Small Town, Big Picture

Kevin Gorsky1, Tyler Safran1
Published online: 03 November 2017
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1 Faculty of Medicine, McGill University, Montréal, Canada.

Time moves a bit slower in the countryside. The people are friendly, neighbours look out for one another, and denizens are grateful for the miles that separate them from the high-octane hustle of city life. When a city-slicker tries to integrate into this new world, certain dichotomies quickly become apparent. For those who call small-town Canada their home, the start of hunting season is a far more substantial date than the start of the new fiscal quarter. These remarks are not a reproach, far from it, but rather an attempt to illuminate a culture and perspective that many metropolitans have lost, if ever grasped at all. Though the overall ethos throughout the expansive plains of the Pontiac may be humble, the practice of medicine is anything but.

Urban hospital medicine is representative of the highest aspirations of modern medical science, dozens of expert services interact in a highly collaborative, though sometimes chaotic, setting designed to direct patients to the physicians capable of offering the most specialized and precise care. In a large city centre like Montréal, a hospital is an elaborate intersection of hundreds of different healthcare professionals including a multitude of specialized nurses, nurse practitioners, occupational therapists, physical therapists and respiratory therapists, social workers, nurse' aides, psychologists, a plethora of technicians, unit coordinators and many more1,2,3. As far as doctors are concerned, it often appears as if there are as many breeds of highly specialized physicians as there are known diseases. In a small-town hospital site like Shawville, this could not be further from the truth. Diametrically, rural hospital medicine is largely provided by family physicians. This was recently confirmed in a new study out of British Columbia, which grouped health clusters into Local Health Areas (LHAs) and demonstrated a significant skew of specialists towards urban areas4.

City -based family physicians are multitalented, broadly- practicing administrators of medicine at their own right. The family physician is required to understand health and disease across various organ systems, presentations, treatments and patient population demographics. However, this breadth and scope is multiplied, seemingly exponentially, the further one gets from urbanite areas. Moreover, while 19% of Canadians live in rural areas, fewer than 10% of Canadian physicians practice in rural areas5. This distribution is increasingly skewed when looking at the breakdown of family doctors in rural areas (14%) compared to specialists (2%)5. All this adds up to rural populations relying heavily on their family doctor. With a distribution curve as such, an outside observer might assume that urban practitioners are less saturated and overworked. Incredibly, according to recent survey data, only 50% of urban physicians believe they have a reasonable workload, compared to 83% of rural doctors6.

What are the essential services provided by a hospital? It's important that there is an emergency department to see the most pressing cases. Surely a medical ward for sick patients who need significant and often lengthy intervention is indispensable. What about someone to read medical images? A hospital certainly requires staff trained in obstetrics to deliver babies. Furthermore, what about surgeries, both simple and more complex? And isn't anesthesia necessary to facilitate these procedures? In the city, this skeletal list of basic needs would call into service at least a dozen different medical specialists. At the Pontiac Hospital Centre in Shawville, every one of these essential needs are met by family doctors. One of the McGill's most eminent physicians Sir William Osler once quipped, "The modest country doctor may furnish you the vital link in your chain, and the simple rural practitioner is often a very wise man." The rural physician must not only be wise, but competent across a wide array of fields that the urban physician, both generalist and specialist, is not often exposed to. Not all family doctors are cut from the same cloth. Just as the old-adage says that it takes a village to raise a child, so too does it take a diverse group of different family physicians to run a hospital. Some family physicians practicing at Shawville have more interest or experience in obstetrics or anesthesia; while others might be experts in simple procedures. The intersection of personalities and experience allows a rural hospital like the Pontiac Medical Centre to function and service it's population with tact and skill.

The most uniquely defining feature of the Shawville hospital physician workforce is undoubtedly the foreign- trained doctors on staff. Foreign-trained physician's makeup a significant portion of the Canadian workforce, with 23% of Canadian doctors graduating from a foreign medical school5. However, an impediment to foreign doctors practicing in Canada is the difficulty of having their qualifications recognized here. Certain foreign specialists, many of whom may have been practicing for years, are required to re-enter a Canadian residency program and recertify as a member of The Royal College of Physicians. Rather than spend a significant amount of time retraining, over 5-years in many cases, many of these doctors gravitate toward residencies in family medicine, a two-year endeavour. This discrepancy in recognizing qualifications has helped to establish a trained population of family physicians with prior specialization. At Shawville Hospital, there are foreign-trained gastroenterologists turned family doctors performing gastrointestinal scopes while they also manage their own family medicine clinics. The same physician may also cover emergency shifts in the emergency room, a heterogeneity of practice not seen in the city. Although Québec has the lowest proportion of foreign-trained doctors in Canada at 11%, the foreign-trained specialist adds a defining flavour to this rural medicine centre5.

Rural family physicians practicing at hospital centres must be proficient in a variety of procedures. The society of rural physicians of Québec published a manual of rural practice, which is a textbook penned in part by one of the Pontiac Medical Centre patriarchs, Dr. James Wootton.7 This manual describes a wide variety of medical procedures such as casting, breech deliveries, skin grafts and even burr holes. However, all those procedures are described in a rural context. According to the manual, rural populations are older, sicker and less afluent.7 Medical transportation is not always readily available, and thus the rural generalist must be proficient in a multitude of procedures with a variety of additional tools highlighted by this manual. The manual discusses several invasive procedures, performed in a variety of ways, leaving room for the variation of supplies and techniques. Each procedure is paralleled by a commentary or a story from an experienced rural physician. They describe the procedure and even highlight some important differences between rural and urban equipment.

A substantial proportion of the family doctors in rural areas are transient workers. In a recent Québec survey of rural practitioners, out of 145 family physicians; eighty were locally settled full-time staff, while twenty-four were regional physicians living in bigger cities, and forty-one were on part time locum8. Furthermore, a deficit in full time specialists in rural centres often mirrors a deficit in the state-of-the-art equipment that is often taken for granted in urban tertiary care centres. While all necessary medical devices are well stocked and equipped, much of the specialized accoutrement of urban centre medicine is lacking. This understandable specialists and certain technologies puts the onus on the family practitioners to be highly resourceful. A survey of rural emergency room across Québec by Fleet et al. indicated that approximately 74% of rural centres have access to computed tomography scanners, and 78% to general surgery services, and that rural areas have fewer medical specialists9.

In Shawville, the decision whether to treat more complex cases in hospital, often reserved for critical emergencies, or transfer to the larger hospital in Gatineau, can be a matter of extreme morbidity and mortality - of literally life and limb. When the medical decision tree indicates immediate treatment, ingenuity is often required. Again, citing the Manual of Rural Practice, rural physicians must be true generalists7. The burr hole can be a lifesaving procedure that the ruralist should be familiar with. While surgical drills and neurosurgical devices may be standard medical devices in the city, similar outcomes can be achieved with regular hardware store bits when a true emergency presents itself and you are hours away in bad weather from a tertiary care centre1. The necessity for adaptation, paired with a veritable pantheon of medical skills and broad knowledge set, are fundamental to rural hospital practice.

The Pontiac Hospital Centre experience is an exercise in scope and adaptability. The family doctors who practice in Shawville manage a patient population with a high burden of chronic disease. Tobacco use, poor nutrition, obesity, hypertension and diabetes present with high incidence in Shawville7. With population health requirements expanding into obstetrics, emergency, psychiatry and dermatology, the practice of rural medicine must rise to match these needs. This variety of practice, without the ability to readily consult other services in the same capacity as in the city, puts the onus on family doctors to broaden their skills across diverse fields and specialties. The true generalist of yesteryear is alive and well, and they reside in Shawville, Quebec.



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