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Alberta Medical Association says general surgery is at a tipping point with lives on the line

Alberta’s general surgery is at a tipping point, with lives on the line says AMA

According to a July 8 Alberta Medical Association news conference, Alberta’s general surgeons are facing increasing human resources shortages, which are limiting their ability to provide urgent, life-saving care to patients.

This news conference marked the start of the AMA’s general surgery information campaign, seeking to inform the public of the issues faced in their hospitals.

“General surgeons, to put it succinctly, are essential and the lifeblood of surgery in our hospitals,” said AMA president Dr. Paul Parks in the conference. “Hospitals simply cannot function without having general surgeons available.”

“These are the patients that need timely, lifesaving care,” he said.

According to a pre-meeting briefing, every full-service hospital requires general surgeons to function and provide safe, timely care.

“The vast majority of the emergency conditions treated by general surgeons, if not rectified promptly, lead to serious outcomes such as sepsis, long-term complications and sometimes death,” read the briefing.

 

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According to the AMA, patients are waiting too long for care, and the province has seen an increase of diversions, situations when patients are transferred to other facilities due to a lack of available services.

“We need to get ahead of this problem,” said AMA Section of General Surgery president Dr. Lloyd Mack. “It’s not safe and clearly a poor use of resources shipping patients around the cities.”

AMA is also calling for more transparency from Alberta Health Services on the full impact of these diversions.

Delays and diversions in care are serious issues, which Mack said could be resulting in patient deaths.

Growing staffing shortages is at the heart of this issue, and according to the AMA, it’s unprecedented in North America and has now reached a tipping point.

“The chronic shortages of health-care professionals that you’ve been hearing about are hitting general surgery patients particularly hard,” said Mack. “Hospitals just can’t run without general surgery care.”

The capacity to provide adequate general surgery relies on more than just surgeons; it also involves other health-care professionals and house staff, from administration to housekeeping.

 

 

To tackle the growing issue, the AMA is highlighting the need for adequate anesthesia support, surgical nurses, more hospital beds in cities, review of information systems that have been offloaded onto surgeons, increasing trained housekeeping for faster turnovers, and surgeon incentives.

Mack also noted that making sure the public understands the issue is essential, and investment must be made to ensure the province can become attractive to the workforce of the future.

“We need focus and a plan for investment on the workforce,” he said, noting general surgery has not been growing with the population or adequately replaced as professionals retire or leave.

“I personally think this is a crisis,” said Mack. “It’s only going to get worse if we don’t start taking action now.”

Pincher Creek’s surgeon, Dr. Jared Van Bussel, highlights that Pincher Creek, too, is affected by these gaps in surgical coverage.

“In order for an OR to run effectively, it requires the combined skills of several OR-trained registered nurses, certified OR cleaning technicians, surgical instrument processors, surgeons, anesthetists, surgical assists, as well as a supportive administration and a facility to bring it,” he said in a statement to Shootin’ the Breeze.

Being able to have these resources requires funding, training and hiring.

 

 

“Pincher Creek has suffered incremental losses to many of these areas,” said Van Bussel, highlighting loss to local instrument cleaning facilities, on-call OR nursing and resultingly several OR-trained nurses.

“We previously had three surgeons and three anesthetists in our small community and we are down to one of each,” he said. “More than that, we’ve lost vision.”

Workforce planning and the breaking down of barriers have not been prioritized, which has come with a lack of adequate training in the province and significant barriers within the privileging process of visiting surgeons.

“Visiting surgeons have faced significant barriers to working in Pincher Creek, with the privileging process for two of our recent surgeons taking longer than a year to complete,” he said.

The Pincher Creek hospital has also faced gaps in its capacity to provide maternity care, which Van Bussel describes as a keystone in rural health care.

“In order for this to change, decision-makers need to speak in specific, measurable, achievable targets and the system has to correct the currently insurmountable barriers for rural surgery,” said Van Bussel. “Otherwise we will see further loss in the OR services provided in Pincher Creek.”

 

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Table setting of wedding venue — the Cowley Lions Campground Stockade near Pincher Creek in southwestern Alberta.

