"Northern, rural, isolated..."

Introduction

Dease Lake has the most northern, rural, isolated health care centre in the province, far more isolated than Fort St. John or Dawson Creek. It also happens to be the community that I know best, as far as health care in isolated areas is concerned, as I have been going there since the mid-1980s. Therefore I have used it as the example for this article. However, for those who work in other areas, simply supplant the name Dease Lake with the name of your community or facility, and we will be on the same wavelength.

The first clinic in Dease Lake, a joint project of the BC government and the BC College of Family Physicians, opened in 1981–82. I became part of a regular rota of family doctors who went up for a month every year or so. By the time the community had opened its own Stikine Health Centre in 1994, I was the identified medical director of that clinic (read: trouble-shooter) for the BC College of Family Physicians.

Stikine Health Centre also serves four First Nations reserves: IR9, just a few miles out of Dease Lake; Telegraph Creek, a spectacular 2-hour drive up and down three immense canyons including the Stikine; Iskut, 80 kilometres south on Highway 37; and Good Hope Lake, 11/2 hours north.

For many years, there was agitation with the Ministry of Health because the doctor might only see 10 or 15 patients a day. However, that doctor was also on call 24-hours-a-day, 7-days-a-week, which is fine if one is there for a month or 6 weeks, but impossible if he or she is the only doctor for months on end. That same doctor might work all day in the clinic (a busy day: 18 people), be called out twice during the night, drive to Telegraph Creek the next day, get back at supper time, be called out again once or twice during the night, be in the clinic all day Wednesday, and take care of a major MVA with four badly hurt people that night. The numbers aren’t the story; the hours are the story. This epitomizes what it is like to provide health care in truly northern, rural, and isolated areas.

The Stikine Health Centre has beds to accommodate, in a pinch, four people overnight. However, it means that someone has to be there all night—usually the nurse; that means that if there is only one nurse on staff, there is no nurse in the clinic during the next day. The full complement is two doctors and two nurses—Utopia!

General problems

Medivacs
In the early years it was fairly common to find oneself arguing with a medivac dispatcher who was 1700 kilometres away about whether a patient needed to be evacuated. This was understandably exasperating for the doctor at the scene.

The medivac situation has improved tremendously and it is unusual to have to argue anymore (although still not unknown). The airport at Dease Lake has a great landing strip sufficient to accommodate a small jet, but has no tower. This used to present a problem after dark, but that problem also seems to have been solved, and a turbo-prop plane can now land in the dark, aided by floodlights on the runway. I am sure, however, that similar problems regarding night medivacs still occur in other northern, rural, and isolated areas.

On the other hand, if one cannot acquire an air medivac due to darkness or fog or driving snowstorm or the fact that all the planes are flying somewhere else, the drive to Terrace Hospital, which is the nearest referral hospital for Dease Lake in BC, is a painful and time-consuming 61/2- to 7-hour journey. There is Watson Lake Hospital, a mere 31/2 hours away, but that is in the Yukon and generally Air Ambulance Services would prefer to keep the patient in BC. Exceptions might be made in life-threatening circumstances. It is also a small hospital with very limited resources.

There are similar transportation problems for some of the small island communities on our long, convoluted coastline, where finding a water taxi to transport a very ill patient may be difficult and finding an airplane even worse.

Recruitment
Recruiting for medical personnel to work in northern, rural, and isolated areas is a daunting task. HealthMatch BC does a superb job, but the roadblocks are enormous. They range from getting through the demands of the College of Physicians and Surgeons, if the prospective physician is from out of the country, to having available and affordable housing and schools. As many doctors serving in northern, rural, and isolated areas come from other countries, any idea of charging a huge tax for schooling would eradicate most applicants.

It takes a certain personality type to enjoy working in such small centres. Usually it means that he or she likes the outdoor life; this is important, especially in the winter in order to avoid cabin fever. The candidate must also be very self-sufficient emotionally. It is best if there is a family, or at least a significant other, because socializing in the community can be dicey. Does one go to the local bar? Only see others in the medical or government fields? Risk getting involved romantically? Access to religious and spiritual support may be a significant factor.

