Ok, first let me say I don’t have all the answers. But I have some thoughts, based on experience. I am a retired family physician and of my 43 years in practice, 5 were spent in Nova Scotia, 12 in Ontario, and 26 in Newfoundland. I never practiced in Labrador. I have a lot of experience in Newfoundland, but also experience in other healthcare systems in Canada.
First, I’ll tell you about what I am doing now — which I think is a possible solution for some of the small rural clinics around Newfoundland who have trouble recruiting and retaining physicians and Nurse Practitioners. I am currently doing phone clinics for the Bay St. George Medical Clinic in Stephenville. I have never set foot inside the door of the clinic. I have never physically met any of the clerical or administrative staff there, or any of the family doctors or nurses or Nurse Practitioners who work there. I have communicated with them via the messaging feature of the EMR and feel like I know some of them very well. I “see”, mostly by phone (and occasionally via video), about 100 patients per week. You cannot fully run a practice virtually, you cannot be a patient’s main provider virtually, and I don’t try to be. There are no patients assigned to me. I am a virtual locum for the clinic, not for any one physician or NP. The clinic is short of physicians and NPs, they come and go. My role is to do the “maintenance” type work and much of the chronic disease management. I can refill medications, I can order blood work and imaging needs (xrays, ultrasounds, CTs etc), I can give patients reports of BW and x-rays, etc and interpret it for them. I can also do some basic treatment of acute conditions like Urinary Tract Infections or acute exacerbations of COPD, and a few other things like that. I can do counselling and “talking therapy”. I can’t examine abdomens, or listen to chests, or examine joints by phone, obviously. So whenever I agree to do virtual work for a clinic, there must be at least one on-site primary care provider (NP or MD) who can see people in-person if I feel that is needed.
Let’s imagine a small clinic operated by one of the health authorities in the province. Doctors come and go, usually foreign medical graduates who stay for a while until they get a license and then go to either a larger community in NL, or more likely leave the province altogether. A clinic like this could be run with 1 or 2 Nurse Practitioners(NPs) depending on size and a MD doing virtual clinics. The actual number of onsite primary care providers (PCP) needed can be decreased by having a physician doing virtual clinics. But where do you find these physicians to do virtual phone clinics. You recruit the retired family doctors, who, like me, though retired from having my own practice, want to keep my license, keep my mind active, and continue to enjoy the practice of medicine. And where do we find the NPs to practice in the clinics…well we have to significantly increase the enrollment of NPs in the training programs, especially those who want to do primary care. Another place to find physicians who would like to do virtual locums, are those who want to practice part time only. This might be primarily female (or male) physicians who have young families and, like the retired physicians, may only want to do clinics a few days a week. Two or three days a week doing virtual clinics might be enough to support the 1 or 2 on-site NP or MDs. So train more primary care NPs, and utilize the family physicians who are retired and/or those who only want to practice part-time without having to go through the process of setting up a practice.
Now that I have the problem solved for the small rural clinics, let’s look at the community hospitals out there that are struggling to find family physicians. It’s more difficult in that, while a virtual physician working in the hospital’s out-patient clinic can still help, they need more than that. They need doctors (or NPs) looking after the in-patients, and running the emergency rooms. There are community hospitals around the province that do not have trouble finding and keeping family physicians to practice on-site and live in the communities. I will name a few
—Twillingate, Goose Bay, Burin, Port aux Basque. And some that have trouble recruiting — Harbour Breton, Stephenville to name two. One thing that is common about the community hospitals that have been able to recruit and retain doctors is they have cultivated a relationship with the Discipline of Family Medicine at MUN and have become known as excellent teaching sites for family medicine residents. The residents spend months at these sites during their residency training, they get to know the doctors and nurses and staff at the hospitals, they get to know the communities, and they choose to go back there to work after they finish their two year residency program. So we need to make every community hospital an excellent training site. To do that we need at least one Canadian trained physician to be recruited to these sites and be the lead preceptor and a full time faculty member in the Discipline of Family Medicine. That person’s job has to be to build the site into a fantastic training location and the recruitment problem will fix itself. We probably also need to increase the number of positions for trainees in the family medicine residency program at MUN.
For St. John’s and the other large towns in the province the Collaborative Care Clinic idea that the government is setting up in St. John’s right now is a great idea. It is team based, it is multidisciplinary, and patients will have an assigned physician or NP (a PCP). However, its the implementation that is ruining it. To take physicians from St. John’s and hire them for these clinics just leaves the patients they were looking after without a doctor. It is like cutting a 6 inch piece off one end of a length of string and attaching to the other end and thinking you have made the string longer. It’s idiotic and does not help anything. These clinics have to be staffed by new physicians and new NPs. These clinics could also be helped by the two ideas I discussed above… have some of the care delivered by virtual physicians and connect with the Discipline of Family Medicine. Become excellent teaching sites. Utilize physicians and NPs who want to work part-time and want to work from home virtually to do the things that can be done virtually.
And finally, the virtual thing can be expanded to what is a higher level of telemedicine. This is being used in a number of places, including at the Bay St George Clinic where I work virtually now. Here is the scenario: The virtual physician decides that what the patient needs in a particular situation cannot be met by telephone only. An appointment is set up where the patient comes into the clinic and the patient and a nurse go into a room that is equipped with video and telemedicine capabilities. The nurse does the patient’s vitals. The physician signs in online. They can all see each other. By telemedicine capabilities I mean there is a stethoscope that can be positioned on the patient’s chest and abdomen or over the carotid artery etc by the nurse and the physician can hear the sounds. There is an otoscope that can be inserted into the patient’s ear by the nurse and the physician can see the canal and the ear drum. If there is a skin lesion the camera can be directed at it by the nurse and the physician can see it. The nurse can be asked to feel it for dryness, whether it is scaly, is there increased skin temperature, and report to the physician. If there is a joint problem, say the shoulder, the nurse can be directed to palpate in various places, can be asked to moved the shoulder around to look for ROM and whether certain movements hurt. Abdominal palpation is a little difficult but the nurse can be asked to feel the abdomen in specific spots and check for firmness, and rebound tenderness.
It is not fully the same as the physician actually being on-site and with the patient, but it approaches it.
These are not radically new ideas and they are all being used in various places in the province. But they are the ones that have proven to be successful. They should be expanded and supported and funded. Hopefully the powers that be will see this blog and give the ideas some consideration.