Why are so many of Alberta's rural doctors from South Africa?

In January 2014, Dr. Cornelius Nortje arrived at the Edmonton International Airport, ready to start his new life in Alberta.

Nortje was met at the airport by the chief of staff at the Lac La Biche hospital. The chief of staff had two large down jackets, one for Nortje and one for his wife.

Nortje had never previously been in Canada. The day he and his wife landed, the chief of staff drove them250 kilometres northeastto their new home town.

"We were probably just looking for a bit of an adventure," said Nortje, who is now in the chief-of-staff role himself at theWilliam J. CadzowLac La Biche Healthcare Centre.

"Most of the South African doctors know someone that's either been in Canada or was on their way to Canada, and the feedback we've always had from them once they've been here has been that it's absolutely fantastic," he said.

As the local physician in charge of recruitment, Nortje says he's never received an application from a Canadian-trained doctor.

Lac La Biche isa hamlet within Lac La Biche County, which has a population of about 8,000 people. There are five doctors, allof them from South Africa.

Overall in Alberta, 6.5 per cent of all practising physicians graduated medical school in South Africa, according to figures provided by the College of Physicians and Surgeons of Alberta.

Outside of Edmonton and Calgary, 13 per cent of Alberta doctors trained in South Africa, the CPSA said.In the North zone of Alberta Health Services, South African-traineddoctors represent one-third ofall rural physicians.

Across the province, the CPSA website lists more doctors who speak Afrikaans, the Dutch-derived colonial language in South Africa, than those who speak Mandarin, Cantonese, Tagalog, Punjabi, Hindi or Ukrainian.

Amid ongoing physician shortages, the provincial government last month announced it will provide some funding to train more rural doctors.

The CPSA has also responded to the pressure. It launched a pilot to remove some barriers for international doctors from approved jurisdictions to start practising in the province.

Since the 1970s, South African doctors have been one of the largest demographics answering the call in Western Canada's rural communities.

Community service to community health

South African doctors' experience at home prepares them for rural medicine in Canada, Nortje said.

The country's medical training requires an internship at public hospitals, which are under-resourced compared to the separate private system. In addition, medical graduates complete a community service year in which they travel to townships and other communities in need before they register as physicians.

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"We get thrown into the deep end," Nortje said.

"Every physician that finishes [medical school] has to have done 10 C-sections ... so everyone's got a bit of exposure with procedural skills and maybe working a little bit more with less resources available."

Nortje said hospital roomsdesigned for two patientswould be overflowing with 10, with some patients on the floor and in the hallways. As a medical intern, he would have to monitorintensive-care patients and deliver babies on his own without a supervising doctor,he said.

That experience translates well to adapting in a small community hospital, he said.

When Nortje started, Lac La Biche had nine physicians, but that number has dwindled. And of the hamlet's five physicians now, only four work in the hospital.

"We do fit in well because you have to be able to do a little bit of anything," Nortjesaid of working at the Lac La Biche hospital.

"After 11 o'clock at night, it's me and one RN in the emergency department. Anyone can walk through that door and you have to be able to deal with it."

Barriers for International medical graduates

Some Canadian colleges of physicians give doctors with South African training and experience preferential status over their counterparts withother international medical credentials.

Since 1974, South Africa has been on a short list of countries the CPSA recognizes as approved jurisdictions.

Physicians who have trained there are able to skip some evaluation and training requirements that other international doctors need to work in Canada.

The majority of doctors who trained abroad have to complete a medical residency in Canada unless they've been recruited to work in Canada in their specialty.

Doctors from Australia, Ireland, United Kingdom and the United States can transfer the skills directly in all specialties.

Physicians from South Africa and more recently Singapore, Hong Kong and Switzerland can transfer into some specialties in Canada.

Each province designs its list of approved jurisdictions based around guidelines from the College of Physicians and Surgeons of Canada.

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"It does make it easier for South African physicians to come here and to come to Alberta when the training is recognized as similar to Canadian residency training ," said Dr. Michael Caffaro,assistant registrar with Alberta's college.

