Transitions to Practice

Are You Ready for the Country?

Andrea Berntson, MD, PGY2
University of Toronto, based at Sault Area Hospitals, Sault Ste. Marie, Ontario

Abstract: A career in rural or remote psychiatry has many rewards. However, the initial transition to this type of practice can have unique challenges. This paper explores issues of practice selection and sustainability using key informant interviews and a review of the rural and remote practice literature. Recommendations to ease transition include thorough research of a prospective practice group, getting rural exposure during training or as a locum tenens, realistically assessing your own career expectations and getting expert advice on contract negotiation. Following transition, use of the Internet and membership in professional associations can maintain collegial contact and provide ongoing professional development. Teaching and research opportunities in rural and remote settings are exciting developing trends for those with an interest in an academic career.

Résumé : La campagne vous attire?

Une carrière en psychiatrie en région rurale ou éloignée apporte de grandes satisfactions. Toutefois, la première transition à ce type de pratique peut poser des problèmes particuliers. Cet article aborde les questions de la sélection et de la viabilité de la pratique, à l’aide d’entrevues avec des témoins privilégiés et d’une analyse de la documentation portant sur la pratique en région rurale et éloignée. Pour faciliter la transition, l’on recommande entre autres de rechercher avec soin un groupe de pratique potentiel, de s’exposer au milieu rural durant la formation ou comme psychiatre suppléant, d’évaluer de façon réaliste ses propres attentes quant à sa carrière et d’obtenir les conseils d’un expert en négociation de contrat. Après la transition, l’utilisation d’Internet et l’adhésion à des associations professionnelles peuvent entretenir un lien collégial et procurer le perfectionnement professionnel continu. Les possibilités d’enseignement et de recherche en région rurale ou éloignée sont des tendances stimulantes et croissantes, pour ceux qui s’intéressent à une carrière universitaire.

Key Words: rural, remote, psychiatry, career planning, transition to practice

Rural and remote areas can be exciting places to work. However, there are some important and unique issues attached to selecting and starting practice in these areas.

There is great potential to make a big difference in a small community. Demands are heavy, and different opportunities are evolving with the advent of Northern medical schools in Ontario and British Columbia. Provincial governments are increasing their efforts to help physicians establish and maintain rural practice. Examples of these initiatives include Ontario’s Underserviced Area Program and Alberta’s Rural Physician Action Plan. International medical graduates may be obligated to settle in under- served locations as part of licensure.

What can be done to limit the stresses of rural and remote environments? Dr. Steve Baxter, a senior psychiatry resident taking on a staff position in North Bay, Ontario, says that the best thing he did was to talk to as many people as possible about the psychiatrist groups he was hoping to join (personal communication, September 2003). This meant that he and his wife spoke not only to the recruitment committee but also to nurses, administrators and community members. Dr. Baxter had learned in his earlier career as a family physician that his relationship with his colleagues was ultimately the single most important determinant of professional satisfaction.

Many communities have recruitment committees that can support the efforts of the staff physician group. While these committees can be a good source of information, it is important to be sensitive to territoriality, which can be common in small communities—even in underserved areas—where a potential new hire can mean a loss of power, privilege or salary for existing physicians. Awareness of this often-hidden dynamic is important when researching a new practice group.

Locums and senior electives are ways of getting a feel for a community. Dr. Chi Cheng, a recent McMaster graduate, undertook outreach electives in many small communities before graduating (personal communication, September 2003). In fact, she eased her transition to practice by spending her first few months in a practice that had known her as a senior resident. Dr. Andrew Harris, Dalhousie University’s program director, commented on a similar phenomenon in their smaller core teaching sites (personal communication, November 2001). He noted that the limited licensure possible for Nova Scotia’s senior trainees allows residents to experience nearly independent practice while still in contact with the resources of the training program.

Dr. Cheng highlights the real importance of boundary setting in a small community. She describes six months’ experience in St. Andrew’s, Nfld., where she was one of two psychiatrists serving a large population dispersed throughout the northern region of the province. Social contact with patients was unavoidable, and she describes having to maintain constant vigilance about the privacy of patient information. A small literature in this area offers some advice to practitioners about managing social boundaries and mental health stigma in small communities (1–3).

Boundaries are important for both patient and practitioner. Health service supply in rural and remote communities has been a challenge for decades, and individuals can easily feel they are never doing enough to address their community’s needs. Long waiting lists must be balanced with administrative obligations—not to mention the necessity of protected personal time and vacations.

