Doctoring a solution

Thousands of local residents have no family doctor. Here’s why – and what we must do to get more.

One of the most pressing problems facing Kawartha Lakes is the lack of family doctors willing to practise in the area. According to the Kawartha Lakes Health Care Initiative (KLHCI), the city is short between 15-18 doctors leaving 6,000 residents without a family doctor and another 25,000 having to travel outside the city for primary care.

Kawartha Lakes remains chronically underserviced with only 35 family doctors currently practising — and a number of those GPs are either very close to, or on the cusp of, retirement.

For the last 19 years the KLHCI, a non-profit charitable organization with one full-time employee and a board of dedicated volunteers, has taken up the challenge to find more doctors for the city and have been successful in recruiting 43 family doctors.

Their task is a challenging one, competing against almost every other region in Canada for the services of recent graduates. Our area also competes for those who have arrived in Canada after receiving their training in other nations, or doctors who might be looking to move for personal or professional reasons.

The vision of the KLHCI is that “all Kawartha Lakes citizens have access to a local family doctor,” but that is easier said than done.

Cindy Snider, recruitment and retention coordinator for the KLHCI and Barbara van der Veen, acting president of the board of directors of the KLHCI, spoke with the Advocate about the challenges the local group faces.

The challenges of recruiting doctors for rural areas

When asked why most doctors do not want to practice in rural areas, like Kawartha Lakes, Snider and van der Veen itemized a number of critical issues that can make, or break convincing a doctor to locate and practise in the city.

“The number one problem,” Snider says, “is finding work for the spouse. Family doctors can go anywhere to work and they are looking for guaranteed employment for both.”

Location is also a key issue for many new doctors.

“Generally, new doctors want to be no more than an hour away from extended family,” Snider says. “They want grandparents to be close by for support with childcare and when the time comes and parents are aging themselves, they (the child with medical training) want to be close by to assist with that too.”

Proximity to nightlife and entertainment opportunities is also an issue the KLHCI deal with. KLHCI makes a point of illustrating to potential recruits how close Kawartha Lakes is to Toronto, Peterborough and Oshawa for entertainment not available locally.

“Until we get the potential recruit to the city for medical training or a visit we suffer from being off the 401 (highway) corridor,” Snider says.

“They don’t realize how close we are to Toronto until they spend some time here,” van der Veen noted. “A recent medical school survey tells us that only eight per cent of doctors want to practice rurally…that isn’t much.”

Both van der Veen and Snider agree that almost three years of the pandemic have stopped many medical students and medical residents from training in rural areas, even if they wanted to.

“If we can get them here for a residency, 80 per cent of them stay,” van der Veen says.

When asked if the lack of ethnic diversity in Kawartha Lakes makes doctor recruitment more difficult, Snider says that both the local medical community and the city itself are becoming more diverse and that she hopes that isn’t the issue that it used to be.

Finally, those who are interested in clinical practise are typically not interested in rural practices as quite often a rural practice includes the additional responsibilities of working in the ER, delivering babies and assisting at long term care homes.

Problems faced by new family doctors

When new doctors receive their license, they are faced with a myriad of decisions including where to practise. They also need to determine if they want to complete fellowship training and become a specialist, along with how they are going to pay down the staggering debt that most are carrying.

“The average debt for new doctors is between $350,000 and $500,000,” Snider says. “If they decide to become family doctors, they will find themselves the lowest paid doctors in the province.”

“Their payment model is lower and their business model is challenging,” Snider says. “They are only paid for seeing patients. They don’t get paid to do paperwork. Doctors need small business advice as they have to pay their expenses, hire staff and find money left over to pay down their student debt, none of which they are trained for.”

“Many new family doctors (when faced with these challenges) prefer a locum (covering for another doctor or working part-time) where they have no overhead and significant flexibility,” Snider says.

“New family doctors are looking for a different family-work balance than those general practitioners who came before them.”

“They want smaller practices,” Snider adds. “We find we need two and a half new family doctors to replace each current family doctor that retires. The province has given permission to split patient rosters from retiring doctors to hopefully make the practice more attractive to a new physician.”

Fifty per cent of new doctors are female, Snider says, and many want to start their families. Overall, she notes female physicians continue to be most responsible for childcare.

“Many new doctors are also looking for variety in their workday such as surgical assist, emergency medicine or hospitalist medicine. Seeing 30 patients in a day is not how they want to practise,” van der Veen adds.

Taking the pressure off family doctors?

When asked if the community paramedic program that began in Kawartha Lakes in 2019 and the expanded power for pharmacists to prescribe a limited number of medications without a doctor’s note might help the current situation, Snider said these programs may be beneficial as the province struggles with providing primary care.

“Right now,” Snider says, “it takes six years to train a family doctor and there is even talk of adding another year to the residency so doctors are better prepared for what awaits them in their own practice.”

