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Factors influencing the location of practice of residents and interns in British Columbia : implications… Wright, David Stuart 1985

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FACTORS INFLUENCING THE LOCATION OF PRACTICE OF RESIDENTS AND INTERNS IN BRITISH COLUMBIA: IMPLICATIONS FOR POLICY MAKING By DAVID STUART WRIGHT B.Sc. (Pharm), The University of Br i t ish Columbia, 1980 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health Services Planning and Administration) in THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October 1985 0 David Stuart Wright, 1985 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date DE-6(3/81) ABSTRACT Upto the middle of the 1970's most government pol icies dealing with physician manpower dealt with the problems of increasing the supply of physicians, rather than changing the geographic disparity of physicians between urban and rural areas. In 1983 the Br i t ish Columbia government introduced legislat ion (passed in a modified form in 1985) that would restr ict certain groups of physicians from obtaining Medical Service Plan b i l l i ng numbers in certain areas of the province, in an attempt to change the geographic distr ibution of physicians in this province. Regulation is only one of a number of approaches to altering the distr ibution of physicians. The purpose of this study is to attempt to recommend other approaches that could be used to alter the geographic distr ibution of physicians, based on the factors which the residents and interns of Br i t ish Columbia would consider necessary before they wi l l establish practices in the rural areas of the province. The l i terature was examined to determine the present supply and distr ibution of physicians in the province of Br i t ish Columbia. It was shown that the metropolitan areas had much higher concentrations of physicians than did the non-metropolitan regions. The l i terature was then searched to determine what types of pol icies had been used in an effort to change this geographic disparity and also to determine what factors influence physicians to locate their practices where they do. From this research a questionnaire was developed and mailed to a l l residents and interns registered in the University of Br i t ish Columbia medical program in the academic year 1984-85. A response rate of 31.8% was obtained in this survey. It was found that many physicians were raised in large communities and planned to locate their practices in similar geographic areas to where they were raised. It was also found that the factors which the residents and interns considered to be the most important f e l l into the "Fixed Determinant" category, that is factors that are personnal preferences of the physician. This makes i t very d i f f i c u l t to formulate any type of non-regulatory policy to affect the geographic distr ibution of physicians in Br i t ish Columbia. - iv -TABLE OF CONTENTS PAGE Abstract , i i Table of Contents iv L is t of Tables v i L is t of Figures ix Acknowledgements x Chapter I. Introduction 1 Chapter II. Methods of Measuring Physician Requirements and Supply 5 Physician Requirements 5 Need-Based Method 5 Demand-Based Method 7 Util ization-Based Method 8 Physician Supply 10 Shortage Cr i te r ia 14 References 20 Chapter III. The Current Supply and Distribution of Physicians 22 Current Physician Supply 22 Physician/Population Ratios 24 References 34 Chapter IV. Current Pol ic ies Directed at Changing the Geographic Distribution of Physicians 36 Regulatory Pol ic ies 37 Educational Pol icies 40 Economic Pol ic ies 46 Summary 54 References 55 Chapter V. Factors Which Affect the Location of Practice 58 Fixed Determinants 62 Climate and Geography 62 Upbringing of Physician and Spouse 64 Socio-Economic Characteristics of an Area 67 Li festyle Preferences 68 Recreational Amenities 70 - V PAGE (Chapter V continued) Manipulable Determinants 71 Negative Views of Rural Areas 71 Rural Preceptorships and Other Training 72 Professional Amenities 74 Loan Forgiveness 76 Summary 76 References 80 Chapter VI. Methodology 83 Sample 85 The Questionnaire 86 Development 86 Variables 87 Structure 89 Expectation of Findings 91 Administration 92 Coding 93 Stat is t ica l Analysis 94 References 96 Chapter VII. Results and Discussions 97 Response Rate 97 Frequency of Response 97 Cross-Tabulations of Dependent and Independent Variables 102 Determinants of Choice of Rural Practice 118 References 134 Chapter VIII. Conclusions and Recommendations 135 Bibliography 141 Appendix A Methods of Determining Physician Requirements and Supply 147 Appendix B Non-Postgraduate Physician/Population Ratios in Br i t ish Columbia by Hospital D is t r i c t . (1984) 151 Appendix C Study Questionnaire 156 - v i -LIST OF TABLES PAGE Table I Number of Directory Active Physicians Practising in Br i t ish Columbia by Specialty 1974 and 1984 23 Table II Number of Directory Active Physicians by Specialty in Metropolitan and Non-Metropolitan Regions of Br i t ish Columbia 24 Table III Comparison of National Physician/Population Ratios 25 Table IV Physician/Population.Ratios of the Canadian Provinces and Terr i tor ies 1984 26 Table V Physician/Population Ratios for Various Regional Hospital D is t r ic ts in Br i t ish Columbia 1984 28 Table VI General Practitioner and Specialist/Population Ratios Across Canada by Province 1983 29 Table VII Non-Postgraduate Physicians by Specialty per 10,000 Population for Selected Hospital D is t r ic ts 32 Table VIII Breakdown of Respondents by Indicated Specialty 100 Table IXa Area in Which a Physician Plans to Establish a Practice by the Sex of the Physician 103 Table IXb Area in Which a Physician Plans to Establish a Practice by Marital Status 103 Table IXc Area in Which a Physician Plans to Establish a Practice by Age 104 Table X Area in Which a Physician Plans to Establish a Practice by Area in Which Physician was Raised 105 Table XI Area in Which a Physician Plans to Establish a Practice by Type of Training 106 Table XII Area in Which a Physician Plans to Establish a Practice by Specialty 107 Table XIII Size of Community in Which a Physician Plans to Establish a Practice by Specialty 108 Table XlVa Area in Which a Physician Would Most Like to Establish a Practice by Sex of Physician 110 - v i i -PAGE Table XlVb Table XIVc Table XV Table XVI Table XVII Table XVIII Table XIX Table XX Table XXI Table XXII Table XXIII Table XXIV Table XXV Table XXVI Table XXVII Area in Which a Physician Would Most Like to Establish a Practice by Marital Status 110 Area in Which a Physician Would Most Like to Establish a Practice by Age 111 Area in Which a Physician Would Most Like to Establish a Practice by Area Raised 111 Area in Which a Physician Would Most Like to Establish a Practice by Type of Training 112 Area in Which a Physician Would Most Like to Establish a Practice by Specialty 112 Size of Community in Which a Physician Plans to Establish a Practice by Size of Community in Which the Physician was Raised 113 Area in Which Physicians Plan to Establish Their Medical Practices by the Area in Which the Physicians were Raised, Controlling for Rural Training 116 Size of Community in Which Physicians Plan to Establish Their Medical Practices by the Size of Community in Which the Physicians Were Raised, Controlling for Rural Training 117 Frequency and Percent Selection of Factors by A l l Respondents 118 Frequency and Percentage Selection of Factors by Sex, Marital Status and Age of Physician 120 Frequency and Percentage Selection of Factors by Specialty of Physician 121 Response Rate of Guaranteed Net Income Plus Set of Minimum Conditions 126 Response Rate of Guaranteed Net Income Alone 126 Frequency of Selection of Guaranteed Income Level Plus Other Factors by Sex, Marital Status and Age of Physician 129 Frequency of Selection of Guaranteed Income Level Plus Other Factors by Specialty of Physician 129 - v i i i -PAGE Table XXVIII Frequency of Selection of Guaranteed Income Level ALONE by Sex, Marital Status and Age of Physician 130 Table XXIX Frequency of Selection of Guaranteed Income Level ALONE by Specialty of Physician 130 - ix -LIST OF FIGURES PAGE Figure 1 Model for Physician Manpower Distribution Process Figure 2 The "Avenues" of Postgraduate Medical Training in Br i t ish Columbia 84 s ACKNOWLEDGEMENTS A study of this type can only be completed with the help of many people. I would l ike to take this time to thank a l l of those persons, who were in some way involved in this study. I would l ike to single out several individuals and groups who deserve special recognition for their help in this project. F i r s t l y , my thesis supervisor, Dr. Morris Barer. I am grateful for a l l the help and suggestions made by Dr. Barer. I also appreciate his help with the photocopying and distr ibution of the study questionnaires. My two other committee members, Dr. Nancy Waxier-Morrison and Dr. William Buchan, also deserve many thanks for the work and aid they committed to this thesis. I would also like to thank a good fr iend, Mrs. Catherine Garnett for her proof-reading and edi tor ia l comments. Dr. Barer 1s staff should also be thanked for their help in sorting out the questionnaires as they were returned. Elizabeth M. Zook's help in typing the f inal draft of this manuscript is also greatly appreciated. Final ly I would l ike to thank my family for putting up with me while the f inal editions were being prepared. CHAPTER I INTRODUCTION Up to the middle of the 1970's most medical manpower pol icies in Canada and Br i t ish Columbia were aimed at increasing the number of physicians practising in these regions. These pol icies have had a great effect on the number of physicians in Canada and Br i t ish Columbia, but only in particular areas of the country and the province. The metropolitan or urban areas tend to have higher concentrations of physicians than do the rural areas. This has caused both the federal and provincial governments to change their manpower pol icies in an attempt to reduce the geographic disparity of physicians between urban and rural areas. In Br i t ish Columbia, there have only been two pol icies speci f ica l ly aimed at changing the geographic distr ibution of physicians. These are: a di f ferent ia l fee schedule known as the Northern and Isolation Allowance for physicians in remote areas of the province; and the most recent, an attempt to restr ict certain specialt ies from obtaining a Medical Service Plan (MSP) b i l l ing number in certain urban areas of the province. An MSP b i l l ing number is essential for doctors to b i l l the medical service plan for the services they provide for their patients. The evidence tends to point out that these pol icies have had very l i t t l e effect on the geographic distr ibution of physicians and that therefore the urban areas of Br i t ish Columbia continue to have a disproportionate supply of certain types of physician specia l is ts . The^question to be addressed in this thesis i s : What types of incentives would have to be offered to physicians before they would be wil l ing to practise in rural and remote areas of the province? - 2 -In order to answer this question, the Rosenthal and Frederick model for physician manpower distribution process, presented in Figure 1, wi l l serve as the framework for this thesis. Figure 1; Model for Physician Manpower Distribution Process Medical School Selection Process A Country's perceived need for Physician Man power Medical Socialiation and Education = 0 Changing Socia l , P o l i t i c a l and Economic Factors. Changing Health Po l ic ies , Programs and Implementation Individual's Choice of Specialty and Location Uncontrolled and Unforeseen Alternatives From: Rosenthal, Marilyn; Deborah Frederick. "Physician Maldistribution in Cross Cultural Perspective: United States, United Kingdom and Sweden." in Inquiry. Vol . XXI, No. 2, Summer 1984. pp 60-74. There are three areas in this model which wi l l not be dealt with in this thesis. These are: i) the medical school selection process; i i ) the changing soc ia l , po l i t i ca l and economic factors of the country or province; and i i i ) the uncontrolled and unforeseen alternatives. - 3 -A country's perceived need for physician manpower wi l l serve as the basis for Chapters II and III. The method and problems associated with determining the requirements and supply of physicians wi l l be presented in Chapter II. The methods to be examined are: i) Need-based; i i ) Demand-based; and i i i ) Uti l ization-based. As well several formulae which are used to determine whether an area has a physician shortage or is an underserviced area wi l l be examined and discussed. In Chapter III the current stock of physicians in Canada and in Br i t ish Columbia wi l l be examined. This stock wi l l include both the number of general practitioners and special ists currently practising. Physician/population ratios wi l l then be used to examine the distr ibution of physicians in these regions. The overall Canadian ratio wi l l be compared with that of several other industrial ized nations to give an indication of where Canada ranks in the world. The Canadian ratio wi l l then be broken down into general practitioner/population and specialist/population ratios for each of the provinces and terr i tor ies to give an indication of where Br i t ish Columbia ranks in Canada. The Br i t ish Columbia ratios wi l l be further broken down into hospital d is t r ic ts and various special ist groups to give an indication of the variation between urban and rural areas of the province. The pol ic ies which are currently being used to change the geographic distr ibution of physicians wi l l be examined in Chapter IV. This chapter would - 4 -be equivalent to the box labelled "Changing health po l ic ies , Programs and Implementation" in the model. The pol icies under examination wi l l f a l l into one of three categories: i ) Regulatory i i ) Educational or i i i ) Economic. They wi l l be discussed from within this framework. The pol ic ies currently being used in Br i t ish Columbia wi l l be compared to pol icies currently in use in other Canadian provinces as well as those in other nations. This chapter wi l l also contain a discussion on the effectiveness of some of these po l ic ies . The individual 's choice of specialty and location wi l l be the topic covered in Chapter V. This chapter wi l l look at the factors which have been found to be important in influencing where physicians locate their practices. These factors wi l l be examined as being either Fixed Determinants - those which pol icies or incentives wi l l have no effect upon, or Manipulable Determinants - those which pol icies or incentives may be able to effect . Chapter VI wi l l describe the methodology used in the gathering of data for this thesis. In this chapter the sample wi l l be discussed, as wil l the questionnaire and i ts development. The results and a discussion of them wi l l be presented in Chapter VII. The f inal chapter in this thesis wi l l present recommendations for the basis of future pol icies which may be used to change the geographic distr ibution of physicians in Br i t ish Columbia. - 5 -CHAPTER II METHODS OF MEASURING PHYSICIAN REQUIREMENTS AND,DISTRIBUTION. Many problems are associated with defining what .an adequate supply of physicians would be for a particular region and in doing so, establishing physician requirements. These problems are fundamental to determining whether there exists a "geographical maldistribution" of physicians in a region or between regions. Since there is no uniformly accepted method of measuring either the distr ibution of physicians or unmet needs (1), this chapter wi l l br ief ly examine and discuss the three most commonly used methods - i ) need-based; i i ) demand-based; and i i i ) uti l ization-based - of determining physician requirements.(2) This wi l l be followed by a discussion about how the supply of physicians presently practising in a region is determined and wi l l conclude with several definit ions of medically underserviced or physician shortage areas. PHYSICIAN REQUIREMENTS  Need-Based Method This method of determining the physician requirements for a particular community starts by assessing the current health status of the population and then attempts to determine the number of physicians needed to attain and maintain a good health status. The overall health status of the population is often determined by measuring the frequencies and types of i l lnesses among various subsets of the population. From this measurement of i l l n e s s , "expert" opinion determines how much service would be required to treat the i l lness - 6 -present. This service is then converted into manpower requirements.(2-6) (See Appendix A, where Evans' (6) model is presented.) Lomas, Barer, and Stoddart (2) point out that because of the vagueness of the def ini t ion of NEED and the complicated measures required, this method is very seldom used for determining physician requirements. Despite th is , these authors state that three approaches to measurement can be taken to determine physician requirements under this method. The f i rs t approach uses epidemiological surveys "to estimate...the extent of the ideal v s . observed health status d e f i c i t , and to translate such def ic i t into health services requirements".(p.48) In order to measure the def ic i t between ideal and observed health status the following indices must be compiled: i) overall health status;( l ,7) i i ) composition of the population - age, sex mix;(l,7) i i i ) infant mortality rates;(7,8) iv) incidences and rates of disease;(2) and v) environmental and occupational factors which affect health; (1,9) Once the observed health status has been measured the number of physicians required to address the disease incidence is calculated. This serves as the base year physician requirement from which future requirements can be derived. The second need-based approach uses patient- ini t iated demand for treatment or information as a proxy for need. This type of approach s t i l l leaves unmet needs unaccounted for and wi l l incorporate some demand that does not represent need. In order to establish physician requirements estimates would have to be - 7 -made on the health services which would be required to satisfy adjusted episodic requests. The third approach uses present ut i l i za t ion of health services as a proxy for need. This ut i l i za t ion has to be modified to account for unmet needs and over-ut i l izat ion in order to arrive at accurate requirements. Present u t i l i za t ion , as adjusted for these factors, then can be translated into the base year physician requirement using workload information. Demand-Based Method The demand-based method focuses on the demand for physicians' services in a particular region to arrive at the base year requirements. Under this method a dist inction must be made between need for and demand for services. Demand has been stated to depend on the underlying health status of the community and wi l l only exist when need is backed up with purchasing power.(5,10) It is based on socio-economic and demographic variables of the population and i ts willingness to pay for or buy health services.(1,5) Lomas et. a l . (2) note that demand is an expression of personal choice, rather than a joint personal /social / professional determination. These authors also state that demand is affected by prevailing prices and individual resource constraints. In order to determine physician requirements under the demand-based method, present u t i l i za t ion rates can be used as a proxy. If these rates are used, only pat ient- ini t iated requests should be considered as demand. Also, some demand may not be expressed in the ut i l i za t ion rates due to physicians' refusal to provide some services. Lomas et. a l . (11) cite abortion as such an example of this type of demand. In order to arrive at the base year requirements, the same - 8 -steps are taken as described previously under the second approach of the need-based method, except that unmet need is not accounted for. Another way of determining physician requirements has been developed by Rowley and Baldwin (10). These authors claim that most demand-based approaches to determining physician requirements are either too simplistic or too complicated. Therefore, they developed the Health Services Marketing Formula, (see Appendix A) which attempts to determine the number of physicians that could be supported within a particular region. This is determined by counting the number of potential v i s i t s and multiplying this by the average cost of a v i s i t to obtain the total revenues which would be available. The total revenue is divided by the total yearly cost of operating a physician's practice. The total cost takes into account the physician's salary and of f ice overhead expenses. Although this determines the total number of physicians who could be supported in the region, this formula could also be used to determine the number of general practitioners and special ists which could be supported by the area in question. This formula may also be c lass i f ied as a modified ut i l i za t ion approach to determining physician requirements because i t uses both demand-based and uti l ization-based measurements. The number of patient- init iated v i s i t s may approximate demand, but average cost per v i s i t is a u t i l i za t ion determinant. Util ization-Based Method This method of determining physician requirements states that the service requirements are whatever is being provided for and ut i l i zed by the population in the region.(2) In other words, i t assumes that the current supply of physicians in the region is the number that is required to give adequate medical - 9 -care to the region's population. This supply also acts as the base year requirement in the calculation of future requirements. This method focuses on services provided and takes as given the organization of the delivery system.(4, p.34) This method sets as i t s standards the amount of service which the community expects. It directs attention to manpower utilization rather than health needs. It is also known as the Service Targets Method and is the most often used method in Canada. Lomas et. a l . (2) claim that two problems arise and are not taken into consideration when this method is used. These problems are: i) demand or need wi l l not be translated into utilization in the absence of supply; in other words, i t does not take account of need where there are no providers. and i i ) providers can influence the population to use more or less of a particular service. Other considerations which have to be taken into account when this method is used to determine physician requirements include: i) the number of hospital f a c i l i t i e s or other health services in the region and their utilization rates;(1,2,11) and i i ) the d i f f i c u l t y in determining specific specialist/ population ratios because general practitioners may perform some "specialists" duties in remote areas.(2,11) Once the base year physician requirements are determined, they must be converted to future requirements. Again two approaches can be taken.(2) The f i r s t is by considering that no modification to the delivery system will occur. In this approach the only considerations which must be accounted for are: the - 10 -changing population in the region in terms of growing numbers and a changing age/sex mix; and other exogenous factors which affect morbidity (eg: env ironment). The second approach is to consider modifications to the health care delivery system. Under this approach not only wi l l the demographic features (as above) have to be addressed but the changes in the delivery system wi l l also have to be considered. These changes could include: personnel mix; technology; practice organization and governmental po l ic ies . The preceding section has br ie f ly described the three methods which can be used to determine physician requirements. Because the ut i l i za t ion or supply-based method has been the one most often used in Canada (11), and because the next chapter in this thesis wi l l discuss the current supply of physicians in Br i t ish Columbia (in terms of actual numbers and physician/population ra t ios) , the next section of this chapter wi l l discuss how the current supply of physicians can be determined. PHYSICIAN SUPPLY The uti l ization-based method presented in the preceding section alluded to physician/population ratios as a variable in determining physician requirements. i This ratio is the most widely used method of determining physician requirements and distr ibution in Canada (11) and i t is also the easiest to calculate. The physician/population ratio relates the number of physicians to the population in the area. The steps outlined by Lomas, Stoddart and Barer (11), for determining the physician/population ratio are l isted in Appendix A. Basical ly , the ratio divides the current supply of physicians in an area by the population of the same area, to obtain a physician/population ra t io . This ratio can then be used to compare one area with another or estimate future physician requirements by multiplying the ratio by the expected future population.(3-5,11) Although this would seem to be a very easy ratio to calculate, problems arise when the numerator (the current supply of physicians) has to be determined. The ratios which are calculated wi l l depend on who has been defined as a physician and where the data are obtained.(1,2,5,6,11-17) In Canada data can be obtained from the provincial Colleges of Physicians and Surgeons. These data include a l l Directory Active Physicians or a l l physicians who have been licensed by the appropriate College to practise in that province.(11,13,15-17) The data obtained from a provincial College wi l l not only include these physicians, but also physicians who are: i ) practising in another province; i i ) not practising due to postgraduate commitments; i i i ) involved in research or administration; or iv) retired.(11,15-17) Two problems may arise when provincial college numbers are used to determine physician supply and requirements. F i rst the actual number of physicians involved in c l i n i c a l areas wi l l be upwardly biased due to the inclusion of a l l physicians on the colleges' registers. The second problem arises i f college totals are used for interprovincial comparisons. The ratios calculated from these totals wi l l be misleading, i f the interest is in relative c l i n i c a l supply because the number of physicians involved in non-cl in ical act iv i t ies may vary across provinces. Other sources of data on the number of physicians practising in Canada can be obtained from the Sales Management Systems (SMS), Revenue Canada, and Federal Government Medicare tapes.(11,13) The SMS data include records on a l l Active C iv i l ian Physicians. The information is obtained from provincial licensing bodies, provincial medical associations and medical schools. It provides information on the migration of physicians both to and from Canada. It does not ref lect level or mix of physician activi ty nor is allowance made to c lassi fy physicians in other than their cer t i f ied special t ies. It also does not provide information on the number of physicians who are abroad, re t i red, or in the military.(11) The data obtained from the Federal Government Medicare tapes are converted into physician Full-time-Equivalents (FTE's) depending on the amount of money physicians have received from medicare payments. By using these data three different FTE measurements are generated. The f i rs t defines one FTE on the basis of earnings, as any physician who has received $20,000 or more in medicare payments. Physicians who received less than $20,000 are counted as part ial FTE's proportionately. The second defines an FTE on the basis of s ta t i s t i ca l adjustments. In the definit ion an FTE is defined as any physician who b i l led medicare during each quarter and whose income is greater than 50% of the median income for his specialty.(11) Foulkes (14) argues that income should not be used as the basis for determining FTE's , but that the basis should be workload. He claims that by using incomes the number of FTE's calculated wi l l be misleading. He also claims that this method is inappropriate i f "the objective is to plan medical manpower to meet the requirements of prospective patients with due consideration given to a l l factors including the avai labi l i ty of other - 13 -resources. . . and physicians' preference for hours of work" (p.271). The third FTE definit ion is calculated by counting a l l physicians who submitted at least one claim to medicare. A study carried out by Barer, Wong Fung and Hsu (15) wi l l help to point out how differing estimates of the physician supply for an area can be generated. In the f i rs t part of their study, the authors attempted to determine the supply of physicians in Br i t ish Columbia for the year 1981-82. In order to determine the supply the authors used two different sources, i ) the records of the College of Physicians and Surgeons of Br i t ish Columbia (CPSBC) and i i ) records of u t i l i za t ion and payments made by the Medical Services Plan of Br i t ish Columbia. They used as their definit ion of a physician "a l l practitioners registered with the CPSBC and therefore licensed to practise in the province". From the records of the CPSBC, the authors determined that there were 7,094 directory active physicians registered in the province. Only 5,684 resided in Br i t ish Columbia and this was further reduced to 5,306 when only "non-postgraduate directory active in B.C." and "postgraduate paying directory active in B.C." physicians were counted. The authors then tr ied to determine the supply of physicians through the calculation of FTE's based on the physicians' earnings paid through the Medical Services Plan. Various cutoff points and approaches were used in determining specif ic FTE's. The authors found a range from a low of 3,648 based on the number of physicians earning at least one-half the median earnings in peer type of practice, to a high of 4,857 when an FTE was defined as a physician who received some remuneration from the Medical Services Plan in f isca l year 1981-82. The second half of the study used these FTE's in an attempt to - 14 -determine whether or not there was any maldistribution of physician services in the province. The results of this half of the study wi l l be examined in the next section of this chapter. As has been seen from the above discussion many definit ions of physicians are used and also many different FTE's can be calculated from the same data. This makes the designation of an area as being a medically underserviced area very d i f f i c u l t . The following section wi l l examine some of the c r i te r ia which have and are being used to designate such areas. 