Rural and Remote Health Care in Canada — Dr. Katharine Smart

Alex Maheux

Hi, welcome to the CHIP, the Canadian Health Information Podcast. I’m your host, Alex Maheux.

In this show from the Canadian Institute for Health Information, we’ll give you an in-depth look at Canada’s health systems and talk to patients and experts you can trust. Join me as I go beyond the data to find out more about the work being done to keep us all healthy.

When imagining the life of a doctor, some of us may picture a busy emergency department in the heart of a big city. However, that’s not the reality for a large percentage of physicians in rural areas whose experience is vastly different.

Today, we’ll hear from Dr. Katharine Smart, the newly appointed president of the Canadian Medical Association and pediatrician from Whitehorse, Yukon. She tells us what it’s really like to provide care in remote communities and opportunities for making health care more equitable.

Katharine, welcome to the CHIP. It’s great to have you here today.

Dr. Katharine Smart

Thanks for having me.

Alex Maheux

Well, 1st of all, I just want to say a huge congratulations on your recent appointment as the 154th, I believe, president of the CMA. You’re coming into the position with a very unique perspective and position. You’re a pediatrician; you have expertise in rural communities. What are your main priorities for the next year?

Dr. Katharine Smart

Well, as you said, it’s certainly an interesting time to be in leadership in medicine, that in the middle of a pandemic, lots of things happening, and also, I think, an evolving human health resource crisis. So, being someone from the North where we’ve had long-standing challenges, it is definitely been interesting

So, I think my priorities are really to make the voices of health care professionals heard and out in the public arena so that Canadians can really understand the challenges right now that the health workforce is facing and the need really to rethink health and health systems in this country. And that really aligns with the work at the CMA and our Impact 2040 strategy where we’re really trying to advance new ways of looking at health, the health system and the health workforce. So that’s really important to me.

And then the 2nd piece, I think, is really helping us get through the last part of what I hope is the soon-to-end pandemic. As a pediatrician, of course, we’re hopefully about to see more vaccines coming online for children. So I think educating the public, really encouraging confidence in vaccination, and really encouraging people to keep moving forward with using public health strategies to keep as many people safe as possible and try to bring this pandemic to a close, that’s also I think a real top priority for myself and the CMA at this time.

Alex Maheux

Well, I think it’s safe to say you have your hands full for the next few years.

I want to ask and kind of take a step back. You’ve spent your whole career in rural and remote care for the most part. What attracted you to practising in rural communities in the 1st place?

Dr. Katharine Smart

Yeah. So I’ve been really fortunate in that my career sort of straddled both rural and remote medicine, which I’ve always had some foot in that door throughout my career, but also I’ve also had the opportunity to work in tertiary hospitals as well, at the Alberta children’s hospital. So I feel like I have that unique perspective as someone who’s done both things.

For me, it really started as a pediatric resident. I had the opportunity to spend a month in Nunavut as a pediatric resident. That was back before they had pediatricians in the territory of Nunavut. So, I was there for a month working with the family doctors there to provide care to kids. And that was really, I think for me, my 1st real opportunity to immerse myself in pediatrics and medicine in Northern Canada, and that really sparked my interest in that type of health care.

From there, I went on to do a lot of work as a general pediatrician in northern Manitoba. And even while I was working as an emergency medicine physician at the Children’s Hospital in Calgary, I continued to do regular locums in northern Manitoba because I really enjoyed that type of practice. And then ultimately, that led me here to the Yukon, were I’ve been for the last 4 years working full time in rural pediatrics.

Alex Maheux

You mentioned you went back to that because it’s something you really enjoyed. What is it about rural and remote care that you like the most?

Dr. Katharine Smart

I think for me, the thing I enjoy the most is the real opportunity to get to know the community and partner with the community. When you live in a smaller place, like right now in the Yukon, it’s much easier to get to know people and understand who does what in the community and where you can have some influence. So, when you’re trying to build partnerships or make change, it’s much easier when you can build on relationships, and I think its easier to find those people, get to know them, and find areas for synergy; and naturally, then, a lot of what I’ve been focusing on my time here in the Yukon. And that’s what I’ve enjoyed in other places I’ve been as well, is just those relationships form, I think, more quickly in smaller communities.

The other thing I really like is just the challenge of it. When you’re in these rural and remote places, the resources, of course, are very different. So, as a physician, you really have to be willing and able to use the very broad skill set that you have because you don’t have a lot of other people to necessarily rely on like you would in a bigger hospital. So, I like the teamwork that that brings.

