Final Report of the Physician Resources Committee
New Brunswick Regional Health Authority 2
June, 2003

TABLE OF CONTENTS

1.0  Executive Summary 

"Across Canada, every province and territory is looking for the most effective ways to address the challenge of training, recruiting and retaining health care providers, and encouraging them to practice in rural and remote communities. Competition between provinces and territories is intense and, in many ways, counterproductive."

 Commission on the Future of Health Care (p.91)(Romanow, 2002)

Management of physician resources is seen as a key factor in the planning of health services. Health care organizations must plan and manage their physician resources, in light of an environmental context of limited resources, and a shift in emphasis to disease prevention, health promotion, community involvement, health outcomes and collaborative practice to mention a few (Graham, 2002).

The issue of having sufficient professionals to do the work in health care has long been a problem. This report will address the issue of physician resources within Atlantic Health Sciences Corporation – New Brunswick Regional Health Authority 2, specifically to identify issues of recruitment and retention.

The issues that affect physician resources within AHSC are the same as those that affect the resources of physicians across the country. These include:

• An aging physician workforce
• Gender (more female physicians who may juggle family demands as well as practice)
• Speciality chosen and opportunity for education
• Clinical demands
• Community needs and size
• The number of graduates from medical schools
• Place of graduation from medical school
• Workload in a practice
• Remuneration method and amount
• The availability of International Medical Graduates to meet the needs of communities

Communities across Canada are actively competing for the scarce resource of qualified physicians. Recruitment and retention strategies are developed and implemented by provincial and municipal levels of government, Regional Health Authorities, professional associations and (in many instances) are supported by the private sector at the community level. These strategies have been targeted to new and practicing physicians; and to residents and undergraduate medical students.

The government of New Brunswick, through the Department of Health & Wellness, maintains control over the number and distribution of physicians permitted to practice in New Brunswick. This directly impacts the ability of AHSC to recruit physicians to the region. The recruitment and retention of physicians on a provincial basis is a macro approach to physician resource planning and is usually driven by a desire to manage physician spending provincially and to ensure that physician resources are being directed to under-serviced areas.

The current physician resource issue across Canada has left the public unsure of the future capacity to ensure the availability of continued quality health care. The Physician Manpower Resource Committee (PMRC) of the AHSC Medical Advisory Committee (MAC) was formed in 2001 and was working on a strategic plan for physician resources. The Board of Directors of RHA 2 formed a Physician Resources Committee (PRC) as one of its first duties in 2002. The purpose of this committee was to hear the public's concerns and to identify further opportunities to address local and regional physician recruitment challenges. They were to bring forth recommendations to the Board of Directors on physician recruitment opportunities and strategies.

The Physician Resources Committee was chaired by Carole Fournier, Board member for RHA 2 and included members from the communities of the region, as well as other members of the Board of Directors. From October 2002 to April 2003, the committee explored:

• the factors that give rise to national physician shortages and the situation we face across our region,
• the perspective of medical students in choosing their discipline and establishing a practice,
• the perspective of physicians currently in practice,
• the needs and perspectives of communities within RHA2, with respect to physician resources,
• the role of the Provincial Physician Resource Advisor ,
• to obtain an understanding of current physician resource strategies, and
• a background report to identify issues of recruitment and retention as well as to place the situation of AHSC within the context of national and provincial thinking.

Following their consultation process and review of the background report, the committee participated in a facilitated session to outline recommendations for their final report. During this session, the committee was asked to recall the highlights of their consultation and brainstorm about the issues that had arisen. They were then asked to review in small groups the recommendations that had arisen during their consultation process. The recommendations from public meetings in Eastern Charlotte County, Saint John, Sussex and Western Charlotte County; as well as those that came from the Region 2 and resident physicians meetings were categorized into theme areas. Small group work involved identifying the area of responsibility and a timeframe for the recommendation. Areas of responsibility where the recommendations could be addressed were at the community, RHA and provincial levels. Identified timeframes were immediate, within 1 year, or within 5 years. Each group was challenged to think about what must be worked on, should be worked on, and could be worked on. Following the facilitated session, the work of the small groups was reviewed, compiled and recommendations were determined.

It is through its Board of Directors, Management and Medical Staff, that AHSC will address the issue of physician resource (including the elements of recruitment and retention). The hiring of a full-time Physician Resource Coordinator in April 2003 is a timely addition for beginning to address these recommendations. 

The ideas and concerns represented here, emerged during the work of the Physician Resource Committee. The scope of these directives includes a spectrum of relationships that exist and are important to consider when addressing Physician Resource in this region. There are recommendations that are directed toward the relationship between AHSC and: 

• the communities of the region; 
• the learners (residents and medical students) who spend time in RHA2; 
• the physicians who currently practice in this region; 
• the new physicians who may want to begin practice in this region; and 
• the provincial Department of Health and Wellness. 

It is also important to note that there are elements of these recommendations that overlap. Categorizing a particular strategy with one recommendation does not negate the role it may have in addressing any other recommendation.

Recommendations

Preamble
With the analysis of information and feedback received, a common recurring theme was "Communication". It was perceived that open communication between RHA2 and the communities within, could both promote and facilitate recruitment. It is believed that effective communication develops from a strong framework, or plan, with strategies supported by all participants. The desire was expressed for better communication and knowledge-sharing among all levels: community, RHA and government.

Preamble
The consultative process this committee conducted also highlighted the value of participation and collaboration. While Regional Health Authority 2 has the responsibility to take the lead in recruitment and retention initiatives, it quickly became evident that communities have a strong desire and commitment to successful physician resource outcomes in the region.

Preamble
As a teaching organization, AHSC has the advantage of rotating residents and medical students through its facilities and programs. More than 150 Royal College and Family Medicine residents and 50 undergraduate medical students participate in core, selective and elective rotations each year, with an average of 50 on-site at any one time. Medical trainees on-site contribute to the promotion of quality patient care, as well as the continuing education of staff. They also represent an enhanced recruitment opportunity.

