Workload of French-speaking family physicians in francophone rural and northern communities in Ontario.

INTRODUCTION: Previous studies have shown that French-speaking family physicians (FSPs) in Ontario are less numerous in areas with high proportions of francophones. The purpose of the current study was to assess whether the degree of concordance between physicians' language of competence and the linguistic profile of the community in which they practise is associated with workload and to explore variations in this relation in rural and northern regions of the province. METHODS: This was a secondary analysis of the 2013 College of Physicians and Surgeons of Ontario Annual Membership Renewal Survey. We analyzed the primary practice location and language of competence of family physicians/general practitioners. We compared the practice characteristics of FSPs and non-French-speaking physicians (NFSPs) by the proportion of the francophone population, geographic location (north vs. south) and community size (urban vs. rural). RESULTS: Data for 10 548 family physician/general practitioners were analyzed. In areas densely populated by francophones, FSPs worked more hours per week on average and had a greater mean number of patient visits than NFSPs. Non-French-speaking physicians working in areas densely populated by francophones had fewer patient visits per hour on average than FSPs. In most cases, the results were particularly accentuated in rural and northern communities. CONCLUSION: Our findings suggest that, compared to NFSPs, the demands placed on FSPs are disproportionately greater in communities where the need for French-language health care services is greatest and the supply of FSPs is the smallest. Our results underline the importance of properly preparing family physicians to work in areas densely populated by francophones.

INTRODUCTION: Des études antérieures ont révélé que les médecins de famille francophones (MFF) en Ontario sont moins nombreux dans les régions à forte population francophone. L'objectif de cette étude était de déterminer si le degré de concordance entre la langue de compétence des médecins et le profil linguistique de la collectivité dans laquelle ils exercent est associé à la charge de travail, et d'examiner les variations de cette relation dans les régions rurales et nordiques de la province. METHODS: Il s'agit d'une analyse secondaire des données du sondage de 2013 sur le renouvellement annuel de l'inscription à l'Ordre des médecins et chirurgiens de l'Ontario. Nous avons déterminé le principal lieu de pratique et la langue de compétence de médecins de famille et d'omnipraticiens. Nous avons comparé les caractéristiques de la pratique des MFF et des médecins de famille non francophones (MFNF) par rapport à la proportion de la population francophone, l'emplacement géographique (nord par opposition à sud) et la taille de la collectivité (urbaine par opposition à rurale). RESULTS: Nous avons analysé les données provenant de 10 548 médecins de famille ou omnipraticiens. Dans les régions à forte population francophone, les MFF travaillaient en moyenne davantage d'heures par semaine et accueillaient en moyenne plus de patients que les MFNF. Les médecins non francophones qui travaillaient en régions à forte population francophone accueillaient en moyenne moins de patients par heure que les MFF. Dans la plupart des cas, les résultats étaient particulièrement marqués dans les collectivités rurales et nordiques de la province. CONCLUSION: Nos résultats suggèrent que les demandes imposées aux MFF sont disproportionnées par rapport à celles imposées aux MFNF dans les collectivités où le besoin de services de santé en français est le plus élevé et où la disponibilité de MFF est la plus faible. Nos résultats mettent en lumière l'importance de bien préparer les médecins de famille à travailler dans les régions à forte population francophone.

Geographic variation in FP and GP scope of practice in Ontario: Comparative provincial study.

OBJECTIVE: To describe and compare the scope of practice (SoP) of GPs and FPs between the rural northern, rural southern, urban northern, and urban southern regions of Ontario. DESIGN: Cross-sectional retrospective analysis of the 2013 College of Physicians and Surgeons of Ontario official register and annual membership renewal survey data. SETTING: Ontario. PARTICIPANTS: All independently practising GPs and FPs with a primary practice address in Ontario. MAIN OUTCOME MEASURES: For each of the 4 regions, we determined the distribution of GPs and FPs, the mean number of hours worked per week, the mean number of clinical activities reported, the proportion of GPs and FPs reporting specific clinical activities, and the proportion of time dedicated to each activity. RESULTS: The rural north has 2.4% of the province's GPs and FPs, who on average report working more hours per week (a total of 50.82 hours a week) than practitioners in all other regions do. Rural northern and rural southern GPs and FPs report participating in more types of clinical activities than their urban counterparts do. The types of clinical activities reported vary across regions. For example, 13.3% of GPs and FPs in the urban south reported that emergency medicine was an aspect of their clinical activities, compared with 57.5% in the rural north. Urban GPs and FPs engage in fewer clinical activities and thus spend proportionately more time on each clinical activity than rural GPs and FPs do, indicating that clinical practice concentration and narrower SoP is more common in urban practices. CONCLUSION: The SoP for GPs and FPs is not uniform across Ontario. Rural physicians work more hours and engage in a broader spectrum of clinical activities. Clinical activity variation was found across all practice locations, indicating that SoP is driven by patient and community needs, which vary from region to region. Our findings are relevant for rural and northern policy and program development in medical education, continuing professional development, and physician recruitment and retention.

