Maria Matthews, Guest Columnist
How do we get more doctors to practice in rural communities? This has been a long standing challenge in Canada — getting physicians to work where we need them — especially in provinces with large rural populations. Policy makers have created and implemented some promising solutions, but until recently, there has been little evidence on whether or not the solutions are working.
Unfortunately, new research indicates that some programs aimed at retaining doctors in rural areas across the country may not be as successful as we’d hoped.
Return for service programs are seen as a key tool in addressing physician shortages, so much so that both the Conservatives and the Liberals promised a return for service program during the last federal election, and the current federal government is rolling out their own program later this year.
In a study published recently in Healthcare Policy, my colleagues and I found that most medical trainees who take return for service agreements in Newfoundland and Labrador complete their service commitments in full. Moreover, return for service physicians stayed in these underserved communities for the long term (up to 10 years after their required service). We also found that return for service physicians were less likely to leave these communities than their counterparts who did not hold similar agreements.
Sounds pretty good, right?
Except that we also discovered that most physicians who choose to take return for service agreements wanted to work in these underserved communities in the first place.
Rather than finding new physicians who were uninterested in working in rural Canada, in Newfoundland and Labrador, these agreements appear to be encouraging already interested physicians to stay the course.
Our study also uncovered another important finding: of the 20 per cent of physicians who defaulted on some or all of their return for service contract obligations, more than half were international medical graduates (IMGs) — physicians who graduated from a medical school outside of Canada.
Why might this be the case? IMGs are obligated to take a return for service agreement to obtain a residency position in Canada, which is a necessary step for full licensure. In other words, their return for service commitments aren’t really as “optional,” as with Canadian graduates. Results from our study suggest that few of these physicians go on to complete their service commitment or pay back their funding.
Using international medical graduates to fill physician shortages in rural communities is nothing new. In fact, many IMGs start their careers in Canada working under special licenses that allow them to work only in underserved areas. However, requiring IMGs to take return-for-service agreements will likely do little to stop the revolving door of short-stay physicians in rural communities. It is a stop-gap, not a solution.
In 2013, the federal government will introduce its own “return-for-service program” to encourage physicians and nurses to work in underserved communities. Physicians can qualify for the program’s financial incentive ($8,000 student loan remission each year for up to five years) if they work in “eligible” communities, defined in the federal program generally as a rural community with a population of 50,000 or less that is not near a large urban center.
Unlike provincial programs, the federal government’s program does not require physicians to co-ordinate their “return” community with provincial planners so eligible communities may not necessarily be considered underserved from the local perspective.
Without meaningful follow up studies, the new federal program, like similarly structured provincial and territorial programs, may look good on paper but fail to retain doctors in underserviced areas over the long-term.
Problems with physician shortages in rural regions in Canada have existed for a long time. Isn’t it about time we had a better idea about what actually works?
Maria Mathews is an advisor with EvidenceNetwork.ca and a Professor of Health Policy/Health Care Delivery at Memorial University of Newfoundland.