I think here in Whitehorse, when we have a sick child or something complicated going on, you really see all the physicians pulling together to support each other and provide the care that that person needs. And I really enjoy that aspect of it and just the challenge of that.

And then just the breadth of the medicine that you get to do is really interesting because you’re really doing everything. My outpatient practice here has a large mental health focus. I work a lot with kids that have experienced childhood adversity, so I do a lot of mental health in my daywork. But then I also deal with really sick children — babies, children that are ill in the hospital, resuscitations, those types of things as well. Those things often happen after hours or in the night. So, it’s a really interesting kind of combination of skills that you need and opportunities that you have to serve the community.

Alex Maheux

It’s incredible to hear the level of collaboration there is, even in remote care like that.

But as you said, not all cases can be cared for in some settings when there’s not access to the right technology or the right tools, and in some cases, you do have to fly to get the proper level of care. I’m wondering if you’d be willing to share a story that I heard, a pretty extraordinary case in which you did yourself help to get a child in need to another centre and how that came about.

Dr. Katharine Smart

Yeah, that was a very interesting experience. So, you’re absolutely right. When we have children or babies who are critically ill who require intensive care, they do need to be medevacked or transferred to another centre, which for us is generally the Children’s Hospital in Vancouver, and sometimes the Children’s Hospital in Edmonton.

That is, again, another long-standing challenge in rural centres that I think sometimes people don’t entirely appreciate, is how difficult it can be to obtain a team to come and get your patient and move them. So as you can imagine, it’s quite a limited resource, the specialized teams that come and help care for critically ill children and babies. And when you’re in a territory like the Yukon, traditionally we’ve been dependent on teams from other centres to come and get our patients, which means at times, they’re not available when we want them, and we can have very long waits to get the teams up here to move our patients.

And I had a very unique experience where I had a very, very sick little girl who was very much in front of my eyes over a matter of hours deteriorating into multi-organ failure, and it was quite clear that she was not going to survive if she did not get to an actual ICU where they could do different interventions that she required to reverse what was going on. And we had done all the things we were able to do locally but the next things she needed — dialysis, life support — were not available here.

And it was a really challenging situation because the teams that we were trying to get to come and get her weren’t available. So, we had conferred with the ICU physicians in both Vancouver and Edmonton. They both agreed this child was critically ill, needed to move immediately, but both groups didn’t have a team available. And there was a lot of back and forth between the 2 centres — team’s coming, no, team can’t come, team’s coming, team can’t come. And this happened over a period of hours and into the middle of the night. And by about 3 o’clock in the morning, it was pretty clear no one was coming until the next day, which meant they weren’t really going to be on the ground where we were moving this child ’til at least another 12 hours from where we were, and it was pretty clear to me that she wasn’t going to be alive at that point.

And the ICU physicians I was speaking to agreed with me, but they didn’t have a solution because they didn’t have a team that was available. So, I was sort of in this situation where I was left feeling like I just can’t accept that this is the reason that this child dies because I can’t get her the care that she needs.

At that point in time in the Yukon, our medevac team, which does a lot of medevac both within the territory and moving patients down to either B.C. and Alberta, was not doing any medevacs for children. They didn’t have pediatric equipment, they weren’t trained in that, so there was sort of a blanket rule that they weren’t allowed to take kids.

But this was obviously a very extreme situation. So I consulted with the paramedic that was on call that night. I asked him to come to the hospital, and we sat down there at 3:00 a.m. and I just sort of told him the situation. I said, this child isn’t going to survive if we don’t take her to Vancouver now; the time is running out; we’ve got to go. And he was in a really difficult situation because he was the only paramedic on that night for medevac. There’s supposed to be 2. So he wasn’t supposed to be taking anybody as it was, and it was a child.

But he was a parent himself, and we talked about it, and he was like, okay, I trust you, if that’s what you’re saying, let’s do it. So, we loaded up the child and both her parents and we had a giant box of medications. So I’d had the nurses in the emerg drop every possible thing we could think of that we might need to keep her stable on the flight, and we got in the plane, and we flew her to Vancouver.

And fortunately, we were able to give her a blood transfusion en route. That helped to stabilize her a bit more, and she was fairly stable during the flight. And we did get her there, and within a few hours, she was on all the life support they had, kidney replacement, all sorts of things. And she was the sickest child in their ICU for almost 6 weeks, but she survived. And I’m happy to say this month she received her last dose of chemotherapy and has been cured of her cancer and she’s thriving and doing incredibly well.

