Need a doctor?

Then don’t come to Halifax

(Updated to include a correction on assistance to doctors locating in rural areas.)

That nasty red lesion you see in the middle of the map above is the sore spot of Nova Scotia’s family doctor shortage.

Yep. Half of the people in Nova Scotia who can’t find a family doctor live in the communities surrounding Halifax Harbour.

That’s half the misery resting on the shoulders of 40 per cent of the population.

“We should really get that looked at,” Haligonians say? Well, good, but bear in mind the province still subsidizes new doctors for locating anywhere but Metro Halifax.

And this is a case where raw numbers have more meaning than percentages. Most egregiously, Halifax and Chebucto Peninsulas have 10,502 residents who want a doctor but can’t find one–the worst total of any district. Residents do things like drive to Shubenacadie for care or maintain their own medical records during chemotherapy because they have no family practice to do it for them.

Dartmouth/Southeastern fares almost as badly, with 6,720 doctor-less residents. Together, the Dartmouth/Southeastern, Halifax Peninsula/Chebucto, Bedford and Sackville account for 20,727 of the 41,877 Nova Scotians without a family physician. That’s 49.9% of the entire problem. (NSHA has four zones — Central, Western, Eastern and Northern — each divided into sub-units called Community Health Networks such as Dartmouth/Southeastern in the Central Zone.)

The only record worse than Metro Halifax belongs to the counties of Annapolis and Kings, where eight per cent cannot find a doctor. But, percentages don’t tell the whole story: there are 20,727 people needing docs in Metro vs. 6,720 in Annapolis and Kings.

In percentage terms, Halifax and Dartmouth are the second- and third-worst performers. (This didn’t stop Halifax from attempting to recruit 50,000 Amazon employees to a municipality where already 20,727 people couldn’t find doctors.)

I don’t mean to diminish the problem in Annapolis and Kings. If people in Halifax drive to Shubenacadie to see a doctor, then god knows what you do if you live in one of those counties. Were it not for the misery in Annapolis and Kings in the Western Zone, I would blame this on the rural favouritism baked into our politics.

Percentage of the population currently seeking doctors

Central Zone/ Community Health Network Total # Not Yet Placed Population % of population seeking doctors Entire Central Zone 21,531 409,706 5.3% Halifax Peninsula / Chebucto 10,502 167,379 6.3% Dartmouth / Southeastern 6,720 115,427 5.8% Bedford / Sackville 3,505 87,838 4.0% Eastern Shore Musquodoboit 484 18,165 2.7% West Hants 320 20,897 1.5%

Nova Scotia 41,877 919,849 4.6%

The table below shows the big picture.

Percentage of the population currently seeking doctors

Zone/ Community Health Network Total # Not Yet Placed Population % of Population without MDs Annapolis and Kings 6,248 78,507 8.00% Halifax Peninsula / Chebucto 10,502 167,379 6.30% Dartmouth / Southeastern 6,720 115,427 5.80% Yarmouth / Shelburne /Digby 2,809 58,393 4.80% Pictou County 2,023 45,668 4.40% Queens and Lunenburg 2,623 59,384 4.40% Bedford / Sackville 3,505 87,838 4.00% Inverness / Victoria / Richmond 944 33,505 2.80% Colchester East Hants 1,938 69,991 2.80% Eastern Shore Musquodoboit 484 18,165 2.70% Cape Breton County 2,487 102,397 2.40% Cumberland 802 34,750 2.30% West Hants 320 20,897 1.50% Antigonish and Guysborough 322 27,548 1.20% Unknown 130 – 0.00% Unknown 20 – 0.00% Western Zone 11,680 196,284 6.00% Central Zone 21,531 409,706 5.30% Northern Zone 4,893 150,409 3.30% Eastern Zone 3,753 163,450 2.30%

Government gets away with this because most of us have family doctors, so we don’t pay attention. But during your next visit, have a close look at your doctor. Does she look tired, is she nearing retirement? If so, you’d better learn how to keep your own medical records.

In any case, government’s fixation on rural doctor shortages needs to change.

NSHA says it has added a recruitment consultant to the Central Zone, which includes Halifax. (It already had one in Western, which covers Annapolis and Kings.)

However, while NSHA seems to have the right idea, the Department of Health and Wellness is still offering physicians agreements worth as much as $60,000 to locate outside Halifax, as it has since as early as 2014.

The $60,000 is a bursary for locating “in a rural Nova Scotia community outside of the metro Halifax Regional Municipality.” Alternatively, DHW also offers up to $45,000 in debt assistance for docs establishing “in a rural Nova Scotia community.”

I don’t understand the distinction between the rules for the bursary and debt assistance but it doesn’t matter because the message is the same: “We don’t care whether our provincial capital has enough doctors.”

DHW has a 2014 web document called “Shaping Our Physician Workforce.” It was updated in December 2017, so it’s current. Here’s an excerpt from the FAQ:

“Q: Isn’t it true that Nova Scotia has more doctors per capita than any other province?

A: Yes, we do have a generous supply of physicians, but as the consultants found, many are concentrated here in metro Halifax . . .”(Emphasis mine).

Sorry, but I call bullroar on this. As we’ve seen, many patients--i.e. people who need doctors—are also “concentrated here in metro Halifax.” Please note the bureaucratic vagueness of the language and how it leads the unwary into mistakenly believing the root of the problem is still too many doctors in Halifax. That misconception seems to be part of DHW dogma, evidence notwithstanding.

By the way, NS does indeed have the most physicians per capita in Canada at 258/100,000 (Canadian Institute for Health Information. Physicians in Canada, 2016: Summary Report Figure 3. Ottawa, ON: CIHI; 2017.) The number for Manitoba is 207, where there are 1.2 million people spread over a land area 10 times larger.

I asked NSHA whether it had adjusted its incentives to reflect the evidence. Here’s the answer: “NSHA does own two incentive programs that are for the entire province: site visits and relocation allowance. We have recently doubled the amount available for relocation allowance. All of NSHA’s western zone was already eligible and now the site visit program has been expanded to include areas within NSHA’s central zone, including urban Halifax and Dartmouth.”

So, thanks to NSHA and no thanks to DHW, doctors seeking subsidies are no longer being entirely waved away from Halifax. Sadly, the Western Zone still lags despite having enjoyed recruitment incentives from the get-go.

Here’s a look NSHA’s recruitment strategy. Here is an example of its pitch to physicians.

It’s hard to understand how we got into this mess, but here’s a conjecture. In the ’90s Nova Scotia was one of the provinces that attempted to reduce health-care costs by limiting the number of doctors eligible for payment by medicare. I guess the theory was fewer doctors meant fewer patients and/or less illness. (What could go wrong with that idea, eh?) So, perhaps the policy produced a cohort of doctors too small to replace their retiring colleagues 20 years later.

There are also politics. Successive governments have demanded policies to drive doctors to rural areas, but perhaps they failed to also keep an eye on the provincial capital (aka the Devil’s Vestibule.)

Or, maybe they did track Halifax and just didn’t care, assuming we would take care of ourselves.

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