Rural and Remote Health Care in Canada — Dr. Nicole Ranger

Alex Maheux:

Hello, and welcome to the Canadian Health Information Podcast. I’m your host, Alex Maheux. In this program from the Canadian Institute for Health Information, we’ll be analyzing Canada’s health systems with qualified patients and experts. Stay tuned as we go beyond the data to learn more about the work being done to keep us healthy.
 

When we imagine the life of a doctor in Canada, many of us probably think of an emergency room in a big city. However, this is not the reality for a large percentage of physicians in rural areas. Today we’re talking with Dr. Nicole Ranger from Hearst, in northern Ontario. She is not only a family physician, but has a full scope of practice in emergency medicine, long-term care and hospital services.

Hello Nicole, welcome to the podcast.

Nicole Ranger:

Thank you, it’s a privilege to be here today.

Alex Maheux:

You have a really fascinating story. I was really looking forward to talking to you. At the age of 42, you decided that you were going to dedicate yourself entirely to becoming a doctor and specifically a rural physician. You studied at the Northern Ontario School of Medicine. Where did your passion for becoming a doctor in northern Ontario come from?

Nicole Ranger:

I think, for me, it comes from my youth. I was raised in a small rural community just outside of Sudbury. I had the great privilege during medical school of doing my internship with the Northern Ontario School of Medicine. In our 3rd year, we do an internship of about 8 months in a rural community. For me, it was in Hearst. So I found a 2nd home. When I went there to begin my 3rd year of medical school, it really reaffirmed my choice to become a rural community physician.

Alex Maheux:

Tell me about it. How has your experience been so far? What kinds of decisions do you have to make every day as a rural physician? How is it different from being a doctor in an urban area?

Nicole Ranger:

In my experience, and still to this day, I find that no 2 days are alike. Every day is different. We’ll see each other in completely different contexts every day. We can go from the office to the emergency room for an evening shift or be called in to make emergency visits during the day. We can also be called on to see clients or patients in the long-term care setting, depending on our work arrangements. A hospitalist system has been set up here very recently to manage patients admitted to acute medical care.

Hospitalists are also the 1st on call for assisting in the operating room. We are also on call depending on the conditions of the patients in the long-term care unit. So it can change a lot in a day. This makes our work super rewarding. Patients recognize the great value of having a physician who will move from one setting to another and see them in different settings for continuity of care.

Alex Maheux:

I guess it must be a major advantage to be able to oversee all areas of care. This is perhaps a consideration when considering rural versus urban medicine.

Nicole Ranger:

Exactly. Usually, physicians in urban communities will have a clinically oriented practice in their office. They can sometimes see patients in the hospital, but it is not an obligation on their part. So there are some doctors who will choose to do that. The unique context of rural practice is that physicians are expected to go beyond clinical work in the office. Rural physicians often have personalities that are open to new adventures, and different passions like emergency medicine.

We also have doctors that do clinical work. I mainly work in the office, hospital services, emergency and long-term care. But some of my physician colleagues also do obstetrics, C-sections or anesthesia. So when you’re in a rural area, it’s important to have doctors who have a wide variety of backgrounds in the community and who have really developed a passion for providing a range of services to patients. This continuity cannot be underestimated in terms of the value it gives to patients. When I see a patient in the office and then that patient is admitted to acute medical care, I already know their history. I can match the patient’s condition with existing conditions that may have contributed to them being admitted, for example.

Alex Maheux:

I’ve always wondered what people do when they face a health emergency in a rural area. For example, a cardiac arrest, a heart attack, a stroke. How does that impact patient outcomes?

Nicole Ranger:

Yes, that’s a great question. As a rural physician, when you see an emergency, you 1st have to know yourself and recognize your strengths and your ability to function in an environment where you don’t have all the resources at your disposal. So when I started working in the Hearst community, there was no CT scan. So people who presented symptoms that were potentially associated with a stroke had to be assessed fairly quickly and then we had to take urgent steps to transport the patient to another community for a diagnostic test.

This in itself presents challenges.

