RECRUITMENT AND RETENTION OF MEDI AL PHY I IAN IN NORTHERN
RURAL OMMUN ITIE

by

C hristine Mcdeiro

PROJE T UBMITTED IN PARTIAL FULFILLM NT
THE REQUIREMENTS FOR THE D GREE OF
MAST R OF BUS IN S AD MINI TRA TI

UNIV RSITY

F NORTHERN BRIT! H
Apri l 2014

©

hri stine Medeiro. , 2014

OLUMBIA

F

ABSTRACT

Thi pr ~ ec t explor

p cific fac t r and tra tegi

medical phy ician in rural communiti
di cu ed r garding th
Briti h

and other fac t r ha

. Imp rtant pr blem and one n1 facing

f m al-di tributi n with an mph a i

olumbia. Thi project expl r

government

:D r th r cruitm nt and r tention f

anada are

n the province of

th ro le th communi ty, m dical ch

1 , pr vincial

in r cruitm nt and retenti n. Th g al of thi proj ec t is to

empha ize the grow ing ec n mi c pre ure th B . . h althcar

y tern face and th e increa ing

demand fo r recruiting and retaining medi al phy ician in rural area . Th proj ect h uld prov id e
in ight to the unique and difficult circum tance fac d by phy ician in rural and remote areas
and the cau ative fac tor of retenti n in rural practice; moreover, it will ex pl ore potenti al
recruitment and retention strategie .

CONTENT
ABSTRACT ............... ......... ........ .. .... ... ....... ...... ..... ... ........ ........... .... .... ...... .. .... .. ............. .. I
ACKNOWLEDGEMENT .. .. ... ... ................... ... ............ ...... ... .......... .. ...... ................. ........ 1
INTRODUCTION .. .... .. .... ... ... .... .......... .. ........ ... ............ ................... .... .. ........ ....... ........... 1
THE PROBLEM ..... ..... ... .. ....... .... .. ... ... ............................................ ....................... ....... .. 3
Briti h Co lumbia Dem graphic hift ... ...... .. ............................................................ ....... 4
Health care Expenditure ... ...... .... ... ....... .. ............................. ............................ .... .......... ... 7
Key Trend

on iderati n ............................................................................................... 7

Econ mi Opportunitie and Implicati n ......................................................................... 8
Regional Differenc

.................................................................................................... 12

Health Inequity ...... ... .............. .... .. .................. .... ... .... .... ....................... ... .... .... ............ 13
CAUSATIVE FACTORS ......... .. ....... .... ....... ...... ................... ...................... ..... ....... ....... 13
Personal factor ............................................................................................................ 14
Profe ional Factor .. .. ...... .. ...... .... .......... ... ....... .... .... .... .... ...................... .. ............... .. .. 16
Cotrununity Factor .. ........ .. .......................................................................................... 21
Personality/Background Factor ....... ........... ...... ... ... ..... ...... .. ...... ............ ......... ...... ......... 22
Education Factor .......................... .......... ........... ..... .... ........ .......... ... ...... ................... .. . 24
Current Retention Programs Offered by the Province of Briti h Columbia .... ........ .... .. .... ... 27
MODIFIABLE FACT ORS ....................................... ......... .. .......................................... . 31
RECOMMENDATIONS ....... ...... ..... ...................... ..... .. .. ......... ..... .......................... .. ..... 31
CONCLUSION .............................................................................................................. 41
APPENDIX .................................................................................................................... 44
REFERENCES .......... .................. .... .............. ... ... ......... .......... .. ..................................... 4 7
ACRON.YMS ................................................................................................................. 50

ii

ACKNOWL EDGEMENT
Thank you Kri for all o ur upport through ut the entire MBA

' pen nee, I

uldn ' t

have done it without y u .

INTROD UCTION
Canadian health ar i b ing challenged by p
availability of adequat medi cal car in rural

r di tributi n of m di cal phys ician and

mmuniti

. Th m aj r f, rce the healthcare

y tem face includ e d m graphic and c n mic change, uch a co t pre ure from changing
demographic · growin g co t of mana ging chronic di ea e ; and th e increasingly aging
population, which will create an ven grea ter hortag in m edical human re ource du e to the
demand the aging populati n ha on the medical ystem. The e force will add additional train
on the recruitinent and ret ntion of physicians in rural area ; thi proj ect discu e how and why
the e strains are occurring. Thi proj ect first di cus e a broad vision of the current tatus and the
future of British Columbia 's economy and dem ograph y and the implicati ons the e hav e on the
healthcare industry. It will describ e a specific view of the implication facing the B . . healthcare
industry with a focus on attracting and retaining medical physicians. The project wi ll expl ore an
in-depth look at the causes for the mal-di tribution of m edi cal ph ys icians and possible
recruitment and retention solutions. Traditionally, the recruitment of phy ician r placements ha
been viewed a the responsibility of the cunent local ph y ician or the local ho pita!.
ommunities are increasingly recognizing that medical care is a important to the infra tructur
of their community as schools and road . The ava ilability of qu ality healthcare afD ct everything
in a c mmunity from eco nomic dev lopment to the overall well -being of the population ( RP ,
20 14).

1

Many rural ar a ha

pra tic . M di al phy i 1an pr

id a wid rang

f h alth

contribut t th h alth and w 11-b mg f rural r id nt .
to nt r r I a

i

i c mpl

,. thi

in th

rvt

tud y analyz

ment pp rt u n it i ,

tly

c mm n tr nd and charact ri ti c

r

ian ' fa m iI , a r r ad an

ar a and dir

nd er tanding why ph y ician

tan

fph
ph

rural prac ti

r f phy ician in 1 cal

difficulty maintaining an a pr priat num

ntentm nt f th

m m u n it tn

I em nt and

lation from p r , w rkl ad, upbringing, and fin an ial inc nti e . Tr nd

f~ rin g ,

h w the furth r the

c01nmunity i from an urban centr th m r di ffi cult th e recruitm ent and rctenti n i u
becom . R urk ( 1993) n t , " ph

tan

t t urban

nt r repoti d th greate t

ati fa ction with their j b, hour ofw rk, pr fe i nal ba kup , a ailability o f peciali t ,
continuin g medical educati on, p u al j b opp rtuniti e, cultural pp rtunit ie and children'
edu cation. A expect d, the phy ician in th mo t di tant and mall
I a t ati facti n. '' Thi project analyz

current program

t rural area rep rted th

t up to help ail e iate ome f th

i ue and ugge t recommendati on . Id ea lly, the 1 a t costl y, mo t effecti ve method

e

[I r

retention would be benefic ial to all the stakeholder , and f cour e to prov ide the maximum
hea th benefit for Canadian i mo t important.

Thi report examines the u tainability of the healthcare y tem by r
from 8

tat , tati ti c

anada, data from the B. . Mini try of Health

journals, new paper peri odi cal , and other govemm ent r carch.
Medline were u edt obtain and conduct a literature r

tewmg tati ti
, peer reviewed

cademi

arch Prem iere and

iew pertai ning tom dica l ph , i · ian and

their m ti ve for entering or leav in g rural practi ce. Th lit ratu r r

i

, ourccd con.· istcd

r

phy ician urvey and interv iew,. Key w rd included in the literature carch were: gcn raL

2

phy ician , rural , r cruitment, r t ntion, m dical and

anada.

p cia li t and ther h althcare

provid r were exclud ed from th re arch.
' Rural practic ' can be defined in man
con idered by population d n ity and i
literature. Th Rural Practice ub idiary

ay · forth purpo e of thi pap r, ' rural

lation a d tennined from a gen raJ
gr

m nt (R

de ignation by cate g ry, which pr vide a p r pecti ve

plorati n f

) (app ndix B) li t c tnmunity
or phy ician

demand . Government incenti ve pr gram are de ignat d ba d n these 1 vel of rem ot ne .

THE PROBLEM
The hortage of phy ician in rural areas of anada i a p ersi tin g and enou

ue; we

continuou ly face the chall enge of findin g effective and efficient ways to inc rease the amount of
physicians to Jural c01nmuniti e . The uneven di tribution of physicians is likely to becom e
exacerbated as the population age , and having acce

to a family physician is a ba ic need for all

Canad ian s that can be difficult to o btain . Over 95% of Canada ' land mass is rural - town
populati on under 10,000 accou nt for 22.2o/o of the nati on's popul ation yet they are erved by
onl y I 0. 1% of Canad a's ph ys icians, and the larger rural and regio na l centre w ith populati on of
I 0,000 to I 00 ,000 co nstitute J 5.9% of the nati on ' popul ation and have onl y I 1.9% of the
physician pool (SRPC, 20 14). Many of these regions have few er than two family phy icians,
with orne cmmnunities having none. Therefore, in em ergencies, people have to be transported to
the nearest urb an city hospital whic h is, in ome ca es, hours away - the e rural or remote ar a
dw ell er have a hi gher mortality rate than urb an dw ell er ( . H ea lth) . With D w r phy ician and
peciali t in rural area , famil y d ctor work longer hour , are obli gat d to provide a much m r
comprehensiv ran ge of

rvice , and ar on-call more often than urb an phy icians.

3

Briti h

olumbia mu t maintain a 01npetiti e and lucrativ bu ine

envirorunent for

isting re ident and t attra t populati n migrati n t th pro ince. Th pr
hg- term economic gr wth to upport go
1pulation. The ultimate goal i t ha

nunent h alth ar

pending a w 11 a th aging

qu al to r bett r than the level of

that currentl y exi t. Th rea l thr at to the futur of Briti h

I•t come from external fact r

lumbi a' healthcare doe

uch a g neral inflati on, p pulati n growth, and aging, but rather

1m forces w ithin, such a incr a ing utiliza ti n, eliminating redund anci
d inflation on price

olid ,

a healthcare y tern that i portabl , univ r al,

cmpr hen ive, acce ibl e, and of ub tantial qu ality that i
~rvice

in e ne d

and ineffi ciencies,

peci fi c t th healthcare indu try (Berlin, 20 10) .

ritish Colum bia Demographic Shifts

The age of the acti vely working populati on will decline teadily from 65% to 59% by
t35, creating a ri e of dependents in B.C . (i.e. people under the age of twenty or over the age of
.l(ty-five). British Columbia w ill have the highest senior dependency spread in we tern Canada,

ith people over eighty being the fastest grow ing segm ent in the B .C . popul ation accordin g to
:::' Stats 20 13. British Columbia continues to be an attracti ve place fo r retirees in C anada;
Jwever, when it comes to working-aged people, inter-provincial migration has be n low in
cent years and was actu ally negati ve in 201 2 (Muzyka, 20 13). Thi i largely du e to other inkin g provinces seeing more economic grow th than Briti sh Columbi a. When looking at BC
ats' popu lation projecti ons, th e overall popul ati on is ex pected to grow at 1.2o/o per year but the
·)pu lation over eighty is growing at a rate of 3.5% annuall y. Thu , popul ati on aging i one of the
· imary cau es of government spending; seniors account [i r on -third of phy i ian ervi ·e ,
mo ·t 50% of acute care service , and 74% of hom e and conununity care e p ndi ture (Muzyka,

) 13 ).

