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Improving access to needed medical services in rural and remote Canadian communities : recruitment and… Barer, Morris Lionel, 1951-; Stoddart, Gregory Lloyd, 1948- Jun 30, 1999

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Improving Access to Needed Medical ServicesinRural and Remote Canadian Communities:Recruitment and Retention RevisitedMorris L. BarerGreg L. StoddartJune 1999Centre for Health Services and Policy ResearchThe University of British ColumbiaDiscussion paper prepared for Federal/Provincial/Territorial Advisory Committee onHealth Human Resources.  The views expressed herein are those of the authors and do notnecessarily reflect the opinions of any member of the Advisory Committee.Canadian Cataloguing in Publication DataBarer, Morris Lionel, 1951-  Improving access to needed medical services in rural and remoteCanadian communities  (Research reports / Health Human Resources Unit ; HHRU 99:5)  ISBN 1-894066-94-41. Rural health services—Canada.  2. Physicians—Supply anddemand—Canada.  3. Physicians—Recruiting—Canada.  I. Stoddart,Gregory Lloyd, 1948-  II. University of British Columbia. HealthHuman Resources Unit.   III. Title.  IV.  Series: Research report(University of British Columbia. Health Human Resources Unit) ;HHRU 99:5.RA771.7.C3B372 1999 362.1’04257’0971C99-911117-5iHEALTH HUMAN RESOURCES UNITThe Health Human Resources Unit (HHRU) was established as a demonstration project by theBritish Columbia Ministry of Health in 1973.  Since that time, the Unit has continued to be fundedon an ongoing basis (subject to annual review) as part of the Centre for Health Services and PolicyResearch.  The Unit undertakes a series of research studies that are relevant to health humanresources management and to public policy decisions.The HHRU’s research agenda is determined through extensive discussions of key current issuesand available resources with the senior staff of the Ministry of Health.  Various health careprovider groups participate indirectly, through on-going formal and informal communications withMinistry of Health officials and with HHRU researchers.  Research is undertaken by sevenprofessional staff, including secretarial and analyst support; Arminée Kazanjian is the AssociateDirector and Principal Investigator for the Unit.Three types of research are included in the Unit’s research agenda.  In conjunction withprofessional licensing bodies or associations, the HHRU maintains the Cooperative Health HumanResources Database.  The Unit uses these data to produce regular status reports that provide abasis for in-depth studies and for health human resources planning.  The Unit undertakes moredetailed analyses bearing on particular health human resources policy issues and assesses theimpact of specific policy measures, using secondary analyses of data from the CooperativeDatabase, data from the administrative databases maintained under the HIDU, or primary datacollected through surveys.  The HHRU also conducts specific projects pertaining to themanagement of health human resources at local, regional and provincial levels.Copies of studies and reports produced by the HHRU are available at no charge.Health Human Resources UnitCentre for Health Services and Policy Research#429-2194 Health Sciences MallVancouver, BCV6T 1Z3Ph:  (604) 822-4810Fax:  (604) 822-5690email:  hhru@chspr.ubc.caURL:  www.chspr.ubc.caiiAcknowledgementsWe wish to thank the many individuals who took the time, on short notice, to respond toour requests for information and share with us their candid views on the issues and policyoptions in this discussion paper.   The responsibility for the views expressed herein is oursalone.About the AuthorsThe authors are experienced researchers and policy analysts in the field of medical humanresources.  Morris Barer is the Director of the Centre for Health Services and PolicyResearch and a Professor in the Department of Health Care and Epidemiology at theUniversity of British Columbia.  Greg Stoddart is a Professor in the Centre for HealthEconomics and Policy Analysis and the Department of Clinical Epidem ology andBiostatistics at McMaster University.  Both are also members of the Population HealthProgram of the Canadian Institute for Advanced Research.  In 1991 they wrote thecomprehensive report T ward Integrated Medical Resource Policies for Canada.iiiTable of ContentsAcknowledgements iiAbout the Authors iiPreamble 1Section I: Introduction and Background 2Why does the problem persist? 2Is this persistent problem uniquely Canadian? 5What did we say about this problem in our 1991 report? 6Section II: Commonly Offered Policy Solutions 8Why not continue to carry on as we have been? 8Would increasing medical school enrolment help solve the current problem?9What about billing number allocations or other similar regulatory/administrativeapproaches? 11Will financial incentives for rural and remote practice help? 13Why not increase the recruitment/entry of foreign medical graduates (FMGs)? 15Why not use the licensure process to channel physicians to where they areneeded? 18Is a nationally-based return-of-service program worth considering? 19What scope is there for increased emphasis on educational initiatives?21Is there scope for re-examining the mix of residency opportunities? 23Don’t professional support programs help? 24What about family/spousal support initiatives? 26How does the present organization of medical care help or hurt therural/remote situation? 27Section III: Future Directions 29Where do we go from here? 29Rethinking the purchasing arrangements for medical care 30Increased training and use of non-physician personnel 33New responsibilities for academic health centres 35What’s the bottom line? 37ivPreambleThis discussion paper addresses the problem of improving access to medical services inrural and remote communities in Canada, and reviews policy options for addressing thisproblem.  It is written in a question-and-answer format appropriate for a wide generalaudience.  The questions cover a range of topics including some of the history of theproblem, approaches which have been used in Canada and elsewhere, assessments of theseapproaches, and the scope for further policy development in this area.Our assignment was to revisit the analysis of geographic maldistribution of physicians inour 1991 report, Toward Integrated Medical Resource Policies for Canada, and to re-assess current policy options in this area, in the context of emerging access issues in ruraland remote areas of the country.  We draw on a comprehensive recent review of theseissues contained in a just-completed companion report by Barer, Wood and Schneider,Toward Improved Access to Medical Services for Relatively Underserved Populations:Canadian Approaches, Foreign Lessons (available from Health Canada).  Among otherthings, that report contains for each province and territory detailed descriptions of policiesdesigned to address access in rural and remote areas.Although we are aware that concerns about access to care are surfacing in some urbanareas, an analysis of these situations was not our assigned task.  Nevertheless, some of thepolicy directions we identify in section III of this paper are relevant to the urban context aswell.Given the compressed time frame, this discussion paper is not intended to be acomprehensive research report.   Rather it is an attempt to integrate the history of theproblem and the new understandings revealed by experience since 1991 into an updatedanalysis of policy options for improving access in rural and remote areas.The discussion paper begins with our assessment of why improving access to neededmedical services in rural and remote areas is such a persistent policy problem.  We thenbriefly review our 1991 analysis.  In section II we address a series of questions, each ofwhich represents a commonly offered policy solution in this area, based on what arewidely understood to be the major policy levers.  We begin with the question of whethercontinuing as we have been would be a  productive policy approach (we think it would notbe).  Readers will find that our assessment of accumulated policy experience leads us toconclude that most of the commonly advanced policy ‘solutions’ hold limited potential.We shift gears in section III, where we discuss three general policy directions that, in ourview, continue to hold considerable unexplored potential.   Our intent is to stimulatediscussion and further consideration of these directions, because it seems clear that realprogress will require real change.2Section I:  INTRODUCTION AND BACKGROUNDWhy does the problem persist?Canadians living in rural and remote areas of the country have always found physicianservices less accessible than their city-dwelling counterparts.  The problem is as old aswritten commentary on physician resource issues in this country.  For the most part, thereasons are no mystery – there is a fundamental mismatch between the needs of rural andremote communities on the one hand, and the needs and choices of (and influences on)those who become physicians on the other.  There are many communities across thiscountry that are simply too small to support a general practitioner, or that are largeenough to support one, but too small to support two or three, let alone the full range ofspecialists found in large urban centres.  For their part,  most Canadians who are acceptedinto the medical schools across the country have grown up in urban settings; the bulk oftheir medical training occurs in urban settings; that training takes place largely in tertiaryhospitals which are only found in urban settings; much of the training is provided byphysician-educators who work in urban settings; there are (even in per capita terms) morepractice opportunities in urban settings; access to specialist colleagues and othercomplementary treatment and diagnostic resources are more plentiful in urban settings;hours of work are more likely to be ‘regular’ in urban settings and, in particular, callschedules are less onerous; and there are many more social, educational, recreational,employment and cultural opportunities for physicians and their families in urban settings.One might be led to wonder why any physicians would choose to practice elsewhere.Historically, relatively few have.But some do.  Indeed, some physicians seek out rural and remote opportunities, becausethey cherish the quality of life in smaller communities, or because they seek the uniquechallenges of practice in such settings.  For them, these rewards outweigh the problems.Providing medical care in rural and remote areas can be one of the most fulfilling, exciting,and challenging types of work that a physician could imagine.  And despite the inevitablepersonal and professional challenges faced by their physicians, hundreds of thousands ofCanadians across the country have been w ll-s rved by these dedicated professionals.Nevertheless, those who explicitly seek out rural and remote practice opportunities havehistorically been the exception, rather than the rule, which brings us back to why theproblem persists.   Looking at the reasons in more detail, we would suggest that they areof three types.  A first cluster of reasons are largely endemic to the setting, and by theirnature particularly resistant to policy intervention.  It is not possible for those responsiblefor physician resources policy in this country to imbue small towns with big city ‘perks’(and, indeed, most of those living in such small towns might be aghast that anyone wouldeven suggest such a thing).  For most physicians, big (or at least moderate-sized) cities arewhere they would prefer to live and work, for both professional and personal reasons.Those at the stage where they are facing decisions about where to practice rank personalfactors at or near the top of the influences on those decisions, time and time again.  Larger3concentrations of population create a greater range of educational, religious, cultural andrecreational opportunities for families, more possibility to create social networks ofsimilarly educated friends and colleagues, and a greater range of (often professional) workopportunities for a spouse.A second cluster of reasons for the persistent problem of physician service access forrural/remote populations arises out of the circumstances of practice  At least one of theseso-called “professional practice considerations” is, in the final analysis, another “personal”factor -- the issue of lack of relief, which leads to high stress and burn-out.  Everyone isaware of situations in which physicians are on-call one night in two or three, or havedifficulty taking holidays from rural communities, or even have to be on-call continuouslyin one-physician towns.  Even if on most occasions the on-call times are quiet, times whenone is on-call are qualitatively different than those when one is not.  This may ‘go with theterritory’ of rural/remote practice, but it is a key consideration for physicians decidingwhether to make that choice.Other professional considerations include relatively less accessible professional support(e.g. colleagues with whom one might discuss a troublesome case or with whom one canperform general surgery, or specialists to whom one can refer patients) andcomplementary facilities (e.g. hospital beds, diagnostic equipment and supplies), and theflexibility, convenience and funding to take advantage of continuing educationopportunities.A third key reason for the persistence of the problem in Canada is that there have always,and almost everywhere, been urban alternatives.  