But that was just one of those moments as a rural physician, I think, where you just think, wow, we have all these things but yet they’re not always available when you need them. And some things in medicine are very time sensitive and, in that case, I just really wasn’t willing to accept that that was going to be the reason that this family lost their child. And fortunately it worked out.

What was positive that came out of that is that did sort of motivate people here in the territory to get more proactive about pediatric medevac. So we actually now have all the equipment to provide medevac to children and infants. We’ve trained our paramedics locally in pediatric and neonatal care, so we’re now much more prepared for cases like this in the future to be able to provide a higher standard of care to our own population when we’re not able to access it from other places in the country.

So, I’m really happy that that’s happened, because, unfortunately, I think as resource limitations are happening more and more in bigger centres, it’s getting harder and harder for us to sometimes access those services for our patients, and we need to be able to do more ourselves.

Alex Maheux

It’s an incredible story with an amazing outcome. And I think too, the fact that a larger outcome of the story was that you were able to implement better resources going forward.

But I do want to ask. I think that kind of story goes to speak about the impact that that would have on health outcomes for those who live in rural communities. Is the CMA or in your role, is part of your new position thinking about the models of care in rural communities? And perhaps a more pan-Canadian strategy for that?

Dr. Katharine Smart

For sure. Like I was saying earlier, when we are looking at health care at the CMA, we’re really looking at it through 3 lenses: health, what is health, how do we define it, how do we create it; the health system, which is what you’re asking about, what does that look like, how does it work better; and the health workforce, how do you create healthy providers who are thriving in their work.

And I think there’s no question that reimagining the health system is a critical part of how we provide better care to people in rural areas. And that, I think, requires some innovation and new ideas about how to reach people, but it also requires better planning around human health resources. Some things, like that child I was just talking about, sometimes you just need the right person at the right time with the right skill set to be able to provide care to patients. And that can be challenging in a rural centre, for sure. And that’s a very sort of dramatic example.

But in the day-to-day management of people’s care, I think there’s a lot of different ways we could be more innovative to get people the care that they need. And I think what’s exciting is, now that there is this, I think, increasing comfort with virtual care, I think that could create a lot more opportunities for people in rural areas to access care, specialized care, that they maybe haven’t really been able to access in the past without significant travel, which is a huge barrier.

So I think there’s lots of opportunities here to reimagine the health system that we’re in, and I think that’s a huge priority. Because I think right now what’s pretty clear is the system is broken, right? We have an antiquated system that was developed in the ’50s, that maybe worked then, that does not work now, and it’s not working really for anyone, right? It’s not really working for patients. So many people don’t have care. We know almost 5 million Canadians don’t have access to primary care.

It’s much worse in rural areas because it’s harder to recruit and retain physicians, partly because the burden of work in these settings is huge. When I was here, the 1st 2 years I was here, I was the only pediatrician in the entire territory. That story I told you about that little girl, that was the one day off I had that whole month that that happened. So, when you’re in these places and you’re basically alone, of course, you’re going to step up when people need you, but that’s not sustainable for people.

Now, fortunately, we have 3 full-time physicians here for pediatrics and it’s much more reasonable. But as you imagine, how do you recruit and retain health care providers in these scenarios where that’s what the work-life integration is like? It’s very challenging to do that. So how do we reimagine some of that? And then how do we leverage, I think, technology to do some of that work for us and to provide more of that day-to-day support that some people need? And I think we need to get more imaginative because it’s pretty clear that more of the same isn’t going to do it.

Alex Maheux

You’ve touched on quite a few things I actually was hoping to talk to you about.

Let’s start with health workforce. Obviously, COVID has played a part in this. But one of our coworkers at CIHI held a stakeholder engagement session where it was noted that in some rural communities, vacancy rates for health workforce was as high as 70%. I’m wondering what you’re hearing and seeing and how we can help address this.

Dr. Katharine Smart

Yes. This is a huge issue. And then as you can imagine in those contexts, as you’ve described, where there’s not enough people, there’s two problems. One, there’s not enough people, but then the burden on the people that are actually there, of course, increases, so actually retaining those people becomes very problematic. So, at the CME, that issue of human health resources is a huge priority. We are really advocating at the federal level to have the government step up more around human health resource planning.

