Abstract
Objective To assess Memorial University of Newfoundland’s (MUN’s) commitment to a comprehensive pathways approach to rural family practice, and to determine the national and provincial effects of applying this approach.
Design Analysis of anonymized secondary data.
Setting Canada.
Participants Memorial’s medical degree (MD) graduates practising family medicine in Newfoundland and Labrador as of January 2015 (N = 305), MUN’s 2011 and 2012 MD graduates (N = 120), and physicians who completed family medicine training programs in Canada between 2004 and 2013 and who were practising in Canada 2 years after completion of their postgraduate training (N = 8091).
Main outcome measures National effect was measured by the proportion of MUN’s family medicine program graduates practising in rural Canada compared with those from other Canadian family medicine training programs. Provincial effect was measured by the location of MUN’s MD graduates practising family medicine in Newfoundland and Labrador as of January 2015. Commitment to a comprehensive pathways approach to rural family practice was measured by anonymized geographic data on admissions, educational placements, and practice locations of MUN’s 2011 and 2012 MD graduates, including those who completed family medicine residencies at MUN.
Results Memorial’s comprehensive pathways approach to training physicians for rural practice was successful on both national and provincial levels: 26.9% of MUN family medicine program graduates were in a rural practice location 2 years after exiting their post-MD training from 2004 to 2013 compared with the national rate of 13.3% (national effect); 305 of MUN’s MD graduates were practising family medicine in Newfoundland and Labrador as of 2015, with 36% practising in rural areas (provincial effect). Of 114 MD students with known background who graduated in 2011 and 2012, 32% had rural backgrounds. Memorial’s 2011 and 2012 MD graduates spent 20% of all clinical placement weeks in rural areas; of note, 90% of all first-year placements and 95% of third-year family medicine clerkship placements were rural. For the 25 MUN 2011 and 2012 MD graduates who also completed family medicine residencies at MUN, 38% of family medicine placement weeks were spent in rural communities or rural towns. Of the 30 MUN 2011 and 2012 MD graduates practising family medicine in Canada as of January 2015, 42% were practising in rural communities or rural towns; 73% were practising in Newfoundland and Labrador and half of those were in rural communities and rural towns.
Conclusion A comprehensive rural pathways approach that includes recruiting rural students and exposing all medical students to extensive rural placements and all family medicine residents to rural family practice training has resulted in more rural generalist physicians in family practice in Newfoundland and Labrador and across Canada.
Memorial University of Newfoundland’s (MUN’s) Faculty of Medicine has had a social accountability mandate since it was founded in 1967, focusing its attention specifically on training physicians for practice in a province that features a widely distributed population across an expansive geographic area. This mandate includes a focus on training physicians with the interest, knowledge, and skills to practise in rural areas. Its rural-focused, experiential-learning-based curriculum forms the backbone of what MUN considers its “pathways” to rural family practice. Memorial’s comprehensive pathways approach augments the conventional pipeline approach to develop and support medical students, residents, and physicians by recognizing the different paths that people take through their lives to get to rural practice. This study assesses MUN’s commitment to a comprehensive rural pathways approach to education for rural family practice, as well as the national and provincial effects of using this approach.
Canadian studies demonstrate the importance of rural admissions and rural medical education at both the undergraduate medical student and the postgraduate family medicine vocational training levels, resulting in a higher percentage of doctors who practise in rural areas. These studies include influences on the supply of rural physicians,1–3 rural background as an element of diversity recruitment to medical school,4–6 distributed learning and integrated and rural-focused family medicine residencies,7 and duration of residency training.8
A recent study of medical doctor (MD) graduates from MUN’s Faculty of Medicine confirmed that those with rural backgrounds were more likely to practise in rural locations.9 A study of 2011 to 2013 Northern Ontario School of Medicine family medicine graduates also found that those with rural backgrounds were more likely to practise in rural locations.10 Similar to MUN, the Northern Ontario School of Medicine provides distributed, community-based learning with an emphasis on rural and remote areas.11
Across Canada, and in Newfoundland and Labrador specifically, there continues to be a shortage of rural family physicians. Memorial’s comprehensive pathways approach addresses this shortage with interventions that begin before an individual enters medical school and follows the student throughout their medical education and subsequent medical career. Memorial’s Learners and Locations (L&L) ongoing study explores the result of increased recruitment of rural students into medical school, along with extensive exposure to rural medicine through undergraduate placement weeks and a rural-focused family medicine postgraduate training program.