7 SHORTAGE, CRITERIA There seem to be as many formulae used to d e s i g n a t e areas as b e i n g m e d i c a l l y u n d e r s e r v i c e d o r p h y s i c i a n shortage areas as t h e r e are methods o f d e t e r m i n i n g p h y s i c i a n r e q u i r e m e n t s and s u p p l y . Most o f t h e s e formulae use a comb i n a t i o n o f requirement measurements - such as percentage o f p o p u l a t i o n aged 65 o r o v e r , i n f a n t m o r t a l i t y r a t e , u t i l i z a t i o n r a t e s and i n d i c a t o r s o f h e a l t h s t a t u s ; and supply measurements - such as p h y s i c i a n / p o p u l a t i o n r a t i o s , as p r o x i e s f o r the c r i t e r i a f o r d e s i g n a t i n g m e d i c a l l y u n d e r s e r v i c e d and p h y s i c i a n s h o r t a g e a r e a s . In t h i s s e c t i o n shortage c r i t e r i a w i l l be examined under each o f the Need, U t i l i z a t i o n and Demand based methods o f d e t e r m i n i n g p h y s i c i a n r e q u i r e m e n t s . NeedxBased A l l o f the formulae a l l u d e to the o v e r a l l h e a l t h s t a t u s o f the p o p u l a t i o n to be s e r v i c e d . T h i s i s one o f the b i g g e s t problems with the use o f these formulae - t r y i n g t o determine the o v e r a l l h e a l t h s t a t u s o f the p o p u l a t i o n and therefore the amount of service required in the area. This is usually determined by a panel of "experts".(1,5,7,12) This is often referred to as a professional or optimal standard and i t has been claimed that a shortage could be identif ied in ALL areas by using this type of assessment.(5) In the United States two different formulae are currently being used to designate medically underserviced and manpower shortage areas. Under the Health Maintenance Organization Act of 1973, an Index of Medical Underservice used to designate an area as being medically underserviced, is computed as the weighted sum of the following four variables; i ) the ratio of primary care physicians per 1,000 population; i i ) the percentage of the population with a household income below the poverty l ine; i i i ) the infant mortality rate; and iv) the percentage of the population aged 65 years and older. A value below 62 (the average value calculated for a l l counties in the United States) designates an area as being medically underserviced.(8) The second formula in use in the United States, was created under the Health Professions Educational Assistance Act of 1976.(7) This act defines regions as being health manpower shortage areas based on the following c r i t e r i a : i) the primary care physician/population ratio of the area; i i ) the infant mortality rate; i i i ) the overall health status of the area; iv) the access to health services; - 16 -and v) other indicators of need such as hospital f a c i l i t i e s and ut i l i za t ion rates of the fac i l i t i es . (1 ,7 ) Despite the other c r i te r ia mentioned, the primary care physician/population ratio carries the most weight and an area is c lass i f ied as having a manpower shortage i f this ratio is below 1/3,500.(7) In Great Br i ta in , the RAWP Formula has been developed as a means of assessing and allocating health resources.(1) This formula is similar to the two formulae used in the United States. It takes into account the following indicators when allocating resources to regions of the country: ~ i ) the composition of the population (age, sex mix); i i ) the indicators of the health status; i i i ) the ut i l i za t ion rates of health services; iv) economic and po l i t i ca l factors; and v) environmental and occupational factors which affect health. More recently, in the United States, Hadley (9) has proposed that the economic theory of production be used as the framework for determining whether physician or other health manpower distr ibution problems exist . He states "that this theory is a representation of how firms combine resources to produce f inal products in the most ef f ic ient manner."(p.1057) In order to apply this theory to health manpower, Hadley states that there must be an acceptable measure of "health", and that health is the f inal product (function) of a combination of medical care and other factors which affect health and can be described in the following s ta t is t ica l relationship: - 17 -D = f(M,B,H,E) where: D = the health measure or f inal product; M = medical care (current stock of health manpower); B = behavioral factors; H = heredity factors; and E = environmental factors. In theory Hadley claims that by applying his formula an adequate supply of health manpower would be determined by the overall health measure of the region. The lower the health measure, the greater the need for health manpower in that area. At present none of these methods are used in Canada or Br i t ish Columbia to identify or designate underserviced or manpower shortage areas. As mentioned previously, Barer, Wong Fung and Hsu (15) in the second half of their study attempted to i l lust ra te that apparent interregional supply dispari t ies were in many instances upward biased by the use of physician location rather than patient location. They did this by assessing the distr ibution of physicians in two ways. The f i rs t method was based on allocating each practitioner to the Regional Hospital Distr ict (RHD) containing his/her off ice and the second method attempted to allocate "pieces" of each physician to the RHD of his/her serviced patient population. The physician stock used were the specialty specif ic FTE's calculated in the f i rs t part of their study and the RHDs of the patients were based on the payments of the Medical Service Plan. They found that by allocating the physicians to the estimated RHD of their patients changed the distr ibution of physician services rather dramatically for many types of - 18 -practice. That i s , the apparent extent of "maldistribution" was found not to be as bad as i t or ig inal ly looked. Many of the special ists who were established in the Greater Vancouver area of the province served as provincial resources. Other cri t icisms of these methods of determining physician shortages have included: need is only determined from a professional viewpoint and substitution of services is not taken into account (5,8); the cutoff point at which a shortage is defined is often very arbi t rar i ly chosen (8,9); there are no standards for defining need or the concept of underserviced (5,8); and some of the variables used are not related to health.(8) Demand-Based Under the demand-based method of calculating physician requirements, shortages can arise under the following c r i t e r i a : i) Excess Demand - when demand for physician services exceeds supply at the prevailing prices (1,5); and i i ) P o l i t i c a l Shortage - when i t is perceived that the public is wil l ing to pay more in taxes for more medical services (1,5,12). Uti l ization-Based As with the other two methods of determining physician requirements, shortage situations can arise when the uti l ization-based method is used. A shortage may be defined when the physician/population ratio for one area is lower than the mean ratio of similar regions.(5,12) Depending upon the ratio chosen to designate a shortage, there wi l l always be areas which are c lass i f ied as being underserviced. Two methods for defining what an appropriate ratio - 19 -ought to be are: i ) a committee of experts reviews the health conditions in the area and sets a standard (3,13); and i i ) the ratio chosen is the highest in a particular area and acts as the target which should be met in a l l other areas.(13) As has been seen throughout this chapter every method used in the determination of an adequate supply and distribution of physicians has i ts own set of problems. In the next chapter the current supply of physicians in Canada and Br i t ish Columbia wi l l be outl ined. This supply wi l l then be converted to physician/population ratios to compare Br i t ish Columbia with the other provinces in Canada. F inal ly the physician/population ratios for the hospital d is t r ic ts in Br i t ish Columbia wi l l be compared to point out the distribution patterns of physicians in the province. The rationale for using this method is that i t is the one that is most often used in comparing various countries and regions in terms of manpower and therefore these ratios are readily available. - 20 -REFERENCES 1. Rosenthal, Marilyn and Deborah Frederick. "Physician Maldistribution in Cross Cultural Perspective: United States, United Kingdom and Sweden." In Inquiry. Vol.XXI No . l , Spring 1984. pp 60-74. 2. Lomas, Jonathan; Morris Barer; and Greg Stoddart. Physician Manpower  Planning: Lessons from the Macdonald Report. Prepared as an Ontario Economic Discussion Paper. Draft ed. January 1985. 3. Aziz , Jawed. Supply and Requirements for Physicians in Canada. Health Manpower Report 5/75. Health & Welfare Canada. Ottawa, 1975. 4. United States." Methodological Approaches for Determining Health Manpower  Supply and Requirements. Vol . I & II. DHEW Publication No. (HRA) ~^ 76-14512, 1976. 5. Lave, Judith; Lester Lave; & Samuel Leinhardt. "Medical Manpower Models: Needs, Demand and Supply." In Inquiry. Vol . XII No.2, 1975. pp 97-125. 6. Evans, R.G. Strained Mercy: The Economics of Canadian Health Care. Butterworths & Co. L t d . , Toronto, 1984. ' • ' 7. Werner, Jack; Kathryn Langwell; & Norbert Buddie. "Designation of Physician Shortage Areas: The Problems of Specialty Mix Variations." In Inquiry. Vol.XVI No . l , Spring 1979. pp 31-37. 8. Kviz, Frederick & Jacquel'yn Flakerud. "An Evaluation of the Index of Medical Underservice." In Medical Care. Vol.22 No.10, October 1984. pp 877-889. 9. Hadley, Jack. "Alternative Methods of Evaluating Health Manpower Distr ibut ion." In Medical Care. Vol.XVII No.10, October 1979. pp 1054-1060. 10. Rowley, Beverly; & DeWitt Baldwin. "Assessing Rural Community Resources for Health Care: The Use of Health Services Catchment Area Economic Marketing Studies." In Social Science & Medicine. Vol.18 No.6, 1984. pp 525-529. 11. Lomas, Jonathan; Greg Stoddart; and Morris Barer. "Supply Projections as Planning: A C r i t i c a l Review of Forecasting Net Physician Requirements in Canada." In Social Science, & Medicine. Vol.20 No.4, 1985. pp 411-424. 12. American Medical Association. Contributions^to a Comprehensive Health  Manpower Strategy. Chicago 1973. > v '> ' 13. Roos, N.L.; M. Gaumount; & J.M. Home. "The Impact' of the Physician Surplus on the Distribution of Physicians Across Canada". In Canadian  Public Pol icy. Vol.11 No.2, Spring 1976. pp.169-191.' - 21 -14. Foulkes, Richard. "Observations on the Studies of the Joint Committee on Medical Manpower. i s i t a Real Basis for Planning or A Euphemism for Income Pooling and Physician Reduction?" In B.C. Medical Journal. Vol.26 No.5, May 1984. pp 272-273. 15. Barer, Morris; Patrick Wong Fung; David Hsu. "Referal Patterns, Full-Time-Equivalents and the ' E f f e c t i v e ' Supply of Physician Services in B r i t i s h Columbia." In Conference Volume; Second Canadian Conference on Health  Economics. Boan, J.A* ed. Saskatchewan, Regina, -1984. 16. B r i t i s h Columbia. Report of the Joint Committee on Medical Manpower. V i c t o r i a , November 1982. 17. University of B r i t i s h Columbia. R o l l c a l l Update 84. D i v i s i o n of Health Services Research and Development. A p r i l 1985. CHAPTER III THE CURRENT SUPPLY AND DISTRIBUTION OF PHYSICIANS. Despite the inadequacies inherent with the use of physician/population rat ios, these figures "generally serve as a reasonable proxy for the distr ibution of health services."(1) These figures wi l l therefore be used throughout this thesis to indicate the distr ibution of physicians in Canada and part icularly Br i t ish Columbia. In this chapter physician/population ratios wi l l be presented to show the distr ibution of physicians in general starting on a national level and gradually working down towards physician spec ia l is t / population ratios for urban and rural areas of Br i t ish Columbia. Before the physician/population ratios are examined, the growth of the current stock of physicians and the actual number of physicians practising wi l l be examined. Due to the education pol icies (which wi l l be discussed in the next chapter) implemented by the various levels of governments in the United States and Canada, the number of practising physicians has increased greatly over the past twenty years. The number of board-certif ied physicians in the United States nearly tr ipled between 1960 and 1977 (2) and the enrollment in medical schools more than doubled in the same period.(3,4) It has also been estimated that by 1990, there could be a surplus of 70,000 physicians in the United States.(2) Similar s ta t is t ics can be found in Canada and Br i t ish Columbia. CURRENT PHYSICIAN SUPPLY Between 1961 and 1983 the number of active c i v i l i a n physicians practising in Canada (a l l physicians who are registered with their respective provincial Colleges of Physicians and Surgeons) increased from 18,363 (5) to 41,440.(6) - 23 -This is an increase of 125%, while during the same period of time the overall Canadian population only increased by 33%.(6) It has been estimated that i f the current supply of physicians continues to increase at the same rate, there wi l l be a surplus of almost 6,000 physicians in the country by the year 2000.(5) In Br i t ish Columbia the number of directory active physicians (a l l physicians registered by the College of Physicians and Surgeons of Br i t ish Columbia) practising has risen from 4,310 in 1974 to 6,206 in 1984.(7) This represents an increase of 44% over this ten year period. Table I shows the increase in the number of physicians by medical specialty groups between 1974 and 1984. TABLE I NUMBER OF DIRECTORY ACTIVE PHYSICIANS PRACTISING IN , BRITISH COLUMBIA BY SPECIALTY 1.974 AND 1984. SPECIALTY* GENERAL PRACTICE CLINICAL SPECIALTIES SURGICAL SPECIALTIES LABORATORY SPECIALTIES 1974(8) 2,129 993 709 70 1984(7) Average Annual Percentage Change 3,095 1,523 916 142 4.5 5.3 2.9 10.3 *For definit ion of specialt ies see Reference 7 Table II compares the increasing number of physicians, by specialty group, practising in metropolitan and non-metropolitan areas of Br i t ish Columbia in 1974 and 1984. From this table i t can be seen that the number of general practitioners has increased by approximately the same percentage over the ten year period. The number of laboratory special ists has dramatically increased more so in the metropolitan areas. The number of c l i n i c a l and surgical special ists practising in non-metropolitan areas seems to have increased by a - 24 -higher percentage than in.the metropolitan areas, but as is shown by the physician/population ratios in Appendix B, most of these physicians are practising in the larger non-metropolitan communities. TABLE II NUMBER OF DIRECTORY ACTIVE PHYSICIANS BY SPECIALTY GROUP IN METROPOLITAN AND NON-METROPOLITAN REGIONS OF BRITISH COLUMBIA METROPOLITAN NON-METROPOLITAN SPECIALTY 1974(8) 1984(7) 1974 1984 ALL PHYSICIANS 2,674 3,798 1,252 1,878 GENERAL PRACTICE 1,272 1,847 857 1,248 CLINICAL SPECIALTIES 818 1,211 175 312 SURGICAL SPECIALTIES 511 632 198 284 LABORATORY SPECIALTIES 50 108 20 34 The number of physicians practising in an area does not easily lend i t s e l f to defining a shortage or surplus of physicians in that area. The rest of this chapter wi l l be devoted to presenting physician/population ratios to compare Br i t ish Columbia with the other provinces in Canada. PHYSICIAN/POPULATION RATIOS As of December 1983 the Canadian physician/population ratio was found to be 1/512 when a l l active c iv i l i an physicians, residents and interns were counted.(6) When residents and interns are excluded from the count the national ratio decreases s l ight ly to 1/604. Both of these ratios place Canada among the most "doctored" nations in the world in terms of physician/population ra t ios . In Table III Canada's physician/population ratio is compared to that of several other industrial ized nations. - 25 -TABLE III COMPARISON OF NATIONAL PHYSICIAN/POPULATION RATIOS NATION RATIO CANADA UNITED STATES -WEST GERMANY UNITED KINGDOM JAPAN 1/603 (9) 1/622 (") 1/516 (") 1/761 (") 1/868 (") Although these ratios are form the mid-1970's and different definit ions of "physician" may have been used to determine the rat ios, they do point out that Canada has one of the highest physician/population ratios among industrial ized nations, but they do not give any indication of the distribution of physicians in these nations.(10) These ratios also indicate that even in the mid-1970's Canada, l ike the other nations was very close to the optimum physician/population ratio of 1/600 as set by the World Health Organization.(1,11) There is a wide variation in the physician/population ratios throughout Canada when the individual provinces and terr i tor ies are taken into consideration. Again the figures in Table IV represent a l l Active C iv i l ian physicians, excluding residents and interns. - 26 -TABLE IV PHYSICIAN/POPULATION RATIOS OF THE CANADIAN PROVINCES AND TERRITORIES 1983("6T PROVINCE - RATIO NEWFOUNDLAND PRINCE EDWARD ISLAND NOVA SCOTIA NEW BRUNSWICK QUEBEC ONTARIO MANITOBA SASKATCHEWAN ALBERTA BRITISH COLUMBIA YUKON NORTHWEST TERRITORIES 1/733 1/848 1/610 1/831 1/577 1/589 1/605 1/733 1/720 1/529 1/720 1/1,256 The provincial ra t ios , as seen in Table IV range from a high of 1/529 in Br i t ish Columbia to a low of 1/1,256 in the Northwest Terr i tor ies . Most of the other provinces have physician/population ratios of less than 1/750. Similar distr ibution patterns are seen in other nations. In the United Kingdom, for example, regional ratios were found to range from 93.5 - 160.,3 physicians per 100,000 population.(12) This is equivalent to ratios of 1/624 -1/1070. In the United States many areas have been c lass i f ied as underserviced because they have physician/population ratios lower than 1/3,500 (13), while other areas have ratios as high as 1/500.(14) Several studies and reports (1,8,16,17) have shown that even when a province has a high physician/population ra t io , there can be great discrepancies between urban and rural areas. Using 1977 data, Rubin (15) points out that across Canada in communities of under 10,000 population, the physician/population ratio was found to be 1/1,158. This ratio rose to 1/630 for communities of between 10,000 to 99,999 population and to 1/528 for communities of over 100,000 population. This situation is found in a l l provinces and terr i tor ies in Canada. In his study on medical manpower in Alberta, Angus (16) found that although Alberta had an overal l physician/ population ratio of 1/691, Edmonton and Calgary both had ratios well above th is , while remote areas such as Peace River and Medicine Hat had ratios well below the provincial average. Similar results were found by Roos, Gaumont and Home (1) in their study of the "surplus" of physicians and their d istr ibut ion. This study also pointed out that physician/population ratios increased more rapidly in the rural areas than in the urban areas between 1968 and 1974. The authors attribute this to the fact that the population in the rural areas did not / increase as fast as that in the urban settings. Northcott (17), who also studied the medical manpower situation in Alberta, found that over the twenty year period from 1956 to 1976, the distr ibution of physicians between urban and rural areas has not changed greatly and that the urban areas s t i l l have higher ratios than the rural areas. The situation in Br i t ish Columbia is very similar to that found in Alberta. The physician/population ratios for eight out of the province's twenty-nine regional hospital d is t r ic ts are found in Table V. These ratios are of a l l directory active physicians in the hospital d i s t r i c t . A complete table is presented in Appendix B. - 28 -TABLE V PHYSICIAN/POPULATION RATIOS FOR VARIOUS REGIONAL "HOSPITAL DISTRICTS IN BRITISH COLUMBIA 1984(7) HOSPITAL DISTRICT RATIO TOTAL BRITISH COLUMBIA 1/504 TOTAL METROPOLITAN 1/383 CAPITAL (VICTORIA) 1/364 GREATER VANCOUVER 1/386 TOTAL NON-METROPOLITAN 1/747 BULKLEY-NECHAKO 1/1,138 EAST KOOTENAY 1/749 MOUNT WADDINGTON 1/1,330 OKANAGAN-SIMILKAMEEN 1/568 PEACE RIVER-LIARD 1/1,198 THOMPSON-NICOLA 1/637 The hospital d is t r ic ts chosen for Table V include Vancouver and V ic tor ia , the two metropolitan (urban) areas found in the province, as well as a variety of mixed urban-rural d is t r ic ts (based on the size of the largest community in the hospital d is t r ic t ) l ike Thompson-Nicola and Okanagan-Similkameen, and mainly rural d is t r ic ts (again based on the size of the largest community in the hospital d is t r ic t ) l ike Bulkley-Nechako and Mount Waddington. From the data presented in Table V i t is clear that the urban areas of the provinces have much higher concentrations of physicians than do the rural areas. The non-metropolitan ratios range from 1/533 to 1/1,330 with the average being 1/747. This is approximately half of the ratio found in the metropolitan areas and is approximately equal to 2/3 the provincial average of 19.86 per 10,000 (1/504). In the s t r ic t l y rural d is t r ic ts the ratios average 8.37 per 10,000 (1/1,195) or less than one-half the provincial average. Again these ratios tend - 29 -to point out that many areas have a high concentration of physicians while others do not. These ratios do not indicate the breakdown between general practitioners and special ists in a given region. In Table VI data are presented to indicate the general practitioner and specialist/population ratios for Canada, as well as each province and terr i tory. The physicians included in the ratios in Table VI are a l l active c iv i l i an physicians excluding interns and residents. TABLE VI GENERAL PRACTITIONER AND SPECIALIST/POPULATION ,RATIOS ACROSS CANADA-BY PROVINCE ,1983(6) SPECIALISTS ' M l PROVINCE GENERAL PRACTITIONER CANADA 1/1,183 1/1,232 NEWFOUNDLAND 1/1,156 1/2,005 PRINCE EDWARD ISLAND 1/1,466 1/2,010 NOVA SCOTIA 1/1,146 1/1,304 NEW BRUNSWICK 1/1,499 1/1,865 QUEBEC 1/1,252 1/1,070 ONTARIO 1/1,163 1/1,193 MANITOBA 1/1,152 1/1,276 SASKATCHEWAN 1/1,161 1/1,988 ALBERTA 1/1,342 1/1,551 BRITISH COLUMBIA 1/986 1/1,142 YUKON 1/864 1/4,320 NORTHWEST TERRITORIES 1/1,633 1/5,444 Although there is a two-fold difference between the lowest and highest general practitioner ratios across the provinces, there is an even wider variat ion in the special ist rat ios. For example the general practitioner ratios range from 1/1,633 to 1/864 and the special ist ratios range from 1/5,444 to 1/1,142. The general practitioner ratio for Br i t ish Columbia, as noted in the table, is the second highest of a l l provinces and terr i tor ies and the special ist - 30 -r a t i o i s the h i g h e s t . T h i s v a r i a t i o n i n c r e a s e s s u b s t a n t i a l l y when the r a t i o s f o r c e r t a i n t y p e s o f s p e c i a l i s t s are look e d at i n d i v i d u a l l y . F o r example the d e r m a t o l o g i s t / p o p u l a t i o n r a t i o i n New Brunswick was found to be 1/700,000 v e r s u s the n a t i o n a l average o f 1/71,474 (6) and the p e d i a t r i a n / p o p u l a t i o n r a t i o i n P r i n c e Edward I s l a n d was found to be 1/130,000 v e r s u s the n a t i o n a l average o f 1/16,469.(6) These f i g u r e s i n d i c a t e , i n o t h e r words, t h a t t h e r e was one o f each o f t h e se s p e c i a l i s t s to se r v e the e n t i r e p r o v i n c e . S i m i l a r r a t i o s , a l t h o u g h not as d r a m a t i c , can be found f o r o t h e r t y p e s o f s p e c i a l i s t s i n the o t h e r p r o v i n c e s . (15) The problems o f i d e n t i f y i n g the areas o f the p r o v i n c e i n which g e n e r a l p r a c t i t i o n e r s and s p e c i a l i s t s are p r a c t i s i n g when p r o v i n c i a l averages are examined, are the same as t a k i n g the n a t i o n a l average and t r y i n g t o i n f e r the d i s t r i b u t i o n o f p h y s i c i a n s a c r o s s the c o u n t r y . In o r d e r to d i s t i n g u i s h what ty p e s o f s p e c i a l i s t s are p r a c t i s i n g and where, a p r o v i n c i a l average again must be d i v i d e d i n t o h o s p i t a l d i s t r i c t s and s p e c i f i c s p e c i a l t i e s . In h i s study o f A l b e r t a m e d i c a l manpower, Angus (16) found a g e n e r a l p r a c t i t i o n e r / p o p u l a t i o n r a t i o o f 89.3 per 100,000 or 1/1,120 but when he broke t h i s r a t i o down i n t o urban and r u r a l a r e a s , the r a t i o s were found to be 106.4/100,000 o r 1/940 i n the urban areas and 62.9/100,000 o r 1/1,590 i n the r u r a l a r e a s . The r a t i o determined by Angus may p o s s i b l y be h i g h e r than t h a t found i n T a b l e VI due to a d i f f e r e n c e i n the d e f i n i t i o n o f " g e n e r a l p r a c t i t i o n e r " used i n the stud y . T h i s f i n d i n g i s c o n t r a d i c t e d to some e x t e n t by N o r t h c o t t (17), who found t h a t when the r a t i o o f g e n e r a l p r a c t i t i o n e r s was looked at by census t r a c t i n A l b e r t a , t h e r e was almost an e q u i t a b l e d i s t r i b u t i o n between r u r a l and urban areas i n 1976. Yet when the r a t i o s were compared by - 31 -i n c o r p o r a t e d c i t i e s , towns and v i l l a g e s , t h e r e was a h i g h c o n c e n t r a t i o n o f g e n e r a l p r a c t i t i o n e r s i n r u r a l a r e a s . The two s t u d i e s do agree on t h e i r f i n d i n g s r e g a r d i n g s p e c i a l i s t s . Angus fo und that the overfill specialist/population ratio to be 55 100,000 (1/1^805) f o r A l b e r t a . When broken down t h i s r e v e a l e d a r a t i o o f 87.2/100,000 (1/1,147) i n urban areas and 6.3/100,000 (1/15,873) i n the r u r a l a r e a s . N o r t h c o t t found a h i g h e r c o n c e n t r a t i o n o f a l l s p e c i a l i s t s i n the urban a r e a s . He a l s o i n d i c a t e d t h a t t h e r e was a t h r e s h o l d p o p u l a t i o n f o r each group o f p h y s i c i a n s i n h i s study. He d e f i n e d t h r e s h o l d as 75% o f a l l towns i n a g i v e n s i z e c a t e g o r y h a v i n g at l e a s t one p r a c t i s i n g s p e c i a l i s t . The t h r e s h o l d p o p u l a t i o n s were: g e n e r a l p r a c t i t i o n e r s , 1,000-1,499 p o p u l a t i o n ; g e n e r a l surgeons, 10,000-24,999 p o p u l a t i o n ; p r i m a r y c a r e p h y s i c i a n s ( f a m i l y p r a c t i t i o n e r s , i n t e r n i s t s , p e d i a t r i c i a n s and o b s t e t r i c i a n s ) and o t h e r s p e c i a l i s t s , o v e r 25,000. S i m i l a r d a t a r e g a r d i n g the d i s t r i b u t i o n o f g e n e r a l p r a c t i t i o n e r s and pri m a r y c a r e p h y s i c i a n s f o r B r i t i s h Columbia can be found i n T a b l e V I I . The f i g u r e s p r e s e n t e d i n T a b l e V I I are the number o f non-postgraduate p h y s i c i a n s per 10,000 p o p u l a t i o n f o r s e l e c t e d r e g i o n a l h o s p i t a l d i s t r i c t s . The r e g i o n a l h o s p i t a l d i s t r i c t s i n T a b l e V I I are the same as those s e l e c t e d f o r T a b l e V. A g a i n , a more complete t a b l e can be found i n Appendix B. - 32 -TABLE VII NON-POSTGRADUATE PHYSICIANS BY SPECIALTY PER 10,000 POPULATION FOR SELECTED REGIONAL HOSPITAL piSTRICTS (7) HOSPITAL DISTRICT G.P. F .p. G .S. I .M. PED. OB/GYN* TOTAL BRITISH COLUMBIA 9.19 1 .64 0 .91 1 .43 0 .61 0 .54 METROPOLITAN 10.76 1 .92 1 .02 2 .28 0 .94 0 .76 CAPITAL (VICTORIA) 12.43 1 .84 1 .18 2 .08 0 .55 0 .63 VANCOUVER 10.41 1 .94 0 .99 2 .32 1 .02 0 .79 NON-METROPOLITAN 7.55 1 .36 0 .79 0 .54 0 .26 0 .31 BULKLEY-NECHAKO 6.84 1 .22 0 .49 0 .00 0 .00 0 .00 EAST KOOTENAY 8.96 0 .53 1 .41 0 .70 0 .18 0 .18 MOUNT WADDINGTON 6.27 0 .63 0 .00 0 .00 0 .00 0 .00 OKANAGAN-SIMILKAMEEN 9.23 1 .68 1 .17 0 .84 0 .50 0 .50 PEACE RIVER-LIARD 5.57 0 .66 0 .82 0 .33 0 .00 0 .16 THOMPSON-NICOLA 7.20 1 .40 1 .03 0 .84 0 .75 0 .65 * G.P. = GENERAL PRACTITIONER G.S. = GENERAL SURGEON PED. = PEDIATRICIAN F.P. = FAMILY PRACTITIONER I.M. = INTERNAL MEDICINE OB/GYN = OBSTETRICIAN/GYNECOLOGIST As seen in Table VII, the d i s t r i b u t i o n pattern of s p e c i a l i s t s i n B r i t i s h Columbia i s very s i m i l a r to that in Alberta. The metropolitan areas of B r i t i s h Columbia have a high concentration of a l l s p e c i a l t i e s and the s p e c i a l i s t / population r a t i o s in these areas are a l l higher than the p r o v i n c i a l averages. The mixed urban-rural h o s p i t a l d i s t r i c t s have sp e c i a l i s t / p o p u l a t i o n r a t i o s which are almost equal to the p r o v i n c i a l averages, and in most instances the r a t i o s found are higher than the non-metropolitan averages. It can also be seen from the data in Table VII that these d i s t r i c t s , l i k e the metropolitan d i s t r i c t s , have a complete complement of primary care s p e c i a l i s t s , as defined by Northcott. The mainly r u r a l d i s t r i c t s , a l l have s p e c i a l i s t / p o p u l a t i o n r a t i o s well below the p r o v i n c i a l average and in most instances below the non-metropolitan averages. - 33 -Also, these d is t r ic ts lack certain of the primary care specia l is ts , most notably pediatricians and obstetr icians. It should be noted here that although there is a wide variat ion in the specialist/population ratios throughout Br i t ish Columbia, some of these special ists may require a certain threshold population before moving into a particular area.(17) The demographics of a particular region may also dictate the types of special ists which are required in that region. These two topics are beyond the scope of this thesis and wi l l only be dealt with i f they are found to be factors which influence where physicians tend to locate their practices. This wi l l be discussed in Chapter V. In the next chapter the pol icies which have been and are being used in an attempt to change the geographic distr ibution of physicians wi l l be examined. - 34 -REFERENCES 1. Roos, N.L.; M. Gaumont; & J.M. Home. "The Impact of the Physician Surplus on the Distribution of Physicians Across Canada." In Canadian Public.  