Because one of the huge issues we have in this country, which is sort of in some ways a bit hard to believe, but there is no human health resource plan that’s pan-Canadian. We don’t have the data. It’s not being collected. So we can look at who’s advertising for positions, what positions are filled, which positions aren’t, but there’s really no plan that’s saying we need this many doctors in these places, these are the types, we need this many nurse practitioners, we need this many nurses, social workers, et cetera, to really understand how to deliver integrated team-based care across the country in a sustainable way.

So it’s hard to plan for something when you don’t really know what you’re planning for. So I think what we have right now is a bit of a hodgepodge approach of individual places kind of trying to ascertain what they need, advertise, fill these positions. But without, really, a plan, it’s hard to know how many people are we training, are they the right number of people, are we getting people from the right parts of the country and training and retaining them where they are. This is, again, a huge issue.

In the North, I think you’re much more likely to retain people here that are from here. And when you look even in the Yukon, about what family doctors have been recruited and retained since I’ve been here, it’s largely Yukoners that went out, trained as physicians and have come back because this is their home. It’s going to be harder to get someone from downtown Toronto who grew up there to want to come live in Whitehorse or Yellowknife or Iqaluit.

So I think we need more diversity as well in our profession. And that, again, links to that human health resource planning about what are we doing to actually address that and understand it. So I think that’s really the next step.

What’s also interesting, I think, is we recently held an emergency summit at the CMA with just over 35 different national health professional organizations, and we heard the same thing from everybody at that table. No one felt there was a human health resource plan for their area of health practice. So this is a broad issue. I think it’s opportunity for the federal government to show that leadership and really step up and provide that data together in partnership with the provinces so that we can move forward on actually actioning some solutions.

Alex Maheux

I’ve heard it said that, if you’ve seen one rural community, you’ve seen one rural community, that’s just how different they all are. How difficult does that make it in order to come up with a plan, like a pan-Canadian plan, when all the communities are that different?

Dr. Katharine Smart

Yeah, I think that’s a really good point. And I certainly see that even here in the Yukon because I have the opportunity to do outreach to various rural communities. And it’s true, they are all different. But I think there’s certain basic things that would be similar in terms of the number and types of providers. Then I think what’s different is picking providers who are then willing to form relationships with community to find health care solutions that meet their needs uniquely in those areas.

So, for example, as a physician, I can go to different communities and interact with those communities and sort of find out, hey, what do you want the way we work together to provide health care to your community to look like? So I can adapt myself and how I work differently depending on what works for them. So I think there’s lots of opportunities for that.

But again, one important piece of that is that longitudinal relationship. You can only provide that type of care or personalize that care to a community if you get to know that community, and that’s much harder when you’re in and out. And I think that’s what’s been very challenging; a lot of rural places rely heavily on locums or physicians that are in and out of those communities. And while that can be an important piece of providing some short-term relief for long-term providers in those communities so they can get a break, I don’t think it provides that same level of personalized care that can happen from people that really live and work in these places.

Alex Maheux

Absolutely. And I want to talk a little bit more about virtual care. Health care providers have said that COVID, in a way, has helped advance it by 10 to 15 years. And as you said, there are certainly major benefits to introducing more virtual care in rural communities. But I’d also imagine that there are some barriers to doing that. How do you see virtual care playing a part in improving care in rural communities?

Dr. Katharine Smart

I think virtual care can improve things in rural communities in many ways. I think I kind of break it down into different domains. So 1st of all, if you think — speaking for myself as a provider in the rural place — so patients of mine across the territory now can access me much more easily, right? So, if they’re in Old Crow but something comes up, we can have a virtual appointment to see if we can deal with it that way, rather than perhaps the patient having to travel. So accessibility to the providers that are there I think is huge. And especially, again, in places where the travel is expensive and far. And sometimes that’s needed, but often, it’s not. So that’s one opportunity to really make yourself more available for people that you’re already serving.

Then I think when you look at how do you retain health care workers. Well, a huge part of that is them enjoying their work, feeling fulfilled and feeling like they’re doing a good job. And a big part of that in rural medicine is feeling supported. You can’t be an expert in everything. So you need to be able to access other physicians to provide care to your patients on things where you need help.

So that serves two purposes. One, it makes sure your patients are getting the care they need, but of course, it also provides you with an educational opportunity to increase your own skills. So how can virtual care help with that? So for me, it’s being able to bring some of those people into the exam room with me, like I’d mentioned before. That I’ve found has been really powerful. We do, for example, a diabetes outreach clinic here; an endocrinologist from BC Children’s sees the kids here with type 1 diabetes in the Yukon. While they were coming in person, but with COVID, they couldn’t, well, we put that on to Zoom. But I can still join all those appointments. So now I’m learning a ton about type 1 diabetes at the same time as my patients are getting the care from that expert. And I’m there with that local perspective to say, oh, actually, this child, we could do this for them; oh, they also have a mental health problem, let me get them back so we can address that.