To assess MUN’s commitment to a comprehensive pathways approach to rural family practice, this study examined the following questions: What are the national geographic effects of MUN’s comprehensive pathways approach to rural family practice, as measured by the proportion of MUN family medicine program graduates practising in rural Canada compared with other Canadian family medicine training programs? What are the provincial geographic effects of MUN’s comprehensive pathways approach to rural family practice, as measured by the location of MUN MD graduates practising family medicine in Newfoundland and Labrador? What are the indications that MUN has an ongoing commitment to a rural pathways approach, as measured by the proportion and distribution of students with rural backgrounds, rural clinical learning opportunities in MD and postgraduate programs, and rural family medicine practice locations of 2011 and 2012 MUN MD graduates?
METHODS
Measurement approaches
The following methods were used to measure the national and provincial effects of MUN’s comprehensive pathways approach to rural practice, as well as the university’s ongoing commitment to the approach.
National effect.
National effect was measured by the proportion of MUN family medicine program graduates practising in rural Canada compared with those from other Canadian family medicine training programs. The study population for this portion of the analysis comprised physicians who completed family medicine training programs between 2004 and 2013 and who were practising in Canada 2 years after completion of their postgraduate training (N = 8091).12 This study component analyzed this practice-entry cohort and determined the proportion practising in rural locations.
The Canadian Post-MD Education Registry (CAPER) gathers post-MD training data and practice locations for all residency programs at all Canadian medical schools. Practice location is reported for graduates 2 years after exiting their post-MD training. Rural locations are defined by CAPER as those locations outside census metropolitan areas and census agglomerations, as well as the territories. This means communities with a population of less than 10 000 outside the commuting zone of large urban centres.
Provincial effect.
Provincial effect was measured by the location of MUN MD graduates practising family medicine in Newfoundland and Labrador. The study population for this portion of the analysis comprised MUN MD graduates practising family medicine in Newfoundland and Labrador as of January 2015 (N = 305).
This study component analyzed the location of MUN MD graduates practising family medicine in Newfoundland and Labrador based on data for physicians licensed by the College of Physicians and Surgeons of Newfoundland and Labrador. These data were georeferenced and analyzed using the definitions of rural developed for the L&L project described below. ArcGIS Online was used to create the map.
Memorial’s ongoing commitment to a comprehensive pathways approach.
This was measured by the proportion and distribution of students with rural backgrounds, rural clinical learning opportunities within the MD and postgraduate programs, and rural family medicine practice locations of recent MUN graduates. The study population for this portion of the analysis was MUN’s 2011 and 2012 MD graduates (N = 120). To gather information for this section (eg, students’ backgrounds, clinical placements), the L&L database was used.
The L&L database
The L&L database was developed in 2008 as the basis for a longitudinal study that links students’ backgrounds and educational placement locations with their eventual practice locations in Newfoundland and Labrador and further afield.
The L&L database includes admissions information and education placement administrative information (One45 software) on educational placements and Canadian Medical Directory data on practice locations. This study included anonymized data from the L&L database on MUN 2011 and 2012 MD graduates (N = 120), including those who completed family medicine residencies at MUN (N = 25), those who practised family medicine in Canada as of January 2015 (N = 30), and those who practised family medicine in Newfoundland and Labrador as of January 2015 (N = 22). To analyze statistics, SPSS software was used, and ArcGIS Online was used to create maps.