4

Average pub li c health costs per cap ita by age group 2008
Average cost = $3 ,333 per person
.., 16 )

)

c; 14 )( )
Sll,O Jl
-:,

~ SHll
v

OJ
~

:r
c

h
..

l(l

ll)

)()

<,

I

I

F ig ure 1, (BC Stats. 2013)
The graph above illu trate th e dramati c co rrelati on between ag and co t pe r apita per
yea r. In 2008, th e ave rage co t of pub! ic hea lth ca re per per on in B. . wa

3, "~ 33, with peo pl e

over the age of eighty co ting $ 15. 137 per yea r and tho e ove r th e age of ixty acco untin g for
alm o t half of th e total government hea lth expenditure . By takin g BC tat · popul ati on
proj ecti ons and hi stori cal mental illn e

data into co n id erati on, by 2036 it may be pos ibl e t

have one milli on new pati ents diagnosed with th e top five chronic co nditi on aero

th e

prov in ce: depre sion, hypertension, o teo-arthriti s. di abete , and a thm a.

5

2036

2011

1976

30%

59"'

60%

1

U mler 1

1

5 -:~nd o. er

1

< ... r,d

e

I

l fl j

J

I

:

tlri j

t:

Fig ure 2. (BC Slats. 20 13)

Generati on Y (th o e born in 1980 and nwa rd ) wiII oo n co n titute a large porti on of th e
wo rkin g demographi c. T hi ge nerati on ha diffe rent ex pectati on of th eir wo rk life th an th e Baby
Boo mer generati on did in that th ey expect to have greater wo rk and Iife balance ( iang. 20 I 3 ).
These cultural shift will ha ve a direct impact on th e wo rkplace a yo un ger wo rker may be le
wiII ing to wo rk th e long hours of prev ious ge nerati ons: not onl y wi II th e number of 'v\ orker in
the labour force decrease, but th ey will al so ex pect to wo rk less hour (Mini try of Adva nced
ducati on, 2009). The maj or indu try group th at are proj ected to ex peri ence th e fas te t gro wth
rate are retail trad e, hea lth ca re, oc ial ass istance, accomm odati on. manufac turing. and
constru cti on (Mini try of Advanced - du cati on, 2009). Briti sh

lumbi a will need to re ly on

immi grant to meet th e future need of the labour market and th B.C. go ernm ent vie'v\
immi grants as an opportunity to bring n w ski ll and innova ti e id ea to th e labour mark et
(Mini stry f Ad va n ed Edu cati on, 2009) .

6

Healthcare Expenditure

Advan

in medical techno! gy ha

b

n ignificant v r the pa t d cad . Improv d

urg ri e , and n w dru g treatm nt ha e mad h althcare

technology in diagno ti c , le

far mor advanced and fD ctive but, imultane u ly m re exp en JV . Having th
a ailabl ha incr a ed th d mand [! r m or pati nt
repla cement urgerie t ju tify th c

eking pr

edur

e techno logie

uch a MRI or joint

t f hav ing the new equipm nt.

Provincial hea lthcare p nding gr w fr m

illi n in 2000 t

1 .I billi n in 20 10,

with an average annual growth rate f 5. % (B MA 20 13) . The e healthcare costs are ri ing
fa ter than th rate of population growth (1 .2% per year) and at a fa ter rate than the economy.
The provincial gove rnment' healthcare pendin g w ill account for a rapidl y increa in g
share of economic output (Berlin, 201 0) . With the econom y growin g at an average of ju t und er
2% per year to $2 98 .6 billion by 2039 and provincial governm ent health spending gr w ing at a
rate of4.5o/o per year, hea lthcare pendin g a a hare of B . . 's real GOP will in crea e from 8.7%
today to 11 % by 2019 and 17% by 2039 (BC Stats) ; it would effectively m ore than doubl e in
fifteen years.

Key Trend Considerations

om pared to Alberta and

askatchewa n, B.C .' economy will und er-perfonn w hil e till

facing an increasing need for healthcare services. Thi will creat additi onal train on the
eco nomy and ma y potentiall y lead to hi gher taxes, low r pendin g in other government-fund d
areas, or increased lab ur producti vity for governm ent worker (Mu z yka, 20 13).

7

According to 8
di

tat ' hi t rical data th numb r of p ople in B . . with chr me

a e i ri ing. T day, m re than 1.3 milli n pe pl in B . . hav

ov r 90,000 p

pl hav ov r four with mental h alth i u

ne chronic

nditi n while

b ing the mo t c 1111n n .

Economic Opportunitie and Implication

Over the ne t decade, B . . willn
a growing and more vari d econom y.

d increa in gly advanced kill and knowledg to drive
a r ult of ec n mi c gr wth empl yment in Briti h

Columbia hould grow by an average of 1. %each yea r thr ugh 20 19, creating a total of
450 000 new job (WorkB , 20 13) .

cc rding t workbc.ca the average annu al growth rate of

employment for general practitioner and family phys icians in theN rth

a t region is 3 .2%, th e

Cariboo region is 2.7%, and Kootenay region i 2.6% . There i al o a need for medi ca l
specialist in these area , with the e speciali ts experi encing similar growth trend .
Another consideration is that as B.C.'s populati on ages, o do the ph ys ician . As
illustrated in the figure below , the retiree popul ation al o affect the number of physicians
leaving the workforce and, therefore, the need to fill these vacancies in this industry (BC tat ).
As an aside, it is impotiant to note that although thi s paper focuse on physicians, other hea lth
professionals will face imilar chall enges.

8

Percentage of BC phys icians over 55 years of age : Years 2001 and
2011
4'

5:o 40

~

0

~

r

'L

L

J"'

L

>

1.1"\

~

IS

> 1

, r

'11

•

•

F ig ure 3. (BC , tats. 20 13)

Growth in B. .' minin g ector i e pec ted to graY\ 7o/o from 201 2 to 2020 a Briti sh
olumbi a take ad vantage of it natural re ources. The deve lopm ent f pipelin es for oil and
natural ga i a potenti all y pro mi in g deve lopm en t for th e B.C. eco nomy, but will require a
signifi cantl y large capital in ve tm ent and face environm ental crutin y. In fac t, all natural
resource extrac ti on wiII require bi li ons of do ll ars in fundin g and th e deve lopm ent f the
infrastructure needed to support such indu tri e . In additi on, the B. . fo re try ector i foreca ted
to trengthen as Ameri ca n home co nstructi on ri e (Muzyka, 20 13).
British olumbi a is well pos iti oned to res um e growth when th e eco nom) turn aro und . It
can ca pitali ze on opportuniti e

uch a se rvin g as th e Pacific Gateway to A ia and in ve ting in

emergin g ector like bi o-energy and oth er green techn o Iog ie (WorkS , 20 I 3) . The A ia Pac ifi c
ateway i a network of maj or infrastructure connecti on stretchin g aero
South to th e

We tern

anada and

nited t le . Th e federal governm ent initi ated thi in ve tm ent t enco urage trade

between th e A ian Pacifi c region and

anada . Th e

ateway wiII upport th e creati on of ne\\ jo b,

and in crea e economi c pr perity. Durin g th e c nstructi on neces, ary for th e Jatewa) to ex ist
9

and to upport th population gr wth that will b a direct r u]t f thi
increa ed d mand for additi nal m di al fa iliti

infra tructur , and medical taff will b

1ih m regi n

n ed d. Thi will b

pp t1:unity, ignificantly

wh re current phy ician staffing i

alr ady tre ed. Th Gat way may al

hav a direct effect on the cultur

it elf. Linkage with the

at way and th gr wth fa green economy will al

create new bu ine

ia Pacific

and inv

labour mark t opportuni ti
Japan 's healthcare

tm nt pportuniti

fBriti h

lumbia

in th provinc , inc luding teclmology and

(W rkB , 20 1 ) .

tern i ranked am ng the be tin the world according to th W rld

Health Organization (WHO). Canada and Japan both converted r lativ ly earl y to public
healthcare and both have imilarly aging p pulation . Japan i noted by the WH

for having a

healthy long-living population - in fact, Japan enjoy the high est life expectancy in th e world.
Its healthcare system is relatively inexpen ive and cover dental procedures and pre cription
pharmaceuticals, and it u es less private funding with ho pitals being 81 .7% publicly fund d
(Asian Pacific Foundation of Canada, 2008). According to a report by the Asia Pacific Foundation,
the management of Japan ' hospital plays a maj o r factor in the efficiencies of its public
healthcare system. All of the ho pitals in Japan are centrally managed and hi ghly efficient. Will
the Asia Pacific Gateway create a clo er relationship with Japan, in tum influencing the tructure
and efficiency of Canada' healthcare syste m? It is important to acknowledge a deficiency in the
Asia Pacific Foundation tudy: the report doe not look into other potential rea ons for Japan'
healthcare succes e such as a genetically-predi po ed population to health and longevity, more
favourabl e environmental co nditions, or co t per patient.
Briti h
like Japan,

olumbia ha br aden d it trading focu , trengthening tie with

hina, Korea , and lndia . Th

ia Pac ific

ian countrie

ateway i e pected t have a igni ficant

10

effect n

lumbia' lab ur mark t b attracting a ki ll d and imag inati e

riti h

(W rkB , 201 ). Th B . . g

rnment rna ha

ur e m ch

t

I in rd r t

n id r imp ! m nting m r Mandarin and
ly

Japan

languag

lan gua g

in b th th g n ral p pulati n and the ub

quent n

ian Pa ifi F undati n f

indi

flu ncy t help th

rk[i r

d [! r h a lth ar w rker '

anada, 2 08).

riti h

I baliza ti n ha been
mark t wher employer c mp et D r tal nt and pe pl
around thew rid, rea ting pr

ur

ar h D r empl yment pp rtuniti

n the la b ur uppl y (W rkB , 20 1 ). In th e future, th

B . . g v rnm nt may ha e t r du e th le el f care a ai labl in rd r to fill th gr w in g n
of phy ician horta ge acr

the prov ince and I

k t

d

ati fy h rtc min g with the addition of

foreign phy ician .
It i nece ary to ensure that B . .' m edical fa c iliti e and infra tru cture ha ve th ca pac ity
to accept the rapidly chan g ing d mand and te hnolo gical advancement . F r exa mpl e, Burn
Lake is et t receive a new Lake Di tri ct Ho pita! and H ea lth

ntre; the pr ject i imp rtant

for the region as it will prov ide enhanced pati ent ca re ervice and will upport

orth m H ealth

by meeting demand proj ecti n for hea lthcare erv ice in the r g i n (H a lth, 20 13 ). H owever,
according to

B

New H ealth, Burn Lake co uld oon be with ut an y d ctor at all , putting a ll

re idents at an increased ri k.

very ph y ician in the co mmunity ha ei ther re igned or plan to

move away from the area in th e n ea r future . Ph y ician fr m Burn
" microco m f rural

mmuniti

pract ice, plu a co mbinati n

ake de

"w ith a c mbinati o n o f uniqu e remot n

f new and r tiring phy ician ( B

are c urrentl y I ,7 2 pe pi e li ing in

urn

proj ec tion, , by 20 6th r will b 7,4 19 p

ake and , ac ord ing to B

rib the regi n a a
, a ta. ing rural

ew - H ea lth, 20 II ). There
tat ' rorulation

pi in th a rea . T hus, North rn Health i, a ' live!

