Northern Rockies Regional Municipality Physician Recruitment Program September 2010
History In 2005, the Northern Rockies Regional District purchased a home, to furnish and provide to a new physician, in order to make the relocation to Fort Nelson as seamless as possible. The initial tenancy agreements with the physicians were for one year, with a token amount of rent exchanged ($1 per month), all utilities included, as well as use of a Town vehicle. Renewal of the agreement was determined by the Council of the day, and has on more than one occasion been extended given the individual physician s circumstances. Other initiatives during that time included advertising and marketing campaigns, the formation of a Physician Recruitment Committee, and attendance of various events in other communities to showcase Fort Nelson and network with medical students. Several physicians joined the medical team in Fort Nelson throughout 2006 to 2008. The most recent, Dr. Lisa Nickson, is the only one remaining. In 2008, Dr. Nickson and her family located to Fort Nelson, having been provided housing by the municipality, and remain today in the same residence. From 2007-2008, Mayor, Council, and staff were actively engaged with the University of Northern British Columbia Medical Program. Annual Family Practice Resident s Dinners, membership on the UNBC Medical Programs Trust Board of Directors, and involvement with the Community Partnerships program ensured that Fort Nelson was among those that received regular communications and updates. Staff believes that this relationship could be reinvigorated, and efforts have been made to reconnect with UNBC staff and liaisons. One of the recurring themes during the Family Practice Resident s Dinners was that new graduates and physicians in general have less of a desire today to own or acquire practices, due to the overhead and burden of management that can pose. For the most part, physicians today simply want to practice medicine, and not be business people. Having the ability to walk into a clinic and just start growing your patient base is another example of a turn-key operation, and making the relocation for a physician as effortless as possible. From 2007-2008, the NRRM provided welcome baskets to new physicians, and in some situations locums. In addition, NRRM staff would assist in providing Physician Recruitment and Welcome Tours. This initiative is no longer carried out. Currently The Airport Way Medical Clinic is owned and operated by Dr. s Kassa and Mostert. In most private clinics, revenues are generated through Medical Services Plan billing, with the majority of expenses going to the salaries for the Medical Office Assistant staff, supplies, property taxes, and utilities. Northern Health s involvement comes into play only when medical services are conducted at the hospital (i.e. emergency visits, maternity services, sets and casts for broken bones, minor surgery). Combined, Dr. Kassa and Dr. Mostert offer specialized care through anaesthetics and surgery. Currently, full medical services (i.e. emergency, maternity) are available only when both physicians are present, with all required nursing staff and Dr. Nickson present to complete the team in the operating room. The matter of pursuing a specialty as a General Practitioner is one of personal interest. The time requirements for being an understudy in any given specialty varies from 6 months to 1 year, which is generally arranged by the physician themselves, and supported by the Health
Authority. Privileges are then granted by the Health Authority given successful completion and approval by the overseeing doctor. Finding a Candidate Health Match BC posts positions available under advice from the varying Health Authorities, and serves as a central agency specializing in the recruitment of physicians to British Columbia, with the intimate knowledge of working with the Canadian Medical Association and Immigration Canada. The community s involvement in the recruitment process is better served in developing incentives not already offered by the Health Authority, and in ensuring that the physician and their family s relocation to the community is as seamless as possible. This can be accomplished through a number of means, whether it is the provision of housing, provision of a vehicle, assistance in introducing the physician to clubs and organizations, assistance in sourcing child care or spousal employment, or the provision of other resources to alleviate the time involved in fulfilling some of the needs encountered upon relocation. Entrance to the University of Northern British Columbia s Northern Medical Program (UNBNMP) is contingent on the applicant s interest and ability to practice medicine in the North beyond graduation. The Program s ultimate goal is to train physicians in the North, to then practice in the North. Still somewhat in its infancy, the program s first cohort of