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Can Fam Physician. 2005 September 10; 51(9): 1247. Published online 2005 September 10. | PMCID: PMC1479469 |
Factors influencing family physicians to enter rural practice Does rural or urban background make a difference? Benjamin T.B. Chan, MD, MPH, MPA, Naushaba Degani, MHSC, Tom Crichton, MD, FCFP, Raymond W. Pong, PHD, James T. Rourke, MD, FCFP, James Goertzen, MD, FCFP, and Bill McCready, MB BCH, FRCPC OBJECTIVE To examine where rural physicians grew up, when during their training they
became interested in rural medicine, factors influencing their decision to
practise rural medicine, and differences in these measures according to
rural or urban upbringing. PARTICIPANTS Rural family physicians who graduated between 1991 and 2000 from a Canadian
medical school. MAIN OUTCOME MEASURES Backgrounds of recently graduated rural physicians, when physicians first
became interested in rural practice during training, and most influential
factors in decisions to practise rural medicine. RESULTS Response rate was 59% (382/651). About 33% of rural physicians grew up in
communities of less than 10  000 people, 44% in cities of
10 000 to 499 999 people, and 23% in cities of more
than 500 000 people. Physicians raised in rural areas were more
likely than those raised in urban areas to have some interest in rural
family practice at the start and end of medical school (90% vs 67% at the
start, 98% vs 91% at the end, respectively, P
< .0001). Physicians raised in urban areas were more
likely to state that rural medical training was the most influential factor
in their choice of rural practice (19% vs 9%, P
= .015). Other factors cited as influential were the challenge of
rural practice (24% for both urban and rural upbringing), rural lifestyle
(14% for urban and 18% for rural upbringing) and, for physicians raised in
rural areas, having grown up or spent time in a rural area (27% for rural
and 4.1% for urban upbringing, P < .001).
Financial incentives were least frequently cited as the most influential
factor (7.5% for urban and 4.9% for rural upbringing, P =
.35). CONCLUSION Although other studies have suggested that physicians with a rural upbringing
are more likely to practise rural medicine and policy makers might still
wish to target students raised in rural areas as candidates for rural
medicine, this study shows that physicians raised in urban areas remain the
main source of human resources for rural communities. They account for two
thirds of new physicians in rural areas. Education in rural medicine during
medical training has a stronger influence on physicians raised in urban
areas than on physicians raised in rural areas. Undergraduate and
postgraduate training periods, therefore, offer an important opportunity for
recruiting physicians raised in urban areas to rural practice. OBJECTIF Déterminer le milieu dans lequel les médecins ruraux ont grandi, le moment de
leur formation où ils ont commencé à s’intéresser à la médecine rurale et
les facteurs qui ont influencé leur décision de pratiquer la médecine
rurale; établir si les résultats obtenus diffèrent entre ceux qui ont été
élevés en ville ou à la campagne. TYPE D’ÉTUDE Enquête postale. PARTICIPANTS Médecins de famille ruraux diplômés d’une faculté de médecine canadienne
entre 1991 et 2000. PRINCIPAUX POINTS À L’ÉTUDE Le passé des médecins ruraux récemment diplômés, le moment de leur formation
où ils ont commencé à s’intéresser à la médecine rurale et les facteurs qui
ont le plus influé sur leur décision de pratiquer à la campagne. RÉSULTATS Le taux de réponse se situait à 59% (382/651). Quelque 33% des médecins
ruraux avaient grandi dans des collectivités de moins de 10 000
habitants, 44% dans des villes de 10 000 à 499 999
habitants et 23% dans des villes de plus de 500 000 habitants.
