The Cost of Care

Unable to get a university education in her native Romania, Elena Mihu emigrated to Canada, arriving in 1986. She was alone, with a dental technician’s certificate and a hunger for knowledge. In less than ten years, she taught herself English, was accepted into university, and graduated from McMaster University’s medical school. She also owed the government $100,000 in student loans and dearly missed the rural life of her childhood. On weekends she and her husband, Jean-Claude, would drive north in search of country property. On one such trip they found both the perfect home and a “Doctor Wanted” notice pinned to the door of the Kinmount township office.

The sign was not new. For almost six years there had been no local health services in Kinmount, Ontario—no family doctor, no immediate emergency care, with the nearest hospital some twenty kilometres away. The town, cradled by a long bend of the Burnt River at the edge of the Haliburton Highlands, numbered almost 400 permanent inhabitants. Several thousand more people lived in the immediate townships, and each summer the population increased significantly. If you fell ill here, however, you were on your own.

Then suddenly, in 1999, the sign was taken down and a banner welcoming Mihu replaced it. Kinmount, miraculously, had acquired a family physician.

Visit any medical school in Canada and ask, “Who plans to practise family medicine” and too few hands will go up. Having competed with thousands to get into these prestigious schools, and already deeply in debt, most of these ambitious young adults feel they cannot afford to become family doctors in Canada. Without fringe benefits, and after the expenses of renting a clinic, paying for receptionists and nurses, and buying equipment and supplies, a family doctor working forty-hour weeks could expect to take home roughly the salary of a union plumber, auto worker, or skilled bricklayer (around $70,000). But with a few more years of training, medical students can become specialists, virtually guaranteeing them twice the income of a family doctor.

No wonder family medicine is an increasingly unpopular option, especially if it means having to move to a community that cannot provide a job for your spouse or decent schools for your kids. Reside in a Canadian city and you will be lucky to have a family doctor. Move to the suburbs and you can spend years waiting to join a local clinic. Live in rural Canada and there is a good chance that an emergency ward in a distant city will be all your children will ever know. In 2004, almost five million Canadians did not have a family doctor, and in Ontario, according to the Ministry of Health, there are 138 communities facing a critical lack of physicians.

While our attention was focused else-where—on long waiting periods for surgery and spiralling hospital costs—the bedrock of our medical system was eroding. A report by the Society of Rural Physicians of Canada shows that between 1994 and 2000, the number of family doctors practising outside our largest cities declined by 15 percent. Furthermore, a 2004 report by the College of Family Physicians of Canada stated that up to 3,800 physicians were expected to retire over the next two years, among them some 1,400 family doctors. Are we seeing the last of those general practitioners committed to the complete welfare of familiar patients, and, if so, do we truly understand what we are losing

Remember when I was so sick after the flu...remember when I first got chemo...remember when Wayne died?” So starts a conversation between patient and doctor. We ask our physicians not just to cure what ails us but also to bear witness to our lives. The very presence of a doctor in our community means that society cares. The absence can only imply that it does not.

Usually a doctor new to a rural community must buy an existing practice and clinic but Kinmount had neither to sell. Instead the community rented the old township building from the county and, through years of fundraising, saved enough money to renovate and equip the building to a doctor’s specifications. They could now offer this to Mihu as her clinic. They could also offer her a population of roughly 4,000 underserved residents. However, this hunger placed a huge pressure on any doctor coming into the county. Would Mihu burn out before she could make a difference

For decades Kinmount residents had listened to politicians promising better health care. Now that they had found a doctor, many in the community assumed that there would be government support waiting for her. They were wrong. While the official opening of the new clinic made a nice photo op for local and provincial politicians, after that Mihu was essentially left to sink or swim. She had to build the vital networks of emergency care and regional specialists, while her husband returned to his schoolbooks to create a viable business plan for the new clinic. There were no recent models to follow. It had been decades since a doctor had opened a new practice in rural Ontario.

Rural GPs quickly discover that they “are not just physicians, but small-business owners as well. After signing a simple fee-for-service contract with the Ontario Health Insurance Plan (ohip), Mihu was expected to organize an office, hire staff, and pay for insurance, syringes, Q-tips, and all the other tools of her trade before opening for business. Office hours were up to her.