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second year of their training in rural. Manitoba communities such as. Dauphin, Sainte Rose, Churchill,. Morden, Winkler and, possibly,. Thompson. I believe that ...
LETTERS * CORRESPONDANCE

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Dilemmas in rural family practice T n he article "Bitter physicians react angrily to uncertain future facing rural medicine" (Can Med Assoc J 1994; 150: 571573), by Michael OReilly, made me think of my rural family practice experience. For 5 years, in which my on-call schedule was, at best, 1 day in 3, I experienced great satisfaction from providing primary care to people with urgent medical concerns and from treating and getting to know several generations of families. Certainly, family dynamics were much easier to understand. In retrospect I think that I returned to residency training mainly because of the toll rural practice had taken on my family life. Caring for a terminally ill patient in his or her home at 4 am and spending time comforting the family after the patient died was satisfying, but subsee- For prescribing information see page 473

quently trying to catch a flight at 6:30 am to a continuing medical education conference made for little sleep. I have numerous anecdotes about time spent on patient care to the detriment of personal life and simple pleasures such as sleep. In those days I felt that I could always catch up on sleep later. I recognize myself in the article's descriptions of the rural physicians who solved this problem by moving on, back to residency training. I was too involved in my rural practice to realize that I was missing anything in my life. I returned to residency training, initially commuting 130 km each day, sometimes getting up at 4:30 am during the winter. I did not realize how little time I had had for my family during rural practice until my children commented that they enjoyed the residency period more because of the time I could spend with them, despite the commute and the on-call hours every fourth night. Some plan must be developed for physicians in rural practice to maintain a balanced lifestyle and not to burn out from the afterhours workload. This plan will have great importance as physicians become increasingly burdened by deficiencies in the current health care system. Patrick J. Potter, MD, FRCPC Department of Physical Medicine and Rehabilitation University of Western Ontario London, Ont.

In his article Mr. OReilly quotes Dr. David Fletcher extensively about the problems facing rural physicians. However, there is little evidence that Fletcher's tactic, waging war, is appropriate. Unfortunately, the victims of this war will be the residents of rural communities and, possibly,

family physicians, as the situation in Mount Forest demonstrates. I feel well qualified to write about the Mount Forest situation because I was chief of staff at the Louise Marshall Hospital there at the time of the 1990 crisis in emergency services and the only physician who did not stop providing such services. The lack of mention of this in OReilly's article implies that all physicians in Mount Forest supported this action. The withdrawal of medical services is something that will not rest easy with many conscientious family physicians. The Mount Forest solution includes a mechanism for paying physicians for emergency coverage on nights and weekends, but the physician must stay in the hospital. This has resulted in my spending less time with my family than when I provided emergency services on an on-call basis. So much for lifestyle! It also includes the unwritten demand that physicians take the next day off after a night on call. As a result I have found it impossible to make house calls and nursing-home visits without appointments being backed up in my office, which has resulted in unacceptable waiting times for patients who have become frustrated and are sometimes forced to use the hospital emergency department at night. This has made me so frustrated that I often ignore the "day-off' rule. The Mount Forest solution seems more like an attempt to bring an urban group-practice style to the rural setting. Unfortunately communities such as Mount Forest, which opt for a financial solution to their physician resource problems, may find that their capitation level does not allow new physicians to enter the commuCAN MED ASSOC J 1994; 151

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nity except to replace a departing doctor. Thus, they will remain persistently understaffed. In my experience doctors are not interested in practising in rural communities where the on-call workload is onerous, regardless of generous financial arrangements. Rural communities and family physicians who are wrestling with physician resource problems would be well advised to consider carefully how a proposal would affect family practice and continuity of care in the community and the ability to attract new doctors there.

Manitoba or in rural areas in Canada. I am pleased to say that since 1990 the numbers in urban and rural areas have been relatively balanced (Table 1). It is unfortunate that Dr. David Cram, mentioned in Mr. OReilly's article, has been unable to recruit Canadian physicians to his town of Souris, Man., but I suspect that this has nothing to do with the family practice program at the University of Manitoba. Table 1 shows that 9 of the 18 graduates of the University of Manitoba in 1992 were practising in rural Canada, 5 in rural Manitoba. In the undergraduate curriculum most Stephen J. Wetmore, MD, CCFP clerkships take place in rural comAssistant professor munities. In the postgraduate curricuDepartment of Family Medicine lum the intention is for 16 of next University of Western Ontario London, Ont. year's 34 new residents to spend the second year of their training in rural The Department of Family Medicine, Manitoba communities such as University of Manitoba, Winnipeg, Dauphin, Sainte Rose, Churchill, has made strenuous efforts over the Morden, Winkler and, possibly, years, during the headships of both Thompson. I believe that only by Dr. Gary Beazley and myself, to en- spending a substantial portion of sure that graduates practise in rural postgraduate training in a rural setTable 1: Location of family medicine graduates from the University of Manitoba. Winnipeg ~~~~~~~~~~~~~~~~~. .*

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ting will graduates be encouraged to practise in these areas. The data confirm this belief. Peter Kirk, MB, ChB, CCFP Professor and head Department of Family Medicine University of Manitoba Winnipeg, Man.

Forms, forms and more forms T n his article (Can Med Assoc J 1994; 150: 943-946, 948), by Jill Rafuse, on the increasing demands being made on physicians to complete forms on behalf of patients, is timely and accurate. I have practised occupational medicine for 20 years and have often been the author of some of these forms. In addition, although most of my time is spent consulting to industry I maintain a small private practice and therefore complete many forms. I can see the issue from both sides that of requesting third party and that of medical practitioner. In general, most doctors' notes are illegible, if not useless. I rarely rely on such notes when deciding on an employee health issue. Therefore, to collect better data most companies have generated their own forms. This of course increases physicians' workload and frustration. Industry's needs, however, are usually quite simple: it wants to know the answers to Is the employee fit to work? If the employee is not fit to work, when can he or she return to work? and When the employee returns to work, would the employer need to make any special accommodations? This information is useful in assessing staff and workload needs and in administering benefit plans. For organizations that have rehabilitative policies and procedures, relevant data from physicians can help managers make decisions on alternative work or modified work for an employee. It is important that sick or injured workers re-establish their LE 15 AOUT 1994