BY NORM TOLLINSKY

Twenty years after the establishment of regional geriatric programs (RGPs) at academic health sciences centres in Ottawa, Kingston, Toronto, Hamilton and London, efforts are finally underway to create one or more regional geriatric programs in Northern Ontario.

In the northeast, the push to establish an RGP was sparked by the City of Greater Sudbury’s successful recruitment of Dr. Jo-Anne Clarke, who will be northeastern Ontario’s first and only geriatrician. Born and raised in Lively, now part of Sudbury, Clarke will head up the fledgling Northeastern Ontario Specialized Geriatrics Services program from a clinic at Pioneer Manor, a long-term care facility owned by the City.

A graduate of McMaster University, Clarke completes her residency in geriatrics at the University of Western Ontario in February, and begins practicing in Sudbury the following month.

A parallel effort is underway in Thunder Bay, where Northern Ontario’s only other geriatrician, Dr. Trevor Bon, practices.

Northeastern Ontario Specialized Geriatric Services will begin operating in March with an ambulatory care clinic and an outreach team funded through the Northeast Local Health Integration Network’s (LHIN’s) Aging at Home Strategy. The establishment of a full-fledged regional geriatric program with nurse specialists, social workers, physiotherapists, dieticians and resource consultants will be dependent on the province’s response to a formal application.

“We’ll be starting small, but it will grow,” said Rossi, co-ordinator of community, seniors and health development for the City of Greater Sudbury. “Other RGPs provide more services, but we’ll have to walk before we can run.”

Fee-for-service

The province’s fee-for-service payment model is the primary reason there are so few geriatricians outside academic health centres, explained Clarke.

“Under the fee-for-service model, the more patients you see, the more money you can bill, but when I see a patient, it can easily take an hour and a half, and that’s with a nurse already having seen them. These patients are frail. They just don’t jump up on the table. And we have to do a complete assessment. If you’re practicing at an academic centre, you get a salary.

“Sudbury Regional Hospital doesn’t provide salaries and the Northern Ontario School of Medicine (NOSM) isn’t accredited to provide salaries, so that’s why we’re working closely with the LHIN.”

A five-year residency and the complexity of the medical conditions they have to deal with deter medical students from specializing in geriatrics, said Clarke.

“Medical students are required to decide what they want to do in the second or third year of their program, so they’re still very fresh, and the challenge of working with patients who are on 15 medications and have 25 medical conditions is overwhelming.”

Also contributing to the problem is the staggering debt load medical students are faced with.

“The average debt of medical students coming out of residency is between $160,000 and $180,000,” said Clarke. “Students are telling us more and more that it’s influencing what they decide to do and where they decide to practice. When I went to medical school, I had no idea how I was going to pay for it. There’s no funding from the government. The only way I could go to medical school was to borrow money from the bank, which I think is just ridiculous.

“I had friends say to me, ‘You’re going to do more training to make less money? That doesn’t make any sense.’ That’s the message medical students are hearing. We need an alternate funding plan for geriatricians. Otherwise, there won’t be enough geriatricians and there certainly won’t be any outside the academic centres.”

In medical school, learning is based on the model of one disease presenting many symptoms, but in geriatrics, “you have multiple diseases presenting as a syndrome,” said Clarke. “Your patient may have vision impairment, cognitive impairment, hypertension, heart failure, and you have to sort all that out.

“Family doctors often don’t have time to muddle through all of that. It’s too complicated, too overwhelming.”

Chronic conditions

Eighty-two per cent of seniors have one or more chronic health conditions and 43 per cent have three or more conditions.

In a regional geriatrics program, geriatricians, nurses, physiotherapists, occupational therapists, dietitians and social workers work as a team to manage and optimize the patient’s health and ability to function independently.

Several of the existing RGPs in Ontario are set up to provide service to outlying communities. The southwestern Ontario program based in London, for example, serves a region stretching from Windsor all the way to the Bruce Peninsula. The program’s nine geriatricians provide outreach service to communities throughout the region and work with teams of health-care providers in each county. The RGP organizes an annual conference and offers other learning opportunities via videoconference through the year.
A similar model is envisioned for Northern Ontario.

One of Clarke’s goals is to share her passion for geriatrics with medical students at NOSM and convince some of them to follow in her footsteps.

“I love geriatrics because the patients are fantastic to work with,” she said. “They’re filled with history and stories. They’ve lived through wars. They’re just amazing. You learn more from your patients than you’ll learn from any school.”

On October 9, advocates for regional geriatric services in northeastern and northwestern Ontario will meet in Thunder Bay to decide what makes more sense – a joint proposal for a single RGP with two hubs, similar to the Northern Ontario School of Medicine, which operates campuses in Sudbury and Thunder Bay, or two separate programs.