Residents in South West Nova Scotia are becoming increasingly alarmed about doctor shortage in the region.
Some physicians are nearing retirement. Others are leaving. ER closures in Digby and Shelburne due to the unavailability of doctors are a common occurrence. Recently, notice of the upcoming departures of family doctors Dr. Winston Wertlen and Dr. Iris Kim, who practise in Yarmouth, caused even more concern.
Dr. David Webster, a fifth-generation physician in the Webster family, was the third doctor in Dr. Wertlen’s clinic. His office is moving to Main Street, at the rear of City Drug.
His medical legacy begins with Dr. Isaac Webster who arrived in Nova Scotia in the late 1700s. Dr. Webster says the answers to why there aren’t more family doctors, and why doctors are leaving family medicine and Nova Scotia, are complex. The cost of practising medicine compared to income earned from the profession is foremost. Changes to the federal Small Business Act led doctors to literally close their offices, he says.
“The worst paid doctors I believe in the country, at the moment, are family doctors in Nova Scotia,” he says.
He, Sheila Watson-Poole and others started a recruitment committee in Yarmouth in 1995 with success. However, it seemed specialists were attracted more than family doctors. More recently, the recruitment focus has been on the Dalhousie Family Medicine Residency Program training.
“For five years we’ve been training family physicians who have graduated from Canadian universities. It had been a really successful program in terms of retention until the tax changes,” Dr. Webster says.
But retention of overseas graduates has not been successful.
“We put a great deal into training them but our ability to retain them was simply hampered by the fact that they had (extended) family elsewhere,” he says.
It’s also difficult to attract younger physicians.
“Because of the cost of setting up an office and working there for poor renumeration, they’re doing their math and the kids are just saying I can work in the hospital and pay off this much debt; or go to the office and never pay off my debt," Dr. Webster says. “It’s a big responsibility, it’s a big liability and doesn’t pay that well. It truly is a labour of love. Kids are coming out (of med school) with such big debts.”
One thing Dr. Webster will be giving up at his new location, he says, is computerized medicine, referring to electronic medical records. He believes that for the vast majority of physicians using computerized medicine in family practices there is the rare one that seems to make money with it.
“The vast majority don’t. I think the average Canadian family physician spends at least an extra half hour out of their day managing the computerized medical system. Even the young ones that are computer savvy.”
Another issue family doctors are coping with in the region is the age demographic of their patients. It’s changed during the past three decades. Dr. Webster has many elderly patients, which have multiple, complicated health problems.
“A practice in Yarmouth is quite different than even a practice in the city. There’s a (fictional) 78-year-old with hypertension and diabetes, for example. He’s already had a heart attack and stints and now his kidneys are not good,” he says. “One of those people takes a lot of time to see, compared to kids with ear aches and sore throats and young women, mothers who need their birth control. In the time it takes to see a family of four, you still haven’t solved all the problems of the 78-year-old.”
The absence of an airport that can handle a regular carrier is also a problem, especially for physicians with relatives in other countries.
Municipality of Yarmouth Councillor Patti Durkee, the new chairwoman of the Yarmouth County Doctor Recruitment and Retention committee, says part of the problem is the requirement for physicians that have been mentored here for five years to write an exam at the end of that time.
“The process to work here is too rigorous. That’s one of the reasons we are having such a hard time getting doctors,” she says.
Dr. Tim Holland is the president of Doctors Nova Scotia, the professional association representing all physicians in the province.
He says recruiters are facing challenges with attracting doctors in two broad categories: one being compensation, the other being work environment.
“Nova Scotia is far below the national average for pay, and even far below our closest neighbours in N.B. and P.E.I.,” he says.
“While you’re sort of in the bottom of the pack nationally, it’s very hard to recruit, however, beyond the compensation issue, the work environment issues are probably just, as if not more, serious.”
Physicians in Nova Scotia are having to shoulder more and more responsibilities to compensate for the shortcomings in other aspects of the health-care system and the overall shortage of physicians. As a result, many are getting burnt out and frustrated. Even beyond those work hours, a big component of this is doctors not being able to impact their patient’s lives in a positive manner, says Dr. Holland.
“Physicians feel disengaged from the system. They don’t feel like they have any say in the decisions that impact their patients and at the end of the day … almost everyone who went into medicine did so because they wanted to help people. If you don’t feel like you’re helping, then there’s no job satisfaction. A lot of physicians are leaving because of that, they can’t really make that positive impact on their patient’s lives the way they can in other jurisdictions.”
