Healthcare in Rural Nova Scotia Improves with Support for Physicians
Emphasis on Physician Recruitment and Retention
While this is true of all aspects of healthcare delivery, it is particularly critical in the area of physicians' services - both family doctors and specialists. Recruiting doctors to work where they are needed is the first hurdle; retaining them once they have moved into a rural community is an even bigger challenge. Issues of lifestyle, practice supports, and financial viability all come into play when a doctor - or any other healthcare professional - makes the decision about where to set up practice.
Gone are the days, it seems, when the local doctor spends his or her career from graduation to retirement in the same town, providing cradle-to-grave primary medical care to generations of local patients. Even though it is widely agreed that a long term doctor-patient relationship is fundamental to quality service and continuity of care, more often than not, in rural communities the turnover of family doctors and areas specialists is swift and frequent. To those ends, there are a number of rural health initiatives that have been undertaken in Nova Scotia, with the objectives to improve access by patients to medical services and create an environment in which medical practice is both rewarding and sustainable.
Here are some of the major initiatives that are currently
- On-call payments for doctors working in community hospital emergency departments. This responds to the problem (reinforced by the fee-for-service system) of a physician being on call without the sufficient critical mass of patients to generate earnings to pay for the service. This program means that doctors are compensated for their time, regardless of how few patients may actually require medical attention after hours or on weekends, and ensures that local medical coverage is provided.
- Rural locum service provides relief for doctors who want vacation or CME. It is not uncommon for rural doctors to go years without an opportunity to get time away from their practice, which can contribute to burn out, family stress, and lost opportunities for ongoing professional development. Having a pool of physicians who are available to be scheduled in to provide practice relief is critical to rural practice sustainability.
- There are initiatives with the Dalhousie Medical School to produce more family doctors, train more outside Halifax and encourage them to spend summers in rural areas. The Physician Re-entry Program allows family doctors from rural Nova Scotia to return to medical school for specialty training - a career option that was previously not available to them.
- The Rural Incentive Program guarantees minimum income in remote communities where the number of patients makes attracting doctor difficult. To date, 21 of 24 designated spots have been filled in communities such as Canso and Bass River which have historically had trouble attracting doctors.
- There have also been significant Emergency Health Services improvements - an important part of the rural health safety net. A fleet of 140 new ambulances, has been purchased, 100 of which are equipped with defibrillators and all staffed by paramedics. Improvements in pre-hospital care means that we have mobile emergency departments, improving response time to care and health outcomes. (By contrast, prior to the improvements in emergency health services, there was an average of five mechanical breakdowns a week affecting patient care. That meant that 250 times a year, an ambulance either didn't make it when called or broke down with a patient in the back. Furthermore, there were no standards to be met by ambulance attendants other than possession of a valid drivers' license. Many ambulance companies were owned and operated by local funeral homes.)
TeleHealth Network One of Largest in the WorldNova Scotia is also making use of innovations in technology - bringing services to patients rather than moving patients to services. Following a successful initial pilot project conducted during 1996, Nova Scotia's TeleHealth Network is now in its first phase of implementation. Telemedicine uses advanced telecommunications technology to transmit medical data, video images and audio between doctors or other healthcare workers at two or more locations. Information is transferred from a rural site with limited specialist resources to a specialist site with greater resources. The doctor in the rural site gets assistance with a diagnosis or with planning treatment for a patient.
This is the first telemedicine project in Canada to demonstrate that affordable, readily available computer hardware can be easily adapted to multiple clinical applications and video conferencing use. It is also the first Canadian project to be subject to a complete evaluation that determined the acceptance of the system to specialists, rural physicians and patients. One hundred percent of patients who were exposed to the system during its trial, felt that it was an advantage to their community. As, well the majority of healthcare providers felt that the system increased their access to education and training resources and reduced their feelings of isolation. In their opinion, the pilot project determined that the TeleHealth Network provides a satisfactory way to see patients without compromising communication between patients and physician.
It was also determined that the accuracy of diagnoses was similar to "live" consultations. For example, of five emergency cases in radiology that occurred during the pilot project, the immediate response of a radiologist in three of the cases meant the patient didn't need to be transported to a regional healthcare facility for further assessment. The result: considerable reduction in stress to the patient, the patient's family and to the rural healthcare providers treating the patient, cost savings for ambulance transport and possible reduction of hospital admission and inpatient days.
With 43 sites, one of the world's largest and Canada's first province-wide telemedicine project will support local doctors and help rural Nova Scotians avoid travel to larger healthcare facilities to see specialists. Telemedicine will permit real-time clinical consultations from various parts of the province, vastly improving patient access to specialists with fewer disruptions and inconveniences. Together with private-sector partners, TecKnowledge Healthcare Systems Inc. and MT&T, the Department of Health has established the $8-million high-tech network in two stages as a major improvement in Nova Scotia's healthcare system.
The challenges of planning a quality and sustainable rural healthcare system are many, and every province will be required to use innovation and ingenuity as expectations mount and resources diminish. It might well be argued that the rural health crisis facing communities across this country did not emerge overnight, but that there have been signs of trouble for some time. (For the sake of perspective, however, if you are lying beneath the wheels of the locomotive, it matters little how quickly it was traveling!). What is important is that we learn from the past - protecting what worked, but having the courage to make changes when the benefit to the patient, the community, and healthcare providers can be demonstrated. Evaluation of any new initiative ought to be rigorous and ought to be shared, so that future policy direction is informed.
If our rural communities are going to survive and thrive, they will depend on access to a high quality, sustainable, and responsive healthcare system. In Nova Scotia, significant progress has been made, but we all - government, healthcare providers and the public alike - must continue to be receptive to new ways of responding to old problems. Our best hope is to work on those problems together.
About the Author(s)
Mary-Jane Hampton is Executive Director of Strategic Planning with the Nova Scotia Department of Health.
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