What’s so Special About Northern Medicine?

Everyone is special, some more than others.

Need trumps merit in our socialized healthcare system. So naturally, we all compete to be the most needy. It’s in our best interest.

Appearing needy maximizes the chance of getting funding. Strength invites scrutiny or funding cuts.

Is the whole thing a sham?

Should all stakeholders get identical gifts?

Despite cynicism about interests and special favours, small towns have unique needs. Northern medicine is truly special. The big issues are, for the most part, the same as everywhere else:

Funding cuts cause decreased access to care.

Overcrowded hospitals leave patients in hallways.

Lack of long-term care beds exacerbates hospital crowding.

Bad management makes everyone suffer.

The issues are identical. The impact is unique.

I worked for a few years in a small emergency department. During that time, I thought advanced life support course instructors were funny when they said, “Call for help early!” What if it’s just you and 1 nurse? No RT, no ward clerk, and call 911 for security?

I also grew up in the woods outside Thunder Bay. My parents are still there. I live and practice in a rural, not remote, village of a few thousand just north of the GTA.

None of this makes me an expert on rural care or small towns, but I have some sense of the experience.

Northern Medicine

I finished the annual OMA President’s roadshow across Ontario last week by visiting the doctors in Kenora, Dryden and Fort Frances. I also visited with many other small town doctors, across Southern Ontario this fall.

Nothing replaces face-to-face meetings. Nonsense emails or gossip shared with pressured speech seem to vanish in significance with a few lines of rational interaction.

More than anything else, I was impressed. Small town doctors are the genuine articles. They do everything. They’ve seen just about everything. They care deeply about their hospitals and how their medical community functions. Most of us do not appreciate the work done by doctors in small, remote communities.

Three things stood out in conversations with these doctors about Northern medicine and small-towns in general:

A. You cannot hide.

Curmudgeons cast an unavoidable shadow in a small town. Just to be clear, someone, somewhere, thinks each one of us is crazy or difficult to work with. We are all eccentric in someone’s eyes.

In a large centre, you can avoid people you do not like or trust. Just wait a few hours and refer to the next consultant on shift.

In a small centre, there might only be one consultant. As a physician, you have to see the same guy, over and over again…for years.

He remembers all your dumb referrals. You remember all his grumpy consults. You know the clinical conditions he cannot handle. He knows all the problems you are too scared to manage.

The same thing happens between nurses and doctors. “Dear Lord, do I seriously have to work alone with THAT doctor/nurse for 24 hours over the holidays?

In large towns, doctors can fire abusive/stalking/scary patients. In small towns, doctors can fire patients too, but they just come back.

City people think that country folk just want to get away from it all, to be alone with nature.

Country living is more like living with family. If you want anonymity, move to Toronto.

B. Small changes create massive impacts.

Resources act like discreet variables, in a small town, and more like continuous variables, in larger centres.

Adding one nurse to a staff of 100 creates a 1% change in spending, resources and scheduling.

Adding 1 nurse to a staff of 1 creates a 100% increase. This makes access and efficiency mutually exclusive most of the time.

The same applies when people leave. Staffing can swing from feast to famine and back again, within weeks.

Also, staffing changes create ripple effects with an irreversible impact.

One new surgeon could impact 3 local doctors: for example, the minor procedures doctor, the vasectomy doctor and the scoping doctor.

Within a year or two, all the family doctors who used to provide these services will have lost skills and interest. When the surgeon leaves in a few years, the community could be much worse off than before the surgeon came.

The same thing happens when a specialist starts flying in for clinics or doing cases that used to be handled by the local surgeon.

Shifting practice scope is normal, but the shifts can be huge in small towns.

One day, a family doctor could have a very broad scope of practice with acute care, CCU, procedures and long-term care. The next day, she might be kicked out of the hospital by internists and hospitalists, have ED shifts covered by locums with EM credentials and find the minor procedure rooms all booked by visiting doctors.

C. Northern and small towns have less competition.

It is not uncommon to hear about CEOs or Chiefs of Staff holding court for decades, while a medical community ossifies and crumbles.

These towns scare away new recruits. New doctors smell decay and find reasons to go elsewhere. Few people want senior admin jobs after someone else has held the spot for decades. No one wants to try to figure out a culture unchanged since 1995.

Just like curmudgeons and eccentrics, bad leadership casts a big shadow in a small town. It’s hard to dilute.

But lack of competition can be good, too. One passionate person, with a heart for service and change, can radically transform a small town.

More often, I found small communities held together by one or two people dedicated to helping their colleagues. Big things happen when one person gets fired up in a small town.

