It takes more than rural roots to make a rural doc

Adam Spencer, MD, MSc
Shamin Spencer, BASc, CHRP, Masters of Management (in progress)

CJRM 2006;11(2):129-130

There is a significant gap between health care needs in rural Canada and the availability of health care professionals. Although 30% of Canadians live in rural communities, 17% of family physicians and 4% of specialists practise rurally.1 Recruitment and retention continue to be significant issues in eliminating this disparity. Early exposure to rural medicine is crucial for later recruitment of physicians into rural practice.2 The Northern Ontario School of Medicine (NOSM) and the University of British Columbia's Northern Medical Program are currently trialling years of research indicating that physicians with a rural upbringing are more likely to practise rurally.3 In addition, distributive learning models are requiring more trainees to be exposed to rural medicine, but the majority of medical training is still conducted in urban centres.3

Despite the significance attributed to rural medicine exposure, few studies focus on process and outcome evaluations related to trainees' rural experiences. Process evaluation focuses on program delivery with the aim to learn about participant characteristics, perceived barriers and problems with service delivery.4 Outcome evaluation pursues a program's impact on participants and dropouts and seeks differences in baseline characteristics. Applied to medical trainees' rural experiences, these evaluations could address shared characteristics of those completing rural clinical rotations, overall experience of participants, problems encountered during scheduling and completing rotations. Long-term evaluations could explore residency program and career choices comparing participants with a rural and urban upbringing.

The lack of process and outcome evaluation became evident during my (A.S.) medical training. I was raised and completed my secondary and post-secondary education in Northern Ontario. I moved to Southwestern Ontario primarily to further my education. I was exposed early to rural medicine through electives and core rotations.

There are many not-for-profit organizations with the primary goal of facilitating recruitment of future physicians to rural areas. In Northeastern Ontario for example, the NOMEC (Northeastern Medical Education Corporation) is responsible for managing undergraduate medical training opportunities and postgraduate residency programs in family and specialty rural programs.

During my first year of medicine I completed an elective in Sault Ste. Marie funded through NOMEC.

A few weeks before starting a scheduled anesthesia elective, a letter informed me that because of unforeseen circumstances my elective would be changed to another discipline. "Was there anything I could do to help find an anesthetist?" I asked. NOMEC policy does not allow medical student's participation in setting up electives (i.e., prearranging an elective with a preceptor). Nevertheless, I turned to my family physician for help and within a day I had a preceptor and a 3-week elective in Sault Ste. Marie. NOMEC reluctantly approved the funding of the elective as it was not organized internally. Surprisingly, I received an email from the CEO explaining the drawback to students setting up their own electives without a central body involved. I did enjoy my elective, but was concerned about the scheduling problems. The majority of my colleagues who completed rural clinical rotations enjoyed the work, but many felt getting there was onerous, and most discussed constructive improvements directed to program delivery. The lack of organization left many concerned. The worst experience was shared by a colleague who was switched communities and discipline a few weeks before the elective and decided to cancel his trip to Northern Ontario.

Students have months of elective time to explore the breadth of medicine and its practice in various settings. Completing a rural rotation is not only a chance for exposure to rural life, but also an excellent opportunity to learn about these organizations that are closely tied to rural residency programs. A student's experience setting up an elective, completing forms, getting questions answered, meeting rural residents and staff, are all reflections of potential residency life.

The Northeastern Ontario Stream Anesthesia Residency Program is a 5-year program based in Ottawa, offering trainees 4 months of each year to be spent in Sudbury and surrounding area. I completed anesthesia electives in Ottawa and Sudbury and was impressed with this new program. CaRMS (Canadian Resident Matching Service) interviews approached and I contacted NOMEC for information about accommodations for my wife, newborn baby and our small dog. I was assured that accommodations would be provided for my family during the month-long rotations in Sudbury. However, pets were not accepted. I later learned that pets had been an on-going issue for interested residents over the years. After voicing my concerns, NOMEC suggested I propose new "pet rules" to be presented at an executive meeting. A few days after my CaRMS interview in Ottawa, NOMEC informed me that the proposed pet rules were not accepted and no changes would be made to the policy. The option offered was to find and cover the costs of accommodations while in Sudbury despite paying for rent in Ottawa.

Important data ascertained from research focused on characteristics of current rural physicians has helped shape recruitment practices across Canada. Despite increases in the number of medical students, despite junior medical students competing for electives every year in Northern Ontario, there is a constant struggle to fill training positions. Additional research on trainees' overall experience in rural regions is desperately needed. Collecting rich data through the use of targeted and follow-up focus groups could prove a very useful methodology. Why do trainees believe that Northern Ontario can offer unmatched elective experiences but stray away from its rural training programs? Why are trainees with a rural upbringing not choosing rural programs? Are there real or perceived barriers that could be addressed? Process and long-term outcome evaluative data could offer new insights needed to foster change and to improve current recruitment practices with a mission to improve patient care in rural Canada.

Competing interests:;None declared.

Correspondence to:;Dr. Adam Spencer; adam.spencer@learnlink.mcmaster.ca

References

1. Ministerial Advisory Council on Rural Health. Rural health in rural hands: strategic directions for rural, remote, Northern and Aboriginal communities. Ottawa: Health Canada; 2002. Available: www.phac-aspc.gc.ca/rh-sr/pdf/rural_hands.pdf (accessed 2006 Jan 3).
2. Easterbrook M, Godwin M, Wilson R, et al. Rural background and clinical rural rotations during medical training: effect on practice location. CMAJ1999;160:1159-63.
3. Chan B, Degani N, Crichton T, et al. Factors influencing family physicians to enter rural practice: Does rural or urban background make a difference? Can Fam Physician 2005;51:1246-7.
4. Myers A. Program evaluation for exercise leaders. Champaign (IL): Human Kinetics; 2000.

© 2006 Society of Rural Physicians of Canada