FAMILY PHYSICIAN RECRUITMENT AND RETENTION

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1 FAMILY PHYSICIAN RECRUITMENT AND RETENTION Retention of physicians in smaller communities has been a long standing problem. Family physicians typically have stayed in smaller communities for one to three years. While this was never an ideal situation, in the past this turnover rate was workable. At that time many physicians wished to come to Canada from the United States, South Africa, Great Britain and Northern Ireland, Ireland, Australia and New Zealand. Other countries freely allowed their physicians to emigrate and Canada was a popular choice. Our Saskatchewan licensing bodies put into practice temporary three-year licences to encourage physicians to locate to rural communities, and the Saskatchewan Medical Association set up a locum coverage program so that rural doctors could get much-needed vacation time. The temporary three-year licences allowed physicians the time to study and write their Canadian qualifying exams. Upon passing these exams many physicians then moved on to larger centres and the recruitment cycle began again. Today, a global shortage of physicians has exacerbated the problem so that it is now not only smaller communities in Saskatchewan but also Regina and Saskatoon who have difficulty recruiting and retaining sufficient physician supply. Smaller communities compete with large urban centres, and recruitment worldwide is much more competitive. Several things have changed in recent years that have made recruitment of physicians a difficult and constant process. Worldwide Shortage of Physicians. Throughout the world the number of physicians being graduated is not meeting the demand. Some of the factors that have increased the need for larger physician numbers are aging populations, longer life expectancy, advanced technologies that extend medical capabilities and prolong life, increased public expectation for a high standard of medical care, and improved health care development in previously underdeveloped countries. Immigration. Canada, and in particular rural Saskatchewan, has relied heavily on foreign trained physicians, most notably from South Africa. In recent years South Africa and other countries have been increasingly vocal in their criticism of Canada for raiding their physician base, referring to this practice as unethical recruitment. South Africa has now put in place greater restrictions so that their physicians cannot easily emigrate. Immigration into Canada became more complicated following 9/11 and security issues and related paperwork have delayed the immigration approvals. Where in the past it took two to three months for the full immigration process and work visa, it now typically takes 18 months or longer. Licensure. In Saskatchewan the licensure of physicians is done by the College of Physicians and Surgeons of Saskatchewan. It is a complicated process. Health regions and individual communities cannot influence this process. As physician supply tightens and communities and health regions delve deeper to find physicians, it is important that the College of Physicians and Surgeons of Saskatchewan licensing process safeguard the public by ensuring physicians have adequate training and abilities. Page 1 of 9

2 Most Canadian-trained physicians are eligible for full licensure. Unfortunately there are not enough Canadian-trained physicians to meet the needs of our population. Recently governments have increased the number of training seats at medical schools, but this increase will not ease the crisis until the new students graduate in seven years. Once in Saskatchewan, foreign trained physicians must attain licensure. Most physician training obtained in the United States, South Africa, Great Britain and Northern Ireland, Ireland, Australia and New Zealand is accepted as meeting Saskatchewan requirements. A physician who has a minimum of 12 months of postgraduate training from an approved program can obtain a temporary supervised licence. Such a physician can only practise in a location in which another licensed physician is available to provide assistance and supervision as may be necessary. In order to obtain a temporary unsupervised licence, a physician must have a minimum of 24 months of postgraduate training from a university-affiliated teaching hospital located in a country recognized by Saskatchewan. In some circumstances, the College of Physicians and Surgeons of Saskatchewan will refer a physician to the Clinical Assessment and Professional Enhancement (CAPE) program. The CAPE program is an assessment program offered in Winnipeg for certain physicians who meet some but not all of the College's requirements for postgraduate training. The CAPE assessment involves approximately three to four days in a formal assessment program in which the physician's skill, knowledge and judgment is tested and compared with the assessments that have been made of physicians in active practice in Manitoba. Most physicians choose to begin practice with a temporary licence and later transfer to a provisional licence. They use the time while practising on a temporary licence to decide if they want to continue to practise in Saskatchewan, and in that community. After they decide that they want to practise medicine on a longer-term basis in that community, they transfer to a provisional licence. In order to obtain a provisional licence, a physician is required to agree to remain in a named Saskatchewan community for three years. They may move to another community if the community and health region agree to release them. However, some physicians choose to leave Canada and return to their home country without completing their three-year commitment. A provisionally registered physician who passes the three examinations of the Medical Council of Canada will be fully registered. Once fully licensed, a physician may freely move within Canada and often will relocate from the smaller rural communities to larger centres. Licensure Terminology: FLEX - The Federal Licensing Examination. An American examination available until approximately MCCEE - The Medical Council of Canada Evaluating Examination. The MCCEE is an examination that is offered at least twice per year. The examination is administered by the Page 2 of 9