4. Medical Students

Preamble
It is becoming more evident that "the personal touch" is an important marketing tool. When recruiting physicians we are effectively marketing our facilities, our communities and our people to prospective candidates. Our most successful recruitment efforts to date have been those that focus on bringing former New Brunswickers home. Taking an interest in the career paths of our young people as they pursue their studies can be a basis for providing that personal touch to future medical residents.

Recommendation: That AHSC communicate with students of Canadian medical schools who have the potential to come to southwestern New Brunswick for a core, selective or elective experience; or to practice here.

5. Recruitment and Retention

Preamble
An emerging theme throughout the consultative process was the fact that no one person or service recruits in isolation. While there is agreement that physicians are well placed to recruit new physicians, concern was expressed that this may be putting too high an expectation on the role played by the Department of Family Medicine.

Recommendation: That AHSC evaluate the current process of physician recruitment and retention, in order to identify potential improvements.

6.  Provincial partnership

Preamble
Through discussions with community groups, it was recognized that sometimes municipalities feel disadvantaged when it comes to advocating for health care reform with provincial and federal governing bodies. It was suggested by many participants that AHSC should be a "standard bearer" and actively bring forward the health care issues and concerns of local communities within this region to the attention of decision-makers.

Recommendation: That AHSC assist communities in having their messages on health heard by provincial policy makers; and report on progress in addressing existing concerns.

7. Practice models

Preamble
While the work of this committee focussed mainly on the recruitment and retention of physicians in our region, the current issues with access to family physicians often led to discussion of other ways to access primary health care. Repeatedly, community health centres, featuring collaborative care models were cited as alternative ways to access primary health care. Discussion also centered on the fact that many younger physicians who are beginning practices, welcome a collaborative care model (particularly in a more rural setting), making this style of practice an important recruitment tool.

Recommendation: That AHSC support: the exploration of alternative practice models, and existing collaborative models (which will accommodate the choice of new physicians.

2.0  Introduction 

Despite years of study, why don’t we seem to make progress? Canadian researchers have characterized health human resource planning as a "classic policy soap opera – tune out for a few years and there is a reasonable chance that not much will have changed when one returns."

(Barer, Wood, & Schneider, 1999)

 The issue of having sufficient professionals to do the work in health care has long been a problem. This report will address the issue of physician resources within Atlantic Health Sciences Corporation (AHSC) – New Brunswick Regional Health Authority 2 (RHA2), specifically to identify issues of recruitment and retention as well as to place the situation of AHSC within the context of the national and provincial thinking.

In April of 2002, the Government of New Brunswick brought in legislation that created Regional Health Authorities (RHA) in this province. These RHA are charged with the responsibility to guide the delivery of health care services in the areas they serve. The Board of Directors for RHA 2 provides direction for the delivery of quality, accessible health care throughout the communities of southwestern New Brunswick.

The current physician resource issue across Canada has left the public unsure of the future capacity to ensure the availability of continued quality health care. The Physician Manpower Resource Committee (PMRC) of the AHSC Medical Advisory Committee (MAC) was formed in 2001 and was working on a strategic plan for physician resources. The Board of Directors of RHA 2 formed a Physician Resources Committee (PRC) as one of its first duties in 2002. The purpose of this committee was to hear the public's concerns and to identify further opportunities to address local and regional physician recruitment challenges. They were to bring forth recommendations to the Board of Directors on physician recruitment opportunities and strategies.

3.0  Process 

The Physician Resources Committee was chaired by Carole Fournier, Board member for RHA 2 and included the following members:

• Robert Brown, Mayor of St. Stephen
• Patricia Crowdis, Director Communications and Media Relations
• Mr. Ed Farren (attended 2 meetings on behalf of Mayor Shirley McAlary)
• Floyd Haley, Council member for the Town of St. Stephen
• Dr. David Henderson, RHA 2 medical staff
• Muriel Jarvis, Saint John Board of Trade representative
• Erma MacAulay, RHA 2 Board member
• John Malone, Sussex, N.B.
• Shirley McAlary, Mayor of Saint John
• Bob McVicar, Saint John Board of Trade representative
• Dora Nicinski, President and CEO RHA2
• Dr. James O’Brien, Chief of Staff
• Dr. Robert Rae, RHA 2 medical staff
• Todd Stephen, RHA 2 Board member
• Donna Walsh, previous Hospital Corporation Board member
• Wayne Wamboldt, RHA 2 Board member

The first meeting of the committee was held on Tuesday, October 8, 2003. This meeting was an information and orientation session for members. Dr. James O’Brien presented an overview of the current challenges pertaining to physician resources planning and recruitment.

Members of the PRC met with eight medical residents on October 16, 2002. The purpose of this informal gathering was twofold. Firstly, it was to find out how and why medical students chose their current discipline. Secondly, the factors that residents take into consideration when deciding where to establish a practice were discussed.

In November, the committee met with five members of the medical staff. These physicians explained how they thought RHA 2 could capture and retain the attention of potential recruits. They were also able to help the committee members understand the needs of physicians who are currently practicing here.

The Physician Resources Committee met in December to establish a process to consult the citizens of Regional Health Authority 2. Members agreed to hold four community Focus Groups in February 2003.

Members met with Lyne St-Pierre-Ellis, Provincial Physician Resource Advisor in January 2003. Ms. St-Pierre-Ellis explained her role and how it links with RHA2. The brochure "Physician-Friendly New Brunswick - A Comprehensive Approach to Physician Recruitment and Retention" was distributed to all members.

The Chairperson of the PRC, Carole Fournier and Dr. James O’Brien, Chief of Staff met with close to 100 citizens of Health Region 2 during the community Focus Groups held in Eastern Charlotte, Saint John, Western Charlotte and Sussex. These Focus Groups gave committee members an opportunity to understand the needs and expectations of residents. Many good recommendations came out of these sessions.

A background report on Physician Resources was prepared by RHA2 Planning Services in January 2003. The report addressed the issue of physician resources within AHSC - RHA2, specifically to identify issues of recruitment and retention as well as to place the situation of AHSC within the context of the national and provincial thinking.

Background information identified that the issues that affect physician resources within AHSC are the same as those that affect the resources of physicians across the country. The report gave some historical perspective within Canada, including the development of the current situation as based in recommendations within the past 20 years. It looked at numbers / information with respect to the scene provincially, and then identified the issues specifically within RHA2. The report did not include recommendations as the Physician Resource Committee continued with public consultation sessions. The report was received at the committee meeting on February 25, 2003 (see Section 4.0 Background).

