Proceedings from the Rural Alberta Community Physician Recruitment and Retention Workshop

23 & 24 April 2008 Nisku, Alberta

(Full report including appendices available here; © RPAP All Rights Reserved)

Introduction – the seeds of the conference

Through the course of its work with Alberta communities, RPAP has received many inquiries from community members asking about the activities and situations in other communities around physician recruitment and retention. How were other committees and towns dealing with the challenges of recruiting and retaining physicians? What were those challenges? What was working? As a method of responding to these questions and to begin to develop an understanding of the cross-community situation, RPAP began to collect community stories about the development, functioning and challenges facing community-based health committees involved in recruitment and retention activities. From these stories grew the idea of holding a workshop that would serve to bring together those individuals actively involved in recruitment and retention in their communities in order to share their experiences.

The idea of a provincial workshop was also discussed as follow up to previous workshops hosted in partnership with the Northern Alberta Development Council (NADC) in Falher and Lac la Biche in 2007. The NADC is a regional development council with a focus on advancing the development of the northern economy. The mission of the NADC is to identify and implement measures that will advance northern development, as well as advise government on opportunities and issues. Since the 2006 Challenge North Conference, the NADC Health Committee has worked with northern stakeholders to advocate for northern health issues. Northerners indicated that recruitment and retention of health professionals was priority issue in the region, affecting northern communities. NADC involvement and support of a provincial workshop was evidence of their support for initiatives that will advance the development of the region.

Alberta Culture and Community Spirit, in its role to provide services that enhance the capacity of community leaders and organizations to address their goals, has been working with communities and RPAP in the development of health committees. Their support has focused on helping organizations and communities to: work together to develop and sustain relationships; to identify and solve problems and make collective decisions; to collaborate effectively, to identify goals and to get the work done; and, to identify strengths and help build the momentum for further success in community projects and initiatives. Alberta Culture and Community Spirit’s involvement in the workshop was a natural extension of the work they had already done.

The provincial workshop, attended by more than 55 people from 22 communities across 7 health regions, took place April 23 and 24, 2008 in Nisku. The format of the conference was such that it would encourage participation, dialogue and networking between practitioners, those community members working on physician recruitment and retention in their communities. Participants were members of community health committees, municipal and county politicians, business representatives, and community volunteers.

WEDNESDAY, APRIL 23

Exposing Possibility: Creative Ways to Explore

(Ian Prinsloo, facilitator)

Ian Prinsloo, actor and artistic director, led the group in a series of activities designed to help them "think outside the box" and look at situations in different ways so that they might identify new approaches and solutions to their situations. Ian engaged the group in thinking about "What if…?" with respect to health and our communities.

With workshop participants working in small groups, "What ifs?" were generated in a brainstorming session where no idea was rejected or edited. The exercise generated responses like

"What if we did nothing"

"What if it wasn’t about money?"

"What if we thought about health in a different way?"

"What if we tried an old idea with a new twist?"

"What if we let doctors doctor and we, the community, do the rest?"

"What if we weren’t a rich province?"

"What if immigration processes/standards change?"

Participants acknowledged that there were some things they could really do nothing about, like "what if no one grew old". And, rather than getting stuck on those, groups were asked to choose one idea that they could possibly do something with and to begin to expand on that one idea by addressing the question "What would need to happen to make it a reality?" This question generated great discussion in the small groups and the ideas were brought back to the group as a whole.

This opening session was energizing and that energy generated a creativity that led to an expanded, collective understanding of the situations that communities are experiencing. The approach that Ian introduced in this session, brainstorming solutions rather than problems, allowed participants to see their situations in a new light and perhaps shed some insight on how a problem might be newly identified and subsequently solved in a different way. Participants were encouraged to keep this question "What if…?" in their mind throughout the conference as a way to "step outside the box".

For a list of "What ifs" please refer to Appendix A in the full report above.

Community Story Collection Presentation

(Carmen Plante, Presenter)

Although a brief, non-interactive session, this PowerPoint presentation set the context for the workshop sessions that followed. The Retention and Recruitment Story Collection Project was initiated by RPAP in response to the recruitment and retention comments/questions they were receiving from the communities consultants were working with. Community groups were wanting to know what was happening elsewhere in the province. What were other communities experiencing? How successful were their strategies? Was there something that a community could do differently that would yield better results? There was keen interest shown in understanding and learning from other committees involved in the recruitment and retention of physicians for their communities. The resulting story collection project included ten communities across Alberta involved in recruitment and retention activities in some manner. The stories, and the information that they provided, helped form the contextual framework for this community based conference.