graduates was in 2007/2008, many of which are just now practicing medicine independently, after having completed their residency (clerkship) this year. A student s introduction to a community at an early stage in their career development is likely very beneficial, although communication with and relationship building should be ongoing. The community also has an opportunity to nurture communication and a relationship with a student should the student choose to do a clerkship in the community. The success of such relies heavily on the interest and availability of a vested Family Practice Physician to oversee the clerkship, however. Northern Health s recruitment policy in general is not to actively recruit from foreign nations. That being said, if a physician expresses interest in practicing in the region, Northern Health will proceed aggressively to ensure that an opportunity is available. Regardless of how a physician finds an opportunity in Fort Nelson or any community in BC, if the physician is licensed in another country, he or she must satisfy the requirements of the Medical Council of Canada (MCC) in order to practice medicine in Canada. Firstly, the physician must prove credentials from an approved university, then pass a Medical Council of Canada Evaluating Examination to demonstrate equivalent general medical knowledge. Depending on the MCC s evaluation of the physician, the person may or may not have to undergo postgraduate training (Residency Training), of varying lengths (two years for Family Practice, four to five years for other specialties). In the interim, the physician can practice under an educational license, however not independently. Once their residency is complete, the physician must pass the Certification Examination of either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada (dependant on their interest in either Family Practice or another specialty). Following successful completion of either of the exams noted above, the physician must complete the MCC Qualifying Examination Part 1. After a minimum of one year of acceptable postgraduate training, the physician can apply to take their MCC Qualifying Examination Part 2, to receive an independent license to practice medicine in Canada.
Once the physician is involved in the licensure process described above, Immigration Canada is actively engaged to ensure that the immigration process is as fluid as possible. From the time that the physician passes their MCC Evaluating Exam, they may practice under the privileges of a Health Authority. If the physician does not work directly for the Health Authority (as in the case of Dr. Kassa, Mostert, and Nickson), the physician will still apply and be vetted by the Health Authority in order to be granted privileges to admit and discharge. Should the physician have specialized skills (anaesthetic, surgery, ears/nose/throat), the Health Authority grants additional privileges through the same process to allow the physician to administer care in those areas. Essentially the physician must pass the Health Authority s requirements to practice within the hospital. Just as medical licenses require annual renewal, so do privileges. Dr. s Kassa and Mostert continue to communicate actively with colleagues from overseas to consider relocating and practicing in Fort Nelson. Dr. Chris Fourie is one such person, who will be conducting a three month locum in Dr. Mostert s absence, from late August to October 2010. Considerations After extensive research, it has become clear that some general considerations should be given in the development of a comprehensive Physician Recruitment Program. 1. The career culture of physicians has changed over the years. The most prevalent feedback received in meeting with UNBCNMP students is that the inevitable (and very accessible) amount of debt incurred to secure education and housing are prohibitive to the traditional succession of events where a physician would purchase or become a capital partner in a clinic to begin a practice. 2. Demographic and general lifestyles have changed over the years, with those entering their careers today more focused on a work-life balance, desiring time away from work to allow them to nurture relationships with family, friends, and personal commitments. With a trend towards getting married and starting families later in life, the pressure of earning an income to support an entire household is virtually non-existent in the first ten years a person enters the workforce. 3. Accessible amenities; housing, continued education, recreation, health care, transportation, social integration, vacations. Physicians value many of the same amenities as other working professionals, and measure the community on its ability to offer those things. 4. Attractive organizational infrastructure for a family practice, with space, adequate support personnel, and an environment conducive to equality within the practice.