Although the availability of physicians isconsiderably greater (per capita) in most urban settings across the country than in mostrural/remote settings, even for general/family practitioners, new entrants have always hadan urban alternative (if not in a particular urban location, or in a particular province orterritory, then in others), and most who have made that choice have managed to establishbusy and successful practices.  Why, in such circumstances, would we expect any but thefew who are committed to the rural way of life (who will often have come from thatbackground as children) to make that choice?There is a fourth reason that has nothing to do with the nature of the settings or personalor professional circumstances and considerations.  It arises from policy decisions from therecent past.  Many rural and remote areas have sufficient population bases to support onlyfamily practitioners. As a result, the vast majority of physicians in these communities havealways been, will continue to be, and indeed should be, general/family practitioners.  Butrecent licensing and training decisions appear to have reduced the probability that anyparticular physician emerging from the Canadian undergraduate and residency trainingprograms will go on to family practice.In the early 1990s decisions taken by provincial/territorial licensing authorities in line withpositions taken by the Federation of Medical Licensing Authorities and the College ofFamily Physicians of Canada (CFPC) led to the “rotating internship” being replaced by a4two-stream choice: either a specialty residency leading to Royal College certification, or atwo-year family practice residency leading to CFPC certification.  This has had threeeffects.  First, for those who would, under the old model, have completed a rotatinginternship and gone on to family practice, a second year of training is now required.  But itappears that few internal (within academic health centr ) adjustments were made to themix of residency positions, although reallocations were recommended by the NationalCoordinating Committee on Postgraduate Medical Training.  The effect has be n  tochannel fewer residents overall into the family practice stream.Second, it is alleged by some that those emerging from rotating internships had received awider range of exposures and experiences, and so were in fact better equipped to handlethe breadth of clinical problems faced by rural/remote primary care practitioners, than aremany of those emerging from some of the current two-year family practice residencies.Third, the elimination of the rotating internship has tended to force the hand of physiciansregarding career specialty decisions somewhat earlier than previously.  While switchingspecialties during training, and re-entry into specialty training, are certainly possible anddo occur, the current system is perceived to be relatively inhospitable to changing one’smind.  For example, a young MD who under the old system might have contemplatedgeneral practice for a number of years before finally deciding which specialty to enter (andwho might possibly have chosen a rural or remote area in which to do that familypractice), now faces a much more restrictive environment; if he or she has any thoughtsabout a specialty practice, the choice is best made early – rural/remote areas may be losingout on those early years of family practice.One could argue about matters of relative competency, or about who is to blame for thereduced opportunities to train in family practice.  Our intent here is not to point fingers,but only to point out the current realities, which seem to be fewer family practice-trainedCanadian graduates, with (at least in some situations) less confidence and competence ofthe types required for rural and remote practice.  This can only add to the difficulties ofrural/remote communities.Having said all that, the effect of the policy-based reasons for the persistence of theproblem may be quantitatively relatively small.  Prior to the elimination of the rotatinginternship, about 900 new Canadian-trained physicians were entering general practice.With the advent of the family practice two year residency requirement, it appears thatabout 700 new Canadian-trained physicians now enter general practice annually.  Onaverage, about 15-20% of new family practitioners establish practices in rural or remoteareas each year.  Thus, although the ‘graduating’ complement has fallen by about 200, onewould expect the reduction in those likely to take up rural or remote practiceopportunities to have declined by about 30-40 per year, for the country as a whole.5Is this persistent problem uniquely Canadian?The problems associated with ensuring reasonably equitable access to physician services,irrespective of where one lives, are found virtually everywhere in the developed world.Indeed, it is only in geographically compact, relatively densely populated countries such asSwitzerland, Belgium and Israel, that one is unlikely to see physician distribution amongthe top few health care policy issues.In countries such as Canada, Australia, France, Germany and New Zealand, which varydramatically in size and population density, issues of appropriate access to physicianservices persist, particularly in the more remote areas.  They are found across the fullspectrum of health care financing arrangements, from the United States to Sweden.  Thispoint, perhaps more than any other, reinforces the complex and thorny nature of theissues.  In all of these countries, the geographic distribution of physicians is a policypreoccupation.  This suggests rather clearly that one will not find a magic bullet solutionhidden in any particular choice of financing health care, purchasing services, or paying ortraining providers.  Despite the fact that the problems are so widespread, a relatively smallset of generic policy approaches has emerged internationally.  None has completelyeradicated the problem.  But even within this limited menu, Canadian policy-makers  havegiven insufficient attention to some potentially fruitful avenues.6What did we say about this problem in our 1991 report?In 1991, we synthesized the literature to date on this subject, and performed  ew analysesfor the report Toward Integrated Medical Resource Policies for Canada.  Th t reportanalyzed problems and policy options in a dozen specific areas of physician resourcepolicy, including the current one, and created an analytic framework for future policydevelopment.  “Geographic maldistribution of physicians” was identified as a “first tier”problem in the report, largely because it was labeled as a major problem by almost all ofthe over 70 people (involved in a variety of ways with the physician resource sector) thatwe interviewed.  The problem of geographic maldistribution was shown to be linked withseveral other problem areas, including graduates of foreign medical schools, residencytraining and specialty certification, the role of fee-for-service remuneration, medical schoolcurricula, licensure and regulation, and global expenditure control policy.  Indeed, one ofthe over-arching themes of the report was the need to recognize the complex policyinteractions in the physician resources sector and to develop co-r inated (across bothjurisdictions and stakeholders) “policy packages.”The report summarized the basic causes as follows:  1.  Individual practitioner decisions are driven by professional incentives andpersonal lifestyle factors which strongly favour concentration in urbanpractice  settings.  2.  The selection of students by medical schools takes inadequate account of therelative need for rural physicians.  3.  Exposures and influences during training encourage urban practice.It also noted that at the same time as some Canadians in remote or rural areas did nothave timely and convenient access to physician services, some regions had many morephysicians than were required to meet local needs.The policy package which was recommended included:· increased use of non-physician personnel working with regional physicianconsultants· new training programs for these non-physician personnel· improving science programmes and career counselling in rural areahigh schools· reserving medical school places for qualified applicants willing tocommit to rural practice· revising medical school admissions criteria· enhancing rural exposure in both undergraduate and postgraduate MDtraining· developing new residency programmes to prepare rural regional consultants· introducing or increasing financial incentives of various types· providing clinical decision-making support networks and regular relief· providing amenity packages that included benefits for spouses and children· encouraging alternative remuneration methods.7It is worth noting that there was almost universal agreement among interviewees andanalysts that the problem of geographic maldistribution was the most difficult to solve ofall the physician resource policy problems identified, and that no optimal “solution” waslikely possible.  What was possible was a concerted and sustained management strategy toreduce the problem.The report stressed other themes relevant to the problem of access to services in rural andremote areas.  First, in addition to co-ordinated policy packages, policies had to addressaspects of the recruitment and retention problem at all stages of the medical career lif -cycle, from early high school education through to retirement.  Second, inter-provincial/territorial co-ordination of policy was badly needed.  Third, more attentionneeded to be paid to sensitive but effective ways of resolving the tensions created by theCanadian model of physicians as “private participants in a public enterprise”, especiallywhen the decisions of individual physicians, their professional associations and theirtraining and licensure institutions fall short of achieving important public policy objectivessuch as appropriate access to medical services for all Canadians.Since 1991 there have been a number of relevant research studies, much policycommentary, and several important reports by organizations involved in what has becomean increasingly politicized issue.  This material has been recently reviewed for the HealthCanada report, Toward Improved Access to Medical Services for Relatively UnderservedPopulations, and is incorporated in the questions and answers in section II below.8Section II:  COMMONLY OFFERED POLICY SOLUTIONSWhy not continue to carry on as we have been?The answer appears simple.  Business as usual will almost certainly continue to guarantee“results as usual” --  there is no obvious reason that we will not continue to have theproblems we have.“Carrying on as we have been” means letting each jurisdiction in Canada continue todevelop its own home-made strategies for improving rural/remote access.  Fiveimplications come immediately to mind. First, policies will continue to be crafted withoutregard to the potential side-effects that policies adopted in one jurisdiction may have onothers, or, worse, with sights firmly fixed on the fact that making matters worse for otherjurisdictions will make matters better ‘at home’.  Second, individual jurisdictions areunlikely to take advantage of synergies available through the collaborative development ofpolicies in this arena. Third, it virtually guarantees that problems beyond the control of anyindividual jurisdiction (but potentially amenable to collective actions) will remainproblems.  Fourth, it means continued duplication and lack of coordination, resulting inwasted resources and squandered opportunities.  And fifth, potentially fruitful approachesthat might work nationally will not be contemplated because they could have disastrousside effects if implemented in a single province or territory; as a result, we limit our rangeof potentially fruitful experimentation.Provinces/territories have had decades to ‘solve’ the problems of rural/remote access, andhave deployed an extensive array of approaches in the attempt.  They have used variouscombinations and permutations of financial incentives, administrative/regulatory fiat,educational initiatives, contracting/direct service arrangements, and telemedicine initiativesYet we find the problems are more acute, or at least there is a perception across thecountry that they are, now than ever before.If “carrying on as we have been” means “more of the same” in terms of outcomes, it willalmost certainly mean “more of the same” on the dissatisfaction meter.  The currentsituation satisfies no one.  The affected populations in many areas appear  unhappy abouttheir access; the health care providers in many of these areas are complaining of beingburnt out; provincial/territorial Ministries of Health face ongoing problems of budgetpredictability, and concerns about quality, accountability and continuity of care; andprovincial/territorial politicians (those representing these regions, and also Ministers ofHealth)  are buffeted daily by claims that they are not dealing effectively with thesesituations.  It seems difficult to imagine a better way to guarantee a “lose, lose, lose”situation.9Would increasing medical school enrolment help solve the currentproblem?Probably not.  