Physicians leaving northwestern Ontario towns because spouses can't find jobs, new study finds

Research by a group of health-care professionals in northwestern Ontario has found burnout, and a lack of amenities and career options for physicians' spouses are among the leading reasons doctors leave small towns in the north.

The paper, titled "Why They Leave: Small town rural realities of northern physician turnover," is by Doctors Jilayne Jolicoeur, Eliseo Orrantia and Lily DeMiglio, and kinesiologist Lindsay Nutbrown. It's published in the Canadian Journal of Rural Medicine.

"People who had children who were approaching high school age were looking for opportunities for their children that didn't … exist in the community, so [in] some of the communities, organized sports for their children to participate in or certain types of classes at the high school that weren't offered," Jolicoer said.

Physicians often found themselves having to weigh the advantages of rural life, such as proximity to nature and access to unorganized outdoor activities, with the disadvantages for their families, she said. 

Rural communities in the north are dealing with a growing shortage of physicians since the early days of the COVID-19 pandemic, according to Orrantia.  

They're currently short 97 rural generalist physicians, he said.

Medical school grads concentrated in urban centres

The Northern Ontario School of Medicine opened in 2005 with a mandate to train physicians to work in the north, and research published in 2017 found more than two-thirds of graduates remained in the region.  

However, a study published in 2016 found only around 16 per cent of family physicians who graduated between 2011 and 2013, and who had done either or both of their graduate or postgraduate studies at NOSM, were working specifically in the rural north.

"People are staying in the north and mostly staying in the large centres of Sudbury, Thunder Bay, Timmins, Sault Ste-Marie and North Bay," Orrantia said.

Jolicoeur, who is from Fort Frances, instigated the research project during her second year of medical school, inspired by her own experience.

"I noticed growing up in our community, we definitely had a lot of troubles with recruitment and retention of physicians," she said.

Struggling with community integration

The team interviewed a total of 12 physicians who had closed their practices in small northern communities over the preceding five years to find out why they left.

"Some of them did really struggle, depending on what sort of area of work their spouse was in, in gaining that community integration piece," Jolicoeur said.

LISTEN | The challenges of recruiting, retaining physicians in small northern Ontario communities:

The study quotes one physician who felt a lack of reciprocity from her community when it came to helping her spouse find employment.

"He is a very skilled worker. He has two degrees in university with significant job experience, and the community was unable to ever find job opportunities that would fit for him. Even when there [were] opportunities that came up, they were never offered," the paper quotes her as saying.

Burnout was also a major factor in decisions to leave, according to the study.

"Some of the things that make rural practice really appealing also make it really difficult," Orrantia said. "There's a huge scope of work that we cover. And that for many is really what medicine is about.

"That can be very consuming ... You start to lose control of the boundaries that you have with regards to work and your own health, and your own personal life and family life. 

Other challenges raised by physicians in the study include:

• Distance from other family members.
• Poor team dynamics.
• Feeling like outsiders in their communities.
• A lack of privacy in the towns in which they worked — illustrated by an anecdote about patients approaching doctors at gas stations to ask about their cholesterol. 

In addition, physicians cited a lack of flexibility in the standard Rural and Northern Physician Group Agreement (RNPGA), the contract under which most rural northern physicians work, including a lack of options for working part time, Orrantia said.

The distance issue

Dr. Sarah Giles, a physician in Kenora and member at large for the Society of Rural Physicians of Canada, said the challenges outlined in the report aren't unique to northwestern Ontario.

"We hear a lot about why people leave," Giles said. "We don't hear much about why they stay, but it's rare to have it in a more formal academic paper and to try and do a study that looks at it in a rigorous manner."

However, northwestern Ontario does present unique challenges.

"One of the things about northwestern Ontario is distances," she said. "If you think about southern Ontario ... there are those rural hospitals about 50 to 100 kilometres apart, whereas in northwestern Ontario, you could have 500 kilometres between you and the nearest centre, and then your centre might not be that much bigger."

The distance issue can impact patients who need to be transferred, as well as general travel, especially in winter when heavy snowfall can cause serious problems for travellers, she said.

Opportunities for improvement

The government could improve physician retention by amending the RNPGA contract to allow for part-time work, the study suggests. It could also provide wellness initiatives, funding for travel to visit family members and incentives for physicians to reside in their communities of practice to promote long-term retention. 

Giles agreed that the RNPGA contract needs to be more flexible.

"I would say this about any physician contract," she said. "We know that people are looking for control of their lives."

"Sometimes that means working part-time hours in order to do things like be able to look after elderly patients, parents look after younger kids"

"Part-time contracts and flexibility is needed."

In addition, standards for full-time employment are needed, too, she said.

"If you go to a community that must have seven positions, and there's three, you're going to be working ... above and beyond what any sane person would call full-time," Giles said. "So if you're working more than full-time, is there a way that back can be remunerated?"

Orrantia said the government could increase the number of physicians allowed to work in rural communities at any one time to reduce the workload on individual doctors and thus the odds of burnout.

For NOSM's part, the study suggests that the school consider instituting mandatory rural postgraduate rotations in small rural or RNPGA communities. 

When asked how small towns that lack amenities such as junior sports leagues and 24-hour grocery stores can improve efforts to retain physicians, Orrantia said when communities look to recruit physicians, they also need to be recruIting partners. 

"If you have a physician with a partner, it's really important to spend some time thinking about and looking at, "How might we have this person find a fulfilling career in our community?"