 

 

 

Three white envelopes blow in the wind in front of an open grey mailbox

With a commitment, we move forward

The health system remains under immense pressure. I am pleased that the Alberta health minister has made two commitments with the 2024 budget in response.

First, she has agreed to implement a new funding model for the comprehensive, lifelong care provided by family and rural physicians.

Second, she will ensure that Alberta can compete with our neighbouring provinces when it comes to retaining and recruiting physicians and medical learners.

Budget 2024 also provides more funding for the additional services that physicians are providing to more Albertans as our population continues to grow. We will work with the government to implement our AMA agreement.

I had a chance to speak with Minister Adriana LaGrange after the budget announcement. As you know, the AMA has been advocating loudly and ceaselessly for a commitment to a new comprehensive-care payment model and stabilization for family and rural medicine.

I am grateful to many members who lent their voices to our SOS campaign to save family and rural medicine. You were heard.

The minister has given me her word that we will implement the physician comprehensive care model as quickly as possible. She went further with a commitment to ensuring that Alberta will once again be competitive with other provinces for retention and recruitment — and make family and rural medicine viable across the province.

 

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The minister can move forward, now that there is money in the budget that can be used, to lock stabilization and the new payment model down and get the job done. We need to move expeditiously. The urgency is still very real.

This will allow us to work collaboratively on some of the other big pieces. I made a promise to physicians in acute specialty care that we would advocate strongly for their needs when family and rural medicine matters were starting to turn in the right direction.

We will need to keep pushing on primary care, but you will be seeing acute-care advocacy really coming to the fore. I hope we can count on members to continue to participate and show support for your colleagues in all specialties.

By the numbers, Budget 2024 has funding for primary care. There’s been an increase to the physician services budget that will offset some of the volume we have seen from population growth and add a partial funding top-up for inflation. It does not catch up, but because we negotiated a rate agreement, this is less of an issue.

Among line items in general, the specifics need to be worked out about where the money is going. We’ll be digging into that as we head into the busiest two-year period of our four-year agreement.

Dr. Paul Parks, President
Alberta Medical Association

 

Shootin’ the Breeze welcomes submissions about local issues and activities. Personal views expressed in Mailbox articles are those of the writers and do not necessarily reflect views of Shootin’ the Breeze management and staff. 

 

 

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Map showing Pincher Creek, Alberta, and the number of hours the ER was closed in 2023.

Alberta ERs closed for 38,000 hours in 2023

Emergency departments in Alberta were forced to close for more than 38,000 hours, or about 4.3 years, in 2023.

Disruptions ranged from a few hours without a physician to communities losing ER services for months on end. Of the 26 emergency departments that shut their doors in 2023, more than half had closures lasting 20 days or longer.

In almost all cases, these service disruptions were caused by staffing shortages, and the communities left without access to emergency care were in rural Alberta.

This data comes from biweekly hospital service disruption updates published by AHS, which were collected, analyzed and mapped by Great West Media.

Compiling and quantifying the extent of emergency care disruptions shows it is more than a random event, said Dr. Warren Thirsk, president of the emergency medicine section of the Alberta Medical Association and a practising emergency physician.

“It is evidence of the resource gap between what Albertans need from an emergency health-care system and what is being provided,” Thirsk said.

“I think that is important to understand that there have been cuts throughout the health-care system — in terms of personnel, in terms of training of personnel, in terms of facilities and infrastructure building — that have been going on for a long time.”

As the cuts go deeper, and the gap between the population and available resources widens, emergency rooms close as a last resort, Thirsk said.

“Then it just becomes more obvious that the system is not doing well. And it’s not funded adequately or resourced adequately to meet the needs of Albertans.”

 

 

Total length of emergency department closures in 2023

David Shepard, Alberta NDP rural health critic, said it’s troubling how access to care in rural parts of the province has been impacted, and called it “a direct result of a lot of decisions that were made by the UCP government, going back to the war on doctors in 2020.”

Since then, Alberta has lost not only clinic staff but those providing training as well, Shepard said, creating deficits in the professionals needed to keep ERs open.

“People should be able to expect that their emergency department is going to be there when they need. It should not be running like a fast-food restaurant where it closes in the evening,” he said.