Les médecins d’origine rurale étaient plus enclins que ceux provenant de
centres urbains à s’intéresser à la pratique familiale rurale au début et à
la fin de leurs études en médecine (respectivement 90% par rapport à 67% au
début, et 98% contre 91% à la fin, P
< ,0001). Les médecins issus de milieux urbains étaient
plus portés à dire que la formation en médecine rurale était le facteur qui
avait le plus influencé leur choix de la pratique rurale (19% par rapport à
9%, P = .015). Au nombre des autres facteurs mentionnés
figuraient les défis de la pratique rurale (24% tant chez ceux d’origine
urbaine que rurale), le mode de vie en milieu rural (14% pour les citadins
et 18% pour ceux de provenance rurale) et, pour les médecins élevés dans des
milieux ruraux, ayant grandi ou passé du temps en milieu rural (27% chez les
médecins d’origine rurale et 4,1% chez les citadins, P
< .001). Les mesures d’incitation financière étaient le
moins souvent mentionnées comme le facteur le plus influent (7,5% chez les
citadins et 4,9% chez ceux d’origine rurale, P= ,35). CONCLUSION Contrairement aux études qui suggèrent que les médecins élevés en milieu
rural ont plus de chance d’aller en pratique rurale et aux politiques des
décideurs qui voudraient encore favoriser les candidatures des étudiants
élevés en milieu rural pour cette raison, cette étude démontre que les
médecins élevés en milieu urbain demeurent le principal réservoir de
ressources humaines pour les collectivitiés rurales. Ils représentent les
deux-tiers des nouveaux médecins dans les régions rurales. Le fait d’avoir
eu une formation sur la médecine rurale durant les études médicales a plus
d’influence chez les médecins élevés en milieu urbain que chez ceux élevés
en milieu rural. Les périodes de formation au premier et au deuxième cycle
représentent donc une occasion idéale pour amener les médecins élevés en
milieu urbain à pratiquer à la campagne. EDITOR’S KEY POINTS- This study found that physicians who grew up in rural areas were more likely
to return to rural areas to practise. Most rural physicians, however,
actually come from cities and were greatly influenced by their rural
training experiences.
- For students from both urban and rural backgrounds, the challenges of rural
practice and its lifestyle had the greatest positive influence on choice of
practice location.
- Are encouraging rural applicants to apply for medicine, making exposure to
rural practice available during training, and promoting the challenges and
lifestyle of rural practice to physicians from both urban and rural
backgrounds the best strategies for recruitment to rural practice?
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POINTS DE REPÈRE DU RÉDACTEUR- Cette étude a montré que les médecins élevés en milieu rural ont plus de
chances de retourner pratiquer en région rurale. Toutefois, la plupart des
médecins ruraux proviennent des villes et ont été fortement influencés par
leur expérience de formation rurale.
- Pour les étudiants d’origine urbaine comme rurale, le défi de la pratique
rurale et de son mode de vie est le facteur le plus important dans le choix
du lieu de pratique.
- Pour améliorer le recrutement en médecine rurale, devrait-on inciter les
étudiants ruraux à se porter candidats en médecine, offrir plus de stages en
médecine rurale durant la formation, et vanter les défis et le mode de vie
de la pratique rurale auprès des médecins des milieux urbains comme
ruraux?
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Inequitable geographic distribution of physicians in countries with vast areas, such as
Canada, the United States, and Australia, has been a continuing challenge for policy
makers. Attempts have been made to encourage more doctors to practise in rural areas for
the past 40 years. These attempts have included financial incentives; recruitment
drives; offers of free tuition, access to educational resources, teaching opportunities,
and locum tenens 1; and medical education
specifically targeted at preparing doctors for rural practice. 2One factor identified as predicting rural practice has been where a physician grew up.
Studies from Canada, 3,4 the United States, 5-9 and Australia 10,11 demonstrate that people raised
in rural communities are two to four times more likely to ultimately work in rural
areas. This prompted suggestions that more young people with rural backgrounds be
admitted to medical schools. 12One of the Australian studies, 11 however, noted
that, although rural background predicts rural practice, most rural practitioners
actually did not spend any of their formative years in rural areas. This finding
suggests a great potential for bringing physicians raised in urban areas into rural
practice. We could not find any studies that explored this phenomenon in Canada. Another predictor of rural practice cited in the literature is exposure to rural
training. Graduates of both undergraduate medical programs with a rural focus 13 and postgraduate rural residency training
programs 14,15 in the United States had relatively high rates of participation in rural
practice. Choosing rural electives has also been associated with recruitment to rural
areas; this appears to have a greater effect on people raised in urban areas. 16 What is less clear is exactly when physicians
solidify a decision to engage in rural practice and whether these key decision points
vary by whether physicians were raised in rural or urban areas. Studies have also examined other factors influencing the decision to choose rural
practice. Spouses’ preferences and proximity to family also strongly influence practice
location. 17 Financial incentives influence
choice of rural practice, but have a greater effect on short-term recruitment than on
long-term retention. 18 Again, however, the
difference in degree of influence of these factors on physicians raised in rural and
urban areas remains to be clarified. This study has three objectives. First, it explores whether recently graduated Canadian
rural physicians tend to have urban or rural backgrounds, and whether, as in Australia,
most of Canada’s rural practitioners were raised in urban areas. Second, it examines
whether the time during a physician’s training at which he or she became interested in
rural medicine differs by whether the physician has a rural or urban background. Third,
it identifies the most influential factors in physicians’ decisions to practise rural
medicine and how these factors differ depending on where physicians were raised. For our survey, we developed broad questions examining the influence of rural medical
education on the decision to engage in rural practice. The survey was pilot-tested
by 10 rural family physicians who provided feedback on questions, wording, and
layout. Questions that relate to this study are listed below. - How large was the community in which you lived when you were of high school
age?