A key aspect of the L&L project is the definition of rural, for which L&L has adapted standard Statistics Canada categorizations in order to reflect what are commonly accepted operational differences in practice locations throughout the province. Statistics Canada defines rural and small town as follows:
municipalities outside the commuting zone of larger urban centres (with a population of 10 000 or more). These individuals might be disaggregated into zones according to the degree of influence of a larger urban centre (called census metropolitan area and census agglomeration influenced zones).13
This study used the following classifications: rural community (population of less than 10 000), rural town (population of 10 000 to 29 999), small city (population of 30 000 to 99 999), mid-sized city (population of 100 000 to 499 999), large city (population of 500 000 to 999 999), and metropolis (population of more than 1 000 000). In accord ance with this categorization system, this study used Statistics Canada 2011 population data to classify background, placement, and practice locations. (The 2011 census data were used to best correspond with the cohort being studied.) Smaller centres with less than 50% commuting flows to larger centres were categorized in accordance with the larger centre. We have included rural towns as “rural,” as from a practice perspective, family physicians in these towns often play a rural generalist role that includes a considerable portion of hospital work such as emergency services and obstetrics, as well as substantial responsibilities in caring for hospital patients. When classifying student backgrounds, educational placements, and practice locations, rural communities and rural towns were both categorized as “rural.” Students who spent most of their time in rural locations before their 18th birthday, according to data reported in medical school applications, were considered students with rural backgrounds.
RESULTS
National effect
National comparative data provided by CAPER (Table 1) found that 26.9% of MUN’s family medicine program graduates were practising in a rural location 2 years after exiting their post-MD training from 2004 to 2013 compared with the national rate of 13.3%.12
Practice entry cohort, 2004 to 2013, completing family medicine programs who are located in Canada in 2 years after exiting post-MD training, by practice location
Provincial effect
Figure 1 shows the locations of all MUN MD graduates practising family medicine in Newfoundland and Labrador as of January 2015 (N = 305). As Figure 1 shows, 22% of these graduates are practising in rural communities and 14% are practising in rural towns.
Map showing locations of all MUN MD graduates practising FM in Newfoundland and Labrador as of January 2015: N = 305.
FM—family medicine, MD—medical doctor, MUN—Memorial University of Newfoundland.
Commitment to a comprehensive pathways approach
Data on MUN’s 2011 and 2012 MD graduating classes demonstrate that of 114 students with known backgrounds, 32% had rural backgrounds. Memorial 2011 and 2012 MD graduates spent 20% of all clinical placement weeks in rural areas; of note, 90% of all first-year placements and 95% of third-year family medicine clerkship placements were rural. While the proportion was lower in second year, it still remained fairly high, with 57% of all second-year placements being rural. Figures 2, 3, and 4 show total placement weeks in all location types for MUN’s 2011 and 2012 MD graduates. For the 25 MUN 2011 and 2012 MD graduates who also completed family medicine residencies at MUN, 38% of family medicine residency placement weeks were spent in rural communities or rural towns. Of the 30 MUN 2011 and 2012 MD graduates practising family medicine in Canada as of January 2015, 42% were practising in rural communities or rural towns; 73% were practising in Newfoundland and Labrador and half of those were in rural communities and rural towns. Figure 5 shows practice locations of these graduates practising family medicine in Newfoundland and Labrador as of January 2015.
Map showing total year-1 and year-2 medical student clinical placement weeks spent in all location types for MUN MD in 2011 and 2012 graduating classes
MD—medical doctor, MUN—Memorial University of Newfoundland.
Map showing total year-3 clerkship placement weeks spent in all location types for MUN 2011 and 2012 MD graduates
FM—family medicine, MD—medical doctor, MUN—Memorial University of Newfoundland.
Map showing total postgraduate placement weeks spent in all location types for MUN FM residents from its 2011 and 2012 MD graduating classes
FM—family medicine, MD—medical doctor, MUN—Memorial University of Newfoundland.
