“We are at the forefront of virtual care technology in the country, and in some areas, in the world,” Dr. Ivar Mendez said.
In the town of Preeceville, Sask. — population slightly more than 1,000, give or take — pretty much everyone knows Stacey Strykowski’s son Jackson as the kid with the deadly peanut allergy.
“We’re told to rely on 911 … but there’s not always an ambulance here,” says Strykowski, a former provincial NDP candidate. “We don’t have that reassurance he can be safe when he needs to be.”
Strykowski’s story is shared in small towns peppered throughout rural Saskatchewan, and it’s a story that’s been ongoing for many chapters across many decades. Access to health care in rural and remote communities has long been a point of contention for Saskatchewan’s governments and health authorities — and there still isn’t a clear solution.
What is certain, from Strykowski’s point of view, is there just isn’t enough available service in rural communities for everyone to have equal access. The EMS in Preeceville covers multiple communities. If the limited number of emergency vehicles are called away, Strykowski isn’t confident they’d be able to help her son if he was in a life-threatening situation. The next nearest ambulance unit is more than 40 kilometres away in Norquay, and the next nearest emergency medical services would be at the hospital in Canora, around 50 kilometres away.
Services can be tenuous, as well. When COVID-19 first struck in Saskatchewan, Preeceville’s emergency room was one of 12 in the province that was temporarily shut down by the provincial government in an attempt to maintain capacity for potential COVID-19 surges and outbreaks. The Preeceville emergency room reopened this summer.
“There’s always one emergency car and one transfer car. If the emergency car is out with your advanced care paramedic on it, the other ones can’t do a whole lot if you need to be intubated or whatever,” Strykowski says.
Rural population a challenge for health care delivery
Steven Lewis, a health policy consultant formerly based in Saskatchewan, says the province’s low population density has long contributed to difficulty in providing health care services. Rural Saskatchewan, as Lewis puts it, does not provide “attractive” opportunities for Canadian medical school graduates, even with initiatives like the province’s Rural Physician Incentive Program offering financial incentives.
According to the Statistics Canada 2016 census, more than 35 per cent of Saskatchewan’s population lives outside of census metropolitan areas (CMA) and census agglomerations, meaning more than a third of the residents of the province do not live near a municipality with a core population of at least 10,000.
Per the census, only 10 cities in Saskatchewan hit that mark: Saskatoon, Regina, Prince Albert, Moose Jaw, Lloydminster, North Battleford, Yorkton, Swift Current, Estevan, and Weyburn. The cities of Warman and Martensville are both considered part of the Saskatoon CMA.
The province has historically relied on international recruitment to bring more doctors into rural areas, but Lewis says the problems with delivering care run deeper than employment numbers.
“The great majority of (doctors) still prefer to practise in cities. So you have, in many Canadian cities, a very high ratio of family physicians to population, and in rural areas the ratio can be (lower),” he says.
“Just adding doctors doesn’t solve your problem — you need a joint commitment by government and by doctors, collectively, through their medical association, to ensure that, as far as possible, communities are not underserved.”
Lewis pointed to provinces like Quebec and New Brunswick as examples of attempts at such agreements. Quebec’s Plans régionaux d’effectifs médicaux, or PREMs, was created in 2004 to assign doctors permits to be able to practise in Quebec as a way of equally distributing new physicians across the province, though it has come under fire recently as being biased against major population centres. And the New Brunswick provincial government implemented a “physician billing number system” to regulate where and how doctors could be distributed throughout the province, particularly in rural areas — but the system was scrapped in 2019 after the province and the New Brunswick Medical Society said it hindered recruitment.
Brenna Bath, an associate professor at the University of Saskatchewan’s School of Rehabilitations Science and a member of the Canadian Centre for Health and Safety in Agriculture, describes what researchers refer to as a “rural paradox” when it comes to health care delivery — the need is greater in rural areas, and the barriers are far more significant.
Remote health care provides opportunities
“I think this shift to virtual care could be, in the long term, a real benefit to rural and remote communities,” she says. “These are technologies and mechanisms that have been around for several years, but there’s been a really slow uptake of it, for a variety of reasons.”
Bath says the COVID-19 pandemic spurred an “exponential shift” toward virtual care in the province. It could keep remote communities alive longer without having to constantly recruit and incentivize rural doctors. Virtual care — which ranges from video-call doctor’s appointments to more comprehensive and technologically advanced services offered remotely from major hubs — could help fill some of the gaps in rural care.