Impact of the rural pipeline in medical education: practice locations of recently graduated family physicians in Ontario.

BACKGROUND: The "rural pipeline" suggests that students educated in rural, or other underserviced areas, are more likely to establish practices in such locations. It is upon this concept that the Northern Ontario School of Medicine (NOSM) was founded. Our analysis answers the following question: Are physicians who were educated at NOSM more likely to practice in rural and northern Ontario compared with physicians who were educated at other Canadian medical schools? METHODS: We used data from the College of Physicians and Surgeons of Ontario. We compared practice locations of certified Ontario family physicians who had graduated from NOSM vs. other Canadian medical schools in 2009 or later. We categorized the physicians according to where they completed their undergraduate (UG) and postgraduate (PG) training, either at NOSM or elsewhere. We used logistic regression models to determine if the location of UG and PG training was associated with rural or northern Ontario practice location. RESULTS: Of the 535 physicians examined, 67 had completed UG and/or PG medical education at NOSM. Over two thirds of physicians with any NOSM education were practicing in northern areas and 25.4% were practicing in rural areas of Ontario compared with those having no NOSM education, with 4.3 and 10.3% in northern and rural areas, respectively. Physicians who graduated from NOSM-UG were more likely to have practices located in rural Ontario (OR = 2.57; p = 0.014) whereas NOSM-PG physicians were more likely to have practices in northern Ontario (OR = 57.88; p < 0.001). CONCLUSIONS: NOSM education was associated with an increased likelihood of practicing in rural (NOSM-UG) and northern (NOSM-PG) Ontario.

Milestones on the social accountability journey: Family medicine practice locations of Northern Ontario School of Medicine graduates.

OBJECTIVE: To assess the effect of different levels of exposure to the Northern Ontario School of Medicine's (NOSM's) distributed medical education programs in northern Ontario on FPs' practice locations. DESIGN: Cross-sectional design using longitudinal survey and administrative data. SETTING: Canada. PARTICIPANTS: All 131 Canadian medical graduates who completed FP training in 2011 to 2013 and who completed their undergraduate (UG) medical degree or postgraduate (PG) residency training or both at NOSM. INTERVENTION: Exposure to NOSM's medical education program at the UG (n = 49) or PG (n = 31) level or both (n = 51). MAIN OUTCOME MEASURES: Primary practice location in September of 2014. RESULTS: Approximately 16% (21 of 129) of FPs were practising in rural northern Ontario, 45% (58 of 129) in urban northern Ontario, and 5% (7 of 129) in rural southern Ontario. Logistic regression found that more rural Canadian background years predicted rural practice in northern Ontario or Ontario, with odds ratios of 1.16 and 1.12, respectively. Northern Canadian background, sex, marital status, and having children did not predict practice location. Completing both UG and PG training at NOSM predicted practising in rural and northern Ontario locations with odds ratios of 4.06 to 48.62. CONCLUSION: Approximately 61% (79 of 129) of Canadian medical graduate FPs who complete at least some of their training at NOSM practise in northern Ontario. Slightly more than a quarter (21 of 79) of these FPs practise in rural northern Ontario. The FPs with more years of rural background or those with greater exposure to NOSM's medical education programs had higher odds of practising in rural northern Ontario. This study shows that NOSM is on the road to reaching one of its social accountability milestones.

Barriers to offering French language physician services in rural and northern Ontario.