Cost borne by rural Albertans

People in rural Alberta are often far more likely to turn to the emergency department for care, and the temporary loss of these care centres is a sign of deeper problems in the health-care system. Communities like Lac La Biche, Consort, Boyle and Swan Hills all went several weeks, or even months, without an ER last year.

The local populations also have emergency visit rates for semi-urgent or non-urgent problems between 2.8 and 6.5 times the provincial average, according to Government of Alberta data released in 2022.

 

 

“There are people who rely on that emergency department for every other gap in the health-care system,” Thirsk said.

If their family doctor or specialist is unavailable, the ER is often the only alternative.

“I think that is a cost borne more by the rural communities in terms of time. Because it’ll take them a lot longer to get to the next care facility that might be open,” he said.

Researchers from the University of Alberta’s Faculty of Rehabilitation Medicine have estimated that rural patients pay an extra $450 out of pocket every time they have to travel to Edmonton to see a specialist.

Taking a patient out of their community also removes them from their support network and puts additional pressure on already-strained hospitals in larger centres, said Mike Parker, president of the Health Sciences Association of Alberta.

During Covid when hospitals in Calgary and Edmonton were overrun, they were overrun with Albertans, not just Calgarians are Edmontonians, Parker said, because the high-level resources and intensive care required didn’t exist anywhere else.

“It all started right back where there was no community care in the areas that needed it most, that are hours and hours away,” he said.

Every year, Parker said, he sees a loss of front-line professionals. The cheapest fix would be to take care of staff that are already hired who are “the experts in the system.”

“Covid devastated our health-care system to the point where people cannot come back to work anymore. And the response from government is that we’re going to reduce hours, we’re going to reduce people, and we’re going to privatize services.”

 

Aerial view of the Cowley Lions Campground on the Castle River in southwestern Alberta

 

Promises to recruit, promises to cut

“Work is currently underway to attract more doctors to rural communities. This includes increasing the number of physicians educated and trained in the province, strengthening programs to attract and retain physicians, conducting targeted recruitment campaigns, streamlining registration processes for international medical graduates to work in Alberta,” Alberta’s Ministry of Health said in a statement.

The province is also establishing regional training centres for physicians in Lethbridge and Grande Prairie, which will serve as hubs for the surrounding communities, the statement said.

“Once developed, the training centres will include interprofessional teaching clinics and the ability for medical students to complete most of their medical education outside the metropolitan regions.”

Thirsk said health-care professionals are highly skilled and the time frame to train and subspecialize new workers is measured in years.

“And we make decisions, and budget cuts are made, on a very short-term basis. And that’s where the gap is happening. It’s happening to our nursing colleagues right now,” he said.

A recent AHS memo, obtained by the United Nurses of Alberta, asks management to cut nurse overtime by 10 per cent and reduce the use of private agency relief staff — a move the union has said could put additional strains on remaining workers and worsen patient care.

Shepard said it is almost a universal truth that if you train people in a rural area, they are far more likely to return to work in a rural area. But the rural physician recruitment incentives and new training programs “mean nothing in an environment and in a province where health-care professionals know they cannot trust their government.”

 

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What the data doesn’t show

The AHS data used to map ER closures gives some indication of the health-care crisis in Alberta. Missing from these statistics, however, is the dire situation faced by staff and patients in the ERs that have stayed open.

Alberta Medical Association president Paul Parks has said ERs are critically overcrowded, with patient wait times hitting record lengths this winter.

Last year, 190 Calgary doctors signed an open letter calling for the government to respond to “collapsing” emergency departments, which they blamed on a combination of pandemic aftermath and government policy that destabilized primary care and caused critical labour shortages.

“It is now common to have 40 to 50 people waiting to be seen by a doctor at any given time in any of our emergency waiting rooms. Frail, elderly patients languish on stretchers in hospital hallways. Patients with mental health crises are housed in the emergency room, often for several days, while awaiting inpatient beds,” the letter reads.

Hidden behind the number of hours each department was closed is also a personal cost that data can’t capture, Thirsk said.