So the care suddenly becomes much more holistic when we’re working in teams. And it’s fun for me because I’m learning something and I feel supported. It’s great for the patient because everyone involved in their circle of care is collaborating, and we’re all sort of learning together. So I think there’s huge opportunities there as well.

And then I think when you also look at continuing medical education, again, that’s another challenge of being rural. How do you stay up to date? When you’re in a big tertiary hospital, there’s rounds all the time, there’s presentations, tons of opportunity. And that’s part of what makes you like your job. People go into medicine because they’re lifelong learners. That can be harder to access in a rural area. Well, again, suddenly now, a lot of these things are virtual. So now I can join in on rounds in Calgary or Vancouver or Toronto and be learning from experts in subspecialist scenarios, which then make me feel like I’m better prepared to care for my patients here, that I’m up to date, even though I’m living in a small place without a lot of colleagues. And you start to feel that sense of connection. You’re connected to colleagues, you’re not alone.

So I see it on all those levels. And I think part of retaining people in their work is having them find joy in what they do and purpose.

Alex Maheux

You’re talking about providing tools and extra support. Obviously, at CIHI, we’re focused on gathering and analyzing data to help make decisions easier for health care providers, for decision makers, for the provinces and territories. Where do you see some opportunities to improve the comprehensiveness and availability of data to support decision-making in rural health communities?

Dr. Katharine Smart 

That’s a great question. And I think it’s really exciting right now as we’re moving forward with more electronic medical records, more systems-based electronic medical records; more provinces and territories trying to get on one system so the data is in one place, and then having groups like CIHI that can then gather and leverage that data. I hope where we find ourselves one day is where data is being generated in real time and fed back to clinicians so they can actually see what they’re doing — dashboards, feedback on your own practice, what are your own outcomes, how does what you’re doing compare with other people, where are you in terms of being up to date with guidelines and your chronic disease management with your patients, are you hitting those targets.

And I think as that data becomes more broadly available, as it’s more — it’s all in one place, as the data we’re collecting in our day-to-day work starts being able to feed into some of these systems, there’s no reason we could not be getting some of this data back in real time to improve the quality of our care and to also give us feedback on what we’re doing.

Because this is another huge challenge in medicine, is around accountability and quality and what systems are in place to ensure those things. And without data, it’s really hard to do that. And I think there’s a lot of opportunities now with the evolution of electronic health records to have more of that type of data available and then putting it in the hands of people in real time so that they can change what they do.

Alex Maheux

Yeah. That’s incredible. That’s the dream.

It’s hard to do a health interview these days without mentioning COVID. How do you think COVID has affected rural communities differently than what’s been happening in urban settings? I’d imagine that there are some things that are perhaps easier, some that are a bit more difficult. What were some of the different challenges that you’ve found for rural communities?

Dr. Katharine Smart

Yeah, I think there’s been a lot of different challenges, and I think they’ve evolved and changed as the pandemic has gone along. When I look here in the Yukon, we locked down very hard at the beginning of COVID, and we had extremely strict public health measures here for a very long time. Very much, it limited people’s ability to move in and out of the territory; there were strict self-isolation guidelines if you did leave the territory and return, that really limited movement.

So I think in a lot of ways, that was challenging for people because if you did have to go out to get care, when you came back, you had to isolate or quarantine for 14 days. So for families that had to leave the territory for care and maybe had other children, other kids in school, that was not a small burden to have to bear, coming back and having to deal with that. And for some kids that have significant chronic health issues that needed to be out of the territory semi-regularly or even regularly for care, that was a huge burden for many, many months. So I think that was difficult, for sure, for people.

It was also very challenging to get any help, locums, coverage for people’s practices, because of the different rules and limitations. So that meant the burden on the local health care providers was much higher. So I think that was very challenging. We’re working in a very resource-limited setting, so I think just the stress of how we were going to manage these patients, knowing that we had limited resources, and that as the resources were being overwhelmed in what are our traditional referral centres, what did that mean for our ability to care for patients and move them when needed. So those, I think, were a lot of those early stressors.