Pol icy, Vol . II No. 2, Spring 1976. pp 169-191. " 2. Schwartz, W.B.; J . P . Newhouse; B.W. Bennett & A.P. Williams. "Changing Geographic Distribution of Board-Certified Physicians." In New England  Journal of Medicine, Vol . 303 No. 18, Oct. 30, 1980. pp 1032-1038. i 3. Ha l l , F.R.; P.C. Whybrow. "Financial Aid for Medical Students: A Review and a Proposal." In Journal of Medical Education, Vol . 59 No. 5, May 1984. pp 380-385. ! r — ~ 4. Freun, Mary; & James Cantwell. "Geographic Distribution of Physicians: Past Trends and Future Influences." In Inquiry, Vol . XIV No . l , Spring 1982. pp 44-50. 5. Canada. Physician Manpower in Canada 1980-2000. A report of the Federal/ Provincial Advisory Committee on Health Manpower. Ottawa, October 1984. 6. Canada. I. Active C iv i l i an Physicians, by Type of Physician, Canada, by . Province, December 1983. II. General Practitioners and Family Physicians,  and Special ists by .Specialty Grouping, Canada by Province December 31,  1977- December 31, 1983. Mimeo Health & Welfare Canada, March 1984. 7. University of Br i t ish Columbia. Ro l lca l l Update 84. Division of Health Services Research and Development"! Vancouver, B . C . , Apr i l 1985. 8. Rol lca l l ?4. Division of Health Services Research and Development. Vancouver B.C. March 1979. 9. Kuran, George T. The, Book of World Rankings. Facts on F i le Inc., New York, New York, 1979. 10. Rosenthal, M.; & D. Fredrick. "Physician Maldistribution in Cross Cultural Perspective: United States, United Kingdom & Sweden." In Inquiry, Vo l . XX No. l , Spring 1984. pp 60-74. 11. Aizenman, Al lan. "The oncoming hordes: physicians in Canada." In CMA  Journal, Vo l . 127, Dec. 15, 1982. pp 1177-1179. 12,. Maynard, Alan; & Arthur Walker. Royal Commission on the National Health Service. Doctor Manpower 1975-2000: Alternative Forecasts and Their  Resource Implications.' Research paper ~W. London, 1978. ~ 13. Wise, D.A.; & C . J . Zook. "Physician Shortage Areas & Pol icies to Influence Practice Location." In Health Services Research Part II, Vol . 18 No. 2, Summer, 1983. pp 251-269. . ; - 35 -14. Woolf, M.A.; & V. U c h i l l ; & I. Jacoby. "Demographic factors associated with physician s t a f f i n g in r u r a l areas: The experience of the National Health Services Corp." In Medical Care, Vol. XIV No. 4, A p r i l 1981. pp 444-451. 15. Rubin, Joe. "Placement incentives: w i l l they lure doctors into underserviced areas? In CMA Journal, Vol. 124 No. 10, May 15, 1981. pp 1360-1366. 16. Angus, Douglas E. A Study of Medical Manpower in Alberta 1963-72. S t a t i s t i c s Canada D i v i s i o n . February 1976. 17. Northcott, H.C. "Convergence or Divergence: The Rural-Urban D i s t r i b u t i o n of Physicians and Dentists i n Census Div i s i o n s and Incorporated C i t i e s , Towns, and V i l l a g e s in Alberta, Canada 1956-1976." In S o c i a l Science &  Medicine, Vol. 14D, 1980. pp 17-22. CHAPTER IV CURRENT POLICIES DIRECTED AT CHANGING THE GEOGRAPHIC DISTRIBUTION OF PHYSICIANS. Ever since 1914, when small communities in rural Saskatchewan offered physicians a public salary to work in their town (1,2), a l l levels of government in Canada have tr ied to establish pol icies and incentives which would entice physicians to practise in rual and remote areas of the country. A l l pol icies affecting practice location and geographic distr ibution f a l l into one of the following three channels as defined by Evans:(3) "(i) Use of state authority to regulate occupations, either direct ly or indirect ly . ( i i ) Provisions of subsidies for educational costs, and the determination of how much and what kind of training capacity wi l l be available. and ( i i i ) The structuring of public delivery or reimbursement systems to determine how many of what classes of people shall be hired to provide or reimburse for providing, which kinds of service." (p. 299) In other words, Evans states that, through the use of occupational regulations; educational subsidies; and reimbursement mechanisms, governments have tr ied to develop incentives which would induce physicians to establish practices in rural areas. In this chapter the pol ic ies which are presently in place in Br i t ish Columbia wi l l be discussed within the context of this regulatory, educational and economic framework. They wi l l be compared to those pol icies currently being used in other nations, and other Canadian provinces. REGULATORY POLICIES Through the f i rs t channel, that of occupational regulation, Evans (3) states that the boundaries between occupations are established. As well , the "processes of production" (the type of training required) and the legal i t ies of using these s k i l l s are laid out. To a limited degree this channel has been used in other countries, and quite successfully, in an attempt to have physicians set up practices in rural areas. Medical students in Poland were required to complete a mandatory two year period of rural service before they would be granted a medical l icence, but the program was disbanded in 1963 when the country had a suff icient supply of rural physicians.(1) This type of program is s t i l l carried out in other nations. Norway, for example, requires students to do a six month assistantship to a d is t r ic t doctor before licensure.(1) Mexico has required a period of "social service" in a rural area since 1935, and has recently extended the period from six months to one year. Malaysia and the Soviet Union, also require a certain period of rural practise before students are granted a medical licence.(2) In Canada, the federal government modified i ts Manpower and Immigration Act in 1975 by reclassifying physicians into the group of professions which are given zero occupational points on their immigration applications.(4) This effect ively barred the immigration of physicians to Canada, except for those situations in which a provincial College of Physicians ver i f i es that a physician is required for a certain posting. In 1982 approximately 140 physicians qualif ied to enter Canada under this provision.(5) Those physicians who are allowed to immigrate to Canada may s t i l l face licensure restr ict ions in several provinces. These restr ict ions may indicate - 38 -where these immigrant physicians may practise as well as any further educational training which is required in order to obtain a f u l l medical licence in the province.(1,4-8) Several provinces require that graduates of foreign medical schools do at least one or two years of preregistration training before they become e l ig ib le for a medical l icence. These provinces include Ontario, Quebec and Br i t ish Columbia. The College of Physicians and Surgeons of Br i t ish Columbia has indicated that by 1986, only those graduates from medical schools c lass i f ied as being in Category I, as defined by the College, wi l l be e l ig ib le for licensure in the province.(5) Other restr ict ions placed on immigrant physicians can include the issuance of only a temporary licence and being restricted to working in underserviced areas. When the immigrant physicians gain their Canadian ci t izenship, they are usually granted a f u l l licence and can practise anywhere in the province with which the physician has registered. It has been noted that once these physicians have gained either landed immigrant status or c i t izenship, they tend to move out of the underserviced and rural areas to the more urban centres.(7) The same observation has been made in the United States. Physicians, who have completed two years of practise in an underserviced area in exchange for their military service tend to migrate back to the urban areas.(2,9) Lately, government regulations, especially in Canada, have become prominent in establishing where physicians are allowed to set up their practises. These regulations (10,11,12) not only indicate where a physician may practise, but also (in Quebec) indicate the amount of reimbursement per service the physician may receive. In Great Br i ta in , where this type of regulation has been used since the early 1950"s, the government designates the areas which are considered - 39 -"open" for physicians to set up a practice and receive reimbursement under the National Health Service.(1,13) The Br i t ish government also has control over the avai labi l i ty of training and practice postings for physicians. A similar situation has evolved in Sweden since 1969, when the National Board of Health & Welfare became responsible for postgraduate medical training. In both countries, the governments have limited the number of postgraduate hospital or specialty postings available, while at the same time increasing the number of postgraduate general practitioner postings. This , plus an increase in the status of general practi t ioners, has been claimed to have greatly reduced the distr ibution problems of general practitioners in both countries.(13) A more drastic form of regulation is carried out in Tunisia. In this country a l l newly licensed physicians are completely banned from practising in the capital and largest c i ty in the country.(2) Several areas in Canada have tr ied to repel and "ban" physician manpower in overserviced areas by restr ict ing hospital pr ivi leges. It has been noted that this has had no demonstrable effect on the distr ibution of physicians.(8) Similar legislat ion was proposed in Br i t ish Columbia in 1983. Under the province's proposed leg is la t ion , B i l l 24,(11) physicians would be denied a Medical Services Plan (MSP) b i l l i ng number in an area which had been c lass i f ied as overserviced. (An MSP b i l l ing number is required by a physician in Br i t ish Columbia in order to b i l l the medical service commission for the services which are provided to his patients.) Although this b i l l was never enacted into law, several sections were applied, part icularly those sections which enabled the Medical Services Commission to restr ict the issuance of b i l l i ng numbers in certain areas of the province. In early 1985 these sections were challenged in - 40 -the courts and found to be unconstitutional in the Br i t ish Columbia Supreme Court.(14) After this court ru l ing, the Bri t ish Columbia government quickly proposed new legislat ion during i ts 1985 spring s i t t ing . The government introduced a new b i l l known as B i l l 50. This b i l l was quickly revoked and replaced with B i l l 41. B i l l 41 was passed and proclaimed as the Medical Service  Amendment Act in May 1985.(12) Section 8.1 of this act states that any physician applying for an MSP b i l l i ng number within the f i rs t 90 days of the act's passage would be granted one provided they had previously submitted an application form to the commission after September 1, 1983 and had participated in the Medical Services Plan at anytime in the preceding two years. Although now guaranteed a b i l l i n g number, the physicians could s t i l l face certain restr ict ions laid out in Section 8.2 of the Act. One of these restr ict ions is that the b i l l ing number may only be va l id in a specif ic geographic region of the province. It is too early to determine i f this form of regulation wi l l have any effect on the distribution of physicians in Br i t ish Columbia. It has been claimed that this regulation may have just the opposite effect to what was intended. Physicians who would have located in rural areas for short periods of time may not do so now because they are afraid of not being able to establish a practice in the Vancouver or Victor ia areas later in their careers.(15) EDUCATIONAL POLICIES  Supply Expansion Evans (3) claims that "the state has a fundamental role in determining the numbers and types of professions that are to be trained through i ts funding and - 41 -subsidy po l ic ies . " This can be accomplished in the medical context by one of two methods: i ) by altering the number of positions available in the medical schools, and i i ) by controll ing the numbers and types of postgraduate residency positions that are available. This type of approach has been c lass i f ied as the Supply-Side policy (16) or Accumulation programs (8) to encourage physicians to practise in rural areas. The premise behind (i) is that by increasing the supply of physicians in an area, some physicians wi l l eventually migrate into the less attractive areas, which are often the rural and remote areas.(17) Certain examples of this type of policy have already been c i ted , eg: the control of the number of postings available in Great Britain and Sweden. Hall (18) in his 1964 Royal Commission on Health Services, implied that before physicians could be distributed to the remoter areas, there would have to be enough of them to service the urban areas. In this report Hall recommended that seven new medical schools would have to be constructed by the mid-1970's, and programs for postgraduate specialt ies would have to be increased i f Canada were to have enough physicians to service i ts expected population. A provincial report for Ontario also recommended that a sixth medical school be established in that province. This , i t stated, was necessary in order that the province could become self suff icient in terms of meeting i ts increased need for physicians.(19) Upon these recommendations, the Canadian provinces, l ike many other areas increased the number of medical schools and also increased the - 42 -enrollment in existing schools during the late 1960's and early 1970's. Br i t ish Columbia was an exception and f i rs t year medical school enrollment was not increased to 100 students unti l 1979 and was expected to reach 160 students within the next few years.(20) Current f i rs t year intake to the U.B.C. medical school is 130 students per year.(5) Under the Health Professions Educational Assistance Act of 1963, the United States federal government has provided capitation grants to medical schools to increase their enrollment.(21) As well i t has provided construction grants to other postgraduate institutions to build more medical schools. As previously mentioned, the philosophy behind increasing medical school enrollment was that as the urban areas become "overdoctored", the increasing numbers of physicians would distribute themselves to the more remote areas due to "market conditions". Evidence of this " t r ickle down theory" (22) due to the "surplus" of physicians is very contradictory in the l i terature. Schwartz et. a l . (23) claim that by 1979, the surplus had influenced the distr ibution of board-certif ied physicians to rural areas of the United States because they found that a l l towns with a population of greater than 2,500 had ready access to a physician. On the other side, Hynes and Givner (16), Schrag (17), and Fruen and Cantwell (24) claim that only the larger towns, of at least 25,000 population, saw any real increase in their physician/population rat ios. Even when medical schools were moved into smaller communities, as in I l l i n o i s , physicians were s t i l l found to be attracted only to those communities which had a population of greater than 25,000.(25) Due to the increasing numbers of doctors graduating from medical schools, and not much change in the physician distr ibution pattern, the federal - 43 -government in the United States started to decrease the amount of funding i t provided to medical schools in 1980.(13) This change in policy wi l l have very l i t t l e effect unt i l the late 1980's, due to the long periods needed to train physicians. Similar recommendations have also been made in Canada in recent years. Hall (26) in 1980 stated that even though there are now a suff icient number of physicians in Canada, certain specialt ies are s t i l l in very short supply. He recommended that the deans of medical schools form a manpower study group to look into th is . In an attempt to restr ic t the number of physicians in Ontario, the province has recently decided to cut back the number of postgraduate residency positions available which wi l l be followed by lower undergraduate medical enrollment.(27) Similar recommendations have also been made by the Federal/Provincial Advisory Committee on Health Manpower.(5) This committee has recommended: i) that by 1986 the output from Canadian postgraduate training in General Practice be reduced by 125 positions/year with a further reduction of 20% by 1991. i i ) that by 1994 there be a 20% reduction of output from Canadian postgraduate training to Medical specialt ies stock. i i i ) that effective 1985 the f i r s t year medical enrollment in Canadian medical schools be reduced by 17%, and iv) that effective measures be adopted to ensure physicians establish only in areas of demonstrated need for medical serv ices. o - 44 -Loan Foregiveness Programs The United States Government also provided scholarships, bursaries and loans to aid medical students fund their education.(9,13,16,17,21,28,29) Under this program, the loans did not have to be repaid by the students i f they promised to practise in rural underserviced areas after graduation. This program appears to have had l i t t l e effect on the distribution of physicians in the United States. Upwards of 45% of the students who have received loans buy their way out of the commitment.(17,29) In 1976 the Health Professions Educational Assistance Act was revised in an attempt to make i t harder for students to buy out their loans.(9) One proposed method for solving the geographic maldistribution of physicians in the United States is that medical students who have their education subsidized through loans would only be e l ig ib le to receive a temporary medical licence unti l they f u l f i l l e d their obligation of service in an underserviced area.(30) Despite the large increase in the number of physicians graduating from American medical schools, Hall & Whybrow (21) argue that loan forgiveness programs should be maintained at their present levels in that country. Several Canadian provinces also use loan forgiveness programs in an attempt to encourage physicians to practise in rural areas. These provinces include: Newfoundland, Nova Scotia and New Brunswick (for psychiatry residents), Ontario and Manitoba. Other provinces have established similar bursaries for other health professions as well.(31) Under a l l of these plans the students who receive loans for their undergraduate tuit ion must promise to practise in a rural area for an equivalent length of time for which loans were received. If the rural service is not completed, the student is often required to repay the f u l l amount of the loans received plus any accumulated interest. Between 1969 - 45 -and 1974 (when this program was temporarily suspended) 220 medical students partook in Ontario's loan forgiveness program. Of these students, one-half f u l f i l l e d their obligations to practise in the rural regions of the province and 73 of these continued to practise in these areas after their obligations had been fu l f i l l ed . (7 ) Ontario's program was reinstated in 1978. Again this type of program has been recommended for Br i t ish Columbia.(20) Under the proposed B.C. plan, students who accepted loans would have to f u l f i l l their obligations of practising in a rural area. Payback of the loans would only be considered under the most extreme circumstances. Rural Training Programs Like the Canadian provinces, none of the American states require that their medical students perform any rural service before l icensure, but most of them do offer this opportunity to students at some point in their training.(32-34) One American state, Minnesota, has a special rural physician program within i ts medical curriculum. The purposes of this program are: (i) to encourage medical students to choose primary care careers and practise in rural areas of the state, and ( i i ) to place special emphasis on the c l i n i c a l , humanistic, economic and sc ient i f ic approaches to health care and disease management.(33) The students receive a $5,000 yearly stipend from the state and are not required to return to a rural area after completion of their medical t raining. Up to 1976, of the one hundred and sixty-three students who had completed the program, twenty-seven were in practise in rural areas and f i f ty-eight were in primary care residency programs. In the northeastern states, several medical schools offer primary care residency programs in rural areas.(34) These programs are - 46 -r e a d i l y accepted by the s t u d e n t s , many o f whom s t a y to p r a c t i s e i n the a r e a a f t e r t h e i r r e s i d e n c y t r a i n i n g has been completed. A l t h o u g h some o f the r u r a l t r a i n i n g programs seem to have been s u c c e s s f u l i n the d i s t r i b u t i o n o f p h y s i c i a n s to r u r a l a r e a s , most have n o t . Schrag (17) has proposed one method o f s o l v i n g the p h y s i c i a n d i s t r i b u t i o n problem i n the U n i t e d S t a t e s . T h i s p r o p o s a l would r e q u i r e a minimum o f f o u r y e a r s o f p r a c t i s e i n an u n d e r s e r v i c e d area as a c o n d i t i o n o f admission to m e d i c a l s c h o o l and f i n a l m e d i c a l l i c e n s u r e . Schrag a l s o s u g g e s t s t h a t new l i c e n c e s s h o u l d o n l y be i s s u e d i n areas t h a t are c l a s s i f i e d as u n d e r s e r v i c e d . T h i s type o f s e r v i c e has a l s o been recommended as a method o f improving the g e o g r a p h i c d i s t r i b u t i o n o f p h y s i c i a n s i n B r i t i s h Columbia. B l a c k (20) advocated t h a t a l l f o u r t h y e a r m e d i c a l s t u d e n t s s h o u l d complete a minimum e i g h t week summer p r e c e p t o r s h i p i n a r u r a l community and p o s s i b l y some form o f compulsory s e r v i c e a f t e r g r a d u a t i o n . At the same time, B l a c k s t a t e d t h a t the s t u d e n t s who p a r t i c i p a t e i n the r u r a l t r a i n i n g programs shou l d r e c e i v e h i g h e r s a l a r i e s f o r t h i s t r a i n i n g than they c u r r e n t l y r e c e i v e i n an attempt to a t t r a c t more s t u d e n t s to t h i s program. In B r i t i s h Columbia, b e s i d e s the i n c r e a s e d e n r o l l m e n t at the m e d i c a l s c h o o l and the summer p r e c e p t o r s h i p s , no o t h e r forms o f e d u c a t i o n a l p o l i c i e s have been t r i e d i n an attempt to a f f e c t the g e o g r a p h i c d i s t r i b u t i o n o f p h y s i c i a n s . ECONOMIC POLICIES Economic i n c e n t i v e s , such as guaranteed incomes, d i f f e r e n t i a l fee s c h e d u l e s , s u b s i d i z e d h o u s i n g and o t h e r f a c i l i t i e s , which would f a l l i n t o Evans' (3) t h i r d c h a n n e l , have been and are being used to d i s t r i b u t e p h y s i c i a n s to - 47 -rural areas. The most widely used form of economic incentive would be a guaranteed net income. This format is used in many nations, as well as several Canadian provinces. In Norway, the Distr ic t Doctor Program guarantees that a physician wi l l receive a basic salary for assuming public health responsibi l i t ies in the area in which he practises. In conjunction with the basic salary, the physician can also b i l l the insurance plan for regular c l i n i c a l services he has performed.(1,17) This program also offers physicians who practise in northern regions of the country other incentives such as: subsidized housing, longer holiday periods and credits towards receiving specialty status i f desired.(1) Austral ia , also uses a salary system for rural physicians. Under the Australian system physicians are paid a salary to see patients during certain hours each day. If a v i s i t is required outside these hours, the physician is allowed to b i l l the national health insurance plan for his services.(1) Other regions which use salaries to entice physicians to set up practises in very sparsely populated areas include: Scotland, New Zealand and several of the American states.(2) Although guaranteed incomes are available in some areas of Canada, i t has been claimed that the largest economic incentive here, is the Universal Medical Insurance Plan.(7,8) With the introduction of the plan in 1968, i t was claimed that physicians who chose to practise in rural areas would not face any economic barriers in terms of not being able to earn a "decent" income, as a l l physicians would receive the same fee for service regardless of where they practised and payment of these fees was guaranteed by the provincial governments. Despite the Universal Medical Insurance Plan, the distribution of physicians in rural areas - 48 -has not greatly changed since 1968, and therefore guaranteed incomes are s t i l l offered in several provinces. The offering of a guaranteed salary for physicians is widely used in various regions of Canada. Ontario, Newfoundland, New Brunswick and Manitoba (6,7,31,32) a l l use this form of incentive to entice physicians to establish a practice in the rural areas of these provinces. In Newfoundland physicians were offered positions within the Cottage Hospital system, or as Dis t r ic t Health Officers and were guaranteed an annual salary of between $50,800 and $63,000 to work in remote outposts of the province.(6,31,32) Although this program seems to work in Newfoundland, most of the recruits have been from Great Britain.(8,31) The province used to also pay a l l costs for the physician to move back to Britain after he had spent two years in the province.(8) Ontario has had a guaranteed income program for general practitioners since 1969. In 1978 the program was expanded to include special ists will ing to set up practices in Northern Ontario. Under Ontario's program, general practitioners who set up a practice in Northern Ontario could be guaranteed an annual income of $38,000, or an income tax free grant of $40,000 paid out over four years. Special ists under this program receive a $20,000 tax free grant paid over three years. The program also aids underserviced areas in southern Ontario, but in these regions the guaranteed income and grants are lower. A general practit ioner who sets up a practice in an underserviced region of southern Ontario, is guaranteed either a $28,000 net income or a grant of $15,000 paid over four years.(6,7,31,35) Upon the tenth anniversary of the program, 499 physicians had set up practices in rural Ontario communities and as of September - 49 -1979, 275 were s t i l l practising in these areas.(7,35) There has been a high turnover rate among the special ists who enter the program.(7) Manitoba has become the latest province to offer physicians a guaranteed income to practise in rural areas. Again, l ike Ontario, Manitoba offers either a guaranteed income of $40,000 or an income tax free grant paid over four years.(31,32) Unlike Ontario's plan, once a physician has joined in Manitoba, he has contracted to stay in the rural community for at least one year, after which he may renew his contract.(32) Various communities in Alberta also offer physicians, part icularly specia l is ts , guaranteed income levels and other fringe benefits to establish practises in these communities.(32) Nova Scotia does not have a guaranteed income program, but i t does provide income subsidies to physicians practising in rural areas.(31) In Nova Scotia subsidies are only paid to physicians practising in remote areas where they are the sole physician for the region. Such physicians are engaged by the government to practise in the area for a minimum period of twelve months. If the physician leaves the area before his contract has expired, he may be required to repay the government an appropriate portion of the subsidy received.(31) Br i t ish Columbia also does not have a guaranteed income program, in such terms, but does offer similar income subsidies to i ts physicians practising in remote areas of the province which amount to a guaranteed income.(31,35) The subsidies provided in Br i t ish Columbia depend on the fee-for-service income made by the physician, as well as the size and isolat ion of the community. The subsidy provided can range up to $42,000 per year. The fu l l subsidy is provided i f the physician's fee-for-service income is below this - 50 -leve l . Above the $42,000 leve l , the subsidy is reduced by $1.00 for every additional $2.00 income made.(31,35) As of 1982, only two physicians in the province received this subsidy.(31) Saskatchewan ini t iated i ts rural incentive program in 1979. Under this program the government may provide up to one half the costs (to a maximum of $15,000) needed to open a medical of f ice in a rural community. The .physician and community are expected to fund the other half of the costs.(6) For each $5,000 received under this program, the physician must promise to stay in the community for one year. Original ly the program was only open to general practi t ioners, but in 1980 anaesthetists were also included.(31) Anaesthetists are now e l ig ib le to receive a maximum of $25,000 to defray start up costs. It has been recommended that Br i t ish Columbia establish a similar income-tax free establishment grant program.(20) This grant would be for a maximum of $25,000 and the physician would then be contracted to work in the rural area for a period of three years. Also under this recommended program the physician would be required to repay any outstanding part of the grant i f the three years of service was not completed. Another form of economic incentive used in several provinces is that of d i f ferent ia l fee schedules between urban and rural areas of the province.(1,6,31,35) This type of program is used in Quebec, Manitoba and Br i t ish Columbia. Under amendments made to the Quebec Health Insurance Act in 1981, the Quebec government can set dif fering remuneration rates for physicians and special ists in different regions of the province. The Minister of Health in Quebec has the authority to determine which areas of the province are considered to be "professionally overserviced" and therefore, which regions wi l l receive which remuneration rates. The rates received by the physicians not only depend on the region, but also on the length of time the physician has practised in the region.(1,10,31) Under the new law, general practitioners and special ists who practise in areas deemed overserviced only receive 70% of the negotiated fees for their f i r s t five years of practise. After five years, they receive the fu l l 100% of the negotiated fee. Prior to June 1982 general practitioners who had set up practices in areas deemed underserviced and/or isolated could receive up to 115% of the base fee schedule. After June 1982 these physicians have received 100% of the base fee. Special ists who practised in the same areas could receive up to 120% of the base fees.