“It’s the cost borne by every patient who’s suffering in a waiting room anywhere or driving another two hours in pain down the road,” he said.

“I challenge you to go into any emergency department in any facility or find any Albertan waiting for any aspect of health care. And to actually ask them how much they’re suffering as they wait.

“That’s where the real cost is. Because it’s not really dollars. It’s humans and human suffering that we’re missing.”

 

 

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Heading for My Little Corner and editorial by Shannon Peace

‘It’s crumbling around us as we speak’

Should there be public consultation when changes affecting health care are proposed? Should there be an opportunity to ask questions? Should we be concerned when budget cuts could drastically affect our community?

I asked these questions in a March 2020 article after Pincher Creek physicians voiced concerns about budget changes at a community town hall.

A key point, one I hadn’t considered before, was that rural family medicine practices are small businesses with fixed costs. And when cost outweighs income, changes must be made for a practice to remain viable.

Financial costs aren’t the only consideration. At the time, Dr. Jared Van Bussel referred specifically to potential changes to maternity care and the cost of losing it. His concerns have not changed.

He also noted that disruptions to maternity care and individual health services impact the viability of the community.

A month later, Associate Clinic physicians announced a planned withdrawal of hospital-based services to come in 90 days. The move was prompted by a continuing lack of trust between doctors and Alberta Health, and ongoing uncertainty for the future. The uncertainty was not just for the physicians themselves but for their staff, patients and community.

 

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The point hit home, and Pincher Creek rallied around its doctors. Letters were sent to government officials and a drive-by rally was held in June.

At the same time, Covid-19 was moving in, stretching local, provincial, national and global medical care to its limit.

Negotiating a master plan between the Alberta Medical Association and the provincial government piled even more pressure on Alberta’s medical professionals.

In October, local physicians chose to continue working in the emergency room and hospital rather than withdrawing those services. The community gave a collective sigh of relief, but problems remained unsolved.

By April 2021, a tentative master plan from Alberta Health had been brought forward and voted down by AMA members. Tyler Shandro, then minister of health, had also been to Pincher Creek to meet with Associate Clinic doctors, who were cautiously optimistic that agreement could be found.

It was September 2022 before a new funding contract was agreed to between AMA and the province.

The number of doctors at the clinic began to decline. Some retired while others chose to pursue careers elsewhere.

Finding replacements continues to be a challenge. Meanwhile, the cost of operating the clinic remains.

As we have all seen the cost of living rise dramatically, the cost of running any kind of business has increased as well.

To put this in perspective, as with any business, the financial burden on each partner increases substantially when the number of partners declines.

Speaking from personal experience, the stress and workload also increase significantly when staffing changes occur.

 

 

Let’s take stock of what we have in Pincher Creek.

We have a clinic and hospital providing continuity of care under one roof, personal relationships with physicians, an anesthetist and a surgeon, and even a CT scanner. Most importantly, we have a team of family doctors providing comprehensive care.

We also have our medical community working in difficult circumstances and likely losing hope for positive change. The emergency department was closed overnight twice in July due to a shortage of physician coverage.

About 800,000 Albertans do not have a family doctor, a situation especially dire in rural areas.

Our community has amazing medical resources, which are easy to take for granted, but a lack of stability under the very foundation of our health care system leaves it in danger of caving in.

“It’s crumbling around us as we speak.”

Dr. Paul Parks, president of the Alberta Medical Association, spoke those words Tuesday morning while sharing the results of a family and rural generalist physician survey conducted last week.

Asked to put the current state of affairs into medical terms, he likened it to a mass casualty that is bleeding out. The bleeding needs to be stopped and the patient stabilized.

Only then, once the chaos has passed, can treatment proceed.

 

Pig roast at wedding venue — the Cowley Lions Campground Stockade near Pincher Creek in southwestern Alberta.

 

About 30 per cent of Alberta doctors participated in the AMA survey. Most have been practising for 11 or more years and 43 per cent are dealing with 1,000 or more patients.

Of respondents, 21 per cent feel their finances can sustain their practices for up to a year, while 20 per cent say they are unlikely to be viable beyond six months and eight per cent say only three months.

