Northern Ontario doctors face ‘hidden crisis’ of emotional distress amid staffing shortages

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In the small town of Mindemoya, Ont., on Manitoulin Island, the hospital has struggled to keep a full staff of doctors for years.

Since the late 1990s, Mindemoya Hospital has had funding for six full-time physicians, a number that has remained unchanged despite growing patient volumes and increased complexity from an aging population, many of whom are Indigenous, along with opioid and mental health crises that increased during the pandemic.

It currently has 4.75 positions filled and has rarely been able to keep six doctors over the past several years, according to Maurianne Reade, a family physician in the town since 2001.

“We’ve been really running on open adrenaline for the last three years and we just can’t do it anymore,” Dr. Reade said.

In Northern Ontario, the burden of the doctors’ shortage is felt much more acutely than in other parts of the province. Rural doctors are responsible for both primary care in their family practices and emergency care in the hospitals.

“In rural settings, and certainly that’s the majority of the communities in Northern Ontario, family physicians may be the only physicians in the community,” said Sarah Newbery, a rural physician in Marathon, and associate dean of physician workforce strategy at NOSM University, the school of medicine in Northern Ontario.

Keeping emergency rooms open becomes the priority, often requiring doctors to close down family practices and to work overtime. This causes what many doctors refer to as “moral injury” – the emotional and psychological distress they experience from being unable to deliver the level of care they know their patients deserve.

“If the emergency room closes and there’s a bad patient outcome as a result of that – for family physicians to have to live in the community knowing that a community member suffered because they couldn’t pick up one more shift – that’s a big burden to carry emotionally,” Dr. Newbery said.

“What I hear from colleagues is that it is easier to leave than to stay in the community as the very visible face of health care services and not be able to meet the need.”

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Dr. Reade on Manitoulin Island said the burden to keep emergency rooms open as it becomes harder to recruit physicians is a “hidden crisis” affecting Northern communities in the province.

There is currently a shortage of more than 200 family doctors in Northern Ontario, according to the Ontario College of Family Physicians. Every month, there are hospitals that find themselves unable to fully staff emergency rooms. If an ER has to close, the next one might be two hours away.

Across Northern Ontario, 38 communities with seven or fewer physicians are part of a funding model called the Rural and Northern Physician Group Agreement (RNPGA), negotiated between the provincial government and the Ontario Medical Association.

The agreement was first conceived in 1996 but has not been “meaningfully reviewed between 2012 and 2020,” Dr. Newbery said.

The RNPGA is a misnomer, she said. It is supposed to be a “primary care contract,” but it also applies to communities with hospitals, which provide in-patient and emergency care, as well as minor surgical services. “It is really a comprehensive medical services contract and should be seen as such,” she said.

In the town of Atikokan, about 200 kilometres northwest of Thunder Bay, the RNPGA is cutting the number of physicians from seven to five for a population of about 3,800.

This means if a physician moves away or retires, they will not be replaced, said Sara Van Der Loo, chief of staff at the Atikokan General Hospital.

While the community is stable with seven physicians, they are seeking a dispute process against this staff cut.

Having worked as a rural physician for 18 years, Dr. Van Der Loo has seen what happens with fewer doctors. Between May, 2015, and March, 2016, she was one of only two doctors in the community, and the only one able to cover the emergency room full-time.

Since the ER always requires a back-up doctor, who cannot be a locum (a temporary physician), she needed to be on call 24 hours a day, seven days a week.

In terms of the number of doctors needed in Atikokan, Dr. Van Der Loo said: “Seven is is ideal. Six is is good. Five is always on the edge of problems.” If a doctor gets sick or takes a holiday, a locum should be able to cover it but seldom are locums available when needed, creating a “snowball effect.”

Ontario’s Ministry of Health says it is mindful of providing medical service in the communities where it is most needed.

The ministry and the Ontario Medical Association “jointly conducted a full physicians complement review for all 38 RNPGA communities,” as part of the 2021 Physician Services Agreement and determined physician numbers in each community based on the “right sizing,” ministry spokesperson Hannah Jensen said in a statement to The Globe and Mail.

This, Ms. Jensen said “resulted in an overall increase of physician complements in rural and northern communities.”

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Dr. Reade said Mindemoya Hospital has advocated for substantial increases in physician numbers owing to the “intensity and volume” of their work, but she said they were told “that the predominant metrics of success relate to seeing patients in the office.”

“By these metrics we were doomed to failure, precisely because we have kept our emergency and hospital open throughout the pandemic to care for those in need,” she said.

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Dr. Van Der Loo said the decision to close emergency rooms falls on the physicians themselves. “The reality is none of us want to be the one that says we’re too tired to work another shift or we have to take holiday.”

“If somebody’s cancer diagnosis is delayed because you didn’t order their mammogram because you were working emerge, it’s too much and that’s the part that starts to fall apart,” she said.

She said one of the reasons moral injury is having an impact more in Northern Ontario is because of the dual role that rural doctors play. In Southern Ontario, there is a separation between family practices and emergency departments.

“The family doctor’s office doesn’t close because someone had to work an extra shift in emerge in Toronto. It does in Red Lake. It does in Dryden. It does in Kenora. It does in Atikokan,” Dr. Van Der Loo said.

The fact that emergency rooms haven’t closed is often viewed as a success, she said. But it’s only because doctors are working overtime to ensure that doesn’t happen. “I’m going to work until I drop and that’s not safe and it’s also very much not fair.”

Working to exhaustion has an impact on doctors’ mental and physical health, but it also affects their families, she said, recalling a time when Dr. Van Der Loo was working so many shifts her kids were not used to seeing her at home around the dinner table.

“I love my job but I love my family and that’s very sad to hear your children say that.”

Editor’s note: This article has been updated to express more fully the range of challenges facing health care professionals on Manitoulin Island.