(31) Manitoba offers physicians who practise north of the 53rd paral lel a 10% increase in the basic fee schedule.(6) Since 1978, physicians in rural and northern Br i t ish Columbia have been able to earn up to 15% above the regular fee schedule rates through the Northern and Isolation Allowance program.(20,32,35) This allowance is based on a point system. Points are allocated to the community in which the physician has established his practice, on the basis of: the number of physicians in the community, the distance from the nearest major hospital and from Vancouver, the climate and the physician/population for the region in which the community is located. In order to qualify, a physician must l ive in a community which has at least 31 out of 75 points and he must gross at least $20,000 per year.(31) In 1982 over 200 physicians were receiving additional payments under this program.(35) Various other forms of economic incentives have also been t r ied. For example, in the United States i t was thought that i f rural areas had hospitals, - 52 -this would draw physicians to those regions. Under the H i l l Burton Act of 1946 (13,17,30,36) many hospitals were built in small rural communities, but this has fai led to attract many physicians into the areas.(17,36) Similar attempts at providing f a c i l i t i e s have been tried in Ontario.(7) In Canada, small communities on the Prair ies and the Northwest Terr i tories try to recruit physicians with incentives such as: a guaranteed income leve l , the provision of a c l i n i c and a l l other necessary f a c i l i t i e s and in some instances subsidized housing.(32,37) Cl in ics in Prince Edward Island guarantee a minimum income to physicians who are will ing to practise there. Once the physician has made over this l imit he can b i l l on a fee-for-service basis.(6) Other attempts at improving physician distr ibution range from: travell ing special ists and a locum tenens pool (7,38), to the provision of air ambulance serv ices.(1,7,35) Although these programs and incentives have been implemented, their effectiveness has been limited.(7,29,35) Eisenberg & Cantwell (29) point out that certain economic incentives, such as the provision of c l i n i c a l f a c i l i t i e s and guaranteed incomes have not been successful in the United States. Due to this these types of programs have been abandoned completely in some areas. The authors also state that a threshold income level may have to be met before i t wi l l be a successful incentive for physicians to practise in rural areas. As previously mentioned, the Ontario income program has been somewhat of a success. Since i ts inception in 1969, 173 communities had been designated as underserviced and as of January 1983 there were only 28 s t i l l on the "active l is t" . (6 ) It was also noted though that there was a 7% at tr i t ion rate among physicians who started in the program in 1981.(31) - 53 -Another report states that since the introduction of the Northern and Isolation Allowance in Br i t ish Columbia there has been a 16% increase in the number of general practitioners ie : from 150 to 174 practising in those communities which were e l ig ib le for the allowance. This report also points out that the increase in the number of general practitioners (relative to the population growth) was higher in the hospital d is t r ic ts which had at least one community e l i g i b l e , than for the rest of the province. However, this report also notes that the increase in the numbers of general practitioners in the communities e l ig ib le for the allowance has not s ignif icant ly changed when compared to the increase in the numbers of general practitioners in these communities for the four year period immediately prior to the introduction of the allowance.(35) The incentives and programs described thus far f a l l under the reimbursement schemes for physicians only. Evans (3) also states that under his third channel, governments can decide on other classes of health professionals which can be reimbursed under the provincial health schemes. In many nations of the world nurse pract i t ioners, midwives and other forms of auxiliary health workers carry out many of the medical duties in the rural and remote areas.(2) These personnel, although present in Canada, are not used except in certain circumstances, to alleviate the shortage of physicians in rural areas. In the Northwest Ter r i tor ies , nurse practitioners are employed in remote health stations.(1) Also, in Ontario, the province operates fourteen nursing stations in communities c lass i f ied as too isolated and too small to support a physician. These nursing stations are v is i ted by a physician at least once a week.(7) Governments should consider hiring moire of this type of personnel i f they cannot entice effect - 54 -more physicians to practice in rural areas. A recommendation has been proposed for certain areas in the United States.(39) to this SUMMARY This chapter has described the various pol icies and incentives which have been and are being used in an attempt to improve the geographic distr ibution of physicians. These pol ic ies have been shown to f a l l into one of three categories: regulation, education and economic. The few policies used in Br i t ish Columbia can be summarized as follows: The Medical Pract i t ioner 's Act (40) which dictates who can c a l l themselves physicians and practise medicine in the prov ince. B i l l 41 (12): the sections which allow for the restr ict ions on physician b i l l ing numbers to be va l id only in certain regions of the province. Educational The Supply-Side approach of increasing enrollment at the University of Br i t ish Columbia medical school, from 80 f i rs t year students in the early 1970's to the present f i rs t year enrollment of 130 students. Economic. i) The payment of a Northern and Isolation Living Allowance to physicians in remote areas of the province. i i ) The provision of subsidies for those physicians in the most remote areas of the province. Regulatory i ) i i ) The use of these pol icies has not been too effective in distributing physicians around the province, except to the larger communities. In the next chapter of this thesis the factors which tend to influence physicians to locate a practice in a particular area wi l l be examined in an attempt to determine what types of pol icies would be helpful . - 55 -REFERENCES 1. Roemer, Milton I.; and Ruth Roemer. Health Care Systems and Comparative  Manpower Po l ic ies . Marcel Dekker Inc. New York. 1981. 2. Roemer, Milton I. Rural Health Care. C.V. Mosby Company. St. Louis. 1976. 3. Ev ans, Robert G. Strained Mercy: The Economics of Canadian Health Care. Butterworth & Co. (Canada) L td . 1984. 4. Roos, N.L.; M. Gaumont and J.M. Home. "The Impact of the Physician Surplus on the Distribution of Physicians Across Canada." in C an ad i an , Public Policy 11:2 Spring 1976. pp 16.9-191. 5. Canada. Physician Manpower in Canada 1980-2000. A Report of the Federal/ Provincial Advisory Committee on Health Manpower. October 1984. 6. Rubin, Joe. "Placement Incentives: Will they lure doctors into underserviced areas?" in CMA Journal. Vol . 124, No. 10, May 15, 1981. pp 1360-1366. 7. Ontario. Medical Manpower for Ontario. Ontario Council of Health. Toronto. 1983. 8. Canada. Distribution of Health Manpower. Health Manpower Report #2-73. Health & Welfare Canada. Ottawa. 1973. 9. United States. Report of Discussions of the Task Force on the Manpower  Distribution Project of the National Health Council. U.S. Dept. of Health, Education & Welfare. New York. 1973. 10. Quebec. Statutes of Quebec 1981 Chapter 22. Quebec O f f i c i a l Publisher. 1982. 11. Br i t ish Columbia. B i l l ,24. Draft Legis la t ion. . 1983. 12. B i l l 41. Medical Service Amendment Act, 1985. Queen's Printer, V ic tor ia . 1985. ~ ; r~~' 13. Rosenthal, M.; & D. Frederick. "Physician Maldistribution in Cross Cultural Perspective: United States, United Kingdom and Sweden." in Inquiry. Vol . XXI, No. 1, Spring 1984. pp 60-74. 14. Br i t ish Columbia. "Mia vs Medical Services Commission of B.C." in Br i t ish  Columbia Law Reports. Vol . 61, 1985. pp 273-310. 15. Mullens, Anne. "The battle of the b i l l i ng numbers: Victor ia controls where doctors go." in The Sun, Vancouver, B .C . , Monday, February 11, 1985. - 56 -16. Hynes, Keven; & Nathanial Givner. "Physician Distribution in a Predominately Rural State: Predictors and Trends." in Inquiry. Vol . XX, No. 2, Summer 1983. pp 185-190. " 17. Schrag, Brian. "Justice and the Just i f icat ion of a Social Pol icy: The Distribution of Primary Care Physicians." in Social Science a^nd ,Medicine. Vol . 17, No. 15, 1983. pp. 1061-1074. *"~ 18. Ha l l , E.M; Royal Commission on Health Services. Vol . 1, Queen's Printer, Ottawa. 1964. 19. Dowie, J .R . (Chairman). Report of Athe Committee on the Healing Arts . Ontario Queen's Printer, Toronto. 1970. 20. Black, W.D. (Chairman). Report of the Advisory Committee on Medical  Manpower. Province of Br i t ish Columbia, Ministry of Health. V ic tor ia . March 1979. 21. Ha l l , F.R. and P.C. Whybrow. "Financial Aid for Medical Students: A Review and a Proposal." in Journal of Medical Education. Vol . 59, No. 5, May 1984. pp 380-385. 22. Budetti, Peter. "The 'Tr ickle Down' Theory - Is That Any Way to Make Policy?" in American Journal of Public Health. Vol . 74, No. 12, December 1984. pp 1303-1304. 23. Schwartz, W.B.; J . P . Newhouse; B.W. Bennett and A.P. Williams. "The Changing Geographic Distribution of Board-Certified Physicians." in The New  England Journal of Medicine. Vol . 303, No. 18, Oct. 30, 1980. pp 1032-1038. 24. Fruen, Mary; and James Cantwell. "Geographic Distribution of Physicians: Past Trends and Future Influences." in Inquiry. Vo l . XIX, No. 1, Spring 1982. pp 44-50. 25. Spencer, David; and Gabrielle D 'E l i a . "The Effect of Regional Medical Education on Physician Distribution in I l l i n o i s . " in Journal of Medical  Education. Vol . 58, No. 4, Apri l 1983. pp. 309-315. 26. H a l l , E.M. Canada's National-Provincial Health Program for the 1980's: A  Committment for Renewal. Crown Copyrights, Saskatoon. 1980. 27. Lomas, Jonathan; Morris Barer; and Greg Stoddart. "Supply Projections As Planning: A C r i t i c a l Review of Forecasting Net Physician Requirements in Canada." in Social Science.and Medicine. Vol . 20, No. 4, 1985. pp 411-424. " ' 28. Coleman, S inc la i r . Physician Distribution and Rural,Access^to Medical  Services. Rand Corporation, Santa Monica. Apr i l 1976. - 57 -29. Eisenberg, Barry; and James Cantwell. "Pol ic ies to Influence the Spatial Distribution of Physicians: A Conceptual Review of Selected Programs and Emperical Evidence." in Medical Care. Vol . XIV, No. 6, June 1976. pp 455-468. 30. United States. Factors Influencing Practice Location of Professional  Health Manpower: A Review of the Literature. U.S. Dept. of Health, Education & Welfare. July 1974. 31. Canada. Provincial and Terr i tor ia l Health Manpower Incentive Programs, mimeo Health & Welfare Canada. December 1982. 32. Brent, Ruth. "Getting Doctors to Underserviced Areas." in Canadian Doctor. Vol . 48, No. 6, June 1982. pp 46-49. 33. Verby, John E. "The Minnesota Rural Physician Redistribution Plan 1971 to 1976." in JAMA. Vol . 238, No. 9, Aug. 29, 1977. pp 960-964. 34. McPhee, John. "Heirs to General Practice." in New Yorker. July 23, 1984. pp 39-85. 35. Br i t ish Columbia. Report of the Joint Committee on Medical Manpower. V ic tor ia . November 1982. 36. Clark, L . ; M. F ie ld ; T. Koontz; and V. Koontz. "The Impact of H i l l Burton: An Analysis of Hospital Bed and Physician Distribution in the United States, 1950-1970." in Medical Care. Vol . XVIII, No. 5, May 1980. pp 532-547. 37. C.B.C. National News Broadcast. December 9, 1984. 38. Kronhaus, A l lan . "An Organized Locum Tenens Service and the Cost of Free Time for Rural Physicians." in Medical Care. Vol . XIX, No. 12, December 1981. pp 1239-1246. 39. Hicks, Lanis. "Social Policy Implications of Physician Shortage Areas in Missouri ." in American Journal of Public Health. Vol . 70, No. 12, December 1984. pp 1316-1321. 40. Br i t ish Columbia. Medical Pract i t ioner 's Act. Revised Statutes of Br i t ish Columbia, Chapter 254. V ic tor ia . 1979. - 58 -CHAPTER V FACTORS WHICH AFFECT THE LOCATION OF PRACTICE. It has been shown that there is a wide discrepancy in the distribution of physicians between rural and urban areas of Br i t ish Columbia. The pol icies and incentives which have been implemented in an attempt to change this distr ibution pattern were discussed. The effectiveness of several of these policies was commented on and i t was shown that most of the pol icies have not had any effect in changing the distr ibution of physicians between urban and rural areas. In this chapter the factors which have been found to have an influence on the location of physicians' practices wi l l be examined and discussed within the framework of Fixed and Manipulable Determinants.(1) Fixed determinants are those factors for which no direct medical manpower pol icies can be implemented or incentives offered in such a manner as to overcome physicians' decisions regarding the location of their practices i f these are the most important factors regarding the decision.(2,3) Factors which f a l l into this category include: climate and geography; physician's upbringing; socio-economic characteristics of the area; and l i fes ty le preferences. Manipulable determinants also tend to influence where physicians have established or plan to establish practices. Manipulable determinants are factors for which pol icies and incentives can be developed in an attempt to affect the geographic distr ibution of physicians. These include: negative views of particular area; exposure to rural areas during medical training; professional amenities; loan forgiveness and other monetary incentives. In their study on the effect of a medical school as an influencing factor on location of practice, Bueching and Glasser (4) commented that two types of - 59 -studies have been carried out in this area. The f i rs t type, c lass i f ied as Retrospective studies, ask physicians to specify why they chose the area they are presently practising i n . Bueching & Glasser claim that this type of study rel ies on secondary sources to determine demographic or similar correlates of practice location and that the factors most often identif ied in this type of study are general characteristics of the social or physical environment of the physicians, rather than motivational character ist ics. These social and physical environment factors include: (i) the location of residency training; ( i i ) the size of community in which the physician had or ig inal ly l ived; and ( i i i ) the size of community in which the spouse had or iginal ly l ived. In the second type of study, c lass i f ied as Prospective studies, medical students are asked to state their preferences for locating a practice in a particular area. The signif icant factors were motivational and related to the perceived geographic and professional amenities available in the area. They included: (i) perceived openness of the medical community; ( i i ) form of practise organization; and ( i i i ) desire to maintain family t i es . In 1976, Eisenberg and Cantwell (5) developed a series of hypotheses on the factors which affect physicians' location of practice decisions. They then - 60 -reviewed the l i terature and labelled each paper as being supportive, weakly supportive or contradictory of each hypothesis. Their definit ions of each category were: (a) Supportive - the l i terature examined provided strong evidence leading to acceptance of the hypothesis; (b) Weakly Supportive - the l i terature examined provided weak evidence leading to tentative acceptance of the hypothesis; and (c) Contradictory - the l i terature examined provided va l id findings which in some cases lead to acceptance and in others to rejection of the hypothesis. Among the hypotheses which Eisenberg and Cantwell found to be supported by the l i terature , in that the hypothesized factors tended to influence physicians to a great extent on where to locate their practices were: the population of the area; the size of the community in which the physician was reared or attended school; and the ab i l i ty to join a group practice. Physicians were found to locate in areas where there was a large population base, which prompted the authors to claim that there may be a "threshold population" needed to support a physician. Physicians also tended to establish practices in communities similar in size to the ones in which they had been raised. As well , i f they were able to join a group practice in a rural area, they were more l ike ly to locate in that area. Another unrelated finding which the authors noted in their review was that physicians who attended "higher quality" or private medical schools tended to practise in urban areas more than physicians who attended other medical schools. - 61 -The hypotheses which were found to be weakly supported by the l i terature were ones based on: the presence of a medical school in an area tending to influence physicians to establish in that region; and the opportunity to have done a preceptorship or other form of training in a rural area. It was also found that physicians tended to locate in areas which had a "high quality of l i f e . " The two hypotheses for which evidence was contradictory were based on the following factors: the presence of hospital f a c i l i t i e s and the income potential of the physicians. In other words some physicians were persuaded to locate in rural areas because of potentially high incomes and the presence of hospital f a c i l i t i e s , while others were not. After their review of the l i terature, Eisenberg and Cantwell l is ted some of the existing pol icies and programs used to affect the geographic distr ibution of physicians in the United States by their incentive mechanisms. Each incentive was then compared to one of the authors' hypotheses. It was found that most of the incentive programs were based on hypotheses for which evidence was found to be contradictory or at best only weakly supportive. The only programs which were completely supported by the l i terature were those based on the hypothesis that physicians would practise in communities of a similar size to the one in which they were raised. A l l of these programs encouraged selective admissions to medical school. Another review ar t ic le , published by the United States Department of Health Education & Welfare (2), found that the demographic characteristics of an area had the greatest influence on where physicians chose to practise. These factors included: the age and educational status of the population, as well as the - 62 -racia l mix. In several studies examined in this report, i t was determined that general practitioners tended to locate in areas where there was a higher percentage of the population over 65 years. Specia l is ts , on the other hand, tended to locate in areas near medical schools and in areas where the population had a higher educational standard. Along with the demographic character ist ics, this study found social and cultural act iv i t ies of the region to be important influencing factors. These included the education f a c i l i t i e s for chi ldren, the soc ia l , sporting and cultural amenities in the region and a preference of the spouse to l ive in a particular area. Since the publication of these two review ar t ic les , many researchers have continued to study the factors influencing location of practice decisions. These studies continue to be both retrospective and prospective and the results are also very similar to those of the review ar t ic les . This chapter wi l l now examine these latter studies and their resul ts . The factors to be discussed wi l l be divided into Fixed and Manipulable Determinants.(1) FIXED DETERMINANTS  Climate and Geography Hale et. a l . (6), in a before-and-after type of study, sent questionnaires to students in a Northeastern U.S. medical school, a l l of whom were required to participate in a month-long rural preceptorship program. Through the questionnaire the authors were able to divide the students into two groups depending on whether or not the students would have chosen the preceptorship i f i t had been an elective course. The students were asked to rank - 63 -their preferences of specialty of practice, type of practice sett ing, and locational determinants on a seven point scale. The students were also asked to rank their knowledge of primary care and confidence in their relevant c l i n i c a l s k i l l s . Among the choices of locational determinants were geographic area, size of community, distance from a medical school, community economic status, income, and recreational opportunities. In both groups the geographic location of the community was the most important factor which determined where the students would l ike to establish practices. This was closely followed by the population of the community. Income, community economic status, and the po l i t i ca l climate in the area were the least important factors for both groups. Similar findings were made by Steinwald and Steinwald.(7) These authors sent questionnaires to a l l U.S. medical graduates of 1965 in an attempt to determine whether a period of rural training had had any effect on where physicians tended to locate their practices. They found that only 13.5% of these graduates had taken any training in a rural area, and that only 17.8% of a l l graduates had decided to locate their practices in rural areas. Again, the most important factor which influenced where the physicians established a practice, both in urban and rural settings, was the climate and geographic features of the region. Coleman (8) also found this to be the most important factor when he analyzed similar data. Woodward and Ferrier (9), after questioning medical students at McMaster University about factors which were important in where they would locate a practice, also determined that the climate and geography of the region were the most important factors. - 64 -On the other hand Cooper et. a l . (10) found climate to be an insignif icant factor in practice location decisions, part icularly among primary care physicians (defined as those physicians in general or family practise, internal medicine, pediatrics and obstetrics and gynecology). These authors mailed questionnaires in the spring of 1972 to a l l recently-graduated primary care physicians in the United States. They examined personal, soc ia l , and professional factors, which tend to influence physicians' choice of practice location. As well , they examined the role of the spouse in the decision process. Although climate was found to be an insignif icant factor, the geographic features of a rural centre were found to be signif icant in the decision to locate there, part icularly i f the rural centre was close to an urban one. This finding is contradicted by Yett and Sloan (11) who found that general practitioners tended to settle in rural areas away from the urban centres and i t was the special ists who tended to settle in the more urbanized areas. Although i t has been shown that the climate and geography of an area have an influence on where physicians locate their practices, several authors claim that physicians are only following the general populations' migration patterns to the "sun-belts" and the suburban areas.(8,12) Upbringing of Physician and Spouse After the climatic and geographic features of an area, the second most important factor found to influence where physicians establish their practices is that of their upbringing. Yett and Sloan (11) determined where newly-graduated physicians were born, attended medical school, did their postgraduate training, and correlated these variables with the areas in which these - 65 -physicians had set up their f i r s t practices. They found that physicians tended to establish practices in areas in which they had the strongest contacts. The more events, eg: b i r th , schooling, residency and internship, which had occurred in a particular area, the more l ike ly i t seemed that the physicians would locate in that area or one very similar. As the number of events in a particular region decreased, i t was shown that the most recent events had a stronger effect that previous ones. For example, physicians who had completed their schooling and residency in one area, but were born in another, tended to establish i practices in the area of their schooling. In a similar study Aaronson et. a l . (13) compared the population of the communities in which physicians had: l ived unt i l the age of 18; completed undergraduate studies; completed medical school and residency; participated in a preceptorship; and where their spouse had or ig inal ly l ived; with the population of the communities in which the physicians eventually established a practice. Like Yett and Sloan, these authors found that the likelihood of a physician locating a practice in a particular sized community varied proportionately with the number of events which had occurred in that sized community. Another finding of this study was that the size of community in which the physician lived unt i l the age of 18 had the strongest influence on where the physician located his practice. The size of community in which schooling or preceptorship were completed, appeared only to have a slight influence on the decision of fh practise location. Bueching and Glasser (4) questioned physicians over a three year period to determine why they had moved into an area surrounding a medical school. They found that the size and urbanization of the area were the most important - 66 -reasons, followed by the fact that the area was near the home town of either the physician or spouse. This finding that physicians tend to locate their practices in towns or c i t ies of similar size to those in which they were brought up has also been substantiated by other authors.(7,12,14-16) When Parker and Sorensen (14) questioned physicians as to why they had moved into rural communities, again most of the responses indicated that the physician had spent some time in a rural area prior to practising there. Not only is the size of community in which the physician was brought up an important factor, but the size of the community in which the spouse was brought up is also very important. Taylor, Dickman and Kane (15), when questioning medical students on their attitudes towards rural practice, found that students with a rural background tended to favour a rural practice location. The same trend occurred for students with an urban background; they preferred urban practices. These authors also claimed that the background of the spouse, part icularly wives, was important. If the wives were from a rural background, then the physicians tended to practise in rural areas. Stewart and Mi l ler (17) found that spousal background in terms of size of community in which that individual was brought up, was no more inf luent ial than the background of the physician. These authors mailed questionnaires to physicians and their wives in New Mexico and Arizona, asking about the size of community in which each was born and had spent the majority of their formative years. In their analysis the authors found that when both physician and wife were from rural areas, there was a slight tendency to locate in a rural area. In the situations of mixed background, in which one spouse was from a rural area - 67 -and the other from an urban area, i t was found that the physician tended to practise in a metropolitan area. This was part icularly true i f the physician rather than the spouse was from a metropolitan area. In their study of women physicians in rural areas, D'El ia and Johnson (18) found that most women physicians who practise in rural communities, do so because they have physician relatives in the same area. Older women physicians practised in the most rural communities; younger female physicians tended to locate their practices in areas surrounding the medical school. Scycio-Economic Factors Characterizing the Area Along with climate and geography, the demographics of an area tend to influence the choice of practice location. Woolf, Uchi l l and Jacoby (19) conducted a study to determine why some rural areas were picked more often than others by physicians who participated in the National Health Services Corp (a service under which physicians may repay any scholarships or loans received during medical school by working for a set period of time in rural underserviced areas) in the United States. Areas with: a high percentage of white col lar employees; higher than average family incomes; and higher levels of education among the population, tended to be the ones chosen most often. Physicians are least l ike ly to locate practices in areas: where there is a high percentage of the population employed in agriculture, which have low per capita incomes, or which have a low education index.(19) These correlates and other behavioural determinants have also been found important by other authors. Evashwick (20) found that the per capita income in an area, the percentage of the population below the poverty l ine and educational - 68 -levels tended to influence physicians on where to set t le . The author found that the areas which had the highest physician/population ratios were those of highest per capita income and population density. Another factor which tended to attract physicians to a particular area was the percentage of the population over 65 years of age. Bryant (21), as well as Rowley and Baldwin (22) found that centres of high income and re ta i l trade tended to attract physicians more than other areas. Rowley and Baldwin point out that this may be caused by the indebtedness of recently-graduated physicians, who are concerned with finding an area in which there wi l l be enough f inancial support for their practises. Areas of high per capita income and areas of high urbanization were also found to attract physicians by Clark et. al.