As the stories were gathered themes began to emerge. Communities that felt themselves successful in their recruitment and retention activities identified that they:

• Approached recruitment & retention as a community issue, not just an issue for the clinic;
• Involved various stakeholders from across the community, like business, government, physicians, the health region, community members;
• Had organized an on-going core community health group, supported more broadly by community members; and,
• Had developed a good working relationship and communication between the community health group, local physicians, and the RHA.
• Communities were also using multifaceted approaches to address the complex problems. These approaches included:
• Community development strategies;
• Marketing of their community’s assets;
• Incentive packages;
• Multi-pronged recruitment strategies, and
• Long-term, community involved retention strategies.

Through this presentation participants came to see that there were commonalities of experience in recruitment and retention. They were also introduced to some of the successful approaches communities were using to address their need for physicians.

For a copy of the PowerPoint presentation and the stories please refer to Appendix B and Appendix C respectively, in the full report above.

This first session was designed to take a look at how communities developed their recruitment and retention committees and what made them successful. Working in small groups participants shared their stories about how and why their committees came into being. In many communities the committee was a response to a crisis or a stressor such as a shortage of physicians or the hospital’s emergency room becoming the local health clinic. In other communities the committee was formed out of concern for the future health needs of community, in anticipation of what might occur if nothing was done or in response to projected population growth. Physicians, other health professionals and/or community members initiated the first discussions.

When asked to explore what has made those committees successful participants identified things such as:

• clearly understanding the problem
• understanding of the health care system
• committed committee members
• involvement by local physicians, business, town or municipality, media and the Health Region as well as citizens. Committees drew on expertise from both inside their community as well as outside to help them get organized.

Notes from this session can be found in Appendix D in the full report above.

[Resources that were made available for participants to use included: the RPAP Recruitment and Retention resource guide; and, handouts on how to form a committee and how to build a committee]

Session 2: Marketing Strategies and Incentives

In the process of deciding where they will settle and practice most physicians look not only at the nature of the work environment but also at the community in which they and their families will be living. "What is it like to live there?"

In this session participants were again assigned to small working groups, giving them an opportunity to meet and share with people that hadn’t necessarily met previously. They were provided with a scenario, comprised of a potential physician profile and a brief description of a rural town, and given the task of developing a marketing strategy and incentives for their community. The strategy included identification of community assets to promote in a community profile and a list of possible incentives that would work to attract the potential physician to the community.

Through the discussion participants worked to understand the possible needs of their "physicians", identifying community assets that would be attractive to them as well as identifying incentives that would assist in strengthening the "fit" between physician need and community offering.

Profiles were created for communities such as ‘Hearts Content’, ‘Plunketville’, ‘Sunnyskies’ and ‘Clearwater’, Alberta. The profiles highlighted the assets in each community; such things as:

• natural attractions such as lakes, mountains, forests;
• community facilities and programs like the library, theatres, symphony, and the sports centre;
• school offerings;
• community based services such as homecare and daycare;
• available shopping;
• annual special events or attractions;
• the economy and real estate;
• population size and demographics.
• Incentives included basic items such as:
• help with accommodation on arrival;
• orientations to the community;
• assistance with credit/loans, and signing bonuses.
• Participants also thought ‘outside of the box" and identified incentives particular to the individual needs of their candidates:
• financial planner services;
• provision of potential work contacts for spouses;
• a free berth at the local marina;
• a turnkey clinic, mentorship;
• education incentives;
• housekeeping services; and,
• matchmaking services.

A representative from each small group presented their fictional community to the larger group. These scenarios were kept to be used the following day in the session on retention strategies.

A broader description of community assets and recruitment incentives can be found in Appendix E in the full report above.

[Resources available for this session included: RPAP Recruitment and Retention resource guide, developing a community profile handout, examples of incentives across Canada]

THURSDAY, APRIL 24

Session 3: Retention Strategies: site visits, settling in, and …?

Site Visits:

This morning session built on the work that small groups had undertaken the night before. First, participants were to develop a site visit for the fictional doctor (and/or their family) coming to meet their fictional town. Facilitators for this session began by asking the group what they thought should be included in a site visit. Some of the things identified by communities for consideration in a site visit were:

• the length of the visit;
• what information and how much information should be presented to the visitors;
• who should be involved; and,
• how does the community follow-up the visit with the candidate.
• Participants shared their site visit experiences: the preparation and the event itself. Strategies that worked and had successful results had been:
• well planned, and
• designed to illustrate but not overwhelm.