Today we had a big snowstorm. There is no way for planes to land, etc. So that can necessarily jeopardize a patient’s health. Fortunately, the Hearst community is truly a passionate community that is focused on raising funds and taking the necessary measures to support its members. They set up a fund-raising project. Through the efforts of the community, we were able to buy a new CT scan for the Hearst community to ensure continuity of care. So that was a big relief for the doctors.

However, we don’t always have access to the resources we need. Improving health conditions or health outcomes for patients can go one way or the other. It all depends on the resources at our disposal and how easily we can access them. Some systems were put in place, and again since COVID-19, the services that are offered are by video or audio conference with other specialists outside the community.

I must say that we are quite fortunate to have a whole range of medical specialists who come to visit us every month. We have general surgeons, gynaecologists. We also used to have access to neurology and urology services. So the community benefits from a good range of medical specialists, even though we don’t have all the services needed to serve all patients.

Alex Maheux:

I must admit that sounds reassuring. I imagine that the lack of resources must be a real burden at times.

Nicole Ranger:

Absolutely. I remember when one patient had to be transferred to another facility for medical imaging.   So I’m on the phone with a medical specialist at a tertiary centre in another community. The patient is not in front of me. I’ve got the patient and his family on the phone. I have the medical specialist in the other community on another phone to try to coordinate services so that the patient does not incur delays for being transferred to specialist services. Because typically, a patient who is sent for medical imaging has to return to their community before being sent back to another community. This complicates the situation, as you can see. I didn’t want to cause delays for that patient because he needed emergency care that we couldn’t provide. Basically, I was also jeopardizing the possibility that the patient could go back because it was in the middle of winter. So I couldn’t take the chance of having a patient who was caught between 2 facilities and too sick to be able to be transported to the services he needed.

Alex Maheux:

It must be really hard. What do you think is the biggest misconception that Canadians have about rural medicine?

Nicole Ranger:

I think there are perhaps 2 areas where there are misconceptions about rural health. On the side of health care providers, I think we often think about the fact that people do not necessarily have access to a wide range of health care services in terms of specialized care. This is not necessarily always the case. Health teams in rural communities have to work together to be able to develop different areas of expertise to best serve the people of the community. This is perhaps one of the biggest misconceptions.

When we look at people’s health per se, people tend to think that those in rural communities are less healthy. I think that in some contexts this can be true. On the other hand, depending on where you are located, the health and vitality of the community will depend in large part on all the health services available in the region. So it’s almost like a double-edged sword. We can see health disparities among people in rural communities. On the other hand, we can also see innovations or certain strategies that are put in place to be able to improve the quality of services and through this, the level of health of people in the community.

Alex Maheux:

Indeed. I guess there’s a lot of creativity required of physicians in rural communities as well. You talked about the disparities that sometimes exist in rural health. This brings me to my next question, which applies specifically to rural Indigenous health. These 2 populations are sometimes wrongly grouped together, perhaps because of similar themes and approaches related to the determinants of health. But what are the unique things we should be considering when we talk about Indigenous health in remote regions specifically?

Nicole Ranger:

There are still a lot of challenges in terms of being able to implement strategies to support Indigenous health. So here we have an Indigenous community that is served by the local hospital. This is the Constance Lake First Nation. They have a medical health clinic onsite. Unfortunately, they are not able to offer a wide range of services in the community because of shortages of nurses and health care personnel in general. This makes it very difficult to support people in the community in caring for their health.

You are absolutely right, Alex. When we look at the determinants of health, we often look at investment in the supply of services and then access to services. But we also need to have an investment plan to address the causes which are poverty, lack of safe housing, lack of access to safe food, clean water and transportation access problems. For the people of Constance Lake First Nation, even though there is a service in place, it’s very difficult for them to get into town for appointments because there is a lack of access to transportation. This sometimes puts people’s health at risk. They may not be able to come in if they need intravenous antibiotics administered multiple times during the day. Because there is a lack of health care workers in the community, they are not able to receive these services at home either.

So these are just a few examples that really show the challenges faced by people living in rural communities. Indeed, especially by Indigenous peoples.

