The last physician working permanently in the northwestern Ontario town of Manitouwadge had his final day at the local hospital on Sept. 8.
The move left the community of about 2,000 residents, located 390 kilometres northwest of Thunder Bay, without a permanent physician, and capped off a summer of crisis in the health-care workforce.
It's a situation that has one expert warning could be replicated in other rural communities in the region and across Canada.
"These are fragile systems. They depend on a very small group of people to function and to function well," said Dr. Sarah Newbery, assistant dean of physician workforce strategy for the Northern Ontario School of Medicine (NOSM) and a rural generalist family physician in nearby Marathon, Ont.
"We are anticipating that we will see more early retirements and more physicians cutting back on their practice and leaving communities altogether, in part because of the stress of COVID-19 and of the increased work that has meant for many physicians."
The physician workforce in northern Ontario has already been decreasing over the past year, Newbery said.
"So we need to be paying attention to what's happening in Manitouwadge because I don't think that they will be the only community that is at risk of having no physician workforce at all."
'A significant crisis in our workforce'
Santé Manitouwadge Health, which is responsible for providing services to the entire community, has three full-time positions for family medicine and rural emergency department physicians. Effective Aug. 30, the organization has been without permanent physicians, according to an open job advertisement on its website.
But there were signs of a coming health-care staffing shortage weeks earlier.
The urgent-care clinic was cancelled the week of July 5 to 9 "due to physician shortages across the province," according to a Facebook post by the Manitouwadge Family Health Team. Those clinics were cancelled again for two weeks in August, with Facebook posts citing "physician shortages" as the reason.
Santé Manitouwadge Health put community residents on notice when it warned in a news release Aug. 12 that it was "experiencing a significant crisis in our workplace."
The release added "the short-term impact is that on an interim basis only, people requiring admissions to the acute side of the hospital may need to be transferred to another location in order to have their urgent/emergent needs met in a safe manner."
It's been an ongoing problem in the rural town, as the organization's 2018/19 annual report, the only year for which one is available online, noted "the physician shortage is more complex."
A high workload and an inability to retain physicians are cited in the annual report as some of the reasons for the physician shortage.
In an email to CBC News on Sept. 2, the organization's chief executive officer, Debbie Hardy, said "the situation is resolving," but did not provide any additional details.
Quality of care suffers without permanent staff
When a health-care organization is unable to retain its full complement of physician staff, locum physicians — the equivalent of substitute teachers in the education field — come into a community and work for as long as they are able.
Sometimes, that can be for a couple of weeks or months at a time, Newbery said. Other times, it can be even shorter.
"What we've seen this past summer is that many communities have needed to bring in physicians for one or two shifts in order to keep the emerge departments open," the rural family physician said.
That kind of disruption can affect the quality of care for residents, especially for people with more challenging health needs.
"It's not that the physicians coming in aren't excellent physicians … but complex chronic illness needs to be followed over time," added Dr. Newbery.
Physicians call on action from federal parties
While Newbery acknowledged that health is largely a matter of provincial jurisdiction in Canada, she said the federal government has an important role in rural health care for two key reasons.
Ottawa is responsible for providing health services to Indigenous people, "and rural health-care systems are the places where many of our Indigenous citizens receive their care," she said.
The second piece, Newbery added, is the federal government has a rural economic development portfolio.
"Without health-care infrastructure, without physicians in the community, the economic vibrancy of our rural communities will decline."
With the federal election in its final week, rural health-care practitioners are demanding answers from the parties.
"These recommendations are not new … we hope that the next federal government will truly act upon these recommendations." - Dr. Gabe Woollam, president of the Society of Rural Physicians of Canada
The Society of Rural Physicians of Canada, which represents over 1,900 members, released a statement calling on the parties to address persistent inequities in access to rural health care.
"In regions hardest hit by [COVID-19] outbreaks, rural health-care centres have often found themselves short-staffed, exhausted and barely able to cope," said the statement.
The statement demanded all federal parties to invest in resources and infrastructure to:
Enable a national rural health-care and workforce strategy.
Provide access to rural health care.
Promote rural health-care innovation.
Prioritize Indigenous health services.
Collaborate with rural Canada.
"These recommendations are not new … we hope that the next federal government will truly act upon these recommendations," the society's president, Dr. Gabe Woollam, added in the statement.