Where to set up practice?

The best place to set up your practice is where you can best build a good life.But that can be a tricky proposition. As I’ve been pondering this topic for the last couple of months, I have spent a lot of time thinking about two assumptions I had about how physicians decide where to set up practice in Canada that I ultimately decided were false.The first false assumption came out of me wondering if the medical education system in Canada drives a significant number of doctors out of their home province to do their residency. We know there is a strong correlation between where doctors do their residency and where they settle, perhaps because it’s so easy in your 20s and 30s to move to a different part of the country away from your extended family. I know I did, but I also know that later in life you can miss physical proximity to that family. So, one of my assumptions was that the best place to practise in Canada is wherever your extended family is.I ran this idea by some doctors I know and Dr. Gillian Arsenault, 66, replied: “For some people, the best place to practicse may be where your extended family isn’t!” There may be some truth to that. After spending a couple of weeks in Victoria with my extended family this summer, I remembered you can love these people but they’re nuts (in the lovely way all families probably are). And moreover, though the med-ed system in Canada does shuffle many trainees to different provinces, the data doesn’t tell us whether a significant number ultimately end up settling in a different province than they grew up in.1The second (probably) false assumption was that we can easily measure what makes a satisfactory practice location. We spent significant time gathering the professional metrics that we used to create the chart on pages 12 to 15. But when I spoke to a number of doctors over the last two months about how they decided where to practise and what about that location gives them satisfaction, they often talked about things that aren’t easy to measure.Professional satisfaction, many doctors said, is not so much about where you practise as it is about with whom you practise and the environment within which you all practise. Dr. Arsenault, who was forced to retire from practice as a medical health officer by a disabling medical condition not yet diagnosed, said she thinks “the things that really count are relationships with colleagues and patients, the ability to be able to get appropriate care for your patients when they need it (without having to fight tooth-and-nail for it), and when what you do helps make things better, especially in tough times; whether by figuring out a difficult diagnosis or by finding a more effective or less burdensome treatment, or just by being there.”With that in mind, I want to tell a few stories from doctors I spoke with and what stood out about their choices.1. The power of passion and returning to your rootsDr. Rithesh Ram, now 39, grew up in Camrose, Alta., and imagined his professional career would take him “bigger and better” places. His path to family medicine was circuitous. He studied electrical engineering in Edmonton and then did a PhD in epidemiology intending to become a health researcher. “I distinctly remember in the first year the physicians came in and for 45 minutes ran through what our life was going to be like as a health researcher.” (Short answer: unstable, contracts for a year and lots of moving around.)Dr. Ram said about 20% of the class were MDs and the doctor who spoke to the class said to him: “Why don’t you grab that MD at the same time?”That proved to be a key decision. He finished the MD/PhD program in Calgary but even with his medical degree he was still driven by the dissatisfactions that had caused him to switch his earlier career focus. “I was very disgruntled with the way medicine was being done on the individual and (system) level.” He even thought about—again—going back to school to train for something else.That all changed during his FP residency on a six-week rotation in Drumheller, Alta. He returned to Calgary after the first few days in Drumheller and started talking about the experience with his wife. “I think you’re smiling,” she said, looking at him.He was taken aback. “Don’t I smile?”“Not when talking about your work.”That was an eye-opener for him and as he thought of returning to an Alberta community about the same size as the one he’d grown up in, he wondered if maybe he’d missed something.So on July 1, 2015 he moved full-time to Drumheller and began his practice with a group. Starting July 1, 2017 he opened his own clinic and that, he said, is what really offered him the opportunity to shift how medicine was done. One example: “In Drumheller, for as long as anyone can remember, patients would call on the first Monday of the month to book an appointment with their doctor for the next month. They would have called Aug. 6, 2018 to book an appointment with their doctor in September. So the fastest appointment available to you would be at least four weeks away unless you were fortunate enough to have a doctor who was not always full. Unfortunately for patients, if they were worried about their health, many would choose to simply book appointments, regardless of whether they might need them,” Dr. Ram said. “This obviously disrupted continuity of care, as patients would then have to go to the emergency department for simple prescription refills. It also created a system where no-shows were prevalent, and patients who actually needed to see their doctor could not get in to see them . . . As a very simple solution, we offer same day and walk-in appointments. This significantly improved our access and continuity of care while reducing our no-shows.”Dr. Ram said his clinic now has 3,000 patients and he’s the sole doctor but he works with an NP and LPN in a team environment. “We managed to really turn care on its head, 180 degrees.”As for Drumheller, with its famous dinosaur fossil collection and its rock formations known as Hoodoos, “it was such an excellent shift in life in terms of living, community and job,”he said. “The openness and warmth was just great.”2. For FPs, the value of mid- to small-sized communities“I am in the Goldilocks city, just right,” said Dr. John Crosby, 71, of Cambridge, Ont. “When you are in a university centre you line up behind the residents and interns and watched, but in Cambridge I was thrown into the deep end and was delivering babies, seeing patients on my own and assisting at surgery. Pure heaven.”Dr. Crosby said he loves his city since it’s neither too big nor too small and is close to Toronto, Kitchener, Hamilton and London. “We raised three boys and they could have cheap, close tennis, ski and guitar lessons. They went to terrific schools and had a great small-town upbringing,” he added.