- Please rate your level of interest in rural family practice at different
stages of your training and career. (Stages of training were start of
medical school, end of medical school, and end of postgraduate training.
Levels of interest were “little or no interest in rural medicine”; “some
interest in rural medicine, but I was uncertain”; and “was certain I wanted
to practise rural medicine.”)
- How much of a positive influence did the following factors have on your
decision to work in a rural area? (Factors included rural training,
financial incentives, past exposure to rural areas, and other issues listed
as “other” factors. Respondents were asked to identify first, second, and
third most influential factors.)
Other questions examined length of exposure to rural practice during postgraduate
training and breadth of rural experiences (eg, opportunities to work in very remote
settings with no local specialist backup) and the effect of these training-program
factors on choice of rural practice. Sample size calculations indicated that all recently graduated rural family
physicians needed to be sampled in order to detect a difference in proportion of
0.10, assuming an alpha of .05, a power of .80, and a response rate of 50%.
Accordingly, we surveyed all family physicians and general practitioners in Canada
who had graduated recently (between 1991 and 2000) from Canadian medical schools and
were practising at the time of the study (2002) in rural communities (less than
10 000 people and situated outside Census Agglomeration or Census
Metropolitan areas). Potential respondents meeting these criteria were identified
from the Southam Medical Database, a commercial database widely used in Canada. A
French version of the questionnaire was sent to Francophone physicians in Quebec and
New Brunswick. Physicians received a first mailing in October 2002, then a reminder
card and a second mailing. A third mailing was done in regions where response rates
were still below 50% after the first two mailings. We tested for differences in characteristics between those with urban upbringing and
those with rural upbringing. Because outcomes of interest were categorical
variables, we used chi-square tests. In testing for differences in “other” factors,
we limited formal statistical testing to four broad categories of factors rather
than individual factors to avoid reduction in statistical power due to multiple
comparisons. Analyses were performed using SAS version 8. Ethics approval was obtained from Sunnybrook and Women’s College Health Sciences
Centre in Toronto, Ont. We surveyed 784 physicians; 133 returned questionnaires were removed due to
ineligibility. Reasons for ineligibility included not in family practice, not in
rural practice, did not graduate between 1991 and 2000, and no longer located at the
address listed in the database. This left an eligible sample of 651 physicians. The
382 completed eligible questionnaires represent an effective response rate of 59%
(382/651). The response rate was higher among Anglophones (63%) than among
Francophones (51%). Mean age of respondents was 35 years. There was no significant
difference between respondents and nonrespondents in average age or number of years
since graduation. Female physicians were more likely to return the survey than male
physicians were (65% vs 51%, P = .0004). Among respondents, one third grew up in communities of less than 10 000
people; the remainder grew up in urban communities of widely different sizes. Almost
one quarter of rural physicians grew up in cities with more than half a million
population ( Table 1). | Table 1Size of community where physicians practising in rural areas were raised |
As rural physicians progressed through training, their interest in rural medicine
increased. The proportion of respondents who were certain they wanted to practise
rural medicine rose from only 28% at the start of medical school to 77% by the end
of postgraduate training. Respondents with a rural upbringing were more likely than
those with an urban upbringing to have at least some interest in rural family
practice at the start of medical school (90% vs 67%, P
<.0001). At the end of medical school, this difference, while substantially
reduced, remained significant (98% vs 91%, P <.0001). By the
end of postgraduate training, the difference in proportion of physicians reporting
little interest in rural medicine disappears, although physicians raised in rural
areas were still more likely to report they were certain they wanted to practise
rural medicine (92% versus 71%, P < .0001). The challenge of rural medicine and enjoyment of a rural lifestyle were two of the
most important factors for physicians from both urban and rural backgrounds in the
decision to practise rural medicine (Table 2). Physicians raised in urban areas were more likely to indicate that
exposure to rural practice during medical school or residency was the most important
factor in their decision to practise rural medicine. Physicians raised in rural
areas were more likely to report that having spent time in rural areas before
university was the most important factor; among these physicians, this was most
commonly cited as the most important factor. There were no statistically significant
differences between the two types of physicians with respect to other factors. | Table 2Most important factors in deciding to practise rural medicine |
This study suggests that it is indeed possible to entice individuals who grew up in
urban areas into rural practice. Two thirds of rural physicians who responded did
not come from rural backgrounds. This finding has been noted previously in
Australia, 11 and our study now confirms
that a similar pattern exists in Canada. Those with an urban upbringing appear to be
attracted to rural medicine for a variety of reasons, including community
recruitment, challenge, a desire to serve society, and exposure during residency
training. This study also sheds new light on the timing of decisions about rural practice.
