"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!