Four physicians share the joys and challenges of practising remote medicine in Canada
A few decades ago, Dr Braam de Klerk decided his life needed more adventure. In search of a challenge, he closed his South African medical office, packed up his family and headed for Canada. Months later, he was practising in one of the coldest, most northern and isolated areas in this country.
“My wife jokes that the move was my midlife crisis,” laughs the 60-year-old who recently received the Order of Canada for his commitment to Canada’s North as one of the longest-serving doctors in Inuvik and its surrounding areas.
Like many remote physicians, De Klerk stays because the work is exciting. “I love the medicine up here. It’s extremely interesting and the challenges are addictive — almost like a drug.” Part of the appeal is simply variety. On any given day, his medical hats include surgeon, anesthesiologist, obstetrician (he’s delivered over 1000 babies in Inuvik), emergency doctor and general practitioner. “I’m a jack of all trades, but master of none,” he confesses.
Above the Arctic Circle doctors also encounter things city physicians would never see. “We’ve had seafood botulism cases from people eating fermented whale fat,” offers De Klerk who showcases many North of 60 medical experiences on his blog (polardoc.typepad.com).
That medical multi-tasking is par for the course in remote locations. “There are many remote GPs in Canada that do a very similar job to mine,” explains the now semi-retired doctor who works with eight physicians to provide medical care to the citizens of Inuvik and residents in outlying areas via fly-in visits.
Realizing that rural medicine offers unique challenges, De Klerk was one of the founding members of the Society of Rural Physicians of Canada (tel:877-276-1949; www.srpc.ca) to help promote rural health and improve this often neglected and impoverished sector of the health care system. “The bottom line is that there are not enough rural doctors,” he says. “We need to train many, many more.”
Founded in 1992, the SRPC’s mission is to provide leadership for rural physicians and to promote sustainable conditions and equitable health care for rural communities. It performs a wide variety of functions, such as developing and advocating health delivery mechanisms, supporting rural doctors and communities in crisis, and promoting and delivering continuing rural medical education.
“One of the biggest roles of the SRPC is to give rural doctors clinical courage,” explains SRPC president Dr John Wootton, a 60-year-old rural physician who has been practising in Shawville, Quebec since 1983. By offering rural-specific CMEs taught by small-town colleagues, the workshops focus on procedures that rural doctors may not encounter everyday, but can be lifesaving when performed. Examples include putting in chest tubes and central lines or interpreting cervical spine X-rays.
“We believe that rural GPs learn better from their peers,” he explains. “The fact that none of the faculty are specialists is generally seen as a bonus because it allows people to be taught with their perceived insecurity in mind and reassures them they are not alone. It gives them better confidence.”
Without such confidence, Wootton says doctors will often leave rural communities and head back to the cities. “They will often say: ‘I don’t need this,’ and move somewhere else where life seems less complicated,” he explains.
Cradle to grave
Part of the attraction of isolated medicine for Wootton is the cradle-to-grave aspect of patient care. “It gives you a window into people's lives that really isn’t available in any other branch of medicine anymore,” he explains. His rural Quebec medical practice includes obstetrics, emergency, inpatient and office-based care.
“The appeal and difficulty of practising remote medicine is that every day is different,” offers Dr Trina Larsen-Soles, a 54-year-old rural GP in Golden, BC. She describes her practice as an interesting ‘hodgepodge’ of family medicine, emergency medicine and obstetrics.
Her small mountain community is surrounded by various national parks and home to Kicking Horse Ski Resort and other adventure-tourism activities such as mountain biking and paragliding. As a result, anything and everything comes through the doors of the emergency room — even the occasional bear-mauling victim.
When dealing with her first bear attack, Larsen-Soles consulted a senior colleague for advice. “He told me that bears have long dirty claws, so you need to scrub everything out well, cover with antibiotics, sew anything that is gaping and put in lots of drains.” In the end, her colleague’s advice was lifesaving and the woman survived. “A bear-mauling is truly rural medicine,” says Larsen-Soles who has treated both black and grizzly bear attack victims.
Excitement aside, challenges abound in remote medicine. And getting in over your head is potentially one of them. Says Larsen-Soles: “Good rural physicians know their limits, and know when it’s appropriate to hand things off to specialized services.” She adds: “The people who function really well ask lots of questions and know when to ask for help.” Assistance takes the form of consulting other staff members, phoning out-of-town specialists, or accessing a critical-care transport service.
