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Ontario Medical Review
Oct. 25, 2021
Kurt Kleiner
OMR writer

This article originally appeared in the Fall 2021 issue of the Ontario Medical Review magazine.

Physicians teetering on “edge of a cliff”

Doctor shortages, burnout plague the North

Since early 2021, the OMA has been consulting widely with physician leaders and members, representing different specialties and regions, as well as health-care stakeholders, community leaders and the public to develop recommendations for better health care. The result is a solutions-based plan that focuses on five key themes plus specific actions to address the unique needs of northern Ontario. 

It had cycled through 85 doctors in the previous decade, losing many of them within months to overwork and burnout. With only one physician left, the 10-bed hospital was in danger of shutting down.

“We were shown a stack of burlap sacks and we were told that those were the burlap sacks that would be going over the blue hospital signs on the highway should we choose not to come to Marathon,” said Dr. Newbery, who grew up in a small town in northern British Columbia.

Dr. Newbery and five other doctors — which included her husband and four friends — met at a family practice residency in Thunder Bay and were looking at potentially setting up a northern practice together in Marathon.

They decided to join that practice, with one physician left, and for more than 25 years have helped build a stable family health team that includes nine family physicians who are supported by a nurse practitioner, physician assistant, registered nurse, registered practical nurses, registered dietitian, social worker and an epidemiologist.

“Like many rural communities, our practice is what we would describe as a comprehensive rural generalist practice,” Dr. Newbery said. “So, the expectation is that we all maintain a roster of patients within our primary care practice; that we all follow our own inpatients when our patients are hospitalized in our 10-bed hospital, that we all participate in the emergency shift roster, and of course now, that we staff the COVID assessment centre.”

The work is satisfying but demanding, Dr. Newbery said. It’s made harder by a lack of specialists, the need to transport patients for tests and specialized care, and a shortage of general practice physicians.

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Despite restricting her practice to only the surrounding Algoma District, and limiting patients to mostly those suffering from inflammatory diseases, after only 24 months in practice Dr. Saara Rawn’s wait-list is already a year long.

“We were shown a stack of burlap sacks and we were told that those were the burlap sacks that would be going over the blue hospital signs on the highway should we choose not to come to Marathon.” —Dr. Sarah Newbery

From left to right: Dr. Sarah Newbery, Dr. Stephen Cooper, and Dr. Stephen Viherjoki say practising medicine in the North has its rewards when it comes to lifestyle and the broad skillset required. But burnout and doctor shortages continue to plague the North, with one doctor describing it as being “on the edge of a cliff.” 

The OMA’s Prescription for Ontario: Doctors’ 5-Point Plan for Better Health Care recognizes that northern Ontario faces unique challenges. Although the North comprises 90 per cent of Ontario’s land mass, it contains only six per cent of its population. Weather and distance make it hard to access care, and lack of high-speed internet makes virtual care more difficult. Many people in remote communities don’t have a family doctor.

The OMA is making recommendations it hopes the political parties will adopt in their platforms leading up to the 2022 election. The recommendations include providing incentives for physicians to practice in northern Ontario; focusing on education and training; and ensuring that students and residents have the robust training opportunities they need to develop the skills to be confident in choosing rural and remote practices.

Many doctors in the North say it’s the shortage of family doctors that’s the biggest problem. Current estimates indicate rural northern Ontario needs more than 90 rural generalist physicians to provide adequate care. But in some rural communities, there are less than half the number of doctors needed to serve the population.

“We’re always recruiting,” said Dr. Stephen Viherjoki, a doctor in Dryden, Ont. The town is about midway between Thunder Bay and Winnipeg, each one about a four-hour drive away. “There hasn’t been a period since I’ve been here that we haven’t been recruiting hard. We’ve been lucky, we’re doing better than some of the communities around us.”

Nevertheless, he estimates he routinely works 60 hours and sometimes up to 80 hours per week. Dr. Viherjoki went to medical school at Queen’s University and did a family medicine residency in Thunder Bay.

“If one person leaves unexpectedly, and we can’t recruit soon enough, the whole group suffers, and then we’re at risk of losing multiple people to burnout or being unwell.” —Dr. Stephen Viherjoki

“I’m from Thunder Bay, originally. And I wanted to be a doctor since I was like knee high, and I’m 6’6” now. So, basically, it was my plan my whole life.”

Like all the doctors interviewed for this story, he likes practising medicine in the North because of the sense of community, the lifestyle, and the varied nature of the practice. But the challenges of a northern practice often make it hard to get enough doctors to share the load.

“We’re chronically understaffed,” Dr. Viherjoki said. “So, we really are on the edge of a cliff all of the time. If one person leaves unexpectedly, and we can’t recruit soon enough, the whole group suffers, and then we’re at risk of losing multiple people to burnout or being unwell.”

Dr. Stephen Cooper agrees. He works in Little Current, Ont., a town of 1,500 people on the north end of Manitoulin Island. He’s part of a primary care team that includes seven doctors providing care to Little Current, the 3,000 people in the surrounding area, and another 3,000 in the nearby Wiikwemkoong First Nation.

Dr. Cooper grew up in Fort Langley in the Lower Mainland of B.C., went to medical school in Calgary, and did his residency in Montreal. He said he was drawn to the beauty of the North, but also to the breadth of practice.

“When you think about rural practice, one of the great things about it is that all those things you learn in medical school are not wasted. You use them every day,” he said.

Even in Little Current, which is relatively stable and well-staffed by northern standards, they could probably use two more doctors to handle the load, Dr. Cooper said.

“When you think about a rural practice, one of the great things about it is that all those things you learn in medical school are not wasted. You use them every day.” —Dr. Stephen Cooper

Some of the extra challenges come from the lack of specialists and specialized care in the North. For instance, Dr. Cooper has a patient with complex medical conditions, including cancer. The physician is trying to manage the man’s treatment so that he can continue to live at home, but it might not be possible.

“He may have to leave Manitoulin Island because at the end of his life he just can’t get the services he needs here because we just don’t have the resources for him. And his family is struggling with that,” Dr. Cooper said.

Often, doctors are required to transport patients to distant cities for tests and specialized treatment, and that comes at a cost for patients and doctors. For patients, it can mean days off work and long drives. For the doctors, it means arranging for transporting more serious cases and often making time to accompany them.

“Because we are 300 kilometres from our nearest tertiary centre — Thunder Bay — our inpatients have to travel by air for tests we can’t offer, like CT or MRI. They often have to go with a nurse, and sometimes a physician,” Dr. Newbery said.

On a recent foggy day in Marathon, a patient came to the hospital with a serious heart problem. He needed to be sent to Thunder Bay for care. But because of the fog, the Ornge medical helicopter couldn’t fly in. The doctors faced a dilemma. If they sent the patient by land ambulance, the community would have no paramedic coverage for the rest of the day. If they waited for the fog to clear, they would have to do their best to manage the patient until the weather improved.

They chose the latter, and eventually the fog cleared, and he was airlifted. “It was great to get him out, ultimately, but to manage the complexity of his care locally, waiting for that transfer, was challenging,” Dr. Newbery said.

“Rural communities are realistic in their expectations. We’ll never do cardiac surgery here; we’re not going to have an angioplasty program in Marathon... But I think all rural communities should expect adequate access to rural generalists who have the time and the capacity to be able to provide excellent care within the limitations of the resources of that community.”

In addition to more incentives and training for doctors, the OMA also recommends more social workers and mental health-care workers, increased support for Indigenous communities, and more specialized pediatric and obstetrical care in the North. Finally, it wants better internet access for the area and easier access to digital records.

Kurt Kleiner is a Toronto-based writer.