Following the consultation process and review of the background report, the committee requested facilitation of a session to outline recommendations for their final report. This session took place on March 19, 2003. During this session, the committee was asked to recall the highlights of their consultation sessions and brainstorm about the issues that had arisen.

The participants of the facilitated session were asked to review in small groups the recommendations that had arisen during their consultation process. The recommendations from public meetings in Eastern Charlotte County, Saint John, Sussex and Western Charlotte County; as well as those that came from the Region 2 and resident physicians meetings were categorized into theme areas. (These Physician Resources Committee - Theme areas and suggestions can be seen in Appendix A). The small group work involved identifying the area of responsibility and a timeframe for the recommendation. Areas of responsibility where the recommendations could be addressed were at the community, RHA and provincial levels. Identified timeframes were immediate, within 1 year, or within 5 years. Each group was challenged to think about what must be worked on, should be worked on, and could be worked on.

Following the facilitated session, the work of the small groups was reviewed and compiled. The detailed recommendations, which emerged from that work, are seen in Part 5.0 of this report.

4.0 Background

The issues that affect physician resources within AHSC are the same as those that affect the resources of physicians across the country. To provide context for the issues within RHA2, it is helpful to first examine a historical perspective within Canada; and the numbers/information about physician resources in New Brunswick.

Management of physician resources is seen as a key factor in the planning of health services. Health care organizations must plan and manage their physician resources, and other health human resources, in light of an environmental context of limited resources, and a shift in emphasis to disease prevention, health promotion, community involvement, health outcomes and collaborative practice to mention a few (Graham, 2002).

"For the past two decades, continuing changes in how health care services are delivered combined with efforts to contain costs in every province and territory have taken their toll on Canada’s health workforce. Although the problems differ for different health care providers, the malaise is widespread and, in some cases, it has moved from mere discontent to outright anger and frustration. Canadians are confronted with these problems on a regular basis both in their interactions with the health care system and through regular media reports of the latest "crisis" in health care."

Commission on the Future of Health Care (p.91)

4.1.1 Physician supply

As cited by Commissioner Romanow in the final report of the Future of Health Care in Canada:

Between 1980 and 1993, the number of general practitioners for every 100,000 people increased from 76.4 general practitioners to a peak of 101.5. By 1999, the number had dropped to 94.0 (one doctor for every 1,063 people) but it has been steadily increasing ever since. The picture for specialists is somewhat different. Between 1980 and 1994, the number of specialists per 100,000 Canadians increased steadily from 74.7 to 90.0. After a slight drop in 1995-96, the number of specialists has been steadily increasing and, in 2001, the number of specialists per 100,000 people reached 92.7 (1 for every 1,077 people), the highest point in over 20 years. (Romanow, 2002)

 In the 2002 Senate Report on the future of health care, Senator Kirby cites an increase in the total number of physicians in Canada from 1996 to 2000. This includes a 7.4% increase in the number of specialists, and a 3.2% increase in the number of family physicians. During this time however, the population of Canada increased by 3.5%. This led to a decreased ratio of family physicians from 95/100,000 to 94/100,000 (Kirby, 2002).

In the 10 year period from 1989 to 1998 there was only a slight decrease (- 0.5% change) in the overall ratio of physicians per 100,000 Canadians . However, looking at average numbers of physicians per population in Canada tells only part of the story. Within the provinces and territories, there are significant differences in the supply of family physicians and general practitioners . The geographic disparities and shortages of practitioners mean that patients have to travel to where service may be available, and may not go (Kirby, 2002).

While physician organizations and many communities point to serious problems in meeting the need for physicians, other studies suggest that there is far less consensus about whether or not there is a crisis in the supply of physicians. A recent report prepared for the Canadian Institute for Health Information suggested that the apparent shortage is more perceived than real. At the same time, access to physicians and specialists varies significantly across the country, and some communities lack the supply of health professionals necessary to ensure access to even basic health services (Romanow, 2002).

The following table indicates the supply and migration of physicians in Canada for the year 2001. One of the limitations of this information is that it is derived from surveys returned by physicians. Information not collected in the survey, would not be included in this tally.

Supply and Migration of Physicians - Canada, 2001 (Canadian Institute of Health Information, 2002)

	Canada - 2001
SUPPLY
Total Number of Physicians	58,546
Family Medicine	29,627
Specialists	28,919
Total Physicians per 100,000 population	188
Family Medicine	95
Specialists	93
Average Age
Family Medicine	46.4
Specialists	48.8
Gender(*)
Male
Family Medicine	19,167
Specialists	21,646
Female
Family Medicine	10,381
Specialists	7,249
Specialty
Family Medicine	29,627
Medical Specialists
Clinical Specialists	19,656
Laboratory Specialists	1,443
Surgical Specialists	7,769
Medical Scientists	51
Years since M.D. graduation
1 to 5	3,335
6 to 10	7,665
11 to 25	26,843
26 to 30	7,370
31 to 35	5,420
36 +	7,913
Place of M.D. Graduation (**)
Canadian
Family Medicine	22,883
Specialists	22,131
Foreign
Family Medicine	6,516
Specialists	6,782
MIGRATION
Moved Abroad
Family Medicine	172
Specialists	437
Returned from Abroad
Family Medicine	138
Specialists	196

(Source: CIHI)

Notes: Includes physicians in clinical and/or non-clinical practice Excludes residents and physicians with ‘No-Pub" status
(*) Excludes physicians where gender is unknown. (**) Excludes physicians where place of M.D. graduation was unknown
na – not applicable
Date as of December 31 of given year.

4.1.2 Factors and issues which affect physician supply

There are a variety of specific factors and issues that affect the supply of physicians in Canada. Factors include age, gender and speciality of the physician, clinical demands, community needs and size, number of medical graduates and place of graduation, and workloads. Additional issues include: remuneration level and the availability of international medical graduates (Romanow, 2002).

