The medical community is feeling the burn of being stretched to the brink. Rates of physician burnout nearly doubled between the two most recent National Physician Health Surveys (NPHS) conducted by the Canadian Medical Association (CMA) in 2021 and 2017, with 53% of physicians reporting being highly burnt out last year. Physicians working in rural and remote areas were identified as a group that was particularly at risk within the health care community.
In the most recent NPHS, physicians practising in rural and remote areas reported significantly higher rates of depressive symptoms, moderate to severe anxiety symptoms and suicidal ideation (lifetime) than physicians in urban/suburban settings. Rural and remote physicians also reported significantly lower professional fulfillment (i.e., a sense of satisfaction and meaning in work) than their urban/suburban counterparts.
What is missing from these statistics is the context of what a day in the life of a rural or remote physician is like. This subgroup regularly faces specific, often life-or-death resource constraints; the fate of an emergency department (ED) can literally rest on one individual's shoulders. Three rural physicians, Dr. Sarah Lespérance, Dr. David Bradbury-Squires and Dr. Sarah Giles, share their perspectives to help raise awareness of their challenges and the opportunities to support rural communities better.
A grim acceleration of health care’s decline
Rural communities are defined as areas with fewer than 10,000 people and where access to medical specialist care or resources is limited or distant. Remote medicine is defined as medical care provided where or when transfer or access to in-time specialist care and specialized resources is high risk or impossible.
Understanding the distinction between rural and remote medicine is the first step in appreciating the potentially dire circumstances some communities face with health care shortages and burnout.
According to the Canadian Institute for Health Information, in 2020 rural physicians made up about 8% of total physicians in the country (~7,000 physicians compared with ~84,000 physicians practising in urban areas).
“Whatever is felt in urban areas is amplified in rural communities in terms of shortages, not just for physicians but all staffing,” says Dr. Lespérance, a rural generalist physician based in Petitcodiac, New Brunswick, and the president of the Society of Rural Physicians of Canada (SRPC). “We’re seeing more communities with emergency rooms closing because there is no staff,” she adds.
Rural physicians are stretched beyond measure, often shouldering the responsibility of multiple communities where they may be one of the few resources to provide care because of their often more generalist skills. The opportunity to develop broader skill sets and experience is often why people pursue a path in rural or remote medicine. Having a meaningful opportunity to provide service to underserved populations is another powerful motivator.
For Dr. Bradbury-Squires, a rural emergency and family physician based in Grand Falls-Windsor, Newfoundland and Labrador, this path satisfied both personal and professional interests. “Family medicine was always something that really spoke to me. I kind of flirted with pretty much every specialty in medical school and really enjoyed emergency medicine because it was like the acute manifestation of potentially seeing every specialty — sometimes all in one day, all at the same time,” he describes.
He and his physician wife grew up in Newfoundland and Labrador and have established their careers there to be close to family roots and give back to the community. “In going into a more general specialty such as family medicine and emergency medicine, one of the big draws was that I could really live or practise wherever I wanted,” he explains.
“And I wanted to end up here close to family. But I am also practising in the community where I did my family medicine training, an environment that treated me so well. I’m also involved with academics in this region to give people the same quality of experience I had when they leave their residency.”
But in fee-for-service practices, physicians have little incentive to take on extra loads. And with the realities of how far today’s health care system is stretched, there’s even less for physicians to give.
“I work in the emergency department, where we’re essentially paid hourly, as opposed to fee-for-service. So, whether there's a medical student there with me or not, it doesn't really matter to my pay,” says Dr. Bradbury-Squires. “But if you're telling a colleague who has to pay overhead and has debt that they're going to have to take on someone and that it isn’t going to result in increased pay but may even decrease their pay and increase work ... why would they do it? And if they’re already near the edge, how can they be expected to do it?”
He explains that the lack of human resources in terms of preceptors and the health care field overall is the most painful issue facing physicians (and ultimately, patient care). In a word, he describes it as “grim.”