While $100 million of federal assistance earmarked for stabilization was announced in December, Parks says “not one cent has flowed to family physicians yet.”

He also noted that financial assistance is available immediately when there are wildfires and other emergencies. The health-care crisis, which physicians and their association have been red-flagging for over a decade, has yet to trigger the same response.

The old model needs to evolve because physicians are leaving Alberta for greener pastures where governments are responding to the crisis. Actions must match promises so health-care workers and all of us can look forward with hope.

If we sit quietly and say nothing, the system will continue to crumble, with disastrous consequences.

At a town hall last May, Dr. Gavin Parker said, “If you want to find someone who can fix this, find a mirror.”

On its website, Alberta Health says, “The future of health care is in your hands.”

Alberta Health is holding public engagement sessions in Crowsnest Pass at 10 a.m. today and in Pincher Creek at 5 p.m. Registration is required.

TODAY!

This long backstory leads to a strong call to action.

If you are concerned about a crumbling health-care system, please register for a session.

Have your say — your life may depend on it.

 

 

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Alberta Health Minister Jason Copping giving bill 4 announcement from a podium in front of a background of provincial and Canadian flags.

Bill 4 announcement met with skepticism at Pincher Creek hospital

 

Pincher Creek’s chief doctor remains skeptical about prospects for an enduring partnership between Alberta doctors and the provincial government after Bill 4 announcement.

Dr. Gavin Parker, community medical director at Pincher Creek Health Centre, spoke with Shootin’ the Breeze Dec. 5, shortly after Health Minister Jason Copping vowed to repeal the province’s authority to unilaterally scrap its funding commitments to the Alberta Medical Association, which represents roughly 1,600 practising physicians across the province.

Copping said the Alberta Health Care Insurance Amendment Act, 2022 (Bill 4) heralds “a collaborative environment founded on mutual respect and trust” more than two years after the United Conservatives, under then-premier Jason Kenney, ended the AMA’s contract and imposed a new one.

The amendment, which Copping endorsed alongside AMA president Dr. Fredrykka Rinaldi, underscores a deal that the two sides brokered over the summer and which was ratified in September by 70 per cent of doctors, Copping said.

The UCP government will undo section 40.2 of the original act, used by former health minister Tyler Shandro in February 2020 to terminate the AMA’s last contract. In return, the AMA will drop its pending lawsuit against the government.

The proposed legislation comes roughly a week after Edmonton removed a cap on the number of daily patient visits that doctors can charge to Alberta Health Services.

 

 

The amendment pledges $750 million to “stabilize the health-care system” over the next four years, delivering a more than five per cent pay bump for family doctors. It also holds out “the potential” for binding arbitration should future contract negotiations break down, according to Copping.

Rinaldi thanked Copping for making a show of good faith, but stopped short of a glowing prognosis.

“It’s a step in the right direction, but it’s not a panacea,” she told reporters. 

Over at Pincher Creek Health Centre, Dr. Parker was less optimistic. Most of Bill 4’s substance had been hammered out months earlier, he said. Meanwhile, the medical community is perhaps less willing to trust the UCP than Copping let on.

“That’s great that they’ve said they’d take (section 40.2) off the books. But, I don’t think we can safely assume this kind of legislation will never come back,” Parker said. 

The health centre and attached medical clinic now have five full-time doctors, less than half of the 11 docs that were on-staff when Shandro tore up their contract.

 

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“It was pretty disastrous at the time,” Parker remembered.

Two doctors left the health centre to practise in urban centres in Alberta. One left the province altogether, highlighting the AMA’s aborted contract in their resignation letter. Others left to retrain in other medical specializations, while another doctor retired, according to Parker.

The health centre has recently brought on extra staff and “Alberta is still a great place to practise medicine,” Parker said, noting that doctors are paid well.

Surgeries are still performed at the health centre. “We’re one of a few places that still provide obstetric care,” while there’s none to be had in neighbouring Fort Macleod or Cardston, Parker said.

And the clinic has held on to its patients, despite the shortage of doctors.

“But, it’s been really tough,” Parker said, “because we haven’t been able to provide the same level of service and efficiency that people have come to expect.”