Then as things sort of changed and evolved and things opened up a lot more, that was great. But now we’re sort of, unfortunately, back in another massive outbreak of COVID here. Because I think what happened is, we pivoted away from public health strategies because we had a high vaccination rate. And I think we’ve learned the same lesson of a lot of the rest of the country, which was, it’s not that anyone ever said you shouldn’t be wearing a mask and you shouldn’t be doing things; they were highly recommended.

But when they were no longer mandated, people’s behaviour changed. And now we’re in the middle of a huge outbreak of the Delta variant. It’s spreading rapidly in the community. It’s back in schools. So now we’re sort of back with our hospitals starting to be overwhelmed, you know, running out of oxygen this week, plans when can they get the oxygen here, how many more patients can we look after, do we have to start cancelling surgeries, et cetera. So we’re back in that space again. And again, in a small place, there’s no pop-off valve. The only other place we can get patients, they have to go on a plane. So it’s not easy to move people or adjust to that rapidly in a small place, so it’s very stressful.

We’re starting — we’ve had several physicians get COVID recently as we were all vaccinated very early in January. So we’re starting to see likely some waning of that vaccine because of that increased community spread and a lot of kids getting COVID. We’re seeing now parents, and some of them are physicians. But again, the impact on the health workforce when you only have a handful of doctors and suddenly 2 or 3 out of 10 have COVID and can’t work for 14 days, even though, fortunately, none of them have been ill because they were vaccinated, so that’s been great, but they can’t work. So the impact of that is huge, and that impacts the whole community. So I think that’s a bit different than a bigger centre where you’re just drawing from more people.

What I’m hopeful for is, since the government’s now come out quite strongly with pretty strict recommendations, that hopefully we get things back under control quite quickly and people can get back to having some more normalcy in their lives. But it’s definitely been a bit of a roller coaster, I would say, up and down like everywhere, but some of these kind of issues that have been a bit unique to being in a small place with just the limited resources that we have.

Alex Maheux

I can imagine how stressful that is for you right now.

I want to pivot back and actually talk about climate change. This past year, we’ve seen really devastating record temperatures, wildfires, flooding, lack of access to clean drinking water; all of this especially in northern and western Canada. I’m wondering if you’ve already started to see the impact of climate change on health in your community. And if it’s affecting the type of care that you provide. And from what you’ve seen so far, how do you anticipate climate change impacting health care over the next few years?

Dr. Katharine Smart

Yes, there’s no question, I don’t think, that climate change is going to be one of or, arguably, the biggest threat to health moving forward. And certainly, here, where we have arctic regions and subarctic regions, and we’re seeing, I think, climate change accelerated even more than we’re seeing in some of the southern parts. And that’s what we’re hearing from our First Nations leaders in the territory very strongly is they’re seeing the impacts of climate change in their communities, and it’s just very different than it was 20, 30 years ago. And we’re seeing the impact on wildlife, fish, even just housing and the ground and what’s happening there, damage to buildings. And then, of course, we’re seeing, this past summer we had a lot of forest fires, that impact on human health.

So I think there’s a lot of different aspects of how that’s impacting people going forward. I think a lot of also anxiety and fear around climate change and what that means for traditional ways of life, I think especially right now in the Yukon, the First Nations here have been self-governing for a long time. They’re incredible leaders. They’re really, I think, recapturing their culture and really leading the way in terms of reclaiming their identity as Indigenous peoples and what that means. So I can only imagine, for their communities, how scary that is when proximal to this rebirth, in a way, or reclaiming of who you are, you’re now also seeing the land that’s so integral to your identity start to be threatened by climate change, and how that intersects with intergenerational trauma, mental health, and all those other concerns.

So I think it’s just one more piece of the pie that people are having to deal with, which is quite scary moving forward on how do we address that in these places. I think it’s a big challenge that we’re going to be seeing for a long time. And it certainly worries me for the future of our kids, what’s it going to be like and what are the health implications going to be. I mean, we see them now — the heat, the smoke — but also, I think more broadly, just on people’s identities and their mental health are also substantial.

Alex Maheux

Absolutely. It’s been actually very upsetting to watch.

You mentioned Indigenous care and health in rural communities. I want to bring up the fact that, sometimes those terms — Indigenous health and rural health — are falsely used interchangeably and might be treated similarly. What has been your experience in your community? And how can we collaborate and support Indigenous health, specifically in rural areas?

