Rural Physicians Research Articles

Medical learner perspectives on elements of an educational rural generalist pathway: survey outcomes

IntroductionThe Northern Ontario School of Medicine University (NOSM U) continues to be challenged in meeting its social accountability mandate of addressing the rural health human resource crises in its catchment of Northern Ontario. Its new educational initiative, the Rural Generalist Pathway (RGP) aims to graduate family physicians specifically prepared for rural practice. This study elicits the perspective of NOSM U learners on the various components being considered for this educational pathway.MethodsA mixed methods survey was created for each of two medical learner groups, undergraduate NOSM U students and its family medicine residents. Quantitative data was analyzed for frequencies and percentages and qualitative data underwent thematic analysis.ResultsWith a response rate of 24.6% for undergraduates and 37.9% for residents, the survey discovered undergraduates consider rural clinical rotations as the most valuable experiences in rural medicine. Among the findings, both the majority of medical students and residents (87.3% and 87.9% respectively) agreed that support for a resident’s family well-being and community integration was the element of the pathway most likely to influence them in pursuing the RGP. Mentorship by a practicing rural physician was an element highly supported by 81% of undergraduate and 81.8% of postgraduate learners as likely to influence them to take the RGP.DiscussionIncorporating learner perceptions into the development of the RGP could help focus institutional resources and enhance learner participation in this pathway, producing more rural family doctors to serve Northern Ontario.

Gender Differences in Planned Retirement Age Among Medical Students: Are Changes on the Horizon?

ABSTRACT Gender Differences in Planned Retirement Age Among Medical Students: Are Changes On the Horizon? Purpose Planned age of retirement has an important effect on the physician workforce. Earlier studies of practicing physicians have reported that the planned as well as actual retirement age was significantly younger for women. Also, previous reports had shown that rural physicians tended to retire earlier. This paper offers a view earlier in the physician pipeline and reports surveys of medical students and pre-medical college students concerning their retirement plans. Methods During 2015-2019, 70 college students and 41 medical students at a regional rural medical campus completed a career eulogy that included their planned retirement age. Results Combining both groups of students, women planned to retire at a mean age of 61.9 and men at 59.1, P=0.048. A longitudinal comparison of just medical students showed that prematriculation students just before starting medical school had the oldest planned age of 66.9, compared to college students (57.4 to 58.9) and medical students (64.0 to 64.6), P=0.049. There was no difference in planned retirement age in rural vs urban upbringing. Conclusions In this group of pathways students, women planned to retire almost 3 years later than men, which differs from earlier reports of physicians in practice. The men planned retirement almost 5 years earlier than in previous reports of planned retirement age. There was no difference in rural vs urban upbringing. Whether this is a generalizable finding will require similar studies in different student populations on other campuses, and our survey instrument is available for others to look deeper into the process of professional identity formation that may explain any differences in planned retirement age.

Training satisfaction and future employment consideration among physician and nursing trainees at rural Veterans Affairs facilities in the United States during COVID-19: a time-series before and after study

The coronavirus disease 2019 (COVID-19) pandemic limited healthcare professional education and training opportunities in rural communities. Because the US Department of Veterans Affairs (VA) has robust programs to train clinicians in the United States, this study examined VA trainee perspectives regarding pandemic-related training in rural and urban areas and interest in future employment with the VA. Survey responses were collected nationally from VA physicians and nursing trainees before and after COVID-19 (2018 to 2021). Logistic regression models were used to test the association between pandemic timing (pre-pandemic or pandemic), trainee program (physician or nurse), and the interaction of trainee pandemic timing and program on VA trainee satisfaction and trainee likelihood to consider future VA employment in rural and urban areas. While physician trainees at urban facilities reported decreases in overall training satisfaction and corresponding decreases in the likelihood of considering future VA employment from pre-pandemic to pandemic, rural physician trainees showed no changes in either outcome. In contrast, while nursing trainees at both urban and rural sites had decreases in training satisfaction associated with the pandemic, there was no corresponding effect on the likelihood of future employment by nurses at either urban or rural VA sites. The study’s findings suggest differences in the training experiences of physicians and nurses at rural sites, as well as between physician trainees at urban and rural sites. Understanding these nuances can inform the development of targeted approaches to address the ongoing provider shortages that rural communities in the United States are facing.