(23) This may not be such an important factor in Canada due to the Universal Medical Insurance program. Lave et. a l . (16) comment that the socio-economic characteristics of a region have more of an influence on internists and paediatricians, than on general practit ioners. This may be due to dif fering l i fes ty le preferences among these groups of physicians. Li festyle Preferences Under this heading can be categorized such factors as: preference for urban or rural l i v ing; specialty of practice - which are fixed factors, as well as income potential and organization of working environment (eg: solo vs . group practice) - which may be manipulable factors. Lave e t v a l . (16) state that a preference for a rural l i fes ty le tends to dominate physicians who locate their practices in these areas, while the need for professional amenities dominates - 69 -among those physicians who locate practices in urban areas. Steinwald and Steinwald (7) also found similar preferences to be factors which influence location of practice, as did Woodward and Ferrier.(9) Langwell and Werner (24), and Langwell (25) have suggested that the choice of practice location may be important to the physician's expectation of his/her l ifetime income. Langwell and Werner (24) attempted to associate the incomes and the number of hours worked for four groups of spec ia l is ts , with the areas in which the physicians were practising. They found that income levels may be a factor in special ists not moving to rural areas, but that net income was not strongly associated with location choice. They also found that the number of hours worked per year had a strong association with the choice of specialty and location of practice chosen. It was pointed out that physicians who located in urban areas tended to work far fewer hours for the same income. Langwell (25) states that current economic incentives encourage general and family practitioners to practise in urban areas. Again when their incomes are adjusted for the number of hours worked, i t was found that those physicians who practise in urban areas work fewer hours. The income potential of a physician in a particular area was another inf luent ial factor found by Cooper et. a l . (10) in their study. Again due to the different payment schemes these may not be relevant to the decisions of Canadian physicians. The type of specialty chosen by medical students, which may be influenced by the expected income potential or the type of training received, has been found to be another factor which influences where a physician wi l l establish a practice. Aaronson et., a l . (13) found that general and family practit ioners tended to settle in the smaller towns in Kentucky. This was also found by Hough - 70 -and Marder (26) when they examined where medical students located their practices after completing their t raining. Primary care physicians were more l ike ly to locate their practices near the area of their schooling, while more highly trained special ists tended to move to larger urban areas. A similar finding was made by D'El ia and Johnson.(18) These authors found that the women physicians who practised in rural areas were mainly primary care physicians. Recreational Amenities Several researchers have found that the avai labi l i ty of recreational and cultural f a c i l i t i e s in an area has an influence on where physicians tend to locate their medical practices. The need for such amenities could be c lass i f ied as a l i fes ty le preference. Hale et. al., (6) and Lave et. a l . (16) both found that the wider the variety of sports and other recreational opportunities in an area, the more physicians were drawn to this area. In the Hale study, recreational opportunities ranked as the second most important factor which physicians identi f ied as having had an influence over where they intended to establish a practice. These were also amongst the most frequently selected factors in the Rand Study as analysed by Coleman.(8) The avai labi l i ty of recreational and sports f a c i l i t i e s was the sixth most frequently chosen factor at 56%. The cultural advantages (42%) and social l i f e in the area (34%) were also two other major inf luent ia l factors found in this study. The scarcity of cultural events was cited by physicians in Parker and Sorensen's study (14) as a reason for not moving to rural areas. - 71 -Overall i t can be seen that the l i fes ty le preference and place of upbringing of physicians tend to be very important factors which influence where physicians wi l l locate a practice. Except for selecting more students from rural areas for admission to medical school very few, i f any, policies can be developed to influence these "fixed" preferences. This discussion wi l l now turn to those factors which have been c lass i f ied as the Manipulable Determinants. MANIPULABLE DETERMINANTS  Negative" Views of Rural Areas Physicians who practise in rural areas usually have a preference for that type of l i fes ty le and they probably have a positive view of rural areas and rural practice. Taylor et. a l . (15) interviewed medical students about rural practice and found that many had negative views about this type of practice. Parker and Sorensen (14) also found negative views to be a major influence for not practising in rural areas. These views were sometimes found to be influenced by family, friends and professors. Some of the negative aspects of rural practice found by these authors were: the hours of practice were too long, there was an inabi l i ty to get time off for vacations or continuing education, lack of social and cultural f a c i l i t i e s in the area, the amount of f inancial outlay required to set up a practice and the lack of an opportunity for professional growth. Kronhaus (27) found that many physicians left rural areas shortly after starting a practice because of the long hours and insuff icient time of f . These findings were confirmed by Evashwick.(20) She also states that one way to overcome this would be to build a medical centre which would employ more than one physician. - 72 -Rural Preceptorships and Other Training Another reason sometimes cited for not practising in a rural area is the feeling of unpreparedness of the newly graduated practitioner to cope with a l l medical emergencies without "suff ic ient backup".(1) In order to overcome th is , many medical schools now include some elective rural training within their curr icula. Evidence on the effect of this training on where physicians tend to establish their practices is very contradictory. Cooper et. a l . (10), Yett and Sloan (11) and Taylor et. a l . (15) a l l found that a greater percentage of students were wil l ing to practise in rural areas after they had been exposed to this form of practice in their t raining. According to Wunderman and Steiber (12), exposure to a rural area through residency or other training signif icant ly influences a physician's incl inat ion to establish a practice in a similar sett ing. Hough and Marder (26) commented that there was a strong association between having done a residency in a particular state and a physician practising in that state. This was also the finding of Stefana, Pate and Chapman.(28) Aaronson et. a l . (13) found that when physicians had done a preceptorship in a small community, there was an increased likelihood that the physician would practise in a small community. Blumenthal et. a l . (29) questioned pre-c l in ica l students participating in a continuous two year rural clerkship program about their future career plans and the size of community in which they planned on locating. In a pre-clerkship questionnaire most of the students completing the f i rs t year ( f i rst -year students) had indicated they wanted to locate in any ci ty or metropolitan area which had a population of 50,000 or greater. The students who were completing - 73 -the second year (second-year students) had indicated that their f i rs t choice was a ci ty with a population between 50,000 and 100,000 and their second choice was an urban/suburban community with a population between 25,000 and 50,000. The attitudes and choices of both the f i rs t and second year students had changed by the time they were asked to complete a post or mid-clerkship questionnaire. On this questionnaire the f i rst -year students indicated that their f i rs t choice of practice location was now a community with a population of between 15,000 and 24,000 and their second choice was a metropolitan area with a population of over 300,000. Among the second-year students the f i rs t and second choices were in the reverse order of the pre-clerkship questionnaire. After completing the clerkship more of the second-year students had indicated that they would l ike to practise in communities with a population between 15,000 and 24,000. On the other hand fewer of the f i rst -year students chose communities with populations between 5,000 and 15,000 after they had completed one year of the clerkship. None of the second-year students had selected this size of community on either the pre or post-clerkship questionnaire. Steinwald and Steinwald (7) and Coleman (8), on the other hand, claim that preceptorships do not have much of an influence on whether or not a physician wi l l choose a rural practice location. Steinwald and Steinwald (7) did f ind, though, that students who were from an urban environment and who had done a rural preceptorship, were more l ike ly to practise in a rural area, than were students from an urban environment who had not done a rural preceptorship. - 74 -Professional Amenities Such factors as the avai labi l i ty of c l i n i c a l f a c i l i t i e s and support staf f , the need for continuing education, and contact with a medical school would be c lass i f ied as professional amenities. A l l of these have been found to be factors which influence a physician's decision on where to locate his practice.(4,8,10,14,18,20) When Bueching and Glasser (4) asked physicians why they moved into the area surrounding a medical school, the fourth most important reason was found to be that the physicians anticipated a possible appointment to the medical centre. Cooper et. a l . (10) also found that the need to have contact with a medical school was a very important factor which influenced physicians to practise in the urban areas. Among the factors Steinwald and Steinwald (7) found which tended to influence the location of practice were several that would f a l l under this professional amenities c lass i f ica t ions: the opportunity for regular contact with other physicians; the avai labi l i ty of c l i n i c a l support staff and f a c i l i t i e s ; and the opportunity for regular contact with a medical school or centre. The "need" to practise in an area close to a medical school or large hospital was also pointed out by D'El ia and Johnson.(18) These researchers found that most of the younger women physicians who were practising in non-metropolitan areas, a l l tended to be in close proximity to the largest hospital in the area. It was the older women physicians who were practising in the smallest communities. In his analysis of the Rand Corporation's data, Coleman (8) found that special ists of a l l types, tended to locate their practices near a medical centre or graduate teaching inst i tute , while general practitioners tended to locate - 75 -further from these f a c i l i t i e s . Coleman also found that the second and third most frequent responses as to why physicians located in the area they did were: i ) the opportunity for regular contact with other physicians (63%) and i i ) the avai labi l i ty of c l i n i c a l support f a c i l i t i e s and personnel (62%). The avai labi l i ty of continuing education was selected by 42% of the questionnaire respondents. Evashwick (20), in her study of the effect of group practice on the location of practice decisions of physicians, found that in 1960 the distance from a hospital and the actual hospital f a c i l i t i e s in a region had very l i t t l e effect on the distr ibution of physicians. By 1970 there had been a considerable change and the author found that the hospital bed/population ratio was a very important factor in the decision to locate a practice in a particular region. The abi l i ty to join a group practice has been found by many researchers (4,7,8,10,15,16,20) to be a major influencing factor. This has been found to influence both physicians who plan to locate in urban areas (7) and in rural areas.(2) Evashwick (20) points out that as the percentage of physicians in group practice increases in non-metropolitan areas, these areas tend to attract more physicians. In the Parker and Sorensen (14) study the reasons physicians gave for not practising in rural areas were: i) the necessity to be near a large medical centre; i i ) lack of "house staff" in small hospital ; and i i i ) the lack of opportunity for professional growth and continuing education. On the other hand, two of the reasons physicians gave for moving to rural areas were: i) a good community hospital in the town and i i ) the proximity of a medical centre in a larger c i ty . - 76 -Loan Forgiveness One of the major pol icies and incentives that has been tried in an attempt to redistribute physicians from urban to rural areas is that of providing "free" loans to medical students in exchange for practising in a rural area after graduation. The abi l i ty to receive such loans does not seem to be a major factor on where a physician wi l l practise after graduation. Coleman (8) found that only 1.4% of a l l respondents checked this factor as being an inf luent ia l one. This percentage rose to 3.6% when only general practit ioners' responses were looked at. The abi l i ty to receive loans for starting up a practice did not appear to be inf luent ia l either. Only 4.9% of a l l respondents found this to be important, yet Parker and Sorensen (14) found that one of the reasons for not practising in a rural area was the high financial outlay required to establish a practice. Similar findings on the importance of loan forgiveness were reported by Cooper et. al. .(10) SUMMARY Up to this point this thesis has examined the various methods used to determine the requirements and supply of physicians. As well several of the c r i te r ia for designating an area as a physician shortage area have been discussed. It was shown that a l l methods have problems and that no one method is better than another. Because of this and also because they are readily available, physician/population ratios were chosen to identify the distr ibution of physicians throughout this thesis. In Chapter III, the growth of the physician supply was examined as was the current supply of physicians in Canada and Br i t ish Columbia. The current supply was converted into physician/population ratios to outline the distribution of physicians across Canada (by province and terri tory) and in Br i t ish Columbia (by Regional Hospital D i s t r i c t ) . The physician/population ratio for Canada was compared to that of other western industrial ized nations. It was shown that Canada had one of the highest physician/population ratios in the world. The Canadian ratio was then broken down into the individual provincial and te r r i to r ia l ra t ios . When this was done, i t was shown that Br i t ish Columbia had the highest ratio in the country. Br i t ish Columbia's ratio was then broken down into ratios for several hospital d is t r ic ts in the province and f ina l ly into general practitioner and specialist/population ratios for these hospital d i s t r i c t s . In a l l cases i t was shown that the more urbanized areas tended to have higher ratios than the more rural areas. The ratios ranged from an overall ratio of 1/369 in the Capital Hospital d is t r ic t to 1/1,330 in the Mount Waddington D is t r i c t . This was compared to the provincial average of 1/504. In terms of general practitioner/population rat ios, the range was from 1/686 in the Sunshine Coast D is t r ic t to 1/1,605 in the Peace-River Liard D is t r ic t . The provincial average was 1/923. In Chapter IV Br i t ish Columbia's current pol icies with regards to geographic distr ibution of physicians were compared to those of the other Canadian provinces and those in other nations. It was shown that very few of the pol icies which have been implemented have had any effect on the geographic distr ibution of physicians. This past chapter has examined those factors which have been found to influence the locational choice of practice. These factors, i t was found, could - 78 -be divided into Fixed Determinants for which no pol icies could be developed and Manipulable Determinants for which pol icies or incentives may be offered. As was seen in Chapter IV, most of the pol icies and incentives offered across Canada and part icularly in Br i t ish Columbia are directed solely towards the provision of higher fees or a guaranteed income to physicians who practise in remote areas of the province. This , i t was shown in Chapter V is not a highly motivating factor to physicians. As Langwell has pointed out, most physicians feel that they can earn a high enough income and work fewer hours by practising in a large urban centre. This effect was also pointed out in Chapter IV where i t was shown that the higher fee schedules for physicians in remote areas of Br i t ish Columbia have had only a minimal effect in attracting physicians to these areas. This has occurred despite the "supply-side" policy of increasing enrollment at the University of Br i t ish Columbia medical school. Other pol ic ies that have been implemented and which should, according to the studies, be successful are: the provision of a community medical centre for use by the physician. This c l i n i c , i f large enough may encourage two or three physicians to set up a group practice. This would allow the physicians to work fewer hours and also have some professional contact. This type of policy has been tr ied with some success in small Prair ie towns.(30) Medical students have indicated in some studies that the provision of educational grants or loans in exchange for rural practise was an important factor for selecting a rural practice location. Although this form of incentive has been tr ied in various areas, i ts effect has been marginal. The latest regulatory pol icies introduced in Br i t ish Columbia and Quebec may have some - 79 -effect in getting more physicians to practise in rural areas, but i t is too early to t e l l . One of the major factors for not establishing a practice in a rural area was found to be the need for professional contact including continuing medical education and other amenities. This has not been dealt with in any form of policy in Br i t ish Columbia or across Canada. The area of upbringing of the physician and the area in which medical training was completed were found to be very inf luent ia l on the physician's decision to locate in a particular area. It was found that the latter events were usually amongst the most in f luent ia l . It was shown in Chapter IV that areas which have developed rural post-graduate training f a c i l i t i e s tended to attract physicians and the physicians stayed in the area after completion. At the moment there are no post-graduate training f a c i l i t i e s in rural areas of Br i t ish Columbia. Now this thesis wi l l move on to examine what factors might influence the residents and interns in Br i t ish Columbia to move to the more rural areas of the province. From the results of this study an attempt wi l l be made to make recommendations on the types of pol icies or incentives which could be introduced in Br i t ish Columbia to change the geographic distr ibution of physicians. - 80 -REFERENCES 1. Canada. Distribution of Health Manpower. Health Manpower Report #2-73. Report to Health & Welfare Canada. Ottawa, 1973. 2. United States. Factors Influencing Practise Location of Professional  Health Manpower: A Review of the Literature. U.S.' Department of Health Education & W e l f a r e . J u l y 1974. 3. Br i t ish Columbia. Report of the Joint Committee on Medical Manpower. V ic tor ia . November 1982. 4. Bueching, Don and Michael Glasser. "The Role of a Medical Education Centre in Location Decisions of Practising Physicians." in Journal of Medical  Education. Vol . 58, No. 3, March 1983. pp 165-171. 5. Eisenberg, Barry and James Cantwell. "Pol ic ies to Influence Spatial Distribution of Physicians: A Conceptual Review of Selected Programs and Empirical Evidence." in Medical Care. Vol . XIV, No. 6, June 1976. pp 455-468. ' ' 6. Hale, Frank; Kenneth McConnochie; Robert Chapman; and Richard Whitting. "The Impact of a Required Preceptorship on Senior Medical Students." in Journal of Medical Education. Vol . 54, No. 5, May 1979. pp 396-401. 7. Steinwald, B. and C. Steinwald. "The Effect of Preceptorship and Rural Training Programs on Physician's Practice Location Decisions." in Medical  Care. Vol . XIII, No. 3, March 1975. pp 219-229. 8. Coleman, S inc la i r . Physician Distribution and Rural Access to Medical  Services. R-1887 WW. Rand Corporation. Apri l 1976. " "' " 9. Woodward, Christel and Barbara Ferr ier . "Career Developments of McMaster University Medical Graduates and Its Implications for Canadian Medical Manpower." in Canadian Medical Association Journal. Vol . 127, No. 16, September 15, 1982. pp 477-480. 10. Cooper, James; K. Heald; M. Samuels; and S. Coleman. "Rural or Urban Practice: Factors Influencing the Location Decision of Primary Care Physicians." in Inquiry. Vol . XII, No. 1, March 1975. pp 18-25. 11. Yett, Donald and Frank Sloan. "Migration Patterns of Recent Medical School Graduates." in Inquiry. Vol . XI, No. 6, 1974. pp 125-142. 12. Wunderman, Lorna and Steven Steiver. "Physicians Who Move and Why: From Residency to Practice, 1974-1978." in Journal of^Medical Education. Vol . 58, No. 5, May 1983. pp 389-394. - 81 -13. Aaronson, P h i l ; Grant Somes; Martin Marx; and James Cooper. "Relationships Between T r a i t s of Kentucky Physicians and Their Practice Areas." in Inquiry. Vol. XVII, No. 2, Summer 1980. pp 128-136. 14. Parker, Ralph & Andrew Sorensen. "The Tides of Rural Physicians: The Ebb and Flow or Why Physicians Move Out of and Into Small Communities." in Medical Care. Vol. XVI, No. 2, 1978. pp 152-166. 15. Taylor, Mark; William Dickman; and Robert Kane. "Medical Students Attitudes Towards Rural P r a c t i c e . " in Journal of Medical Education. Vol. 48, September 1973. pp 885-895. 16. Lave, Judith; Lester Lave; and Samuel Leinhardt. "Medical Manpower Models: Need, Demand and Supply." in Inquiry. Vol. XII, No. 2, June 1975. pp 97-125. 17. Stewart, Thomas and Clinton M i l l e r . "Community of Origin of Spouse and Physician Location in Two Southwestern States." in Journal of Medical  Education. Vol. 55, No. 1, January 1980. pp 53-54. 18. D ' E l i a , G a b r i e l l e and I r i s Johnson. "Women Physicians in a Nonmetropolitan Area." in Journal of Medical Education. Vol. 55, No. 7, July 1980. pp 580-588. 19. Woolf, Murray; V i c k i U c h i l l ; and Itzhak Jacoby. "Demographic Factors Associated with Physician Staffing in Rural Areas: The Experience of the National Health Services Corps." in Medical Care. Vol. XIV, No. 4, A p r i l 1981. pp 444-451. 20. Evashwick, Connie. "The Role of Group Practice in the D i s t r i b u t i o n of Physicians in Nonmetropolitan Areas." in Medical Care. Vol. XIV, No. 10, October 1976. pp 808-823. 21. Bryant, Bertha. "Issues on D i s t r i b u t i o n of Health Care: Some Lessons From Canada." in Public Health Reports. Vol. 96, No. 5, Sept-Oct. 1981. pp 442-447. 22. Rowley, Beverley; and Dewitt Daldwin. "Assessing Rural Community Resources for Health Care: The Use of Health Services Catchment Area Economic Marketing Studies." i n Social Science and Medicine. Vol. 18, No. 6, 1984. pp 525-529. 23. Clark, Lawrence; Marilyn F i e l d ; Tehodore Koontz; and V i r g i n i a Koontz. "The Impact of H i l l - B u r t o n : An Analysis of Hospital Bed and Physician D i s t r i b u t i o n i n the United States 1950-1970." in Medical Care. Vol. XVIII, No..5, May 1980. pp 532-547. 24. Langwell, K. and J . Werner. "Economic Incentives in Health Manpower P o l i c y . " in Medical Care. Vol. XVIII, No. 11, November 1980. pp 1085-1096. - 82 -25. Langwell,.K. "Real Returns to Career Decisions: The Physician's Specialty and Location Choices." in The Journal of Human Resources. Vol. XV, No. 2, Spring 1980. pp 278-285. 26. Hough, D.E. and W.D. Marder. "State Retention of Medical School Graduates." in Journal of Medical Education. Vo l . 57, No. 7, July 1982. pp 505-513. ~ ' 27. Kronhaus, Allan K. "An Organized Locum Tenens Service and the Cost of Free Time for Rural Physicians." in Medical Care. Vol . XIX, No. 12, December 1981. pp 1239-1246. 28. Stefana, Constantine; Mary Pate; and John Chapman. "Hospitals and Medical Schools as Factors in the Selection of Location of Practice." in Journal of  Medical Education. Vol . 54, No. 5, May 1979. pp 379-383. 29. Blumenthal, Daniel; Meryl McNeal-Steele; Lester Bullard; et . a l . "Introducing Students to Primary Care Through a Community Preceptor Program." in Journal of Medical Education. Vol . 58, No. 3, March 1983. pp 179-185. ' ' 30. Brent, Ruth. "Getting Doctors to Underserviced Areas." in Canadian Doctor. Vol . 48, No. 6, June 1982. pp 46-49. - 83 -CHAPTER VI METHODOLOGY The question being addressed in this thesis What pol ic ies or incentives wi l l have to be implemented in Br i t ish Columbia in order to have more physicians establish their practises in the rural areas of the province? In order to address this question, i t was decided to do a descriptive, prospective type of study. This study is descriptive in that i t has examined and described the reasons physicians have given for locating their practises where they do and also the pol icies which have been tr ied in other jurisdict ions to change the geographic distr ibution of physicians. Ideas from both of these areas were incorporated into the questionnaire which was developed and mailed to the participants of this study. This study is prospective in the sense that i t is questioning the residents and interns, registered in the University of Br i t ish Columbia medical program, as to where they plan on establishing their practices and why. This may be contrasted with a retrospective approach of questioning practitioners after the fact as to their reasons for establishing a practice where they did. The residents and interns were chosen because, as can be seen from Figure 2, i t is this group of medical students who are the closest to obtaining their medical licences and therefore having to make the decision as to where to establish their practices. - 84 -Figure 2. The "Avenues" of Postgraduate Medical Training in Br i t ish Columbia Four years of Undergraduate Medical Training *— \ Internship (One year) if General Practitioner Residency 1st year Residency 2nd year Family practitioner \ Residency 2nd year Residency 3rd year Residency 4th year ' Specialist (eg: General Surgeon, Internist, Pediatrician) I Residency 5th year Sub-Specialist (eg: Cardiac Surgeon, Gastro-Enterologist, Endocrinologist) This figure shows the usual progression from medical school through the internship and residency programs. The dotted lines in the figure indicate route general and family practitioners would take i f they decided to further their training at some point in the future. - 85 -SAMPLE A l i s t of a l l residents registered in Br i t ish Columbia's only medical program at the University of Br i t ish Columbia was obtained from the off ice of the dean (N=417). Within this group there were 25 physicians in the second year family practice residency program and 392 physicians in other residency programs. A questionnaire was mailed to a l l but two of the residents (N=415). Questionnaires were not mailed to these two physicians because the Office of the Dean had no address l isted for them. It was pointed out ear l ier in this thesis that one reason physicians may not establish practices in rural areas is the need for a threshold population, particularly for the most highly-trained specia l is ts . Because physicians could not be distinguished by specialty of training, from the information provided by the Dean's o f f i ce , the questionnaires were mailed to a l l persons l i s ted , rather than just those physicians in primary care residencies (family practice, general surgery, internal medicine, pediatr ics, and obstetrics and gynecology). The questionnaire was also distributed to a l l 89 interns registered with the College of Physicians and Surgeons in Br i t ish Columbia. These physicians were located in three hospitals in Vancouver: St. Paul 's , Lions Gate and Royal Columbian, as well as the Royal Jubilee and Victor ia General Hospital in V ic tor ia . At these hospitals the questionnaires were distributed through the Office of Medical Education because the hospitals would only release how many interns were practising in the hospitals, and would not release the names. Again a self-addressed stamped envelope was provided for the interns to return the questionnaires. - 86 -THE QUESTIONNAIRE  Development The questionnaire developed for this study (see Appendix C) consisted of sixteen questions divided into four sections. This questionnaire was similar to the one used by the Rand Corporation (1) in i ts 1965 study. Several modifications had to be made to the Rand questionnaire in order to make i t va l id for a study in Canada. Several questions regarding the payment for services were deleted from the questionnaire. Other factors not included on the questionnaire used in this study were: the climate and geographic features of a region and the influence of a spouse. The wording of the Rand questionnaire was also modified as appropriate for a prospective study. Pre-testing of two versions of the questionnaire was carried out with the co-operation of the 25 family practise residents. This group of physicians was selected because they were a l l together at a research conference in Vancouver in mid-March 1985. Equal numbers of two versions of the questionnaire were handed out randomly to the participants in the pre-test. The purpose of the pre-test was to determine whether there was any ambiguity in the questions being asked and at the same time determine which of the two versions would be used in the f inal study. The major difference in the two verions of the questionnaire was in question 7. One version was identical to the questionnaire in Appendix C. In the second version one of the factors included in question 6 was a guaranteed net income of $100,000. At the end of question 6 the participants were told to answer question 7 ONLY i f they had selected the income factor. If they had not selected this factor they were told to answer question 8 instead. Question 7, - 87 -then asked the participants to indicate i f they would practise in a rural area for a lower guaranteed net income plus any of the other factors they had not previously selected. They were asked to indicate the income required plus the additional factors. Question 8 asked the