Barbara Zelek is Associate Professor and Co-Chair for the Section of Family Medicine at the Northern Ontario School of Medicine
Marathon, a rural community on the North shore of Lake Superior, made CMAJ headlines in 1997 because it boasted a stable workforce of seven physicians for the first time in over a decade. 2017 marks the 20th anniversary of that CMAJ article and of the arrival of Dr. Sarah Newbery and Dr. Eliseo Orrantia in Marathon.
The article described “a medical renaissance” taking place in Marathon and an end to “the revolving door that has affected rural medicine across the country”. That door has stopped revolving in Marathon since 1997 thanks, in many ways, to the leadership of Eli and Sarah.
Let me put this important milestone in context.
The “coffee index of rurality” was introduced in the early 2000s. It is really quite simple – “you know you live somewhere rural when there is no Starbucks or Second Cup; you know you live somewhere remote when there is no Tim Hortons”.
This coffee shop concept got me thinking about the relationship between remote communities and length of physician service in Marathon. And, I kept hearing the question Eli always asks – “what’s the evidence?”
So like a good clinician, I did a literature review. To my surprise there is very little evidence about the duration of physicians stay in remote or rural communities. There are many studies about impacts on recruitment and retention of physicians in rural communities but scant statistics on length of stay – I suspect that may be because human resource people fear the answers.
I came across one study by Rabinowitz from 2005 that found that on average family physicians remain in a single rural (not necessarily remote) practice for approximately 7 years. In Pennsylvania a program to increase physician retention in rural communities was created where long-term physician retention was defined as 11-16 years.
So, based on the evidence, we might conclude that 20 years for a physician in a remote community is a REALLY, REALLY LONG TIME!
While Eli’s voice was loudly demanding “What’s the evidence?” I could hear Sarah softly whispering, “What about the people?”
Here I must provide a brief history for context.
The Anishnaabek people have inhabited this region for centuries. Built on Anishnaabek land, the community of Marathon started as a railroad camp known as Peninsula. From1881 to 1883 it was estimated that there were 12 000 men and 5000 horses working out of the town. When the railway was completed, the population dwindled. According to the1935 census 23 people remained. The population rose to 2500 between 1944 and 1946 during the construction of a pulp mill. The town’s name was changed, first to Everest, President of the Marathon Corporation of Wisconsin (the pulp mill) at the time, and then to Marathon, in honour of the company itself.
It is difficult to find a comprehensive list of all the physicians who provided service to the community of Marathon. With the help of the health records department I was able to review the list of births dating back to 1946 when the town and hospital were built.
This handwritten list records several generations of births in Marathon. Fortunately, for the purposes of my research, the list includes the name of the attending physician. By extrapolating the data - and by knowing that in those days good country doctors attended all births - I was able to determine how long individual physicians worked in Marathon.
The first physician on record was Dr. Graham who served Marathon from 1946 – 1954, a total of 8 years. Dr. Bastedo also arrived in 1946 and stayed for 12 years. A different Dr. Graham worked in Marathon from 1963-1967 and 1971-1978 for a total of 13 years.
Even with those three relatively long tenures, my estimate is that between 1946 and 1984 physicians stayed in Marathon an average of 3-4 years.
One day when I was doing some shopping at the hospital gift shop, just after I’d reviewed the birth records, I overhead a woman say she was born at the hospital in 1950. I asked her how long she thought Dr. Govan had been in Marathon. Her response was “A long time”. As any good clinician would I pressed her for details. “What do you mean by a long time?” Her response was: “Probably 10 years”.
In fact, Dr Govan worked in Marathon for 12 years from 1984-1995. Much of that time he was the only physician in the community, making his commitment truly exceptional.
Dr. Gordon Hollway arrived in Marathon in 1987 and stayed for 14 years. Gord was the first to highlight factors that might lead to longer tenures of service by physicians in Marathon. These are summarized in an article that was published in Canadian Family Physician.
A total of eleven physicians have provided 10 or more years of service to the community of Marathon since 1946, and 8 are from the last 2 decades.
My goal was to show both scientifically and historically that 20 years is a REALLY LONG TIME for a physician to work in any remote community and in Marathon specifically. Since 1946 – that is the 70 years since this town was established – my colleagues Sarah and Eli are the longest serving physicians in Marathon! We were honoured to celebrate their achievements this year.
A follow up article in CMAJ in 1998 reported that “The recent history of health care in rural and remote parts of Canada can be summed up in 2 words: ongoing crisis”. Twenty years later this is still true. While Marathon and other communities may have succeeded, the task of ensuring adequate health care delivery in rural and remote communities in Canada persists.
Even without a full review of the literature, we know some things about what is needed to recruit and retain physicians in rural communities. Quality-of-life, finances and professional support remain important. We also need to continue to lobby governments to find creative funding and human resource solutions to secure physicians for rural and remote communities.
The 1997 feature article’s final sentence still holds true. “Over time the faces and details will change, but residents of Marathon can, finally, rest assured that when they need to see a doctor, medical services will be available.” My wish is for this to be true for all rural and remote communities in Canada.
So I write this, in honour of all of my past and present colleagues in Marathon, and in honour of all of my rural and remote family physician colleagues across the country. They continue to work hard to provide care to chronically underserviced populations. You know who you are, go out and toast yourself with a coffee from your local gas station or coffee shop!