There is a great need to educate upcoming young physicians about working in northern, rural, and isolated areas, which the Faculty of Medicine at UBC is addressing by extending teaching sites into appropriate small hospitals. One cannot learn rural medicine at the Vancouver General Hospital. Even Prince George is too big a city; but an exceptionally fine rural hospital such as the one at Hazelton is uniquely equipped to undertake this crucial role. It is also close to being northern and, while not exactly isolated, it isn’t in the middle of an outlying metropolis, either. However, apparently closing Hazelton Hospital is on the agenda because its services overlap those offered at Smithers. I feel that this is shortsighted to an extreme degree and may shorten the life of the Rural Program past the resuscitation stage. I think, however, that accrediting a facility such as the Stikine Health Centre would be a very positive step. (But then, funding for that might bring more problems.)

It is also important to encourage new doctors-in-training who come from rural areas to go back to rural areas. Perhaps a scholarship (or some other incentive) to do so for a certain period of time could be established. There are rumors that this is happening.

More and better evaluation of the lifestyle of applicants needs to be done, and actively promoting the opportunities of any particular facility (outdoor activities—hiking, skiing, fishing, etc.) with cross-referencing the applicants’ interests, is vital for successful placement.

Funding
There are many problems regarding funding for tiny community health centres and diagnostic and treatment centres. The main problem, of course, is that they are tiny and serve only a small group of people. Unfortunately, the message being perceived by rural British Columbians now is “If you don’t like it, move.” This is disrespectful. Why should people move when they have been living in an area for decades? Or for generations? That message angers many people, including those of us who go to work in such areas.

The small community of Tahsis on Vancouver Island is a good example. The community is struggling to survive by enticing retired people to live there; it is certainly one of the most beautiful areas on this most beautiful island. But with no full-time doctor, and the nearest one 2 hours away, there’s no chance that retirees will consider it. That seems to be the way health care is going in this province, and it’s sad.

Cultural aspects
Differences in cultural patterns often distract from the basic, important aspects of some health problems, and we need to be sensitive to these. Also, we have, over the decades, created dependency where it was never to be found before, greatly to the disadvantage of aboriginal peoples.

Problems with the elderly and disabled
Senior and disabled persons may get short shrift in northern, rural, and isolated areas because there are simply not enough people to do the work. When community members do need institutional care, they are taken away from their families to a strange place. The caregivers are kind and do their best, but the workload is heavy and time for individual attention is at a premium. Similarly, when someone has to be transferred to a city hospital hundreds of kilometres away from family and the usual social supports, depression all too often ensues and may complicate the recovery process immeasurably.

Youth problems
In the same vein but at the other end of the age scale, the youth in these isolated communities feel that they have nothing to do, which translates into alcohol and substance abuse, car racing, and other thrill-seeking activities. The suicide risk is appallingly high.

Some possible solutions

I do not believe that the answer lies in the draconian cuts that seem to be happening. That only serves to further isolate these communities. I believe it lies in more creative solutions.

Methods of payment
The first possible solution to these problems is salaried physicians. That is the case at Dease Lake, but not so at, for example, Tumbler Ridge, which has lost excellent physicians because it is impossible to live on a fee-for-service basis with such a small population. (Another complication is the high cost of living in such areas.) To reiterate earlier statements, a single physician cannot function alone, even though the population is small; it works for a month, or even two, but not for a year or more. Sessional fees are another possibility to consider.

Physicians’ assistants
With the relative difficulty in acquiring good nurses and good physicians, it is hard to understand the reluctance to use physicians’ assistants (PAs). Most of them are trained in the military and their education is superb. One argument is, “But we don’t even know what their training is! Anyway, it’s all about battle-field trauma!”

That sounds like protectionism; it would be very easy to pick up a telephone and find out what the training courses are all about. PAs are excellent diagnosticians, take thorough histories, have a very good grasp of medications, recognize infections, are superb in major trauma situations such as multi-injury motor vehicle accidents, and—best of all—can help out both with nursing and doctoring. In an isolated area with one nurse and one doctor, such a person can be invaluable. I know, because I’ve been fortunate enough to have had a PA when I have been in such a position, all by myself for more than 10 weeks. With one doctor, one nurse, and one PA, the problem may be solved.

Burn-out and cabin fever
Reasonable respite through appropriate R&R arrangements are crucial to the mental and often physical health of the health care professionals. A long weekend every 3 months is not too much to consider and can usually be arranged. If there is only one physician in the community, a long-weekend locum service needs to be available. The physician on respite should not lose salary over this arrangement.

Changes in policy

There are other areas where changes in policy might improve patient access to good care.