participants to state the level of income needed before they would consider practising in a rural area. Based on the responses of the pre-test (17 out of 25), of those physicians who answered the monetary question, more answered the version included in the f inal questionnaire. The residents included in the pre-test were a l l mailed a copy of the f inal questionnaire and asked to complete i t again. Variables One set of independent variables included in this study was the demographics, background and education of the participants. This was collected through the questions in the third section of the questionnaire. This information included such items as: i) the age and sex of the physician; i i ) the marital status of the physician and whether the physician had any children; i i i ) the geographic area and size of community in which the physician was raised; iv) whether the physician was doing an internship or residency and, i f the la t ter , in which specialty; and v) whether the physician had graduated from the University of Br i t ish Columbia medical program and whether s/he had received any rural training. - 88 -A second set of independent variables included in this study was the factors which physicians may consider necessary in order to establish medical practices in rural and remote areas. These included such factors as: i ) adequate medical f a c i l i t i e s ; i i ) adequate educational f a c i l i t i e s ; i i i ) access to consultants; and iv) a minimum income. The complete l i s t is shown in the questionnaire in Appendix C. The dependent variables measured in the study included where physicians they planned to and would most like to establish their medical practises, and in which size of community this would be. This information was collected by dividing the province into twelve different geographic areas and also including "Oustide of Br i t ish Columbia" as a choice, and by allowing the physicians to choose from three sizes of community: i ) a town of under 15,000. This was meant to represent a rural community, in which not a l l of the primary care physicians would normally be found. i i ) a c i ty of between 15,000 - 50,000. This represented a community in which most of the primary care physicians may be present as well as some other specia l is ts . and i i i ) a ci ty of centre in the other over 50,000. This represented a major urban which a l l primary care physicians and most of special ists and f a c i l i t i e s would be present. - 89 -In B r i t i s h Columbia t h i s group o f communities would i n c l u d e the f i v e c e n t r e s o f Vancouver, V i c t o r i a , Nanaimo, Kamloops, Kelowna, and P r i n c e George and the a r e a g e n e r a l l y known as the Lower M a i n l a n d . S t r u c t u r e The f i r s t s e c t i o n o f the q u e s t i o n n a i r e asked the p h y s i c i a n s to i n d i c a t e i n which o f the g e o g r a p h i c areas and community s i z e s they planned to e s t a b l i s h t h e i r m e d i c a l p r a c t i c e s under the c u r r e n t p o l i c y o f b i l l i n g number r e s t r i c t i o n s i n the p r o v i n c e . The t h i r d q u e s t i o n asked the p h y s i c i a n s to i n d i c a t e whether o r not they would p r a c t i s e i n a r u r a l area f o r f i v e y e a r s i f a f t e r t h a t time they c o u l d p r a c t i s e i n the area o f t h e i r c h o i c e . The f i v e year time span was chosen to d i f f e r e n t i a t e between a s h o r t and long term commitment to r u r a l p r a c t i c e . A f t e r the p h y s i c i a n s had answered these t h r e e q u e s t i o n s they were asked to ASSUME t h a t t h e r e were no r e s t r i c t i o n s on where they c o u l d o b t a i n a M e d i c a l S e r v i c e s P l a n b i l l i n g number i n the p r o v i n c e and to answer the q u e s t i o n s on area and s i z e o f community i n which they would most l i k e to e s t a b l i s h t h e i r p r a c t i c e s . Two q u e s t i o n s were asked o f the p h y s i c i a n s i n the second s e c t i o n o f the q u e s t i o n n a i r e . The f i r s t q u e s t i o n asked the s u b j e c t s to s e l e c t , from a l i s t o f f o u r t e e n f a c t o r s , WHICH, taken i n d e p e n d e n t l y , ( i e : BY ITSELF) would complete the f o l l o w i n g sentence; " I would c o n s i d e r p r a c t i s i n g i n a r u r a l a r e a f o r f i v e y e a r s i f : ." T h i s was i n t e n d e d to e s t a b l i s h t h o se f a c t o r s which, a l o n e , would be s u f f i c i e n t to a t t r a c t a p h y s i c i a n to a r u r a l a r e a . The l i s t o f f a c t o r s i n c l u d e d both F i x e d and M a n i p u l a b l e f a c t o r s . Among the F i x e d f a c t o r s were: - 90 -i ) opportunity for spouse to obtain employment; i i ) cultural and recreational f a c i l i t i e s in the region; i i i ) educational f a c i l i t i e s for children; iv) the abi l i ty to join an established practice; and v) the abi l i ty to have a set vacation period and time off for continuing medical education conferences. Among the Manipulable factors included in the questionnaire were: i) the provision of a medical centre by the community for the use of the physician; i i ) regular contact with the University medical school; and i i i ) working in a rural area in exchange for loans received while completing medical training. The physicians were also given the opportunity to add any other factors which might encourage them to consider practising in a rural area. Also included in the l i s t of factors was the opportunity to indicate that, alone, none of these factors would complete the sentence. The offering of a guaranteed income level is another manipulable factor and one that has often been integrated into po l ic ies . This was not asked as one of the factors in the above l i s t , but was included in the questionnaire as a separate question. The second question in this section of the questionnaire asked the physicians to consider ONLY those factors which they had NOT chosen in the previous question. That i s , among those factors that, alone, would not be suf f ic ient , they were asked to indicate the minimum combination of factors for - 91 -which they would consider practising in a rural area, i f in addition they were guaranteed a minimum net income. The income levels selected for the questionnaire ranged from $30,000 to $150,000 or more. The $30,000 level was chosen because as .a net income this would be close to the guaranteed salary of $38,000 offered by the Ontario government, and the $40,000 income offered by Manitoba. It is also sl ight ly below the level at which subsidies are offered in Br i t ish Columbia. A $50,000 net income would be equivalent to the annual salaries offered by the Cottage Hospital program in Newfoundland. This level would also be equivalent to the current income plus subsidy offered to physicians who work in the remotest areas of Br i t ish Columbia at the present time. Although no province offered a guaranteed income of more than $50,000 several small communities and c l in ics have offered in excess of this amount.(2) The $100,000 and $150,000 or more levels were included in an attempt to determine how much of a monetary incentive alone would be required to entice physicians to practise in rural areas. The f inal section of the questionnaire allowed the physicians to add any comments they had on the subject under investigation. Expectation of Findings Despite the current restr ict ion of b i l l i ng numbers in the Greater Vancouver, Lower Mainland and Greater Victor ia areas in effect when the questionnaire was distr ibuted, the l i terature led us to expect that most of the physicians in this study would s t i l l wish to practise in these large urban areas. Because of this many of them were expected not to be wil l ing to spend - 92 -five years in a rural area prior to establishing a permanent practice. It was also expected that those physicians who have been raised in rural areas would be the ones who choose to practise in rural areas. As to the factors which, alone, would be suff icient to physicians to practise in rural areas the l i terature again led us to expect that the amount and type of rural training would be very important. That i s , those who have had some rural training and feel that this training has been suff icient for them to feel confident in practising in a rural area without immediate special ist backup would prefer to practise in a rural area. It was expected that the married physicians would want their spouses to be able to find gainful employment in the area in which a practice is established. It was also expected that the leisure act iv i t ies in the area would be very important to physicians. As to the monetary issue one might anticipate that at the $30,000 level a l l of the factors not previously chosen would indicate the minimum set of conditions for which a physician would consider a rural practice. As the income levels rose, one might expect to find that the minimum set of conditions would decrease. Past research leaves some doubt as to the importance of income alone. Administration A l l of the questionnaires to the residents were mailed out together in late March 1985. Distribution of the questionnaires to the interns was done in late Apri l 1985. The reason for the delay was that i t was not discovered that the interns were not on the original mailing l i s t obtained from the Dean of Medicine's off ice unt i l this time. A self-addressed stamped envelope was - 93 -included with each questionnaire distr ibuted. The physicians were asked to complete the questionnaire and return i t in the envelope within a week. The survey was done completely anonymously as no codes were added to the questionnaire prior to being mailed. This did not allow the researcher to identify the respondents, nor did i t allow any specif ic follow-up mailings. A l l questionnaires returned by the end of June 1985 are included in the analysis of resul ts . Coding As the questionnaires were returned each was coded by the author. If more than one answer was given for each question, only the f i rs t was included in the analysis. The coded results were entered into the main computer at the University of Br i t ish Columbia according to SPSS:X specif ications.(3) Once a l l of the responses had been coded and entered a frequency distr ibution was run on a l l var iables. From this output several of the variables were recoded for further analysis. The variables which were recoded included: the area in which the physician planned and would most l ike to establish a practise and the area in which the physician was raised. These areas were recoded from the original thirteen areas to three: i) Greater Vancouver; i i ) The rest of Br i t ish Columbia; and i i i ) Outside of Br i t ish Columbia. - 94 -A fourth region, that of "other areas with communities of over 50,000 population", was considered but rejected because this left too few respondents in the area relabelled "Rest of Br i t ish Columbia" to carry out the analysis. The other areas which would have fal len into this category included: Lower Mainland, Greater V ic tor ia , Central Vancouver Island, North Okanagan and Prince George. The other variables recoded were: the age of the physician and the specialty in which the physician was doing his/her residency. Again both of these variables were recoded into three categories: Age became: i ) lowest age through 29 i i ) 30 through 35 and i i i ) 36 through the highest age. Specialty became: i ) General Practitioner i i ) Primary Care Residents and i i i ) Other Residents. S ta t is t ica l Analysis A chi-square (X^) test was performed on a l l cross-tabulated tables. This test is applied to the tables to test the significance of differences in proportions and therefore to determine whether or not a relationship exists between the variables in the table.(4) In calculating the X^ s t a t i s t i c , two sets of frequencies are compared, the observed and the expected values. The expected values are calculated on the basis of the observed total frequencies for the rows and columns in the table. The X^ s ta t is t ic is calculated by summarizing the differences between the 1 - 95 -observed and expected values for each ce l l in the table. The following formula is used in the calculation of the s ta t i s t i c : 2 (0 - E)^ where: 0 = observed values ^ ~ / E and E = expected values The degrees of freedom are calculated by using the following formula: (R - 1) x (C - 1) where: R = number of rows in the table and C = number of columns in the table Under the SPSS:X system missing values (Not Stated in the tables) can be added to the tables but they are not used in the calculation of the s ta t is t ic nor in the degrees of freedom.(3) For this thesis a significance factor (p) of 0.05 was chosen as the point at which to accept or reject the hypothesis under examination. At this level the X^ value would have to exceed 5.991 for tables with 2 degrees of freedom and 9.488 for those tables with 4 degrees of freedom i f the hypothesis is to be rejected. - 96 -REFERENCES 1. Coleman, S inc la i r . Physician Distribution and Rural Access to Medical Sejvices. Rand Corporation, Santa Monica. Spring 1976. 2. Advertisement in Canadian Doctor. Vol . 51, No. 5, May 1985. p 169. 3. SPSS Inc. SPSS:X Users' Guide. McGraw H i l l , Chicago. 1983. 4. P o l i t , Denise and Bernadette Hungler. Nursing Research: principles and  methods. 2nd ed. J . B . Lippincott Company, Philadelphia. 1983. Chapter VII RESULTS AND DISCUSSIONS i This chapter examines and discusses the responses to the questionnaires. F i rs t the response rate wi l l be examined; this wi l l be followed by a discussion of the frequency of the responses; then cross-tabulations wi l l be examined and discussed. Response, Rate A total of 504 questionnaires were distr ibuted, 415 to the residents and 89 to the interns practising in Br i t ish Columbia. Ten of the questionnaires mailed to the residents were returned due to being wrongly addressed. This left a sample of 494 questionnaires. From this sample 162 persons returned their questionnaires, for an overall response rate of 32.8% Of the 162 returned questionnaires, five were returned either blank or with just a few comments and were therefore excluded from the study. The 157 usable questionnaires equated to a response rate of 31.8%. The response rates for the residents and interns were not s ignif icant ly dif ferent. One hundred and twenty-two completed questionnaires were returned from the 405 residents, a 30.1% response rate. The response rate among the interns was found to be 36% with 32 out of the 89 questionnaires being returned. Frequencyvof Responses The breakdown of responses between male and female was 68.2% male and 31.2% female. One respondent did not answer this question. The l i s t of names - 98 -obtained from the Dean of Medicine's off ice only contained the i n i t i a l s and surnames of the physicians; therefore i t was not possible to distinguish the sex of the physicians prior to mailing the questionnaire. Based on data in the University of Br i t ish Columbia 1985/86 Calendar (1), the response rates of male and female physicians would appear to be representative of the sex ratio of residents. The calendar states that in 1984 there were 251 male and 105 female residents registered in the University of Br i t ish Columbia medical program. Ninety-three (59.2%) of the respondents were married, with one non-response. Only 27 (17.2%) of those who responded indicated that they had any children; again one respondent did not answer. The age of the respondents ranged from 23 to 47 years, with the average being 29.6 years and the mode 30 years. Three persons did not answer this question. The average age of the interns was found to be 27.3 years and the average of the residents was found to be 30.4 years. Several of the older respondents mentioned that they had practised as general practitioners in small rural communities for several years prior to returning to medical school to complete a residency program. A few indicated that they would not be returning to rural communities after completing their residencies due to the lack of professional contact in these areas. The responses to the questions regarding the areas in which the physicians were raised and whether or not the physician was a graduate of the University of Br i t ish Columbia (UBC), pointed out that many physicians come to Vancouver to complete their residency requirements. Over one-half (56.1%) of the respondents indicated they were raised in an area outside of Br i t ish Columbia, while 60.5% indicated that they were not graduates of UBC. Of the 69 respondents who were - 99 -raised in Br i t ish Columbia, 47 (68.1%) were from the Greater Vancouver and Lower Mainland regions of the province, eight were from the Greater Victor ia region, 10 were from the Okanagan and Kootenay regions and there was one each from the Cariboo and Prince Rupert - North Coast regions. One person did not answer this question. With the large number of respondents from within the Lower Mainland (including Greater Vancouver) and Greater Victor ia regions, i t is not surprising to find that 72.6% of a l l respondents were raised in communities with a population of greater than 50,000. Only 16.6% of the respondents indicated that they were raised in communities with a population of less than 15,000. The f inal 10% indicated that they were from communities with populations of between 15,000 and 50,000. Again one person did not answer this question. The physicians who completed the questionnaire could be divided into more than 20 special t ies. Of the 32 interns who responded, only 11 (33%) indicated that they were not intending to continue with a residency program at this time. They were grouped as general practitioners and comprised 7.3% of the total respondents. The interns who indicated that they would be going into a residency program after completion of their internship were included in the specialty group they had indicated. Table VIII shows the breakdown of special ists by type, frequency and percentage of total respondents. Table VIII BREAKDOWN OF - 100 -RESPONDENTS BY INDICATED SPECIALTY SPECIALTX FREQUENCY/157 PERCENTAGE General Practitioner 11 7.3 Family Practit ioner 13 8.7 Medicine (a l l types) 25 16.6 Surgeon (general) 8 5.3 Obstetrician/Gynecologist 7 4.7 Pediatrician 9 6.0 Anaesthetist 16 10.7 Radiologist 10 6.7 Plast ic Surgeon 4 2.7 Endocrinologist 1 0.7 Cardiac Surgeon 3 2.0 Dermatologist 3 2.0 Psychiatrist 11 7.3 Ophthalmologist 3 2.0 Pathologist 6 4.0 Orthopedic Surgeon 6 4.0 Neurologist 4 2.7 Other 10 6.7 No Response 7 4.2 When this l i s t is divided into primary care physicians (the top five groups of special ists) and secondary special ists (a l l others), i t is shown that 73 of the 157 respondents (48.7%) were involved in primary care training. These could establish practices in smaller communities without too much d i f f i cu l ty with regards to needing specialized equipment or other support. The f inal question asked the physicians to indicate whether or not they had done any rural training during their medical studies. The responses to this question showed that s l ight ly less than one-half (47.1%) of the respondents had had any rural training. Despite the policy of b i l l i ng number restr ict ions which was in effect when the questionnaire was i n i t i a l l y mailed out to the physicians, and also, despite - 101 -the fact that many of the physicians were raised outside of Br i t ish Columbia, 64.7% of a l l respondents indicated that they planned to establish medical practices in the Greater Vancouver and Lower Mainland regions of the province. This was as expected. Seventeen percent of the respondents indicated that they planned to establish practices outside of the province, yet only four of these persons indicated that they were returning to an area near their "home". The area t i t l ed "Outside of Br i t ish Columbia" represented the second most popular choice. The third most popular choices were the Greater Victor ia and Central Vancouver Island Regions, with a response of 10.7% each. The other respondents (7.8%) indicated that they planned to establish their practices in the other areas of the province. The areas labeled "North of Prince George" and "Prince Rupert - North Coast" were the only two areas not selected. Seven physicians did not answer this question, and they gave several reasons for not doing so. Two persons indicated that they were only in the middle of their residency program, and had not made any plans as to where they would establish their practices. The other non-respondents indicated that this question was no longer va l id due to a Br i t ish Columbia Supreme Court ruling which declared the refusal by the government to issue b i l l i n g numbers to physicians in the area of their choice to be unconstitutional.(2) This may be one reason why so many of the respondents planned to establish in the Greater Vancouver area because they could qualify to receive a b i l l ing number in the area of their choice. When the responses were recoded for analysis, i t was found that 42 (84%) of those physicians who were put in the category "Rest of Br i t ish Columbia" planned on establishing their medical practices in other areas of the province which had communities of over 50,000. This left only 8 (5% of the total respondents) 102 -physicians who planned on establishing practices in communities with populations under 50,000. Cross-tabulations of Dependent and Independent Variables In this section the results of the cross-tabulations performed on the responses to the questionnaire wi l l be discussed. A l l the data wi l l be presented in tabular form and the chi-square (X^) s ta t is t ic wi l l be presented at the bottom of each table. Except where indicated the bracketed figures in the tables represent column percentages. Tables IX a-c test the hypotheses that there is no difference across sex, marital and age groups as to where physicians plan to establish their practices. As seen by the X^ resul ts , none of these hypotheses can be rejected. There was a strong preference across a l l groups to establish a practice in the Greater Vancouver area. In Table IXa i t can be seen that a s l ight ly higher percentage of female physicians plan to establish practices in Greater Vancouver, and that the same percentage of male and female physicians plan to establish outside the province. Very l i t t l e difference is noticed as to where the single and married physicians planned on establishing their practices. In Table IXc the only major difference is for physicians aged 36 and older. Almost two-thirds (61.5%) of this group planned on practising in Greater Vancouver and only 7.7% planned on establishing practices outside the province. Many physicians in this age group indicated that they were returning to university to complete a residency program after several years practising in smaller communities. - 103 -Table IXa AREA- GREATER PLAN VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X2 = 1.981 AREA IN WHICH A PHYSICIAN PLANS TO ESTABLISH A PRACTICE BY THE SEX OF THE PHYSICIAN SEX MALE FEMALE 49 (44.9) 25 (51) 37 (34.6) 13 (26.5) 18 (16.8) 8 (16.3) 4 3 108 49 Degrees of Freedom = 2 p< 0.7393 TOTAL 74 50 26 7 157' Table IXb AREA PLAN GREATER VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X2 = 0.493 AREA IN WHICH A PHYSICIAN PLANS TO ESTABLISH  A PRACTICE BY MARITAL STATUS MARITAL STATUS SINGLE MARRIED 31 (49.2) 42 (45.2) 20 (31.7) 30 (32.3) 9 (14.3) 17 (18.3) 3 4 63 93 Degrees of Freedom =2 p < 0.7813 TOTAL 73 50 26 7 156 - 104 -Table IXc AREA IN WHICH A PHYSIpIAN PLANS TO ESTABLISH A PRACTICE BY AGE AREA GREATER PLAN VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X2 = 2.285 23 - 29 36 (45) 28 (35) 13 (16.3) 3 80 AGE, 30 - 35 28 (45.9) 19 (31.1) 11 (18) 3 61 Degrees of Freedom = 4 36+ 8 (61.5) 3 (23.1) 1 (7.7) 1 13 p < 0.6835 NOT TOTAL STATED 2 74 0 1 50 26 7 157 In Table X the hypothesis being tested is that there is no difference between where physicians plan to establish their medical practices and where they were raised. Other studies (previously cited) have found that the area in which a physician was raised is a very important and inf luent ia l factor on the physician's decision on where to locate a medical practice. Based on the c h i -square (X^) test performed on the data presented in Table X, i t would appear that this relationship is also true of the interns and residents surveyed in this study, and therefore the hypothesis must be rejected. Table X points out that the majority of residents and interns who were raised in Br i t ish Columbia, plan to practise in or near the area in which they were raised. For example, 66.6% of those who were raised in Greater Vancouver plan to practise there and 51.7% of those raised in the "Rest of B.C." plan to return. - 105 -Despite the b i l l ing number restr ic t ions, most (75%) of the physicians who were raised outside of the province planned to establish practices in the province and 60% of these physicians plan to practise in Greater Vancouver. This was an unexpected finding. Table X AREA PLAN AREA IN WHICH A PHYSICIAN PLANS TO ESTABLISH A PRACTICE BY1 AREA IN WHICH PHYSICIAN WAS RAISED GREATER VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X2 = 17.706 AREA RAISED GREATER VANCOUVER 10 (26.3) 2 (5.3) 1 39 REST OF B.C. 15 (51.7) 2 (6.9) 2 29 OUTSIDE B.C. 26 (66.6) 10 (34.5) 38 (43.2) NOT STATED Degrees of Freedom = 4 25 (28.4) 22 (25.0) 3 88 p < 0.0070 TOTAL 74 50 26 7 157 The X^ calculated for Table XI, indicated that the hypothesis: where physicians plan to practise is not a function of their type of post-graduate training, would have to be rejected. This table shows that residents plan to practise in Greater Vancouver more than the interns; interns are more wil l ing to practise in other areas of the province. It also shows that i f residents cannot practise in the Greater Vancouver area, approximately equal proportions plan on practising outside the province as to smaller communities in B.C. - 106 -Table XI AREA PLAN AREA IN WHICH A PHYSICIAN PLANS TO ESTABLISH A PRACTICE BY,TYPE OF TRAINING GREATER VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X 2 = 13.666 TYPE OF TRAINING INTERNSHIP 9 (28.1) 18 (56.3) 3 (9.4) 2 32 RESIDENCY 63 (52.1) 30 (24.8) 23 (19.0) 5 121 NOT STATED TOTAL 73 48 26 7 154 Degrees of Freedom = 2 p < 0.0084 Based on the X 2 calculated for Table XII, the hypothesis: there is no difference as to where physicians planned on establishing their practices based on their type of specialty, could not be rejected. Table XII shows that as physicians become more specialized there is a tendency to establish practices in larger communities. This can be seen with the drop in the percentage of physicians planning to practice in the "Rest of B.C." and the increase in the percentage planning to practice in Greater Vancouver. Again in Table XII i t can be seen that as physicians become more specialized increasing proporations of. those not planning to practice in Greater Vancouver would rather establish outside the province. - 107 -Table XII AREA PLAN AREA IN WHICH PHYSICIAN PLANS TO ESTABLISH A PRACTICE BY SPECIALTY GREATER VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X 2 = 5.661 SPECIALTY GENERAL PRACTITIONER 4 (36.4) 6 (54.5) 1 (9.1) 11 PRIMARY CARE SPECIALISTS 25 (40.3) 22 (35.5) 12 (19.4) 3 62 SECONDARY CARE SPECIALISTS Degrees of Freedom = 4 42 (54.9) 19 (24.7) 12 (15.6) 4 77 p < 0.226 TOTAL 71 47 25 7 150 These results are not unexpected since secondary care special ists would require specialized f a c i l i t i e s in order to practise their specialty. This equipment would only be available in the major centres. Also the need for a large population base, which was another concern raised by the respondents, would indicate that most would settle in the Greater Vancouver area. The data presented in Table XII are sl ight ly misleading in terms of where the primary care special ists plan to establish their practices. This table indicates that roughly the same percentage of primary care special ists chose either Greater Vancouver or the rest of Br i t ish Columbia when in fact quite a few of those who indicated the area entit led "Rest of B.C." actually chose either the Greater Victor ia or Central Vancouver Island regions. Both of these regions have a major city with a population of over 50,000. This, once again, - 108 -suggests that physicians plan to establish their practices in large communities similar to those in which they were raised. Table XIII tests the hypothesis: the size of community in which a physician plans to establish a medical practice does not vary with physician specialty. The calculated X 2 indicates that this hypothesis would be rejected. This was not an unexpected finding. Table XIII SIZE. OF COMMUNITY IN WHICH A PHYSICIAN PLANS TO ~' ! ! ESTABLISH A PRACTICE BY SPECIALTY ~ SPECIALTY SIZE PLAN GENERAL PRIMARY SECONDARY PRACTITIONER CARE CARE SPECIALISTS SPECIALISTS UNDER 15,000 15,000-50,000 OVER 50,000 TOTAL 1 (9.1) 3 (27.3) 7 (63.6) 11 2 (3.3) 15 (24.6) 44 (72.1) 61 6 (8.0) 69 (92.0) 75 TOTAL 24 120 147 X 2 = 13.3097 Degrees of Freedom =4 p < 0.0099 The preference to establish in the Greater Vancouver and Lower Mainland regions of Br i t ish Columbia becomes more evident when the physicians were asked to indicate the area in which they would most l ike to establish a practice i f there were no b i l l i ng number restr ic t ions. Seventy-five percent of a l l respondents would most l ike to establish in Greater Vancouver and the Lower Mainland. This is up from the 65% who planned on practising in these areas. "Outside Br i t ish Columbia" s t i l l had the second highest response rate even when - 109 -the b i l l ing number restr ict ion had been removed and physicians were able to choose the area in which they would l ike to establish a practice, but the numbe was only one-half of those who planned on practising outside the province. Greater Victor ia was the third most popular choice with a response rate of 8.3% After these four areas, there were only 13 physicians (8.3%) who indicated they would most l ike to practise in other areas of the province. Only the Prince Rupert-North Coast region was not chosen in this question. Similar results to those just described in Tables IXa - XII were obtained when hypotheses concerning the area physicians would most like (as opposed to plan) to locate a practice were tested against with the same independent var iables. These results can be seen in Tables XlVa - XVIII. The results indicated that only one hypothesis was rejected, that