11

trying t recruit d ct r t thi region, but it i mu h a i r tor cruit t a larger, mor
m dical community ( B

N w - H ealth, 2011 ). Many phy ician D 1 ov rwork d and und r-

comp n ated for the additional demand put n their tim in rural c01rununiti
the reality and tr

of providing an in rea d individual!

1 f m di cal

. Th y oft n fac
rvice and th

re pon ibilitie that com with thi a a re ult of the lack f trained p ciali t .
th se physician are often dealing with the r aliti
a lack of colleagu

t th

am time,

of D wer infr a tru ctur , gr at r i

lation, and

upp01i c mpar d t that f larg r communiti

In Vancouver, pati ent have acce
t. Paul

, Vancouve r

tabl

to everal nearby multi -fun ctional ho pitals uch a

eneral Ho pita! (V H),

throu ghout the re t of the province.

.

hildren' , and W m n' . Thi i not th eca e

ommuni ty- ba ed care is inva lu able, but ace

to more

advanced faciliti e for more critical ituations i vital ( ullivan , 20 13).

·Regional Differences

When designing a sustainable provincial healthcare ystem , it i nece ary to ob erve the
distribution of chronic illnesses among regions in combinati on w ith the current and proj ected
dem ographics for age, sex, and other fac tors. The e fac tor are th e necessary indi cators requi red
fo r developing a functional healthcare system . They al o erve to identify area of weakne s and
aid in proper resource plamting, such as the number of healthcare profes ional needed and their
training (i .e. specialists versus general practiti oner ). For example, the Fraser Health R gion and
No rth ern Health Region both have a higher prevalence of chronic cond iti on compared with the
provincial averages; these area may require the attenti on of peciali t or sp ciaJized equ ipm nt
( ang, Km tic, & Me arn y, 20 J 0) .
In Briti h

lumbi a, hea lthcare service are m anaged and de li vered by five regional

hea lth authoritic that g vern, pl an, and oordinat h alth ervi

wi thin th ir conesponding

12

region . Th fi e health r gion are: Interi r Health, Fra
Van ou

r H alth Vane uv r

a tal H alth,
f three t

r I land H alth, and N rthetn H ealth. ach f th h alth r gi

:fi ur health

rvice ar a (Fang, Km tic, & M e arn y, 201 0) .

Health Inequity
The cutTent regi nal in quiti

hould al

health ervice . De pit th fact that British

be taken int con id erati n wh n planning for

lumbia i

ne of th hea lthi

t pl aces in

anada -

and the world, for that matt r - th re i a r lati veJy hi gh numb r of di advantaged peopl e in the
province wh n compar d to other r gi n

Jn

anada . Briti h

o lumbi a ha the hi gh

rate, parti cularly child poverty but ven th ugh B. . ha th hi gbe t

t poverty

ct -ec nomi c

di advanta ge in the country, it till manage to refl ect the best health. Thi i because the overall
data illu trate B. .' heath tatu as a who! , di regardin g difference du e to reg iona l data or
· ocial groups . A ide from a moral re pon ibility and obligation to serve the entire population,
there is also a tremendou co t associated with inequity among British Columbian that co ts the
B.C. economy $3 .8 billion annually (Health Offi cers Council, 20 13) . tudi es indicate that
spending more on healthcare is not the answer for increasin g the overall health of the popul ation;
instead, developing better ocial program s, education, and improving the li ving and working
conditions for the less fortunate ma y be the answer. Improved health enables m ore people to be
employed and thus effectively redu ces cost du e to lo t productivity. Th e B . . government
hould consider initiatives to redu ce the existing health inequitie ; by m aking the nece ary
resource allocation to improve thi rea lity, th ey will make these is ue a ocietaJ priority.

AU ATJVE FA TORS

13

Rural area are often chara teriz db i alation, an a peel that an b b th limiting and
attracti e dep nding nan indi idual' per nalit . Be ide cultur and OCIO-ec n m1c
background, ome f the

mm n rea

n why phy

1an lea

rural practic in

ork

h ur . I ife t) Ie. practi e locati n. hi gher alar). areer pr gre i n. and V\ rk en ir nment
( dom Walker et al. 20 I 0). Medi al pro~

i nal V\Orking in rural area are faced with variou

hallenge . whi h will b di

ategorie : p r nal. pr fe i nal ,

u ed in fiv

mmunit ,

per nalit or background. and ducation.
to ph

ician in cho

ing rural pra ti

in relation t their age.

~r (nonfinanCial) recnutment

reteruon
mcentl\ es

22

Phvsician age .-- -l ~ yr

.:!

Fmanctal recnutment
retention tncentiYes

Ph\ SlClan age > -l5 \ T

12
------------------------------ 49

Proxurutv to farrulv

9

Rural expenence m tramtng
Recreational opporturuties

'1

Commuru . · needs a good

7

match w1th career mtere sts - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - .,3
Practice opporturuty
77
\Yas a\·a.Uable ------------------------------------------- 73
Preference for rural prachce

/9
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 79

L~edthe~~s~~ -~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\.:!
Opponuru~- to
practice full skill set

=============------------------------------------- g~

----------------------------------------------------- 86
'i

1

'"~ i

r •o;;

Fig ure 4. (Chauhan, Jong, & Buske. 201 0)

Personal factors
ome per onal factor affecting the recruitment and retenti n of medical ph ' ician to
rural area or anada inc lude job opp rtunities for pou e, the education o r children. cultural
opportunitie , recreation. and retirement plan . Previous tudi

have shov\ n that graduat s ,, ho

14

h

urban pra tic had man r a n £ r d ing
n £ rd

m t frequ ntl
Be au

f th bu

eing the

iding n an urban pti n ( hauhan tal. 201 0) .

dul in a rural n ir runent, int grati n int th

w rk

community i a challen g b au

, with family and p r nal fa

th rear few acti iti

c uld participate in· thi can lead t feeling

that an urbaniz d p u

f b r d m and l n lin

b au e th

and childr n
p u e

par nt wh w rk in m eli al linic

r h pita! ar

trem ly bu, y with their high

w rkl ad. ThereG r , if a p u e i

mpl y d, regard!

f their fi ld f training, th y will b

r

more cont nt and upp rti e, but a I n ly and b r d p u e ca n c ntribute hi ghl y t th e
relocati n of phy ician to urban area wh r th ey will be a ur d fa bu tling c mmunity with
more acti itie to keep th m g ing. The c ntentm nt of medi cal ph y ician i innuenc d by
direct per onal factor

uch a influence fr m p u e and children b cau

not happy in a rural etting, th nth yare le

lik ly t

if ne ' family i

ta y (R urke, 1993 ). Fa t r that limit r

promote the contentment of a pou e or d termine their le el of ati facti n and a imilati n into
the rural community are es entia) for the retention of phy ician in the rural area of anada .
Family is very important to many phy ician ; thi includ e

pou , children, and other

relative . In on of the tudi e , a phy ician of Latino de cent admitted that he could not I ave hi
present I catio n beca u e th family wa ba eel there. Phy ician cite life v nt like marTiag and
having children a

ignificant influence for their career . De pite th typica l quiet and er nity

offered in rural area , one i u ually ome eli tance from famil y and friend , and the demanding
w rkload often make it difficult for physic ian t take h lida y tim e (Mayo & Matthew , 2006) .

Additi nally, perso nal inccntiv , like the opp011unity for per onal gr wth, matt r to
phy ician . h y wi h t ha v opportuniti

to gr w and enhance their li

b developing ncv

kilL . ome phy ician wh wish to g to a difG r nt en ironment and v ork in parti cular pati 'nt

15

h

urban pra tic had many rea n for d in g

m t frequ ntl m nti n d a rea n
Be au

f th e bu

w rk

[! r d

dul in a rural en ir nm nt, int grati n int th

mmunity i a hall ng b au e th r ar
could participate in· thi can I ad t feeling
parent wh w rk in m di cai linic

iding n an urban pti n ( hauhan et al. 201 0) .

~ w acti

iti

that an urbani zed p u e and hildren

f b r d m and I nelin

r h pita! ar

be au e the p u e or

ft n e trem ly bu y with their hi gh
f their fi eld f training, th y will b

more c nt nt and upp rti

, but a I n ly and b r d p u e can c ntribute hi ghl y t th e

relocation of ph y ician t urban area wh re th ey w ill be a ur d f a bu tling c mmunity with
m r acti vitie t k p th m going. Th c nt ntm ent of m dica1 ph y ician i influ enced by
dir ct per onal fa ctor

uch a influ nee from p u e and children beca u e if one' famil y i

not happy in a rural

tting, then they are le

likely to tay (Rourke, 1993 ). Fact r th at limit or

promote the contentment of a pou e or detennine their I vel of ati fac ti n and a imil ati n into
the rural community are e

nti al [! r the retenti n of phy ician in the rural area of anada.