Dr. Holland agrees with Dr. Webster that this province has the highest taxes in the country and that has a major impact on physicians, as it does anyone. He says in the 1990s there was a restructuring of the corporate tax code that allowed physicians to set up entities, allowing them to create their own pension and savings for their children’s education, or their own possible disability, because physicians don’t have a pension, don’t get vacation pay, and don’t have a lot of perks that come with other government jobs.
New tax changes reverse all of that and physicians are feeling very frustrated.
Some provinces are taking advantage of the ability to soften the way those taxes impact physicians at the provincial level. New Brunswick is one.
Dr. Holland adds overhead (funds paid to others) is typically about a quarter of a doctor’s earnings before taxes.
“The investment that physicians make into our health-care infrastructure is incredibly underrated and underappreciated,” he said. He commiserates with the struggles that doctors are coping with right now.
“There’s a whole crew of amazing doctors in the region … I don’t know how they’re making it work, but they’re keeping the system running. Their ability to work in such difficult circumstances is just inspiring.
“Hopefully we get this problem solved before those amazing physicians who are holding up the fort, burn out.”
Top six solutions
Doctors Nova Scotia representatives spoke to physicians and analyzed the problem across the province.
1. Compensation - we’d like to see us move towards a national average
2. Establish a blended capitation model which compensates family doctors based on how many patients they have and the number of services provided
3. Increase physician engagement – allowing physicians the opportunity to have a say on the decisions that impact their patient
4. Increase opportunities for mentoring
5. More education on audit process
6. Reduce daily red tape that doctors deal with
What’s being done?
Nova Scotia Health Authority provided this update on work towards doctor retention and recruitment in region.
Physician recruitment and retention continues to be a top priority for Nova Scotia Health Authority (NSHA), says Fraser Mooney, Public Engagement & Communications officer for Digby-Shelburne-Yarmouth Counties.
Last year, from April 2018 to February 2019, the province lost 109 doctors in Nova Scotia, mostly through retirement or relocation outside of the province. NSHA recruited 125 doctors over the same period. In the western zone (South West, South Shore, Annapolis Valley) there are approximately 34 vacancies for family doctors. Although the Authority is actively recruiting for about 34 vacancies, as Dr. Crystal Todd, director of family medicine says, “We will take as many as we can get.”
In Yarmouth, at least two family doctors will soon be closing their practice (Dr. Wertlen and Dr. Kim). As well, last year there was another family doctor who discontinued his practice to focus on hospital work.
On the plus side, in the past year, two of last year’s graduating class of Dalhousie Family Medicine residents have stayed in Yarmouth County.
“We really can’t overstate the importance of the Dalhousie Family Medicine Residency program in our area,” said Mooney. “Evidence shows that the location of training influences where physicians choose to work.”
Being able to have family medicine residents practice and train right here in south western Nova Scotia has been invaluable for our community, for our physician mentors, and hopefully for the residents themselves, he added.
More resources and additional support has been added to the doctor recruitment team in this zone of NSHA. The newest recruiter has only just started, but she is already focused on how best to highlight this area for potential new doctors.
A new NSHA doctor recruitment website was launched in the past year as part of a larger marketing strategy.
The authority also has a renewed focus on international medical graduates.
This year, NSHA is participating in more than 20 recruitment events and fairs across Canada, in the U.S. and Great Britain. International focus and partnership with the Office of Immigration has started to show some results and 20 per cent of hires this year are on track to be from international recruitment.
NSHA has also kept steady with site visits during the winter. Eight physicians interested in Nova Scotia were hosted in January, which is typically a slow time for site visits.
Regular meetings with community leaders from Shelburne and Digby Counties have been held, including municipal representatives, to talk about things like recruitment, how NSHA can improve access to primary health-care services and to develop local solutions to health-care issues in those areas. At the same time, in Yarmouth County, the authority plans on staying connected with the work of the local municipal health human resources committee.
Mooney says this is part of the work NSHA is doing to try to better support and include communities and local physicians in the recruitment process.
A provincial recruitment working group has been created with membership from Dalhousie Medical School, Doctors NS, the College of Physicians and Surgeons and the College of Family Practitioners, Maritime Resident Doctors and the council of municipalities.
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