Distributive justice and the importance of context

In our past lives, Dr. Ponka and I both practiced in Moose Factory and served the First Nations fly-in communities along the west James Bay and Hudson Bay coasts.

In the Canadian Family Physician • VOL 52: JANUARY • 2006, in an article entitled “Reflections”, Dr. Ponka wrote about his trip to one of the communities “up the coast”.

He wrote…

“I have seen Mary on several occasions during my previous trips, but not enough to call myself her doctor. In fact, few patients feel attached to a particular physician in our area. Understaffing and a high turn-over rate among our typically young and mobile physicians mean that continuity of care suffers. But we do our best, trying to visit the same community during our allotted time “up the coast,” whenever the emergency, inpatient, and obstetric services are sufficiently staffed for us to leave our base hospital in Moose Factory.

Mary suffered a tragic disfiguring injury several years ago. Shortly after that, her husband left her with several young children; he has not been seen or heard from since. With little support, Mary has had to raise these children and run a household on her own. The responsibility and seclusion have, over time, caught up with her and her family. Both she and her children have been suffering numerous aches and discomforts that no physician or test has been able to explain or relieve.”

Dr. Ponka describes the painful and sad realities facing many of our Indigenous communities. He describes the lack of physician resources in the north. He also describes the permanent absence of continuity of care in this community. And he notes the pain and suffering experienced by this young mother and her family. We cannot have an honest medical conversation in Canada concerning distributive justice until we address the geographical maldistribution of healthcare resources in our country. Distributive justice must be inclusive of all Canadians, not just of those 75% of people living in “metropolitan Canada”.

What is missing is practical down-to-earth solutions to this problem. We cannot just leave these issues with the too often stated “further study is needed on this topic” which accompanies far too many published research papers in the medical press.

Some examples of problems that need to be solved as soon as possible are:

1. Physician resource immobility due to medical licensing barriers. We have 13 medical licensing bodies in Canada. To address the problem, we need federal medical licensing reciprocity legislation that mandates that a physician who is licensed to practice by any province or territory in Canada is licensed to practice in any province or territory in the country. This simple act would allow locums to provide services to rural and remote communities without the barrier of having to become licensed in each, and every, jurisdiction with a community in need.

2. Physician skill sets. There is a wide gap between urban and rural/remote physician skill sets. The same gap exists between family physicians and emergency physician skill sets. Family medicine residents need more comprehensive training in procedural techniques than they are currently receiving so that they feel comfortable working in Canada’s rural and remote communities.

3. Medical training. There is a family physician shortage in Canada. I went from high school directly into “medicine” at the University of Toronto. After two years of pre-medicine and four years of medicine, I graduated at the age of 24, completed a one year rotating internship, plus a month of anaesthesia training in Edmonton, and started practice with a classmate in Norway House Manitoba (10,000 patients, 40 bed hospital, 30,000 square miles, 9 nursing stations and the two of us). No road. No airfield. No helicopters. No medical library. An obstetrical delivery almost every day. After a few months we gained a general surgeon. After 5 years of medical practice, I wrote the CFPC exams. In contrast, the medical students of today face numerous barriers (additional entrance exams, interviews, non-medical requirements) and lengthy training periods (4-year undergrad degrees, two plus years of family medicine residency training) and enter family practice 3 years later. Is this necessary? Can we not eliminate some of the barriers and shorten the training period? During WWII and until 1950, physicians graduated from the University of Toronto as young as 22 because medicine was compressed from 4 years to 3 years (11 months per year with one month off in the summer).

Dr. Ponka is right, questions around distributive justice are the most critical of our time.
The bottom line: We must produce more full scope family doctors with better skill sets in shorter time and we must remove interprovincial barriers to physician mobility to address the distributive justice problem that plagues our northern Indigenous communities. It's urgent. The status quo has failed.