There is no reason to believe that simply increasing the number of Canadiangraduating physicians will lead more – or even a significant number (about 10% of allCanadian medical school graduates currently choose remote or rural practice) – of them topractice in rural and remote areas. Th  personal and professional attractions of cities likeToronto, Montreal and Vancouver, or other smaller urban areas often with good back-upand high technology facilities, are still there; as long as there are unfettered opportunitiesto make a “reasonable” living in those locations there is no reason to expect newgraduates to change their location decisions.In the medical field, “saturate the market” policies are likely to be relatively unsuccessful,because there often seems to be an unlimited amount that can be done to provide servicesto a population.  (Although a considerable amount of evidence exists to suggest thatpresent service patterns include a significant amount of utilization that is unnecessary orineffective, it has proven extremely difficult to reduce or eliminate this component.) Thecase of British Columbia is instructive as an example of how it seems impossible tosaturate a market, forcing enough physicians to locate elsewhere to achieve politicalpeace.  B.C. has ranked first among provinces and territories in the number of familyphysicians per capita since 1991 and second in the total number of physicians per capitasince 1987.  An oversupply of physicians in B.C. was recognized as early as 1979, and the1996 physician supply plan negotiated between the B.C. Medical Association and theMinistry of Health showed a provincial surplus of 726 full-time-equivalent (fte) physicianson a base of 6,926 ftes, most of whom are located in the southwestern corner of theprovince. Yet even with this excess supply of physicians, the issue of rural service eruptedpolitically this year.Physician supply policies that rely on training so many physicians that they overflow theurban areas into rural and remote areas are a very expensive and inefficient way to steerphysicians to those areas.  Even observers in the United States, which has traditionallyrelied (relatively unsuccessfully) on this approach as a major component of its policy, havecome to recognize this fact.  In Canada, increasing enrolment to the extent necessary tohave an impact on location decisions would, through its associated and predominant effectof increasing urban supply, greatly exacerbate the global expenditure control problem thatevery provincial/territorial ministry of health is already struggling with.  Under provincialglobal caps on physician expenditures, medical associations and their members also havean interest in managing physician supply in order to maintain income levels.  Whenphysician supply or utilization of services increases beyond a certain point, proration offees occurs.  The strife that ensues within the medical profession and between theprofession and government undermines the public’s confidence in both.Nor does history support a supply expansion policy.  For over thirty years prior to theearly 1990’s, annual increases in the supply of physicians exceeded growth in the Canadianpopulation, fueled in part by a 53% increase in first year Canadian medical school10enrolment between 1967/68 and 1980/81.  Therefore it is discouraging that the problem ofrural and remote access, as perceived by all of the key parties – the public, governmentand health care providers – appears to be worse now than ever before.  At least it has ahigher profile now than anyone currently involved can remember.An increasingly prevalent view is that the reductions in first year medical school enrolmentwhich began in 1993/94 (and had amounted to about a 10% reduction by 1996/97) are amajor cause of the “recent” problems with access in rural and remote areas; howev r thisis incorrect.  The problems existed well before enrolment cuts and more important, themain effects of those cuts would take at least six years (the minimum length of time ittakes to train a doctor) to show up in location decisions.  They would only now bebeginning to appear.  They may contribute to the problem in future if nothing else is done,but they are clearly not the reason for the high profile problems of the past several years.And even in the future, their likely impact will be small.  If the reductions in intake haveresulted in  about 175 fewer entrants a year, and if  about 10% of new graduates continueto choose to practice in rural/remote areas, this would mean a reduction of about 17-18new graduates annually available for rural/remote practice, across the entire country.(Some confuse the reductions in first year undergraduate medical school intake with thereductions in the number of family medicine residencies, which may have had an earlierimpact.  This issue is addressed in a separate question below.)11What about billing number allocations or other similarregulatory/administrative approaches?A number of provinces have had, or currently employ, policies that ‘direct’ wherephysicians can establish practices (or rather where they are eligible for reimbursementfrom the province’s medical plan).  In most cases, these approaches have run afoul of theCanadian Charter of Rights and Freedoms, are currently the subject of legal proceedingsbased in part on violations of sections of the Charter, or have been challenged on suchgrounds but were withdrawn before reaching the courts. To date, no such policy hassurvived a court challenge (although not all policies have been challenged).British Columbia has had the most experience with application of these schemes.  Twoattempts have been made to control where new practices could be established in theprovince.  In each instance, the schemes were found to favour, without sufficientjustification, established self-employed physicians over similarly qualified individualswishing to provide the same services in the same locations under the same terms andconditions.  Such policies have been found to violate inter-provincial/territorial mobilityrights by conferring advantage on physicians already practising in a province relative tophysicians wishing to enter practice in that province from elsewhere in the country.Clearly the courts have viewed the situation of self-employed physicians as quite differentfrom an employment-based situation in which matters of “available positions” and“seniority” might come into play.Because these schemes have run into legal turbulence, none has ever been in place for asufficient period to assess its effectiveness in improving the distribution of physicians.  Inthe case of British Columbia in the mid-1980s, the evidence that is available suggests thatphysicians tended to take up locum opportunities in urban settings rather than establishingnew practices in rural and remote areas of the province.  That policy also ran intosignificant administrative problems which would be likely to plague any similar initiatives.For example, ensuring fairness in the selection of candidates for billing numbers wasproblematic.Experiences elsewhere suggest that administrative/regulatory approaches can be effectivein improving physician distribution.  In particular, the so-called “negative directions”policy in the United Kingdom appears, in conjunction with other policy approaches, tohave been quite successful in directing new primary care practitioners to areas withrelatively sparser supply per capita. Australia has recently launched a national providernumbers policy which uses restrictions in the availability of post-MD training programs tochannel new physicians into gaining experience in hospital posts (the idea being that mostavailable posts will be in smaller communities).  It is too early yet to tell how effective thispolicy will be in affecting distribution.12It appears that an effective approach in Canada would need to be truly pan-Canadian, bothin order to survive a Ch rter challenge (and that cannot, of course, be assured even withsuch a policy) and because otherwise physicians may simply move to provinces/territorieswhich do not have such a policy in place, rather than moving to areas in which they do notwish to live and practice within their ‘home’ province or territory.  Even then, there is noway to ascertain whether such a pan-Canadian policy might not simply  encourage moremovement of physicians to other countries, particularly the United States.13Will financial incentives for rural and remote practice help?Financial incentives already are used extensively by all provinces and territories, and havebeen for many years, but have had only limited success.  Still, th y are the most commonlyused policy strategy in Canada.The incentives have taken many forms: subsidized incomes or guaranteed minimumincome contracts, differential fees for practice in over-serviced and under-serviced areas,special salaries, grants or bonuses tied to return of service, special travel allowances,special funding for locum support, assistance with practice establishment costs, paidvacation time, special on-call payments for emergency coverage, undergraduate andpostgraduate student loans/grants/bursaries with return-of-service conditions, specialfunding for residency skill development and/or travel to summer placements, financialsupport for continuing medical education, and northern or isolation allowances.  As can beseen from the above list, they have also been used for several different objectives: toencourage medical students and residents to consider such practices, to induce new andestablished physicians to locate in rural or remote areas, and to retain those who do so.While they should not be dismissed (and have worked well for some communities some ofthe time), financial incentives as a general strategy have clearly not solved the problem,despite the fact that they have come in numerous forms and amounts.  Given their longtrack record, they seem unlikely to do so in the future.  This should not be surprising inlight of what is known about the factors influencing physicians’ choice of practicelocation.  Financial factors are well down the list, behind things like personal background,family and especially spousal considerations, professional education/support/practicefactors, and community factors.  (Furthermore, many people would argue that they wouldbe uncomfortable knowing that their community physician is there “only for the money”.This is part of the answer to those who would argue that financial incentives have simplynot been large enough.  The other part of the answer is that at some level ofcompensation, the costs of competing approaches become much more attractive.)   Giventhat most practice opportunities in major urban centres continue to offer the potential ofreasonable incomes, it is also not surprising that most physicians choose to locate andremain there, enjoying the attributes of the urban centres o personal, family andprofessional dimensions.Indeed, it can be argued that the main effect of increased levels of remuneration of varioustypes for rural and remote practice is to reward those who might locate there anyway, orwho have already done so largely for non-financial reasons.  This is not unimportant, asmost people agree that the physicians who accept the challenges and stresses of practice insuch locations deserve to be fairly compensated for them.  But increasing incomes forthose in rural/remote practice as a matter of appropriate compensation for the uniquechallenges and stresses associated with such practice is a different issue from doing soexplicitly for recruitment purposes.14It is also worth noting that, depending on how they are designed, some financial incentives(including northern/isolation allowances and on call payments) can actually work againstrecruitment, or at least put physicians already in rural and remote regions in an awkwardposition.  This is the case if new arrivals threaten base incomes or isolation or on-callsupplements that are tied to low physician availability, either through contractual clausesor through sharing of the fee-for-service income from a population.  While existingphysicians might dearly want and need colleagues for professional support/relief reasons,(and the region might need the increased availability of service), the so-called “financialincentives” may make them reconsider the welcome mat.15Why not increase the recruitment/entry of foreign medical graduates(FMGs)?Physicians trained outside Canada (FMGs) have played a very important role in pr vidi gmedical services to communities across this country that have had difficulty recruiting orretaining Canadian-trained physicians.  So what’s the problem?   There appear, in fact, tobe several.  First, while Canadian communities or their local physicians are often able torecruit FMGs, they seldom ‘stick’; over time they, like their Canadian counterparts,disproportionately migrate to urban settings, thereby exacerbating situations of over-supply or pushing adequately supplied communities into an over-supply situation.  Second,one hears reports that some established physicians are actually dissuading Canadian-trained physicians from settling in their communities because foreign physicians brought inon temporary work visas are often prepared to purchase or buy into a practice or paymonthly expenses to an established physician in exchange for entry to Canada.  