3 Medical Council of Canada in a number of locations in the world. The present locations for these examinations are London, Paris, Riyadh, Hong Kong, Tokyo, Muscat, and five locations in Canada. MCCQE - The Medical Council of Canada Qualifying Examination. The MCCQE is a two-part examination. Part I is a computer-based examination. Part II is a structured clinical examination in which the candidate is required to interact with standard patients, obtain histories, conduct examinations, reach potential diagnoses, and suggest possible therapies. Both Part I and Part II are offered twice per year at a number of centres in Canada. Upon passing Part II the candidate is given the designation of LMCC. LMCC The LMCC is the designation given to physicians who are successful in the Medical Council of Canada Qualifying Examination. USMLE - The United States Medical Licensing Examination. USMLE is administered in three parts USMLE Part 1, USMLE Part 2 and USMLE Part 3. Categories of Licence for Family Practitioners: 1. Temporary licences (also referred to as locum tenens permits). For family physicians. A physician who has 24 months of approved postgraduate training, and either full licensure in the country in which their training was obtained or the MCCEE, USMLE or FLEX, may be eligible for a temporary, unsupervised licence. A physician with 12 months of approved postgraduate training may be eligible for a temporary, supervised licence. A temporary licence is limited to 12 months and cannot generally be extended or renewed. A physician practising under a temporary licence must be sponsored by a physician who has full or provisional licensure with the College. A temporary licence is limited to 12 months and cannot generally be extended or renewed. 2. Provisional licences. For family physicians. These are available to physicians who have 24 months of approved postgraduate training and either full licensure with the country in which their training was taken or a pass standing in the MCCEE. A physician must make a commitment to remain in a named Saskatchewan community for three years in order to obtain a provisional licence. The physician must write the MCCEE at the next opportunity and must pass the MCCEE within two years. The physician must pass the MCCQE Part I within four years and must pass the MCCQE Part II within five years. If the physician obtains the LMCC, the physician will be eligible for a full licence. SUNRISE HEALTH REGION RECRUITMENT AND RETENTION OF PHYSICIANS Previously the recruitment of physicians was the responsibility of existing physician clinics and local communities. Over the last five years the health region has been forced into a greater role due to the increasing complexity and difficulty of recruitment, immigration and licensure processes. Page 3 of 9

4 Physician Resources The region has a physician resource benchmark of one physician per 1,500 residents. Recruitment The health region is engaged in ongoing recruitment of physicians and is actively assisting several communities that are significantly under-resourced. However, if approached by a physician interested in another community, the region does not turn them away but reviews their request and the current physician resources in the community of choice and may allow them to settle elsewhere. The region also assesses the current physician resources in all communities on an ongoing basis. Recruitment is both time consuming and costly. The health region invests significant funds and uses the following methods to attract candidates: Physician magazine advertising both in Canada and in other countries, including: o South African Medical Journal (SAMJ) an advertisement runs monthly (revised as the vacancies change) o Canadian Medical Association Journal o Canadian Public Health Association NSSCM members distribution (for MHO position) o Recruitment Canada Physicians Guide Posting positions on physician recruitment websites, including: o MedHunters ads remain on the website until vacancy is filled (Mar/06 to Mar/07 ad package) o o Sask NetWork Gov t website o Health Careers In Saskatchewan ( o CareerMD.com o CanuckCareers website Hiring a professional recruiter (although to date our own efforts have been more successful than those of the recruitment agency) Assisting and encouraging physician-to-physician recruitment Partnerships with existing physicians in the region to assist with recruitment Utilizing contacts and linkages with other health regions within and outside of Saskatchewan Approaching all locums to encourage permanent relocation Participating in student internship programs so that students are placed in Sunrise to learn about and showcase the opportunities here Medical students training in Saskatchewan are approached for employment Attendance and displays at recruitment fairs The region negotiated with the College of Physicians and Surgeons to provide training programs in the region that meet College requirements for psychiatry Arranging tours of the health region to interested candidates Relocation assistance in the form of bursaries, rural practice establishment grants, and other relocation grants Relocation and employment assistance for the families of new recruits Lobbying the provincial government for more training seats Page 4 of 9