A Lifelong Commitment: The Story of Dr. Kisu Song and His Impact on Korean Healthcare.

Dr. Kisu Song, an allopathic medical doctor specializing in general surgery, significantly impacted South Korean medicine and healthcare through his lifelong dedication to serving rural communities. Born on December 25, 1939, during the Japanese colonial period, Dr. Song witnessed the tumultuous transformation of Korea from a colonized nation to a divided one. His early life was marked by the Japanese colonial period and the Korean War and its aftermath, which influenced his decision to pursue medicine over law, a choice guided by the pressing needs of his community and his father's legacy. This biography explores Dr. Song's journey from a young student in a war-torn country to a pioneering rural physician in South Korea. His contributions, particularly in underserved areas, exemplify his profound commitment to healthcare and community service.

Predictors of a positive attitude towards rural practice in female osteopathic medical students.

Women outnumber men in medical school. Given the growing need for rural physicians and the underrepresentation of women in rural medicine, understanding predictors of rural practice among female students is imperative for addressing future healthcare workforce shortages in rural areas. Utilizing current evidence, medical schools should seek to admit students with a rural background and interest in pursuing a primary care specialty; however, whether this holds true for female osteopathic medical students is unknown. This study aims to determine if a rural background, a plan to practice family medicine, and motivation toward civic duty are associated with attitudes toward eventual practice of rural medicine in female osteopathic medical students. An anonymous online survey was administered to actively enrolled female students at Arkansas Colleges ofHealth Education College of Osteopathic Medicine. The survey assessed the respondents' presence of a rural background, degree of civic-mindedness, intention to practice family medicine, and attitudes to rural work and life. Demographics of ethnicity and year of study in medical school were also collected. In total, 129 students responded to the survey, with 97 complete responses for analysis. Hierarchical regression was utilized to compare nested models and interpret interactions. Of the 97 survey respondents, 34.0 % described themselves as first-year students, 37.1 % as second-year students, 16.5 % as third-year students, and 12.4 % as fourth-year students. Linear regression modeling indicated that for female medical students at Arkansas Colleges of Health Education, having a rural background had no relationship with their attitude toward practicing in a rural setting, β=-0.97, standard error (SE)=1.96, t=-0.49, p>0.05, CI [-4.86, 2.92]. Civic-mindedness had a positive relationship with their attitude toward practicing in a rural setting, β=0.17, SE=0.07, t=2.44, p=0.016, CI [0.03, 0.31], accounting for 4.57 % of its variance. Plan to practice family medicine was positively associated with a student's attitude toward practicing in a rural setting, β=4.38, SE=0.85, t=5.15, p<0.001, CI [2.69, 6.07], accounting for 20.25 % of its variance. Civic-mindedness appeared to moderate the relationship between planning to practice family medicine and attitudes toward practicing in a rural setting, F(1, 91) = 3.91, p=0.05, R 2=0.31. The p value for this interaction term was 0.05, but its effect size measure and graphical representation revealed a substantive effect. The regression analysis showed that, for thewomen in this study, the greater the student's civic-mindedness, the more favorable her attitude toward practicing in a rural setting. Additionally, the stronger thestudent's plan to practice family medicine, the more favorable her attitude toward eventual rural practice was. Lastly, the student's civic-mindedness influenced the predictive value of having a plan to practice family medicine.

Evolution of the roles of family physicians through collaboration with rehabilitation therapists in rural community hospitals: a grounded theory approach

