With psychiatrists in rural areas aging and demand rising, Canada is grappling with a crucial challenge: how to lure the next generation of doctors out of cities.
Pitching a rural practice to a pool of young specialists educated mainly in major centres needs to start early in medical school, experts say, and perhaps with a push: more mandatory time spent in northern locations, and more training in how to deliver telepsychiatry to smaller communities.
A Globe and Mail analysis found that the country’s psychiatrists are heavily concentrated in urban areas, with more than one third in Toronto, Vancouver and Montreal. Many regions have no permanent psychiatrists at all, a problem that will grow as more psychiatrists enter retirement age with no replacements.
Young doctors, who primarily study in big cities and often do their residencies at academic hospitals, aren’t rushing to small towns and more northern parts of the country. A 2016 study published in the Canadian Journal of Psychiatry that surveyed Canadian psychiatry residents found that 69 per cent were interested in practising in large urban centres, compared with 29 per cent who expressed interest in rural medicine.
David Cochrane, who has been a hospital-based psychiatrist in North Bay for 25 years, concedes it is a lot to ask a new psychiatrists to come to an area where they will have few colleagues and limited support staff – which is why hospital-based psychiatrists push for more team-based work and better funding for services such as psychotherapy.
Big-city psychiatry “tends to attract individuals who want a better work-life balance and don’t want to be on call, and that puts us behind the eight ball," Dr. Cochrane said. But there are perks, too, he points out, ones residents may not value unless they spend time in a smaller community: less bureaucracy, room to innovate, the chance to treat a wide range of patients.
The Ontario Psychiatric Association has suggested that increasing pay in rural areas would attract more psychiatrists. But Dr. Cochrane suggests an even more important step is training more psychiatrists who come from smaller towns and complete their residencies in those areas. This is similar to approach of the Northern Ontario School of Medicine (NOSM), which opened seven years ago with campuses in Sudbury and Thunder Bay. NOSM is now training 15 psychiatry residents and has graduated four psychiatrists, three of whom remained in the region.
Studies in Australia and New Mexico, for instance, have found that the more time psychiatric residents spend training in smaller communities, the more likely they are to remain there when they begin practising.
Some of Canada’s medical schools do require students to do training in rural communities, but those requirements vary widely in length and timing, as well as the definition of “rural.” For instance, one psychiatry resident of the University of Toronto said that Barrie, Ont., a city with a population of more than 150,000 and 100 kilometres from downtown Toronto, counted as a rural elective.
Saadia Sediqzadah, who will finish her psychiatry residency this year at U of T – where one quarter of the country’s psychiatrists study – says she could have completed her medical degree and residency in Toronto, without ever being required to work in a smaller community. (The University of Toronto has recently added a requirement for psychiatric residence to do rotations with “underserved” populations, but those may still be completed in the city.)
As an elective, Dr. Sediqzadah recently finished a short stint in Iqaluit. She was reluctant to go: “I thought I would be left totally alone with very complicated cases and no support.” Instead, she encountered a collaborative team of counsellors and nurses able to offer patient histories and provide follow-up care. She has accepted a job at St. Michael’s Hospital in Toronto, but is now applying to work as a regular temporary psychiatrist in Iqaluit – a job she wouldn’t have considered if she had not first travelled to the North. “How do you know you like it if you don’t try it?” she asked.
The requirement to spend time in a smaller cities and towns during her medical school degree at the University of Western Ontario helped North de Pencier, now a first-year psychiatry resident at the University of Toronto, see herself in a rural community at the start of her career. Raised in Ottawa, she wasn’t sure she’d like the small-town lifestyle, but she came to appreciate the collegiality of a small hospital and the opportunity to get a wide-range of clinical experience. “I had a spark of interest at the start of medical school, but having all these experience makes it seems a lot more real and feasible,” said Dr. de Pencier, working regular shifts in Parry Sound, Ont., during her Toronto-based residency.
If young psychiatrists won’t, or can’t, go to smaller communities, the next best solution is to stream them in with technology, suggests Antonio Pignatiello, a University of Toronto psychiatrist and the Medical Director of TeleLink Mental Health Program at The Hospital for Sick Children.
Learning how to conduct video consultations with patients in remote communities can also make residents more familiar with the needs in those communities and with building relationships with the local staff. (In research, telepsychiatry has been found to be a cost-effective approach, well-received by patients, but more hesitantly adopted by clinicians.)
Dr. Pignatiello says the training should be mandatory and more extensive than what is offered now, and that psychiatrists need to see telepsychiatry as central to their practice. In fact, Dr. Pignatiello suggests it should be a mandatory chunk of their clinical work. “It needs to be second nature,” he said.
For Sarah Levitt, who completes her psychiatric residency this year, telepsychiatry has become second nature. At U of T, along with time working in Northern communities, she elected to do two six-month rotations that involved training in telehealth – well beyond the mandatory requirements of a couple of consultations. By combining both on-the-ground knowledge of a community and the ability to support a rural team with telepsychiatry, she imagines at some point having a practice that may locate her in Toronto, while working half time in rural medicine.
It can be intimidating going into places with overwhelming need, she said, which makes strong mentorship important. “There is so much to learn” in smaller centres, she says, including how to be nimble with challenging cases, flexible in a team and mindful of cultural context – such the mental-health consequences of climate change in the North. Acquiring those skills made her a better doctor, she said, wherever she practises.