Thesearrangements can result in high turnover, increased physician supply and restrictedopportunities in rural and remote areas for graduates of Canadian medical schools.  If sucharrangements exist, their significance warrants investigation.  Third, relying on FMGsaverts the need to deal directly with the fact that, although our domestic training capacitymay be adequate, the location decisions of graduates continue not to align with relativegeographic needs.FMGs have, historically, entered the country in a number of different ways:· recruited into post-MD residency training programs where there wereinsufficient Canadians interested in pursuing training in particular specialtiesbut where the training program capacity was maintained for other reasons (e.g.perceived need for the specialists; or to meet institutional or regional serviceexpectations). This route into the country was largely closed off in the early1990s, when medical schools agreed to no longer allow visa trainees to enterministry-funded positions;· as foreign-funded visa trainees, with the understanding that they would returnto their country of origin upon completion of their residency training.  This isstill a common, perhaps increasingly common, arrangement, raising the obviousquestion about the proportions returning;· as ‘special circumstance’ academic recruits;· recruited into rural or remote communities that were having trouble recruitingCanadian medical graduates (CMGs).  These FMGs will often not havecompleted the necessary post-MD training (most jurisdictions require at leastone year of post-MD training in Canada for full College registration); as aresult they will be granted “conditional registration”, a condition being thatthey can practice only in certain locations for a specified period of time;· through a family reunification program or as refugees.  This roup of FMGshave had difficulty gaining access to practice opportunities in Canada, for avariety of complicated reasons.  In general, the problem is that these FMGswill not have met the Canadian requirements for post-MD training (rotations of16specific lengths in specific clinical areas). While there are some post-MDtraining spots dedicated as entry portals for these FMGs, the numbers of suchentry positions fall far short of the number of FMGs wishing to take advantageof them.Historically only the fourth of these five routes has provided any significant component ofthe rural and remote area physician supply for the country.  Those physicians recruitedinto rural/remote areas do not, however, sign life-long contracts.  They, like theirCanadian counterparts, disproportionately prefer to practice in urban settings, and seem inmany cases to use the rural/remote positions as an expeditious route to landed immigrantstatus and eventually to practise in Canada wherever they wish.  This is the reason that theproportion of physicians who are FMGs is so similar in urban and non-urban areas. Whileit is assumed by many that a large proportion of physicians practising in non-urban areasof the country are FMGs, in fact in 1998 only about 26% of those practi ing outsidecensus metropolitan areas were FMGs. This was not appreciably different than the overallratio of FMGs to all practising physicians in Canada.As a result, Canada has used a continuous stream of FMGs as short term solutions topersistent long-term problems; while there is no disputing the fact that they have providedimportant primary care access in many regions that would otherwise have done without, itis no less true that over the longer term they have tended to exacerbate urban oversupplysituations, thereby creating additional pressure on global budgets.  Overall, just over 10%of all FMGs practicing in Canada were found in a recent survey to be located outsideurban centres.  Again, this was virtually identical to the percent of all CMGs practicingoutside urban centres.One logical response to this dilemma might go something like this:  since Canadiangraduates continue to show disinterest in practicing where the greatest needs are, andsince we know we can make arrangements to have FMGs me t many of those needs, whynot simply recruit more FMGs and train fewer Canadians?   The mix of recruits andtrainees could be adjusted so as to ensure an adequate overall supply, and an appropriatemix of specialists, and one might gain significant savings on the training side.Well, as with all simple solutions, this one is quick, simple, and doomed.  First, it couldconceivably create new problems around the critical mass necessary to maintain qualityfamily practice residency training programs; second, it would create potentially significantnew problems in providing care in situations where considerable amounts of care arecurrently provided by residents; and, as if these were not enough, third, it would create apolitical nightmare to have a situation where opportunities for Canadians were beingreduced at the same time as government policy was resulting in additional FMGsenteringthe country to practice.But what about that fifth pool of FMGs, who have not been recruited but have entered thecountry for other reasons?  Do they no   represent a potential solution to the problem ofaccess in rural and remote regions of the country?  Again, what appears on the surface to17be a simple solution is, in fact, rather more nuanced, involving considerations of trainingstandards, competency testing, opportunities for post-graduate training, and so on.  Butperhaps most fundamentally, since these individuals enter the country and become landedimmigrants and eventually Canadian citizens, it is difficult to see how one could implementsome sort of return-of-service or geographically restricted practice requirement for thispool of FMGs without it being part of a more general policy (see below for a discussion ofthe more general problems with a return-of-service approach).  Focusing such a policy onthis group alone would likely run afoul of Charter ights.There is another reason not to embrace a policy of ramping up FMG recruitment.  Relyingtoo heavily on graduates trained outside the country leaves the country hostage to changesin the international ‘market’ for physicians.  For example, if changes such as those thathave increased requirements for primary care physi ians as ‘case managers’ in the U.S.were to take place in other countries from which Canada imports physicians, it is quiteconceivable that those sources of supply could dry up.  Were Canada to be in a situationwhere it had reduced its dependence on hom -grown graduates because of the readilyavailable foreign supply, such a change in circumstances could have dire consequences.  Inaddition, recruiting foreign physicians may exacerbate physician supply or distributionproblems in the originating countries.18Why not use the licensure process to channel physicians to where they areneeded?Since every physician who practices in a particular province or territory must receive alicence of some sort (temporary, permanent, conditional, etc.) from that jurisdiction'slicensing authority, some have suggested that having the local College issue conditional orprovisional licences to new entrants would go some way toward improving access in ruraland remote areas.  The conditional licences would come with geographic restrictions, sothat, for example, for the first five years of practice, a physician was licensed to provideservices only in certain specified areas of the licensing jurisdiction.In practice such an approach would be relatively indistinguishable from a “billingnumbers” policy controlled by the funding agency.  It would, undoubtedly, quicklybecome an object of legal action, on grounds similar to those under which billing numberspolicies have been contested (violation of sec. 6 (mobility) rights, among others).But there would seem to be a more fundamental problem with this approach.  Theresponsibility of provincial/territorial licensing authorities is to grant licences to dulytrained physicians who have demonstrated the necessary competence to practice in theirchosen specialty, and to protect the public from physicians who fail to meet professionalstandards of practice.   To ask those authorities to withhold an unconditional licence froma physician who has met all the necessary qualifying requirements but who wishes topractice somewhere other than the locations attached in the “conditions” set out for aconditional licence, would seem to be asking them to exercise authority beyond thatprovided in the regulations under which they operate.As if these issues were not enough, there is also the matter that leaving such decisions inthe hands of each provincial/territorial licensing body would do little, if anything, topromote a coordinated approach to improving national distribution of physician services.19Is a nationally-based return-of-service program worth considering?The feasibility of such a plan is highly questionable.Return-of-service arrangements have been tried in some provinces for many years, andsome are still employed.  Through these arrangements, medical students and residentsreceive grants, loans or bursaries in exchange for agreeing to locate in a designatedgeographic area for a specified period upon completion of their training.  The generalexperience of provinces with these programs has been that participants often exercise theiroption to buy their way out of the service commitment, and even when they do not, theprograms have a limited effect on retention.A national return-of-service program would presumably be much more ambitious,stringent, and coercive.  Th  idea most frequently suggested is that every medical studentwould be accepted into medical school (at a relatively low, possibly zero, tuition fee) onthe understanding/contract that upon completion of training he or she would owe thecountry a specified number of years of paid service in a designated rural or remote area orspecialty.  Several variants of the program can be imagined; for example, the length of theservice period could be inversely related to the remoteness of the area, or a specialprogram stream could be created to provide increased coverage of rural emergencyrooms.  A basic principle, however, would be that the remuneration method would beother than fee-for-service.  During the return-of-service period, it would be understoodthat participants were being paid for providing public service in return for publiceducation, on their way to practice in a publicly funded health care system.If such a program could be developed and maintained, it would undoubtedly improve thesituation.  As can be quickly appreciated, however, the administrative resources equiredare substantial, and its operation could be both a political and logistical nightmare.Identification of priority locations and services, allocation of graduates, allowances forspecial personal/family circumstances, monitoring and enforcement of service contracts,policies for foreign graduates or Canadians returning from training abroad – just tohighlight only a few issues – are complex matters.  And the whole thing would have to benationally agreed and co-ordinated on an ongoing basis.  For example, graduates from theUniversity of Alberta might need to be prepared to practice in remote areas ofNewfoundland, if such areas were at the top of the priority list on graduation.The legal aspects are just as questionable as the operational feasibility.  At the end of theday, the effects of a return-of-service strategy may be found by the courts to be nodifferent than those of a billing numbers policy affecting new entrants  in that both treatexisting and newly graduating physicians differently.  A national return-of-service programwould almost certainly generate a Charter challenge.Could an individual province implement a mandatory return-of-service program in theabsence of a national program?.  Such a program would be subject to many of the samelogistical and legal uncertainties noted above.  In addition, its enforcement would require20inter-provincial/territorial cooperation in denying access to practice to graduates from aprovince who were attempting to violate their return-of-service agreement.21What scope is there for increased emphasis on educational initiatives?This is currently an open question since some specific educational practices and policiesappear to have increased the number of physicians in rural/remote practice but, overall,educational strategies have received relatively little attention compared to financialincentive strategies.There are numerous points in the medical career life- ycle where strategies might be orhave been pursued through education programs and institutions, including:· science education and career counseling in rural high schools;· a focus on recruiting/admitting more medical students from rural or remote areas, andfrom aboriginal groups;· positive promotion of rural practice generally within medical schools and curriculummodification to reinforce this;· exposure of medical undergraduates to rural/remote practice settings, the challengesand rewards of those settings, and the special needs of rural/remote communities;· similar exposures for medical residents, including extended periods of experience withrural/remote preceptors;· extended opportunities for practising physicians for skills upgrading/continuingeducation geared to rural/remote practice;· opportunities for existing physicians to re-enter training to specialize in areas of needin rural/remote areas.The number of educational initiatives is growing, particularly opportunities forundergraduate and postgraduate placements in rural/remote areas, and research isincreasingly being conducted to assess the effect of some of the initiatives on recruitmentand retention.  