Family i very important to many ph y ician ; thi includ
relative . In one of th

pou e, children, and other

tudie , a phy ician f Latino de cent admitted that he could n t leave hi

pre ent location because the famil y wa ba ed there. Phy ician cite life event li ke marriage and
having children a

ignificant influ ence for their career . D pite the typ ica l qui et and ereni ty

offer d in rural area , one is u ually orne di tanc from famil y and friend , and the demand ing
wo rkl oad often make it difficult D r phy i ian to take holiday time (Mayo & Ma tthew , 2006) .
Additi nall y, per onal in entive , like the opportunity for per nal grow th , matter to
phy ician . hey wi h t have pp rtuniti
kill .

to grow and nhan

th eir li e b dev loping nc\

m phy ician wh wish to go t a lifferen t en ironment and\ ork in particular pat1cnt

15

etting might al o be more willing to tay in rura l ar a . F r in tanc , m om

tudie ,

phy ician fr m non-und r- erved ar a hav r p rt d that rural ar a provid e an opp rtunity D r
change and re arch, whil oth r ar m ti at d by mi i n-ba d value lik th commitm nt to
erv in uch a c mmunity, and till th r ar m ti va t d by th eir life tyl

and th y preD r to g t

job in which th w rking hour d not int r~ r with time pent with family or pur uing ther
inter t and bobbie ( dom Walk r t al, 20 10).

Proposition la: Th e opinio n of a phy icia n ' po u e a nd /or fa mil y member a re e sentia l
d eterminants of w h eth er a ph y ici a n stay or leave a rur a l communi ty.
P ropos ition 1 b: A lack of opportuni ty fo r per ona l g rowth a ffect th e ph y icia n 's choice in
stayin g in th e communi ty.

Professional F actors
Professional factors include clinical upport, opp rtunitie for continu ed profe ional
development, career motivation, and financial incentives.
i)

Clinical supp01i
For many physicians, a supporti ve work environment is a significant aspect that

determines satisfaction in their profession. Thi element was a noted factor along with having
professional co-workers who are cooperative and valu e the provision of quality ervices.
' Provi der team' i a term used to de cribe a group of specialist in various field ; for examp le,
mental health, ancillary, and social service provid ers. Som phys ician have reported that their
medical colleague are a major rea on for remaining at their cun·ent location ( dom Walker t
al, 20 10).
ii)

pportuniti e for

ontinued Profe ional Developm nt

16

A maj r challeng in rural area i th minimal pp rtuniti
which i useful for furthering pr fl

t continue with ducation,

i nal de el pm nt. Phy ician are ft n required t make

annual record of th ira ecru d pr fe i naJ d v 1 pm nt which i r quir d the next tim e they
are ren wing th ir regi trati n; thi
development . Thi

n ure that phy ician r main updat d n curr nt m di cal

ft n ha the implication that a phy ician in a rural area will have to travel

long distance fl r th ir cour e and u e their l a e da y t att nd c ur
rural area , keeping up with the c ur

. Thu , for phy ician m

requir m nt mi ght prove difficult and, at time ,

impos ible. A.Inid the e challenge , it remain a nece ary li e n /revalidation requirement that
all phy ician mu t have continued medical edu cation ( M ) and c ntinu ed profe sional
development (CPD) training. R gardl e s of the hard lup involved in acce sing this fonn of
training, regulatory bodie in i ton it (AHP, 20 14).
Previous tudie have indicated that the difficulty in obtaining CME and CPD a a re ult
of rural isolation is one of the major reasons why physician move from rural to urban area .
Generally, a rural physician is expected to play all medical roles found in a small hospital setting,
including pediatrics, obstetrics and gynecology, m ental specialty, emergency services, and
surgery, among others. They are also expected to make nursing home visits, hou se call , and
much more. This is because the e rural areas often have few, if any, speciali t (Odom Walker et
al, 201 0) . Therefore, a rural physician must build and maintain a higher and more varied
knowl edge ba e and associated technical skills of the variou area and ub-specialtie of clinical
practice.
Some r earchers have repmied that compared to urban phy icians, rural phy ician are
in hi gh r need of M

and

PD becau e they are involved in multipl e medical pro edur s

(T guri, Jong, & Roger, 20 12). In addition, they h uld re

ive basic training in all clini cal ' kill

17

and proc dure b cau

th y ar oft n exp ct d to ffer m rg ncy care ( .g. n urolo gical ,

pediatric/ infant, toxicological, and multipl trauma amon g th r ) in r m t place . In om
ca e

rural phy i ian may ne d to have even furth er kn wledg of local cultural factor

aboriginal h althcar and h rbal m di cin

. Ther D r , th a ailabili ty o f

M

and

uch a

PD throu gh

di tance-learning program i vital for nhan ing th e pro fe sional and techni cal kill

f rural

phy i ian . Thi help r du ce pr fe i n al i olati n w hil enabling them to deal with a wid er
cope of practice. The e di tance-lea rnin g program

n ur that rural ph y ician b c m e

competent in ad vanced m edi ca l ar ea and are cap abl e of w rking ind ep end entl y regard I
availability of modern m edi cal techno! gy or the advice of speciali sts (UB

of the

Faculty of

M edicine, 2014).
iii)

Career Motivation
C areer incentive include w o rkin g hours, geography, loan repaym ent program s, and

overall career atisfaction . Salary and benefits are al o among the mo t co1nmonl y m enti oned
career incenti ves. Workin g hour that co rre pond we ll w ith one 's lifesty le are a hi gh pri ority.
Physicians experience career satisfaction and em otional enrichment when they are abl e to
provide a higher opportunity for comprehensive pati ent care. Poor career satisfaction i cau sed
by career instability, lack of suppmi, boredom , and exhausti on . Ph ysician prefer a work
chedul e that limits bmnout, gives them control over their time, and allow them to maintain a
healthy work-life balance (Odom W alker et al, 201 0).
The number of physicians within a given rural con1munity has an impac t on the r ten tion
of phy ic ians beca use rural practi ce involves an xce ive wo rkload, w hich often force many
phys ic ian t work beyond th e regular work ch dul e. Sine a limited numb r ofp hy ician
de ire tow rk in rural area , it incr a e the train o n tho e alread y work ing in th

18

cmnmuniti

- th few r th c 11 agu

th tim they ha
Th e c

, th greater th workl ad [! r ach rural phy i ian and th

[! r th ir famili

and p r onal li

w rkload lack of profe ional

acce ibl training opportunitie ar

( d m Walk r tal, 201 0).
ll eague and peciali t , and lack f

om of the pr fe sional r a on that pu h a rural phy ician

to move to an urban area. Lie n ing requirement areal o career motiva t r ; ome phy ician
opt to r 1 cate t rural ar a b

au

Walker et al, 20 10). A conununitie

th lie n ing r quirem nt th r ar I
ucc

trict. ( dom

fully recruit phy i ian , the burd en on indi vidu al

physician i reduced, thu enabling b tt r coll egial upport and after-hour arra ngement alon g
with increa eel pportunity for per nal vacation and profe ional devel pm ent (Vi comi ,
Larkin, & Gupta , 2013 ).
Medical technology i e sential in the advancement of the practice of medicine. The late t
tool s and equipment make a physician's role easier, treatm nt more effic ient and co nseq uentl y,
the overall quality of care increase . Thi include having electroni c charting, MRI machines, the
ability to offer the latest treatment , and irmnedi ate result with innovative software. Du e to
healthcare budgets, technology is sometimes limited in rural areas, which can influence a
physician 's choice on practice location.
iv)

Financial Incentives
Financial incentives include salary, benefits, loan repayn1 nt program , and

compensation. Health benefits, educational support, alary, and retir ment fund are ignificant
career motivators, esp eciall y for students with high r edu cational debt (Odom Walker eta!,

201 0) .
The effectiv ne s of financial incentive on the r cruitm nt and retention of phy ician in
rural ar a has n t r eived considera ble cl gr e of research and ther i !itt! e iclen e to upport

19

thi relati n hip . However m dical tudent in

ntari ar drawn t initiativ

lik th free
r cruitm nt

and retention program in rural ar a (Vi comi, arkin, &
about return f

rvice (R

) program in

upta, 201 ). Ther ar al

anad a. Phy i ian who ch

cone rn

e rura l ar a are mor

agreem ent ( empow ki , 2004). Th

ucce

f

lik ly to tay than tho

wh go on a R

cholar hip or bur a1i

with rural return of erv ic agre m nt i hi ghl y variabl e and the e

agreem nt mainly impact recruitm nt rath r than retenti n ( hauhan et al, 201 0).
Remuneration i an e enti a! fa tor becau e ther mu t be a balance betw en uffi ci nt
uppl y of phy ician and compen ation . However, a long as phy ician ar content in the rural
etting, compen ation ma y bee me le

of a determinant of their tay.

everthele ,

compen ation i a vital element for those who are not co ntent w ith the idea of practicing in a
rural location . Previou studie have indicated that remuneration alone doe not hav a
significant effect on the retention of physicians in rural area (Odom W alker et a, 201 01). Other
personal and professional factor mu st be taken into account that may lead to better retention of
physicians such as fa mily and education. Multidimensional programs app ear to be more
successful than those relying on financial incenti ve alone (S empowski , 2004). Physic ian al o
desire working close to hom e where they do not have to cotru11ute for hours each day. If th
working location is too fa r fro m where they have acquired housing, th yare more li kely to
become discouraged and leave the rural area. Generally, th e dynamic that influence the
retention of physician in rural communiti es includ e: size of the c01nmuni ty, h althcare
resources, and the proximity to urban centres (Odom W alker et al, 20 10).
Proposition 2a : Diffi cul ty in achi evin g continuing edu ca tion co urse may deter a phy ician
from stayin g in rural practi ce.

20

Propo ition 2b: Doctors in rural area become vulnerable to burnout due to heavy
workload and lack of peer upport.
Proposition 2c: Phy ician ma y become fru trated in rural setting where medical
technology i limited and budget are underfunded.
Proposition 2d: Financial incentives are a good recruitment strategy but do not prove to be
an effective long-term retention trategy.

Comn1unity Factors
tudi

how that long-t rm phy i ian re t ntion in rea e ·harpl y n

a co mmunity'

popul ation exceed 7000 (H arvey T homma en, 2000). Harvey Thomm a en (2000) tate that
additi onal fac tor that increa e phy ician retention includ e recreati onal activiti e , a m ore
outherl y location, decrea e in isolation, and hi gher number of peciali t . Appreciation, a
feeling of coru1 ection, active support, and phy ical and recreati onal a et and opportuniti e were
· al o positively conelated to physician retenti on (Cam eron, Este, & W orthin gton, 20 12). The
chart below illustrates the level of importance each factor ha based on the re ults from a
previous study. It i important to note that every cormnunity is different and every phy ician w ill
ha ve different values so there is no standardi zed fram ework. A common them e noted in the
research was that the relationship between the physician and community wa relevant to the
retention level. Those who disclosed that they felt well prepared both sociall y and medica ll y fo r
practice in a rural area tayed longer than tho e who felt unprepared or who were initi all y
unaware of the uniqu e characteristic of rural practi ce. Those who fe lt pr pared for m all town
living were over tw ice a likely as others to rem ain in a ru ra l area fo r at 1 a t i

r m ore year

(AAFP , 20 14). A vari ety of co mmunity traits can d termine a rura l co mmunit ' abilit to
attract ph ys icians. Th e e community trail includ e fa mil y alu e ,
art and cultural opportuniti

, reli gion/ p

hool , educationa l re ~ ource ,

i fi e fa ith-ba ed re ourc . , p r o nal and professional

21

pp riuniti

,

urit , and di tan

faci lit ie . If a rural

mmunit

fr m urban centre , natural en rronm nt. and re reati ona l
t

ian wil l be di co uraged by

far fr m an urban ce ntre, ph

the Ia k f edu ati nal, ultural and rec reati nal pportuniti e (May

Matth w , 2006).