Age
From 1996 to 2000, the average age of physicians increased from 46.4 years to 47.5 years. Given population trends as a whole, it is likely that by the year 2024, 40% of all active physicians will be over the age of 55 years (Kirby, 2002).

Gender
Currently over half of the medical students in Canada are women (Kirby, 2002). In 2000, women accounted for close to half (49.6%) of all students graduating with medical degrees, an increase over 1980, when only 32% of graduates were women (Romanow, 2002). From 1993 to 2000, the number of practicing female physicians rose from 25% to 29%. It is estimated that by the year 2015, 40% of the physician supply will be women(Kirby, 2002). This shift in the mix of male and female physicians has had an impact on changing trends in physician practice, with more female physicians choosing general and family practice compared to medical specialities (Romanow, 2002). In addition, physicians who are women tend to practice fewer hours than men (48.2 vs. 55.5 hours/week)(Kirby, 2002).

Workload
Witnesses to the Senate Standing Committee on Social Affairs, Science and Technology reported that physicians are straining under their current workload. The average number of hours worked by physicians in Canada is 53/week, with an additional 25 hours/week when on call. In addition, it was cited that there are approximately 2,000 physicians who do not share call, and are therefore "on call 24 hours per day, seven days per week, every day, every week for years at a time"(Kirby, 2002). In addition as the physician workforce ages, more physicians will be unwilling or unable to work such long hours. With respect to gender and age, women and younger medical graduates have expressed a desire for a "better balance in life" and may choose not to work for so many hours in a week (Kirby, 2002).

Speciality
There have also been changes in the nature of practice. This is especially true in relation to family medicine. Here physicians are providing less after hours or on-call care than they did previously. There is greater sub-specialization, and a decline in other family physician roles (in Emergency Room shifts, nursing home visits and house calls). In addition, there is variation in the levels of service offered in rural areas vs. urban ones. Family physicians in rural areas are therefore providing more comprehensive service (likely as a result of fewer specialists in the area)(Canadian Policy Research Networks Inc., 2002).

Graduates from medical schools
In 1991, a report by Barer and Stoddart recommended that enrolment in Canadian medical schools, along with positions in postgraduate training programs, be decreased by 10% in order to deal with a perceived unwarranted increase in physician supply. Despite the report's admonishments that this recommendation not be implemented in isolation from the other recommendations made at the time - that is what was done. As a result, according to data from the Association of Canadian Medical Colleges, the size of first year medical school classes has declined by 16% since 1991(Kirby, 2002).

Place of graduation
The education and training of physicians can have an impact on where they choose to practice. With more exposure to and experience in rural settings as part of their education programs, the likelihood of graduating doctors wanting to practice in rural settings increases (Romanow, 2002). The Society of Rural Physicians of Canada and the College of Family Physicians of Canada have recently made efforts to develop curricula & guidelines that will address this (Romanow, 2002).

Remuneration
According to the Romanow Commission, salaries for both physicians and nurses have the potential to become significant cost drivers in the health care system. The current fee-for-service approach to paying physicians is seen by many as an obstacle to primary health care. In order to address this concern, the Commission suggested consideration of "the deliverables physicians are expected to provide such as ensuring adequate access to health care services, changing their patterns of practice to facilitate primary health care or to meet changing needs in the health care system, or achieving certain outcomes for their patients (e.g., screening for certain tests)" (Romanow, 2002). Physicians who are salaried face a diversity of pay, depending on their speciality and the province in which they are employed. In addition, the range of pay available by province has affected the migration patterns for physicians in certain specialties.

International Medical Graduates
International medical graduates are physicians who have been educated (either initially, or initially and for a specialty) outside of Canada. They may come to Canada as immigrants, and provide an educated physician resource. International graduates have to undergo an extensive assessment process before they are allowed to practice in Canada. The approval and integration process spans several years and is quite complex, causing significant delays. As a result, many health care professionals from other parts of the world find it difficult to get meaningful work in the health care system. The Romanow Commission suggests that "governments and professional organizations need to streamline the process for recognizing foreign training and provide additional training for immigrant health care professionals where necessary" (Romanow, 2002).

Not all International Medical Graduates in Canada have come initially as immigrants. It is noted that some "provinces and territories have actively recruited medical graduates from developing countries in order to meet the needs for physicians in Canada, especially in rural and remote areas. Until the late 1970s, Canada openly sought and recruited international graduates from medical schools, giving them 'preferred status' in our immigration policy. At that time, international graduates made up 30% of our physician workforce, but that number has since dropped to just under 23%. Despite this decline, some provinces like Saskatchewan continue to rely heavily on international graduates to meet demands in their communities while other provinces like Quebec depend far less on international graduates." (Romanow, 2002)

The extent to which International Medical Graduates are a part of the health care system in Canada is seen in the following table.

Distribution of International Medical Graduates, by Province, 2001

Province/Territory	Total Physicians	Canadian MD Graduates	International MD Graduates	Percent Distribution of International MD Graduates
Newfoundland and Labrador	945	531	395	41.8
Prince Edward Island	190	156	28	14.7
Nova Scotia	1,885	1,389	494	26.2
New Brunswick	1,179	923	251	21.3
Quebec	15,866	14,024	1,800	11.3
Ontario	21,482	16,206	5,268	24.5
Manitoba	2,093	1,366	613	29.3
Saskatchewan	1,549	743	796	51.4
Alberta	5,154	3,755	1,385	26.9
British Columbia	8,105	5,854	2,250	27.8
Yukon	54	35	9	16.7
Northwest Territories	37	28	6	16.2
Nunavut	7	4	3	42.8
Canada	58,546	45,014	13,298	22.7

Source: Romanow: Building on Values: The Future of Health Care in Canada. 2002

The report from the Commission on the Future of Health Care in Canada does caution about the recruiting of physicians from developing countries. The cost to these countries is great as their resources are exported in the form of physicians with skills and knowledge. This effect of globalization led the Commission to express "serious concerns about Canada's practice of recruiting physicians from developing countries. While international medical graduates who want to immigrate to Canada should not be prevented from doing so, provinces and territories should reduce their reliance on physicians from developing countries and take steps, instead, to recruit and retain more physicians within Canada." (Romanow, 2002).

