'Keep the doors open': As ERs close, doctor speaks out on the challenges of practising in rural Sask.

The senior lead physician of a Saskatchewan Medical Association program that provides help for rural doctors is speaking out on the challenges they face, after a number of temporary rural emergency room closures forced by a shortage of medical professionals in the province.

"We tend to get the feeling that from an emergency perspective … the importance is placed on just keeping the door open, not necessarily, you know, keeping the door open when we are adequately staffed," Dr. Francois Reitz said in an interview Tuesday, as he was coming off a 24-hour emergency room shift.

Reitz works with the medical association's rural relief program, which provides short-term locum relief to general and family doctors working in rural communities with fewer than five practising physicians.

The workload for health-care workers in rural areas has increased from when he first started with the program 20 years ago, he said, including greater demand from patients as health conditions have become more complex.

At the same time, there is a shortage of health-care workers in rural areas.

"It's not just physician shortages that we're seeing," Reitz said. "My nursing colleagues, my pharmacy colleagues, my lab techs, etc. — there's a shortage of everybody."

That's resulted in many rural health-care workers who are on call "every single day," he said, which means they struggle with work-life balance or may have to reduce services.

When somebody calls in sick, there's often nobody to replace them, Reitz said.

"I need certain things to be able to deal with the heart attack or if there's a motor vehicle accident," he said.

"If I don't have those resources available to me, I cannot do the best that I can from a rural perspective. And rural, classically, we deal with fewer resources that we have to juggle."

The expectation to "keep the doors open" for health services like emergency rooms can compromise the quality of care for patients, which is top of mind for doctors, said Reitz.

"Our concerns are more about not being able to provide that quality of care," he said. "When one hasn't had sleep or [doesn't] have enough staff, what is slipping through the cracks?"

Reitz said the current doctor shortage is not a complete surprise.

He said by 2018-19, it was known the field would run into a "mass retiring of doctors," due to the number of baby boomers working at that time.

Then came the COVID-19 pandemic, which was both a wake-up call and catalyst for the health-care system, he said.

"I think it highlighted a lot of weaknesses within our health-care system, both with current planning and future management," said Reitz.

Many health-care workers also started to reassess their roles within the system and opted for better work-life balance, leading some to restrict their practices.

Residents and leaders in some rural Saskatchewan communities have started to speak out about the shortage of doctors, and how many resign early.

That comes down to a few factors, said Reitz.

As the population grows, the province is not producing enough physicians to replace those who leave the field, he said.

Instead, Reitz said Canada has relied heavily on international medical graduates — he was recruited from South Africa just over 20 years ago.

"You are more likely to find an international medical graduate in rural Saskatchewan than you are to find a Canadian graduate," he said.

Typically, a rural doctor will do a roughly five-year term, Reitz said. But as recruitment relies more heavily on international doctors, there seems to be fewer who stay in rural areas long-term.

For those from some religious or cultural backgrounds, it can be hard to access community, traditional foods or religious services in rural areas, he said.

"Saskatchewan has traditionally been very, very difficult for international medical graduates who are not of a Christian or atheist background," Reitz said.

Many come to realize they would be "happier, healthier and in a better financial state after a year … moving anywhere else, whether it's centrally or out of province," he said.

Pay is another factor in turnover, with the compensation not always matching the long hours rural physicians are expected to work, said Reitz.

"Being a physician is not the high-paying job that it used to be 20 or 30 years ago," he said.

"But then again, how do you sell to the public that a doctor is not being adequately paid? This is something which both culturally, as well as historically, is a very difficult argument to make."

The head of the Saskatchewan Healthcare Recruitment Agency says it works with international applicants to try to ease the transition.

"Once we are aware of an applicant, we start working with them to understand where they were educated, what their currency or practice is, if they would be new to Canada," said chief executive officer Terri Strunk.

The provincial agency's role is to reach out to medical residents and graduates locally, nationally and globally to try to find physicians, she said.

There are many qualifications that have to be met through the Royal College of Physicians and Surgeons of Canada, the national regulatory body, she said.

Once a doctor is deemed eligible, the College of Physicians and Surgeons of Saskatchewan and the Saskatchewan Health Authority work to determine which vacancy they could fill, said Strunk.

The province offers competitive incentives and opportunities to doctors, and "we have a lot of interest in Saskatchewan because of the nature of our physician workforce here," she said.

"They want to make that decision, and then what's the fastest way I can get there."

With that, there needs to be consideration for international workers around where they should be located and how they can best be prepared to practise there, said Strunk.

"Practising in a rural area of Saskatchewan is different from practising in one of our rural centres," she said.

"You might have a physician, you know, practising in a remote or rural community of Saskatchewan that may have never seen … an agricultural accident before."

The recruitment agency has worked hard over the last year to share information with communities about which factors influence retention of health-care workers in rural and remote areas, said Strunk.

"Communities are the first to want to keep their health facilities open — they want to keep their doctors there, but oftentimes they don't know what they don't know," she said.

"They may not realize that … [doctor] might be feeling socially isolated, or perhaps the spouse hasn't been able to find work."

The agency is also looking at what has worked for communities that have good retention, and sharing that with others through a health-care tool kit.

"It's just also about making sure that we, as a recruitment agency … and the employer at the Saskatchewan Health Authority and that community know who that physician is, what their needs are, as much as we can," Strunk said.

"The more we can do as a system to help increase that understanding, the more success we're going to have."