BackgroundThe role of rural family physicians continues to evolve to accommodate the comprehensive care needs of aging societies. For older individuals in rural areas, rehabilitation is vital to ensure that they can continue to perform activities of daily living. In this population, a smooth discharge following periods of hospitalization is essential and requires management of multimorbidity, and rehabilitation therapists may require support from family physicians to achieve optimal outcomes. Therefore, this study aimed to investigate changes in the roles of rural family physicians in patient rehabilitation.MethodsAn ethnographic analysis was conducted with rural family physicians and rehabilitation therapists at a rural Japanese hospital. A constructivist grounded theory approach was applied as a qualitative research method. Data were collected from the participants via field notes and semi-structured interviews.ResultsUsing a grounded theory approach, the following three themes were developed regarding the establishment of effective interprofessional collaboration between family physicians and therapists in the rehabilitation of older patients in rural communities: 1) establishment of mutual understanding and the perception of psychological safety; 2) improvement of relationships between healthcare professionals and their patients; and 3) creation of new roles in rural family medicine to meet evolving needs.ConclusionEnsuring continual dialogue between family medicine and rehabilitation departments helped to establish understanding, enhance knowledge, and heighten mutual respect among healthcare workers, making the work more enjoyable. Continuous collaboration between departments also improved relationships between professionals and their patients, establishing trust in collaborative treatment paradigms and supporting patient-centered approaches to family medicine. Within this framework, understanding the capabilities of family physicians can lead to the establishment of new roles for them in rural hospitals. Family medicine plays a vital role in geriatric care in community hospitals, especially in rural primary care settings. The role of family medicine in hospitals should be investigated in other settings to improve geriatric care and promote mutual learning and improvement among healthcare professionals.

Rural physician recruitment program in Thailand: factors associated with medical student enrollment and post-graduation intentions

Objectives: Thailand’s Collaborative Project to Increase Production of Rural Doctor (CPIRD) recruits students with a rural background and provides clinical year training in provincial teaching hospitals. We studied the main reasons for students attending this rural recruitment project and their intention to work in rural areas. Methods: In 2018, 2,870 4th–6th year medical students from 34 teaching hospitals under the CPIRD were sent a questionnaire surveying the following factors: their gender; year of study; size of the teaching hospital in which they were training; a domicile of origin and the province where they attended a high school; parent’s occupation; family income and main reasons for choosing to attend the CPIRD rural medical schools, as well as their attitudes towards rural job placement. Factors associated with a student's intention to work in rural areas were also examined, using multiple logistic regression. Results: 1,349 (47%) students responded. 809 (60%) were female, 914 (68%) had adequate family income, 519 (38%) had a domicile of origin in rural areas, 247 (18%) had either a mother or father being health professionals. The top three main reasons for choosing to attend the rural medical schools were: intention to return to work in their hometown(32%); student recruitment being less competitive (18.5%); and pre-specified job placement in their home districts (15%). Medical students who had a domicile of origin in rural areas, CPIRD recruitment track, and trained in medium and small-sized teaching hospitals had higher intention to work in rural areas, with Odds ratio of 1.51 (95% confidence interval (CI) 1.06-2.15), 4.39 (95%CI 3.02-6.39), 1.54 (95% CI 1.09-2.17) and1.74 (95% CI 1.14-2.65), respectively. 1,283 (95%) medical students had a favorable attitude towards rural placement after their graduation. Conclusion: Students´ rural background and training in provincial teaching hospitals may enhance their intention to start and remain working in rural healthcare services.

Knowledge Gaps Identified in a Survey of Maine Physicians' Firearm Safety Counseling Practices.

Numerous medical associations have identified firearm injuries as a public health issue, calling on physicians to provide firearm safety counseling. Data suggest that while many physicians agree with this, few routinely screen and provide counseling. We aimed to survey Maine physicians to assess their current firearm safety counseling practices and knowledge of a new state child access prevention (CAP) law. We conducted an anonymous cross-sectional survey of Maine primary care and psychiatry physicians. We recruited multiple statewide medical organizations, residency programs, and two major health systems to distribute the survey to their membership. Group differences were compared by physician rurality and years in practice using Fisher's Exact and Chi Squared tests. Ninety-five surveys were completed. Though most participants agreed that firearm injury is an important public health issue that physicians can positively affect (92%), few had received prior firearm safety counseling education (27%). There were significant differences in firearm screening frequency, with rural physicians screening more often. More rural physicians and physicians with > 10 years of clinical practice felt they had adequate knowledge to provide meaningful counseling, compared with non-rural and early career physicians, respectively. Overall, 62% of participants were unaware of the 2021 Maine CAP law. This study highlights significant differences in firearm safety counseling practices among Maine physicians based on rurality and years of experience. Participants also reported a significant gap in knowledge of a recent state child access prevention law. Next steps include development of firearm safety counseling education tailored to Maine physicians.

The output of cataract surgery performed by trained non-ophthalmologist physicians in rural areas: study of cataract outcomes and up-take of services report 7.