Alex Maheux:

These are important questions, which go beyond health issues. These days, it’s really hard to do an interview about health without talking about COVID and its impact. So I’d like to talk about that a little bit with you. How has COVID has affected your work as a rural physician? There are a few different aspects to consider. For example, is it easier to communicate with members of the community because you know them better than in a big city? Are there any difficulties we would not have considered or faced in an urban area?

Nicole Ranger:

Like in any community, we had to very quickly evaluate what elements needed to be put in place to ensure the safety of our patients, health care personnel and staff who support all health services in the community. I think in the beginning, there was a lot of insecurity. People were very afraid of in-person interactions. In any case, we were trying to get people to understand that it was very important to call for emergency services. People avoided going to the emergency room or calling the office. They wanted to avoid potential exposure to an unknown virus.

Our community has experienced particular difficulties because we’re almost equidistant from the 2 major centres that serve our patients, Sudbury and Thunder Bay. Because of this geographic distribution, we do not fall into the same regions for health services. We also saw that in communities with several cases of COVID, our patients could no longer get access to the medical specialists who had previously seen them for certain medical conditions. There was a very abrupt cut-off of services for our patients during the outbreak of COVID cases.

The other thing is that we depend on other hospitals for biopsies, which fall under radiology services, etc. As for surrounding communities that have larger hospitals, they also depend on physicians from southern Ontario to provide services. So we’ve seen some long delays in certain types of imaging. We have had long delays in being able to send our patients for biopsies of all kinds. This has complicated matters particularly for smaller communities. I don’t know whether there has been as much of an effect in urban communities, but I assume that because the services are available locally, patients in those slightly more urban communities have not had as much waiting time as patients in rural communities.

Alex Maheux:

It’s really hard to hear. Another CIHI colleague recently spoke with stakeholders from across the country. It was noted that vacancy rates for health care workers were as high as 70% in some rural communities. Probably part of it is the stress arising from COVID. But has there been a big impact for health care workers in your area?

Nicole Ranger:

I think that COVID may have been a contributing factor leading to a significant number of burnouts among health care professionals everywhere. So we had to set up the same types of services as in bigger hospitals. But we don’t have the same human resources to make the changes necessary to adapt to something like a pandemic. Here in particular, we are seeing a lot of well-deserved retirements from doctors who have worked in the community for many years. The stress we are experiencing here is due mainly to difficulties in recruiting staff to replace medical personnel who have left.

The challenges of COVID and the stress that health care professionals have had to work with in the last few years only makes it harder to recruit people.

Alex Maheux:

We need more doctors like you who want to work in rural communities. If I may, I’d like to touch on a final topic related to COVID, which is the idea that COVID has been helpful in advancing virtual care. You mentioned that it might have helped in some ways. But I assume that access can sometimes be challenging in rural communities?

Nicole Ranger:

Absolutely. I know that there are already plans to upgrade the resources and infrastructure needed to improve the communications network. This would allow health professionals to have virtual interactions more easily. As you can see, if the internet goes down, we can’t access any our electronic medical records. We are so dependent on technology these days that the improvement of this infrastructure is essential. We also have to realize that, depending on the community, we have a fairly large population of seniors. These are people who are not necessarily well versed on the use of services like zoom or other virtual platforms for communication. Even on the phone, as you can imagine, there are older people who have hearing problems. It’s not easy for them to interact in this way, it can highlight some of the challenges they have.

I’ve even noticed that since COVID, because we have to wear masks and visors, patients who have hearing problems are particularly impacted. They can’t see our mouths because of our masks. I have a hard time hearing at the end of the day because I’ve listened to myself a lot more than my patients. So, that’s another difficult aspect. On the other hand, I have a lot of patients who appreciate communicating by phone, especially for quick follow-ups. Not going to the office saves time for the patient. It avoids exposure to other patients who may have communicable diseases. Since COVID, people are not sitting in waiting rooms waiting for their appointment. They are just in time. So virtual communication is a really good option.

It is also important to recognize that no virtual platform will ever replace in-person consultations. This personal contact is still something that is really important for patients. And they told us they felt that way during the months when we couldn’t see many patients in person. They insisted on the importance for them to have face-to-face meetings.