For example, the importance of recruiting and admitting future physicianswho have grown up in rural and remote settings now seems clearly established (everyoneagrees that it is better to recruit physicians who w t to live in these areas, than to have torely on coercive policies or financial incentives through which one is likely to ‘attract’physicians who would prefer to be somewhere else).  However, the overall impression thatone gets both from the existing literature and from speaking with individuals involved ineducational strategies is that only a fraction of what could be done in this area is currentlybeing done.What would happen if significant financial support and human resources were committedto pursuing vigorously strategies at all or most of the points above (and perhaps others),ignoring for a moment the difficulties of implementing such a plan?  It is hard to know theanswer to this, but neither informed opinion nor current research evidence suggests thateducational strategies alone will turn the tide.  Indeed, evidence to date suggests that thereturns to a vigorous approach here may be less than expected.  It is also difficult to makean assessment independent of other policies affecting remuneration, support, etc.Nevertheless education pr grams remain a potentially fruitful, not yet fully exploited,policy route.22A final caveat: it is very important not to view “educational initiatives” too narrowly ortraditionally.  There is much room for creativity and innovation here.  For example,collaboration between medical and nursing schools to train nurse practitioners alongsidefamily physicians with a focus on rural practice should be in the set of strategies (seebelow).23Is there scope for re-examining the mix of residency opportunities?As we noted above, the combination of shifting from a rotating internship requirement toa minimum two-year residency training program for family practice, together with thedecisions taken about the overall mix of residency positions, have meant that fewerphysicians are now leaving the training pipeline with general/family practice credentialsand skills than was the case at the beginning of this decade.  Since it is general/familypractitioners who are the most likely to take up practice in rural and remote areas of thecountry, this is likely to have exacerbated the problems of recruitment and retention inthose areas.There would seem to be some potential in having the National Co-ordinating Committeeon Post-graduate Medical Training revisit the shifts in mix of residency training positionsduring the past decade, as part of their ongoing mandate to ensure that the mix of publiclyfunded positions aligns with best estimates of future requirements.  In particular, if it canbe confirmed that one of the (perhaps unintended) side-effects of these policy changes hasbeen to reduce the relative production of family practitioners, such side effects shouldreceive priority attention from provincial/territorial Ministries of Health and fromacademic health centres across the country.Any such re-examination must, however, be part of a more global monitoring of academichealth centre throughput in all specialties relative to projected requirements.  For example,one would not wish to see more family practitioner residency positions established at theexpense of residency programs training generalist specialists who also represent  importantsources of care for non-urban communities and who are likely to be in relatively shortsupply in the near future (general surgery comes to mind).It may also be worth revisiting the availability of specialty re-entry positions for familypractitioners who wish to undertake additional specialty training.  As noted above, therelatively restricted ‘change your mind’ opportunities may be resulting in final specialtychoices being made earlier because the perception (and the reality) may be that choicesonce made are now more difficult to change.  If this bottleneck were to be loosenedsomewhat, one might find more MDs willing to complete a family practice residency andpractice for a few years in rural or remote areas before returning for specialty training.Indeed, one might even consider providing specialty re-entry portals for familypractitioners who do precisely this.  Since it is unrealistic to think about meeting all ruraland remote area needs with physicians who take up ‘permanent’ residence in suchcommunities, having a steady supply of Canadian family practitioners prepared to commit,say, three to five years to such communities might be a significant step in the rightdirection.24Don’t professional support programs help?The short answer to the question of whether such programs help is “sometimes”.“Professional support” programs are initiatives taken by Ministries of Health, medicalassociations, local communities or academic health centr s, to improve the conditionsunder which physicians in rural and remote areas often must work.  Without pretending tobe exhaustive, we would include under this umbrella any policies whose primary intent isto provide relief from unreasonable on-call scheduling; back-up so that holidays can betaken; continuing education opportunities which would enhance skills required in thesesettings; and access to complementary personnel such as nurses or nurse practitioners,specialist consultation (e.g. through itinerant specialist arrangements and/ortelecommunications technologies), and complementary facilities, supplies anddiagnostic/therapeutic equipment.Programs intended to provide on-call relief are made necessary by the reality of smallpopulation bases – it is often difficult to justify more than one full-time physician in a smallcommunity, when a minimum of three, for example, might be required to providereasonable on-call relief – and by the fact that in many communities that do have sufficientpopulations to support more than one physician, recruiting remains problematic.  Suchsituations may be made worse by the fact that physicians in these communities are paidfees-for-services; there is insufficient work to support the addition of another physician ifpayment is to be by fees, yet the need for on-call relief remains.We do have extensive experience in this country with attempts to increase recruitment andencourage retention through the use of such policies.  Most common are locu  reliefpools, continuing education subsidies, itinerant specialist programs, and more recently anumber of emerging telemedicine initiatives.   There is no question that many of theseprograms have provided some help in some situations.  Are they enough?  On theexperience to date, clearly not.  Can they ever be enough?  We view these types ofapproaches as necessary but not sufficient.  They need to be part of a comprehensiveapproach to addressing the problem, but cannot, by themselves, be looked to as a solution.Attempts to maintain professional support programs have been plagued by a number ofproblems, such as difficulty in staffing locum programs; difficulty maintaining itinerantspecialist programs; and the fact that locums are unlikely to be able to address continuouscall problems (e.g. 1 night in 3 or more frequent) which lead to burn-out of  localphysicians.Unfortunately recent controversies related to payment for on-call have createdconsiderable confusion about the nature and extent of the on-call problems faced byphysicians practising in smaller communities.  In particular, some rural/remote areaphysicians have argued that real relief is spelled “mon y”.  In other words, a littlesupplement for being on-call will make too-frequent on-call more palatable.  Some recentagreements to pay physicians for on-call time in selected communities where physicians25were already receiving geographic fee supplements have created significant new inequities,and may have made it more, rather than less, difficult to recruit and retain additionalphysician resources in some of those communities.26What about family/spousal support initiatives?A clear message emerging from the extensive research that has looked at what factorsinfluence physicians’ decisions about where to practice medicine is that matters affectingthe lives of spouses and children are among the most important considerations.  Internes,residents, and recently licensed physicians invariably rank this cluster of factors at or nearthe top of the list of priorities affecting location decisions.  Opportunities for (particularlyprofessional) spousal employment, and recreational and educational opportunities forchildren are paramount.  This becomes intertwined with the issue of professional relief, inso far as being on-call affects family life.This constellation of factors is clearly the least amenable to provincial/territorial policyintervention (with the exception of on-call relief, discussed above).  It is, as noted earlier,impossible to imbue a small town with big city perks and opportunities.  And, indeed, arecent comprehensive review of initiatives across the country (the Health Canada reportnoted earlier) revealed nothing in the way of provincial/territorial initiatives to address‘family matters’.  Nevertheless, this should not be taken to mean that nothing can ever bedone.  Many communities take matters into their own hands, trying to create an attractivepersonal and professional environment for new recruits, with variable success.There is also mileage to be gained from attempting to recruit more future physicians fromthe areas to which one hopes they will return, or perhaps even more importantly, fromattempting to identify potential future physicians with spouses from such communities.But this gets back into education-related initiatives.   On the professional support front,beyond on-call relief, or providing periodic paid holidays for physician and family, fewoptions come to mind.But if it is the case that there are few effective ways of addressing what young physiciansclaim are their predominant preoccupations at the point location choices are made, thiswould seem to send a powerful and unmistakable message to policy-makers about the‘science of the possible’.27How does the present organization of medical care help or hurt therural/remote situation?Two central features of the current system – the fee-for-service payment method, and thestatus of physicians as self-employed professionals – together create a situation in whichprovincial and territorial governments can encourage but cannot ensure a geographicdistribution of physicians that corresponds to the needs of the population or thepreferences of communities.Most Canadians know that their provincial and territorial governments are responsible forassuring access to needed physician services, but few fully understand the workings of thehealth care system, the roles of the various institutions and players, the interests of theseplayers, or the incentives and constraints they face.  It is difficult for them to appreciatewhy problems of access, once identified, cannot be “fixed” by government.However, most physicians are self-employed.  Their practices are private businessenterprises and they are free to choose which services to provide, their hours of work, andwhere they choose to locate, based on their own interests, personal considerations,judgement and sense of responsibility.  Increasingly, in urban areas for example, physiciansappear to be basing their practice decisions around lifestyle considerations, choosing notto practice obstetrics or provide hospital coverage, or choosing locums r contract workover establishing an independent full-service practice.Moreover, due to the nature of medical services and the predominantly fee-for-servicemethod of paying physicians, it is usually possible to make a very reasonable living even inurban areas that are well-supplied or over-supplied with physicians.  The urbanalternatives, which most physicians prefer because they offer professional and institutionalcapacity and support as well as social amenities, are therefore relatively unrestricted.Nevertheless, though they are private participants, physicians practice within and are paidlargely by a public system.  Their payors, provincial/territorial governments, areaccountable to the citizenry for providing appropriate and equitable access to medicalservices. Yet they have few, if any, effective and reliable mechanisms for controlling thelocation decisions of the physicians on whom they must rely.This is not a problem of ‘bad people’ making irresponsible decisions; most physicians arehighly dedicated and caring professionals, and provincial/territorial officials likewise havethe interests of patients and prospective patients in mind.  It is a problem of ‘bad systemdesign’, at least as it relates to the problem of access to physician services in rural/remoteareas.  