Community retention f actors
Co mmun ity
Fact or

A

B

c

D

Ap preciation

X

X

X

X

Reciprocit y

X

X

X

Connect ion

X

X

X

X

Act ive sup port

X

X

X

X

Physical and re cre at iona l
asset s

X

X

X

X

Table l , (Cameron el a/. 2012)

Propo ition 3a: La r ge r co mmunity ize, a nd in c reased asset , r e o urce a nd o pportuniti es,
b oth profess ionally a nd pe rso nally, in c rea e phy icia n r ete ntion in r·ura l a r ea .

Personality/Background Factors
A rural upbrin gin g (entire childh ood or more th an ten yea rs pent in rural area ) i

po iti ve ly correlated with retenti on of ph ys ician in rural locati on . If a phy ician ha a rural
ori gin , they are more Iikely to tay th an one with an urban ori gin (Tog uri , Jong, & Roger, 20 12 ).
igure 5 di spl ay an e ce ll ent exampl e of path way to ph y ic ians ente rin g and leav in g ru ra l
practi ce in relat ion to training background . ve n whil e in schoo l, tu de nt from rural
backgro und s are often in favo ur of rural medi cin e and ar more Iikely to adopt ru ra l prac ti ce
after graduati on. Studi es th at have in ve ti gated th e relati on hip betwee n stude nt ba kgr un d and
their willin gne

to wo rk in rural locati ons have reported that tho e with rural ba kgro un d. prefer

lakin g intern . hip or prac ti ce in rural hos pital . Appro im atcly 90o/o of stu de nt vvith rura l
rr grn prefer remainin g and prac ti cin g in rural co mmuni ti e. and have a posi ti\ e pcrspc ' li\ cor

22

the quality of rural life. tud nt with a high t 1 ranc with r gard to unc t1ainty al o have more
int re tin rural practice.
actualizati n alt mati

th r imp rtant fact r include familiarity,

n

f b 1 nging, elf-

com pen ati n, and c mmunity involv m ent (T guri et al 20 12).

An ther important fac tor t m nti n i that rural ph y ician tend t rand mly encounter
the ir pati ent more of1 n than urb an phy ician around th c tmnunity durin g th cour e f
ev ryday li:fi

uch a th gr c ry t re or vent . Being co mf011abl e with thi d gree of clo ene

may or rna not be part of th e fa mil y ph y ic ian ' per ona lity and

ci a! kill et (

Phy ic ians who practic d in rural communi ti e w r m ore likely to have mi

P, 2014).
ion -ba ed

values uch as a en e of re p n ibility or m ral obli gati on to a p arti cul ar co mmunity or a
defined pati ent population, and utilize their e lf- id entity, including race, language and p er onal
or famil y background a m oti vators (Odom W alker et al, 201 0). Finding al o indi cate that wo rk
hours and lifestyle w ere important for all phy ician but that the e factors appeared to pl ay a
particularl y in1portant role for ph y ician w ho had left or consid ered leaving a rural community .
One research tudy al o sho wed that none of the phy ician who trained in a larger urb an setting
went to work in a rural one; this tresses the importance of training in und er- erved location s a a
predictor of long-term practi ce in these sam e settings (Odom W alker et al, 201 0). F indings al o
indicated several person ality differences between rural and urb an phy ic ians w ith regard to
openne , conscientiou ness, and agreea blene s. In fac t, openne

core d clined as geographi c

isolati on increased, and conscienti ousness tend ed to be higher in rural phy ic ian . Overa ll ,
Mi cha el Jone et al. (2 01 2). found th at openness (rural doctors lower), con cienti ousn s (ru ra l
doctor hi gher) , and agreeableness ind ep end entl y di ffe rentiated ru ral fro m ur ban phy i tan . The
practi ca l va lu e ofthi can be seen by n ting that the

three perso nality dim en ion taken

23

tog th r with k y d m graphic chara t ri tic c uld b con id red quit
t t de igned £ r u e in clini al pra tic (Jon
Wh n tudent are e p

dt p

iti e phy ician a r

r cruitm nt to rural ar a will b 1mpro ed.
tudent to pra tice in rural ar a , th
they are

po

d to rural exp rienc

, Humplu· y ,

lth ugh per

r dibl for a diagno tic

ich 1 on, 20 12).
mod 1 £ r rural practi

nal origin influen

, the

th d ci ion for

from urb an ar a canal o d v l p po itive int re t if
while in training (Rourke, 199 ). Finally, elf-id ntity

matt r to om phy ician , e p cia ll y tho e from min rity gr up wh prefer a

tting that

remind them f their language, family, culture, ge graphy, and oci -econ mic background .

Proposition 4a: T h e more tim e sp ent in a r u ra l co mmuni ty settin g, the h ig her th e
correlation of r etention ; esp eciall y if th ey h ave p ent a s ubsta nti al p a rt of t heir fo r m ative
yea r s in a r emote communi ty.
Proposition 4b : Phys ician s th at work in und er-served areas d o so largely becau e of
mission-drive n valu es, self-i d en tity, an d accep tab le wor k hou r a n d lifestyle.

E ducation Factors
Community-based medical education is a significant element in Canadian rural clini cal
schools, especially in Northern Ontario where students ar taken through a cutTiculum that
considers the needs of the immediate conununity.

lerkship programs and the final years of

medicine are b ased in rural or local settings, unlike the conventional model that allocate
clerkship programs to large, urban-ba ed institution . This rural placement exposes tudent to
rural practice and may influence their deci ion to work there. Experienc s during po t-graduate
training may al o influence rural practice. In

anada, graduate can apply for and start sp c ialty

training courses directly after cho 1. In choo ing intent hip , re ear h h w that stud nt from
rural-ba ed p

t-grad uate training in tituti on

ften opt for rural practi e (Vi comi et al , ~ 013) .

24

In rural area
re ow·c

car r oun elling for phy ician i minimal and th a ailability of
ncern. Ther D r , tal nt d tudent who wi h to pur ue advanced

i al o ani u of

training in m di cin are limit d by th
conduct d in

anada have al

chool , a it pertain to rural

carcity of re urce for higher du cation. tudie

indicated that th attitud

f tud ent prior to attending medical

r u urban c mmunity living influ ence their eventual decision to

work in rural or urban area (Vi c mi t al, 20 13) .
A medical ch ol that fD r program of t-ural

cti ve xp ri nee mi ght help increa e

the probability of a tud ent practicing in rural area . Thi s incl ud e

ffering core and elective rural

rotation to promote rural medical pra ti ce. When tud ent are placed in rural etting wher th ey
interact with phy ician , they develop po itive experiences toward rural practi ce. The most
likely candidate for rural medical practice are: tudents ori ginall y from rural area , tho e
exposed to rural elective programs during medical chool, those und er bond ed ch lar hip
contracts to operate in und er- erved areas fo r a specified time period po t-graduati on, tho e
wishing to be generalists with an interest in famil y medicine, and tho e who come fro m
communities where doctors are highl y esteemed (Vi scomi et al, 20 13).
Access to continuing medical educati on and profe sional development are uni qu e to each
physician. Findings fro m Vernon Curran et al. (20 10) indicate that there i strong evid ence
demonstrating that the CME/CPD needs of rural phy icians are uni que and that profe ional
isolation and access to CME/ PD are key fac tors affecting rec ruitment and retention. Fie ibi li ty
and a vari ety of M I PD opportunities to accommodate di fferent educati onal intere t and
requirements are necessary and mu t be indi viduali zed. Supporting the profe sio nal careers of
doctors in a regi n requir

the pr vi ion of integrated edu ca ti onal program that focu on

p ci fi c in[! m1ati on and skill ( una n, Rourke,

now, 20 I 0) .

25

Pr viou

tudie hav r port d that phy ician originating from a rural community ar

two and a half t thr

and a half tim

mor likely to b in a rural practic a c mpar d to tho e

who cam from urban ar a . Training in rural
p

tgraduat 1 v ls, ha been h wn t have a p

in a rural community ( hauhan et al, 201 0) .

tting , at both the unci rgraduate and
itive a ociati n with th e d ci ion to practic
, medica l stud ent who are

po d to rural

m edi ine early in their tudie or durin g their re id ncy and clerk hip ar more lik ly to dev lop
an appreciati n and pa ion £ r rural medi c in

nee they gradu ate (Mayo & Matthew , 2006) .

Howeve r, mo t of th e world ' m eli ca l ch ol are itu ated in large c iti

. Most medi cal tud nt

are raised in afflu ent urban area , learn little ab ut rural hea lthcare need , and exp ri ence !itt! or
no medi cal learning in the rural context (Rourke, 20 10). Many phy ician who are rai eel in a
rural community feel the need to give back to their communi ty; therefore, they return home and
work diligently in patient care beca u e they want to contribute to the developm ent of their
community. By doing so, they create a situati on of mutual benefit where rural citizens receive
excellent patient car e and physicians receive respect and ad1niration in return .
M edical school faculty also have an influence on where student choose to practice by th e
manner with which they discu s rural settings in the cl as room . Therefore, the medical school
faculty should refrain fro m projecting negati ve or bia eel opini on in rega rd s to practici ng in rural
areas as negative connotation could di scourage tudent who are willing to indulge in rural
practice after gradu ation . Faculty should also include problem-based modules that integrate
rural-based issues to help the students und erstand the actu al ituati on in rural area (Hancock,
Ne bitt, Adl er, & Auerswald , 2009) .

26

Propo ition Sa: E po ure to rural community medicine through po itive didactic
education rural rotation and rural intern hip can increa e both ph y ician r ecruitm ent
and retention to under erved communitie .
Propo ition Sb: A lack of educational and profe ional r ource that ma y limit a
phy ician ability to pur ue hig her educa ti on r ad va nced trainin g can n egativel y affect
the retention of ph y ician in rural communiti e .
Proposition Sc:
hallen ge for ph y ician to obtain appropri a te a nd a pplicable rural
community ME / PD in a tim ely and ea il y a cce ibl e ma nn er ca n negati vel y affect th e
r etention of phy ician in rural communiti e .
Propo ition Sd: Ph ician are likely to choo e to pra ctic e in a rura l or r emote communi ty
if th ey have had ex po ure uch a communi ty durin g th ir m edi ca l tra inin g.