Northern Rockies Regional Municipality Physician Recruitment Program 1. Housing/Accommodation Benefits From the feedback received from current physicians, from other communities, from Northern Health, and from numerous other health professionals, the provision of free housing (even on an interim basis) is an excellent benefit. The continuation of one year s free furnished accommodations, with utilities and the short-term use of a town vehicle is a relatively easy element of the program to continue to offer. 2. Relationship Building & Public Relations While the value of relationship building and public relations isn t entirely quantifiable, it is in the spirit of the community and aligned with Fort Nelson s reputation for incomparable hospitality to make efforts towards welcoming visiting physicians (locums, recruits, visiting students or otherwise) to the community upon arrival. In the past, this was done by way of presenting the person with a Welcome Basket, conducting guided community tours, and inviting the person to lunch or dinner with expenses paid by the NRRM. To our knowledge, that last physician to have been extended these benefits was Dr. Nickson. It is suggested that continuing this practice should be done in coordination with the efforts of Northern Health and the Fort Nelson Hospital Foundation (FNHF). A collaboration of the various agencies should result in a comprehensive Welcome Program, to ensure that guided tours meet a standard, and that any materials and publications provided are consistent, etc. In some cases, representatives from Northern Health or the FNHF have conducted guided community tours, in addition to the full hospital site tour, where in others municipal representatives provide community tours and partner with Northern Health to provide the full hospital site tour. 3. Education Supporting education at both the local secondary and regional post-secondary level will offer long-term benefits as students consider their options for employment after graduation. As described earlier in this report, the UNBC Northern Medical Program is designed in such a way (from acceptance to the program to the placement of clerkships) to ensure that doctors who are trained in the north stay in the north. Further, the UNBC School of Nursing now offers a graduate degree in Family Nurse Practitioner (see note (c), below). Maintaining a close relationship with the program, its students, and its staff will ensure that Fort Nelson stays on the radar, and will allow us to position ourselves as an attractive place for a new physician to locate. Maintaining this relationship with UNBC can be done in a number of ways: a) Involvement with the UNBC Northern Medical Programs Trust (NMPT). The NMPT is a membership of communities who contribute funds (either by private, corporate, or public donation) to an endowment which serves to provide students the ability to access funds to offset the high cost of the program. Between 2006 and 2009, a representative from the NRRM held a seat as a Director on the UNBC NMPT Board. This year, no nominations were put forward from the NRRM and subsequently the seat was assumed by
a representative from another Northern BC community. Staff has been advised that there will be three positions available for the 2011 year, with nominations being received in the fall of 2010, to prepare for the elections at the Annual General Meeting in May of 2011. Staff recommends that a representative from the NRRM be nominated to once again represent the community on the NRMPT Board of Directors. Normally, the representative is a nominee of the local Council, however a local health care representative would be equally as suitable. b) Involvement in the Community Partnership Program. The Program is a tripartite initiative between the Northern BC Community, the students, and UNBC (including the Trust where funds may be necessary to offset the cost of travel, meals, etc.) The purpose of the program is to provide students during their undergraduate medical training to experience communities first hand through short-term, weekend visits. In 2008, Fort Nelson hosted two students under this program, and remained in contact with them throughout the year, following their progress. A standardized Welcome Program would be very useful in this application as well. In 2009, the Community Partnership Program was defunct due to lack of student coordination, however it has been revitalized for 2010, and staff has been in contact with the current coordinator. c) Communication with and support of the UNBC School of Nursing. After successes at the University of Victoria and University of BC, the University of Northern BC has received accreditation to offer a designated Masters of Science in Nursing, Family Nurse Practitioner. While Family Nurse Practitioners do no replace Family Practice Physicians, in a clinical setting they very much support a primary patient care model, and would nonetheless serve to alleviate the patient load on existing physicians with other specialties. Family Nurse Practitioners work directly under the supervision of a Family Practice Physician, and are trained in general practice, which is care across all life stages. Typical roles include those of diagnosis, prescribing, ordering diagnostic tests, and managing diseases, disorders, and conditions within a professionally regulated scope of practice. d) The provision of local scholarships and/or bursaries. Each year, Council gives two $2,000 scholarships in Dr. s Kassa and Mostert s names to students entering a post-secondary health-related field, demonstrating academic achievement, positive community involvement, and being a positive role model in the school and the community. 4. Community Family Practice Clinic Traditionally, a physician or group of physicians invest in the capital costs (i.e. building, equipment) and operate a clinic essentially as business partners, generating revenue through their MSP billings, offsetting operating costs such as staffing, supplies, and utilities. Staff have reviewed several case studies of a different model where community-based, non-profit organizations own and operate Community Health Clinics. The motivation to do so was in response to a shortage of physicians, and a desire to create a work
