with psychotherapy. Rural style: Drs Christine McKenna and ... McKenna says is one drawing card. The group of ... fact that this is premier Frank. McKenna's ...
UPDATE
N
Rural practice
E
W~~~*-
s--ssss@sS ***
the area's hospitals. Young people are leaving town, and although New Brunswick Quintal puts in time at the hospital forces the issue in obstetrics, pediatrics, emergency, and assisting at surgery, more and LOUISA BLAIR more of his office time is taken up hysician resource manage- with psychotherapy. the technocrat's ment euphemism for getting the right numbers of doctors to go where they're needed, is the fashion among provincial governments. But New Brunswick strode in where most others fear to tread. The province's Physician Resource Allocation Commitee (PRAC) is designed to limit billing numbers to each of seven reorganized health regions in the province (see "Family medicine resident sues New Brunswick," page 1065). The idea is to get more doctors into underserviced areas. Does it work? Is PRAC the tough player Rural style: Drs Christine McKenna and that it's meant to be among the Greg Archibald offer anecdotes about their many weaker lures that are sup- practice to physicians attending New posed to attract family physicians to Brunswick's Annual Scientfc Assembly. rural practice? A highly unscientific "There's more alcohol and drug sampling of rural and semirural doctors attending the New use, more broken marriages and Brunswick Chapter's Annual dysfunctional families. There's more Scientific Assembly indicates that and more depression," he said, "even yes it's tough and it works in some in children as young as 5 years; areas, and yes it's tough but no it they catch the despair from their doesn't work in others. parents. If the family physician Dr Bernard Quintal falls into the won't see them, they'd have to wait latter camp. He has practised solo 4 to 6 months to see a psychiatrist." for 14 years out of the basement of The PRAC has not solved the his home in Point Le Nim, which is lack of specialists in this region. Half near Dalhousie, a community of of the 10 family physicians in 6000 in northern New Brunswick. Dalhousie dropped out of obstetrics Unemployment is increasing; 400 last year, and many are dropping out people were laid off at the local of psychotherapy. But as the region paper mill 2 years ago and 200 at already has its full complement of
billing numbers for family physicians, no one is stepping in to fill these gaps. "There's no possibility for new family phsicians to come in; they are blocked by PRAC. We're all overworked, and there's no chance of relief," said Quintal grimly. Quintal also worries about retiring doctors. Billing numbers are linked to hospital privileges, and as privileges terminate annually, doctors have to reapply. "It used to be that hospitals would need a lawyer to refuse you privileges. Nowyou need a lawyer to prove you're competent. Older family physicians are being kicked out for not doing obstetrics any more. It's the death of rural medicine." Christine McKenna and Greg Archibald are family physicians (also husband and wife) in Newcastle, a town at the mouth of the Miramichi River in eastern New Brunswick. It's not strictly rural, they say, but the style of practice is rural: "When you go out on a hou'secall, people insist you sit down for a meal as soon as you arrive. You'll be asked for advice on the car, and to treat the family's sick dog. Maritime medicine is full of stories, says Archibald, and goes on to relate the time that his car slipped off the cliff and fell into a fishing dory below while he was visiting an elderly woman. Perhaps it's not PRAC so much as other factors that are luring physicians to the area. The two hospitals in Newcastle and Chatham are going to amalgamate, which McKenna says is one drawing card. The group of family physicians Canadian Family Physician VOL 40: May 1994 1063
UPDATE * NEWS
Briefing Sexually abu:sed men devel~op
more
addictions and mental health problems than women who have been abused or assaulted, reports a Uniersiy,oC Torontsud Abused men w almost three times more likely to have apsychiaic drug, o1r alcohol problem than other men while wvoimen who had benmolestd were twice as; likmel io develob s those whonever eperiprobls tas ^ v^>Canad enced childhood abuse.. A~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
-owe
The "Sa-ve A Heart" program in Eastern Europe is bein launched by Apotex, a Caaian-we
pharmaceutical company,
to
help
detect heart disease among :ithuanian adults. Cardiovascular disease kills (per 100000 pouain) 550 men and 390 women in that country yea-rly. The people there are uneducated on how to manage their own health, and the counItry's ministry of heaIlh is IOOking for a way to reduce the death rate. Health care teams will visit factories across the country to identify those at risk and to promote halthier lifestyles. The prgam Will last about I year.
Emphasis on prevention By the year 2000, the number of new cancer patients in Ontario Will increase to 60000 annually com-
pared wioth 45 700 new cases in 1993. The Ministry of' Health is establishing a cancer care prIogram emphasizing p revention 'that is hoped to increase the nuamber of ontaians surviving the disease from 150 000 this year to 225 000 iIn the year 2000. Currently, the ministry spends less than 1% of the $1 billion budget for cancer on prevention. 1064 Canadian Family Physician VOL 40: May 1994
covers for their specialist colleagues on weekends. Another draw could be a close alliance with Dalhousie and Memorial Universities, whose residents and clinical clerks Archibald teaches for 8 months every year. Four or five have come back to stay for good. There's lots for these young doctors to do, as the stabler employment situation keeps young families in the area. Possibly related to the fact that this is premier Frank McKenna's riding, the area doesn't seem to have suffered too much from the recession. The paper mill in Newcastle was modernized recently to the state-of-the-art Alcell process, a new way of making paper that requires no chlorine or sulphur, the notorious pulp-and-paper pollutants. "This mill is poised to survive the industry," said Archibald. "No one wants to see it go the way of the
cod fishery." Some layoffs do occur, and soon the Chatham military base will be closed down. "But we're used to suffering through hard times," says Dr McKenna. "It forces us to turn to the extensions of the community that people look to to survive." That includes the extended families, the churches, the Kinsmen, the Lions, and public health authorities. Representatives quickly identify people in need, and help out with discretion. "People are more equipped to deal with hardship than they are in more developed areas," she said. "I feel worse for the people in Toronto." There doesn't seem to be one health-related activity in town that these two aren't involved in. Blood donation, community services, Heart and Stroke Foundation, reproductive health clinics, breastfeeding, Alzheimer's disease - to name a few. Just to underline that family physicians are indeed a
resource to their community, their neighbours sometimes knock on their door at 2AM in an emergency rather than go to the hospital. "We have to grapple with setting boundaries," said Dr McKenna.