They also ensured that there were "activities for the children".

Settling In:

The second part of this session focused on helping new physicians and their families to settle into the community. Highlighted in this discussion were issues related to family quality of life and family integration. Some of the ways in which communities/committees having been helping new physicians become settled and integrated have included:

• physically helping them move in;
• helping them to get ‘up and running’ with groceries, bank accounts, driver’s licenses, insurance, etc.
• helping with social introductions
• providing a key community contact or ‘buddy’, particularly for the spouse

Participants determined that the degree of quality of life was related to the level of family integration in the community. And the key to keeping a physician in the community was to be able to provide the feeling of belonging they were looking for.

All participant comments from this session can be found in Appendix F.

[Resources for this session: RPAP Recruitment and Retention resource guide, site visit handouts, settling-in handouts, 2006 Physician Retention Survey - Executive Summary]

Session 4: Ensuring Cross Cultural Success: International Medical Graduates

Cross-cultural Adaptation:

In the process of recruitment more and more communities are finding themselves receiving international medical graduates, physicians coming from different parts of the world quite different from rural Alberta. In situations such as these cross cultural adaptation becomes a more pronounced component in the settlement and retention of these physicians and their families in the community. To help highlight some of the important things to consider in cross-cultural adaptation, workshop participants watched a video clip and then discussed some of the issues to be aware of when a community is welcoming an IMG:

• access to transportation
• ties to their country of origin
• issues pertain to the settlement of children
• religious differences
• prejudice

Following this discussion, participants returned to their small groups and shared amongst themselves their community’s experience in welcoming a physician from another country. Facilitators noted on flip charts participants’ identification of the important points to consider. From the collective list created by the larger group, some of these important points included:

• helping families to manage the weather and its impact;
• separation from extended family and lack of a familial support system;
• different foods, systems, and ways of doing things; and
• differing expectations in the culture
• community support for their interests
• cultural adaptation is not one-directional; the community needs to learn about the culture that the IMG is coming from.
• Communities have helped IMGs with cross-cultural adaptation through:
• introductions to families of similar cultural background
• introductions to businesses and services in the community
• ensuring that someone stays in touch with the family after the first three months
• helping to make them feel important and a part of the community
• ensuring that there is someone who can meet their needs on a personal level
• understanding that there may be language barriers

The Immigration Process:

In the second half of this session Kelly Lyons from RPAP spoke about Canada’s immigration process, walking participants through the steps that are undertaken to bring IMGs to Canada and talking about the time needed for the process from start to finish. This information was particularly useful to communities as many times there is frustration and misunderstanding about the length of time it is taking to have a physician arrive in their community. Participants shared their experiences with one another, particularly what did work well in their relationship with their regional recruiter, as well as where further work needs to occur around collaboration between the communities and the recruiter.

Some of the issues highlighted by participants were:

• the time delay in getting changes to work permits
• the time it takes in filling out work permit forms
• what support is there from the provincial government
• practice based assessments – requirement for IMGs and need to have Drs. to do assessment

Points discussed in these discussions were compiled by the facilitators and can be found in Appendix G in the full report above.

[Resources available to participants in this session included: DVD presentation, immigration process outline, cross-cultural adaptation handout)

Following up on the April 2008 Provincial Community Recruitment and Retention Workshop, workshop participants identified a number of supports that would help their community recruitment and retention efforts. The RPAP is committed to acting on these:

• A Web Blog – For sharing information among communities in a central location. The blog is used to post new learnings/best practices from within and beyond Alberta /Canada, and list events, activities, and resources related to R&R. This is now live at www.rpap.ab.ca/blog.html
• E-newsletter – Send out relevant information and materials to community contacts on regular basis. This e-newsletter will begin in August 2008.
• Videoconferencing – Provide a platform for interactive sharing. Guest speakers can address particular topics/issues of importance to communities. Possible inaugural videoconference on the new provincial health services board structure and its likely impact on community committees planned for Fall 2008.
• Regional face to face workshops – Organized through RPAP’s Rural Physician Consultants as needed/requested. Contact Alberta-RPAP@rpap.ab.ca or 1-866-423-9911 to hold a workshop.
• Annual Provincial Workshop – Hosted by RPAP and partners annually. A forum for sharing best practices, enhancing and expanding “community of practice” and building relationships. Details on the 2009 Provincial Community R&R Workshop will be published on this blog by September 2008.