Cataract is the leading cause of blindness worldwide and surgery can restore vision in most patients. Some patients have little access to surgical services due to lack of cataract surgeons and the unaffordable costs. In 2005 we built a service model that trained rural non-ophthalmologist physicians to perform cataract surgeries in rural China. This study evaluates the long-term impacts of this model. We conducted a retrospective cohort study to analyze patients' hand-written medical records and electronic outpatient record between January 2005 and December 2019 at two rural health clinics in Southern China. In total, 34,601 patients (49,942 eyes) underwent cataract surgery by non-ophthalmologist physicians from 2005 to 2019.Visual acuity was clearly documented in 38,251 eyes. Before surgery, the unaided distance visual acuity (UDVA) of 60.7% (23,205/38,251) eyes was less than 0.05 decimal. On the first day after surgery, the percentage of UDVA < 0.05 eyes was reduced to 6.0%, and 96.7% (36,980/38,251) of the eyes achieved a better UDVA compared to pre-operation. Surgical-related complications occurred in 218 eyes. The most common complication was posterior capsule rupture (114, 0.23%). 44.3% (15,341/34,601) of the patients chose to have a second eye cataract surgery (SECS) in the same clinic. At one of the outpatient clinics, 21,595 patients received basic eye care apart from cataract surgery between 2018 and 2020. Non-ophthalmologist physicians trained for cataract surgeries in rural clinics can improve cataract related visual acuity and basic eye care to the local population.

Changes in outpatient antibiotic prescriptions by U.S. physicians and advanced practice providers, 2011 and 2022

Background: The number of advanced practice providers (APPs)—nurse practitioners (NPs) and physician assistants (PAs)—continues to expand across the United States. Several studies suggest differences in antibiotic prescribing rates and appropriateness by APPs compared to physicians. The objective of this analysis is to characterize population- and provider-specific outpatient antibiotic prescribing rates among physicians and APPs nationally, by state, and within urban versus rural counties. Methods: We estimated outpatient oral antibiotic prescription rates for 2011 and 2022 using county-level prescription dispensing data from IQVIA Xponent® (numerator) and population census estimates (denominator). Provider specialty denominators were provided by IQVIA, based on data from the American Medical Association. Counties were classified as urban or rural per the 2013 National Center for Health Statistics classification. National and state-level prescription volume, rates per 1000 population, and average number of prescriptions per provider were calculated for physicians, NPs, and PAs. We assessed the degree to which provider-specific rates explained the variance of the overall rate by state, using the coefficient of determination (r2) from Pearson’s correlation. Results: Between 2011 and 2022, overall U.S. antibiotic prescribing declined from 877 to 709 per 1000 population, a 19.2% relative reduction. The provider-specific proportion of the overall prescribing rate relatively decreased by 32% for physicians but increased by 157% for APPs (NPs 229%, PAs 86%; Figure 1). State-level antibiotic prescribing rates varied by provider type for both years, shifting towards proportionally greater APP prescribing in 2022 (Figure 2). For 2011 and 2022, physician prescribing rate strongly correlated with the overall state rate (r2 = 0.83 in 2011 versus 0.80 in 2022), whereas the correlation of the NP prescribing rate increased (r2 = 0.20 in 2011 versus 0.76 in 2022). A total of 60,327 (7.2%) physicians practiced in rural settings in contrast to 42,876 (12%) NPs and 14,495 (9.4%) PAs in 2022. Providers in rural counties prescribed more antibiotics per provider on average compared to urban counties; rural physicians prescribed 57% more antibiotics per provider (207 vs 132 antibiotics per provider), rural NPs prescribed 115% more (284 vs 132), and rural PAs prescribed 53% more (289 vs 189). Conclusions: The relative contribution of APPs to outpatient antibiotic prescriptions more than doubled over the past decade, accounting for 1 in 3 prescriptions in 2022. This contribution was especially prominent among NPs in rural counties. Further evaluation of antibiotic prescribing appropriateness among APPs and integration of APPs into antibiotic stewardship efforts in various settings.

Rural physician-community engagement: Building, supporting and maintaining resilient health care strategies in three rural Canadian communities.