C urrent R etention Program Offer ed by the Province of Briti h Columbi a
Th Joint tanding
of Briti h

(i)

olumbia (R

mmittec on rural i sue (J
be) wh

) fund the Rural

ordin ati on

ntre

e intere t li e in impr vmg:

ducation and training to promote l cal continuing profe ional devel pment
( PD) [! r rural doctor and to cr ate a b tter und er tanding of rural hea lth ar

ue .
(ii)

Recruitment and retention[! r a uffi ci nt uppl y f health pr fe ional in B
and t addres ari ing hall enge .

(iii)

Particul ar popul ati on by erving the n cd o f minority co mmuni ti e. and
cstabli hing releva nt upport and b t practi ce .

(iv)

ommunicati on by upporting di

' U.

ions, ' tabli hing n ~ tw rk. , and

c mmunica ti c n for rural pr fc sional and th
( v)

li ve ry through d

'O mmunit .

nt of rural pro[! s. ionaL in

anada .

27

(vi)

valuation and quality impr vement and rural health
a e ing rural health
Plan) and R

TheJ

rv1ce re earch by

rv1ce trategies applied by REAP (Rural

ducation

ction

be and integrating re ult int health policie (B MA , 20 13).

under the Rural Practic

ub idiary

gr em nt (R

), advise the Briti h

Medical A ociati n (B MA) and the g venun nt n rural healthcar i u
phy ician are availabl in rural ar a by

olumbia

and en ures that

lving th chall enge faced by the phy icians in the e

areas. They d thi by addre ing the uniqu e and difficult clinical circum tance exp ri enced by
tural phy ician . The R Aha a li t of communi ti e that are eli gibl e for these program .
Communities are categorized by level of remotene

or level of priority. ee appendix B for the

R A 's communitie li t. Government rural retenti on pr gram include :

(i)

Rural Retention Program (RRP) where retention remuneration i given to
physicians who work in uitabl e R A conununitie .

(ii)

Rural Continuing Medical Education (RCME) which offers CME funding
opportunities for physicians to enhance their m edical credential , edu cation, and
skills.

(iii)

Rectuitment Incenti ve Fund (RIF) offer variable funds to physicians who are
recruited to cover available vacancies which are li ted in th phy ician uppl y
plan of the R A.

(iv)

R cruitment

ontingency Fund (R F) is a recruitment fund u ed in ,e ere a e

to assi t doct r , health authoritie , or communiti es under th R

wh r there

28

are problem filling a ritical acancy and a qualified r cipi nt mu t be out ide
th

ntitled R A

mmunitie .

ther key program are the I olati n
Fund (RE F), Rural

du cati n

llowance Fund (I F), Rural

cti n Plan (

peciali t L cum Program (R LP)

P), Rural

m ergency

nhancem nt

P Locum Pr gram (R PLP) , Rural

ol1hern and I olati n Travel

istance

utreach Program

(NITA P) , and p cialty Training Bur ary Pr gram (B MA, 20 13 ). Typically preference and
allocation of fundin g i provid ed to the m

t i olat d r vulnerable conm1uniti e fir t.

me medical school pr gram recognize the issue facing rural hea lth and have
modified their application proce . For example, admi ions into the Facu lty of M edi ci ne at the
University of British Columbia (UB ) changed in 2004 with the introduction of the Rural and
Remote Sustainability Score (RRSS). Candidate are screened ba ed on their ex perience in rural,
remote, northern, and/or aboriginal communities, and activities relevant to remote northern
li vi ng. The admissions committee analyzes the candidate's wi llin gness to rem ain in rural practice
upon academic compl etion, and candidates are a ked where their preferred campus ite i
located: Vancouver Fraser Medical Program (VFMP) , Southern M edi cal Progra m (SMP), The
Island M edical Program (IMP) and the Northen1 Medical Program (NMP) . For each academic
year there are a total of 288 eats for incoming medical student with the following breakdown:
VFMP with 192 seats and SMP, IMP , and NMP each with 32 of the remaining eats (UBC ,
20 14 ).
T lehealth use vid eoconferencing and uppo1iing teclmo logies to put patient in touch
w ith h alth profe i nal acros grea t di stance . It i

specia ll y u eful in remot areas where

pati ent have to travel far to meet hea lth professiona ls (eHca lth, 2014) .

29

T 1 h alth reduce th travel burd n and di tanc barrier of rural citiz n , and pr vid
acce

gr at r

to a wide rang of p ciali t advic and erv·ice . Teleh alth i a onv ni ent, o t ffl ctiv

program that ha be n impl mented in m

t provin e . For phy ician , it can reduc the en e of

i olation, improve continuing profe ional edu cati n, and provid e an a ier form f
communication b tween pro[!

ional . The Tel h alth program indir ctly acts a a ret ntion

program by reducing w rkload on th ph y ician . In 200 , the Mini try of Health fonn ed a
Telehealth Offi e to facilitat the de ign and impl ementation ofT I health olutions ( eHealth
20 14) .

The Indi genou Phy ician A ociation of anada ha pa1in red with the A ociation of
Facultie of M edi cine of Canada to increase admi

ions and support for indi genou s tud ent in

anada' medical sc hoo ls and to develop a First

at ions. Inuit, and Meti hea lth competenc ie

curriculum framework (Rourke, 20 10) .

Proposal 6a: The Joint Standing Committee on rural issues (JSC) offers man y attractive
incentives for the recruitment and retention of phys icians to rural communities.
Proposal 6b: Rural Practice Subsidiary Agreement (RSA) offers man y attractive
incentives for the recruitment and retention of ph ys icians to rural com munities.
Proposal 6c: Modifications to existing University medical school admissions policies that
increase the proportion of students admitted to medical programs from a rural
background will improve ph ysician recruitment and retention to underserviced
communities.
Proposal 6d: Introduction of physician supportive technologies such as Telehealth
improves physician recruitment and retention to rural communities.
Proposal 6e: I ncrea ed admis ion and support of indi genou medical students addre se
unique cultural needs and improve recruitment and retention of the e physician to
region s of greater indigenous population.

30

MODIFIABLE FACTOR
!though man y tudie h a
th m i equal] y

mpha ized the recruitm nt f rural phy i tan , r taining

enti al. Th an aly i of ph y ician ' e p ri ence in rural ar a

all tage , from the time tudent

ho uld focu

n

tart medi al chool to th tim they graduate and becom

practitioner in rural ar a . Th main modi fi abl factor are opp rtunitie for group prac tice,
du cation, b tter ho pi ta! fac ilitie (impro ed re ource ), fin an ial motiva tor , and rea li tic
w rking co ndition (heavy wo rkl oad and 1 ng on-ca ll h ur ). Rural area that are very remote

and completely isolated have more challenge ( unan t al, 2004 ). The locati on of the h pi tal,
organization, and vision are e

ntiaJ fac tor that can m oti vat phy ician to work in a given

1 cation. Medical schoo l have a role to play in thi , particularly those located in rural campu
locations, and often concentrate on encouraging stud ent to practi ce in tho e area and u e
curricul a that are rural-ori ented and offer continu ed rural experiences to th eir tud ents. Students
who attend m edical chool in rural sett ing are exposed to rural experi ences, hence they are m ore
likely to indulge in rural practice after gr adu ation (Curran et al, 2004).
M odifiable fac tors fo r CME and CPD includ e stud y leaves, m ore training opportunitie ,
and bas ic life support. Financial incenti ve to attract m ore rural physician incl ude reducing
hardship, improving housing and travel all owance , paid vacations and edu cation leave , bonuse
for on-call services, etc.
Proposal 7a : Addressin g modifi able factors improves recru itment and retention of
physician s to rural communities.

R E OM MENDATION

31

Personal
Propos ition la: Th e opinion of a phys ician s pou e and /o r family membe r are e entiat
determinant of whether a ph ys ician ta y or leave .

•

mploym nt for a pou e an b 1mp rtant in r lati n to th ir lev 1of contentm nt;
orth m H ealth hould take thi int con id rati n wh n r cruiting phy ician . R gi nal
ho pital can try t rec ruit th

pou

int m all y r ffer a partn rship with a local chool

t all w the spou e an pp Iiunity t upgrad the ir kill . Thi al o could help to inc r a e
the level of cont ntm nt of the pou e by in tilling a en e of purpo e.

•

In order for a community to appropriately allocate fundin g toward

pecifi c facilities or

r ource , further re earch to detennin th factor which c ntribute both directly and
indirectly to a pou e' leve l of contentment within a rural community hould be
investigated.
•

Reduction of a physician 's work load/hours to n urea better work-life balance with
family .

•

H ealth Authorities and governm ent should consid r offering sc ho larship for ph y 1c1an
children to provide them the opportunity to attend a reputabl e chool.

Proposition 1 b: A lack of opportuni ty for pe rsonal growth affects the physician's choice in
staying in the com m unity.
•

FUiih r research on und rstanding the co nn cti o n betw en the ocia l and profe ional
env ironment of a phy i ian and how that affect their per onall e

l of on t ntment

would impro v rural r cruitm ent and ret ntion po lic ie .

32

•

Rural m di ine p
incentiv

tgraduat re id ncy training program

pro id d to tho

phy ician accepting rural p

provid phy ician with th

hould be enc urag d or have
iti n . This not only will

kill needed D r rural practi c , but will al o prom t doctor

to nt rand tay in rural practic .
•

R m t program

hould place a tr ng r mpha i

n retention; many rem te program

eem to focus more n the D rmal pr c s of recruitment and le
•

attention to retention.

Medi ca l chool d dicated to recruitin g and retaining medical phy ician sh uld place an
empha i on the ocial kill physician need to ucc ed in rural practi ce in the
curriculum. The e could include good I ader hip, adaptability and public peaking skill
Often physician in rural area are call ed on to represent an entire community in regard
to health requirements.

Professional
Proposition 2a: Difficul ty in achi evin g conti nuin g edu ca tion courses may deter a phys ician
from sta yin g in rural practice.

•

Access to CME courses is necessary on a profes ionallevel, but al o i impo11ant in
allowing physicians to as ociate and conununi cate with co lleagues to reduce their
potential feelings of isolation. Flexible programs should be readily available and ea y to
access such as workshops, e- leaming, Skype video conferences, telephone, and funded
learning opportunities.