GP psychotherapy
British Columbia does not have a fee schedule item for “GP psychotherapy,” which is another solution and saves money as well. I don’t know whether this problem is rooted in various sections of the BCMA or with the government because of global budget. If it is budgetary (which it surely is), it is very shortsighted. GP psychotherapy works in the other provinces, so it is hard to understand the reluctance. As it is, a family doctor who is on fee-for-service cannot afford to spend 45 minutes or an hour with patients, weekly for months, when he or she is reimbursed by (perhaps) one 0110, four 0120s for critical situations such as suicidal ideation or depression, and then 0100s. Most of us could not meet our overheads in urban practices in such a situation; in a rural practice with small populations, or in a diagnostic and treatment centre, when the reimbursement is so small (but the need is so great!) it is unrealistic. As a side benefit, this would be of great help to many patients who do not really need a psychiatrist but who cannot afford a psychologist. The emotional and psychological problems of northern, rural, and isolated areas make the topic even more timely.

From personal experience, I know that Criminal Injuries will also not accept a GP psychotherapist, no matter how experienced or how many professional testimonials are provided, and I am presuming that that will remain the policy now that it is under the umbrella of the Attorney General’s office. Of course the family doctor involved would have to verify that he or she had the training and experience to qualify for the title.

Rivalries
There seems to be an inability of provincially funded and federally funded health services to work in partnership and unity in order to provide quality service without wasting overlapping dollars. Rivalries do not produce good health care, which is what it is supposed to be all about. Rather, the community boundaries seem to be more important than the community health. The same could be said for health care based on provincial borders.

Regional health care units
The new arrangement of five huge regional health care districts plus a provincial unit, instead of the previous 11 (plus, let us remember, 34 health councils and 7 community health service societies that worked with the health councils), has done nothing to help the isolated areas. If anything, it seems to have made the situation worse. Prince George may as well be Tokyo as far as Dease Lake is concerned (and vice versa), and it is, as I previously remarked, a fairly large city in the middle of the province—in fact, a little south of the middle of the province. This is not to blame the people in Prince George, who are doing their best. It just adds more isolation to the northern health care facilities. For one locale to be responsible for everything north of Quesnel is ludicrous. The whole Stikine area, for example, is larger than France. It may even things out population-wise, but people-wise, it adds many problems, especially diluting the human resources to skeletal levels.

The provincial unit oversees those services that are province-wide in scope—cardiology and neurology services, cancer and dialysis, and other tertiary services. The impression, however, is that because of reorganization, the regional units have lost both clout and money.

Complementary and traditional medicine
The whole arena (that is not a misprint) of complementary medicine is in a similar situation. If Alberta can come to terms with it, then surely BC could also. In the mid- to late-80s, I served on so many ad hoc committees, task forces, and focus groups that I finally gave up. In my case, it was accepting the fact that, for 45 minutes of therapeutic hypnosis, I would get an 0100. However, I did have the pleasure and honor of being a representative for the College of Family Physicians on the Federal Health Protection Branch ad hoc committee regarding botanical medicines, which ultimately resulted in a third category (neither food nor drug) for many of these products.

In many northern and rural and isolated areas, the traditional medicine of First Nations people must also be encompassed in a more knowledgeable and accepting manner.

Improved understanding of communication patterns
Patients come late or miss appointments without notice and may not understand why the doctor or nurse is crotchety. Many aboriginal people are not going to tell you their problems the first time you see them, especially if those problems are psychological or emotional and they don’t know you. One may not get much of a story the second time, either. And the recounting is usually in a slow manner, with many repeated phrases. That’s just the way the communication goes. Those of us who are used to communicating differently need to simply sit back and appreciate it.

Problems with the elderly and disabled
The First Nations people traditionally took much better care of their elders, and still do; perhaps our best bet is to facilitate these traditions, as already happens in some communities.

Final notes

I have focused on the northern aspect because of the extra dimensions of climate and culture that it brings. However, the other aspects of this article can be found in all communities that are rural and isolated.

Many of the situations described here lead to contemplation of mental health care in northern, rural, and isolated areas. That, however, is a complex topic for another time.

Competing interests
None declared.

Marlene E. Hunter, MD, FCFPC

Dr Hunter has worked intermittently for many years in a very small community in the far northwestern corner of British Columbia. She is the director of the LabyrinthVictoria Centre for Dissociation in Victoria, BC.