“The pandemic seems to have accelerated whatever systemic processes were in place. That feeds the fire that is burnout,” says Dr. Bradbury-Squires. “So, you think to yourself, ‘I don't have much in me left to give, and medicine might be the thing that I need to step back from to continue to lead a healthy and happy life.’”
Ultimately, there is a resounding recognition that no matter the effort put in, it’s not enough to fix the problems gripping our health care system across the country.
Shouldering the weight of many communities
For Dr. Sarah Giles, a family/ED/humanitarian physician based in Kenora, Ontario, her decision to pursue rural and remote medicine resulted from a summer experience in the Northwest Territories when she got to observe what a career in the field could look like.
“Between the second and third year in medicine, I got to go up north for a summer and just hang out with the doctor who covered seven fly-in communities and who was just amazing,” she shares. “To this day, I am in awe of him, and I was, like, ‘Oh no, no, this is what I want to do!’”
Dr. Giles is passionate about helping rural and remote communities because of the inequities that negatively affect the health outcomes of often marginalized groups. It’s led to her working with Doctors Without Borders and serving as a long-term locum across Canada.
“I find great satisfaction in getting people the care they need when barriers have been placed in their way,” she explains. “I feel a strong sense of moral obligation to use my skills for the people who need them most. But, of course, that can lead to burnout.”
Her home base of Kenora is a centre that covers 12 other communities with patients travelling great distances, sometimes coming in via helicopter. The nearest tertiary care centre in Ontario is over 500 kilometres away. Although Winnipeg, Manitoba, is closer at a two-and-a-half-hour driving distance, it’s across a provincial border, which means that seeking care there results in administrative chaos. In addition, few ambulances are available, and using an air traffic runway or helicopter is subject to the volatility of Northwestern Ontario weather. Further compounding these complexities is the all-around short staffing of any transportation options to move patients should the need arise.
Before the COVID-19 pandemic, Dr. Giles did locum work and would be the temporary solution that gave respite to communities. It became increasingly difficult to do locum work during the pandemic, with quarantine and travel restrictions, and local pools of coverage to cover existing colleagues unable to work also quickly dried up. This led to Dr. Giles settling in Kenora, where she predominantly works in the ED, does about four weeks of hospitalist work a year and holds an administrative role linking the medical community and a medical school.
As a critical resource in the community, she is often the first and last line of defence.
“I’ve been incredibly aware of the fact that, if I get sick, we may not be able to keep our ED open,” she explains, sharing that she’s also experienced working shifts without emergency department nurses because of shortages.
“It’s a moral dilemma — do you kill yourself with work? And then start hating your work, hating your life, or likely getting sick?” she asks. “Or do you put boundaries in place that can protect your health and make things more sustainable, but that could also mean having to close an ED, which could have a terrible impact on others?”
A mismatch of what can be done and what should be done
All three physicians voice the pressure to take on more despite rapidly declining resources. It’s led to Dr. Bradbury-Squires having to start working at a walk-in clinic to fill gaps in care, in addition to his emergency and academic responsibilities.
“As an emergency provider, I’m not really equipped to handle chronic issues that need close outpatient follow-up,” he explains. In theory, a patient would follow up with a specialty service. But when that specialist is only available four hours away and a patient can’t get there, it’s soul-crushing. “You’ve done all the medical things and you know that no matter all the work you’ve done, there’s nothing you can do short of driving the patient there yourself.”
So, Dr. Bradbury-Squires began working in a walk-in clinic to continue caring for his ED patients who did not have a primary care doctor to oversee their routine or time-sensitive care. This is another aspect of rural health care that illustrates how dire the circumstances can be for both patient and physician.
To Dr. Bradbury-Squires, burnout is a mismatch of what one can do versus what they think should be done — and then experiencing it as a repetitive hammering. “This is a slow series of moral injury or perceived inability to succeed in life or work. It’s slowly becoming more jaded and less compassionate and leads to eventually wanting to leave this career altogether,” he says.