Map showing practice locations for MUN 2011 and 2012 MD graduates practising FM in Newfoundland and Labrador as of January 2015
FM—family medicine, MD—medical doctor, MUN—Memorial University of Newfoundland.
DISCUSSION
Both external and internal measures indicate continuing success from MUN’s commitment to a comprehensive pathways approach to developing family physicians for rural generalist practice.
Compared with other Canadian medical schools, MUN is very successful at producing rural family physicians. With data from CAPER, this study found that the MUN family medicine program consistently produces doctors who establish rural practice locations; 26.9% of MUN family medicine program graduates were in a rural practice location 2 years after exiting their post-MD training from 2004 to 2013 compared with national rate of 13.3% (Table 1).12
This study finding is consistent with other external measures, most notably research compiled by the Society of Rural Physicians of Canada (SRPC). The SRPC uses CAPER and Canadian Medical Association data files to determine the percentage of physicians in rural practice 10 years after completing their postgraduate family medicine training to determine its annual Keith Award recipient, which is awarded to the university with the highest percentage of such physicians. Memorial received the Keith Award in 2016 (38.9% compared with the national average of 18.8%), in 2013 (43.8% vs 20%), and in 2010 (52% vs 20.9%) (SRPC, unpublished data).
Memorial’s social accountability mandate was developed in response to its location in Newfoundland and Labrador. This mandate includes a focus on training family medicine physicians for the special challenges and opportunities of rural generalist practice. Memorial has demonstrated success in fulfilling its provincial social accountability mandate.9,14,15 By 2014, 78% (approximately 638 of approximately 818) of the fully licensed physicians in Newfoundland and Labrador were MUN MD graduates. In addition, most of the remaining fully licensed physicians who were graduates of other medical schools had completed their postgraduate vocational residency training at MUN. Between 2004 and 2014, the number of MUN MD graduates with a full license to practise in Newfoundland and Labrador increased from about 406 to about 638, an increase of 60% over the decade.
Memorial is very successful in training family physicians for Newfoundland and Labrador, including rural family physicians, in response to its social accountability mandate. This study found that 305 of MUN MD graduates were practising family medicine in Newfoundland and Labrador, with 36% practising in rural areas (22% in rural communities and 14% in rural towns). In comparison, in 2013 to 2014, 14% of all family medicine physicians in Canada were practising in rural or remote areas.16
As demonstrated by the high proportion of students with rural backgrounds, the high proportion of clinical learning that takes place in rural locations within the MD and postgraduate family medicine programs, and the proportion of recent family medicine graduates establishing rural practice in Newfoundland and Labrador, MUN remains fully committed to a comprehensive rural pathways approach to rural family practice that emphasizes rural experience and contextual learning. This study examined 2 full cohorts of medical students and found that 32% of MUN 2011 and 2012 MD graduates came from rural areas, 90% completed their first-year medical student clinical placement in a rural location, 57% completed their second-year medical student family medicine placement in a rural location, and 95% completed their third-year medical student family medicine placement in a rural location. Additionally, for those MUN 2011 and 2012 MD graduates who completed their family medicine residencies at MUN, 38% of their residency placement weeks took place in rural locations. Since this study, the MUN family medicine residency program has increased the proportion of rural placements with an emphasis on longitudinal community placements within geographic streams.
Fifty percent of MUN 2011 and 2012 MD graduates practising family medicine in Newfoundland and Labrador are practising in rural locations. This study thus shows that MUN’s most recent graduates are continuing the strong tradition of establishing rural practice in Newfoundland and Labrador and thus contributing to addressing a critical need in the province and fulfilling the medical school’s social accountability mandate.
As MUN’s L&L database is still growing, the numbers examined in the current study are small, yet they indicate continued success in training physicians for practice in rural areas across the country. Within a few years, the numbers will allow MUN to study the interplay and relative importance of the different component factors along the MUN pathways to rural practice.