 

 

Emergency room patients with routine health concerns can wait up to eight hours to see a doctor if that doctor is busy performing a cesarean section, he said.

The health director also praised former health minister Shandro for his role in bringing a new CT scanner to the health centre.

“I’m glad to see the province’s finances are better now than when we were looking at contract negotiations a few years ago,” Parker said.

Watch news conference

Signing papers of contract negotiation

Alberta government reaches tentative deal with AMA

It’s been a tough year for Alberta physicians.

Pandemic aside, doctors across the province have been practising in an insecure partnership with the Alberta government since the province unilaterally terminated the master agreement with the Alberta Medical Association in an order of council on Feb. 20, 2020.

Negotiations between the government and AMA had been mired for months before the government pulled the plug. The central issue was the province’s insistence that physician compensation remain at $5.4 billion a year, which doctors said didn’t fairly compensate clinics experiencing inflation and rising numbers of patients requiring care.

Health Minister Tyler Shandro and AMA president Paul Boucher announced a new, tentative agreement had been reached on Feb. 26. Minister Shandro said negotiations proceeded on the basis of fiscal sustainability, fair and equitable solutions for physicians, and maintaining focus on patient care.

“I’m confident that what we’re presenting doctors with is an agreement that provides certainty, provides stability, and it does so in the best interests of patients, the best interests of doctors, and the best interests of all Albertans,” he said.

Finally reaching a deal, added Dr. Boucher, was a critical step in helping the province get through the pandemic and bringing the health-care system back to full strength.

 

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“This year of Covid-19 has changed the health-care system and Albertans forever,” Dr. Boucher said. “I know we will find a way through the pandemic, but we also need to look beyond it.”

No specific details of the agreement have been publicly released, as the tentative deal must be ratified by the AMA. One hundred and forty members of the representative forum, which makes up the AMA medical leadership, will meet virtually this week to discuss the agreement.

If approved, the forum will recommend to the AMA’s board of directors that the matter be presented to a general AMA membership vote. The process is anticipated to take about three weeks.

The tentative agreement is a step in the right direction, says Dr. Sam Myhr of the Associate Clinic in Pincher Creek. “We obviously work better together, and that’s been the goal all along,” she says.

Dr. Myhr represents the province’s rural physicians in the representative forum as the sectional president of rural health.

 

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Rural physicians have faced multiple challenges this past year, she says, and terminating the master agreement had an especially detrimental effect on rural practices as the lack of stability deterred recruits from committing to rural areas. Pincher Creek, for example, lost two such physicians who initially expressed interest in coming to the community.

The lack of formalized agreement establishing doctors’ working relationship with the government led local physicians to notify the government last summer they would discontinue hospital care at the Pincher Creek Health Centre unless a master agreement was signed.

Though at the request of town council the group never fully withdrew care, Dr. Myhr says the local advocacy of physicians and community members helped move the situation toward the tentative deal.

“It was tough; those were not easy times,” she says. “But it helped keep the issue in the limelight, and it would have been easy for it to sort of get swept under the rug if there weren’t places like Pincher Creek and other rural sites that have been continually standing up and saying no, this isn’t OK.”

Community members, she adds, are especially to be credited for their advocacy with elected officials and for their public support of doctors that “kept us going.”

 

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Moving forward in co-operation, Dr. Myhr continues, is now the best step, though she acknowledges the actions of the provincial government last year will still weigh on physicians’ minds as they consider voting on the new agreement.

“We all need to put down our swords to some degree and just work together, but I think everyone is quite wary,” she says.

Rebuilding trust with physicians will require concrete action from government officials, such as the health minister visiting the Pincher Creek hospital, which was initially scheduled back in January but was postponed due to rising Covid-19 cases.

The visit is still something that Dr. Myhr feels is important, as it would showcase what rural physicians are able to accomplish and why decisions made in Edmonton have such a dramatic impact on rural medicine.

“It would be an important step to show they are willing to hear us, that they are willing to collaborate, and they are willing to try and understand rural medicine better,” she says.

The health minister’s office has expressed interest in rescheduling the visit but says plans to do so will proceed once the number of Covid diagnoses is low enough to make such a visit safe to do.