5 Writing letters of support to accelerate the immigration process Keeping in constant contact and supporting physicians throughout the lengthy recruitment, licensing and immigration processes Sending information packages about the region to all interested parties Retention strategies are employed to retain the existing complement of physicians In addition to the provincial and health region incentives, the region also works with communities, when invited, to help them establish community-funded recruitment and retention incentives/initiatives. In addition, significant time is dedicated to obtaining locum coverage for temporary physician absences. When the health region becomes informed of a temporary physician coverage problem, the Saskatchewan Medical Association (SMA) is contacted to assist with locum placement. A few years ago the SMA established a locum coverage program which has been very helpful, but it cannot keep up to the current demand. If locum coverage through the SMA program is unsuccessful, the health region contacts individual physicians known to the region and, when time permits, advertises for locum coverage. It is a changing environment. The community and health region often receive little or no advance notice when a physician leaves a community. Once full licensure is obtained many physicians permanently leave their initial host community. Our recruitment efforts have realized a considerable measure of success. In there were 11 family physicians recruited. Additionally, in the past two years the region successfully recruited eight specialists in ophthalmology, pathology, radiology, internal medicine, and general surgery. Despite the best efforts at recruitment and retention, the health region, communities and established physician practices are unable to keep up with the constant transition and demand for new physicians. In 2006 the following communities experienced physician shortages: Yorkton, Melville, Canora, Kamsack, Preeceville, Langenburg, Esterhazy. Melville, Canora and Yorkton have seen some relief, but their complement is still not ideal. There are candidates currently awaiting immigration approval and work visas for the communities of Esterhazy and Kamsack. The credentials of two possible candidates for Preeceville are currently being reviewed. In addition to family physicians, the region is currently recruiting for specialists in urology, pediatrics, and internal medicine. When physician or locum coverage is unavailable, the region must temporarily adjust services to ensure a safe level of care. In 2006 the following communities experienced some form of service reduction due to temporary lack of physician coverage: Preeceville, Kamsack, Canora, Melville, Yorkton. Page 5 of 9

6 Physician Payment Family practitioners are not paid by the health region. They receive payment directly from the Medical Services Branch of the Saskatchewan Government, Department of Health. Payment for family physicians falls into three categories: 1. Alternate Payment Contracts. This is a relatively new method of physician payment, whereby a health region negotiates with a physician an alternate payment contract. The contract includes the expectation that a physician will work with the health region and support primary care site development and provide physician support to a nurse practitioner. It is a complicated process that involves negotiation with the physician, the Medical Services Branch of Saskatchewan Health, and the Saskatchewan Medical Association. Progress on alternate payment contracts has been slow. At the present time there is only one family physician with an alternate payment contract with Sunrise Health Region. 2. Fee-for-service Payment. The majority of family physicians are paid by the Medical Services Branch for each service they provide. Fee schedules are negotiated on behalf of the physicians by their member agency, the Saskatchewan Medical Association (SMA). All fee-for-service family physicians are paid using the same fee schedule, regardless of where they work. 3. Emergency Room On-call Coverage Payment. This is an additional payment made to physicians who participate in on-call rotation for emergency room evening and weekend coverage. The province has established two levels of on-call coverage payment based on the volume of calls a physician may expect to receive and the timeframe in which a physician is expected to respond to a call. Due to their emergency room volumes Canora, Kamsack, Melville and Esterhazy are considered Category A hospitals. Preeceville has a lower number of emergency calls and is designated by the province as a Category B facility. Lower emergency room volumes mean that while the Preeceville doctor is on call, it is expected that he/she will have to attend at the hospital less frequently than a physician in a busier centre. The amounts currently paid for this coverage are: 5 p.m. 8 a.m. weekdays Category A $10/hr Category B $5/hr weekend and statutory holidays Category A $25/hr Category B $20/hr This is still a relatively new initiative; only a few years ago physicians did not receive any additional payment for on-call coverage. While it can be argued whether this system is fair, it is a payment schedule set by the province. The Category A and Category B designations are not used for any purpose other than on-call physician payment. A 24-hour and seven-day-a-week emergency room coverage program is operating in Yorkton. Payment is considerably higher, but the physician must be physically in the Yorkton Regional Health Centre for the entire time. Page 6 of 9