Having a good team of colleagues is also key. While Larsen-Soles has an excellent working relationship with the seven other physicians in her group, not all small-town doctors may be this lucky. “Without colleague support, rural docs will just pack up and go,” she confesses.
“People don’t leave because the work isn’t interesting, they leave because they feel overwhelmed, lack proper training and support, or because their spouse isn’t happy.” As for money? In general, rural doctors tend to be well compensated in most provinces and often receive retention bonuses.
While tertiary care in Golden may be only a three-hour drive away, the winding mountain roads are often closed in the winter due to avalanches and storms. “Our biggest challenge is the weather. Last winter, we were completely cut off (even for emergency medical flights) for six days,” she explains.
Because learning new skills is the best way to deal with the lack of tertiary care, rural doctors are finding advanced technological solutions to the challenges that face them. “We innovate because we need to,” explains Dr Michael Jong, who practises in Happy Valley-Goose Bay, NL. “Sure we’re rural docs, but in some areas we are extremely advanced medically.” Jong is also a rural medicine professor at Newfoundland's Memorial University.
At the forefront of utilizing many of these innovations, Jong happily shares highlights of this relatively new field. Take simulated training, which is key to critical care skill maintenance. “Right now we have a fully simulated patient who breathes, moans, moves and verbalizes,” explains the 59-year-old who has been practising isolated medicine for over 30 years. “You can intubate it, give it medication or put tubes in. If it doesn’t go well, the simulated patient responds accordingly.”
Remote video resuscitation is another groundbreaking area that Jong has been working on. Armed with a laptop, he can lead resuscitation efforts going on in distant health centres not staffed with physicians. With cameras aimed at both the patient and the equipment he records activities and give instructions to the team.
The team, incidentally, is made up of nurses, maintenance staff, health attendants or anyone in the community who wants to get involved. “The maintenance people are very good at CPR,” notes Jong, who regularly flies into smaller health centres within his hospital’s catchment area to provide training. “It’s a different resuscitation team than what you would get in a big city, but it’s still very effective.”
To treat patients in Nain, NL, the most northern community in the Happy Valley-Goose Bay catchment area, Jong uses robotic telemedicine, a new breed of robot called “Rosie.” It stands 165 centimetres tall and has a computer-screen head with two-way audio and video capabilities which serves as a physician’s eyes and ears.
Sitting in his office 350 kilometres away, Jong uses a joy stick to move Rosie around from room to room to interact with different patients. The robotic technology even allows him to zoom in on X-rays or pill bottles. “It’s almost like being in the same room with a patient,” explains Jong. “Rosie can really help in an emergency because there are no doctors in Nain.” At present, it’s the only remote unit of its kind in Northern Canada, and Jong and his team recently won an award for excellence in innovation from Health Canada.
Here to stay
Technology aside, a key factor in the recruitment and retention of rural doctors is buying into the northern lifestyle and community membership. “There are plenty of hours after work, so you have to learn to enjoy living in these places,” explains Jong, who can often be found fly fishing on his days off.
Community membership is also crucial for a rural physician’s spouse. “This is a huge issue for retaining doctors,” he admits. “If the spouse isn’t happy, the physician will move.” On a personal note, Jong met his wife while living up north. He was initially drawn to the community because residents were so welcoming when he arrived. “I just feel so needed up here.”
Recruiting locally is also important. The Happy Valley-Goose Bay Hospital, for example, is recognized internationally for its Northern Family Medicine Education Program. “We are able to retain our physicians because we training them locally,” explains Jong.
While rural medicine offers interesting and challenging work, recruiting and retaining rural physicians is an uphill battle. Despite the solutions mentioned above, the SRPC is looking at the bigger picture and has become politically active.
“We have definitely been raising the profile of rural medicine in Canada,” says Wootton. “We believe there is much the federal government can do for rural medicine without infringing on provincial jurisdictions, and we will pursue this avenue vigorously.”
On a final note, Wooten also believes that the creation of a college of rural and remote medicine is necessary for proper training. At present, rural medicine falls under the jurisdiction of the College of Family Physicians of Canada. Why a new college? “Producing physicians that are appropriately trained for realities of rural medicine is a challenge,” explains Wootton. “Having a separate college will enable us to design an educational system to produce the kind of physicians that we need.”
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