation at any time without negative conseqyences. I am under no obligation

to m e r any questions that i do not feel cornfortable answering.

O 1 understand that my participation in this study is confidentid (ie. the researcher

WU know, but will not disclose my identity).

O 1 understand that the data fiom this study may be published.

1 understand the purpose of this study and know that there is no hidden motive of

which 1 have not been informed.

DEMOGRAPHIC INFORMATION

1. In what year were you bom?

2. What is your Marital Statu?

3. Do you have my chiidren

[ifno, move to question 41

[if yes move to question 3a]

3a. How many children do you have?

3 b. What are the ages of your children?

4. Have you ever hed in a rurai area before? When and for how long?

5. Where did you do your medicai training? What training did you do?

6.1 wiIi provide you with four income categories. Please choose the category that best

represents your annual gross income:

A: $0-L9 999 B: $20 000 - 49 999 C: $50 000 - 74 999 D: $75 000+

I N T E R . OUESTIONS

QUESTION 1:

What sparked your interest in rural practice?

Probes:

cbildhood cxperieace, popular media, professor, coiieague, fw, £butcial incentives, m a l cxperience,

rnedicai training

QUESTION 2:

What factors were most iaauentiai in decidimg to try rural practice?

Probes:

Did knowing you'd receive more rnoney influence your decision to practice in a mal community?

Befocc your medical training, had you ever lived in a curai ami'? [ifyes] For how many y-? in which

country3 if Carda, in which province? Had you intendeci to retum to a rural commtmity7

What aspects of niral life do you fiud attractive? What aspects of rurai lif'e do you frtd unatûactivc?

What are p u r plans for your professional cxreer?

1s a m a l practicc an asset or impediment to your professionai aspirations?

Was it your choice to be in rurd practice? At what stage in your career did you make this choice? Was it

pur ftrst choice? Why or why not?

QUESTION 3 :

What factors were most infiuentid in deciding to stay Meave rurd practice?

Probes:

1s your partna employed m or near the Commzmity in which p u üve?

Do you think that your partnet is content or not cantcnt livmg in a naal mea?

How do you think t b t your partuer f& about your Ni-al practice being in a rumi 8 ~ e ~ 7

Have your partner's feelings about rurai pmtice nifluenced your own feehgs about lurd practice?

Did your c h i l h grow up in this community?

Do your childm attend a school(s) in your comxnunity or in aaother community?

What schools are there for c h i i h in this area? (ie- elemenhy, high schooL college, tmivdty)

1s there a choice of schoois in your area?

How do you rate the quality of those schoois? Why? To what schoois are you camparing them?

Whot are the dvantages for your children in the schools in this region? What are the disactvantages2

Do you feel that this comrnunity is iypicd of rurai comlmities with respect to raising chiidtcn? Why or

why not?

1s there adequate child carc avaiiable m the comrnunity?

How 0 t h dofdid you use chiid care Senrias? (ie. baby sitting, &y care)

M a t type of transportation is avdable for chil--gers?

Do you feel that your children are content Living in a rural area?

To what extent are your children integrated into the community? Examples?

Have your chiltiren's fahgs about naal Living influenced your own feelings about rural pnctice?

Does having chifdten aect your decision to stay in or leavc a nrral commrmity3 llfyes] In what wa;ys?

Arc p u currently rcceivmg h c i d compensation?

1s it a factor in your staying or not?

in what way has k g a nrral physician inhznced your professional aspirations?

QUESTION 4:

What do you cornider to be the major advantages of having a m a i practices? ofbeing a

rurd physiciaa?

Probes:

Did pou teceive haaual compensation for estsblishmg a rural pnictice?

What aspects of mai pmtice are the most ds@ng2 What aspects of mal practice are the Ieast

satisfging?

QUESTION 5:

What do you consider to be the major disadvantages of having a niral practice? of beiog a

Probes:

Do you feel thot you have adequate profeonal support? Why or why not?

Do you have time to &tain a pmgram of C M (Contiauing Medicd Education)? Do you have access to

CME opporttmities? How o h do you participlite?

When you started your rural practice, did you feel prepared or unprepared for curai

medical practice? In what ways prepared? In what ways unprepared?

Probes:

In your undergraduate medical training, did you have any exposure to ruai practice?

Did you discuss rural medicine in your courses?

Did you spend time working m a naal cotnmunity (ie, during the summer, as part of an elrctive?)

Did you fkd this ttainmg to bc usefui or not usefid? in what w q ?

At the t h e thnt you first starteci rurai practice, what part of yotrr eaming did p u k d pucticularfp

appropriate for rurai practice?

QUESTION 7:

Do you fd that rural practice is Merent fiom or d a r to urban practice? In what ways

are they different? In what ways are they similar?

probes:

What types of proftssional support do yau require in your ruml practice? (ie- specialists to whom you can

refer patients, iaboratorp facilities, hospital p d e g e s )

What types ~Fprnfessioaai support do you have?

QUESTION 8:

What suggestions so you have to improve the retention rates of physicians in d

Ontario?

Probes:

ShouId the governent be using financiai incentive pmgrammes to gct and keep more doctots in mai

pmtice? Why or why not?

What other thigs couid be doue to rccruit nxai physicians? To retain rurai physicians?

QUESTION 9:

1s there anythllig that 1 did not ask that you wodd Lice to comment upon?

1 wodd iike to thank you one more t h e for agreeing to participate in this inte~ew. Your

participation bas been instrumental in this study. Ifyou think of anything that you wouid

like tu adci, or any other cornments that you wouid iïke to make, then feei fiee to contact

me. If1 have any questions about what you've said, wodd it be okay El contacteci you

for a confirmation? Wouid you like me to keep you updated as to the progress that 1 am

making with respect to my r-ch and thesis? Thank you very much!