Limitations
This study is limited in that it focuses on one university’s medical school in a province with unique demographic and geographic characteristics, which means that the data might not be generalizable to other provinces in Canada or locations outside the country. Also, it does not address the qualitative factors that might affect the choice to enter rural practice: supports during the transition, issues related to workload, and spousal or family considerations. While a medical school might not be able to control or influence such lifestyle or practice factors, their importance might be notable when considering how a medical school supports the transition from residency to practice.
Conclusion
This study clearly demonstrates that MUN is committed to an integrated pathways approach to training physicians for rural practice. The cumulative effect of focusing on recruiting rural students through admissions and subsequently exposing all undergraduate medical students to extensive rural placements and all family medicine residents to rural family practice training results in an increased number of generalist physicians in rural family practice in Newfoundland and Labrador and across Canada.
Newfoundland and Labrador, like other Canadian provinces and territories, continues to recruit family doctors from underresourced countries. One important implication of the results of this study is that this dependence can be reduced over time through the recruitment of rural students and the implementation of a strong rural curriculum in medical school followed by rural family medicine residency programs. To accelerate this effect, the province funded an MD class size expansion and corresponding family medicine residency program capacity emphasizing long rural learning experiences. This study— and the rural-focused approach at MUN—provides a positive example for other jurisdictions seeking to increase capacity to produce rural physicians.
Acknowledgments
We thank Dr Shabnam Asghari and Mr Oliver Hurley for their help with revisions. And we thank Ms Lynda Buske and Les Forward for their help with the Canadian Post-MD Education Registry data. There was no external source of funding for this paper; however, the initial Learners and Locations project was funded by a grant from Health Canada.
Notes
Editor’s key points
▸ Memorial University of Newfoundland (MUN) is committed to training family medicine physicians for the special challenges and opportunities of rural generalist practice. To train these physicians, MUN has implemented a comprehensive “pathways” approach that focuses on recruiting students through a targeted admissions process and subsequently exposing all undergraduate medical students to extensive rural placements and all family medicine residents to rural family practice training.
▸ As demonstrated by the high proportion of students with rural backgrounds, the high proportion of clinical learning that takes place in rural locations within the medical doctor and postgraduate family medicine programs, and the high proportion of recent family medicine graduates establishing rural practice in Newfoundland and Labrador, MUN remains fully committed to a comprehensive rural pathways approach that emphasizes the rural experience and contextual learning. This study shows that many MUN medical doctor graduates are continuing the strong tradition of establishing rural practice in Newfoundland and Labrador and thus contributing to addressing a critical need in the province and fulfilling MUN’s social accountability mandate.
Points de repère du rédacteur
▸ À l’Université Memorial de Terre-neuve (UMT), on est déterminé à former des médecins de famille qui pourront répondre aux problèmes particuliers de la pratique généraliste en milieu rural et à accepter d’y travailler. Afin de former de tels médecins, l’UMT a instauré une voie d’accès particulière qui comprend un recrutement ciblé des étudiants suivi d’une exposition de tous les étudiants du premier cycle de médecine à des stages en région rurale et de tous les résidents en médecine familiale à une formation en médecine rurale.
▸ Comme l’indiquent le grand nombre d’étudiants avec un passé rural, la forte proportion de l’enseignement clinique qui se donne en milieu rural et le nombre élevé des récents diplômés en médecine familiale qui choisissent de pratiquer en milieu rural à Terre-Neuve et au Labrador, l’UMT demeure entièrement déterminée à utiliser une voie d’accès privilégiée à la médecine rurale, qui met l’accent sur un passé rural et sur une formation appropriée. Cette étude montre qu’un grand nombre de diplômés en médecine à l’UMT poursuivent la tradition provinciale d’adopter une pratique rurale, contribuant ainsi à corriger une situation provinciale critique, tout en aidant l’UMT à remplir son mandat de responsabilité sociale.
Footnotes
Contributors
All authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
- Copyright© the College of Family Physicians of Canada