To explore rural physician-community engagement through three case studies in order to understand the role that these relationships can play in increasing community-level resilience to climate change and ecosystem disruption. Qualitative secondary case study analysis. Three Canadian rural communities (BC n = 2, Ontario n = 1). Rural family physicians and community members. Twenty-eight semi-structured virtual interviews, conducted between November 2021 and February 2022, were included. Communities were selected from the larger data set based on data availability, level of physician engagement and demographic factors. Thematic analysis was completed in NVivo using deductive coding. The presented qualitative case studies shed light on the strategies employed by physicians to establish and foster relationships within rural communities during challenging circumstances. In Community A, the implementation of a Primary Care Society (PCS) not only addressed physician shortages but also facilitated the development of strong continuity of care through proactive recruitment efforts. Community B showcased the adoption of an 'intentional physician community' model, emphasising collaboration and community consultation, resulting in effective communication of public health directives and innovative interdisciplinary action during the COVID-19 pandemic. In Community C, engaged physicians and community advocates are aligned to contribute to the long-term sustainability of the rural community, particularly in the context of food security and climate change vulnerabilities. These findings underscore the significance of trust building, transparent communication and collaboration in addressing health care challenges in rural areas and emphasise the need to recognise and support physicians as agents of change.

Level of competence of rural physicians in primary health care in the diagnosis of malignant neoplasms of main localizations

Objective. To analize the level of rural PHC doctors` competence on the issues of diagnosis and routing patients with suspected cancer. Materials and methods. The study was conducted using a survey of medical workers involved in the diagnosis of malignant neoplasms of four main localizations (specialist doctors and paramedics of examination rooms) of the Central District Hospital of five rural municipal districts of the Magnitogorsk oncological cluster of Chelyabinsk region. 35 physicians took part in the study. Results. The results of the survey were quite negative: the minority of respondents are aware of the exact duration of the mandatory initial diagnostic examination, the period of informing the oncologist about the patient diagnosed with cancer, and the scheme for assigning municipal medical organizations to outpatient oncology centers. Conclusions. The surveyed contingent is characterized by: low oncological alertness and unsatisfactory competence concerning the initial manifestations of malignancies; inclusion of symptoms of the formed cancer in the number of early manifestations of malignancies, which means that a doctor, unsure of the diagnosis, as if waiting for the appearance of an obvious, from his point of view, symptom of a tumor, and as a result, the patient has an advanced stage of cancer; 3) flawed ideas about the full list of necessary methods for diagnosing malignant neoplasms of leading localizations; unsatisfactory knowledge of regulatory documentation on the routing of patients with suspected cancer.

Rural comprehensive cancer care: Qualitative analysis of current challenges and opportunities.

While limited resources can make high-quality, comprehensive, coordinated cancer care provision challenging in rural settings, rural cancer patients often rely on local hospitals for care. To develop resources and strategies to support high-quality local cancer care, it is critical to understand the current experiences of rural cancer care physicians, including perceived strengths and challenges of providing cancer care in rural areas. METHODS: Semi-structured interviews were conducted with 13 cancer providers associated with all 12 non-metropolitan/rural Iowa hospitals that diagnose or treat >100 cancer patients annually. Iterative thematic analysiswas conducted to develop domains. Participants identified geographic proximity and sense of community as strengths of local care. They described decision-making processes and challenges related to referring patients to larger centers for complex procedures, including a lack of dedicated navigators to facilitate and track transfers between institutions and occasional lack of respect from academic physicians. Participants reported a desire for strengthening collaborations with larger urban/academic cancer centers, including access to educational opportunities, shared resources and strategies to collect and monitor data on quality, and clinical trials. Rural cancer care providers are dedicated to providing high-quality care close to home for their patients and would welcome opportunities to increase collaboration with larger centers to improve coordination and comprehensiveness of care, collect and monitor data on quality of care, and access continuing education opportunities. Further research is needed to develop implementation approaches that will extend resources, services, and expertise to rural providers to facilitate high-quality cancer care for all cancer patients.

An "integration" of professional identity formation among rural physicians experiencing an interplay between their professional and personal identities.