4.1.3 Recruitment / Retention Strategies

The effects of solutions designed to increase the supply of physicians may not result in more physicians in the areas where they are needed the most. In the past, the Canadian Medical Association has resisted government action requiring physicians to practice in smaller communities, characterizing it as both punitive and coercive. But the answer also does not lie in simply paying physicians more to entice them to smaller communities (Romanow, 2002). Research shows that: "Heavy workloads and high patient demands and expectations, lack of flexibility in working arrangements and [health services] reorganization, as well as training and career development issues all appear to impact upon recruitment and retention to a much greater degree than does remuneration". (Romanow, 2002)

The geographic maldistribution of physicians has led to both negative and positive incentives in an effort to encourage physicians to settle in underserviced areas (Canadian Policy Research Networks Inc., 2002). In their Summary Report on Health Human Resource Planning in Canada, the Canadian Policy Research Network stated the following:

The geographic distribution of physician resources is an issue that has bedeviled policy makers for decades. Because physicians are free to locate their practices where they choose, negative and positive incentives are used to induce physicians to move to underserviced locations. Financial disincentives such as billing caps or discounted fees to discourage set-up in specific locations have been attempted. They have met with some "success" but the burden has been borne largely by newly graduating physicians thus raising fairness issues. As well, the courts have had some concern as to whether governments can legally exert this control. (Canadian Policy Research Networks Inc., 2002)

Communities across Canada are actively competing for a scarce resource, qualified physicians. Recruitment and retention strategies are developed and implemented by provincial and municipal levels of government, Regional Health Authorities, professional associations and in many instances are supported by the private sector at the community level. The following information was gleaned from web sites and the print media. Personal communication elicited few additional details.

4.1.3.1 Provincial Programs:

There are a variety of provincial programs aimed at attracting physicians to come to an area and to entice/convince them to continue their practice there. These have been targeted to new and practicing physicians; and to residents and undergraduate medical students.

1. Targeted to new physicians / practicing physicians and specialists

All provinces offer a fairly standard menu of financial incentives, which include but are not limited to location grants, relocation cost assistance, special training opportunities, continuing medical education and locum support programs. These initiatives are described here.

• Location grants:

These grants are provided to new physicians who agree to locate in specific areas of a province for a designated period of time. Grants are generally comparable province to province in the range of $15,000, in return for a 2-year commitment of service. Exceptions are made for northern and rural regions by the provinces of Saskatchewan and Ontario. Saskatchewan offers $18,000 for a minimum 18-month commitment through a Rural Practice Establishment Grant. Ontario offers $40,000 over 4 years, through the Incentive Grant Program for Practicing Physicians.

• Relocation Cost Assistance:

Provinces offer $5,000 to $10,000 to assist new physicians with moving, travel and temporary accommodation expenses incurred when relocating.

• Special Training Opportunities

Grants are made available to family physicians who have practiced in a specified area of a province for at least two years and wish to take additional training in a specialty area in order to meet the needs of the community. Examples of these opportunities are found in obstetrics, anaesthesia or emergency medicine.

• Continuing Medical Education

Annual grants are provided by most provinces enabling physicians to maintain and /or upgrade knowledge.

• Locum Support Programs

Locums are physicians contracted to replace local physicians who require short-term relief for vacation, education leave, etc. Locums are offered support through programs which run the gamut from a simple locator service provided through the provincial web site (New Brunswick) to direct funding for travel, accommodation and professional fees (PEI, Nova Scotia), through fully coordinated and funded programs for rural and northern areas, as seen in Ontario, Alberta and Saskatchewan. The latter are established partnership initiatives between the provinces and the provincial medical associations, which administer the program.

A summary of rural incentive programs across Canada is seen in the following table.

Rural incentive plans across Canada, 1998

PROVINCE	RETENTION			RECRUITMENT
	ER call, $	Locum	Remote pay	Signing Bonus	Urban disincentives	Re-entry Training	Contract
British Columbia	Bonus $20/h after hours	Limited	5% to 20% FFS				Some
Yukon Territory					Paid at 50% FFS
North West Territories				upcoming
Alberta	Bonus $17/h after hours	< 5 MD towns		$20,000 (10 & 10 from region)		$76,000/yr pro rata
Saskatchewan	Bonus $10/h weeknights, $25/h weekends	4 MD towns		$25,000/ 18 months		$80,000/yr	$121,000 to 140,000 starting
Manitoba		< 5 MD towns		$44,000/yr			$150,000
Ontario	$70/h flat rate nights, holidays, weekends	Limited	$5000 CME per year	$40,000 /yr	Paid at 70% FFS	Yes	$174,000 -to 194,000 + ER sessional
Quebec	$140 + 50% FFS 2000h to 2400h. $402+ 75% 2400h to 0800h	Limited	15%FFS	$40,000/4yr from region + moving	Paid at 70% FFS		CLSC
New Brunswick			3.8%/yr at 3yr 5.7% at 5yr		Billing no. restrictions	At 50% gross
Prince Edward Island					Billing no. restrictions
Nova Scotia	$50/h & up annual volume dependent			$50,000/5yr + $5000	Billing no. restrictions		$138,000 minimum. FFS guarantee
Newfoundland			$30,000		Billing no. restrictions + global cap

FFS= fee for service, CME= continuing medical education. CLSC = community health centre
Sources: provincial ministries of health
SOURCE: Canadian Journal of Rural Medicine 1998; 3(4): 242-7

 2. Targeted to undergraduate medical students and residents:

• Return of Service ( tuition / bursary) Programs

Several provinces offer these programs to both medical students and residents.

• Ontario offers final year medical students, residents and newly graduated physicians up to $40,000 to cover actual tuition costs in exchange for a full time, 3-4 year, return-of-service commitment.
• Prince Edward Island's Sponsorship Program is open to medical students and residents training in a Canadian program. The recipient must agree to practice in PEI for one year in exchange for each 'sponsored' year.
• Saskatchewan offers bursaries of $18,000 each year to 5 undergraduate medical students and 3 residents. The return of service commitment is also one year of service for each 'bursary' year.
• New Brunswick may offer financial assistance to physicians training in a specialty for which a community need exists. Access to the program is restricted to applicants who - "are unable to secure an alternative training venue, are foreign medical graduates seeking to obtain licensure."
• Newfoundland's resident and medical student incentive program provides financial support to fourth year medical students matched to a family medicine program through the Canadian Resident Matching Service (CaRMS) and first and second year students interested in committing to practice in an 'area of need'. The agreement is one year of service for each year of incentive received. Service can be returned in either a fee-for-service or salaried position.