“Even as a new doctor I was bright enough to know that a middle-sized city was a good choice,” said Dr. Crosby. “If you go to a small one you end up never getting off call and dying in harness. In a big city, you become a triage officer.”Of course if the community is small, you’re going to find that work-life balance can be hard to strike. “You have to accept the fact that you’re going to see patients everywhere and they may or may not ask you questions,” Dr. Ram said. But a lot of the challenges about smaller communities that used to exist have been reduced. Online ordering, for instance, means you don’t automatically have fewer options in your life outside of big cities. “The world is smaller,” said Dr. Ram.For Dr. Barb Watts, 63, of Orangeville, Ont. the move from practising in Scarborough (an east-end Toronto suburb) to a smaller community was great. “As a family doctor, I really enjoyed giving comprehensive care,” she said.“I got to do more.” Dr. Watts does admit that she started to enjoy practising less over the years due to paperwork and changing patient attitudes, so nine years ago she quit her family practice to do full time emerg. “I find that much more satisfying.” Now she’s one year into a three-year role as part-time chief of medicine.Dr. Mike Simon, 55, a family doctor in Saint John, N.B., outlined several benefits he enjoys from practising in a smaller city: Five-minute drive to the office, six to the nursing home, seven to the hospital; home for lunch; relatively small medical community so you can pick up a phone and ask for advice; colleagues will return your call. But he also said there are drawbacks. Because you’re so close, you’re there every day. Small community means small numbers of specialists, and can mean long waiting times. And it’s worse when someone leaves or gets sick. Colleagues are busy. Call is more frequent in smaller groups. And you need a connecting flight to go anywhere.3. Quality of practice environment“Mine was not an impulsive decision” said Dr. Tom DeMarco, 58, of his practice in Whistler, B.C. “I worked in 52 practices in 12 provinces and territories as a GP locum, from coast to coast to coast before settling here in Whistler to join my brother, also a GP.”Dr. DeMarco said his choice had nothing to do with the outdoor recreational opportunities for which this resort town is world-famous, but rather the practice clientele. “I meet people from all over the world on a daily basis, providing me ample opportunity to use my five languages. And patients here actually get better! I have a few diabetics and hypertensives among my 2,000 clients, but no COPD, no malingerers, and virtually no chronic fatigue. Most cases are acute infections, acute injuries or derm conditions.”He said he also enjoys getting out of the office to see patients in the hotels. “I do almost 100 house calls annually. Financially, with a lot of private billings, I do very well. I could have retired years ago, but enjoy my work-life balance, taking 13 weeks per year to travel the world on my bicycle.”4. Social needDoctors make their choices about where to practise for a wide range of reasons. At the core there’s a deeply personal element about the choice. But an important aspect for some is social need.Dr. Sarah Giles, 40, regularly locums in communities in the far north and says it is social need that drives that choice. “It’s a great feeling to provide medical care in chronically understaffed communities,” she said. “I put in a lot of unpaid hours doing chart reviews for every patient before I start the day because I know that people who receive episodic care from different providers often have problems that fall through the cracks and that cancer screening is often missed. I’ve always been the fan of the underdog—so remote fly-in communities, communities where you can’t drink the water, and places where patients complain they have faced systemic racism give me extra satisfaction when I work there. But it’s not all out of the goodness of my heart. These patients are incredibly resilient people in tight knit communities who keep an eye on their neighbours.”1 Canadian medical schools are provincially funded and most reserve seats for students from that province (generally you need to live two years in that province to be considered “from” that province). But Canadian Post-M.D. Education Registry (CAPER) data for the 2017/18 school year show that 53.4% of residents from English-language universities were training in the same province in which they received their MD. (In contrast, 93.3% of post-MD trainees attending a French-language university also received their MD in Quebec.) Most doctors stay in the same region where they did their residency. For instance, recent CAPER data show that two years after residents exited postgraduate training at Dalhousie in 2013, 74% were still living in Atlantic Canada. Compare that to the less-than-half of the exit cohort who had done their undergraduate degree there. However, we don’t have data on where they completed their BSc or BA degrees before entering the MD program.

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