Snider and van der Veen are hopeful that the province recommits to the “Practice Ready” program that allows internationally-trained physicians to re-qualify with an abbreviated six-month residency or supervision.

“It is very hard for these physicians to re-qualify,” Snider said. “We hope the province will reintroduce this program.”

When asked if additional nurse practitioners might be a step in the right direction, Snider returned to the issue of provincial funding that impacts every health care decision made in Ontario.

“Nurse practitioners are also funded by the province. There are limited positions available and with most being women they face the same partner pressures and family situations (that female doctors do),” Snider said.

Can the municipality be doing more?

Kawartha Lakes is fighting an uphill battle in recruiting family physicians. Other jurisdictions in Canada, the United States and Australia are quite prepared to incentivize primary care physicians to move to underserviced rural areas.

The National Rural Health Association, that represents many of the states in the American Midwest realizes that money talks in doctor recruitment.

Brock Slaback, senior vice president of the National Rural Health Association, freely admits that, “offering incentive or reimbursement programs that would pay part or all of a physician’s student debt has proven to be a great way to bring these doctors to rural communities. Paying of signing bonuses is another way to bring in a physician who no longer has student debt.”

Kawartha Lakes CAO, Ron Taylor, was asked if the city should be doing more than they are right now to recruit badly needed family doctors to the area, and whether the provision of office space and clerical support at minimum might make the job of the KLHCI easier.

“The Municipal Act prevents the municipality from giving assistance directly or indirectly to any manufacturing business or commercial enterprise. A doctor’s office is considered a commercial enterprise, so we’re limited in the assistance that we can provide to potential new doctors and their practices,” Taylor says.

“However,” Taylor continues, “the city does annually provide funding to the Kawartha Lakes Health Care Initiative (KLCHI) for physician recruitment through the Ross Memorial Hospital.”

He says the proposed amount of funding for the program in the 2023 budget is about $113,000. They also established a reserve of funds used to support physician incentives to move, locate and establish their practices here.

“In addition to that funding, the city has a partnership with the Victorian Order of Nurses (VON) and their Nurse Practitioner Professional Practice,” he says. The proposed amount of funding in the 2023 budget is about $109,000 to support the services provided by a Nurse Practitioner to those who are unattached and require a primary care provider.

“Furthermore,” Taylor adds, “Kawartha Lakes in partnership with the Coboconk Norland and Area Chamber of Commerce, has committed funding and debenture support, if needed, to the Summit Wellness Centre (in Coboconk) which will be an attractive option for new health practitioners looking to move to the area in the future.”

Taylor believes that a positive business climate in Kawartha Lakes will make doctor recruitment easier to achieve.

“Our Economic Development team is working on several initiatives aimed at bringing workforce-aged people to the municipality; downtown revitalization in Lindsay, Fenelon Falls and Omemee, resources for new business start-up and expansion, and targeted marketing to bring workforce-aged residents and business owners to Kawartha Lakes,” Taylor says. “Although not healthcare specific, these programs that are in place can help attract new doctors to the area to help establish their business. It is often the case that the spouse of a physician requires a community that offers career or entrepreneurial opportunities, and Kawartha Lakes offers a thriving business community.”

Taylor suggests that the ease of which a doctor can set up a practice in the area won’t be the only deciding factor when it comes to opening a new practice here.

“They’ll also want to know whether they can live an enjoyable life in Kawartha Lakes and we’re confident that our business development programs and new business recruitment campaigns will show them that they can,” Taylor adds.

How we can help with doctor retention

Both van der Veen and Snider believe that doctor retention is as important as recruitment of new doctors, and patients across the city can play an important role in keeping the doctors we already have.

“The community needs to understand the challenges faced by family physicians,” van der Veen said. “Doctors are feeling so pressured (by first the challenges of the pandemic and now the fallout of a post-pandemic world) and now many patients are more acute. Patients are becoming more demanding (or entitled) which can strain their relationship with their primary caregiver.”

Even basic patient gratitude and understanding is always appreciated, says van der Veen.

The future

With an average age of 40-50, some of the 35 remaining family physicians in Kawartha Lakes are likely closer to the end of their careers than the beginning, and this never-ending cycle of retirements puts real pressure on KLHCI to find replacements.

“We are currently working to replace the five doctors we have lost (during the pandemic). We expect more retirements to be announced in 2023,” Snider says.

Multiple community-based sources have confirmed with the Advocate that two additional veteran family physicians with well established decades-long practices are soon to inform their patients they will be shuttering their practices with one retiring completely and another leaving to focus solely on surgery.

When asked what the rules are for informing patients regarding retirement, Snider said the College of Physician and Surgeons of Ontario has stated that doctors must inform patients in writing no later than three months before they close their offices to give patients a chance to look for a new care provider and get a copy of their patient file to take with them.