• Rural Practice Exposure

Summer Extern and Summer Rural Preceptorship programs are offered to medical students between the second and third year of medical study by the provinces of Saskatchewan and New Brunswick. The purpose of these programs is to create interest in rural practice / areas. New Brunswick offers 30 positions annually (15 English, 15 French) and Saskatchewan has 20 positions available. New Brunswick offers a stipend of $4,000 for a 10-week placement and preference is given to students from the province. Saskatchewan offers an eight-week program. Stipend details are not available.

• Clerkship Opportunities Rural and Northern

Ontario is offering an increased number of 'clerkship' opportunities for third and fourth year medical students for clinical rotations in rural and northern areas of the province. Students in the program are reimbursed actual travel and accommodation costs and there is no funding cap on the number of rural/northern clerkships the student may undertake.

• Family Practice / Rural Residency Training Programs

PEI has created opportunities for 12 family practice residents to do clinical rotations on the island. Travel and accommodation costs will be reimbursed. Saskatchewan has increased the amount of time family practice residents may spend in rural clinical rotations from 12 to 40 weeks.

• Above and beyond the basics (recruitment strategies directed to students)

The following strategies from other provinces highlight specific opportunities in New Brunswick. These have also been noted.

1. Canada Student Loan assistance (CSL) is provided for medical students planning to return to PEI within 2 years of graduation. There is also a deferred payment of CSL until after 2 year residencies are completed. This may be an opportunity for programs by both the New Brunswick Departments of Health & Wellness and Education.
2. Adopt A Student Program in Saskatchewan involves a member of a regional recruitment team maintaining regular contact with a medical student from that region, providing the student with news and updates on the region. This may be an opportunity for retired physicians in RHA2.
3. The On-Site Physician Recruitment Office in Newfoundland and Labrador provides person to person access to information about provincial/regional vacancies, and initiatives. This may be an opportunity to establish part-time positions at three sites Dalhousie, Laval, and Memorial to implement and/or coordinate recruitment strategies (i.e. coordinate the Rural Preceptor program).
4. Home for the Holidays in Ontario is a program designed to welcome home physicians who have 'gone away' for their medical education. There may be an opportunity for Foundation(s) to host this recruitment initiative.

4.1.3.2 Regional Health Authorities (RHA)

Benefit Packages

RHA's offer a variety of benefit packages in addition to provincial recruitment incentives. These packages usually contain any or all of the following:

• Financial incentives
• Spousal employment
• Turn key clinics
• Office maintenance (cleaning, general maintenance, technical support)
• Computers (including internet and software)
• Telephone/fax
• Health / dental coverage
• Basic life / dependent life insurance
• Basic accidental death
• Long term disability insurance
• Canadian Medical Protective Association dues
• Pension benefits
• Study leave for salaried positions
• Vacation plus travel allowance

Note: all items are 100% employer pay except pension benefits for salaried positions, which are 50% employer pay.

4.1.3.3 Municipal Councils

In many areas of the country municipal councils provide financial and 'in kind' support to Regional Physician recruitment initiatives. Financial contributions may be used:

• to offset the costs of sending regional representatives to recruitment fairs and university site visits,
• for promotional materials, media advertising,
• establishing and training regional recruitment teams,
• to provide all expenses paid visits to the region for interested recruits and their partners.

4.1.3.4 Community /Private Sector partners

The private sector in a region often contribute to recruitment initiatives by offering / providing, custom financial packages, real estate packages and spousal employment opportunities. For example in one Ontario community a real estate consultant works with the recruited physician & partner to coordinate purchase / sale, lease agreements and facilitates all administrative details legal services, moving services, financial services and other related needs (one -stop shopping). In another Ontario community a regional committee of Human Resource Directors from major employers in the area, both private and public sector, work together to ensure an appropriate match when employment opportunities are sought for the physician’s spouse.

4.2 New Brunswick

"Across Canada, every province and territory is looking for the most effective ways to address the challenge of training, recruiting and retaining health care providers, and encouraging them to practice in rural and remote communities. Competition between provinces and territories is intense and, in many ways, counterproductive."

Commission on the Future of Health Care (p.91)(Romanow, 2002)

4.2.1 Historical Perspective

The government of New Brunswick, through the Department of Health & Wellness, maintains control over the number and distribution of physicians permitted to practice in New Brunswick. This directly impacts the ability of AHSC to recruit physicians to the region. The recruitment and retention of physicians on a provincial basis is a macro approach to physician resource planning and is usually driven by a desire to manage physician spending provincially and to ensure that physician resources are being directed to under-serviced areas (Graham, 2002).

One initiative developed to approach physician resource planning from a provincial perspective was the creation of the "Physician Resource Management: Plan for New Brunswick" released in July 1999. This document was revised in 1999 with the release of "Physician Resource Management Plan: 1999". The 1999 document includes recommendations accepted by the then Minister of Health & Community Services from the report submitted by the Physician Resource Advisory Committee (PRAC) in 1997, as well as related policy changes since 1992 (Graham, 2002).

