Public experiences and perspectives of primary care in Canada: results from a cross-sectional survey.

BACKGROUND: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care. METHODS: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models. RESULTS: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who "knows me as a person and considers all the factors that affect my health." After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use. INTERPRETATION: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting.

Starting out rural: a qualitative study of the experiences of family physician graduates transitioning to practice in rural Ontario.

BACKGROUND: New family medicine graduates are a promising group to recruit to underserved rural areas. This study aimed to understand the experiences of this group as they transitioned to practice in rural Ontario. METHODS: We used a hermeneutic phenomenology approach. Purposive sampling was used to recruit participants who graduated from a Canadian family medicine residency program and worked in a rural community in Ontario (Rurality Index for Ontario score ≥ 40) for at least 1 year within the past 5 years. Participants completed an online demographic survey followed by a virtual semistructured interview (May-August 2022). Interviews were video recorded and transcribed. Two researchers reviewed transcripts for codes, and then codes were reviewed in an iterative process to create themes. Transcripts, codes and themes were reviewed by an independent researcher, and final themes were shared with participants to ensure reliability. RESULTS: We included 18 family physicians in the study. We identified 8 themes and 18 subthemes. The themes identified as important to the experience of new graduates were as follows: choosing rural practice, preparedness for practice, navigating work-life balance, navigating transition to practice, challenges during transition to practice, successes during transition to practice, locuming and emergency medicine as part of rural generalist practice. INTERPRETATION: Most physicians interviewed felt prepared for rural practice and enjoyed their work; however, they faced unique challenges associated with being an early-career physician in rural practice. This study identifies opportunities for improvements, which can guide medical educators, rural communities and their recruiters, new graduates and policy-makers.

The economic impact of rural healthcare on rural economies: A rapid review.

Introduction: One critical component of any rural community is its healthcare system. Rural healthcare systems are essential as rural communities have worse health outcomes when compared to urban areas. Rural healthcare systems might also have a positive impact on rural economies. In some rural areas, these health services are threatened with a reduction or closure. This rapid review was carried out to examine the impact of rural healthcare systems' declines on rural economies. Methods: We conducted a rapid review of peer-reviewed and grey literature sources on studies that examined the economic impact of rural healthcare on rural economies in Canada, Australia, Scandinavia and the United States of America (USA). We used a data extraction template adapted from the Centre for Reviews and Dissemination. Results: We found 17 research papers between two databases and nine websites. Articles examined various health professions (dentist, physician assistant and pharmacist), the inclusion of family physicians, a physician with an increased scope of practice (obstetrics and surgery), the impact of a rural primary care hospital, telemedicine, a distributed medical education programme and the health care sector. Conclusion: Rural healthcare seems to have a positive impact on jobs and labour-based wages in rural communities. There is a considerable need for research outside the USA.

Résumé Introduction: Un élément essentiel de toute communauté rurale est son système de soins de santé. Les systèmes de soins de santé ruraux sont essentiels car les communautés rurales présentent des résultats sanitaires moins bons que les zones urbaines. Ces systèmes pourraient également avoir un impact positif sur les économies rurales. Dans certaines zones rurales, ces services de santé sont menacés de réduction ou de fermeture. Cette revue rapide a été réalisée pour examiner l'impact du déclin des systèmes de soins de santé ruraux sur les économies rurales. Méthodes: Nous avons procédé à un examen rapide de documentation évaluée par les pairs et de documentation parallèle sur les études qui ont examiné l'impact économique des soins de santé ruraux sur les économies rurales au Canada, en Australie, en Scandinavie et aux États-Unis. Nous avons utilisé un modèle d'extraction de données adapté du Centre for Reviews and Dissemination. Résultats: Nous avons trouvé 17 articles de recherche entre deux bases de données et neuf sites Web. Les articles portaient sur diverses professions de santé (dentiste, assistant(e) médical(e), pharmacien(ne)), l'inclusion des médecins de famille, un médecin ayant un champ d'exercice élargi (obstétrique et chirurgie), l'impact d'un hôpital rural de soins primaires, la télémédecine, un programme d'enseignement médical distribué et le secteur des soins de santé. Conclusion: Les soins de santé en milieu rural semblent avoir un impact positif sur les emplois et les salaires basés sur le travail dans les communautés rurales. Il existe un besoin considérable de recherche en dehors des États-Unis. Mots-clés: rural, soins de santé, économie, revue.

Disparities in Physician Compensation by Gender in Ontario, Canada.