of: there is no difference in the area physicians would most l ike to establish a practice based on the area in which they were raised as shown in Table XV. None of the physicians who were raised in Br i t ish Columbia indicated that they would most like to establish a practice outside the province. In a l l instances, though, fewer physicians indicated that they would practise outside the province i f the were free to choose the area in which they would most l ike to practise. This again emphasizes the point that physicians wi l l establish their medical practices in areas similar to those in which they were raised. These results also tend to point out that in the presence of the b i l l ing number restr ict ions physicians would rather practise outside the province i f they cannot establish practices in the areas they would most l ike . When asked about the size of community in which they planned to establish their practices, 80.3% indicated that i t would be in a community with a - 110 -Table XlVa : AREA IN WHICH A PHYSICIAN WOULD MOST LIKE TO ESTABLISH A PRACTICE BY SEX OF PHYSICIAN SEX MALE FEMALE TOTAL AREA GREATER MOST VANCOUVER 63 (58.8) 30 (61.2) 93 REST OF B.C. 36 (33.6) 14 (28.6) 50 OUTSIDE B.C. 9 (8.4) 4 (8.2) 13 NOT STATED 1 1 TOTAL 107 49 157 X 2 = 1.005 Degrees of Freedom =2 p < 0.909 Table XlVb AREA IN WHICH A PHYSICIAN WOULD MOST LIKE,TO ESTABLISH A PRACTICE BY MARITAL STATUS AREA GREATER MOST VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X 2 = 1.978 MARITAL STATUS SINGLE 40 (63.5) 20 (31.7) 3 (4.8) 63 Degrees of Freedom = 2 MARRIED 52 (55.9) 30 (32.3) 10 (10.8) 1 93 p <C 0.372 TOTAL 92 50 13 1 157 - I l l -Table XIVc AREA IN WHICH A PHYSICIAN WOULD MOST LIKE TO ESTABLISH A PRACTICE BY AGE AREA MOST GREATER VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X 2 = 3.697 23-29 49 (61.3) 26 (32.5) 5 (6.3) 80 AGE 30-35 34 (55.7) 21 (34.4) 5 (8.2) 1 61 Degrees of Freedom = 4 36+ 9 (69.2) 3 (23.1) 1 (2.7) 13 p < 0.449 NOT TOTAL STATED 93 50 13 1 157 Table XV AREA MOST AREA IN WHICH A PHYSICIAN WOULD MOST LIKE TO ESTABLISH A PRACTICE BY AREA RAISED GREATER VANCOUVER REST OF B.C. OUTSIDE B.C. TOTAL X 2 = 22.317 AREA RAISED GREATER VANCOUVER 30 (76.9) 9 (23.1) 39 REST OF B.C. 12 (41.4) 17 (58.9) 29 Degrees of Freedom = 4 OUTSIDE B.C. 51 (58.6) 23 (26.1) 13 (14.8) 88 p < 0.0011 NOT TOTAL STATED 93 50 13 157 - 112 -Table XVI AREA MOST AREA IN WHICH A PHYSICIAN WOULD MOST LIKE -TO ESTABLISH A PRACTICE BY TYPE OF TRAINING GREATER VANCOUVER TYPE OF TRAINING INTERNSHIP 14 (43.8) 17 (53.1) 1 (3.1) RESIDENCY REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL 32 X = 8.567 Degrees of Freedom = 2 76 (62.8) 33 (27.3) 11 (9.1) 1 121 NOT STATED TOTAL 91 50 12 1 154 p < 0.0729 Table XVII AREA IN WHICH A PHYSICIAN WOULD MOST LIKE TO ESTABLISH A PRACTICE BY SPECIALTY AREA GREATER MOST VANCOUVER REST OF B.C. OUTSIDE B.C. NOT STATED TOTAL X 2 = 3.436 SPECIALTY GENERAL PRACTITIONER 5 (45.5) 5 (45.5) 1 (9.1) 11 PRIMARY CARE SPECIALISTS 33 (53.2) 22 (35.5) 6 (9.7) 1 62 SECONDARY CARE SPECIALISTS 51 (66.2) 22 (28.6) 4 (5.2) 72 TOTAL 89 49 11 1 150 Degrees of Freedom p < 0.488 - 113 -population of over 50,000. Twenty-four (15.3%) physicians indicated a preference for a community of between 15,000 and 50,000. Only 4 physicians cited a preference for communities of under 15,000. Table XVIII tests the hypothesis: the size of community in which physicians plan to establish a practice is not a function of the size of community in which they were raised. As can be seen from the X 2 value, this hypothesis cannot be rejected. Table XVIII SIZE PLAN SIZE OF COMMUNITY IN WHICH A PHYSICIAN PLANS TO  ESTABLISH A PRACTICE BY SIZE 0FxCOMMUNITY IN WHICH. THE PHYSICIAN WAS RAISED UNDER 15,000 15,000-50,000 OVER 50,000 TOTAL X 2 = 2.219 SIZE RAISED UNDER 15,000 1 (3.8) 5 (19.2) 20 (76.9) 26 15,000-50,000 4 (25) 12 (75) 16 OVER 50,000 3 (2.7) 15 (13.4) 93 (83.8) 111 TOTAL 24 125 153 Degrees of Freedom =4 p < 0.6955 This table points out that irrespective of the size of community in which the physician was raised, most prefer to l ive in larger communities. Part of this may be due to the fact that a l l or most of their training is done in larger communities which have the most specialized medical equipment. The four physicians who indicated that they planned on establishing practices in communities of under 15,000 were a l l males who were under the age - 114 -of 35. They were divided equally according to their marital status, area in which they were raised, (two in Br i t ish Columbia but outside the Greater Vancouver-Lower Mainland regions and two from outside Br i t ish Columbia). Only one was raised in a community of under 15,000 while the other three were a l l from communities of over 50,000. A l l of the physicians who gave their ages as over 36 indicated they planned on establishing medical practices in communities with populations greater than 50,000. Of the 37 respondents who cited Greater Vancouver as the area in which they were raised, a l l but four indicated they planned on establishing practices in c i t i es of similar size to Vancouver ( ie: over 50,000 population). The other four cited communities with populations between 15,000 and 50,000. When asked to indicate the size of community in which they would most l ike to establish a medical practice, i f there were no b i l l ing number restr ict ions in ef fect , only two physicians chose communities of under 15,000. Fewer respondents also chose communities in the 15,000 to 50,000 range when asked to indicate the size of community in which they would most l ike to (as opposed to pi an) establish their medical practices. Other differences which appeared between the size of community in which a physician planned, and would most l ike to establish a medical practice were: i ) the number of male physicians who would most l ike to practise in large communities increased. i i ) no single physicians would most l ike to practise in a community of under 15,000, as opposed to 2 who planned on practising in this size of community. and i i i ) no physicians between the ages of 23-29 would most like to practise in communities of under 15,000, as,opposed to 3 who planned to. - 115 -In Tables XIX and XX, the same hypotheses that were tested in Tables X and XVIII were retested, except that in Tables XIX and XX rural training has been controlled for. The bracketed figures in Tables XIX and XX represent row rather than column percentages. From Table XIX it can be seen that rural training made very l i t t l e difference in where physicians planned on locating their practices. Except for those physicians who were raised outside Br i t ish Columbia, most physicians planned on establishing practices near the area in which they were raised. Most physicians raised outside of the province planned on locating practices in the prov ince. Although the numbers of physicians involved is small, one interesting and unexpected finding is seen in Table XX. A higher percentage of those physicians who did not receive any rural training plan on locating practices in communities with populations of between 15,000 and 50,000. Again, despite whether or not the physicians did any rural training during their education, most physicians planned on locating in communities with populations of greater than 50,000. F i f ty -s ix (35.7%) of the physicians who responded, indicated that they would practise in a rural area for a period of five years i f after that time they could obtain a b i l l i ng number in the area of their choice. Several of the physicians who answered no to this question said that five years was too long a period of time to have to spend in a small community. Another responded that he would only be getting his practice established after five years and i t would not be worth resett l ing therefore he would not consider this option. At the time the questionnaire was distributed i t was not known i f physicians who had b i l l ing numbers could transfer them to the Greater Vancouver area. This may have led to - 116 -Table XIX AREA IN WHICH PHYSICIANS PLAN TO ESTABLISH' THEIR MEDICAL PRACTICES BY THE AREA IN WHICH THE PHYSICIANS WERE RAISED, CONTROLLING FOR RURAL TRAINING \ m . • f i • , i r i AREA PLAN YES AREA RAISED GREATER VANCOUVER REST OF B.C. OUTSIDE B.C. TOTAL X 2 = 9.541 GREATER VANCOUVER 15 (75) 6 (42.8) 18 (47.4) 39 (54.2) REST OF B.C. 4 (20) 7 (50) 10 (26.3) 21 (29.2) OUTSIDE B.C. 1 (5) 1 (7.1) 10 (26.3) 12 (16.6) TOTAL 20 14 38 72 Degrees of Freedom = 4 p < 0.0489 RURAL TRAINING-NO GREATER VANCOUVER REST OF B.C. OUTSIDE B.C. TOTAL X 2 = 8.686 10 (58.8) 4 (30.7) 20 (42.6) 34 (41.9) 6 (35.3) 8 (61.5) 15 (31.9) 29 (35.8) 1 (5.9) 1(7.6) 12 (25.5) 14 (17.3) 17 13 47 77 Degrees of Freedom = 4 p < 0.192 ) Table XX YES - 117 -SIZE OF COMMUNITY,IN WHICH PHYSICIANS PLAN TO  ESTABLISH THEIR'MEDICAL PRACTICES BY THE SIZE OF  COMMUNITY. IN WHICH THE PHYSICIANS WERE RAISEPT" CONTROLLING FOR RURAL TRAINING SIZE RAISED UNDER 15,000 15,000-50,000 OVER 50,000 TOTAL X 2 = 1.6092 SIZE PLAN UNDER 15,000 1 (7.2) 2 (3.8) 3 (4.2) 15,000-50,000 3 (21.4) 1 (16.7) 6 (11.5) 10 (13.9) OVER 50,000 Degrees of Freedom = 4 10 (71.4) 5 (83.3) 44 (84.6) 59 (81.9) p < 0.25 TOTAL 14 52 72 RURAL TRAINING" NO UNDER 15,000 15,000-50,000 OVER 50,000 TOTAL X 2 = 1.636 2 (16.7) 3 (30.0) 10 (83.3) 7 (70.0) 1 (1.7) 9 (15.3) 49 (83.0) 1 (1.2) 14 (17.3) 66 (81.5) Degrees of Freedom = 4 p <, 0.123 12 10 59 81 - 118 -the low response r a t e o f t h i s q u e s t i o n . T h i s would tend to i n d i c a t e t h a t w i t h o u t some form o f r e g u l a t i o n , such as B i l l 41, v e r y few p h y s i c i a n s w i l l c o n s i d e r p r a c t i s e i n a r u r a l community. Det e r m i n a n t s o f C h o i c e o f R u r a l P r a c t i c e The second s e c t i o n o f the q u e s t i o n n a i r e asked the p h y s i c i a n s to s e l e c t those f a c t o r s which, a l o n e , would be s u f f i c i e n t f o r them to p r a c t i s e i n r u r a l a r e a s . T a b l e XXI o u t l i n e s the o v e r a l l response r a t e s to these c o n d i t i o n s . The f a c t o r s i n T a b l e XXI are l i s t e d from most to l e a s t o f t e n s e l e c t e d and not i n the o r d e r they appeared on the q u e s t i o n n a i r e . T a b l e XXI FREQUENCY AND PERCENT SELECTION, OF FACTORS BY ALL RESPONDENTS FACTOR FREQUENCY PERCENT NONE 53 33.8 ADEQUATE LEISURE ACTIVITIES 53 33.8 ADEQUATE HOSPITAL FACILITIES 49 31.2 SET VACATION PERIOD 41 26.1 EMPLOYMENT FOR SPOUSE 40 25.5 UNIVERSITY CONTACT 32 20.4 ADEQUATE EDUCATION FACILITIES FOR CHILDREN 31 19.7 OTHER 28 17.8 ADEQUATE MEDICAL TRAINING 26 16.6 ACCESS TO CONSULTANTS 22 14.0 FINANCIAL ASSISTANCE IN EXCHANGE FOR RURAL PRACTICE 16 10.2 ABILITY TO JOIN ESTABLISHED PRACTICE 15 9.6 BELONG TO LOCUM POOL 14 8.9 MEDICAL CENTRE PROVIDED 14 8.9 As can be seen from the above t a b l e , f o u r out o f the top seven r e s p o n s e s can be c l a s s i f i e d as F i x e d D e t e r m i n a n t s f o r which no p o l i c i e s can be develop e d to affect the decision of a physician on where to locate a medical practice. These are: adequate leisure ac t iv i t ies ; set vacation period; employment for spouse and adequate education f a c i l i t i e s for children. Pol icies could be developed to ensure that there were good hospital f a c i l i t i e s and that the physicians could have contact with the university medical school, as well as the governmental formation of a locums pool to allow physicians in rural areas to have more time off for vacations or medical conventions. Among the later six responses only two factors could be c lass i f ied as Fixed Determinants, those of feeling adequately trained to practise in a rural area and the abi l i ty to join an established practice. The response rates for each factor across sex, marital status and specialty group are given in Tablex XXII and XXIII. The factors are l is ted in the same order as presented in Table XXI. The responses between male and female physicians were very similar , except that twice as many male physicians indicated that education f a c i l i t i e s for their children was an important consideration in where they planned to locate their practice. Also twice as many men were wil l ing to accept f inancial assistance during their formal medical education in exchange for practising in a rural area for a set period of time. The same pattern was seen between single and married physicians, as well in the different age groups. That is the younger physicians were more wil l ing to accept the educational grants or loans for practising in rural communities. This was not an unexpected f inding. Physicians in the 36 and over age category did not select this factor at a l l , but there were not many physicians in this group. Table XXII FREQUENCY AND PERCENTAGE SELECTION OF FACTORS  BY SEX, MARITAL STATUS AND AGE OF PHYSICIAN Factor Sex Male Female None 36 (33 .6) 16 (32.7) Leisure Act iv i t ies Adequate 40 (37 .4) 13 (26.5) Adequate Hospital Fac i l i t i es 35 (32 .7) 14 (28.6) Set Vacation Period 30 (28 .0) 11 (22.4) Employment for Spouse 25 (23 .4) 15 (30.6) Contact with University Medical School 22 (20 .6) 10 (20.4) Education Fac i l i t i es for Children 26 (24 .3) 5 (10.2) Other 20 (18 .7) 8 (16.3) Medical Training Adequate 20 (18 .7) 6 (12.2) Access to Consultants 15 (14 .0) 7 (14.3) Financial Assistance in Exchange for Rural Practise 13 (12 .1) 3 (6.1) Abi l i ty to Join an Established Practice 11 (10 .3) 4 (8.2) Abi l i ty to Belong to a Locums Pool 10 (9. 3) 4 (8.2) Medical Centre Provided 11 (10 .3) 3 (6.1) Marital Status Age Single Married 23-29 30-35 36+ 18 (28.6) 34 (36.6) 21 (26.3) 25 (41.0) 7 (53.8) 24 (38.1) 29 (31.2) 31 (38.8) 19 (31.1) 3 (23.1) 25 (39.7) 24 (25.8) 29 (36.2) 17 (27.9) 2 (15.4) 16 (25.4) 25 (26.9) 26 (32.5) 12 (19.7) 2 (15.4) 10 (15.9) 30 (32.3) 22 (27.5) 14 (23.0) 3 (23.1) 18 (28.6) 14 (15.1) 19 (23.8) 11 (18.0) 2 (15.4) 10 (15.9) 21 (22.6) 21 (26.3) 8 (13.1) 1 (7.7) 6 (9.5) 22 (23.7) 13 (16.3) 14 (23.0) — — 14 (22.2) 12 (12.9) 20 (25.0) 5 (8.2) — — 10 (15.9) 12 (12.9) 14 (17.5) 7 (11.5) 1 (7.7) 9 (14.3) 7 (7.5) 11 (13.8) 4 (6.6) — — 8 (12.7) 7 (7.5) 10 (12.5) 5 (8.2) — — 9 (14.3) 5 (5.4) 11 (13.8) 2 (3.3) 1 (7.7) 8 (12.7) 6 (6.5) 10 (12.5) 3 (4.9) — — Table XXIII FREQUENCY AND PERCENTAGE SELECTION OF FACTORS BY SPECIALTY OF PHYSICIAN F a c t o r S p e c i a l t y General Primary Care Secondary Care Practitioner Specialists Specialists None 4 (36.4) 20 (32.3) 27 (35.1) L e i s u r e A c t i v i t i e s Adequate 2 (18.2) 28 (45.2) 20 (26.0) Adequate H o s p i t a l F a c i l i t i e s 4 (36.4) 22 (35.5) 20 (26.0) Set V a c a t i o n P e r i o d 3 (27.3) 22 (35.5) 15 (19.5) Employment f o r Spouse 1 (9.1) 21 (33.9) 15 (19.5) Contact with U n i v e r s i t y M e d i c a l School 1 (9.1) 13 (21.0) 17 (22.1) E d u c a t i o n F a c i l i t i e s f o r C h i l d r e n — — 17 (27.4) 13 (16.9) Other — -- 8 (12.9) 18 (23.4) M e d i c a l T r a i n i n g Adequate 2 (18.2) 14 (22.6) 8 (10.4) Access to C o n s u l t a n t s 1 (9.1) 15 (24.2) 5 (6.5) F i n a n c i a l A s s i s t a n c e i n Exchange f o r Rural P r a c t i s e 2 (18.2) 8 (12.9) 5 (6.5) A b i l i t y to J o i n an E s t a b l i s h e d P r a c t i c e 1 (9.1) 8 (12.9) 4 (5.2) A b i l i t y to Belong to a Locums Po o l 4 (36.4) 3 (4.8) 7 (9.1) M e d i c a l Centre P r o v i d e d — — 8 (12.4) 5 (6.5) - 122 -Differences in response rates across age groups were very evident. Over one-half (53.8%) of those physicians 36 years of age and older indicated that no one factor alone would be enough for them to practise in a rural area. This compared to approximately one-quarter (26%) of those aged 23-29. It was also noticed that older physicians chose fewer factors overa l l . Those in the 36+ age group did not select five of the factors on the questionnaire. These were: other, adequate medical t raining, f inancial assistance in exchange for rural practise, ab i l i ty to join an established practice and having a medical centre provided. The younger physicians considered their experience to be an important factor in their decision on where to locate their practices. This is pointed out by the 25% selection response to the factor regarding the adequacy of their medical training and the 36% response rate to the factor regarding adequate hospital f a c i l i t i e s . This group also cited leisure act iv i t ies and the need for holidays and educational leave as being more important than the older physicians. The responses of the 36+ age group tend to be consistent with the "Other" comments this group added at the end of the questionnaire. As mentioned previously many in this age group indicated that they had practised in small rural communities and they had no intentions of returning. This is seen in the high response rate given the factor labelled "NONE". Several major differences among response rates of the various groups of special ists can be seen in Table XXIII. The major differences between the general practit ioners and special ists were that: - 123 -i ) general practitioners did not select the factors of educational f a c i l i t i e s , the provisions of a medical centre, nor did they provide any other factors. i i ) general practitioners did employment to be as import in a rural area as did the specia l is ts . not consider spousal ant a factor to practising primary and secondary care and i i i ) general practitioners were more wil l ing to belong to a locums pool and work for short periods of time in rural areas, and they were sl ight ly more wil l ing to accept f inancial assistance in exchange for working in rural areas for a set period of time. As seen in Table XXIII, primary care special ists tended to select those factors which were c lass i f ied as Fixed Determinants more than the other physicians. The factor most often selected was found to be adequate leisure ac t i v i t i es . This was followed by a set vacation period and employment for spouse. Adequate hospital f a c i l i t i e s and access to consultants were also important factors to this group of physicians. Primary care special ists were the least l ike ly to want to belong to a locums pool despite the fact that they required a set vacation period and additional educational leave. The responses of the secondary care special ists were similar to those of the primary care special ists in that the most often selected factors were Fixed Determinants. One interesting finding among these two groups was that over one-third of the primary care special ists (35.5%) and one-quarter of the secondary care special ists (26%) indicated that i f there were adequate hospital f a c i l i t i e s in rural areas, they would consider practising in these regions. Not surprising is the finding that primary and secondary care special ists consider contact with the university medical school to be an important factor, - 124 -and that general practitioners do not consider this an important factor. This finding has been found in several other surveys. This may be due to the fact that medicine, part icularly in the secondary f i e lds , is rapidly changing and therefore these physicians want to stay current as to the latest therapies and procedures. The provision of non-repayable educational grants and loans to medical students in exchange for practising in a rural community for a certain period of time has been recommended as a method of getting more physicians to practise in rural Br i t ish Columbia. As was seen previously in this thesis, this type of policy has been tr ied in other areas without too much success. The response to this factor in this survey would tend to indicate that i t would not be too successful in Br i t ish Columbia at this time. It might be offered to students who are from rural areas in an attempt to increase the percentage of students from these areas entering medical school. As was shown ear l ier in Table X it is these students who most often return to small communities to establish their practices. Another often cited inf luent ia l factor in the physician's decision to locate in a small rural community is the abi l i ty to join an established practice and therefore be able to share the "on c a l l " duties and have some professional company. This response was cited six times amongst the "OTHER" factors, yet the factor i t se l f was always cited amongst the lowest few factors, which alone, would be suf f ic ient . Although the factor of having a set vacation period ranked as one of the top five selections in a l l groups, not many physicians were wil l ing to belong to a locum pool which would allow for such a poss ib i l i ty . This might be caused by - 125 -the l a r g e number o f p h y s i c i a n s p r e s e n t l y p r a c t i s i n g i n the G r e a t e r Vancouver area and the ease o f o b t a i n i n g locum p o s i t i o n s i n t h i s r e g i o n . Many p h y s i c i a n s may be doing t h i s u n t i l they can o b t a i n t h e i r own MSP B i l l i n g number i n the Vancouver ar e a . Among the "OTHER" f a c t o r s t h a t were g i v e n by the r e s p o n d e n t s , the most o f t e n c i t e d f a c t o r was t h a t the area i n which the p h y s i c i a n e s t a b l i s h e s a m e d i c a l p r a c t i s e would have to be ab l e to p r o v i d e a l a r g e p o p u l a t i o n base. The reason f o r t h i s response g i v e n by some p h y s i c i a n s was t h a t o n l y i n l a r g e p o p u l a t i o n bases w i l l t h e r e be enough work and d i f f e r i n g c a s es t o keep a p h y s i c i a n busy. T h i s type o f response i s not s u r p r i s i n g i n t h a t most p h y s i c i a n s had a l r e a d y i n d i c a t e d t h e i r p r e f e r e n c e f o r e s t a b l i s h i n g i n a community w i t h a p o p u l a t i o n o f over 50,000. The second most o f t e n c i t e d Other f a c t o r was t h a t t h e r e be o t h e r s p e c i a l i s t s o r p h y s i c i a n s i n the area to share d u t i e s and f o r p r o f e s s i o n a l company. T h i s was the response' g i v e n by s i x o f the r e s p o n d e n t s . The n e x t two most common re s p o n s e s were a f i n a n c i a l i n c e n t i v e o r a g u a r a n t e e d income; and a combination o f the o t h e r f a c t o r s l i s t e d . Each o f these r e s p o n s e s were g i v e n t h r e e t i m e s . The r e m a i n i n g "OTHER" f a c t o r s were g i v e n by o n l y one p h y s i c i a n and i n c l u d e d : i ) i n a b i l i t y to g e t a job i n Vancouver; i i ) p r a c t i s e i n a r u r a l a r e a was a s t a t e d requirement p r i o r to acceptance to m e d i c a l s c h o o l ; i i i ) o p t i o n o f r e l o c a t i n g at convenience; i v ) f i n a n c i a l support f o r r e s e a r c h ; and v ) one p h y s i c i a n i n d i c a t e d t h a t i f he were m a r r i e d he would work i n a r u r a l a r e a . - 126 -Some of these ideas reappeared in the f inal section of the questionnaire when the physicians were asked to add their own comments. At this time 19 physicians who responded indicated that a large population base was needed for physicians to maintain their s k i l l s due to the large variety of cases that could be found in such a community. The lack of an "interesting" peer group and research f a c i l i t i e s in rural areas were the second and third most commonly found comments with six and four responses respectively. Only three physicians indicated that they feared not being able to get back to Vancouver i f they practised in a rural area for even a short period of time. Three other physicians indicated that a mandatory period of practise in a rural area without the immediate backup of special ists should be included in the medical curriculum, and another three indicated that the di f ferent ia l fee schedules between rural and urban areas of the province should be increased in order to attract more physicians to rural areas. Despite the mention of f inancial incentives and guaranteed incomes and the proposal to increase the fee d i f fe rent ia l , only 112 (72%) of the respondents answered the question regarding the guaranteed income that would be required before a physician would consider a rural practice. From those who did answer the question, the overwhelming response was for a guaranteed income of $150,000 or more in addition to a set minimum of other factors. This guaranteed income level accounted for 45/112 (40.2%) of the responses. Among a l l respondents this only represented 28.7%. A guaranteed net income level of $100,000 drew 38 responses, while $30,000 drew 16 and $50,000 was cited 13 times. Several comments were l isted on the questionnaires of those who did not answer this question. Several indicated that the question was complicated and - 127 -they did not understand i t , and another nine physicians indicated that money was not a major factor in deciding where to practise. Four physicians said they would NOT work in a rural area for any amount of money. As expected, the frequency with which income plus other factors was indicated increased as income level rose. Table XXIV shows the overall response to this question. In the table the guaranteed incomes are combined with the minimum set of factors which would also be needed. Results of a guaranteed net income, ALONE, are shown in Table XXV. Table XXIV 'RESPONSE RATE OF GUARANTEED NET INCOME PLUS SET OF MINIMUM CONDITIONS ^ , - - -'-GUARANTEED INCOME LEVEL FREQUENCY $ 30,000 16 (10.2) $ 50,000 13 (8.3) " $100,000 38 (24.2) $150,000 45 (28.7) Table XXV RESPONSE RATE OF GUARANTEED NET INCOME ALONE GUARANTEED INCOME LEVEL FREQUENCY $ 30,000 2 (1.3) $ 50,000 3 (1.9) $100,000 8 (5.1) $150,000 25 (15.9) The factors on the questionnaire were divided into medical and personal factors for the purpose of determining what type of combination of factors physicians required in addition to a guaranteed net income. Medical factors included: adequate hospital f a c i l i t i e s , access to consultants, abi l i ty to join an established practice, and the provision of a medical centre. The personal - 128 -factors included: abi l i ty for the spouse to find employment, adequate education f a c i l i t i e s for the children, adequate leisure act iv i t ies and a set vacation time. In a l l cases a combination of medical and personal factors was most often selected. The least often selected set of conditions was found to be a guaranteed net income plus personal factors alone. Tables XXVI and XVII provide the response rates of the lowest guaranteed income plus other factors for which a physicians would be will ing to establish a practice in rural area by the sex, marital status, age and specialty of the physician. Tables XXVIII and XXIX show the response rates of the lowest guaranteed income ALONE by the same variables. For Tables XXVI - XXIX the sample size for each group of physicians answering the monetary questions is given in Table XXVI (eg: Male n=79). The bracketed figures represent the percentage of the sample who responded to the question. The expected finding that as the guaranteed income level rose, more physicians would be will ing to practise in rural areas was clearly found. As seen in Tables XXVI - XXIX the response rates increased as the income levels rose. As seen in Table XXVI, there is a dramatic shift in the response rates between $50,000 and $100,000 in a l l cases except in the over 36 age category. The percentage of physicians wil l ing to practise in rural areas for a minimum guaranteed income of $100,000 plus a combination of other factors was roughly the same across a l l groups. Twice the proportion of female as male physicians were found to be wil l ing to practise in rural areas for a minimum guaranteed income of $30,000 plus a Table XXVI FREQUENCY OF SELECTION OF GUARANTEED INCOME LEVEL PLUS OTHER FACTORS BY SEX, MARITAL STATUS AND AGE OF PHYSICIAN INCOME LEVEL SEX MARITAL STATUS AGE Male (N=79) Female (N=33) S i n g l e (N=44) M a r r i e d (N=68) 23-29 (N=60) 30-35 (N=45) 36+ (N=7) $ 30,000 8 (10.1) 7 (21.2) 4 (9.1) 12 (17.6) 7 (11.7) 6 (13.3) 2 (28.6) $ 50,000 10 (12.7) 3 (9.1) 5 (11.4) 7 (10.3) 5 (8.3) 6 (13.3) 2 (28.6) $100,000 27 (34.2) 11 (33.3) 14 (31.8) 24 (35.3) 20 (33.3) 16 (35.6) 2 (28.6) $150,000 33 (41.8) 12 (36.4) 20 (45.5) 25 (36.8) 27 (45.0) 17 (37.8) 1 (14.3) T a b l e XXVII FREQUENCY OF SELECTION OF GUARANTEED INCOME LEVEL INCOME LEVEL $ 30,000 $ 50,000 $100,000 $150,000 PLUS OTHER FACTORS BY SPECIALTY OF PHYSICIAN General P r a c t i t i o n e r (N=10) 1 (11.1) 2 (22.2) 3 (33.3) 3 (33.3) SPECIALTY OF PHYSICIAN Primary Care S p e c i a l i s t s (N=46) 7 (15.2) 10 (21.7) 10 (21.7) 19 (41.3) Secondary Care S p e c i a l i s t s (N=51) 6 (11.1) 1 (1.9) 23 (42.6) 24 (44.4) Table XXVIII FREQUENCY OF SELECTION OF GUARANTEED INCOME LEVEL ALONE BY SEX, MARITAL STATUS AND AGE OF PHYSICIAN INCOME LEVEL SEX MARITAL STATUS AGE Male Female Single Married 23-29 30-35 36+ $ 30,000 2 (2.6) 1 (2.3) 1 (1.5) 2 (3.4) $ 50,000 3 (3.8) 1 (2.3) 2 (3.0) 2 (3.4) 1 (2.2) $100,000 6 (8.0) 2 (5.9) 4 (9.1) 3 (4.6) 5 (8.5) 3 (6.7) $150,000 16 (20.8) 8 (23.5) 12 (27.3) 12 (17.9) 13 (22.0) 12 (26.1) Table XXIX  INCOME LEVEL $ 30,000 $ 50,000 $100,000 $150,000 FREQUENCY OF SELECTION OF GUARANTEED INCOME LEVEL ALONE BY SPECIALTY OF PHYSICIAN General Practitioner 1 (10.0) 4 (40.0) SPECIALTY OF PHYSICIAN Primary Care Specialists 2 (4.4) 3 (6.5) 6 (14.0) 10 (22.7) Secondary Care Specialists 1 (1.9) 11 (20.8) CO o - 131 -c o m b i n a t i o n o f o t h e r f a c t o r s . The same r e s u l t was seen between s i n g l e and m a r r i e d p h y s i c i a n s . The response r a t e among the p h y s i c i a n s aged 36 and o v e r i s p a r t i c u l a r l y i n t e r e s t i n g . The response r a t e o n l y changed at the $150,000 income l e v e l . T h i s may i n d i c a t e t h a t to t h i s group o f p h y s i c i a n s money i s a l e s s i n f l u e n t i a l f a c t o r as to where to e s t a b l i s h a p r a c t i c e . T h i s i s brought out even more c l e a r l y when the d a t a i n T a b l e XXVIII are examined f o r t h i s age group. In T a b l e XXVIII i t i s seen t h a t no amount o f money ALONE was enough o f an i n c e n t i v e f o r t h i s group o f p h y s i c i a n s to be w i l l i n g to p r a c t i s e i n r u r a l a r e a s . T a b l e XXVI p o i n t s out t h a t secondary ca r e s p e c i a l i s t s would demand a much h i g h e r g u a r a n t e e d income l e v e l than any o t h e r group o f p h y s i c i a n s . T h i s i s c l e a r l y p o i n t e d out i n T a b l e XXIX when a guaranteed income ALONE i s examined. In t h i s t a b l e i t can be seen t h a t almost a l l secondary c a r e s p e c i a l i s t s i n d i c a t e d t h a t they would o n l y p r a c t i s e i n r u r a l areas f o r a guaranteed income ALONE of $150,000 o r o v e r . G e n e r a l p r a c t i t i o n e r s showed the same type of response p a t t e r n when income ALONE was examined, yet t h i s group o f p h y s i c i a n s most o f t e n i n d i c a t e d t h a t an income o f $100,000 p l u s o t h e r f a c t o r s would be s u f f i c i e n t i n c e n t i v e to e s t a b l i s h i n a r u r a l a r e a . I f some o f those o t h e r f a c t o r s were o f the M a n i p u l a b l e t y p e , p o l i c i e s c o u l d be d e v e l o p e d i n t h i s a r e a to persuade p h y s i c i a n s to e s t a b l i s h i n r u r a l a r e a s . The r e s p o n s e s o f female p h y s i c i a n s as shown i n T a b l e XXVIII are a l s o v e r y i n t e r e s t i n g . T h i s t a b l e shows t h a t i f a guaranteed income were the o n l y i n c e n t i v e , female p h y s i c i a n s would o n l y c o n s i d e r incomes o f $100,000 o r g r e a t e r . In the o t h e r groups o f p h y s i c i a n s seen i n T a b l e s XXVI - XXIX, the response r a t e s - 132 -slowly increase as the income level raises. When income ALONE is compared a dramatic shift in response rates is seen between $100,000 and $150,000. One interesting phenomenon that was noticed across a l l groups was that despite the amount of guaranteed income offered, more physicians chose the income plus a combination of medical factors alone, than income plus personal factors alone. This may indicate that physicians may forego personal factors, which may not be available in rural areas, for a net guaranteed income plus a combination of medical factors. It should be noted that the combination of medical and personal factors plus the income level was the most often cited response in a l l groups. This is an area in which certain pol icies could be developed in an attempt to get more physicians to practise in rural areas. Although the physicians did indicate the exact combination of factors each would require, i t was not possible to analyse each response individually to determine the most often cited combinations. Of the 27 physicians who indicated they had children, only six (22%) cited adequate educational f a c i l i t i e s as the only factor needed in a rural area before they would establish a practice there. This factor received the same response as the factor regarding the abi l i ty of the physician's spouse to find employment in the area and was the fourth most frequent response among this group. Like a l l other groups the responses of "none" and "adequate leisure act iv i t ies" were the two most often c i ted. Unlike the other groups of physicians, those with children most often selected a guaranteed net income plus personal factors alone. This was part icularly noticeable in the $30,000 and $50,000 income levels . - 133 -Overal l , this survey has shown that amongst the current residents and interns practising in Br i t ish Columbia most plan and would most l ike to establish practices in the Greater Vancouver area. Most of these physicians consider Fixed Determinants more important than Manipulable determinants when deciding on where to establish practices. This would make i t very d i f f i cu l t for any non-regulatory policy to have any effect on the geographic distr ibution of physicians in Br i t ish Columbia at this time. The uncertainty surrounding the restr ict ion of b i l l i n g numbers which was occurring at the time of this survey may have led to some of the results which have been reported here. This issue has real ly not been c la r i f i ed at this time either, except that a l l physicians who had applied for b i l l i ng numbers prior to and during the period of restr ict ion wi l l receive a number in the area of their choice. This s t i l l leaves the Br i t ish Columbia government free to restr ic t other physicians from practising in areas that i t considers to be "over-doctored". In this type of "atmosphere" i t is unlikely that the attitudes of the residents and interns wi l l change in the near future. Therefore, those areas which have high physician/population ratios may continue to do so i f the interns and residents decide to do locums in the large urban areas unt i l such time as they receive their own b i l l ing numbers. Based on the results of this survey, several conclusions and recommendations can be made. These are la id out in the f inal chapter of this thesis. - 134 -REFERENCES 1. University of Br i t ish Columbia. 