Currently
The Department of Health, in its "Physician Resource Management Plan 1999", adopted the National Full-Time Equivalency Physician Measure (FTE) as the basic methodology to define physician activity and supply in New Brunswick. The national system was modified to include radiology services, GP anesthesia services, sessional payments for clinical services including emergency, salaried payments for clinical services, and fee-for-services indirect payment system (Graham, 2002). In December 2002, the Government of New Brunswick reported to the province the current progress of the Physician Recruitment and Retention Initiative (PRRI) (New Brunswick, 2002). A Physician Resource Advisor was hired to "coordinate provincial recruitment efforts and to work in conjunction with regional health authorities in their efforts". In addition as of November 2002, the PRRI has meant the following:

• 52 new physicians have come to work in New Brunswick
• since June 1999, total net gain of physicians = 82
• 26 physicians have received location grants (8 GPs, 18 specialists - $830,000)
• during the past 3 years, New Brunswick has recruited 37 foreign-trained physicians to work. Looking at providing more opportunities for International Medical Graduates, working with federal authorities and the College of Physicians and Surgeons of New Brunswick
• agreement has been reached with the Medical Society to provide an after-hours on-call fee for physicians who provide service to hospitals
• the summer employment program (in its 3^rd year) for 30 medical students each year.
• 18 residents added to the Supernumerary Residency Training Program
• working with New Brunswick Medical Society to enhance remuneration for salaried physicians
• establishment of a $1 million contingency fund to assist Regional Health Authorities to address recruitment issues (8 GPs & specialists have been recruited) (New Brunswick, 2002)

4.2.2 Strategies

Currently New Brunswick participates on the Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources. This committee is working on establishing a national physician database, and maintaining open communication among jurisdictions about how to address the issue of physician supply. According to the New Brunswick Physician Resource Advisor, there is no current national strategy for physician resources. On a provincial level, the Regional Health Authorities are chiefly their own recruiters - with assistance from provincial incentive programs.

A new Physician Recruitment and Retention website has been established which outlines information about New Brunswick including the health care system; opportunities for practice (locum and permanent positions), licensing, incentives (location grants of up to $25,000 for family physicians and $40,000 for eligible specialists, residency training program), remuneration information, and a section just for medical students and residents (Summer Rural Preceptorship Program, newsletters, calendar and a Who's Who Registry). As well, New Brunswick medical students are contacted in their first year of study and presented with a stethoscope and a $300 bookstore gift certificate, by the province.

In addition, there is an International Medical Graduate Task Force, which reports to the Deputy Minister of Health and Wellness. This group is concerned with standardizing and facilitating the appropriate assessment of these physicians, prior to their beginning practice here.

4.3 Atlantic Health Sciences Corporation – Regional Health Authority 2

While most physicians are not employees of AHSC, and their recruitment and retention are shared responsibilities with other agencies, they constitute an important component of the health human resources of the RHA (Graham, 2002). 

While macro level planning is required to help identify and address the broader provincial issues, Regional Health Authorities must continue to plan to deal with local dynamics. Consideration must be given to such factors as the health status of the residents, the demographics of the area, the ability of the community to support specific specialties and to other resources that may be available or required to sustain specific specialties (Graham, 2002).

Population health, available technology, physician supply and distribution of supply affect the physician resource plans for specialty services. The 'critical mass' of workload that ensures development and maintenance of skills, adequate remuneration, acceptable on call arrangements, career and personal objectives are all variables that lead to successful recruitment and retention. The actual number of physicians available (head count) at any given time must be considered in light of the dynamics relating to the personal health, age and profile of services supplied by those physicians. Estimation of future physician resource requirements is dependent on anticipated market requirements (e.g., patient demands and physician supply) and as such requires that AHSC be proactive and may, on occasion, require that the Authority exceed what is considered current need. The key is flexibility as well as coordination of efforts between regions to ensure that provincial needs are met and contingencies exist when services or programs are threatened (Graham, 2002). Tertiary services that are limited to a small number of centers may also require unique arrangements if they are to compete successfully in a national market (Graham, 2002).

4.3.1 AHSC Physician Profile

As Of December 2002, there were a total of 1,275 active physicians in the province of New Brunswick. Region 2 had 25% of the total number of active physicians in the province, ranking second to Region 1 (27%)(Department of Health and Wellness, 2002).

Source: NB Department of Health and Wellness, Physician Recruitment and Retention Status Report, December 27, 2002

Source: NB Department of Health and Wellness, Physician Recruitment and Retention Status Report, December 27, 2002

 

Of the total complement of physicians in the province, 49% were general practitioners and 51% specialists. Of the total complement of active physicians within the AHSC, general practitioners accounted for 46% and specialists 54%, at that time. In addition to family physicians or general practitioners, there are a total of 18 specialties affiliated with the AHSC. Of this figure, 26% are female and 74% male. Much of the recruitment concern within the region is in Family Medicine, as specialists have been somewhat easier to recruit to the region.

4.3.2 Current Process

In October 2001, a Physician Manpower Resource Committee (PMRC) was established. The Committee, chaired by the Chief of Staff, met monthly preceding Medical Advisory Committee meetings to, in collaboration with Clinical Department Heads:

• Plan recruitment and retention initiatives according to the identified needs of each Clinical Department; and
• Monitor and prioritize the needs of the Clinical Departments and AHSC with respect to physician recruitment and retention issues.

In October 2002, the Physician Resource Committee (PRC) appointed by the Board of Directors, replaced the PMRC. In addition to the work done by the previous PMRC, the PRC was to present recommendations to the Board of Directors on physician recruitment opportunities and strategies. In spring 2003, this committee met with residents of Region 2 to gather information about the needs and expectations of communities with respect to physician resources.

4.3.3 Current Status

As of June 5, 2003 there were a total of 16 vacant positions at AHSC and six pending retirements. In the physician resource recruitment summary as of January 2003 (see Appendix B) services are classified as:

• Stable (no problems anticipated for 5 years).
• Concerns (potential problems in 2-5 years, service currently stable).
• At risk (current problems identified with issues within two years if not addressed).
• In crisis (current problems present a threat to access to or quality of care or stability of the service).

The following table outlines the most recent status classification by service and department.

5.0  Recommendations

It is through its Board of Directors, Management and Medical Staff, that AHSC will address the issue of physician resources (including the elements of recruitment and retention). The hiring of a full-time Physician Resource Coordinator in April 2003 is a timely addition for beginning to address these recommendations.

The ideas and concerns represented here, emerged during the work of the Physician Resource Committee. The scope of these directives includes a spectrum of relationships that exist and are important to consider when addressing Physician Resource in this region. There are recommendations that are directed toward the relationship between AHSC and:

• the communities of the region;
• the learners (medical residents, interns and students) who spend time in RHA2;
• the physicians who currently practice in this region;
• the new physicians who may want to begin practice in this region; and
• the provincial Department of Health and Wellness.