Suggestions for Northern Medicine

Dozens of doctors offered ideas. Some advice came in what was not said. We can capture much of it in these basic requests:

  1. Find out what the local doctors think might work. What won’t work? What’s been tried before? And have the courage to push back if they cling to failed ideas [last sentence added after an email from a friend].
  2. Understand the real issues. Every town has its own special problem(s). It might not be obvious or come up easily in conversation.
  3. Let local doctors try to solve their own problems. Don’t solve something they didn’t ask to have solved. When they ask for help, follow 1) and 2).
  4. Embrace the unexpected. Every place has unique people and interesting characters. Small towns allow eccentricity to flourish.

Overall, I was impressed with how many small communities find their own solutions. They pull together. They make themselves irresistible to new graduates.

Some towns get first pick for new hires: Students love learning there and choose to stay after residency.

Many communities find creative solutions to staffing and on-call coverage. Groups tend to feel ownership for all the resources in a community. The connection between hospital and community is more intimate.

To paraphrase Tolstoy: Happy towns are all alike; every unhappy town is unhappy in its own way.

In our system, need usually trumps merit when it comes to government funding. We might consider shining a spotlight on success instead.

So many small town doctors provide a scope and level of care unseen in larger centres. Many tiny communities enjoy high quality, acute care services only found in much larger, urban hospitals.

We should learn from northern medicine. Many small towns are truly special. Instead of trying to fix northern issues, we might listen for tips that could transform our whole system.

photo credit: tourismredlake.ca

Share this:

22 Replies to “What’s so Special About Northern Medicine?”

  1. Thanks Shawn for visiting the northwest and for sharing your insights. Well said. 39 years after first moving here to practice, including some years of practice abroad, I cannot think of any career I could have enjoyed more.

  2. I’m with you on all of this! Thank you for shedding light on how medicine works in the North. I think your recommendations are excellent and would like to add to them. I’d suggest that nurses and other health care providers besides MDs be consulted on how to make things work better. Also I’d suggest that patients be asked too. Asking MDs is a good start but those other perspectives are essential to improving the system. Looking at a system through various users’ experiences is part of “design thinking” which I’m pleased to see is being increasingly applied to the health care system.

  3. The essence of socialism and of socialized medcne in particular is central planning….as pointed out by Dr. Shawn Whatley’s article, the failure of socialized centrally planning is particularly apparent in Northern and rural Ontario.

    No amount of ingenuity on the part of the MOHLTC ‘s MBAs with all their computing powers and flow sheets can figure out the the true value of our colleagues in Northern and rural Ontario….nor of those colleagues of ours in urban and suburban for that matter….only the market place can solve that problem.

    Collectivization and rationing , the alternative to free market forces, is not and never has been the answer.

    Ontarians perceive their present dysfunctional monopolystic and monosoptic socialized health care system to be permanent much as East German officials perceived their Berlin Wall ( I was building housing in West Germany for refugees from the Communist Block in 1961 when it went up) ….right up to the last moment they believed it would remain erect for the next 100 years( Erick Honecker) and then pooof , in November 1989,it was gone.

    1. Very interesting comments, as always, Andris!

      Two things stand out: 1) Things that look and feel permanent often are not, and 2) We need to understand the ideas behind our system before we can improve it. While I’m not convinced that the free market can save us in areas where no market exists, I am convinced that central planning, collectivization, lack of freedom and lack competition (among other things) leads to pain and suffering.

      Thanks again for taking time to share your thoughts!

  4. Shawn,
    Thank you for making the effort to come to Northern Ontario in this very full year… I hope that you had a bit of a feeling of “coming home”. I appreciate your observations of rural, Northern practice. I think you have captured well some of what makes rural and remote medicine worthy of both second look and, more importantly, of support.

    I would shine a different light on the notion of ‘you can’t hide” a little differently. It is not about whether or not we can “fire patients” or walk away from relationships that are challenging. It is about figuring out how to provide good care when the relationship is difficult because people need care and there is no where else for the patient to go. It is also, though, that being known in a small community setting (being a big fish in a small pond, if you will) means that successes are celebrated in lovely ways too. There is a delight in running into moms with new babies at the grocery store, newly discharged patients at the post office and watching kids play high school sports when all those kids – the whole team – you have seen in one clinical context or another over the years. To me, rural medicine is about accountability…accountability to a community and to people with whom we, as a clinical team, live our lives.

    That accountability – a social accountability – means that rural docs are resourceful, working hard to find or create the resources that meet community needs. We learn to do things about which we may not have a “clinical interest” because we have a patient (or patients) who need us to know about an area of care so that patients can receive care close to home. So we learn a new area of care, or a new skill, so that we can serve our patients.

    And we need to sustain the courage, and the commitment to one another, to do the things we don’t want to do. Do I want to be called to support a difficult intubation, a neonatal resusc, or a multiperson MVC at 2am? No. Do I answer the call and go anyway? Yes. Every time. And I know my colleagues locally will too if I am the one calling them. We are in this together.

