Why would a well-respected surgeon from a prestigious Canadian university decide, in his early 50s, to enlist in the Canadian Forces Health Services Group (CFHS)?

“It’s about the best surgical unit in Canada and I wanted to be a part of it, and the way to be a part of it is to join up,” says Dr. Vivian McAlister, a professor of surgery at the University of Western Ontario in London, who is now also a major who has served with 1 Canadian Field Hospital in Afghanistan.

The medical professionals who have responded to recent intensified recruiting efforts by the Canadian Forces have many different motivations. Some, like Captain Jason Bailey, a neophyte physician at CFB Petawawa, signed up to ease the financial burden of earning a medical education. Others, like Captain Chiam Liew, a civilian physician for seven years before she signed up, are simply motivated by the urge to serve their country.

Still others are attracted by the working conditions, benefits such as pensions and paid vacations, or the excitement of deploying overseas to a battle zone or mission with NATO allies.

Whatever their motivation, the CFHS is happy—and relieved—to have them.

Addressing the medical manpower shortage was one of Brigadier-General Hilary Jaeger’s top priorities when she assumed the office of Surgeon General of the Canadian Forces in 2004. The health and welfare of Canada’s 87,000 serving troops and reservists is ultimately her responsibility, a responsibility she was hard pressed to meet initially due to a chronic 35-per-cent shortfall in general duty medical officers (the CF equivalent of family physicians), as well as shortages of specialists, nurses, pharmacists, physician assistants, medical technologists and other qualified medical personnel.

With only 98 of 150 general duty medical officer positions filled, “it was affecting our ability to retain the people we did have,” says Jaeger. With each departure, the stress on remaining physicians intensified, “making them more likely to leave, which of course made the situation worse.”

A new recruitment strategy was needed. When it comes to recruiting professionals, says Jaeger, ads don’t work. “You’ve got to get out there and talk to them.” With the philosophy “it takes one to recruit one,” the CFHS established full-time physician recruiters for the West and East, and asked Lieutenant-Colonel Randy Russell—a physician himself—to lead them.

Russell visited medical schools, spoke at physicians’ meetings and set up recruiting booths at medical conventions. And CF physicians backed up that effort: they made themselves more visible by wearing their uniforms to meetings and conferences, where they fielded questions from interested colleagues.

The result? There are now about 130 general duty medical officers in uniform and Jaeger expects to be back to the full complement of 150 in 2009.

“The key to our success is we were given authority to be innovative and aggressive,” says Russell. The team had two challenges: to address the critical shortfall immediately, while developing a plan to deliver a sustainable stream of physicians over the long term.

An appeal to Canadian physicians through the Canadian Medical Ass­oc­ia­tion resulted in waves of specialist physicians serving 56-day tours as reservists or contractors in Kandahar. Then-president Dr. Ruth Collins-Nakai travel­led to Kandahar and later told the CMA Bulletin: “I am convinced that we must do something to ease the burden on our medical colleagues there.”

The CFHS addressed longer- term staffing issues by offering signing bonuses to bolster the number of experienced physicians and by recruiting medical students to provide long-term stability in numbers. The result is a “pipeline of physicians” that “allows us to operate with a 10-year horizon,” says Russell.

Where once perhaps four or five licensed physicians would sign up annually, “in the last two years we’ve enrolled 15 or 16,” Russell says. Signing bonuses for doctors who commit to four years of service—initially $80,000 but quickly bumped to $225,000—helped, says Jaeger.

Malaysian-born Chiam Liew wanted to join the Canadian military right after finishing medical school about 10 years ago, “in gratitude” to her adopted country. She decided against it, she says, because “the (military) pay scale at that time wasn’t all that great, so it would have taken me a long time to pay off my student loan.” She practised in the civilian world for seven years until, in 2006, the military’s signing bonus and competitive pay scales spurred her to sign up. She opted for a lower bonus and a two-year commitment, because “I wasn’t sure at the time if the military lifestyle would fit me.”

Since then, “life has been interesting,” she says, with basic training, a flight surgeons’ course, and five and a half weeks aboard HMCS Toronto, circumnavigating Africa on a NATO mission. “My practice right now is very busy,” she says, noting she also has many opportunities for professional development and is thinking about post-graduate studies. And she plans to re-enlist once her two years are up.

