We sat in the restaurant in remote Marathon, Ont., flying in the snowy day before on a Bear Skin Airlines flight. The dinner created the opportunity for the local physician recruitment committee to make its pitch to us about why we, two new grads with physician partners, should choose the community to launch our careers as rural family doctors.
Midway through the meal, one of the committee members produced a small stack of burlap sacks.
“What’s that?” we asked.
“Those are the burlap sacks we’ll be using to cover the blue ‘H’ signs on the highway if we don’t recruit soon. We won’t be able to keep the (emergency department) open any longer…”
While that bit of information wasn’t part of the pitch that made us choose Marathon, it was the compelling message that helped us understand how perilously close the local health system was to being unable to meet the expectations and needs of the community.
Fast forward to 2023:
Across the country and in many rural communities in Ontario, there are staffing crises leading to service closures in emergency departments (EDs) and obstetrical units in particular. Some of these are temporary, but some reflect the beginnings of the unravelling of local health systems.
What happens when small health-care systems in rural communities begin to unravel? What does it take to rebuild them when they reach a breaking point? We can look to the experience of the community of Marathon in 1996 for a glimpse of the challenge.
The key lesson is this: Health systems depend on the people who work in them, and their commitment to care and service improvement over time. It is the consistent people who create the policies and procedures and, importantly, create the organizational culture of excellence in care that Canadians have a right to expect.
When health-care providers are diminished, or inconsistent in their presence, local services decline, the reliability of the system declines. Ultimately, the health outcomes of the people who seek health services become less predictable.
To learn from the Marathon micro-system, let’s go back to 1996.
We were four newly graduated family physicians keen to make a difference in an underserved area – we would now say our sense of social accountability guided us. Recognizing the challenge of going to an underserved community in rural Northern Ontario as one or two clinicians to fill two or more spots, we chose to find a place where, as a group of four, we could fill three vacant positions. Our payment model was fee for service and we shared the incentive grants available at the time. We believed that approach would help ensure that we weren’t stretched too thin, that we would have time for social connection and self-care, time to connect to the community and time to learn well on the steep learning curve that is the first year in practice. All things that enable clinician retention.
After a brief tour of underserved communities in Northern Ontario, we chose to go to Marathon, a community of 5,500 located on the north shore of Lake Superior, 300 kilometres east of Thunder Bay, 400 km northwest of Sault Ste. Marie. It was a community in significant need of physicians, having dropped to only one despite needing a minimum of four. The remaining doctor had indicated that he would not work more than one out of every four days in the ED (those being 24-hour shifts); the hospital was facing the possibility of shuttering its ED if it was not able to recruit physicians.
As it turned out, our group of four was joined by two other friends; we embarked on our career path as practicing physicians as a group of six physicians filling the three vacant physician positions in Marathon. This was such a significant event that it was featured on the cover of the Canadian Medical Association Journal in 1996 with the headline, “Youthful Enthusiasm Solves Chronic Physician Shortage in Marathon, Ontario.”
When we arrived in August that year, we quickly realized that we would need all the energy and enthusiasm we could muster because the system was in significant decline.
We would need all the energy and enthusiasm we could muster because the system was in significant decline.
We discovered that policies that should have been current were, in fact, a decade or more out of date. The hospital had lost its accreditation. The hospital board was being closely monitored by the Ministry of Health and the CEO was being replaced. Surgical services had been lost and the obstetrics program had closed. Women had to travel to Thunder Bay, three hours away, to have their babies. Community trust in the health-care system was lacking and staff morale at the hospital was declining.
Together with local hospital and nursing leadership, we embarked on the process of rebuilding the health-care system and physician services. We rewrote and updated hospital policies, restarted the obstetrical program to try to meet the needs of young families, launched a local chemotherapy program with our regional chemotherapy service, and supported the hospital to achieve accreditation again. We began a nursing education program to support nurses in enhancing their clinical skills and to “grow our own” through a locally run college program. We became a teaching site for the Northern Ontario Medical Program, hosting residents and medical students. We renovated the clinic, knocked down walls, hired a couple of nurses and began a collaborative interprofessional practice together.
The lost surgical services were never fully regained.
A statement of mission and values, developed together as a group of seven physicians, guided our work both in clinic and in the hospital. Our decision-making process was inspired by Ralph Nader’s PIRG (Public Interest Research Group) and used a consensus based decision-making model. We built something new based on balancing community need and physician wellness that has continued over the past 25 years with sustained physician staffing in a remote and rural setting.
It has, to date, been successful. Critical to that success, however, was our shared willingness to work hard to build something better. We needed more physicians than the community was designated for because the commitment of time and energy to rebuild the system was more than could have been sustained if we didn’t have the margin of capacity that we built in by being a group of seven, including the remaining physician, in a community designated for four. Once again, our payment model was fee for service and we shared the available incentive grants.
We were told that prior to our launch in Marathon that 75 physicians had rotated through the community in the preceding decade. A couple of physicians had provided the backbone of clinical care but the majority who came either were on a rotating locum basis or anticipated making a commitment to the community but quickly left after burning out. The emphasis on “providing access” without continuity of care and commitment to the community led to a slow decline in Marathon’s health-care system. The revolving door of 75 physicians – 75 well-meaning, clinically skilled, hard-working physicians – was a stopgap option that was well intended but was not a long-term solution to the community’s health challenges.
The rebuilding took a few years, hundreds of hours of time, and a committed group of clinicians with capacity to rebuild – and the optimistic naivete to believe it could be done. The original values of balancing our commitment to a community with our self-care was, and continues to be, essential to the success of the model of physician resourcing in Marathon.
There is ample evidence that comprehensive primary care provided by family physicians improves patient outcomes and reduces health-care costs. The health of rural communities depends on family physicians working to meet the needs of patients and communities. As rural health-care systems like High River, Alta., and Minden, Ont., sound the alarm about the erosion of local health-care systems, we must remind ourselves collectively of what it takes to rebuild services once they are lost.
It is not enough to simply “keep the doors open.” There is an entire system behind those open doors that needs to be sustained if we want high-reliability, high-quality care in. When clinical services are lost, especially when physicians and skilled nurses leave a community, it takes huge efforts to rebuild. Investing in retaining skilled clinicians now – and sustaining the experienced clinical teams who can mentor and support new clinicians and ensure that there is, in fact, a local “system” – will be critical to the near future of health services in rural Ontario.
The authors thank Drs. Eliseo Orrantia, Michael Sylvester, Gord Hollway and Steve and Ruby Klassen for all their work in 1996 and beyond, and are grateful to the physicians and the health-care team and administrators who have sustained clinical services in Marathon since then.