Bath hopes the “rapid shift” toward virtual care sticks around.
“Health care providers don’t work in isolation, and they’d prefer not to work in isolation,” she says. “There’s lots of different gaps there … but there’s movement toward improvement.”
Because of Saskatchewan’s low population density — a little less than half the average population density of Canada, according to Statistics Canada — remote health care has always been an area of interest. As Lewis puts it, health care researchers in Saskatchewan have long been on the cutting edge of developing new technology to reach remote communities.
Lewis pointed to the Telehealth Saskatchewan program and other remote medical service projects as examples of Saskatchewan’s leadership in the field, even if that leadership is by necessity.
Telehealth Saskatchewan, according to its website, has saved patients and families more than six million cumulative kilometres of travel by connecting patients to health care teams through secure video conferencing.
The Saskatchewan government started financially covering appointments scheduled through the Lumeca app developed in Regina, which acts as a virtual clinic for patients to connect with available doctors, just as the COVID-19 pandemic arrived in March.
“I think the genie is out of the bottle … and while there will be some interesting twists to it and it won’t work wonderfully in every circumstances, I can’t imagine the system going back to the old way of doing things 100 per cent,” Lewis says.
Dr. Ivar Mendez, the provincial head of the Department of Surgery at the U of S and the Saskatchewan Health Authority and one of the champions of remote-presence medical technologies in the province, says the pandemic has forcibly pushed virtual care “several years” into the future as the province’s health care system rose to meet the challenge of COVID-19.
“We are at the forefront of virtual care technology in the country, and in some areas, in the world,” Mendez says. “We are ahead of everyone else in the institution of complex virtual care to remote and rural populations.”
Mendez noted that COVID-19 made the use of services like Zoom and FaceTime for connecting doctor and patient much more normal, shifting the culture toward one more accepting of remote care in place of in-person visits.
The work of Mendez and his team reaches far beyond video calls. Saskatchewan is now the only jurisdiction in Canada with robotic pediatrics care — the ability to use special robots remotely to help with child medical care. And as a direct response to the difficulties caused by COVID-19, Mendez and his team deployed a “telerobotic ultrasound system” to the remote community of La Loche while it was under lockdown, to provide ultrasounds remotely to more than 30 women in need of the service.
Mendez predicted that within five to 10 years, about half of all patient-doctor interactions will be through virtual care.
“This has huge implications for societies like us in Saskatchewan, with a huge territorial expansion and a relatively small population dispersed in a lot of rural areas,” he says. “Virtual care is now considered a true revolution in health care delivery, and it’s here to stay.”
Mendez likened the rise of virtual care to the advent of the GPS — now that the technology exists, nobody would want to go back to using a paper map. In the same way, Mendez says virtual care has transformed the idea of medical appointments always being conducted “face to face.”
Remote care can’t replace health care infrastructure
There are drawbacks to virtual care — the most significant of which is the telecommunications infrastructure to connect to remote communities, and the ability of specialists to see emergencies in real time.
Mendez says once Saskatchewan makes a provincewide upgrade to a 5G network, that will help tremendously. And even as technology continues to evolve, specialists have the ability to “triage” emergencies even if they are somewhat limited in how they can treat them.
“It’s going to be one of the solutions. It’s not going to be a panacea for absolutely everything,” he says. “What we want is, we want to be able to have the appropriate physicians … assess a patient in a timely fashion.”
Strykowski is less optimistic about the role of virtual care in replacing the need for medical professionals in rural communities. While she admits that Telehealth is “excellent” for remote care, she also points to the same obstacles of emergency care and technological access, especially for seniors.
With a small number of health care practitioners in the area and an ER with limited hours, Strykowski says it is “embarrassing” that the province can’t do more to increase health care access in rural areas. It doesn’t seem right that the best solution to feel her family has equal access to health care would be to leave Preeceville, she says.
“This is a thriving province. Everyone should have access to timely health care, regardless of where they live.”
Like it or not, this is the direction rural health care is heading. Now that Saskatchewan has made a concerted push down the path of technology as a solution, it can’t be undone.
And it doesn’t seem anyone wants to go back to how health care was delivered before, at least not entirely.
“Our patients would not allow it,” Mendez says. “The expectations have changed … once you have something, you can’t go back.”