How do we get more doctors to practice in rural communities? This has been a long standing challenge in Canada -- getting physicians to work where we need them -- especially in provinces with large rural populations. Policy makers have created and implemented some promising solutions, but until recently, there has been little evidence on whether or not the solutions are working.
Unfortunately, new research indicates that some programs aimed at retaining doctors in rural areas across the country may not be as successful as we'd hoped.
Almost all provinces and territories in Canada offer "return-for-service" agreements to attract and retain physicians in rural and underserved communities. Known by many names (including conditional scholarships, return-in-service bursaries, loan forgiveness programs), these agreements provide medical students and post-graduate residents with financial support for a commitment to practice in an underserved community, usually for one year for each year they receive support. Physicians have the option to pay back their funding if they can't complete their service commitments.
Return-for-service programs are seen as a key tool in addressing physician shortages, so much so that both the Conservatives and the Liberals promised a return-for-service program during the last federal election, and the current federal government is rolling out their own program later this year.
In a study published recently in Healthcare Policy, my colleagues and I found that most medical trainees who take return-for service agreements in the province of Newfoundland and Labrador complete their service commitments in full. Moreover, return-for-service physicians stayed in these underserved communities for the long term (up to 10 years after their required service). We also found that return-for-service physicians were less likely to leave these communities than their counterparts who did not hold similar agreements.
Sounds pretty good, right?
Except that we also discovered that most physicians who choose to take return-for-service agreements wanted to work in these underserved communities in the first place.
Rather than finding new physicians who were uninterested in working in rural Canada, in Newfoundland and Labrador, these agreements appear to be encouraging already interested physicians to stay the course.
Our study also uncovered another important finding: of the 20 per cent of physicians who defaulted on some or all of their return-for-service contract obligations, more than half were international medical graduates (IMGs) -- physicians who graduated from a medical school outside of Canada.
Why might this be the case? IMGs are obligated to take a return-for-service agreement in order to obtain a residency position in Canada, which is a necessary step for full licensure. In other words, their return-for-service commitments aren't really as 'optional,' as with Canadian graduates. Results from our study suggest that few of these physicians go on to complete their service commitment or pay back their funding.
Using international medical graduates to fill physician shortages in rural communities is nothing new. In fact, many IMGs start their careers in Canada working under special licenses that allow them to work only in underserved areas. However, requiring IMGs to take return-for-service agreements will likely do little to stop the revolving door of short-stay physicians in rural communities. It is a stop-gap, not a solution.
In 2013, the federal government will introduce its own "return-for-service program" to encourage physicians and nurses to work in underserved communities. Physicians can qualify for the program's financial incentive ($8,000 student loan remission each year for up to five years) if they work in "eligible" communities, defined in the federal program generally as a rural community with a population of 50,000 or less that is not near a large urban centre.
Unlike provincially run programs, the federal government's program does not require physicians to coordinate their "return" community with provincial planners so eligible communities may not necessarily be considered underserved from the local perspective.
Without meaningful coordination, provincial and federal return-for-service programs may end up being counterproductive and do little to resolve the physician shortages they hope to address.
And without meaningful follow up studies, the new federal program, like similarly structured provincial and territorial programs, may look good on paper, but fail to retain doctors in underserviced areas over the long-term.
Problems with physician shortages in rural regions in Canada have existed for a long time. Isn't it about time we had a better idea about what actually works?
Maria Mathews is an advisor with EvidenceNetwork.ca and a Professor of Health Policy/Health Care Delivery at Memorial University of Newfoundland.
<a href="http://www.prostatecancer.ca/Prostate-Cancer" target="_hplink">One out of seven Canadian men will develop prostate cancer</a>, according to Prostate Cancer Canada. This particular type of cancer remains the most common type affecting men in this country.
Mental health is one issue Bali thinks is often overlooked. In Canada, <a href="http://www.cmha.ca/public_policy/men-and-mental-illness/#.T9oiNhdPrnQ" target="_hplink">four of every five suicides are committed by men</a>, according to the Canadian Mental Health Association. Depression, anxiety and addiction are all key areas men should be thinking about, Bali says.
Low sex drive in adult men can be caused by <a href="http://www.mensclinic.com/low-sex-drive/" target="_hplink">drug abuse, obesity and even poor sleep patterns</a>. Although there are <a href="http://www.huffingtonpost.ca/rose-reisman/sex-food_b_1575410.html" target="_hplink">natural ways to boost your libido</a>, Bali says adult men should see a professional.
There are various reasons why men may have difficulty with fertility. Age, sperm disorders and problems with the immune system are all factors men should take into consideration.
<a href="http://www.edhelp.ca/en/men/how/what_if/" target="_hplink">Erectile dysfunction (ED) affects about half of all Canadian men</a> over the age of 40, according to survey by EdHelp.ca. This is a condition that should never be ignored -- ED can even result in depression, some experts say.
Andropause, or male menopause, is part of a man's aging process when <a href="http://chealth.canoe.ca/channel_condition_info_details.asp?disease_id=300&channel_id=8&relation_id=55661" target="_hplink">testosterone levels can decrease </a>about 10 per cent each decade after a man turns 30.
Another common condition for aging men -- and even men in their 20s -- is hair loss. <a href="http://www.hairlossmonth.ca/" target="_hplink">One out of four Canadians don't know who to ask for help </a>when dealing with the loss of hair. You can talk to your doctor about cosmetic procedures or hair replacements.
HPV, for example, is one sexually transmitted infection that can affect men. For the most part, <a href="http://www.phac-aspc.gc.ca/std-mts/hpv-vph/hpv-vph-man-eng.php" target="_hplink">men won't have any symptoms and some infections can go away in a few years</a>, according to the Public Health Agency of Canada. However, some infections can lead to penile and anal cancer -- another reason men should have annual check-ups.
Obesity, fatty liver, high blood pressure, high cholesterol, high blood sugar and overall cardiovascular health are all areas men should focus on as they age. Between 2003 and 2010, the <a href="http://www.statcan.gc.ca/daily-quotidien/110621/dq110621b-eng.htm" target="_hplink">obesity rate among men in Canada rose from 16 per cent to almost 20 per cent</a>, according to Statistics Canada.
There are more than<a href="http://www.arthritis.ca/local programs/bcyukon/media/FAQ/default.asp?s=1" target="_hplink"> 100 types of arthritis, and it is among the top three most common chronic illnesses in Canada.</a> Ankylosing spondylitis (an arthritis that attacks spinal joints) is more common among men between the ages of 15 to 40. Bali says men are also more likely to suffer from sports related injuries.