Importance: Men and women should earn equal pay for equal work. An examination of the magnitude of pay disparities could inform strategies for remediation. Objective: To examine gender-based differences in pay within a large, comprehensive physician population practicing within a variety of payment systems. Design, Setting, and Participants: This cross-sectional study used data from the Ontario Health Insurance Plan (OHIP) in the 2017 to 2018 fiscal year to estimate differences in gross payments between men and women physicians in Ontario, Canada. Pay gaps were calculated annually and daily. Regression analyses were used to control for observable practice characteristics that could account for individual differences in daily pay. In Canada's largest province, Ontario, medical services are predominantly provided by self-employed physicians who bill the province's single payer, OHIP. All physicians who submitted claims to OHIP were included. Data were analyzed from January 2020 to July 2021. Exposures: Physician gender, obtained from the OHIP Corporate Provider Database. Gender is recorded as male or female. Main Outcomes and Measures: Gross clinical payments were tabulated for individual physicians on a daily and annual basis in conjunction with each physician's practice characteristics, setting, and specialty. Results: A total of 31 481 physicians were included in the study sample (12 604 [40.0%] women; 18 877 [60.0%] men; mean [SD] time since graduation, 23.3 [13.6] years), representing 99% of active physicians in Ontario. The unadjusted differences in clinical payments between male and female physicians were 32.8% (95% CI, 30.8%-34.6%) annually and 22.5% (95% CI, 21.2%-23.8%) daily. After accounting for practice characteristics, region, and specialty, the overall daily payment gap was 13.5% (95% CI, 12.3%-14.8%). The pay gap persisted with differing magnitudes when examined by specialty (ranging from 6.6% to 37.6%), practice setting (8.3% to 17.2%), payment model (13.4% to 22.8% for family medicine; 8.0% to 11.6% for other specialties), and rurality (8.0% to 16.5%). Conclusions and Relevance: This cross-sectional study examined differences in magnitude of annual and daily payment gaps and between unadjusted and adjusted gaps. Comparing the gaps for different specialties, geography, and payment systems illustrated the complexity of the issue by showing that the pay gap varied for physicians in different practice settings. As such, multiple directed interventions will be necessary to ensure that all physicians are paid equally for equal work, regardless of gender.

Integration of care in Northern Ontario: Rural health hubs and the patient medical home concept.

INTRODUCTION: Primary care reform in Ontario that provides accessible, comprehensive patient-centred care has been a work in progress for more than a decade. With the recent emergence of Ontario Health Teams and the conclusion of the Rural Health Hub (RHH) pilot project, insight into the philosophy, culture and expectations of rural and remote centres with regard to primary care delivery is required. The concept of the patient medical home (PMH) and the RHH offers frameworks that emphasise positive attributes towards quality care systems - continuity, accessibility, comprehensiveness and localisation of services and funding for system efficiency. METHODS: The application of these frameworks to rural and remote centres was explored via semi-directed face-to-face and phone interviews with physicians, patients and healthcare administrators at six rural centres in Northern Ontario. RESULTS: Continuity of care, local integration and healthcare culture reform were cited by participants as the most important aspects of optimisation of primary care in their environments. CONCLUSION: These concepts support the RHH and PMH models and their further implementation as part of healthcare system transformation in Northern Ontario.

Résumé Introduction: La réforme des soins de première ligne en Ontario, qui entend fournir des soins axés sur les patients accessibles et complets, est en chantier depuis plus de dix ans. Avec la récente création des équipes de santé Ontario et la conclusion du projet pilote Carrefours santé en milieu rural, il nous faut une fenêtre sur la philosophie, la culture et les attentes des établissements des régions rurales et éloignées en matière de prestation des soins de première ligne. Les concepts de Centres de médecine de famille (CMF) et de Carrefours santé en milieu rural sont des infrastructures qui insistent sur les caractéristiques positives des systèmes de soins de qualité, soit la continuité, l'accessibilité, l'intégralité et la localisation des services et du financement afin d'assurer l'efficacité. Méthodologie: L'application de ces cadres aux établissements des régions rurales et éloignées a été évaluée par l'entremise d'entrevues semi-structurées téléphoniques et en personne avec des médecins, patients et gestionnaires de santé de 6 établissements situés en milieu rural du Nord de l'Ontario. Résultats: Les participants ont cité la continuité des soins, l'intégration locale et la réforme de la culture en santé comme les aspects les plus importants de l'optimisation des soins de première ligne dans leur environnement. Conclusion: Ces concepts étayent les modèles de CMF et de Carrefours santé en milieu rural et leur élargissement dans le cadre de la transformation du système de soins de santé du Nord de l'Ontario. Mots-clés: Soins de première ligne, centres de médecine de famille, carrefours santé en milieu rural, équipes de santé Ontario, régions rurales et éloignées.

Marathon maternity oral history project: Exploring rural birthing through narrative methods.

OBJECTIVE: To explore how birthing and maternity care are understood and valued in a rural community. DESIGN: Oral history research. SETTING: The rural community of Marathon, Ont, with a population of approximately 3500. PARTICIPANTS: A purposive selection of mothers, grandmothers, nurses, physicians, and community leaders in the Marathon medical catchment area. METHODS: Interviews were conducted with a purposive sample, employing an oral history research methodology. Interviews were conducted non-anonymously in order to preserve the identity and personhood of participants. Interview transcripts were edited into short narratives. Oral histories offer perspectives and information not revealed in other quantitative or qualitative research methodologies. Narratives re-personalize and humanize medical research by offering researchers and practitioners the opportunity to bear witness to the personal stories affected through medical decision making. MAIN FINDINGS: Eleven stand-alone narratives, published in this issue of Canadian Family Physician, form the project's findings. Similar to a literary text or short story, they are intended for personal reflection and interpretation by the reader. Presenting the results of these interviews as narratives requires the reader to participate in the research exercise and take part in listening to these women's voices. The project's narratives will be accessible to readers from academic and non-academic backgrounds and will interest readers in medicine and allied health professions, medical humanities, community development, gender studies, social anthropology and history, and literature. CONCLUSION: Sharing personal birthing experiences might inspire others to reevaluate and reconsider birthing practices and services in other communities. Where local maternity services are under threat, Marathon's stories might contribute to understanding the meaning and challenges of local birthing, and the implications of losing maternity services in rural Canada.