environment attractive for new recruits. In all cases, the inception of a Community Health Clinic was successful in recruiting and retaining physicians. The specific organizational structure of a Community Health Clinic varies based on the group that manages it (Societies, Foundations, Cooperatives, Associations, etc.). Generally, administration and operation is the same across the board, regardless of nonprofit designation. The organization owns the building (most having been donated, or set up within a hospital), hires, manages, and administers the payroll and benefits for the Medical Office Assistants (under consultation with the physicians), maintains the building, purchases supplies and equipment as required, and revenues are generated through a negotiated lease with practicing physicians for the office and exam space. Physicians within the clinic continue to earn revenues through MSP billing, the burden of running a business is borne by the organization, rather than the physician themselves. The appeal of this model is that a new physician need not bear overhead costs, management responsibilities, maintenance requirements, and high costs of start up. While we embrace the very realistic potential of a Community Family Practice Clinic, we do not feel that the NRRM should be in the business of running a clinic. Ideally, a nonprofit organization with the resources, capacity, and access to additional funding when necessary would be best suited to do so. Some of the many considerations in terms of feasibility include: support of stakeholders, facility, provision of equipment, economic viability, a commitment by partner agencies for continued recruitment efforts, and support of the community. Health Service Considerations & Additional Options Fundamentally, the concern faced by the Northern Rockies community is disruption to and the unreliable nature of health services. An adequate number of physicians is one element of this, but perhaps equally as crucial is the recruitment and retention of nursing and other health service staff (i.e. lab technicians, x-ray technicians, radiologists, physiotherapists, etc.), and the cost of travel associated with Fort Nelson s geographical isolation when medical care is required outside of the community. While the four-point list above is by no means considered exhaustive, we feel that the points above represent a very reasonable start to reinitiate the Northern Rockies Physician Recruitment Program. By making efforts in the areas of Housing & Accommodations, Relationship Building & Public Relations, Education, and the inception of a Community Family Practice Clinic, we believe that this four-streamed approach will serve to address both shortterm and long-term recruitment challenges. Some additional potential options include: 1. Loan Relief for Physicians and/or Health Service Staff This could be achieved similar to the Province of BC s formula, where individuals in the health care field are granted loan forgiveness in the amount of 33.3% each year for a period of 3 years of employment in an underserved community (of which Fort Nelson qualifies). Council could denote a maximum loan relief amount as desired.
2. Locum Rotations Working with Northern Health, the NRRM could potentially request a rotating schedule of locums, to ensure that physicians with specialties better fulfill the need in the community. Some smaller remote communities rely entirely on locums for the provision of medical services. Currently locums are used only when required in either Dr. s Kassa or Mostert s absences, and are arranged personally by the doctor who plans to be absent from the community. 3. Host Guest Specialists Work with Northern Health to invite guest specialists and surgeons to use the facilities at Fort Nelson General for scheduled surgeries, etc. The cost of a number of patients travelling to one of the Peace hospitals could easily be greater than hosting a specialist in Fort Nelson for a short period of time. Equipment replacement at FNGH has been ongoing, and rivals most equipment in neighbouring hospitals in terms of newness and quality. 4. Provision of Accommodations for Out-of-Community Care Having reviewed the idea of purchasing a residence in Fort St. John to provide to residents requiring out-of-community care, it is recommended that it would be less of a liability to negotiate a reduced rate with one or more of the hoteliers, and/or provide a subsidy for cost to residents in need. The maintenance and subsequent liability of a residence could prove very onerous, where the responsibility of property management is removed in the case of using a hotel. Currently, the Quality Inn Northern Grand offers a medical rate of $120 per night where the guest has medical appointments during their stay. Council may wish to consider setting up an Out-of-Community Health Care Grant-in-Aid where a predetermined budget is distributed on a by-request basis, under set criteria (number of disbursements per person, per year, maximum monetary amounts of disbursements, etc.) to offset the costs of travel, whether that be transportation, accommodation, or additional costs at Council s discretion.