•

B MA facilitation of continuing medical education conferenc
areas on ite, with topic

specifically for rural

pecific for the i ue facing tho e patii ular rural r gion .

Proposition 2b: Doctor in rura l areas are vulnerable to burnout due to heavy workload,
long hours, and lack of peer upp ort.

33

•

Clinic admini trator

hould c n ider modified or reduced work hour and creative

n1 an to accomm date oth r phy ician lifestyle factor in order tor tain a great r
numb r of doctor who have a trong commitm nt t practic in und r- erved ar a
•

Nur

Practitioner (NP ) are trained in a broad c pe f practice. They are health-car

pr fe ional who treat the whol p er

n, addr

ing need r lating to their physical and

m ntal health, ga thering their m edica l hi tory, focu ing n h w their illn s affect their
live and their family, and off! ring way for p e pie t lead a h ealthy life and teaching
them how to manage chr nic illn

(N ur e Practitioners, 20 ll ).

P are edu cators and

researcher who can be c n ulted by other health -care team m mber . Nurse
practitioner ' are able to diagnose and treat illnes es, ord r tests, and prescribe
medication (Nurse Practitioners, 201 1). In areas that are und er-served by pri1nary
healthcare physician , NP

cope of practice can be increa ed to include orne increa ed

responsibilities that may currentl y be reserved so lely for the primary physician,
alleviating the workload and reducing burnout on physicians. The Health Profe ions Act
should provide guidelines for each corrununity. Duties such as diagnostics, primary care
assessments, and prescriptions of routine medicines such as first-lin antibiotics can be
increa ed . Further research should be condu cted to review the positive or negative ffect
that an increase of the N P ' re pon ibilities co uld have on the deli ery and effecti

nes

of healthcare to rural communities. Increa ing the scope of practice for other healthcare
workers in other disciplines should also be considered . Rural health are provider

hould

focu on a team approac h, working together with the same nd goal of impro ing public
hea lth. Primary car phy icians are re i tant to rc ommcndati n that call for an
ex panded role of NP and an increase in their numb r (Ready, 20 l ). Despite thi ~ , it

34

would b mutually b neficial for both ide within the m dical c mmunity to come to an
agr eabl
•

o lution before it i legi lat d in govenm1 nt.

Impl em ntati n of a pecific rural nur ing program pecialty for nur e during their
undergraduate univer ity tr aining. A lternati vely, po t-gradu ate training with a
cuiTi culum focu

ing on pecific rural h alth i ue

u ch a

pecifi c health care needs

m ore co1nm n in rural area a well a add ed em ergency care etc.
•

Phy ician

hould be comp n ated appro pri ately for w rking xtended hour and be

reimbur d ~ r continuing edu cation, partic ul arl y w hen travel co t are requir d .

Proposition 2c: Ph y ician s may becom e fru strated in rural ettings where medica l
technology is limited and bud gets are und erfund ed.
•

Local h ealth authoriti es hould work wi th th eir re pective M ember of Legislati ve
Asse1nbly (MLA) to ensure adequ ate fu nding to improve the leve ls of and access to
m edical teclm o logie .

Proposition 2d : Fin ancial incentives are a good recruitment strategy but do not prove to be
an effective lon g-term retention strategy.
•

Physicians w ho have invested a significant amount of their life in rura l communities have
a m ore substantial chance of remaining in rural pract ice. This is an important factor in
retention th at re-emphasizes the need for m edical school and po tgraduate training
progra ms to work closely with organiza ti on such a the WHO recomm ndati n ~ r
socially acco untab le medica l education.

•

R ecruiter

hould focu

np r

na lity traits and per onal ba kground befor the u e of

fi nanc ial incentive to attract phy ician . Physician who ar attracted to the oppotiuniti
th at ru ra l prac tice life of.G rare b ttcr andidat ~ for long-term ret ntion. These

35

pp rtuniti
phy ician

hould b
p

mpha iz d by medical pr gram and r cruiter and may includ e

ure to a larger cop of practice and re pon ibility, xpen encmg a more

p r onal r lation hip with pati nt and aut n my etc.

•

In tead of m netary in

nti e , th g v nlffient can a i tin thee tabli lun nt f pri vat

practic faciliti e .

Community
Proposition 3a: Larger community ize, increa ed as ets, re ources and opportunities, both
professionally and per onall y, increase ph ys icia n r etention in rural areas.
•

Hospital could partn r with local recreati onal fa ciliti

including gyms, librari es, mo vie

theaters, pools etc. to provid e phy ician and their famili e opportuniti e for exercise,
lei ure, and cultural enriclunent. This could also fost r a sense of belonging to the
cmnmunity, improv ing the likelihood of long-term retention.

Proposition 4a: Physicians are likely to choose to practice in a rural or remote community
if they have had ex posure to such a community during their medical training.
•

M edi cal school curri culum should highlight the hea lth need of under- rviced
communities. Thi s curriculum combined with unique and eruiching tural clini cal
pl acements at va ri ous j un ctures durin g a phys ician 's medi cal tra inin g may serve to help
stimulate the de ire to practice in a rural community as they w ill have e peri n e wi th
and a better und er tanding of Iura! c01nmuniti e , their people and their oft n uni qu e
hea lth challenges.

Proposition 4b: The more time spent in a rural community setting, the higher the
correlation of retention; c pecially if they have pent a substantial part of their form a ti ve
years in a remote community.

36

•

rad

ch

h uld includ pr gram in th ir curriculum that enc ura g

tud nt t pur u a car r in medi ine.

•

M di al ch

h uld r

candidate' per

nal ba kgr und and pre~ ren

mp th eir admi i n p lici e t pla

m r weight n a

for li in g and pra tiein g m di me m a

rural c mmunit

amining humani tic and

intrin ic typ fact r m m r detail earli r in th e medical edu ca tion election pr ce

may

be an imp rtant trat gy [! rid ntifying ph y ician who are moti va ted to practi ce in
und r rviced ar a ( d m Walk r t a], 20 10). Th r cruitment pr ce
b th th a

hould includ e

ment f acad mi ca chi vement and an exploration f deeper tud ent

c mmitm nt tow rking with under- erved p pul ation and increa e the proportion of
medical tud ent wh c me from rural background .

•

Phy ician in rural practice hould act a ment r t children in the co mmunity. Program
hou ld be encouraged for phys ician to vi it el mentat-y and ec ndary ch ol to
prom te the practice of medicine and how to achieve the goa l of becoming a d ct r.

Personality/Background

Proposition 4 b : Ph y icians that work in under- erved areas do so largely becau e of
mi s ion-dri ven va lu e , elf-identity, and acceptabl e w ork hour and life tyle.

•

tudi e on the effectivcne

of the RR

conducted to detcnnin the long tcnn

and imilar creening pr
~~ cL of rc ·ruitment and more imp

t1antl the

impact th y have on long-tenn r tenti on or physician in rural ·ommunitic ..

Edu cation

37

Propo ition Sa: Expo ure to rural community medicine through po itive didactic
education rural rotation and rural intern hip can increa e both ph y ician recruitment
and retention to under erved communitie .

•

M di al ch
ur
f tudi

•

amil phy ician wh pra ti
p

h uld impl em nt mandat ry clini al r tati n in rural ar a during th

m rem te and I

ial trainin g r lated t rural health i ue

uch a

m rg n y ca r , lead r hip kill ,

m ntal h alth and primary urgi a! ca r . Thi training mu t be readil y ava ilabl e t
ph

ician thr ugh n it , di tan

1 arning or virtu al

ntinuing edu ati n mean

a ure phy ician comp tency and increa e th eir co nfidence in th eir abiliti e t handl e
ituati on with littl e to no ut id e a i tance.
•

Medical ch

hould de elop academi c outrea h program to nc urage tud cnt t

parti cipate in rural practi ce, mpha ize the importance f acti vely re ruiting rural
tud nt with ex po ure t

r a backgro und in famil y medi cin , facilitat

tud nt ex p

ure

to po itiv role models fr m rural area , and train tudent in advanced pr c dural kill
that may be required in a rural etting.

Proposition Sb: A lack of educational and profe ional re ource that may limit a
physician' ability to pur ue higher education or advanced training can negatiYely affect
the retention of phy icians in rural communitie .

•

Medi ca l cho 1 and ho pita!

h uld provide r

urce for phy ic ian to faci litate

c ntinuing medi ca l educa ti on and pr fe sional development.

r ating a ompr h n

central dat ba e [! r continuing edu ca ti n pr gram. and ppoti unitie: a. a pri mary
re

urc for phy ician to as. ist in their

ction and parti ci pation in ap pli ca I"' lo ' aL

di tanc , r e-1 arning programs.

38

Proposition Sc: Challenges for physicians to obtain appropriate and applicable rural
community CME/CPD in a timely and ea ily acces ible manner can negati vely affect the
retention of physicians in rural communitie .
•

M di cal chool

h uld c 1nmit to ffe ring f1 xible

M

cour e

online and e-learning

opti n t increa e acce ibility and to r due b eling of i olation, r m otenes and
minimize or eliminat travel time.

Proposition Sd: Ph ysici ans are likely to choose to practi ce in a rural or remote communi ty
if they ha ve had exposure uch a communi ty durin g their medi ca l trainin g.

•

M edi al chool
proc

hould modi fy their applicati on proc

ba d on p r onali ty.

es in1il ar to the Rural and Remote u tainability core (RR

) at UB

creenmg
can be

u ed to assess personality.

C urrent R etention Progra ms
Proposal 6a : T he Joint Standin g Committee on rural iss ues (J SC) offers ma ny attracti ve
in centives for th e r ecruitment and r etention of physicians to rural com muni ties.
•

M edi cal students from rura l areas often face financia l and ocial chall enges and hould be
offered supp01t and assistance for accommodations, tuition fee , and travel expen es etc.
to help faci litate their medi cal education.

Proposal 6b : Ru ra l Practice Subsidiary Agr eement (RSA) offers man y attractive
incentives for the recruitment and r etention of physicians to r ural communi tie .
•

T he main obj ective of the RSA shoul d be to optimize the health of Briti h

olumbian .

T he all ocation and effecti venes of fu nding should be va luated in relation to o erall

health of the citiz n and th e ffectiv ncs of phy ician r cruitment and ret nti on,
particularly in under erviccd communi tie .

39

•

A lth ugh om incentiv

currently

ist for phy ician who work at a ho pita l a a

gov rmnent empl ye , r ura l privat practice incentive

hould be made avai lable. It i

m r difficult for a phy i ian with a rura l private practic to leave a c01run unity than it i
D r a g v rnment emplo y e.