If Drs Archibald and McKenna play down the problems of practice in close communities, Dr Bill O'Flaherty is a walking advertisement for rural practice in the Miramichi. Having practised solo for 22 years in the Newfoundland community where he was born, he decided it was time for a change. "I became a fixture," he said. He didn't need a boot from PRAC to settle on Blackville, which he says is one of the best clinics in rural New Brunswick. "When I saw it I couldn't believe they couldn't get anyone to come here," he says. An avid fly fisherman, he now lives on the best salmon river in the world. Government interference, if anything, has given him the freedom to practise the way he wants to. "In Newfoundland I had to do all the hiring and firing, the payrolls, all the administration. I felt more like a businessman than a GP The government here now looks after all that at the regional level. I contribute a certain percentage of the fee per patient to overhead costs, and they let me get on with my clinical work, which is what I want to do." The PRAC has done what it was meant to do in the Miramichi, says O'Flaherty. "We're getting more specialists. You'd suspect they'd rather be somewhere else, but they seem quite content. Before PRAC we had a huge turnover of family physicians, but now they stay, because they have to. So it's good for us." O'Flaherty sees no signs of the recession in his area. "The only layoffs at the lumbermill have been the higher-ups," he said, "and you don't see a downturn in the economy because of it." The tourist industry
UPDATE * NEWS ....-. vvvvvvv-
is another employer, he adds, returning to the subject of salmon. Thousands of wealthy tourists come from around the world each summer to fish in the Miramichi, including Prince Charles and baseball hero Ted Williams. Men work as guides and women as cooks in the camps. "I don't see the signs of poverty here," he said. There's no hint of suffering in O'Flaherty's voice, either. "My only regret is that I didn't come here earlier," he says, returning once again to the subject of fishing. "One windy day I had to extract a fly out of a young man's face, and I asked his father where they'd been fishing. 'We're fishing in paradise,' he said. I didn't recognize the name. 'Now what pool is that?' I asked him." You get the feeling it's going to take more than PRAC to ruin this man's day. Saint John, N/B
F"amily mnedicine resident sues New Brunswick Billing numbers refused LOUISA BLAIR
A
family
resident from New
LA7Brunswick who is graduating
in June 1994 will be unable to return to practise in his home town of Fredericton, after all. According to the province, that region already has enough doctors, thank you very much, so Dr Neil Young was refused a billing number. Along with two other colleagues, Dr Young is suing the province, citing several breaches of the Charter of Rights and Freedoms. But the economic climate these days is not the same as it was in British Columbia during 1984, and all eyes are on New Brunswick, whose Liberal premier Frank
Brunswick hospitals, now they cannot get away from them. Chapter president DrJohn Keddy doesn't like the fact that family physicians are forced to obey the by-laws of the regional corporation that administers the hospital; for example, they might be required to work in emergency rooms against their wishes. For rural family physicians, making an appearance at the local hospital can mean a lengthy trek over roads that in winter can be impassable, and that by spring are so filled with potholes that CBC radio New Brunswick devoted an entire commentary to their abominable condition. Others are quietly pleased that family physicians are being required to keep up their hospital skills and follow their patients through bouts of hospital care. "I wish we had that in Alberta," said national president Dr David Moores, who lives in a city where three quarters of family physicians have no hospital privileges and most do not want them. "It's not all bad that we are tied to hospitals," said the chapter's past president Dr Don McDonagh. "It means we keep up on our skills, we advocate for our patients, and most important there is peer review on Dr Neil Young: "We're al/ going to be an ongoing basis." to the States when we But if feelings about tying billing shlipped off graduate." numbers to hospital privileges vary, when they are granted hospital Young can at least count on most of his colleagues to agree that the privileges. Acronyms like PRAC (the restriction of billing numbers is province's Physician Resource based on a faulty assessment of Allocation Committee) and FTE needs, and will turn out not to be (full-time equivalents) bounce cost effective after all. The PRAC around at the New Brunswick allotted a certain number of FTEs Chapter's Annual Scientific to each region. "We feel the figures Assembly like squash balls at a PRAC used didn't take into account tournament. current practices. They used Assembled physicians had mixed national averages but didn't look at feelings about being tied to hospital specific communities. People may work. Some resent being tied to the not have been practising full-time," hospital, complaining that, while said Chapter President Keddy. once they were afraid family physiAlthough many physicians object cians were being edged out of New to the restrictions primarily on a McKenna is in the vanguard of a social experiment that could spread to the rest of the country. As part of his plan to attract business back to the province, McKenna has cut hard into social programs, including health care. Health care in the province has been organized into regions, each of which is administered by a single corporation, and each corporation has been allocated a certain number of physicians. If the region has its full complement of doctors when you apply for a number, you're out of luck. In addition, family physicians can get a billing number only
Canadian Familv Phlysician VOL 40: Mlay 1994 1065
