A Reflection on Rural Medicine

I was in Perth, Ontario on Thursday evening for the Lanark County Medical Society Annual General Meeting and will be in Renfrew County Monday evening for that AGM. These meetings allow me a chance to catch up with the way of life of small town doctors, struggling with the disadvantages of rural medicine.

I grew up in a small town much the same size as Perth and was actually born in Pembroke where Monday’s meeting will be held. What I recall the most about the plight of doctors when I was very young was that, in pre-medicare days, many of them struggled to make a living in small towns. It is not a myth that, in farming communities, they often received payment in the form of produce and that many relied on payments from their wealthier patients because poorer patients had nothing to pay. I recall the doctor who lived near us in Joliette borrowing money from my father. I also remember that, at times, no matter how tired he was, there was no one else to go out to see his patient, suddenly requiring urgent attention.

While medicare changed the financial situation, it did not change the fact that most doctors still prefer to practice in cities and, at these small town meetings, a topic of conversation is recruitment. These communities have relied upon international medical graduates, a few thousand dollars worth of CME funding and one or two people returning to practice at home after their training is completed. On Thursday evening, they told me that a problem seems to be that “No one wants to practice this way anymore.” Practising this way means having a full service family practice including obstetrics and nursing home care as well as house calls. It means ER shifts – finding balance would certainly be problematic at times.

This kind of practice also means a loss of anonymity. Imagine if, whenever you went shopping or on a date, everyone in town knew what you were doing. I recall a time when I was travelling to Pembroke for the day to do some consultations at the Children’s Aid Society. I arrived at the agency to learn that my aunt was having the workers and me over for lunch – I had not even told her I was going but word gets around in small towns. Everyone also knows you, whether they’re your patient or not. That cannot always be easy.

Only 10% of Canadian doctors practice in these settings while 20% of Canadians live in these communities. Those numbers have not changed in at least ten years. Most people would agree that recruitment is necessary, but is there anything you can learn from a physician like me, born and raised in small towns, who does not go back to work in one.

If you were to ask me what the main reason is that I do not live in a small town, the answer would be that my husband prefers to live in the city. I suspect that this is true of many of us who started medical school with an intention to go home. I do travel outside of Ottawa to work with agencies in the countryside around Ottawa but it is not the same investment as being the member of a community and I know it.  When you live in a community, the people matter. They are your friends and neighbours, your children’s teacher and the local reeve. What you give to them they give you back, in a way that is not known in a larger, much more anonymous city. People do know more of your business than you might like but they also help when something comes up.

I remember being home from medical school one Easter. The doctor called me because my family’s neighbor was failing and was going to have to be transferred to Montreal for more care. He needed me to watch her for several hours while he was tending to the delivery room. He had not been able to reach any of the other local doctors and he wanted me to do this. I thought this was pretty much illegal but I also knew that many people knew I might be able to help and they would know if I hadn’t. Between a rock and a hard place, I stayed with my neighbor for several agonizing hours. It was not different from care I had given in my internal medicine rotation but I was on my own and I felt the responsibility of knowing that my decisions about what care she should have were the final ones. The bulk of the care I provided was comfort: I talked about where she was going in Montreal, since I knew the hospital well, and told her that I would visit her. She thanked me afterwards and I remember how her face would light up when I did visit her on the ward at the Royal Victoria Hospital.

Afterwards she always told people that I had saved her life, which I know was not true.  No one was ever convinced, however, and so my reputation as “a good doctor” was established in the town where I grew up. While I certainly thought of working there, in my last year of medical school, my mother moved to Montreal when my younger sister and brother were to start university. Everyone in town knew that I would stay near my family, because that is what people do and they would have thought less of me if I had not done that.

In the end, I do think that the place to find doctors to work in small towns is in those towns, among the children there who can grow up to study medicine. The evidence supports that and I hope the Society of Rural Physicians of Canada has a program in place to encourage the youth of their communities to undertake a medical career. That is the best hope to find doctors for these towns.

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