Physicians raised in rural areas have greater interest in rural medicine before
medical school than physicians raised in urban areas. Interest in rural practice
gradually increases as training progresses, especially among physicians from urban
backgrounds. One third of these physicians had little or no interest in rural
medicine before medical school. Only 9% had little or no interest by the end of
medical school, and only 2.5% by the end of postgraduate training. This finding
underscores the fact that medical school and postgraduate training offer important
opportunities for enticing physicians raised in urban areas into rural practice. Those raised in urban areas appear to be more sensitive to rural training than those
raised in rural areas. They rate exposure to rural medicine through electives and
rotations as having greater influence on their decision to choose rural practice.
Among these physicians, rural training might offer more than just the clinical
skills needed to survive in a rural environment. It might also offer exposure to
other positive aspects of the rural experience, such as the challenge of rural
practice and a rural lifestyle. These factors were rated highly influential by
physicians raised in urban areas. Without exposure to rural settings, physicians
raised in urban areas would have difficulty appreciating these aspects of rural
practice. Our findings do not contradict previous studies that report that those who grew up in
rural areas are more likely to enter rural practice. The reality, however, is that
the number of rural students applying to and getting into medical school remains
small. According to one study, while rural residents account for more than 20% of
the Canadian population, only slightly more than 10% of medical students are of
rural origin. 19 Although policies that give
rural students preferential access to medical training have merit, training programs
should also consider the fact that students from urban backgrounds will be an
important source of rural physicians. Limitations First, there is the potential for respondent bias. Baseline characteristics for
respondents and nonrespondents were, however, reasonably similar. Second, there is a
possibility of recall bias in responses to questions about the timing of interest in
rural medicine and the effect of various factors on choice of rural medicine. This,
however, is mitigated to some extent by restricting the sample to more recent
graduates. Third, we examined only one aspect of rural upbringing: the high school
years. This narrow definition was used because of space limitations on the survey.
One Australian study confirms, however, that location of primary and secondary
schooling both predict rural practice. 11Conclusion Other studies suggest that physicians with a rural upbringing are more likely to
practise rural medicine, and policy makers might still wish to target students
raised in rural areas as candidates for rural medicine. Physicians with an urban
upbringing, however, remain the main source of human resources for rural
communities, where they account for two thirds of new physicians. Rural education
during medical training has a significantly stronger influence on physicians raised
in urban areas than on physicians raised in rural areas. Undergraduate and
postgraduate training periods, therefore, provide an important opportunity for
recruiting physicians raised in urban areas to rural practice. We gratefully acknowledge funding for this study from the Canadian Institutes of
Health Research, grant no. RLH-54126. | • | Dr Chan is a Senior Scientist at the Institute for Clinical Evaluative
Sciences in Toronto, Ont; was an Assistant Professor in the Faculty of
Medicine at the University of Toronto at the time of the study; is Chief
Executive Officer of the Health Quality Council in Saskatoon, Sask; and
is an Adjunct Professor in the College of Medicine at the University of
Saskatchewan in Saskatoon. | | • | Ms Degani was a research coordinator at the Institute for Clinical
Evaluative Sciences at the time of the study. | | • | Dr Crichton is Program Director of the Northeastern Ontario Family
Medicine program in Sudbury and is an Assistant Professor at the
University of Ottawa in Ontario. | | • | Dr Pong is Research Director of the Centre for Rural and Northern Health
Research and is an Adjunct Professor at Laurentian University in
Sudbury. | | • | Dr Rourke was Director of the Southwestern Ontario Rural Medicine Unit in
the Faculty of Medicine and Dentistry at the University of Western
Ontario in London at the time of this study and is now Dean of the
Faculty of Medicine at Memorial University of Newfoundland in St
John’s. | | • | Dr Goertzen was Program Director for the Family Medicine North program
in the Northwest Ontario Medical Programme in Thunder Bay, Ont, at the
time of the study and is now an Associate Clinical Professor in the
Faculty of Health Sciences at McMaster University in Hamilton, Ont. | | • | Dr McCready is Chair of the Northwestern Ontario Medical Programme and is
now an Associate Professor at McMaster University. |
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