Some provinces have developed programs to match physicians with vacancies in rural areas. In British Columbia, Healthmatch BC is an online community recruitment listing (www.healthmatchbc.org). In Ontario, the PAIRO Resident Placement Program (PRPP) is a service provided by the provincial housestaff organization (www.pairo.org/whatsnew/prpp.htm). This program interviews graduating residents and links them to communities that meet their career interests. The PRPP benefits from the participation of Community Development Officers who represent different Ontario regions and, among their many activities, work with the program to match residents. PARI-MP, the housestaff organization for the Maritime provinces (www.parimp.ca), is developing a community registry that should be launched in the next few years.

Once a physician selects a community in which to set up practice, there are more challenges ahead. Contract negotiation will be an unfamiliar exercise for many newly licensed physicians. For the practical aspects, MD Management offers the services of its Practice Solutions team. Chartered accountants and administrators who have worked with medical professionals in the past are available to do individual consultations. These professionals can do limited assessment of contract proposals and can certainly offer financial advice to CMA members. MD Management is also a good referral source when seeking personal financial consultants and accountants. Although most of the contact list is urban-based, the organization will pursue specific requests to find a suitable person in any community. While not offering legal advice, MD Management can provide resources to inform physicians about their legal rights and the practical aspects of running an office and managing staff.

Practically speaking, it may take a year or more to establish a full practice. In the early phase, billing numbers may be delayed by at least two months post-graduation, which can delay the first paycheques by several months. At the same time, the various professional colleges and associations require significant fees, and CMPA coverage must also be maintained. One useful resource documenting some of the rural incentives across the country is the Society of Rural Physicians Regions page at www.srpc.ca.

It has been established that isolation—meaning detachment from peers more than physical distance—is a significant risk factor for loss of competence (4). Most rural or remote practitioners would likely also link isolation to risk of burnout. Dr. Pippa Moss, a rural child psychiatrist working in Nova Scotia and New Brunswick, maintains links with colleagues by frequent conference attendance and participation on both provincial and national committees (personal communication, 2001). Topical online discussion groups help keep some practitioners current in areas like psychopharmacology, while also enabling collegial contact. In Australia, a Special Interest Group in Rural Psychiatry has developed within the national psychiatric association (5). Given the service delivery challenges we share with Australia, this perhaps predicts the development of a similar group within the CPA.

Opportunities to participate in teaching networks vary from province to province. For the most part, program directors report difficulty recruiting interested teachers in the community (personal communications, May 2001– May 2002). Outreach opportunities are often developed according to the interest of a motivated preceptor. Staying in touch with the academic centre can provide opportunities for appointments and continuing professional development, as well as access to Internet and library resources. Informally, it can also lead to connections for finding locum relief and practitioners willing to assist in visiting clinics.

Moving away from the academic centre does not necessarily prevent participation in research. Small regional centres do participate in large clinical trial networks and often have fewer patients lost to follow-up. Further, increasing funding is being focused on rural health research, although it is often linked with university department affiliation.

In summary, the transition to practice in rural and remote areas can require more preparation than stepping into urban practice. There is a wonderful diversity of psychiatry careers to be explored in these areas, and the work is rich and rewarding.

Acknowlegements

I thank Dr. Henry Leung, Sault Ste. Marie, Ontario; Dr. Mark Tapper, Comox, British Columbia; Dr. Usama Zahlan, Kenora, Ontario; and Dr. Pippa Moss, New Glasgow, Nova Scotia, for their regular and ongoing advice and example in becoming a rural or remote area psychiatrist.

References

1. Crawford P, Brown B. ‘Like a friend going round’: reducing the stigma attached to mental healthcare in rural communities. Health Soc Care Community 2002;10:229–38.

2. Simon RI, Williams IC. Maintaining treatment boundaries in small communities and rural areas. Psychiatr Serv 1999;50:1440–6.

3. Roberts LW, Battaglia J, Epstein RS. Frontier ethics: mental health care needs and ethical dilemmas in rural communities. Psychiatr Serv 1999;50:497–503.

4. Lewkonia R. Educational impact of practice isolation. Med Educ 2001;35:528-9

5. Special Interest Group in Rural Psychiatry. Australas Psychiatry 2001;9:387–8.