Propo a l 6c: M odifi cation s to existin g Uni ve rsity medical school admi sion s polici es th a t
increase th e proportion of stud ents admitted to m edical programs from a rural
background will improve ph y ici a n r ecruitm ent a nd r etention to underserviced
communiti e .
•

ince there is a tron g co rrelation b tween phy ician with rural background and rural
training, m edi cal

hould con id er increa ing the proportion f tudent admitted

to rural campu e .

Proposal 6d: Introduction of ph ysician suppor tive technologies such as Telehea lth
improves physician r ecru itment an d r etentio n in r ura l communities.
•

Further studies should be p erformed on the utili zation of the Telehealth program and the
impact it has on assisting rural physicians.

tudy results on usefLilness, effectivene s, and

overall efficiency of the system could then be used to make modifications to the program
or expand the existing service.

Proposa l 6e: I ncreased admission and support of indigenous medical students addresses
uniqu e cul t ural needs and improves recruitment an d retention of these physicians to
regions of greater indigenous population.
•

Increa ing the admittance of aboriginal people into m dical school may erve t
enco urage these graduating phy ician to practice in undersc1 iced rural co1nmuniti

and

th ose of an increased population of indi g no us pcopl . Physician of parti ular
aborigina l thnicity may be more und erstanding of cultura l difTcren ' CS and uniqu
chall enge that face some rural and indigenous popu lation..

hi ma facilitate a mor ~

40

m utually ben ficia l r lati n hip and gr at r und r tanding betw

n pa ti nt and phy i 1an

and ther £ r a m re ffecti e and impr v d d livery of heal th car .

Modifiable Factors
Propo al 7a: A ddre sin g modifi abl e fa ctor improves recrui tment and retention of
phy ici an to rural communi tie .
•

Human r
communiti

urce pr fe i nal r p n ibl e [i r recruitm ent of phy ic ian to rural
h uld r ceiv

p cialized training t enhance th e f[i c tivene

recruitm nt and rete ntion proc
imp rtant a p c t

f their

and trategie . Thi training hould empha iz

uch a the particul ar p r

nality charac teri ti c that are m

t likely to

re ult in I ng-t rm retention ofphy ician in rural c mmuniti es and id ntify tho e
p t ntial phy ic ian that are more likely to embra ce rural ca reer devel pment and rea li ze
job ati faction in uch an env ironment.
•

Introduce programs to enhance rural physician ' cope of practice. A Ithough it may be
difficult to quantify how relative cop e of practi ce is in th e role of recruiting and
retaining phy icia n , there i

trong evidence that ph y ician job at i fa tion increa e

with an increased scope of practice.

ONCLU ION
There are several factors influen mg ignificant c hange in British
y tern th at a re undeniable and mounting. Th futur

f h alth are in Briti h

olumbia' healthcar
olumbia will , c

th prov i ion of hea lthcarc servic s t a p pul ati on dramati all altered from that v hich
cunentl y exi t today.

41

Th pr bl m fa h rta g
c nununiti

111

anada will

rural phy ician will b

f primary healthcare phy ician in remot regi n and rural

ntinue t w r en. R tention trat g1

f

t mcrea

th number of

r-iner a ing importanc . R t nti n trat gie are diffi cult t

m a ure a r tenti n t nd to be a much m re c mpl ex i u than recruitm ent. Place and pe pi e
are uniqu e; th refi re, it i imp

ible t u e a on - ize-fi t -all trategy.

ommunitie , ho pital ,

cho 1 , and phy ician all have a r 1 in th recruitm nt and retention of ph y ician .
r gardl e

fin

m e and practi c

en rall y,

c tabli h d phy ic ian may I ave rural practice du e to la ck of

p e r upport, long hour , bum ut, lack of pou al UJ p rt/cont ntment, in uffi cient co mmunity
recreati nal a et , and lack of appreciation from th community. The relati n hip between th
phy ic ian and th e community i intimately connec ted and strongly influ ence long-t nn
retention .
As the effectiv ne

of phys ician retention i difficult tom a ure, more re earch i

needed to anal yze the new programs and trategies. Thi i especiall y true when id entifyin g
per onality trait , spou al contentment, personal moti va tors, and other trait that are diffi cult to
quantify . With

an ada's increa ing aging popul ati on, the uppl y of phy ician in und er- rviced

communitie is becoming an ever increasing conce111.

ery community is unique and it i

imposs ibl e to use only one strategy or rely on any one organi za tion or per on to improve rural
phy ician recruitment and retention. Government , medical a ociation , communi tie ,
hospital , school s, citizens, and all other takeho ld er mu t come together to crea te a plan and an
env1r nment that will attract and r tain phy ic ian long-t rm in mral communitie .
inancial inc nti ves and

M

pr grams have proven to b b nefi ial in short-term

recruitm ent. However, recruiting physicians w ho arc content with a rural lircst lc, free or
finan c ial inc nti ve. , results in more sati fied physi · ians and in Teases the likelihood or Jong-tenn

42

retenti n. Phy ician who ar
experienc in a rural

ati fi d with th rural life tyle tend to hav had previou

tting and typi ally have a long-tenn de ire to pra tice rural medicine.

Modification of them di al

hool admis ion proce

that put a high r weighting on the

applicant' per onality, place of ri gin , backgr und , and per onal motivat r ar more likel y to
graduate physician with an impr ved rate fret ntion in rural comrnuniti
of phy ic ian in rural co mmuni ti e may be t be increa

v rail, r t ntion

d throu gh a combination of per onality

trait el cti n criteti a during medical tudent admi ion and eventual financia l incentive for
tho e who hoo e to practice in rural communi ti e . ~ inancial incentive can prove effective in
the initial r cruitment proc

, but do not neces aril y tran late to long- t nn retention. Once the

number of physicians starts to increase in a community, the level of contentment of phy ician
also increa es. The pre ence of coll eagues allows for a support network and a better wo rk-li fe
balance that results in a b tter improved levels of personal and profe ional ati faction, thu
improving long-te1m retention of physicians.

43

APPENDIX A

Trained in

'''ork:ing in
underserved area

\\ ·ork.ing in
nonunderserved
area

Recruitment strategies

Retention strat gies

- :Ylission-dm·en values
- Self-identity
- \\iork hours'1ifestyie

- '\ ·ork hours ·lifestyle
- Practice location
- Higher salary
- Career progression
- \V ork enviroment

Figure 5, (Odom Walker eta!, 201 0)

44

APPENDIXB

tRSA COMMUNITIES - A B C D
A
100 Mile House

Fort St. James

Mackenzie

Sayward

Ahousat

Fort St. John/Taylor

Masset

Seton Portage

Alert Bay

Fort Ware

McBride

Sirdar

Alexis Creek

Fraser Lake

Miocene

Skin Tyee

Anahim Lake

Gold Bridge/Bralorne

Moricetown

Smithers

Ash croft/Cache Creek

Gold River

Mount Currie

Sointula

Atl in

Golden

Nadleh

Sparwood

Barnfield

Gran isle

Nakusp

Spences Bridge

Bella Bella/Waglisla

Greenwood/Midway/Rock Creek Nee Tahi Buhn

Stellat'en

Bella Coola

Halfway River

Nemaiah Valley

Stewart

Blueberry River

Hartley Bay

New Aiyansh

Tahsis

Blue River

Hazelton

New Denver

Takla Landing

Bridge Lake

Holberg

Ocean Falls

Tatla Lake

Burns Lake

Hornby Island

Port Alice

Tatlayoko Lake

Canal Flats

Hot Springs Cove

Port Clements

Telegraph Creek

Canoe Creek

Houston

Port Hardy

Terrace

Cheslatta

Hudson 's Hope

Port McNeill

Tofino/Ucuelet

Chetwynd

lnvemere

Port Renfrew

Tsay Keh Dene

Christina Lake/Grand Forks

Kaslo

Port Simpson

Ts 'il Kaz Koh (Burns Lake Band)

Clearwater

Kimberley

Prince Rupert

Tumbler Ridge

Clinton

Kincolith

Princeton

Ucluelet

Cortes Island

Kingcome

Quatsino

Valemount

Cranbrook

Kitimat

Queen Charlotte

Vanderhoof

Creston

Kitkatla

Quesnel

Wardner

Dawson Creek

Kitsault

Revel stoke

Wet'suwet'en (Broman Lake)

Dease Lake

Kitwanga

Rivers Inlet

Williams Lake

Doig River

Klemtu

Saik'uz

Win law

Edgewood

Kootenay Bay/Riondel

Salmo

Woss

Elkford

Kyuquot

Samahquam

Woyenne (lake Babine)

Fernie

Lower Post

Savary Island

Zeballos

Fort Nelson

Lytton

45

B
Balfour

Galiano Island

Pender Island

Slocan Park

Barriere

Lillooet

Powell River

Teppella

Big White

Mayne Island

Prince George

Texada Island

Castlegar

Merritt

Saturna Island

T rai 1/Rossland/Fruitvale

Chase/Scotch Creek

Nelson

Skatin

Wasa

Crescent Valley

c
Agassiz I Harrison

Duncan I N. Cowichan

Madeira Park

Salmon Arm/Sicamous

Blind Bay

Enderby

Mill Bay

Saltspring Island

Bowen Island

Gabriola Island

Nitinat

SecheiVGibsons

Campbell River

Hope

Oliver/Osoyoos

Shawnigan Lake

Chemainus

Keremeos

Parksville/Qualicum

Sorrento

Cobble Hill

Ladysmith

Pemberton

Squamish

Courtenay/Comox/Cumberland

Lake Cowichan

Port Alberni

Whistler

Denman Island

Logan Lake

Quadra Island

Armstrong I Spallumcheen

Lumby

D

(Adapted from Rural Coordination

Sooke

entre, 201 4)

The R A communi tie li t i ba ed on a point y tern . Isolation is establi hed on a number of
factor including the number of GPs in the community and the distance of the community fr m a
major medical community (Rural Coordination Centre, 2014).

46

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ACRONYMS
Briti h

lumbia M di caJ

anadian Medical A

ociation (B MA)

ciation ( MA)

ontinuing medical edu cation ( ME)
Continuing profe ional developm ent (CPO) .
I land Medical Program (IMP)
Joint Standing Cmnmittee (J C)
Northern Medical Program (NMP)
N ur e Practitioner (NP)
Return of ervice (R S)
Rural and Remote Sustainability Score (RRSS)
Rural Coordination Centre of Briti sh Columbia (RCCbc)
Rural General Practice Locum Program (RGPLP)
Rural Practice Subsidiary Agreement (R A).
Southern Medi cal Program ( MP)
Vancouver Fra er M edical Program (VFMP )
Vancou v r

eneral Hospital (VGH)

World Health

rga ni za ti on (WHO)

50