    And we are in this with our teammates. RN’s, imaging tech’s, NP’s, PAs, lab staff…. we rely on one another and our communities rely on our collectives skills and professionalism.

    I agree that models of success in rural practices should be examined for the lessons that they offer the wider system. And I agree with Janet ( commenter above) and would suggest that we need to listen to patients, community members and inter-professional teammates about the ways in which we can improve what we do – together. There is nothing (or at least very little) that is done alone in rural medicine.

    At a system level, we need to ask what we need to put in place to support success. Good governance supports for clinical groups, good infrastructure for care, education, and research where that is of interest, leadership support, and mentorship for both clinical work and leadership – all would help rural docs do what we can do well.

    It is, to your final point, not about “fixing Northern medicine” but about ensuring that what is good, effective and meaningful for health care in small communities can be supported in a way that ensures capacity, sustainability and excellence in care delivery. Health care teams matter in small places…not only for the health of individuals, but for the vibrancy and confidence of the whole community.

    1. Great post, Sarah!

      Thanks for expanding on the content and making it much better. Your experience in Marathon is invaluable. It’s impossible to respond to each of the points you made with the length they deserve. So, I will let your comments stand. Readers love the comments best, and I know they will enjoy reading yours!

      Best regards,

      Shawn

  5. From a patient perspective: When my husband retired we moved from a larger GTA suburb to a small northern town. It had a decent sized hospital for the size of the population it served and was one of our considerations when moving there. Doctors of course were in short supply (and very difficult to attract) and it took us a few months to get a family doctor to accept us as patients. The hospital and physician community was limited in the “specialty” services it could provide but we understood that. Larger centres with more services were 1 1/2 to 2 hrs away. The community had many dedicated volunteers and benefactors. It was astonishing just how much a small community could actually raise in support of their hospital. Within a few short years after moving there, the erosion started. First a very small hospital in a very small town (but with a sizable catchment area) about an hour north of us was closed. Not long after, services at our local hospital began to be cut. For various reasons, health care being near the top of the list, we decided to move closer to the city. But my sister remains in that small town. Since we moved (3 yrs ago) they have closed the lab at the hospital and there is no more maternity ward. There are constant rumours that the hospital will be closed altogether. So here’s the kicker – my sister and her husband have always been generous contributors to the hospital foundation. But now she’s asking, along with many of their friends, if their money will just “go up in smoke” in a few months, or a year, or two years. They wonder about the major equipment purchases made over the past few years, by the hospital foundation, that is no longer used because that dept has been shut down. They wonder what is the point. And of course it becomes more and more difficult to attract doctors to a community with a dying hospital and shrinking resources. And of course it has to be concerning to the doctors who are there and see what is happening. Again, just a patient’s perspective.

    1. As a wag put it ” keep way from the margins ” as this health care system implodes towards the main centers…London, Hamilton, Toronto, Kingston, Ottawa and Sudbury.

      One hears of people retiring in GTA and ,with their windfall in selling their primary residence, settling in cottage country expecting the same services as they did in the GTA ….as their local hospitals fade they are beginning to feel the general implosion…one hears of the ex big city folks , without FPs, going to the already overburdened local ER expecting their long lists of prescriptions to be renewed driving the busy ER Doc’s up the wall.

      Some of the cottage country retirees ,thinking about moving back to the GTA , find that their original homes have gone out of sight and are unaffordable.

      1. Good point, Andris. I don’t think these ideas come with the brochures that seek to lure retirees to cottage country!

    2. Wow. Thanks for sharing this, Valerie!

      I had not thought of this perspective. Indeed, it would be hard to come up with this scenario unless you had some first hand experience of it. I sure appreciate you taking time to share your comments!

      Best,

      Shawn

    3. The government of Ontario (Ministry of Healthcare and Long-term Care) is promoting Nurse Practitioners and Physician Assistants to reduce the cost of healthcare. These healthcare providers are faster to train for most basic healthcare needs and are easy to relocate to small towns. They can also work in a team environment with lead physicians that work in larger medical centers and can transfer patients when skilled procedures (ie. major surgeries) are required. This will be a likely solution for the future of healthcare.

      – Physician Assistant Student, University of Toronto

  6. Great article and I extrapolate further. Those on the front lines know better how to fix things than those in govt & ivory towers.

    1. Paraphrasing President Dwight Eisenhower ” Farming ( medicine) looks mighty easy when your plough is a pencil and you’re a thousand miles from the field”….or in an academic ivory tower far from the actual coalface.

      The government is not the solution where the plight of Northern and Rural health care is concerned ….it is the problem….and a part of each of its ‘solutions’ is more government, more bureaucrats, more rules , more supervision, more protocols and guidelines all thrown onto the backs of those already over burdened health care providers at the coal face, increasing their burden even further and eroding their morale even more.