This problem does not provide grounds for altering the single-payor public-financemodel of ‘medicare’ that has by and large served Canadians well, and made medicare thecountry’s most highly valued social program. It does underline the need for newinstitutional mechanisms to allow provincial and territorial governments to meet theirresponsibilities.28Nor does it, as some may fear, support the view that physicians should become civilservants.  Rather, what is needed are new mechanisms – be they financial, managerial, oreducational  – that ensure that the health care needs of the population are met by the sumof the myriad private decisions of physicians.The alignment of private interests with public goals in a way that is perceived to be “fair”by all parties is a formidable task and should be acknowledged as such.  The transitionfrom the current system is possible, but it will be difficult; it will require strong politicalwill.  And the number of policy avenues that remain largely untested and hold somepromise is limited, but there are a few.29Section III:  FUTURE DIRECTIONSWhere do we go from here?In 1991 we noted that “[b]ecause of the distribution of Canada’s population, we do notfeel that this problem will ever be solved to everyone’s satisfaction, particularly if it isviewed narrowly as a physician resource problem.”   Nothing in our review for thisbackground paper suggests that we should alter this view.  We have noted a number ofareas above where some gains might yet be made.  For example, the variants onregulatory/administrative pproaches which restrict where physicians are able to establishpractices may not yet have been exhausted.  But the virtual certainty of legal challenge,and the uncertainty of outcome (and of effect) suggest that investments elsewhere maybring greater returns.Most of the other approaches reviewed above fall into one of two groups:  a) those notlikely to work, or that have not worked (e.g. use of the licensure process or increasingmedical school enrolment); and b) those providing some benefits at least in somesituations, but for which more of the same is not going to bring the major inroads soughtby all parties affected by these problems (e.g. financial incentives; recruitment of FMGs).If there were a simple, straightforward, solution to this challenge, it would have beenfound and tried long ago, if not in Canada, then elsewhere.  There is not, and it has not.The problem is always going to be with us, in some form and to some extent.  There are,we believe, ways to manage it which would lead to improvements relative to the existingsituation.  But they will take more than fiddling around the edges, another financialincentive here, a few more locum and itinerant specialist pools there.  We are driven to theconclusion that any significant inroads are going to be found only in different, moresystematic, approaches to thinking about the problem.In our view, there are three such approaches worthy of further consideration and furtherdevelopment:· a fundamental restructuring of the way in which funding for medical care isallocated and in which medical care is purchased;· a far greater reliance on non-physician personnel with some additional trainingfor front-line primary care in rural and remote regions of the country;· new and expanded roles and responsibilities for academic health centres.These are, of course, not mutually exclusive options.  Choosi g among and between themdepends, in part, on whether the overarching objective is to improve access in rural andremote communities, or whether it is to ensure that there is at least one physician living inevery small town in the country with sufficient population to support a potential practice.The answer to this question will dictate the nature of the policy choices available.  Ourview is that if the real objective is the latter, then this problem will remain a problem forthe foreseeable future.30Below we provide a sketch (but not a detailed blueprint) of  each approach, and run a‘problem check’ for it.  The ‘problem check’ allows us to assess each option against thekey factors, described in the opening question above, which underlie the persistence of thegeographic access problems.  Those factors are the continued unfettered availability ofurban alternatives; inadequate professional support and relief; spousal/familyconsiderations; and historical policy decisions.Rethinking the purchasing arrangements for medical careThe key guiding principle for a restructuring of allocation/purchasing arrangements is thatfunds for medical care be made available, on the basis of the size and characteristics ofpopulations, to accountable agencies/organizations such as regional authorities or othernon-profit health care organizations – in other words, medical care funding would followpeople, and would then flow to providers who accept responsibility for caring for thosepeople.There are many ways such a restructuring might play out in practice, and we do notbelieve it is important to suggest here any particular model.  As but one example, funds formedical care might be allocated to regional authorities in a manner similar to the way thatfunds for hospital care are now allocated in many parts of the country.  The regionalauthority could then contract with provider groups (in- or outside the region) for theprovision of a negotiated range of services for a specified population.  Regional authoritiescould contract directly for specialty care, or sub-contract to provider groups who would,in turn, be responsible for ensuring adequate provision of secondary and tertiary services.How individual physicians would be reimbursed for services would be a matter ofnegotiation between the physicians and those with whom they are contracting, butmethods could range from entirely fees for services, to fixed sum contracts, with blendedcombinations being possible as well.  For example, one might find capitation contractswith physician groups for a set of “core” services, supplemented by fees or otherarrangements for the provision of specific ‘listed’ services, as is the case for the paymentof general practitioners in the United Kingdom.While our example above involves provinces/territories flowing medical care funding toregional authorities on the basis of size and composition of the registered populations inthose regions, regions are not the only possible contractors for/purchasers of care.Provinces and territories could, for example, contract directly with provider-based orother organizations, which would, in turn take the responsibility for purchasing care onbehalf of enrolled or ‘r stered’ populations.It seems important to reinforce the idea that such a restructuring would need to be pan-Canadian if it is to be expected to provide an effective remedy to the problems of rural andremote communities.  Absent such cross-country agreement, provinces and territorieswould likely be faced with whipsawing and increased migration between jurisdictions.Equally important is the notion of flexibility – individual contractors should be free to31negotiate with provider groups, and provider groups should be free to make whateverarrangements they wish for the provision of the contracted services (including, forexample, contracting with, or hiring, nurse practitioners to provide some components ofprimary care and on-call relief).  In return for this autonomy and flexibility, however, boththe contractors and  the provider groups must be held accountable for the quality andintegration of care provided to the populations for whom they have acceptedresponsibility.We do not wish to minimize the logistical, political and, potentially, legal challenges posedby such a fundamental restructuring.  How to determine appropriate allocation formulae,how to incorporate secondary and tertiary care, how to minimize risk-avoidance and risk-shifting, are among some of the immediately obvious logistical challenges.  Any newfunding arrangements will need to be designed to comply with the Canada Health Act andthe Competition Act.  And on the political front, it seems inevitable that such arestructuring will also mean new roles for physician associations which have historicallynegotiated fees and budgets on behalf of all members of the profession.However, these ideas are not new.  Demonstration/pilot projects incorporating some ofthese ideas are currently being developed in some parts of the country with federalgovernment support, and many groups, including some physician groups, have beencalling for similar initiatives for many years.  Internationally one finds many examples ofpopulation-based funding in countries with health care systems as different as those in theUnited Kingdom, New Zealand and the United States.  Indeed, Canada’s current approachto purchasing medical care is fast becoming out of step.How is such a restructuring likely to address the fundamental problems underlying thecurrent situation that we described in section I above?    Its scope for improving access tomedical care in rural and remote areas of the country comes from its potential to curtaildramatically  the availability of what we have called the ‘urban alternative’, since the newpurchasing arrangements for medical care would be system-wide.  One might expect thatpopulation-based allocation of funds for medical care would, initially, channel less funds tomost urban areas and more to smaller regions of the province or territory.  Depending onhow the contracting was established, this could lead to more care being provided topopulations in those smaller regions.  Whether it also resulted in more physicians residingin those areas would depend on the contracting terms and conditions.  For example,groups of urban physicians might contract with smaller rural and remote regions toprovide care and coverage for those regions.  Whether this meant placing physicians inparticular communities full-time would be a matter of negotiation between the contractorsand the provider groups.The effects on the other key underlying causes of the problem are less obvious.  Withrespect to lack of professional support and relief, contracting organizations would now beresponsible for ensuring that call was organized in ways that met the needs of thecommunities.  How this played out for individual communities and their physicians wouldlikely vary.  But it is not clear that the call/relief issues would be adequately resolved.32This would hinge on the formulae by which funds are allocated to purchasers – if, forexample, capitation rates for rural and remote areas reflected the need to provide orpurchase relief, one might expect more impact on this problem.  The family/spousal qualityof life challenges would remain challenges – this type of restructuring does not directlyaddress those issues.  As for past policy decisions regarding rotating internships that haveaffected the numbers of Canadian-trained physicians likely to locate in rural and remoteareas of the country, this approach would have no direct effect on reversing or alteringthose circumstances.Such a restructuring offers a number of  potential benefits.  First, it encourages physiciansto ‘go where the work is’ moreso than is the case under the current predominantly fee-for-service reimbursement arrangements.  Both public needs and the arrangements for meetingthose needs, would be made more explicit.  Second, it provides the potential for a morerational integration of all aspects of care.  At the moment, for example, in parts of thecountry with regional authorities, funds for physician and ambulatory pharmaceuticalservices are allocated in a manner completely divorced from the allocation of funds forinstitutional and community programs.  The result is regional authorities with a job to do,but without the tools to do it.  Not only are regional authorities hamstrung, but to theextent that co-ordinated care means better quality care, patients suffer as well.But this approach is not without its potential risks as well, and should there be a pan-Canadian initiative of this type, it will be important to head down this road with eyes open,with realistic expectations, and with a willingness and flexibility to fine-tune ‘on the fly’.For example, a wholesale move to purchasing primary care services largely throughcapitation-based contracting could exacerbate the current problems by encouraging morestudents to choose specialty careers.  If the residency positions are not available inCanada, those students might seek them in the United States or elsewhere.  This points tothe need to develop a consistent and coherent approach to the purchase of all medical careservices, not just primary care.  It is also possible that a wholesale restructuring of the typeenvisioned here would send more physicians south of the border seeking (an admittedlyshrinking number of) opportunities to continue to practice in a fee-for-serviceenvironment.  While we believe there is scope for, and potential in, pan-Canadian co-operation, there is absolutely no prospect of international co-operation in this respect.Furthermore, one should not minimize the challenge on the accountability/qualitymonitoring fronts.  Just as fee-for-service reimbursement embodies incentives to focus onthe provision of services rather than on the health of patients, every other method ofreimbursement has long been known to carry its own perverse incentives.  Undercapitation-based schemes, issues of risk-selection, risk-sh fting, and under-provision ofcare become concerns.  