Jaeger, for one, was surprised by the type of physicians attracted by the signing bonuses. “We thought we would get young physicians just out of training struggling to pay off education-related debts,” she says. Instead, the bonuses are drawing older physicians who “are tired and looking for a change.” After seeing 35 patients a day and working 100-hour weeks, many of these doctors find the work/life balance offered by the CFHS attractive.

“They are perfectly aware they’re liable to be sent off to Afghanistan or somewhere else for six months,” says Jaeger. But, she explains, “when (doctors are) not deployed, our work/life balance is actually better than the average physician in private practice.”

One innovative solution—contracting civilians to fill specialist positions—went against the grain for Jaeger. The forces used to “grow their own” specialists by training from the ranks of CF general practitioners. “I was one of the last converts,” she admits. “I used to be adamant that you lose so much in terms of military ethos and true understanding of the nature of our business.” But “that rule was not allowing us to fill the ranks of specialist positions, and it’s expensive and very, very slow. So the rule had to change.”

For McAlister, a civilian contract led to a military career. After training several younger surgeons and anesthetists for overseas duty, “I asked if there was a role for a civilian to play.” In 2007, he was contracted as a surgeon and served two months in Afghanistan. The “immediate and lasting impression” was so strong, he signed up once he got back to Canada.

“I think there’s a role for an experienced surgeon to play, mainly to complement the career surgeons within the forces who are doing a wonderful job, and making up for some retirements,” he says. Since the closing of the last dedicated military hospital in the late 1990s, CFHS personnel have been embedded in civilian facilities across the country, so McAlister was able to continue his association with the University of Western Ontario. “I had to make an agreement with the department of surgery here that I would be free to leave at any time and my colleagues would cover me.” Although initially committed to serve only four years, McAlister, who is now a major, expects he’ll serve right up to retirement.

But it’s people at the other end of their careers who will give the CFHS the stability to confidently plan for the future. “Historically, we’ve enrolled eight or nine medical students a year,” says Russell. “Two years in a row now we’ve enrolled 25 to 30,” partly by allowing first-year students to sign up. That means six years from now, the CF can expect two dozen new physicians to join the ranks each year.

The Medical Officer Training Program (MOTP) pays registered medical students a signing bonus, covers medical school fees (which average $12,000 a year), picks up costs of books and materials, and pays students a salary while they study. The signing bonuses range from $40,000 to $180,000, depending on the year the student signs; salaries range from about $44,000 to $58,000 per year while they’re students or residents.

“For me, the fees were more like a bonus,” says Bailey. “I wanted to make sure I was joining because I would enjoy it.” Since he comes from a military family, the opportunity for deployment was big on his agenda. “I expect to go to Afghanistan sometime before 2010.”

During the time MOTP participants are students or residents, “they don’t have to do anything but be a successful medical student,” says Russell. Basic military training and on-the-job training take place during breaks in the school year.

One myth dispelled by recruiters is that students are expected, like reservists, to devote a certain amount of time to the services each week or month. Not true. “We do nothing to jeopardize any time or energy for studies,” says Russell. Another myth is that everyone in the military moves around all the time. “The reality is for physicians, once we post them to a base, they stay there for their four years of service,” barring deployments.

When they emerge from medical school, new physicians are posted and begin duties without debt and without the costs of setting up a practice, says Bailey. “You don’t have to worry about paying off the debt, working a hundred hours a week to pay your debt off quickly. It’s less stressful. You can focus on your personal life. This allows you to build other aspects of your life that get pushed aside with schooling.

“I like my day-to-day job right now. It’s hard to say what the future will hold; I’ve only been in eight months,” Bailey continues. But if the opportunities are right, he says, “I think I’ll stay over the long term.”

To capitalize on its investment in medical schooling, the CFHS wants young physicians to do just that. To keep them in, it has recognized that pay and the work environment have to be as appealing as their equivalents in the private sector. To keep that pipeline full, retention is as important as recruiting, says Russell. “Our retention rate went from 30 per cent to 80 per cent over two to three years,” says Russell. “It’s a dramatic change and it reflects the branch really stepping forward to create a more positive work environment.”

Salaries for military physicians are competitive, ranging from around $134,000 for first-year physicians to $184,00 for those with seven years’ experience. Compensation for majors and lieutenant-colonels ranges from about $180,000 to $234,000 annually. When civilian physicians are polled about benefits they’d like to have, says Russell, “the top three are paid vacation, parental or maternity leave, and a pension plan. We offer all three.” The military also provides time and funding for professional development.