It is also important to note that there are elements of these recommendations that overlap. Categorizing a particular strategy with one recommendation does not negate the role it may have in addressing any other recommendation.

5.1 AHSC and the communities of the region

Communication

Preamble
With the analysis of information and feedback received, a common recurring theme was "Communication". It was perceived that open communication between RHA2 and the communities within, could both promote and facilitate recruitment. It is believed that effective communication develops from a strong framework, or plan, with strategies supported by all participants. The desire was expressed for better communication and knowledge-sharing among all levels: community, RHA and government. 

Recommendation: That AHSC establish and sustain a Communications Plan with communities/ groups that will: enhance communication and knowledge-sharing between all levels involved in physician resources, and facilitate recruitment and retention efforts at the local level.

Communities

Preamble
The consultative process this committee conducted also highlighted the value of participation and collaboration. While Regional Health Authority 2 has the responsibility to take the lead in recruitment and retention initiatives, it quickly became evident that communities have a strong desire and commitment to successful physician resource outcomes in the region.

5.2 AHSC and the learners who spend time in RHA2

Residents and medical students

Preamble
As a teaching organization, AHSC has the advantage of rotating residents and medical students through its facilities and programs. More than 150 Royal College and Family Medicine residents and 50 undergraduate medical students participate in core, selective and elective rotations each year, with an average of 50 on-site at any one time. Medical trainees on-site contribute to the promotion of quality patient care, as well as the continuing education of staff. They also represent an enhanced recruitment opportunity. 

Recommendation: That AHSC Medical Staff, Management, and Board of Directors maximize the opportunities to build relationships with residents and medical students while they are on-site in the region.

Medical Students

Preamble
It is becoming more evident that "the personal touch" is an important marketing tool. When recruiting physicians we are effectively marketing our facilities, our communities and our people to prospective candidates. Our most successful recruitment efforts to date have been those that focus on bringing former New Brunswickers home. Taking an interest in the career paths of our young people as they pursue their studies can be a basis for providing that personal touch to future medical residents. 

Recommendation: That AHSC communicate with students of Canadian medical schools who have the potential to come to southwestern New Brunswick for a core, selective or elective experience; or to practice here.

5.3 AHSC and the physicians who currently practice here; and the new physicians who may want to begin practice in this region.

Recruitment and Retention

Preamble
An emerging theme throughout the consultative process was the fact that no one person or service recruits in isolation. While there is agreement that physicians are well placed to recruit new physicians, concern was expressed that this may be putting too high an expectation on the role played by the Department of Family Medicine. 

Recommendation: That AHSC evaluate the current process of physician recruitment and retention, in order to identify potential improvements.

5.4 AHSC and the provincial Department of Health and Wellness

Provincial partnership

Preamble
Through discussions with community groups, it was recognized that sometimes municipalities feel disadvantaged when it comes to advocating for health care reform with provincial and federal governing bodies. It was suggested by many participants that AHSC should be a "standard bearer" and actively bring forward the health care issues and concerns of local communities within this region to the attention of decision-makers. 

Recommendation: That AHSC assist communities in having their messages on health heard by provincial policy makers; and report on progress in addressing existing concerns.

Practice models

Preamble
While the work of this committee focussed mainly on the recruitment and retention of physicians in our region, the current issues with access to family physicians often led to discussion of other ways to access primary health care. Repeatedly, community health centres, featuring collaborative care models were cited as alternative ways to access primary health care. Discussion also centered on the fact that many younger physicians who are beginning practices, welcome a collaborative care model (particularly in a more rural setting), making this style of practice an important recruitment tool.

Recommendation: That AHSC support: the exploration of alternative practice models, and existing collaborative models (which will accommodate the choice of new physicians.

6.0  Conclusion

The recommendations of this report have evolved through a process of review, consultation, and inquiry. They are submitted with respect to the Board of Directors of Regional Health Authority 2 as an approach to the issue of physician resources within the region. It is anticipated that the continuing work in this area will rest in the care of the Physician Resource Coordinator, Chief of Staff, Clinical Department Heads and Senior Management of AHSC.

7.0  References

Barer, M. L., Wood, L., & Schneider, D. G. (1999). Toward Improved Access to Medical Services for Relatively Underserviced Populations: Canadian Approaches, Foreign Lessons. Vancouver: The Centre for Health Services and Policy Research, University of British Columbia. 

Canadian Institute of Health Information. (2002). Supply, Distribution and Migration of Canadian Physicians, 2001 (ISBN 1-55392-052-X (PDF)). Ottawa: Canadian Institute of Health Information. 

Canadian Policy Research Networks Inc. (2002). Health Human Resource Planning in Canada: Physician and Nursing Work Force Issues. Ottawa: Commission on the Future of Health Care in Canada. 

Department of Health and Wellness. (2002). Physician Recruitment and Retention Status Report. Fredericton: New Brunswick. 

Graham, C. (2002). Health Human Resource Plan: A work in progress. Saint John: Atlantic Health Sciences Corporation. 

Hutten-Czapski, P. (1998). Rural incentive programs: a failing report card. Canadian Journal of Rural Medicine, 3(4), 242-7. 

Kirby, M. J. L. (2002). The Health of Canadians - The Federal Role. Volume Two: Current Trends and Future Challenges. Interim Report on the state of the health care system in Canada. Ottawa: Senate Standing Committee on Social Affairs, Science and Technology. 

New Brunswick. (2002). A Progress Report to New Brunswickers. Fredericton: Government of New Brunswick.

 Romanow, R. (2002). Building on Values: The Future of Health Care in Canada. Ottawa: Commission on the Future of Health Care in Canada.

Appendix A: Physician Resources Committee - Theme areas and suggestions 

APPENDIX B: RECRUITMENT SUMMARY BY SERVICE, DEPARTMENT, FACILITY (current to January 2003)

Level I In Crisis: Current problem is a threat to access or quality of care or stability of service
Level II At Risk: Current problems with serious issues within 2 years if not corrected
Level III Concerns: Potential problems 2-5 years. Service currently stable
Level IV Stable: No problems anticipated for 5 years 

Copyright © 2003  Atlantic Health Sciences Corporation. All rights reserved.