      1. Government always says, “More!” Bureaucrats must come up with new ideas and better ways to do things. New and better are good, but only when we get rid of ‘old’ and ‘bad’. The problem comes when ‘new’ and ‘better’ get piled on to all the silly rules and expectations that already stand. On top of that, there is no way to get rid of the ‘new’ and ‘better’ when we realize they aren’t as good as we had hoped.

  7. When was the last time an Ontario government’s bureacrats and central planners came up with better ideas that worked in the real world?

    The ivory towered and the MBA’d central manners have no lack of unworkable but ideoogcally correct ideas, some so crazy that only over educated intellectuals could believe them…they will only do the right thing after all their crazed alternatives become exhausted….there are so many more unworkable blind alley ideas that they haven’t tried as yet….the tragedy is that we could have tried out the evidence based for health care restructuring a long time ago….and be rolling on the right track in the right direction.

    Instead we are wasting our time and scarce resources on going down yet one more blind alley….so , in the mean time, patients and MDs ….keep way from the ever decreasing fringes , much like the edges of a melting ice floe, gravitate toward the main health care centers of Ontario.

  8. Great Article Shawn,
    Sorry to break character here because if you have read any previous medically related thread you are likely expecting this post to fill all 250gb of memory on your phone (Shawn, if you actually like that stuff don’t worry just carefully look in the comments section for the proposed OMA code of conduct. I actually think it is a good start but my comments on it are so extensive I actually worry that they may theoricaly be capable of creating a black hole.)

    However I have spent most of my life shifting between very small and very Northern towns, some that don’t even exist anymore, and although they are different their are only a few things that anyone needs to know to understand them:
    1)They are all boom or bust so either most people have to much money for their own good or everyone is in someway supported by the government
    2)With few exceptions if you are born their it will be the place that you most love on earth. So if boom goes to bust you will either do whatever you have to to stay or you will move away to find better prospects but always plan to return when you retire
    3) Unless, as is now offical government policy, you go to great lengths to stop them a certain percentage of people will do and give absoltely anything to keep their community alive.
    4) Booms and bust occur overnight, can happen overnight and come in all shapes and sizes
    5)If you are booming you health care is not even remotely a problem because there is always a company that is behind the boom that will pay whatever it costs to keep its workforce healthy. Also because everyone has a lot of money houses are expensive so old people will not retire there and the old people there will usually sell their houses for a good profit and move to a bust town where they can buy the same house for a tenth of the price. This is really not a problem for them as if the town is really northern and small it is resources based and they have likely live in two or three similar towns over the years
    6) If it is a bust housing prices will fall so low that most of the people who lived there during the boom days will return because they can easily add at least half a million dollars to their retirement fund by selling their current home in Toronto or wherever and buying a $60000 house. It is fantastic for them because they will be in a beautiful town where everyone knows you and you can walk to the Post Office and spend hours talking to old friends. Best of all if you get sick you will be cared for by at worst the children of people who you knew when you were young. It is really perfect in every way and everything that you could hope for in your golden years. Living in a real community and being cared for by people who are accountable to you because your kids may be looking after their parents.
    7)The only flaw in this perfect world is that funding for things and Physician compliment is almost exclusively population based and caring for 500-5000 young healthy people is not even remotely comparable to caring for the same number of 65 + people. Northern Rural doctors really do care about their communities, often to a dangerously unhealthy degree, but eventually you always end up with a lot of Doctors where you don’t need them providing amazing care and a few hanging on by their finger nails praying that just one other doctor will actually commit to more than semiregular locums but knowing that it won’t happen because everyone that locums can see how it is slowly draining the life out of them and just won’t be able to willingly put themselves in that position no matter how much they feel they are needed

    So basically just boom and bust
    Seasons Best
    John

  9. Actually now that I think about it there really isn’t anything to discuss all the data exists so compliment should= population +adjustment for number of retired people+ adjustment for number of people on social assistance (period).

  10. I agree completely with John about the boom/bust phenomenon that is the reality of many northern towns. The housing opportunities / challenges that arise for “locals” impact physicians also. Buying a home in many northern towns is not an investment and I think that for some docs that makes “settling” in small Northern places less attractive.

    I also think that when we think of physician leadership and system leadership we tend to think about how to provide leadership when programs or hospitals or populations are growing. Small systems (and small and shrinking systems) also need good leadership, and probably tend to be some of the systems the most impacted by loss of leadership. It is hard to stay the course and provide support, and stability to a “microsystem” in rural settings (and by microsystem I mean the whole “system of care” in one place – clinic, hospital, home care) when it is shrinking.

  11. @DrShawn Whatley
    I am a physician assistant student at the University of Toronto. The program is based on the medical curriculum that is taught to medical students. I am interested in practicing in a rural (population around 5000). Do you have any suggestions on how my profession can get physicians to utilize our medical background to improve access to healthcare services in small towns?

Comments are closed.