While South African doctors have a more direct path to practising in Canada than most other international medical school graduates, some requirements for doctors from South Africa have become more restrictive over the years.

Physicians must complete competency exams followed by a three-month in-hospital assessment period before becoming registered as doctors here.

Dr. Peter Bouch, who practises in Red Deer, emigrated from South Africa in 1993 after a patient told him about an open position in Canada.

He wanted to travel and Canada was one country that made it easier to transfer his credentials. Thirty years agohe faced far fewer barriers to entry than doctors do now, he said.

"Back in the good old days of faxesI sent a fax off and they said sure," he said.

Without an interview, a local health board invited him to be the new physician in Whitemouth, Man. He was able to take his competency exams in Canada after he started his practice.

I sent a fax off and they said sure.- Dr. Peter Bouch

Caffaro said he didn't know if fewer South African doctors are practising in Alberta than before, but the trend over the years has been that more internationally trained doctors from other countries are practising in the province.

In January, the CPSA announced a pilot that will waive certain requirements, such as clinical review exams, and the first three-month assessment for international medical graduates. The program is designed to encourage more doctors from approved jurisdictions to apply to work in Canada.

Caffaro said the pilot could also provide a step towardadding more countries to the list of approved jurisdictions in the future.

"There's no other jurisdictions yet," he said. However, in concert with the experts in postgraduate education, the expectation would be that there would be an interest in actually looking at how we can expand the list."

Medical exodus

For years, the South African government has expressed concerns about the steady outflow of trained physicians to other countries, primarily in the commonwealth.

Many doctors who came from South Africa to Canada described the safety of their family as part of the impetus to move.

South Africa has one of the highest homicide rates in the world, according to a United Nations report. Initially, the murder rate continuously declined post-apartheid, but statistics suggest there has been a rise since 2011.

"Safety is definitely, I think for me one of the biggest things," said Nortje."You've got alarm systems and response units that people privately hire to monitor their houses."

Nortje was working at a hospital in Cape Town one night when a physician from Nigeria went to a gas station to get something to eat. But his colleague never returned. Nortje said he found out two days later the man was killed.

Dr. Tracy Lee Lindenberg, another doctor in Lac La Biche who trained in South Africa, said she was held up at knifepoint in her car while stopped at a stop sign in the middle of the day.

She remembered seeing hundreds of people around and a police officer across the street. For years after that, even in Canada, she said she would have heart palpitations while stopped at a traffic lightif it looked like someone was approaching.

"It just made it such an easier decision to move," she said.

Five years ago, Lindenbergmoved to Canada with her husband and six-month-old daughter.

She said many medical challenges are similar to her experiences in South Africa and her family has embraced their new lifestyle in Lac La Biche, ice fishing and going on snowmobile trips.

"I really fell in love with the rural aspect," she said." People here were just so inviting and it just made me feel so much like home."

Doctors wanted

On Jan. 26, the province announced it would provide $1 million to fund four Alberta post-secondary institutions to look for ways to train doctors in Grande Prairie and Lethbridge. It's part of an effort to train more Alberta doctors who want to practice rural medicine.

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Medical resident Dr. Topher Mostert, who is currently working in Lac La Biche, is part of a Red Deer-based University of Alberta training program that includes a rural rotation.

Mostert, who grew up in Fort Nelson, B.C.,wants to be in rural medicine and said the residency has affirmed his decision.

"I can tell you that I will not be going back to a city.I much prefer small-town medicine," he said.

"Every day is different. And it's nice seeing the same patients and having that continuity of care."

Nortje is hopeful Mostert might join the team in Lac La Biche.

In the meantime, the Lac La Biche medical clinic is looking to address its current shortfall of doctors, with one of its five doctors set to retire this spring.

The community has hired two internationally-trained doctors who are already living in Alberta. One studied in South Africa and the other trained in India.

Both are waiting to completeassessments before they can join the team in Lac La Biche.