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Why incentives to attract more physicians to rural areas may be failing

 A version of this commentary appeared in the National Post, Huffington Post and the New Brunswick Telegraph Journal

How do we get more doctors to practice in rural communities?  This has been a long standing challenge in Canada — getting physicians to work where we need them — especially in provinces with large rural populations.  Policy makers have created and implemented some promising solutions, but until recently, there has been little evidence on whether or not the solutions are working.

Unfortunately, new research indicates that some programs aimed at retaining doctors in rural areas across the country may not be as successful as we’d hoped.

Almost all provinces and territories in Canada offer “return-for-service” agreements to attract and retain physicians in rural and underserved communities.  Known by many names (including conditional scholarships, return-in-service bursaries, loan forgiveness programs), these agreements provide medical students and post-graduate residents with financial support for a commitment to practice in an underserved community, usually for one year for each year they receive support. Physicians have the option to pay back their funding if they can’t complete their service commitments.

Return-for-service programs are seen as a key tool in addressing physician shortages, so much so that both the Conservatives and the Liberals promised a return-for-service program during the last federal election, and the current federal government is rolling out their own program later this year.

In a study published recently in Healthcare Policy, my colleagues and I found that most medical trainees who take return-for service agreements in the province of Newfoundland and Labrador complete their service commitments in full. Moreover, return-for-service physicians stayed in these underserved communities for the long term (up to ten years after their required service).  We also found that return-for-service physicians were less likely to leave these communities than their counterparts who did not hold similar agreements.

Sounds pretty good, right?

Except that we also discovered that most physicians who choose to take return-for-service agreements wanted to work in these underserved communities in the first place.

Rather than finding new physicians who were uninterested in working in rural Canada, in Newfoundland and Labrador, these agreements appear to be encouraging already interested physicians to stay the course.

Our study also uncovered another important finding: of the 20% of physicians who defaulted on  some or all of their return-for-service contract obligations, more than half were international medical graduates (IMGs) — physicians who graduated from a medical school outside of Canada.

Why might this be the case?  IMGs are obligated to take a return-for-service agreement in order to obtain a residency position in Canada, which is a necessary step for full licensure.  In other words, their return-for-service commitments aren’t really as ‘optional,’ as with Canadian graduates.  Results from our study suggest that few of these physicians go on to complete their service commitment or pay back their funding.

Using international medical graduates to fill physician shortages in rural communities is nothing new.  In fact, many IMGs start their careers in Canada working under special licenses that allow them to work only in underserved areas.  However, requiring IMGs to take return-for-service agreements will likely do little to stop the revolving door of short-stay physicians in rural communities.  It is a stop gap, not a solution.

In 2013, the federal government will introduce its own “return-for-service program” to encourage physicians and nurses to work in underserved communities.  Physicians can qualify for the program’s financial incentive ($8000 student loan remission each year for up to 5 years) if they work in “eligible” communities, defined in the federal program generally as a rural community with a population of 50,000 or less that is not near a large urban center.

Unlike provincially run programs, the federal government’s program does not require physicians to coordinate their “return” community with provincial planners so eligible communities may not necessarily be considered underserved from the local perspective.

Without meaningful coordination, provincial and federal return-for-service programs may end up being counterproductive and do little to resolve the physician shortages they hope to address.

And without meaningful follow up studies, the new federal program, like similarly structured provincial and territorial programs, may look good on paper, but fail to retain doctors in underserviced areas over the long-term.

Problems with physician shortages in rural regions in Canada have existed for a long time.  Isn’t it about time we had a better idea about what actually works?

Maria Mathews is an advisor with EvidenceNetwork.ca and a Professor of Health Policy/Health Care Delivery at Memorial University of Newfoundland.

February 2013

This work is licensed under a Creative Commons Attribution 4.0 International License.