Family medicine education in rural communities as a health service intervention supporting recruitment and retention of physicians

Education as a health system intervention

Family physicians are a critical resource to rural and remote communities. In practising full-scope, comprehensive family medicine, family physicians often provide needed care services in the absence of other specialists who would traditionally deliver such care (eg, general surgery, general anesthesia). Family physicians adapt and evolve the family medicine competencies achieved while in residency training to meet community needs when they have established their clinical practices. Family medicine learners are provided comprehensive learning experiences to support the acquisition of generalist skills within the newly implemented Triple C Competency-based Curriculum.¹² When learning is offered in rural environments family medicine residents are able to learn and acquire generalist competencies within a rural context. Exposing learners to rural contexts early and often while in medical school and residency gives them a better understanding of the opportunities and realities of rural practice. Exposure to rural practice by rural clinical teachers positively influences recruitment and retention of family physicians in rural and remote Canada.¹³

Currently, there are more than 160 rural-based family medicine clinical teaching sites, 75 of which focus primarily on the provision of longitudinal learning in rural and remote communities.¹⁴ However, further support for distributed medical education delivery is needed in order for rural medical education to serve as a comprehensive, coordinated health human resource strategy that can enhance the recruitment and retention of rural physicians.

Pong and Heng’s rural education “pipeline” (Figure 1) is one model that describes how medical education can support the recruitment and retention of rural physicians by highlighting a mechanism for selecting, supporting, educating, and producing physicians for practice in rural communities in Canada.¹³ The model demonstrates how the pipeline for producing a rural physician begins before entry into medical school and continues throughout the medical education continuum through to practice. It is supported by evidence documenting that students from rural backgrounds are more likely to practise in rural communities than those from urban backgrounds, and that increased exposure to rural communities during the course of medical training enhances the likelihood that students will practise in rural and remote contexts.¹⁵

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Figure 1.

Pipeline model of rural physician production

Reproduced with permission from Centre for Rural and Northern Health Research at Laurentian University.¹³

Pong and Heng identify 4 critical factors that can affect a physician’s decision to practise rural and remote medicine: rural upbringing, positive undergraduate rural exposure, targeted postgraduate exposure outside urban areas, and stated intent to practise or preference for family medicine or generalist practice.^13,15 These factors, in combination with the pipeline approach to medical education delivery, provide a starting point for understanding how medical education programs must be structured to foster interest in practising rural family medicine. Some strategies for the delivery of comprehensive, coordinated rural education include targeted admission of students with rural backgrounds, integration of rural medicine into undergraduate and postgraduate curricula, efforts to ensure that rural learning experiences are positive for students, delineation of rural family medicine streams in postgraduate training, and increased coordination of education with recruitment and retention efforts in rural communities.¹⁴ However, rural and remote clinical teaching sites and teachers often have limited resources to train and graduate family physicians who are equipped with the skills needed to meet community needs. Support and coordination from higher organizational levels for implementation of these strategies remains a challenge.

Advancing Rural Family Medicine: The Canadian Collaborative Taskforce

Action to improve health care outcomes and access to primary care in rural and remote communities through a comprehensive, coordinated approach in Canada is required. Recognizing this need, the College of Family Physicians of Canada (CFPC) and the Society of Rural Physicians of Canada (SRPC) have come together to form Advancing Rural Family Medicine: The Canadian Collaborative Taskforce. The task force aims to advance the recruitment and retention of family physicians in rural, remote, and isolated regions of Canada in order to improve access and health care outcomes for these populations. The task force’s mandate is to develop a pan-Canadian rural education road map that will describe how this goal can be achieved. The road map will include a series of recommendations to enhance undergraduate, postgraduate, and continuing medical education training, with the aim of increasing the proportion of learners choosing rural family medicine practice as a lifelong career. In developing this road map, the task force will engage key stakeholders, including rural communities and all levels of government, in an effort to build the support and momentum needed for the recommendations to be implemented and put into action.

Social accountability framework: Pentagram Partners

Although enhancing rural medical education and training is critical, it is only one part of the solution for addressing the health care challenges in rural and remote Canada. There is a concerted effort needed on the part of national and provincial stakeholders to support evidence-informed physician resource planning, to provide support for the medical education system, and to collaborate in developing an integrated strategy to allocate resources for rural and remote health. Thus, support for rural medical education training requires coordinated efforts and collaboration between multistakeholder partners including rural communities, policy makers, rural health professionals and physicians, universities, and health education administrators (Figure 2).¹⁶ These “Pentagram Partners” are critical players in upholding the social accountability mandate to provide high-quality care to those living in rural and remote Canada.

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Figure 2.

Social accountability framework: Pentagram Partners.

Adapted from Boelen.¹⁶

Collaboration and coordination among the partners in the social accountability framework will be critical to the work of the task force. Despite the many efforts made to advance rural health care delivery and the progress that has been seen in rural medical education programs, much more remains to be done. In developing the recommendations, the task force will make a concerted effort to engage these partners in identifying how to implement them. The recommendations will undergo a stakeholder consultation process to delineate each stakeholder’s role in achieving the goal of high-quality health care delivery in rural and remote communities in Canada.

Each of these partners has a key role to play in advancing recruitment and retention initiatives, and the work of the task force provides an opportunity to bring these partners together in a coordinated way. The task force will explore the roles of medical education, rural communities, and policy makers in advancing the health of those living in rural and remote contexts. By understanding who is responsible and the actions each stakeholder needs to take to make the recommendations a reality, the task force can lay the groundwork for developing a coordinated, comprehensive health human resource strategy that considers the integral role of medical education as a health system intervention. For more information and additional resources, visit www.cfpc.ca/arfm.