The present understanding of professional identity formation is problematic since it underrepresents minority physicians and potentially excludes their professional identity formation experiences. Rural physicians are expected to have similar underrepresented aspects as minority physicians because of their specific sociocultural contexts and consequent private-professional intersection, which lead to ethical complexities. Therefore, to bridge this research gap, we interviewed 12 early- to mid-career Japanese physicians working in rural areas and explored their experiences. Through a narrative analysis guided by Figured Worlds theory, we analysed the data by focusing on the vocabulary, expressions, and metaphors participants used to describe their experiences. A central theme emerged concerning how the rural physicians configurated their personal versus professional participation in their local communities. Further, their identity narratives varied regarding how they constructed their identities, rural communities, and relationships as well as their identity formation ideals and strategies to achieve them. Informed by 'Big Questions' concerning worldview framework, we delineated four identity narratives as prototypes to describe how they participated in their communities. These identity narratives provide a preliminary understanding of how diverse identity formation is for rural physicians. In addition, our findings exposed the current professional identity formation framework as potentially biased towards single forms of participation in monolithic communities, overlooking complicated forms of participation in multiple communities. We argue that applying frameworks and concepts to capture these multiple forms of participation as well as revisiting the 'discourse of integration' are necessary steps to overcome the limitation of the current understanding of professional identity formation.

Academic Medicine and Rural Health System Partnerships: Enhancing Education While Advancing Physician Workforce Priorities.

A worsening shortage of rural physicians paralleling increasing health disparities demands attention. Past and ongoing efforts to address this shortage have had positive effects and can inform new strategies to achieve even greater impact. Interventions have included the development of regional medical school campuses and rural-focused tracks to recruit medical students from rural areas, expansion of rural-based graduate medical education (GME) programs and tracks, and use of institutional and individual financial incentives for rural-based training and/or practice. National policy has also taken aim at this challenge with provisions aimed at expanding rural GME in the Medicare, Medicaid, and State Children's Health Insurance Program Balanced Budget Refinement Act of 1999 and the Consolidated Appropriations Act of 2021. Additionally, several states have funded growth in GME, and supportive pathways for Medicare reimbursement and for Veterans Administration funding have been implemented. The authors recommend a new strategy for bolstering the rural physician workforce, focused on using academic-rural partnerships to incorporate rural rotations as a routine part of GME. They explain how the current health care landscape supports this approach and outline additional steps toward implementation. Centralized data collection and analysis are noted as essential to guide future efforts.

Rural healthcare professionals’ participation in Medical Assistance in Dying (MAiD): beyond a binary decision

BackgroundMedical Assistance in Dying (MAiD) was legalized in Canada in 2016 and amended in 2021. At the time that this study was conducted, the federal government was considering expanding the eligibility criteria to include patients whose death was not reasonably foreseeable. The purpose of this study was to better understand rural healthcare professionals’ experiences with assisted dying set against the backdrop of legislative expansion.MethodsA qualitative exploratory study was undertaken with general rural practice physicians, nurse practitioners, registered nurses, ethicists, patients, and patient families in rural Southern Alberta, Canada. For this paper, data from 18 audio-recorded and transcribed semi-structured interviews with healthcare professionals were analyzed using thematic analysis. Categories and patterns of shared meaning that linked to an overarching theme were identified.ResultsBetween the binary positions of full support for and conscientious objection to assisted dying, rural healthcare professionals’ decisions to participate in MAiD was based on their moral convictions, various contextual factors, and their participation thresholds. Factors including patient suffering; personal and professional values and beliefs; relationships with colleagues, patients and family, and community; and changing MAiD policy and legislation created nuances that informed their decision-making.ConclusionsThe interplay of multiple factors and their degree of influence on healthcare professionals’ decision-making create multiple decision points between full support for and participation in MAiD processes and complete opposition and/or abstention. Moreover, our findings suggest evolving policy and legislation have the potential to increase rural healthcare professionals’ uncertainty and level of discomfort in providing services. We propose that the binary language typically used in the MAiD discourse be reframed to reflect that decision-making processes and actions are often fluid and situational.

How early clinical experiences in rural communities influence student learning about rural generalism considered through the lens of educational theory.