Dr. Katharine Smart

I think it’s really recognizing that the First Nations or Indigenous peoples have a strong sense of what they want and how they want their health care to look, and where we have failed them in the past, and what partnerships look like moving forward to provide culturally safe and relevant care. So I can speak probably most to my own experience because I certainly don’t want to also group all these groups together. Because I think, again, we know they’re all very different. There’s many, as, of course, we all know, different First Nations, Métis and Inuit people, across the country with different cultures and different experiences and different paths forward.

But I can certainly speak to my own experience and what I’ve learned here in the Yukon. I, in pediatrics, have been very fortunate to work quite closely with the Council of Yukon First Nations, which is a group here that represents 12 of the 14 First Nations in the territory. And we’ve partnered now quite extensively on how to better serve First Nations children in the territory through a collaborative partnership.

And what that’s looked like for me has really been trying to partner more around what does safe health care look like to them, and how do we reach First Nations kids and their families in a way that makes our care relevant, culturally safe and accessible.

So we’ve done that right now in a few ways. One has been by actually going to community. So, in the past, when there was very little pediatrics here and it was sort of a model where locum pediatricians would come up for a period of time. Kids that wanted any sort of pediatric consultative care had to come to Whitehorse. So that’s a big barrier for care, obviously. And you also then don’t have that opportunity to see that child in their own community or meet any of the extended family or adults in their lives that might be relevant to what’s going on. So even your ability to provide care to a child with that limited information’s quite difficult.

Now that we actually visit almost all of the communities in the Yukon regularly, the three pediatricians that are now here regularly, we’ve had that opportunity to go to the schools, to meet the Elders, to meet some of the First Nations peoples, to get to know communities and families much more. So I think we’re able to provide much more relevant care because we have that setting of where people are and that opportunity to know them and the strengths and the challenges in their communities and leverage those to their care. So that’s one piece.

The other piece is something we’ve been doing here in Whitehorse which I think is quite unique, which is, we provide care at the Cultural Centre in partnership with CYFN, and they host something they call wellness fairs where they bring in lots of different groups that provide services to children. So things like the child development centre, speech and language pathologists, occupational therapists, Elders, the First Nations education director, people from Jordan’s Principle, all meet together in the longhouse in the Cultural Centre here and provide sort of a fair where people can come and learn about these things.

Well, simultaneously, we provide two pediatricians where we each see a roster of kids and their families throughout the day that have been identified and chosen by CYFN as kids at risk that they want us to see. But it’s much informal, right? It’s not at our office. It’s at the Cultural Centre. They can bring whatever supports they want with them. And it’s just a chance for them to get to know us, us to get to know them, and us together identify what are some health priorities you have for your children, and then start planning those things together. So what comes out of that, often we can identify multiple supports that might benefit that family, and then we can provide support letters to Jordan’s Principle to CYFN so those families can get those services that they need.

Sometimes it means us being able to then connect with the school around unmet needs and advocate for those things or make sure things are happening. It allows us then to invite some of those families that need ongoing pediatric care into our office practice to say, hey, we’d love to see you again; would you be comfortable coming to our clinic? And because we’ve met in this context, it makes it, I think, less intimidating, and often people are more comfortable following up.

So in my view, that’s sort of one of the ways to decolonize health care is by providing it in a different setting, letting it be led by the First Nations themselves around what they want it to look like, and getting their feedback about what it’s been like for their citizens, what was comfortable, what wasn’t, what types of questions maybe people would prefer we don’t ask, how we can work into some of that more personal information over time, how to build those relationships. And try to do it in a way that’s more culturally sensitive.

Alex Maheux

That collaboration is extremely critical, and really just getting to know people, I think, ultimately, that’s super valuable for any health care setting.

What do you think is the biggest misconception about rural health in Canada?

Dr. Katharine Smart

Well, that’s a good question. I think there’s probably lots of misconceptions. I think sometimes it’s hard. People don’t always understand what the roles of different people are in health care. I would start with that.

Health care is a culture, like anything. So we sort of know how it’s supposed to work or what it all means because there’s like a language to it and a way that we do things, and people don’t always realize that. So I think probably, an average Canadian may not realize how being a doctor in a rural area might be different than a doctor in a city, and really comprehending what’s involved with that. So they may not really realize, from an access perspective or just a breadth-of-practice perspective, how different it is for patients seeking care in a rural area and what the physicians there need to do.

Just as an example, like here, a lot of our family doctors, they are also emergency doctors; they also provide anesthesia; they do obstetrics. This is not typical in a city. And I think an average Canadian may not realize that people living in rural areas are getting all these very specialized services from a family physician. That sometimes I think can lead to misperceptions around who you need to see. And I think that’s sometimes a challenge for a family doctor when patients always want to be referred to someone. Because I think there’s sometimes a perception, oh, a specialist knows more. And that may be true in certain contexts, but in a lot of contexts, the family doctor is very well equipped to provide that.