7 Relationships - Physician, Hospital Administration, Health Region, Community Physician Relationship with the Health Region Family physicians operate their business independent of the health region and receive payment directly from the Medical Services Branch, Saskatchewan Health. The health region invites physicians to participate on various committees of the health region. The relationship between the health region and physician is governed by Practitioner Staff Bylaws, created following consultation with the SMA and local practitioners. The Practitioner Staff Bylaws are approved by the Sunrise Regional Health Authority and the Minister of Health. Annually physicians submit an application for privileges which allow the physician to request diagnostic tests, and attend to their patients in health region facilities. The health region reviews the requested privileges and the qualifications/training of the physician and assigns appropriate privileges, approved by board motion. With the granting of privileges the physician is obliged to follow health region policies and procedures, complete medical record information in a timely manner, provide on-call coverage, attend to his/her patients while in health care facilities, work cooperatively with health care providers, and provide safe care to his/her patients. If a physician does not take these obligations seriously, the privileges can be withdrawn at the discretion of the board. Temporary suspension of privileges for incomplete medical records is the most common form of privilege suspension. Suspension of privileges may also result if a physician is abusive to staff or clients, or if there is sufficient evidence to suggest that a physician s care, or lack of care, poses an imminent threat. Suspension of privileges is rare. Physician Relationship to the Health Services Managers Formerly called Nurse Administrator or Facility Manager, the Health Services Manager is hired by and accountable to the health region for managing the staff and budgets of a particular facility or group of facilities. Generally the relationship between physician and Health Services Manager is collegial. However, in applying the directives of the health region, the Health Services Manager must at times communicate information or restrictions on physician activities, which can cause friction between a physician and the manager. The interests of the physician and the health region may not always align. The Health Services Manager does not create the rules; he/she is simply the messenger and must apply the rules for the health region. Coordination of Physician Recruitment and Physician Affairs Within Sunrise Health Region the positions responsible for physician recruitment and physician affairs are: Executive Director of Health Services tele: tele: (secretary) fax: Page 7 of 9

8 Senior Medical Officer tele: fax: Regional Secretary of Medical Affairs tele: fax: Physician Relationship with the Community Some communities choose to provide incentives to attract and retain physicians. The community can maximize effectiveness of incentives by discussing their incentive ideas with the health region. Failure to communicate with the health region may result in duplication of efforts, or creation of strategies that may be unsustainable. One of the most effective physician recruitment and retention strategies is a friendly community that welcomes a physician and his/her family, shows the benefits of living in a rural community, introduces the physician to other professionals, and recognizes that physicians like other people on occasion need time away from the demands of their work. Relationship of the Community and Health Region The Sunrise Regional Health Authority was established by the Province and is governed by the Regional Health Services Act and the annual Accountability Document. The board consists of a maximum of 12 members appointed by the Minister of Health for three-year terms. Currently, there are three vacancies on the Sunrise Health Region Board. The health region is charged with the responsibility of managing annual funding, human and physician resources, and providing health services to the 56,199 people in the region. Sunrise Health Region welcomes any opportunity to improve communication with the public and their municipal representatives. Questions that cannot be answered by your local Health Services Manager may be directed to the region. Quality of Care Concerns: Director of Quality Initiatives/Client Representative tele: or toll free: Executive Office tele: fax: For additional information or to contact the region, you may also visit the Sunrise Health Region website: Page 8 of 9

9 Some of the information used in this paper was taken from the College of Physicians and Surgeons of Saskatchewan website, which is an excellent source of other information on physician services in Saskatchewan: For health care recruitment opportunities in Saskatchewan, visit: Page 9 of 9