The effects of burnout are not just limited to physicians; their burnout also affects their spouses, children and other family members who have had to adapt and make sacrifices to live in rural communities. To be a family member supporting a rural physician often means having to adapt to limited job opportunities, schooling options and recreational activities for both adults and children. The level of burnout and over-extension for family members was further exacerbated over the past few years with pandemic quarantines, intense schedules, collective trauma and harassment reshaping what a “day in the life” of a physician looks like.
“Spouses of physicians, especially those at home with young kids, can experience intense isolation. Not being able to visit families or hang out with other little kids adds to the pressure,” describes Dr. Giles. “It’s better when the weather is good, but we have real winters here. We’re next to Winnipeg. You’re not going to have an outdoor playdate with your six month old in February.”
Dr. Lespérance’s husband has been involved in the SRPC’s partner support network for several years. She describes the network as crucial in providing moral support and connectivity. In addition to her role with the SRPC, she also studies and writes about resilience, leading to thoughtful self-discovery around burnout and wellness. “If I’m going to be talking and writing about these topics, I should, you know, be practising these things as much as I can,” she says.
After transitioning from remote medicine to a rural practice in Petitcodiac, she experienced a change in her scope of work and in her self-care strategies.
“I started running more often and taking time for myself. Being here, I can shift my schedule, so a couple of days a week, I start later and go for a run,” she describes. “Those moments before I go to work actually lead me to be much more effective as a clinician and in my life overall.”
Moving forward from here
To address the systemic problems these rural and remote physicians face, the doctors profiled here believe that adjusting compensation is the first step for rural and remote doctors and their teams of human health resources, including nurses, personal support workers, cleaners, lab technicians and medical technicians. That includes adjusting outdated rules around shiftwork, bonuses, geography and credentialing.
“A lot of health care providers have switched to part-time or casual work and will pick up shifts at time and a half or double time,” explains Dr. Giles. “They're essentially saying, ‘For the regular wage, it's not worth it. It's not worth getting yelled at. It's not worth getting hit. It's not worth overnights and weekends and fatigue.’”
Dr. Giles, who is making significant efforts to keep her ED open, earns substantially less than a doctor in Thunder Bay, Ontario, or Winnipeg. Part of the problem is that standard contracts do not compensate for the time a physician spends navigating transfers, practising a fuller scope of practice than urban colleagues or dealing with a legacy of well-earned mistrust caused by racist colonial policies. But she still puts the call out to doctors in urban/suburban areas to lend a hand.
“I would like to encourage my colleagues in bigger centres to consider coming out to a smaller centre, especially one that feeds into theirs. Even coming out for one shift can keep our doors open,” she says. “It would be a good learning experience for everyone. We say to people that we're like cottage country — it's beautiful. So come out and work a shift. Our hospital has a dock. We had one locum stay on a houseboat,” she describes.
In addition to helping facilitate a little breathing room for rural doctors, occasional visits from physicians from larger centres may enable rural doctors to obtain adequate care for themselves. “In a small community, a doctor may not want to see someone in their local community. Access to providers in another jurisdiction might help with rural/remote physicians accessing health services for themselves. Sometimes licensing is the barrier, but agreements between jurisdictions and technology for virtual care are what's needed,” explains Dr. Lespérance. “Nunavut is small, and a family doctor might be in another province or territory.”
There’s more work than there are people to do it, says Dr. Lespérance. Doctors are cut from an overachieving cloth, and the answer shouldn’t be to pile on more. Instead, fast-tracking international medical graduates and nurses, national licensure to allow for a flexible workforce able to support colleagues as the need arises, and offering round-the-clock daycare would help release the steam valve facing physicians.
“I swear to you, I would put half of my colleagues on stress leave,” admits Dr. Giles. “But we can't. So, you know, we put our heads down and just keep going. But at some point, something breaks.”
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