Rural communities have poorer health compared to urban populations due partly to having lesser healthcare access. Rural placements during medical education can equip students with the knowledge and skills to work in rural communities, and, it is hoped, increase the supply of rural physicians. It is unclear how students gain knowledge of rural generalism during placements, and how this can be understood in terms of place-based and/or sociocultural educational theories. To gain insight into these questions we considered the experiences of pre-clerkship medical students who completed two mandatory four-week rural placements during their second year of medical school. Data was collected using semi-structured interviews or focus groups, followed by thematic analysis of the interview transcripts. Rural placements allowed students to learn about rural generalism such as breadth of practice, and boundary issues. This occurred mainly by students interacting with rural physician faculty, with the effectiveness of precepting being key to students acquiring knowledge and skills and reporting a positive regard for the placement experience. Our data show the central role of generalist physician preceptors in how and what students learn while participating in rural placements. Sociocultural learning theory best explains student learning, while place-based education theory helps inform the curriculum. Effective training and preparation of preceptors is likely key to positive student placement experiences.

The impact of incentive scheme on rural healthcare workforce availability: a case study of Kazakhstan

BackgroundDuring the 1990–2000, Kazakhstan experienced a decline in the number of healthcare professionals working in rural areas. Since 2009, the national government has been implementing financial incentives to encourage healthcare professionals to relocate to rural areas. This study aims to investigate the temporal and spatial patterns in the distribution of the rural healthcare workforce and evaluate the impact of this incentive scheme.MethodsInterrupted Time Series Analysis using ARIMA models and Difference in Differences analyzes were conducted to examine the impact of the incentive scheme on the density of different categories of the healthcare workforce in rural Kazakhstan in the period from 2009 to 2020.ResultsThere was a significant increase in the number of rural healthcare professionals from 2009 to 2020 in comparison to the period from 1998 to 2008. However, this increase was less pronounced in per capita terms. Moreover, a decline in the density of internists and pediatricians was observed. There is substantial variation in the density of rural nurses and physicians across different regions of Kazakhstan. The incentive scheme introduced in 2009 by the government of Kazakhstan included a one-time allowance and housing incentive. This scheme was found to have contributed insignificantly to the observed increase in the number of rural healthcare professionals.ConclusionFuture research should be undertaken to examine the impact made by the incentive scheme on other medical subspecialties, particularly primary practitioners. Addressing the shortage of healthcare workers in rural areas is a complex issue that requires a multifaceted approach. Aside from financial incentives, other policies could be considered to increase relocation and improve the retention of healthcare professionals in rural areas.

Erratum: Pan-Canadian licensure: Potential impact on the rural physician workforce.

Erratum: Pan-Canadian licensure: Potential impact on the rural physician workforce.

How the training pathways and capacity of rural physicians inform their scope of practice: A qualitative study examining the experiences of Australian and international medical graduates in South-East New South Wales, Australia.

Current strategies to address shortages of rural doctors focus on developing a pipeline for rural generalist practice. Limited research has explored how doctors' professional journey engenders the skills required to practice rurally. This paper analyses how rural general practitioners' clinical pathway informs their scope of practice and future retention. Qualitative thematic analysis using semi-structured telephone interviews. Twenty-one general practitioners appointed in their local health district of Murrumbidgee and Southern New South Wales, Australia, within the past 10 years. Participants comprised 10 Australian medical graduates (AMG) and 11 international medical graduates (IMG). AMGs and IMGs contrasted how their pathway into rural practice, and capacity to work rurally, informed their scope of practice. Australian medical graduates' familiarity with rural areas was consolidated through congruous experiences, including at rural clinical schools. Paradoxically, the fluency of their training limited the amount of unsupervised experience and confidence AMGs gained. Together with a focus on work-life balance, this limited many to providing mainstream general practice, precluding extending their scope of practice. International medical graduates described disseminated experiences, often unsupervised in high-volume contexts. However, a lack of professional opportunities prevented them from extending their scope of practice. IMG and AMG motivation and pathway for working rurally differ. Respective cohorts have concerns regarding requisite skills and knowledge for rural practice, which incorporates opportunity and recognition. Entry points for training should be variable to allow consideration of life stage, prior skill development and extension of scope of practice. Doctors' scope of practice is informed by their pathways into rural practice. Australian medical graduates may not gain adequate competence during expedited training programs to confidently undertake extended clinical activities. International medical graduates, however lacked the opportunities and support, to utilise their expertise in rural practice. Complementarily utilising the expertise and commitment of both AMGs and IMGs may synergistically address workforce shortages.