So I think sometimes that misperception can lead to patient demands or desires that aren’t really necessary, that sometimes set up, unfortunately, some conflict or need to explain the roles and who does what within the system because there can be these perceptions of who’s capable of doing what and people not always, I think, fully realizing just how incredibly skilled our rural providers are and the breadth of practice that they have.

I think, yeah, the other piece probably is — and again, I don’t know, this may or may not be true — but I think sometimes people don’t also appreciate maybe just the depth and the breadth of people that live in rural communities. There can be perhaps stereotypes about what rural Canadians are like versus people in the city. And people here, I think, are incredibly knowledgeable. They have all sorts of skills and lived experiences. And it’s really just amazing, the breadth in the community here of the type of people that live here and what they bring and their commitment to the community. It’s not all one type of person.

It’s also much more diverse than people may think. We have people here from all around the world living here in the Yukon, which just, I think, adds to the beauty of the community. And I don’t know if people from a large city may realize that that these centres are full of people with all sorts of incredible lived experience, all sorts of knowledge, and this just diversity from around the world, which makes it really interesting.

So I think there’s lots of unique aspects of living in a rural place. I think the practice of medicine here is definitely unique, but you just have I think a huge level of commitment to the community from the providers that are here, which is amazing to see. And just that rural sense of we’re kind of in it together. And I think that’s one of the unique aspects of being in a smaller community too. You kind of know everybody, so you can’t kind of do anything without considering the impact on the community. And that might be a different experience than what people have had in a city. And I think that applies to health care too, right? Your doctor may be your soccer coach; your doctor may be the person bringing the cookies to your child’s swim meet. And that’s just a different relationship than might happen elsewhere.

And I think that can have its own challenges, both for patients and providers. But it also, it’s very beautiful a lot of the time when you just have that chance to really know each other and support each other. And I think I feel like we, as providers, get a lot of support and respect from the community here, which is really lovely. And a lot of the reward is feeling like you’ve been able to make that different because you really do know people. And I think that’s, again, one of the things that makes working in rural health care very rewarding and one of the things that draws and keeps people.

Alex Maheux

I think it’s incredibly heartwarming to hear how tight-knit those communities can be.

Katharine, I want to ask you one last question. What are your hopes for rural care in Canada? And what would success look like at the end of your tenure?

Dr. Katharine Smart

I think my big hope for rural Canada is that we can continue to attract and retain health care providers who are really motivated to do rural practice. And I think to do that, we have to reimagine some of the systems and make them more sustainable for the people that work in them. So I think we have to not get stuck in the status quo but be willing to open our minds, different ways of organizing ourselves, different ways of working in teams to make the work attractive and sustainable.

Because the people that choose to do rural medicine are passionate about that type of work. They love their community. They want to do that breadth of medicine. But we have to make sure the system then doesn’t eat them alive so that they’re not able to do it. So, what I would like to see is a system that allows those types of people to be here and to find that joy so that they can be healthy themselves while working to keep their communities healthy.

So that’s, I think, really what my dream would be for rural medicine. Do I think that’s going to all happen in my one year as CMA president? No, I don’t. But I don’t think that’s realistic. But I think what can happen is really having these issues be front and centre. I think we have an opportunity right now. Because I think it’s pretty clear people don’t want to emerge out of this pandemic back to the way things were. So I think the opportunities in front of us are probably much bigger than they’ve been in the past. And so I hope that we can start to actually see some movement in that direction. And I hope that we can start to see the diversity of this country reflected in the health care professionals that serve it.

Alex Maheux

I hope so too.

Katharine, thank you so much for your time today, for helping us better understand what it’s like to be a physician in rural care. And I have to say, I’m really looking forward to experiencing what you accomplish as president of CMA.

Dr. Katharine Smart

Thanks so much, Alex.

Alex Maheux

Thanks for listening. Check in next time when we bring you more valuable health care topics and perspectives.

If you want to learn more about CIHI, visit our website, cihi.ca. That’s cihi.ca. And if you like what you heard, subscribe where you find your podcasts, and give us a follow on social media.

This episode was produced by Angela Baker and Stephanie Bright. And our senior producer is Johnathan Kuehlein. I’m Alex Maheux. Talk to you next time.