INTRODUCTION: Rural and Northern Ontario francophones face many health-related challenges including poor health status, a poor supply of French-speaking physicians, and the potential for an inability or reduced ability to effectively communicate with anglophone healthcare providers. As such, it can reasonably be expected that rural and Northern Ontario francophones experience barriers when receiving care. However, the experience of physicians working in areas densely populated by francophones is largely unexplored. This paper identifies barriers experienced by French-speaking and Non-French-speaking rural and Northern Ontario physicians when serving francophone patients. METHODS: A series of key informant interviews were conducted with 18 family physicians practicing in rural and urban francophone communities of Northeastern Ontario. Interviews were analyzed using a thematic analysis process. RESULTS: Five categories of barrier were identified: (1) language discordance, (2) characteristics of francophone patients, (3) dominance of English in the medical profession, (4) lack of French-speaking medical personnel, and (5) physicians' linguistic (in)sensitivity. Some barriers identified were unique to Non-French-speaking physicians (eg language discordance, use of interpreters, feelings of inadequacy), some were unique to French-speaking physicians (eg limited French education and resources), and some were common to both groups (eg lack of French-speaking colleagues/staff, added time commitments, and the particularities of Franco-Ontarian preferences and culture). CONCLUSIONS: Healthcare providers and decision makers may take interest in these results. Although physicians were the focus of the present article, the barriers expressed are likely experienced by other healthcare providers, and thus the lessons learned from this article extend beyond the physician workforce. Efforts must be made to offer educational opportunities for physicians and other healthcare providers working in areas densely populated by francophones; these include linguistic and cultural sensitivity training, in addition to teaching strategies for the practice of 'active offer' of French-language services. In sum, the present study outlines the importance of linguistic concordant communication in healthcare delivery, and describes some of the challenges faced when providing French-language services in rural and Northern Ontario.

Strategies for improved French-language health services: Perspectives of family physicians in northeastern Ontario.

OBJECTIVE: To identify strategies to improve the quality of health services for Francophone patients. DESIGN: A series of semistructured key informant interviews. SETTING: Northeastern Ontario. Participants A total of 18 physicians were interviewed. Ten physicians were interviewed in French, 7 physicians were women, and 10 physicians were located in urban communities. METHODS: Purposive and snowball sampling strategies were used to conduct a series of semistructured key informant interviews with family physicians practising in communities with a large Francophone population. Principles of grounded theory were applied, guided by a framework for patient-professional communication. Results were inductively derived following an iterative data collection­data analysis process and were analyzed using a detailed thematic approach. MAIN FINDINGS: Respondents identified several strategies for providing high-quality French-language health services. Some were unique to non­French-speaking physicians (eg, using appropriate interpreter services), some were unique to French-speaking physicians (eg, using a flexible dialect), and some strategies were common to all physicians serving French populations (eg, hiring bilingual staff or having pamphlets and posters in both French and English). CONCLUSION: Physicians interviewed for this study provided high-quality health care by attributing substantial importance to effective communication. While linguistic patient-to-physician concordance is ideal, it might not always be possible. Thus, conscious efforts to attenuate communication barriers are necessary, and several effective strategies exist.

Outcomes of the Northern Ontario School of Medicine's distributed medical education programmes: protocol for a longitudinal comparative multicohort study.

INTRODUCTION: The Northern Ontario School of Medicine (NOSM) has a social accountability mandate to serve the healthcare needs of the people of Northern Ontario, Canada. A multiyear, multimethod tracking study of medical students and postgraduate residents is being conducted by the Centre for Rural and Northern Health Research (CRaNHR) in conjunction with NOSM starting in 2005 when NOSM first enrolled students. The objective is to understand how NOSM's selection criteria and medical education programmes set in rural and northern communities affect early career decision-making by physicians with respect to their choice of medical discipline, practice location, medical services and procedures, inclusion of medically underserved patient populations and practice structure. METHODS AND ANALYSIS: This prospective comparative longitudinal study follows multiple cohorts from entry into medical education programmes at the undergraduate (UG) level (56-64 students per year at NOSM) or postgraduate (PG) level (40-60 residents per year at NOSM, including UGs from other medical schools and 30-40 NOSM UGs who go to other schools for their residency training) and continues at least 5 years into independent practice. The study compares learners who experience NOSM UG and NOSM PG education with those who experience NOSM UG education alone or NOSM PG education alone. Within these groups, the study also compares learners in family medicine with those in other specialties. Data will be analysed using descriptive statistics, χ(2) tests, logistic regression, and hierarchical log-linear models. ETHICS AND DISSEMINATION: Ethical approval was granted by the Research Ethics Boards of Laurentian University (REB #2010-08-03 and #2012-01-09) and Lakehead University (REB #031 11-12 Romeo File #1462056). Results will be published in peer-reviewed scientific journals, presented at one or more scientific conferences, and shared with policymakers and decision-makers and the public through 4-page research summaries and social media such as Twitter (@CRaNHR, @NOSM) or Facebook.

Promising quantities, disappointing distribution. Investigating the presence of French-speaking physicians in Ontario's rural Francophone communities.