Alex Maheux:

You mentioned medical records. CIHI’s goal is to collect and analyze data to help give people across the health spectrum the information they need to make better decisions for their communities and the people they serve. What opportunities do you see in the collection and availability of data to improve rural medicine?

Nicole Ranger:

This is a crucial question because I believe in the importance of using data to leverage best practices in rural areas in order to support the development of strategies that do not yet exist in some communities. CIHI certainly has a critical role to play in this regard. I think we need to recruit more stakeholders in rural and remote communities to collect continuous data. Often, projects are done in isolation to collect evidence to inform decisions about policy development or new practices. I think there is a lot of room to set up a much larger network. Because as time goes on, human resources are diminishing. Despite the fact that we are trying to implement strategies to increase the number of human resources, there will certainly be a period during which we will have challenges in providing the services that are essential for the survival of health services in rural and isolated communities.

So, with this data, I think we would be able to better establish strategies that could help communities that are currently in a critical situation and that cannot necessarily make up the shortfall within a reasonable time.

Alex Maheux:

We know that data can help improve results in communities. Of course, every community is very different. If you’ve seen one, you’ve only seen one. You’re part of the Ontario Medical Association, which has just released an action plan to address health care challenges in northern Ontario. What does the plan hope to establish to improve the health of all rural communities?

Nicole Ranger:

When we look at this plan, I think that one of the most crucial points is to improve access to equitable health services. So we don’t aspire to equal care, we aspire to equitable care. This means that in the context of rural communities, despite the fact that we cannot always offer the full range of services locally, we really need to develop strategies so that people can easily access services to meet their health needs, with waiting periods similar than those of urban communities. I believe that with the Northern Ontario School of Medicine, which is now going to be a university, we have the capacity to leverage innovative models for training physicians.

Several studies have shown that health care workers will settle in the communities in which they were trained. In my previous experience as a teacher, it was often necessary to send learners to more urban centres. Unfortunately, they were there for very long periods of time. And they met a partner, they made a life and never came back to northern Ontario. I think we need to find opportunities to have students do more internships in northern Ontario so that they can appreciate the range of services that they can offer and the uniqueness of their skills when trained in rural areas.

Above that, allow them to appreciate what the communities themselves can offer in return. So it’s not just career-wise that’s important, it’s really critical to anchor the health professional with their family or their spouse so that they can see themselves settling down and offering health services in rural or remote communities. Having such a privileged career is very rewarding. I think that’s part of the plan. Throughout my life I have been a strong advocate for the provision of health services in French in general. So it’s important for me that the plan really recognizes that we have cultural diversity in terms of language and ethnicity, Aboriginal people and so on. We need people to see themselves reflected in the health system. People need to see themselves reflected in the staff who provide services to them. That is an important part of the plan that was presented.

Alex Maheux:

Nicole, what are your hopes for your community in the coming years?

Nicole Ranger:

For me, in the next few years, I hope we are able to recruit dynamic, passionate people to join our team here. I feel very privileged to have had the opportunity to come and settle here in the community of Hearst, to work with an extraordinary and dedicated team of health professionals and doctors. But the main reason I settled in the community of Hearst to work in rural medicine is basically that I felt at home. The people in the community have shown an incredible appreciation for the services we provide. They are willing to do almost anything to support us so that we can have the essential resources we need.

So, it’s my hope that we can find other people as passionate as the group we have now to join us in making a career here.

Alex Maheux:

I really hope so for you. Nicole, thank you for your enthusiasm and your passion. And thank you so much for being with us today.

Nicole Ranger:

Thank you very much, Alex, it was a pleasure and a privilege.

Alex Maheux:

Thank you for joining in. Come back next time when we will be discussing other exciting health topics. For more information about CIHI, visit cihi.ca. If you enjoyed today’s discussion, please subscribe to our podcast and follow us on social media. This episode was produced by Stéphanie Bright and Angela Baker and by our executive producer, Jonathan Kuehlein.

This is Alex Maheux, see you next time.