The design of any system that is based on the purchase of ‘carecoverage’ rather than specific serv es, must incorporate explicit mechanisms to addressthese issues.  They cannot be entirely removed; the challenge is to manage them in a fair,transparent, and accountable manner.Offsetting this potentially daunting picture is the encouraging fact that a number of33physicians and physician groups are seeking alternatives such as those described here, andthe clear recognition among Ministry/Department of  Health personnel of what it will taketo develop the necessary support.Increased training and use of non-physician personnelThe second general option has the potential to address more directly the issues ofprofessional relief and family considerations.  The expanded deployment of personnel suchas nurse practitioners, with training sufficient to provide a considerable range of primarycare services, enabled by appropriate adjustments on the regulatory front to allowexpanded scopes of practice (e.g. prescribing) offers, in our view, significant untappedpotential to address the problems of access to primary care, particularly in remotecommunities.Here the policy package would require, at least:· additional educational capacity that was able to train personnel with the skillsnecessary to provide a range of primary care services, often with light or nosupervision (but with telephone or other access to consultation fromphysicians);· regulatory modifications in those provinces/territories that have not alreadymade them, for example to Acts governing the ordering of tests and theprescribing of medications;· administrative funding arrangements that make it possible to employ suchpersonnel.On this last point, this option could clearly be pursued either alone or in combination withthe more extensive changes in funding/purchasing outlined above.Of course this approach only deals, in part, with rimary care in rural and remotecommunities, and it is not without its own problems and challenges.  Perhaps the mostsignificant, and obvious, is the quagmire of stakeholder dynamics.  The potential of nursepractitioners, and their acceptability to patients, have been known for decades.  Indeed,the pathbreaking research in this area was Canadian.  It was stakeholder dynamics andlack of political will which undermined the initiative two decades ago to introduce nursepractitioners into primary care in Canada and resulted in the closing of training programsfor them.  Yet even today both professional nursing organizations and physicianorganizations seem to be of many minds about the terms and conditions governingimplementation.  Nursing organizations are concerned that such positions are no longer“nursing”; medical associations are concerned about encroachment into the practice ofmedicine.  What gets lost in such debates is the fact that these personnel represent a veryreal means of improving access to primary care in communities that currently do not haveadequate access, and provide a source of relief and on-call coverage for over-stretchedphysicians even in communities that do have access.In addition, this approach will have its own feasibility challenges.  In the short run, nursepractitioners in Canada are in short supply; although some training capacity has beenadded recently, significantly more would be necessary.  Furthermore, it would be34important to link access to these training programs to commitments to provide service inrural and remote settings (as with similar suggestions for physicians, this raisesenforcement issues).  On the other hand, the opportunity for increased independence inpractice seems likely to be a strong motivation for many potential candidates.  Nursepractitioners who choose to practice in rural and remote settings will, of course, face someof the same personal and professional considerations (e.g. on-call, lack of colleagues,potential burn-out) as those faced by physicians choosing to practice in these settings.This policy approach will need to incorporate whatever measures may be possible toaddress such concerns.A significant advantage of this approach is that training programs for these personnel are,and would be, designed to prepare graduates for practice in rural and remote communities.Applicants would, by the very process of applying to such programs, signal their interestin practising in these communities.  This stands in stark contrast to the current situationwith applicants to medical schools.   Indeed, if the country can gear up to preparesufficient numbers of nurse practitioners, and they are able to resolve many of theproblems in remote communities across the country over time, it may be that this willrelieve pressure on medical schools and even reduce the country’s primary care physiciantraining requirements.  If we train primary care physicians who are not prepared topractice where the needs are, and at the same time train nurse practitioners who are, theappropriate adjustments would seem rather obvious.How does this option address each of the fundamental issues underlying the problemsituation?  Additional nurse practitioners, as an isolated option, does not directly addressthe ‘urban alternatives’.  To the extent that adjustments to medical training capacity arenot made, and physicians continue to locate in urban areas, the nurse practitioner optionwill be an ‘add-on’ expense.  On the other hand, nurse practitioners represent a real andviable approach to dealing head-on with at least some of the on-call and relief issues.  Canthey help with family/spousal issues?  As noted above, individuals who enter trainingprograms explicitly designed to train personnel for service in rural and remotecommunities are presumably prepared to live there.  It seems likely that these programswould be better able to recruit applicants from those areas into the training programs thanmedical schools have been to date.  Finally, does this option do anything to redress theeffects of past training/licensure decisions on the medical side.  In rectly it does so byproviding an alternative source of primary care expertise, and a source more likely to endup practising in some of the more remote areas of the country.Thus, this seems overall a positive approach, with a high likelihood of making a significantdifference.  But this, like the first option of restructuring the funding and purchase ofmedical care, is likely to require a political battle (although perhaps not as pitched).  Canthis battle be won?  We think yes; but if it cannot, or if the political will to take it on issimply not there, then we are leaving ourselves with a rapidly shrinking set of possibilities.35New responsibilities for Academic Health CentresA third policy option to explore might be for provincial/territorial governments to assignthe responsibility for appropriate service provision in designated rural and remote areas tospecific academic health centres (AHCs), at the same time increasing their budgetssubstantially to allow them to fulfill this new role.  Provincial/territorial governmentswould retain responsibility for setting standards for the performance of the role, andmonitoring the performance of the academic centres.One rationale for such a move is that assignment of responsibility to AHCs may be theonly real  “public management” option (perhaps other than regional health authorities) thatprovincial/territorial governments have left, arbitrary though it may be.  A secondrationale, however, is that in two of the other policy options which hold promise, AHCswill have to be integrally involved anyway.  One is the training and deployment of nursepractitioners discussed immediately above.  The other is the vigorous pursuit of aconcerted approach to educational initiatives discussed earlier in this document, in whichthis family of strategies is pushed further to see what its maximum impact might be.  Inthis case, the AHCs must play the lead role.  Also if they have responsibility for serviceprovision in the event that educational strategies to improve recruitment and retention fail,there will be a very strong incentive to make adjustments to admissions processes,curricula and other programs that have been slow to change so far.There would obviously be much to be worked out in the contracts betweenprovincial/territorial governments and the centres.  This approach would require thecentres to embrace an expanded mission that brought them into closer alignment withsocial needs.  It would also require an ongoing and rigorous monitoring and accountabilityrelationship between the centres and provincial/territorial governments.  Each party wouldhave to develop new skills and mechanisms for this accountability relationship to work.But this option does have the potential to utilize further some “best educational practices”that might respect personal/family considerations by attracting to rural and remote areasindividuals whose preference it is to be there, while at the same time giving responsibilityto organizations that have the capability within their institutional umbrellas to provide theneeded professional support and relief, including telemedicine support, that is so importantto rural/remote physicians.  Furthermore, if these “best practices” fall short of solving theproblem, AHCs are large enough organizations that they should be able to design deliverymodels that spread the load of providing services across a number of departments andindividuals.One disadvantage of the AHC option is that it does not alter the situation of unfetteredurban alternatives and the expenditure pressures they create for provincial/territorialgovernments and medical associations.  It just sidesteps the issue.  Another disadvantageis that it may eventually lead to a “solution” in which communities have access to servicesbut without resident physicians (or at least not the same ones, even over short periods),which doubtless is only a second-best solution from the communities’ point of view.  Athird consideration is that it places a significant management burden on the AHCs that36they may not be equipped, or willing or able to equip themselves, to handle.  Withoutfurther development of the policy option, it is not clear that effective accountabilitymechanisms could be designed.  With respect to the last of our fundamental problems, theeffects of past policy decisions on residency training, this strategy gives AHCs an inc ntiveto participate in attempts to make necessary adjustments.A final concern is that this route, by adding to the service delivery role that AHCs mayalready have in specialty care, will further distract the centres from their core missions oftraining and research.  On the other hand, however, it can be argued that the trainingmission broadly viewed is to train the types and numbers of physicians that the populationrequires.  To the extent that current maldistribution problems stem from selectionprocesses which don’t do well at identifying future rural/remote candidates, or fromfeelings on the part of graduate physicians that they are ill-equipped to practice outsideurban areas, then it may be appropriate to direct AHCs to take a more energetic interest inthe problems.Like the funding/purchasing option, this initiative would need to be pan-Canadian innature.  Each AHC would be responsible for certain regions of the cou try, and all regions(including those in provinces/territories without AHCs) would need to be covered.37So, what’s the bottom line?The bottom line is that the issue of access to medical services in rural and remote areas isone of the most complex and difficult problems in health care policy, and it should not beapproached with the expectation that it will ever be “solved” completely, to thesatisfaction of all parties.  The root of the problem is the fact that many people, physiciansincluded, prefer urban living, and policies can’t change human nature.But policies can compound or ameliorate the problems created by it, and severalcharacteristics of the current system do not help the situation. For that reason, to makeheadway will require co-ordinated policy action on multiple fronts.  Increased inter-provincial/territorial co-operation will also be essential.Precisely because the problem has until now been so resistant to the efforts of manydedicated individuals and organizations, we are reluctant to recommend dropping any ofthe current strategies that may be having at least limited success for some communities.We are equally reluctant to suggest a revisiting of “billing numbers” strategies.  In manyways, although it is unfortunately coercive, a nat onally-applied “billing numbers” optionhas the potential to be the most effective solution, and the least costly.  There is also acase for it as an appropriate management mechanism to direct publicly financed physicianresources to areas of public need.  The legal viability of this option, even includingcarefully designed variants of the original B.C. policy, is far from certain however.Provincial/territorial governments would be unwise to count on it.As for future directions, there appear to be three relatively less traveled roads to try.  First,and perhaps foremost, are changes to the funding/purchasing models for medical servicesto link funding to populations rather than to providers and their institutions in the firstinstance.  