INTRODUCTION: Previous studies have suggested that there may be a lack of French language healthcare services in the province of Ontario. The purpose of this study was to determine if physicians in Ontario who expressed a proficiency in providing services in the French language are located in 'Francophone communities'. METHOD: Responses from 10,968 Ontario-based family physicians (FPs) certified by the College of Family Physicians of Canada and uncertified general practitioners (GPs) who responded to the 2007 College of Physicians and Surgeons of Ontario Annual Membership Renewal Survey were analysed and compared to the 2006 census of the population of Ontario. Main outcome measures were the number of FP/GPs categorized by their language of competency to conduct medical practice and the number of people categorized by their first official language spoken. The physician-to-population ratio was then compared for different groups of communities in Ontario categorized by the degree of francophonie of the community: strong French communities, with a Francophone population ≥25%; moderate French communities, with a Francophone population of 10-24%; and weak/no French communities, with a Francophone population <10%. RESULTS: There are 5.6 French speaking FP/GPs for every 1000 Francophones in communities with a French population less than 10%. This ratio is considerably greater than what was found in moderate French communities (3.4 FP/GPs) and strong French (1.3 FP/GPs). Overall the lowest ratios were found in rural strong French communities both in southern and northern Ontario (0.8 FP/GPs and 0.9 FP/GPs respectively). The ratio for all of Ontario was 0.7-1.3. CONCLUSIONS: As the number of Francophones increases in a community, the availability of French-speaking FP/GPs actually decreases, particularly in rural northern Ontario. Furthermore, there is a paradoxical relationship between the potentially high number of FP/GPs in the province with French-language capabilities and the perceived deficiencies in the availability of French language medical services.

Examining the geographic distribution of French-speaking physicians in Ontario.

OBJECTIVE: To determine how many physicians in Ontario express a proficiency in providing services in the French language, and to assess the geographic distribution of such physicians. DESIGN: Population-based analysis of the 2007 College of Physicians and Surgeons of Ontario Annual Membership Renewal Survey. SETTING: Ontario. PARTICIPANTS: A total of 22 688 GPs, FPs, and other specialists certified by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada who responded to the survey. MAIN OUTCOME MEASURES: First official language spoken and languages of competency to conduct practice. RESULTS: The physician-to-patient ratio by first official language spoken is 1 physician per 138 Francophone patients in Ontario. There is 1 French-speaking GP or FP for every 297 Francophone patients, and most French-speaking physicians are located in southern Ontario (91.4%), at a ratio of 1 physician per 111 Francophone patients. The most promising French-speaking physician-to-Francophone patient ratios are found in southern Ontario (1:248 for GPs and FPs, and 1:202 for other specialists) and in urban Ontario (1:266 for GPs and FPs, and 1:209 for other specialists). CONCLUSION: Clearly, there is a promising number of physicians, relative to the amount of French-speaking residents in Ontario, who identified a competency in offering services in French. However, while the number of physicians who indicated a self-assessed competency to deliver health services in French is promising, it is the maldistribution of such services that is of concern. Thus, efforts must be made to attract French-speaking physicians to areas where there is the greatest demand, particularly in the northern part of the province.

A closer look at Ontario's northern and southern rural physician demographics.

INTRODUCTION: In Ontario, Canada, there is a tendency to conflate rural and northern issues and although much of northern Ontario is rural, this is not exclusively the case. In this study, data were utilized from the licensing and regulatory body of physicians in Ontario to provide a more nuanced understanding of the distribution of the physician population across varying degrees of rurality in northern and southern regions. METHODS: This is a report on the geographic distribution of the 22 688 GPs, and specialists certified by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada who had their primary practice address in Ontario. Descriptive statistics were produced to determine differences in distribution of physician numbers, age, sex, international medical graduates (IMGs), and certification for physicians with primary practices coded as northern versus southern across varying degrees of rurality. RESULTS: Differences were found in the Ontario physician population with regard to age, sex and IMG status between rural and urban areas and also from the northern versus southern perspective. There were more younger and male physicians in northern and rural areas. Female physicians were more frequently found in the south with decreasing proportions of females with increasing rurality. In the northern areas of the province, although the proportion of female physicians was lower than in the south, there was a slight increase in the proportion of female physicians as rurality increased. The largest proportions of IMGs were found in urban areas and the proportions of IMGs decreased with increasing rurality. However, northern rural regions did tend to have a higher proportion of IMG physicians than in corresponding rural areas in the south. CONCLUSIONS: The results indicate that although there are similarities in physician demographics in rural and urban areas, there are clear differences between the rural north and the rural south. Likewise, although some patterns distinguish the south from the north, these areas are not homogeneous regions where the urban north is clearly different from the rural north.