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A recent visit to a cardiac surgery unit in Sri Lanka made me realize how similar the medical problems of a country like Sri Lanka and Canada are. Jaffna, in northern Sri Lanka has a population of 88,000 but serves the adjoining provinces, giving a catchment area of 1 million people. The sole cardiac surgeon performed 100 cases per year in the public hospital and had over 1000 patients waiting, having grown that list in just two years since starting the programme. While he also has an opportunity for private delivery of his services in his city , a pipeline for those who have means to other more established centres 6-8 hours south has existed for a number of years. His hospital has only 4 anesthesiologists who cover both the public and (after 4 pm and on holidays) private sectors. The surgeon would like to have both more OR time to deal with the growing backlog of patients and another surgeon to help, and had asked me to try to determine ways in which this could be achieved. I spent time analyzing his situation and realized that he had a similar problem to our western health care systems, namely recruitment and retention of physicians in underserved areas.
In order for him to get more time in either sector, and hope to recruit another cardiac surgeon, I told him he would need more anesthesiologists, not equipment or even beds as he had hoped I would say. While there was a need for beds, this was not the primary obstacle to growth-recruitment was. There was a medical school in the city, which would theoretically improve the chances of recruitment (1) but when asked about potential incentives to increase recruitment, I had to admit that like the author (2), I was at a loss for words. With more anesthesiologists, there would be a greater possibility of improved income, which would be more beneficial to both anesthesiologist and surgeon both from a financial point of view and from a financial incentive to draw more to practice in the area. All recruitment and retention programmes have as their underlying incentive, finances (3). Perhaps there is another way. Perhaps it is time that the governments step in and pass laws that would include a “time” repayment for acceptance to a medical school. If everyone in the country knew that she/he needed to serve in an underserved area during or after, expectations would change. While most students would not stay in the underserved area, some would, eventually reducing and hopefully eliminating the problem. This change would obviously need to be thought about carefully and might even changes to early post graduate training for those entering specialties akin to the old rotating internship.
Incentives for recruitment and retention of health care workers is truly a global problem, as pressing in the first as the third world. Money can buy bricks, beds and electronics but without the people to work in those places, they are useless. Governments need to take action that is palatable, fair to all, not overly expensive and stands a chance at working towards a solution.
References:
1) Hooker, RS. Working with the medically underservced. Can Fam Physician 2013; 59:339-340
2) CMAJ 2018 February 20;190:E203. doi: 10.1503/cmaj.109-5563
3) https://news.aamc.org/for-the-media/article/gme-funding-doctor-shortage/