1985-86 Calendar. Office of the Registrar, University of Br i t ish Columbia. Vancouver, B.C. 1985. 2. Br i t ish Columbia, "Mia vs Medical Services Commission of B.C." in Br i t ish  Columbia Law Reports. Vol . 61, 1985. pp 273-310. - 135 -CHAPTER VIII CONCLUSIONS AND RECOMMENDATIONS Analysis of responses to the questionnaire fielded as part of this project revealed a number of interesting and important findings. This chapter wi l l discuss these and make several recommendations from which pol icies may be developed in an effort to alleviate the "geographic maldistribution" of physicians in Br i t ish Columbia. These recommendations wi l l f a l l into the three categories - Regulatory, Educational and Economic - as previously discussed in this thesis. Prior to these recommendations being made, a comment w i l l be made on the Fixed and Manipulable determinants which were found to be important to the residents and interns registered in the University of Br i t ish Columbia medical school. It was found in this survey that Fixed Determinants such as: adequate leisure ac t iv i t i es , employment poss ib i l i t i es for the physician's spouse, adequate educational f a c i l i t i e s for the physician's children and a set vacation period, were considered as necessities to many physicians i f they were to establish in rural communities. As has been mentioned, i t is very d i f f i c u l t to develop any non-regulatory policy which would meet these needs. Therefore i t can be recommended that leaders from communities which are in need of physician services should conduct a recruitment drive. This would provide the physicians with exposure to the area in terms of the types of f a c i l i t i e s - le isure, sporting, and educational that are available in the smaller communities. This type of recruitment is carried out by smaller communities on the Prair ies and has proved to be successful in many cases.(1) - 136 -The manipulable determinants such as: the provision of a medical centre; f inancial assistance, and access to consultants for which pol icies can be developed were found not to be as important to the residents and interns. Adequate hospital f a c i l i t i e s in the community, another manipulable determinant was found to be important to a l l groups of physicians. Monetary incentives are another form of manipulable determinant. Except at levels of $150,000 or more, these were not alone found to be very important to physicians. Despite the fact that manipulable determinants were found not to be very inf luent ia l factors in the physician's decision on where to establish a practice, several recommendations can be made from the findings of this survey. These recommendations wi l l be made in the framework of regulatory, educational and economic incentives. REGULATORY It was shown that despite the policy to restr ic t b i l l i ng numbers in certain regions of Br i t ish Columbia, which was in effect when the questionnaire was distr ibuted, most physicians planned to establish their practices in these areas. It was also found that under this policy many physicians planned on establishing practices outside of the province, rather than in other areas of Br i t ish Columbia. If i t is the government's policy to reduce the number of physicians practising in the province, then this type of restr ic t ive policy would seem to be ef fect ive. On the other hand, i f the government was trying to al leviate the geographic maldistribution of physicians, then these results suggest that this type of policy wi l l not be effect ive. It is too early to determine whether B i l l 41 has had any effect on physicians' decisions as to - 137 -where to locate their practices. In order to affect the distr ibution of physicians the government may have to change i ts regulatory pol icies in such a manner as to make rural practise mandatory prior to complete licensure. EDUCATIONAL It was also shown in Table X that there is a strong relationship between where physicians were raised and where they plan to locate their medical practices. From this finding i t could be recommended that candidates from rural areas and small communities be allocated a certain number of openings in the f i rs t year enrollment of medical students at the University of Br i t ish Columbi a. A previous report (2) recommended that rural training become a mandatory part of the medical curriculum in Br i t ish Columbia. Mandatory rural training would allow medical students the chance to gain some valuable experience in small communities. Adequate medical training was cited by 25% of the younger physicians and 22% of the primary care physicians as the factor which, by i t s e l f , would be suff icient incentive for them to establish in rural areas. The rural training would build up the confidence of the physicians and at the same time provide an opportunity for them to observe the le isure, educational and other f a c i l i t i e s that are available in such communities situated away from the large urban centres. Despite the fact that rural training did not have much of an effect on where physicians, in this study, planned to locate their practices, i t could be again recommended that physicians receive some rural training while at medical school. - 138 -Contact with the university medical school was cited as an important factor by roughly 20% of the primary and secondary care specia l is ts . This may be overcome by the provision of continuing medical education courses in the smaller communities of the province. Again despite the fact that very few physicians indicated the desire to belong to a locums pool, the formation of such a pool of physicians would allow those physicians working in remote areas a greater opportunity to attend courses/seminars held in the Greater Vancouver area or elsewhere. ECONOMIC Loan Forgiveness, Very few physicians in any category selected the factor regarding the abi l i ty to receive f inancial assistance while attending medical school in exchange for working in a rural area for a set period of time. Although this type of recommendation has previously been made (2), i t would appear that i t would not have much of an ef fect . It may be considered to help those students who are from rural areas get through their medical training i f f inancial need was found to be a factor for these students not applying to medical school. Guaranteed Incomes This survey pointed out that a guaranteed income, except at the $150,000 or greater l eve l , was not, alone, an important factor in a physician's decision on where to locate his practice. At this level i t would be uneconomical to guarantee such an income to physicians to have them establish in rural areas. - 139 -At the $50,000 to $100,000 level i t was found that many physicians considered a combination of a guaranteed income plus the provision of certain medical factors to be necessary. The medical factors included: access to consultants, adequate hospital f a c i l i t i e s , provision of a medical centre and the abi l i ty to join an established practice. A l l of these factors, except the abi l i ty to join an established practice, are areas in which incentives can be offered. For example: smaller communities could build and equip a small medical centre to be used by physicians who practise in the community. This would also allow the possib i l i ty to join an established practice and share the "on c a l l " duties, which were a concern of many physicians. The provision of such f a c i l i t i e s and a guaranteed net income in the range of $50,000 to $100,000 may persuade more physicians to establish practices in rural areas of Br i t ish Columbia. Although certain incentives could be offered to physicians in an effort to have more of them establish in rural and remote areas of the province of Br i t ish Columbia, the uncertainty of the b i l l i ng number policy in effect at the time this survey was conducted may have played a signif icant part in the responses of the residents and interns surveyed. Possibly, now that this issue has been resolved in the courts and the legislat ion changed the responses may di f fer i f such a survey was conducted now. Therefore, in order to determine the effect of the new legislat ion a retrospective study should be carried out. This would re-question the residents and interns once they had established practices as to where and why they located in the area they did. - 140 -REFERENCES Rubin, Joe. 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"Physician Maldistribution in Cross Cultural Perspective: United States, United Kingdom and Sweden." in Inquiry. Vol. XXI No. 1, Spring 1984. pp 60-74. Rowley, Beverly; & Dewitt Baldwin. "Assessing Rural Community Resources for Health Care: The Use of Health Services Catchment Area Economic Marketing Studies." in Social Science & Medicine. Vol . 18 No. 6, 1984. pp 525-529. Rubin, Joe. "Placement Incentives: Will they lure doctors into underserviced areas?" in CMA Journal. Vo l . 24 No. 10, May 15, 1981. pp 1360-1366. Schrag, Brian. "Justice and the Just i f icat ion of a Social Pol icy: The Distribution of Primary Care Physicians." in Social Science & Medicine. Vol . 17 No. 15, 1983. pp 1061-1074. ! ' : " Schwartz, W.B.; J . P . Newhouse; B.W. Bennett; & A.P. Williams. "Changing Geographic Distribution of Board-Certified Physicians." in New England Journal,  of Medicine. Vol . 303 No. 18, October 30, 1980. pp 1032-1038. Spencer, David; & Gabrielle D 'E l ia . "The Effect of Regional Medical Education on Physician Distribution in I l l i n o i s . " in Journal of Medical Education. Vol . 58 No. 4, Apri l 1983. pp 309-315. ' ' SPSS Inc. SPSS,:X Users', Guide. McGraw H i l l , Chicago. 1983. Stefana, Constantine; Mary Pate; & John Chapman. "Hospitals and Medical Schools as Factors in the Selection of Location of Pract ice." in Journal of Medical  Education. Vo l . 54 No. 5, May 1979. pp 379-383. Steinwald, B.; & C. Steinwald. "The Effect of Preceptorship and Rural Training Programs on Physicians' Practice Location Decisions." in Medical Care. Vol . XIII No. 3, March 1975. pp 219-229. Stewart, Thomas; & Clinton Mi l le r . "Community of Origin of Spouse and Physician Location in Two Southwestern States." in. Journal of Medical Education. Vo l . 55 No. 1, January 1980. pp 53-54. Taylor, Mark; William Dickman; & Robert Kane. "Medical Students Attitudes Towards Rural Practice." in Journal of Medical Education. 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Werner, Jack; Kathryn Langwell; & Nobert Buddie. "Designation of Physician Shortage areas: The Problems of Specialty Mix Variations." in Inquiry. Vol . XVI No. 1, Spring 1979. pp 31-37. Wise, D.A.; & C . J . Zook. "Physician Shortage Areas and Pol ic ies to Influence Practice Location." in Health Services Research Part II. Vol . 18 No. 2, Sumer 1983. pp 251-269. . Woodward, Chr is te l ; & Barbara Ferr ier . "Career Developments of McMaster University medical graduates and i ts implications for Canadian medical manpower." in CMA Journal. Vol . 127 No. 16, September 15, 1982. pp 477-480. Woolf, M.A.; V. U c h i l l ; & I. Jacoby. "Demographic factors associated with physician staffing in rural areas: The experience of the National Health Services Corp." in Medical Care. Vo l . XVI No. 4, Apr i l 1981. pp 444-451. Wunderman, Lorna; & Steven Steives. "Physicians Who Move and Why: From Residency to Pract ice, 1974-1979." in Journal of Medical Education. Vol . 58 No. 5, May 1983. pp 389-394. 1 Yett, Donald; & Frank Sloan. "Migration Patterns of Recent Medical School Graduates." in In Inquiry. Vol . XI No. 6, 1974. pp 125-142. - 147 -APPENDIX A METHODS OF DETERMINING PHYSICIAN REQUIREMENTS AND SUPPLY. I . NEED-BASED METHOD I I . DEMAND-BASED METHOD I I I . UTILIZATION-BASED METHOD - 148 -NEED-BASED METHOD An "Activi ty Analysis" Planning Framework. RESOURCES REQUIRED = POPULATION x EPIDEMIOLOGY x TECHNOLOGY (in terms of minutes) MATRIX MATRIX MATRIX where: POPULATION the matrix of population groups distinguished by their dif fering characteristics related to health care needs. EPIDEMIOLOGY the matrix which converts population numbers to quantities of different services needed. TECHNOLOGY the matrix which converts the number of units of resources into units of services. MANPOWER REQUIRED = RESOURCES REQUIRED : Amount of Time (as Calculated Above) Required to Perform Each Service Required. From: Evans, R.G. Strained Mercy: The Economics of Canadian Health Care.. Butterworths & Co. Ltd. Toronto, 1984. pp 304-307. - 149 -HEALTH SERVICES MARKETING FORMULA - A DEMAND-BASED METHOD  STEP I Determine Geographical and Demographical l imits of area STEP II Determine Potential Physician V is i ts (per person; per age group) STEP III Potential Outflow of Average Gross Total Average Physician - Patients to x Revenue Per = Gross Revenue V is i ts Other Areas V is i t STEP IV Total Average x Estimated % of = Total Uncollectables Gross Revenue Uncollectables STEP V Total Average Gross Revenue Total Uncollectables Total Estimated Revenues STEP VI Total Estimated Revenues Cost of Single Physician's Practice Number of Physicians Who can be Supported by the Population. From: Rowley, Beverley & DeWitt Baldwin. - "Assessing Rural Community Resources for Health Care: The Use of Health Services Catchment Area Economic Marketing Studies." in Social Science & Medicine. Vo l . 18 No. 6, 1984. pp 525-529. - 150 -UTILIZATION-BASED METHOD  STEP I E s t i m a t e c u r r e n t s u p p l y - number o f p h y s i c i a n s o r number o f s e r v i c e s p r o v i d e d ( A b s o l u t e numbers). Convert these numbers to F u l l - T i m e - E q u i v a l e n t s (FTE's) based on p r o d u c t i v i t y . STEP I I E s t i m a t e c u r r e n t r e q u i r e m e n t s by a d j u s t i n g s u p p l y f i g u r e f o r any gaps - by d e l p h i methods o r u s i n g v a c a n t a d v e r t i s e d p o s i t i o n s as a proxy. STEP I I I Convert the r e s u l t i n g requirement complement i n t o a p h y s i c i a n / p o p u l a t i o n r a t i o . STEP IV E x t r a p o l a t e the r a t i o i n t o f u t u r e r e q u i r e m e n t s . From: Lomas, Jonathan; Greg S t o d d a r t ; & M o r r i s B a r e r . "Supply P r o j e c t i o n s As P l a n n i n g : A C r i t i c a l Review o f F o r e c a s t i n g Net P h y s i c i a n Requirements i n Canada." i n S o c i a l S c i e n c e & M e d i c i n e . V o l . 20 No. 4, 1985. p 412. - 151 -APPENDIX B NON-POSTGRADUATE PHYSICIAN/POPULATION RATIOS IN BRITISH COLUMBIA BY HOSPITAL DISTRICT (1984). I. O v e r a l l R a t i o s I I . R a t i o by S p e c i a l t y - 152 -' NON-POSTGRADUATE PHYSICIAN/POPULATION RATIOS IN BRITISH COLUMBIA BY HOSPITAL DISTRICT (1984). HOSPITAL DISTRICT RATIO NON-METROPOLITAN SUBTOTAL 1/747 , Alberni-Cl'ayoquat 1/1,008 Bulkney-Nechako 1/1,138 Cariboo 1/928 Central Coast 1/533 Central Fraser Valley 1/791 Central Kootenay 1/836 Central Okanagan 1/604 Columbia-Shuswap 1/968 Comox-Strathcona 1/706 Cowichin Valley 1/701 Dewdney-Alouette 1/842 East Kootenay 1/749 Fraser-Cheam 1/755 Fraser-Fort George 1/813 Kitimat-Stikine 1/960 Kootenay-Boundary 1/541 Mount Waddington 1/1,330 Nanaimo 1/605 North Okanagan 1/678 Okanagan-Similkameen 1/568 Peace River-Liard 1/1,198 Powell River 1/576 Skeena-Queen Charlotte 1/704 Squamish-Lillooet 1/949 Stikine 1/700 Sunshine Coast 1/564 Thompson-Nicola 1/637 METROPOLITAN SUBTOTAL 1/383 Capifal 1/369 Vancouver 1/386 TOTAL 1/504 Non-Hostgraauate Physicians in artttsh Col unto la per 10.000 Population by Regional Hospital District by MSC Specialty September 1984 Regional Hospi ta l D i s t r i c t General P r a c t i c e Family Prac t ice General Pract ice Subtotal Anaesthesia Commmlty Medicine' Dermatology' General Surqery' Interna 1 Medicine' Medical Microbiology Non-Metropoli tan - Subtotal 7.53 1.38 8.90 0.38 0.09 0.08 0.79 0.54 0.01 1 Aloern1-C1ayoquot 6.61 0.90 7.52 0.30 0.0 0.0 0.90 0.30 0 0 2 Bulk ley-Nechako 6.84 1.22 8 06 0.24 0 0 0.0 0.49 0.0 0 0 4 Cariboo 6.82 1.11 7.93 0.0 0. 16 0.0 0.95 0.32 0.0 5 Central Coast 12.52 6.26 18.77 0.0 0.0 0.0 0.0 0.0 0.0 6 Central Fraser Valley 6.68 1.35 8.03 0.48 0.0 0.08 0.64 0.56 0.0 7 Central Kootenay 8.22 1.68 9 91 0. 19 0. 19 0.0 0.56 0.37 0.0 8 Central Okanagan 6.44 2.00 8.43 0.78 0 11 0.11 0.78 1 .22 0.0 9 Columb Ia-Shuswap 7.05 1.41 8.46 0.0 0.0 0.0 0.47 0.23 0.0 10 Cotnox - S t r a t hcona 8.99 0.68 9.67 0.41 0.27 0.0 0.68 0.54 0.0 11 Cowichan Valley 8.67 0.90 9.57 0.36 0.0 0. 18 0.36 0.72 0.0 12 Dewdney-Alouette 7.86 1.70, 9.56 0.31 0. 15 0.0 0.46 0. 15 0.0 13 East Kootenay 8.96 0.53 9.49 .0.18 0.0 0.0 1.41 0.70 0.0 14 Fraser-Cheam 7.81 1.36 9. 17 0. 17 0.0 0.0 0.51 0.34 0.0 15 Fraser-Fort George 6.20 1.37 7.57 0.42 0.0 0. 11 0.84 0.32 0.0 17 Kitimftt-Stikine 6.20 1.55 7.76 0.22 0.0 0.0 0.66 0.22 0.0 18 Kootenay Boundary 11.93 0.60 12.53 0.30 0.30 0.0 1. 19 1.49 0.0 19 Mount Waddtngton 6.27 0.63 6.89 0.0 0.63 o.b 0.0 0 0 0.0 20 Nanaimo 7.90 1.34 9.23 0.73 0.12 0.24 0.61 0.61 0.0 21 North Okanagan 5.90 2.26 8.16 0.52 0. 17 0. 17 1.04 0.87 0. 17 22 Okanagan-Sim)lkameen 9.23 1.68 10.90 0.34 0.0 0. 17 1. 17 0.84 0.0 23 Peace Rlver-Llard 5.57 0.66 6.23 . 0.0 0.0 0.0 0.82 0.33 0.0 24 Powel1 River 10.71 1.02 11.74 0.0 0.51 0.0 1.53 0.51 0.0 25 Skeena-Oueen Charlotte 9.07 1.97 11.04 0.0 0.0 0.0 1.58 0.39 0.0 26 Squamtsh-L 11looet 8.54 1.00 9.54 0.50 0.0 0.0 0.50 0.0 0.0 27 Stlklne 14.29 0.0 14.29 0.0 0.0 0.0 0.0 0.0 0.0 28 Sunshine Coast 10.77 3.80 14.57 0.0 0.0 0.0 1.27 0.0 0.0 29 Thompson-Nicola 7.20 1.40 8.60 0.65 0.09 0.0 1.03 0.84 0.09 Metropol i tan - Subtotal 10.78 1.92 12.89 1.42 0.14 0.28 1.02 2.28 0.08 3 Capital 12.43 1 84 14.27 1 .65 0.24 0.24 1. 18 2.08 0.0 16 Greater Vancouver 10.41 1.94 12.35 1.37 0. 12 0.27 0.99 2.32 0.09 TOTAL 9.19 1.84 10.83 0.90 0.11 0.18 0.91 1.43 0.05 Source: University of British Columbia. Rollcall Update 84. Division of Health Services Research and Development, Vancouver, B.C. April 1985. Non-Postgraduate Physicians' In British Columbia per 10,000 Population by Regional Hospital District by MSG Specialty Septentoer 1984 R e g i o n a l H o s p i t a l D i s t r i c t Neuro- Nuclear Obstetrics 6 Orthopaedic Neurology psychiatry Neurosurgery Medicine Gynaecology Ophtha Into logy Surgery Otolaryngology Paediatrics' i-Metropolltan - Subtotal 0. 04 0.01 0. .02 0 .0 0. .31 0. .30 0. .24 0. ,14 0.26 1 A1bern<-C1 ayoquot 0. 0 0. .0 0, .0 0. .0 0. .30 0. .0 0. 0 0. 0 0.0 2 Bulkley-Nechako 0. 0 0. .0 0. 0 0. 0 0. 0 0. 0 0. 0 0. ,0 0.0 4 Cariboo 0. 0 0. .0 0. .0 0. .0 0. 16 0. 0 0. 0 0 0 0. 16 5 Central Coast 0. 0 0. .0 0 .0 0, .0 0. .0 0. .0 0. 0 0. 0 0.0 6 Central Fraser Valley 0. 0 0. 0 0 .0 0. 0 0. 16 0. 48 0. 24 0. 24 0.24 7 Central Kootenay 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 19 0. 0 0. 19 8 Central Okanagan 0. 22 0. .0 0. .11 0. 0 0. .44 0. 55 0. 44 0. 22 0.44 9 Co 1 unt> i a - Shus wap 0. 0 0. 0 0. .0 0. 0 , 0. .0 0. .0 0. .0 0. 23 0.23 10 Comox-Strathcona 0. 0 0. 0 0. .0 0. 0 0. 41 0. 14 0. 41 0. 27 0. 14 11 Cowichan Valley 0. 0 0. .0 0 .0 0. 0 0. .54 0. .36 0. 36 0. ,18, 0.36 12 Dewdney-A1ouet te 0. 0 0. .0 0. .0 0 .0 0 .0 0 .15 0. 31 0. ,0 0.0 13 East Kootenay 0. 0 0 .0 0. .0 0. 0 0 . 18 0. . 18 0. 0 0. , 18 0. 18 14 Frasei—Cheam 0. .0 0, ,0 0 .0 0 0 0 .34 0. 34 0. .0 0 . 17 0. 17 15 Frasei—Fort George 0. 11 0. 0 0 .0 0. .0 0. 42 0 42 0. 32 0. 21 0.21 17 Kltlmat-Stlklne 0. 0 0 0 0. .0 0. 0 0. 22 0 0 0. 22 0. 0 0.22 18 Kootenay Boundary 0. 0 0. .0 0, .0 0 0 0 30 0 30 0. 30 0. 0 0.60 19 Mount Waddington 0. .0 0 .0 0. .0 0. 0 0. 0 0. .0 0. 0 0. 0 0.0 20 Nanaimo 0. 12 0. ,0 0. 0 0. .0 0. .73 0 .85 0 61 0. 24 0,36 21 North Okanagan 0. .0 0. ,0 0, .0 0 0 0. .35 0, .69 0. 35 0. 17 0.35 22 Okanagan-S1m1lkameen 0, , 17 0. .0 0 .0 0. .0 0. .50 0, ,50 0. .34 0. 17 0.50 23 Peace Rlver-Llard 0. .0 0. .0 0 .0 0. .0 0 . 16 0. .0 0. . 16 0. 0 0.0 24 Powell River 0. ,0 0 0 0. ,0 0. 0 0. 51 0, 51 0. 0 0. 0 0.51 25 Skeena-Oueen Charlotte 0, ,0 0, ,0 0. .0 0. .0 0, ,39 0. .39 0, .0 0. 0 0.0 26 Squam1sh-L11looet 0. .0 0. .0 0 .0 0. .0 0. .0 0. .0 0. 0 0. 0 0.0 27 Stiklne 0 .0 0. ,0 0 .0 0. 0 0 .0 0. .0 0. 0 0. .0 0.0 28 Sunshine Coast 0, .0 0. .0 0 .0 0. 0 0. .0 0. .0 0. 0 0. 0 0.0 29 Thonpson-N 1 co 1 a 0, .0 0. .09 0 . 19 0. .0 0 .65 0 .28 0, 37 0. 19 0.75 :ropolitan - Subtotal 0. .30 0. .01 0 .15 0. .03 0 .76 0 .74 0. .60 0. 35 0.94 3 Capital 0. .24 0. .0 0 . 16 0. .0 0 .63 0. .90 0. 59 0. 35 0.55 16 Greater Vancouver 0. 32 0 .01 0 . 15 0 .04 0 .79 0. .70 0. 61 0. 35 1 .02 AL 0 .17 0 .01 0 .09 0 .02 0 .54 0 .52 0 43 0. 24 0.61 Non-Postgraduate Physicians' In British Col unto la per 10,000 Population by Regional Hospital District by MSC Specialty September 1984 Regional Hospi ta l D i s t r i c t Physica l P l a s t i c Pathology' Medicine Surgery Non-Metropol i tan - Subtotal 0. 23 0. .03 0 07 1 AIbernl-Clayoquot 0. 30 0. 0 0. 0 . 2 Bulkley-Nechako 0. 0 0. 0 0 0 4 Cariboo 0. 0 0. 0 0 0 5 Central Coast 0. 0 0. 0 0 0 6 Central Fraser Valley 0. 24 0. 0 0 0 7 Central Kootenay 0. 0 0. 0 0 0 8 Central Okanagan 0. 33 0. 33 0 22 9 Columbta-Shuswap 0. 0 0. 0 0 0 to Comox-Strathcona 0. 14 0. 0 0 0 11 Cowichan Valley 0 18 0. 0 0 0 12 Dewdney-Alouette 0 15 0. 0 0 0 13 East Kootenay 0 0 0 .0 0 0 14 Frasei—Che am 0 51 0 0 0. 17 15 Fraser-Fort Georoe 0. 53 0 0 0 11 17 KitImat-StIkIne 0. . 44 0. .0 o. 0 18 Kootenay Boundary 0. 30 0 0 0 30 19 Mount Waddlngton 0. .0 0. 0 0 .0 20 Nanaimo 0 .24 0. .0 0 24 21 North Okanagan 0 35 0 0 0 0 22 Okanagan-SImlIkameen 0 .34 0. 0 0 17 23 Peace River-Llard 0 0 0. 0 0 0 24 Powell River 0 .0 0. 0 0 0 25 Skeena-Queen Charlotte 0 .0 0 .0 0 0 26 Scjuamlsh-L11looet 0 .0 0. .0 0 0 27 St Iklne 0 .0 0 .0 0 0 28 Sunshine Coast 0 .0 0 .0 0 .0 29 Thompson-Nicola 0 .47 0 .09 0 . 19 Metropol i tan - Subtotal 0 .67 0 .13 0 21 3 Capital 0 .59 0 . 16 0, ,20 16 Greater Vancouver 0 .68 0 12 0 22 TOTAL 0 .45 0 .08 0 .14 Thoracic Specialty Psychiatry Radiology' Surgery Urology Subtota 1_ Total 0.34 0 51 0 .02 0 , 13 4 .49 13 .39 0.0 0 30 -0 0 0 0 2 .40 9 92 0.0 0. 0 0 0 0 0 0 .73 8 .79 0.0 1 11 0 0 0 0 2 .85 10 78 0.0 0. 0 0 0 0 0 0 .0 18 .77 0.56 0. 56 0 0 0 16 4 .61 12 .64 0.0 0 19 0 .0 0 19 2 .06 1 1 .96 0.78 0. 55 0 22 0. 22 8 10 16 54 0.47 0 23 0 .0 0. 0 1 .88 10 33 0.27 0. 68 0 .0 0 14 4 .49 14 . 17 0 72 0. 36 0 0 0 0 4 70 14 .27 0.31 0 31 0 0 0 0 2 .31 1 1 .87 0.0 0. 88 0 0 0 0 3 .86 13. 35 0 51 0. 51 0 . 17 0. , 17 4 .07 13. 24 0.0 0. 53 0 0 0 21 4 73 12 30 0.0 0. 22 0 .0 0. 22 2 .66 10. 42 1 0.30 0 30 0 .0 0 0 5 .97 18 49 i—. 0.0 0 0 0 .0 0 0 0 .63 7. 52 U i 0.61 0. .73 0 .0 0 ,24 7 .29 16. 52 U i 0.52 0. 69 0. .0 0 17 6 .60 14. 75 1 0.50 0 67 0 0 0. 34 6 . 71 17. 61 0. 16 0. 49 0 0 0 0 2 13 8. 35 1.02 0. .51 0 0 0. 0 5 . 61 ' 17. 35 0 0 0 39 0 0 0. 0 3. 16 14. 20 0.0 0. 0 0. 0 0. 0 1. 00 10. 54 0.0 0 .0 0 .0 0. 0 0. 0 14. 29 0.63 0. 63 0. 0 0. 63 3. 17 17 . 74 0.37 0. 56 0. 0 0. 19 7. 11 15. 71 1.74 1. 06 0. 18 0. 32 13. 40 28 09 1.37 1. 18 0. 20 0. 35 12. 82" 27 09 1.82 1. 04 0. 17 0. 32 13. 53 25 88 1.05 0 .79 0 .10 0. 23 9. .03 19 88 - 156 -APPENDIX C STUDY QUESTIONNAIRE - 158 -6. Again ASSUMING that there are NO r e s t r i c t i o n s on where you can practise in B r i t i s h Columbia, please c i r c l e the l e t t e r beside EACH statement which, BY ITSELF, would complete the following sentence for you: "I would practise i n a r u r a l area for at least f i v e years i f i a) I were able to j o i n an established p r a c t i c e . b) I had ready access to consultants. c) I were assured of a set yearly vacation period, plus a d d i t i o n a l time of f for continuing medical education workshops. d) I found the educational f a c i l i t i e s were adequate for my children. e) My spouse could f i n d suitable employment i n the area. f) I found adequate h o s p i t a l f a c i l i t i e s and support s t a f f available i n the area. g) I could get f i n a n c i a l assistance for my medical education in exchange for p r a c t i s i n g i n a r u r a l area. h) I could belong to a locums pool and would therfore only have to work in a r u r a l area for a short period of time. 1) I found the l e i s u r e and/or c u l t u r a l a c t i v i t i e s i n the area were adequate. j ) I f e l t my medical t r a i n i n g had equipped me to handle any and a l l types of emergencies which I could encounter. k) I had regular contact with the University medical school. 1) The community supplied a medical centre for my use. m) Other. Please specify: n) None of the above. 7. When answering t h i s question, consider ONLY THOSE STATEMENTS WHICH  YOU DID NOT CIRCLE i n Question 6. Please indicate (by l e t t e r ) the minimum combination of factors f o r which you would consider a r u r a l practice IF i n addition you were guaranteed a minimum net (after expenses) income. Please follow the example given below. Example: Guaranteed Income plus Minimum Conditions $30,000 plus b,d,e,g,l  $50,000 plus d.e.l  $100,000 plus 1 $150,000 plus EG: with a guaranteed net income of $30,000, i t would also require conditions b,d,e,g fl before I would practise i n a r u r a l area. For $50,000 i t would also take conditions d , e , l . For $100,000 i t would also take condition 1. I would practise i n a r u r a l for $150,000 alone.  Guaranteed PLUS Minimum Income Conditions $30,000 plus $50,000 plus $100,000 plus $150,000 or plus more. - 159 -Please check the appropriate answers: 8. Sex: Male 9. M a r i t a l Status: Female Single Married or l i v i n g with partner. 10. Do you have any children? Yes No • Kootenays Caribou Prince George Region Prince Rupert - North Coast North of Prince George Outside of B r i t i s h Columbia 11. Your age: 12. What area were you brought up in? Greater Vancouver . ' Lower Mainland Greater V i c t o r i a Central Vancouver Island Northern Vancouver Island North Okanagan ' South Okanagan 13. What size community were you brought up in? A town of under 15,000 (rural area) A c i t y of between 15,000 - 50,000 A c i t y of over 50,000 14. Are you completing: A General P r a c t i t i o n e r ' s Internship If so do you plan to specialize? Yes Please specify No A Residency. Please specify specialty:_ 15. Are you a graduate of the U.B.C. Medical Program? Yes No 16. Have you done any of your tr a i n i n g i n a r u r a l area? Yes No Please add any other comments you may have. Thank you for your time and co-operation i n completing this questionnaire. 

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