This option has the potential to alter dramatically the landscape of medicalpolitics, would be consistent with most provinces’ recent r gionalization initiatives, andmight complement provinces’ avowed intentions to “reform primary care”, although itmay be politically challenging to implement.Second, much more extensive use could be made of  non-physician personnel such asnurse practitioners, working in close consultation with regionally-based physicians.  Thisoption would require significant additional investments in training capacity and significantchanges to existing regulations if it is to be fully exploited.  It would also require moreextensive inter-professional collaboration than we have witnessed to date, both in the‘field’, and within academic training institutions across the country.  And it too promisesto be tiring politically.  But it has long been known that a no - rivial portion of primarycare can be delivered safely, effectively, cost-effectively and in a manner satisfactory topatients by health care professionals other than physicians.Third, an all-out effort could be mounted to use education-related strategies affectingphysicians throughout their career life-cycle to improve recruitment and retention eitherwith or without provincial/territorial governments assigning managerial responsibility for38rural/remote access to academic health entres.  This would clearly require new resourcesfor those centres.  Assignment of responsibility would again represent a major change tothe accountabilities within the current health care system and to the role of the AHCs,although it would at least centralize responsibility and resources with the single institutionmost likely to be capable of dealing with both personal and professional dimensions of theproblem.  The potential impact of the all-out education-related strategy is unknown,though there is some evidence of as yet unrealized gains.  The outcomes of assignment ofresponsibility to AHCs are at this point unknown.All of these options require serious political will, sustained over a long period.  Whetherthis will exists, and can be sustained across electoral cycles and over a varied politicallandscape (since a pan-Canadian approach is essential) are empirical questions.  Time willtell.  The problem is a serious one, however, and appears to have risen close to the top ofthe health policy crisis pile.  And while the existing array of strategies is better than doingnothing, it has not prevented the sharpening of rural/remote access as a policy issue.Something different and additional will have to be done in future if rural/remote access isto be improved.39Health Human Resources UnitCentre for Health Services and Policy ResearchThe University of British Columbia#429 - 2194 Health Sciences MallVancouver, BC  V6T 1Z3Telephone:  (604) 822-4810            Fax:  (604) 822-5690web site:  www.chspr.ubc.ca/Some of the early reports may not be available for distributionHHRU 99:4 INVENTORY UPDATE 98.  A Regional Analysis of Health Personnel in the Province ofBritish Columbia.  June 1999.  ISBN 1-894066-95-2.  ISSN 1196-9911.HHRU 99:3 Toward Improved Access to Medical Services for Relatively Underserved Populations:Canadian Approaches, Foreign Lessons.  (M.L. Barer, L. Wood, D.G. Schneider)  May1999, Vancouver, B.C.  ISBN 1-894066-96-0.HHRU 99:2 ROLLCALL UPDATE 98.  A Status Report of Selected Health Personnel in the Provinceof British Columbia.  May 1999.  ISBN 1-894066-97-9.  ISSN 0828-9360.HHRU 99:1 Regional Health Human Resources Planning & Management: Policies, Issues AndInformation Requirement.  January 1999.  (A. Kazanjian, M. Herbert, L. Wood, S.Rahim-Jamal).  ISBN 1-894966-98-7.HHRU 98:4 Proceedings of the Second Trilateral Physician Workforce Conference, November 14-16,1997, Vancouver.  December 1998.  (M.L. Barer, L. Wood).  ISBN 1-894066-99-5.HHRU 98:3 PLACE OF GRADUATION 97.  A Status Report on Place of Graduation for SelectedHealth Personnel in the Province of British Columbia.  A gust 1998.ISBN 1-896459-99-4.  ISSN 1200-0701.HHRU 98:2 INVENTORY 97.  A Regional Analysis of Health Personnel in the Province of BritishColumbia.  June 1998.  ISBN 1-896459-98-6.HHRU 98:1 ROLLCALL 97.  A Status Report of Health Personnel in the Province of BritishColumbia.  July 1998.  ISBN 1-896459-97-8.  ISSN 0707-3542.HHRU 97:4 Common Problems, Different 'Solutions': Learning from International Approaches toImproving Medical Services Access for Underserved Populations.  October 1997.  (M.L.Barer, L. Wood).  ISBN 1-896459-96-X.  Also listed as Health Policy Research UnitReport  HPRU 97:12D.HHRU 97:3 INVENTORY UPDATE 96.  A Regional Analysis of Health Personnel in the Province ofBritish Columbia.  July 1997.  ISBN 1-896459-95-1.  ISSN  1196-9911.HHRU 97:2 ROLLCALL UPDATE 96.  A Status Report of Selected Health Personnel in the Provinceof British Columbia.  July 1997.  ISBN 1-896459-94-3.  ISSN 0828-9360.HHRU 97:1 PLACE OF GRADUATION 95.  A Status Report on Place of Graduation for SelectedHealth Personnel in the Province of British Columbia.  April 1997.ISBN 1-896459-93-5.  ISSN 1200-0701.40HHRU 96:5 INVENTORY 95.  A Regional Analysis of Health Personnel in the Province of BritishColumbia.  December 1996.  ISBN 1-896459-92-7.HHRU 96:4 PRODUCTION 95.  A Status Report on the Production of Health Personnel in theProvince of British Columbia.  October 1996.  ISBN 1-896459-91-9.  ISSN 1199-4010.HHRU 96:3 ROLLCALL 95.  A Status Report of Health Personnel in the Province of BritishColumbia.  October 1996.  ISBN 1-896459-90-0.  ISSN 0707-3542.HHRU 96:2R Identifying the Population of Health Managers in one Canadian Province: A Two-StageApproach.  April 1996.  (A. Kazanjian, N. Pagliccia).  ISBN 1-896459-89-7.HHRU 96:1R Key Factors in Physicians’ Choice of Practice Location - Level of Satisfaction andSpousal Influence.  March 1996.  (A. Kazanjian, N. Pagliccia).  ISBN 1-896459-88-9.HHRU 95:6E Fee Practice Medical Services Expenditures Per Capita, and Full-Time-EquivalentPhysicians in British Columbia, 1993-1994.  December 1995.  (A. Kazanjian, P. WongFung, L. Wood).  Only available in an electronic format at:  www.chspr.ubc.ca/feepract/.HHRU 95:5R The Impact of Professional and Personal Satisfaction On Perceptions of Rural andUrban: Some Analytic Evidence.  December 1993.  (N.Pagliccia, L. Apland, A.Kazanjian).  ISBN 1-896459-87-0.HHRU 95:4 PRODUCTION UPDATE 94.  A Status Report on the Production of Selected HealthPersonnel in the Province of British Columbia.  May 1995.  ISBN 1-896459-86-2.ISSN 1199-4010.HHRU 95:3 Health Personnel Modelling 1975-1994: An Updated Bibliography with Abstracts.March 1995.  (N. Pagliccia, K. McGrail, L. Wood).  ISBN 1-896459-85-4.HHRU 95:2 INVENTORY UPDATE 94.  A Regional Analysis of Health Personnel in the Province ofBritish Columbia.  March 1995.  ISBN 1-896459-84-6.  ISSN  1196-9911.HHRU 95:1 ROLLCALL UPDATE 94.  A Status Report of Selected Health Personnel in the Provinceof British Columbia.  March 1995.  ISBN 1-896459-83-8.  ISSN 0828-9360.HHRU 94:5 PLACE OF GRADUATION 93.  A Status Report on Place of Graduation for SelectedHealth Personnel in the Province of British Columbia.  Octo er 1994.  (K. McGrail, K.Kerluke, A. MacDonald, L. Wood).  ISBN 1-896459-82-X.  ISSN 1200-0701.HHRU 94:4 PRODUCTION 93.  A Status Report on the Production of Health Personnel in theProvince of British Columbia.  August 1994.  ISBN 1-896459-81-1.  ISSN 1199-4010.HHRU 94:3 ROLLCALL 93.  A Status Report of Health Personnel in the Province of BritishColumbia.  May 1994.  ISBN 1-896459-80-3.  ISSN 0707-3542.HHRU 94:2 Interpreting the Historical Difficult-to-Fill Vacancy Trends - A Multivariate Analysis.April 1994.  (N. Pagliccia, A. Kazanjian, L. Wood).  ISBN 1-896459-79-X.HHRU 94:1 Social Work Personnel in British Columbia:  Defining the population and describingdeployment patterns in 1993. January 1994.  (J. Finch, A. Kazanjian, L. Wood).ISBN 1-896459-78-1.41HHRU 93:8R Health Care Managers in British Columbia  Part I: Who Manages Our System?, Part II:Exploring Future Directions.  December 1993.  (A. Kazanjian, N. Pagliccia).ISBN 1-896459-77-3.HHRU 93:7 Fee Practice Medical Services Expenditures Per Capita, and Full-Time-EquivalentPhysicians in British Columbia, 1991-1992.  December 1993.  (A. Kazanjian, P. WongFung, L. Wood).  ISBN 1-896459-76-5.HHRU 93:6 Social Workers in Health Care in British Columbia, 1991.  July 1 93.  (L.E. Apland,L. Wood, A. Kazanjian).  ISBN 1-896459-75-7.HHRU 93:5 Difficult-to-Fill Vacancies in Selected Health Care Disciplines in British Columbia,1980-1991.  June 1993.  (A. MacDonald, A. Kazanjian).  ISBN 1-896459-74-9.HHRU 93:4 ROLLCALL UPDATE 92.  A Status Report of Selected Health Personnel in the Provinceof British Columbia.  April 1993.  ISBN 1-896459-73-0.  ISSN 0828-9360.HHRU 93:3 Nursing Resources in British Columbia: Trends, Tensions and Tentative Solutions.February 1993.  (A. Kazanjian, L. Wood).  ISBN 1-896459-72-2.  Also listed as HealthPolicy Research Unit Report     HPRU 93:5D.HHRU 93:2 Nursing Resources Models: Part I: Synthesis of the Literature and a Mod lli g Strategyfor B.C.  February 1993.  (N.Pagliccia, L. Wood, A. Kazanjian).  ISBN 1-896459-71-4.HHRU 93:1 Study of Rural Physician Supply: Perceptions of Rural and Urban. Janua y 1993.(N. Pagliccia, L.E. Apland, A. Kazanjian).  ISBN 1-896459-70-6.HHRU 92:8 Diagnostic Medical Sonographers in British Columbia, 1991.  December 1992.(L.E. Apland, A. Kazanjian).  ISBN 1-896459-69-2.HHRU 92:7 Fee Practice Medical Service Expenditures per Capita, and Full-Time-EquivalentPhysicians in British Columbia, 1989-1990.  November 1992.  (A. Kazanjian, P. WongFung, M.L. Barer).  ISBN 1-896459-68-4.HHRU 92:6 PLACE OF GRADUATION 91.  A Status Report on Place of Graduation for SelectedHealth Personnel in the Province of British Columbia.  November 1992.(A. MacDonald, K. Kerluke, L.E. Apland, L. Wood).  ISBN 1-896459-67-6.ISSN 1200-0701.HHRU 92:5R Health "Manpower" Planning or Gender Relations?  The Obvious and the Oblique.  Jun1992.  (A. Kazanjian).  ISBN 1-896459-66-8.HHRU 92:4R A Human Resources Decision Support Model: Nurse Deployment Patterns in OneCanadian System.  November 1992.  (A. Kazanjian, I. Pulcins, K. Kerluke).ISBN 1-896459-65-X.HHRU 92:3 PRODUCTION 91.  A Status Report on the Production of Health Personnel in theProvince of British Columbia.  M y 1992.  ISBN 1-896459-64-1.  ISSN 1199-4010.HHRU 92:2 ROLLCALL 91.  A Status Report of Health Personnel in the Province of BritishColumbia.  May 1992.  ISBN 1-896459-63-3.  ISSN 0707-3542.HHRU 92:1 Information Needed to Support Health Human Resources Management.  February 1992.(A. Kazanjian).  ISBN 1-896459-62-5.42HHRU 91:4R A Single Stochastic Model For Forecasting Nurse Supply and For Estimating Life-CycleActivity Patterns.  May 1991.  (A. Kazanjian).  ISBN 1-896459-61-7.HHRU 91:3 ROLLCALL UPDATE 90.  A Status Report of Selected Health Personnel in the Provinceof British Columbia.  March 1991.  ISBN 1-896459-60-9.  ISSN 0828-9360.HHRU 91:2 Study of Rural Physician Supply: Practice Location Decisions and Problems inRetention.  Volume I.  March 1991.  (A. Kazanjian, N. Pagliccia, L. Apland, S. Cavalier,L. Wood).  ISBN 1-896459-59-5.HHRU 91:1 Registered Psychologists in British Columbia, 1990: A Status Report. March 1991.(C. Jackson, L. Wood, K. Kerluke, A. Kazanjian).  ISBN 1-896459-58-7.HRU 90:7 Place of Graduation for Selected Health Occupations - 1989.(HMRU 90:7) November 1990.  (S. Cavalier, K. erluke, L. Wood).  ISBN 1-896459-57-9.HHRU 90:6 Health Managers in B.C.  Part II: Who Manages Our System? - ociodemographic(HMRU 90:6) Characteristics, Employment Patterns, Educational Background and Training of HealthManagers.  June 1990.  (A. Kazanjian, C. Jackson, N. Pagliccia).  ISBN 1-896459-56-0.HHRU 90:5 Health Personnel Modelling: A Bibliography With Abstracts.(HMRU 90:5) June 1990.  (N. Pagliccia, C. Jackson, A. Kazanjian).  ISBN 1-896459-55-2.HHRU 90:4 PRODUCTION 89.  A Status Report on the Production of Health Personnel in(HMRU 90:4) the Province of British Columbia.  March 1990.  ISBN 1-896459-54-4.ISSN 1199-4010.HHRU 90:3 ROLLCALL 89.  A Status Report of Health Personnel in the Province of British(HMRU 90:3) Columbia.  March 1990.  ISBN 1-896459-53-6.  ISSN 0707-3542.HHRU 90:2 Proceedings of the Workshop on Priorities in Health Human Resources Research in(HMRU 90:2) Canada.  March 1990.  (A. Kazanjian, K. Friesen).  ISBN 1-896459-52-8.HHRU 90:1 Nurse Deployment Patterns:  Examples for Health Human Resources Management.(HMRU 90:1) February 1990.  (A. Kazanjian, I. Pulcins, K. Kerluke).  ISBN 1-896459-51-X.HHRU 89:4 Providers of Vision Care in British Columbia: A Report on the Status of(HMRU 89:4) Ophthalmologists and Optometrists, and On the Utilization of Ophthalmological andOptometric Services, 1975-1988.  July 1989.  (I. Pulcins, P. Wong Fung, C. Jackson,K. Kerluke, A. Kazanjian).  ISBN 1-896459-50-1.HHRU 89:3  Fee Practice Medical Service Expenditures Per Capita, and Full-Time-Equivalent(HMRU 89:3) Physicians in British Columbia, 1987-88.  August 1989.  (A. Kazanjian, P. Wong Fung,M.L. Barer).  ISBN 1-896459-49-8.HHRU 89:2 Health Managers in B.C.  Part I: Methods and Preliminary Findings From Survey of(HMRU 89:2) Chief Executive Officers.  July 1989.  (A. Kazanjian, N. Pagliccia, C. Jackson).ISBN 1-896459-48-X.HHRU 89:1 ROLLCALL UPDATE 88.  A Status Report of Selected Health Personnel in the Province(HMRU 89:1) of British Columbia.  March 1989.  ISBN 1-896459-47-1.  ISSN 0828-9360.

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