With an election on the doorstep and 69,000 Nova Scotians now without a family doctor, how to encourage more family practitioners to set up shop in rural Nova Scotia is a hot-button issue.
Back in 2013, Liberal leader Stephen McNeil promised a family doctor for every Nova Scotian but that turned out to be a promise he couldn’t keep and no one else will try to make this time. Ongoing efforts by Nova Scotia Health, the Dalhousie Medical School, and Department of Health and Wellness to recruit and retain more family doctors were the topic before the Health Committee of the legislature yesterday. And while a great deal of time and money is being put into the issue, the province is only treading water.
Over the past three months, Nova Scotia has welcomed 19 new doctors (eight of whom are family physicians), while 20 have left to either retire or relocate.
Dr. Nicole Boutilier, vice-president of Medicine with Nova Scotia Health, was unable to provide an estimate for how many will retire over the next three years. She said some family physicians close their practices but continue to work in other areas. These might include COVID vaccination clinics or consulting.
For sure, the traditional model of one doctor serving one community is now as rare as a house call. It’s history. The model of care being taught and established in Nova Scotia is based on a team approach. There are now 90 Collaborative Health Centres (CHCs), led by a family doctor or nurse practitioner supported by a team of registered nurses, dieticians, therapists, and social workers. The goal of the Collaborative Health Centre or community clinic is to provide continuous care from the cradle to the grave, following a patient before and after any admission to hospital.
Dr Roop Conyers is a family physician attached to the Annapolis Valley Residency Training site responsible for training doctors who want to specialize in family medicine. Conyers said Collaborative Health Centres are not only great training opportunities but they offer the type of care Nova Scotians need and can expect in the future.
“Our residents are placed in separate communities in group practices that work in teams that deliver care,” said Conyers. “And what’s interesting from that approach is as they enter practice, our graduates are actually seeking that kind of environment. The team approach supports recruitment efforts because it not only provides good care for our citizens but good work-life balance for physicians.”
A recent survey by the National College of Family Physicians showed 85% of family doctors graduating from Dalhousie Medical School say they are “highly or somewhat likely” to choose to work in a group practice setting.
Graduating doctors are less likely to assume all the patients orphaned by retiring family doctors. The Health Committee was told nearly half of new family doctors start their careers doing locums or short-term placements to “get a feel” for whether they would be most comfortable working in a collaborative health centre, mental health and addictions, long-term care, or a traditional doctor’s office seeing patients. This trend may partly explain why it is harder to find a doctor even though more are being graduated.
Taking training outside the city
The chronic shortage of family doctors has been exacerbated by our growing population.
Nova Scotia Health has hired a recruiter dedicated to increasing the percentage of Dal Medical School and Canadian med school graduates working in Nova Scotia. According to the Dr. David Anderson, the Dean of the Dalhousie Medical School, 67% of the doctors working in Nova Scotia today have some training affiliation with Dal. In the past few years, the provincial government has opened the public purse to pay for 16 additional medical students (for a total of 94 each year) as well as an additional 24 residents who have graduated with their M.D.
Anderson told the politicians Dalhousie has made changes to convince students to choose Family Medicine as their specialty and to offer training opportunities outside Halifax:
For our students, a family medicine experience was introduced in 2019, where all first-year medical students spend six half days with a family physician. During the last week of their first year, students spend one week observing a rural physician in practice in a very popular unit called Rural Week. This program provides students with first-hand observations of the opportunities of clinical practice and the physicians’ role in a rural setting including leadership responsibilities.
Second, we recognize the need for physicians outside of the urban Halifax area. As a result, we are providing our students more educational opportunities throughout the province of Nova Scotia. In 2019, Dalhousie introduced the Longitudinal Integrated Clerkship program in Nova Scotia, where four medical students spent their entire third year of medical school training under the direction of physicians in Cape Breton. This program further expanded to the South Shore in September 2020, where the communities of Bridgewater, Lunenburg, and Liverpool welcomed five medical school students from Dalhousie.
Anderson said it’s too early yet to evaluate if the changes made two years ago will lead to more Dal graduates staying in Nova Scotia. A similar model has been successful in New Brunswick.
Meanwhile, the shortage of family doctors has led Nova Scotia Health to also work harder at recruiting internationally trained physicians. From only a handful of doctors in 2018, stepped-up international efforts have attracted about 25 new family docs a year in each of the past three years.
That hasn’t been enough to keep emergency rooms open at smaller community hospitals such as those in Sheet Harbour, Middle Musquodoboit, Pugwash, and Tatamagouche. During summer vacations and holidays when the emergency doctor is off, whether the emergency room is open depends on whether a family doctor is available to cover the shift. The shortage of family doctors in rural Nova Scotia led to a 30% increase in the amount of time emergency departments were closed last year.
“We have realized access to care may not always be possible for all of our smaller rural sites,” said Dr. Aaron Smith, executive medical director of the Northern Zone, ”but what is important is that the care be predictable and reasonably accessible. For example, along the north shore, we have planned and anticipated our closures at Pugwash and Tatamagouche and done our best to ensure when one site is closed, that the other hospital remains open.”
Residents along the Eastern Shore haven’t been as fortunate. Their emergency departments at both community hospitals are often closed on the weekend.
Online visits replacing face-to-face
A new solution to the family doctor shortage is being tried in the northern and western parts of the province where more than 45,000 people (!) are registered on the “need a family practice” wait list.
The Virtual Care project is only two months old. So far, 2,500 people have agreed to try online or virtual consultations provided by retired family physicians. About 13,000 people in Middleton, Yarmouth, Truro, and New Glasgow were invited and despite the slow take-up, Dr. Nicole Boutilier said the reviews have been positive.
“Consults are happening regularly across the province with virtual care providers,” said Boutilier. “Anecdotally, patients tell us they are very pleased with the service, they are getting seen in a timely way after they have requested an appointment and if they need to see someone in person, that’s being facilitated as well.”
Patients must have access to high-speed Internet in order to talk with the doctor or nurse practitioner online using a new software program called “Maple.” Unless more family doctors choose to stay or to migrate to Nova Scotia, it’s possible virtual care may make visits to the doctor’s office as infrequent as house calls.
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A new software program called “Maple”? Is this just coincidence, or is it linked to the for-profit private virtual health care company, also called “Maple”? https://www.getmaple.ca/
Katherine, Jennifer tells me that “The program name is the same as the service provider which is also ‘Maple'”.