In addition, the patient load is much less than that in the civilian world—averaging about 18 per day, says Russell—giving military physicians more time to spend with patients and consult with colleagues. And not all of their time is spent in the office. To keep up their acute care and trauma skills, military physicians work one day a week in a civilian emergency department. They also spend half a day on the operational side of the base, observing and experiencing the various job conditions of troops who staff the helicopters, tanks, ships, planes and submarines.

Other methods the CF is using to increase the number of physicians include training interested career CF officers as medical officers under the Military Medical Training Plan and tapping the talents of retired officers who remain CF reservists.

Retired Colonel Ian Anderson, now a trauma surgeon for the Calgary Health Region at Foothills Medical Centre in Calgary, has kept himself available to the CFHS by remaining in the Primary Reserve. His 32-year career with the CF included deployments to Bosnia, Kabul and Kandahar.

When he joined the CF in the 1980s, “I never dreamt I’d be here at the pinnacle of a tertiary care facility, in possibly the best trauma system in Canada,” Anderson says. By keeping his foot in the door, he gets the occasional shot at deployment. And when he’s not deployed, he points out, “I don’t cost the system one penny.”

While the CFHS is well on the way to resolving the physician shortage, shortages of other qualified medical personnel persist.

For instance, it’s difficult to keep seasoned nurses, says Jaeger. “We have some shortages, but it’s more in terms of a mismatch.” The bulk of nursing officers have 10 years of experience or less, so “sometimes we find ourselves short of nurses aptly trained, experienced and ready to go” on deployment.

With a national shortfall of 12,000, the market for nurses is hotly competitive. Much of the recruiting for nurses is done through the Regular Officer Training Plan (ROTP). Of 236 full-strength positions, “we have basically 195 trained, effective strength,” says Lieutenant-Colonel E.J. Villeneuve, Canadian Forces Chief Nursing Officer. Of those, however, about 80 are new nurses in what is termed their “consolidation period,” when they gain military experience, Villeneuve explains.

Although there is no signing bonus, there is a program to pay for nurses’ education. Nurses who have completed their first year of university can sign on to the ROTP. Their tuition, books and materials are paid for, and they receive a salary of about $25,000 to $30,000, depending on the year they sign up. In exchange for this financial support, the commitment to the military is “usually two months for every month we’ve subsidized, to a maximum of five years,” says Villeneuve.

Although salaries are competitive in the higher ranks, there is a disparity between junior-level salaries for civilian and military nurses. The CF’s benefits package and pension plan do not hold the same attraction for nurses as for doctors, because nurses in the civilian sector tend to be unionized.

One of the big attractions, says Villeneuve, is the appeal to patriotism, “the concept of serving the country and being part of something that is way greater than yourself.” Deployment also solidifies group membership. “Being part of a team, you depend on each other. You cry on each other when you miss your family. You laugh together. That feeling is something really very difficult to replicate here.”

Retaining nurses is a problem, partly because those not on deployment are routinely embedded in civilian health care settings to keep their skills up. Over time, they begin to identify more with the civilian than the military health care system. “It’s possible we just have to accept….we won’t have nurses for 25- or 30-year careers,” says Jaeger.

With 10 per cent annual turnover, new recruits are constantly needed, and the ranks of experienced nurses remain thinner than desired. “If I can get them into the reserves, then I have not lost them,” says Villeneuve. “A lot of the time they cannot come for a six-month deployment, but most of them can accommodate three or four months. And we’ll surely use their skills.”

Recruiters may have turned the battle in recruiting doctors and nurses, but there are other fronts. The CFHS is at about half strength of the full complement of 41 pharmacists, says Jaeger. They, too, are offered signing bonuses and financial support through the ROTP. And though there should be about 20 biomedical technicians, there are only seven, and two are on deployment at any one time. And there are shortages of health care administrators and physician assistants, too. Information about signing bonuses and financial support for education for various positions is available online at www.forces.ca/v3/.

With current and growing shortages of trained medical personnel in the civilian health care system, increased competitive pressure could upset the recruitment/release balance at almost any time.

For instance, this fall, Ontario plans to pilot its first training programs for civilian physician assistants (PAs), and the University of Manitoba is launching the country’s first post-secondary PA program. Although PAs have been trained by and served in the CFHS for decades, it’s a new position in the Canadian civilian world. So where did the qualified people come from to teach the programs?

“On my less charitable days, I’d say they got poached (from the CFHS),” says Jaeger.

Despite a war well fought and many battles won, clearly this is no time for CF medical personnel recruiters to rest on their laurels.

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