Outcomes of the Northern Ontario School of Medicine's distributed medical education programmes: protocol for a longitudinal comparative multicohort study

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

CONTEXT

Women outnumber men in medical school. Given the growing need for rural physicians and the underrepresentation of women in rural medicine, understanding predictors of rural practice among female students is imperative for addressing future healthcare workforce shortages in rural areas. Utilizing current evidence, medical schools should seek to admit students with a rural background and interest in pursuing a primary care specialty; however, whether this holds true for female osteopathic medical students is unknown.

OBJECTIVES

This study aims to determine if a rural background, a plan to practice family medicine, and motivation toward civic duty are associated with attitudes toward eventual practice of rural medicine in female osteopathic medical students.

METHODS

An anonymous online survey was administered to actively enrolled female students at Arkansas Colleges of Health Education College of Osteopathic Medicine. The survey assessed the respondents' presence of a rural background, degree of civic-mindedness, intention to practice family medicine, and attitudes to rural work and life. Demographics of ethnicity and year of study in medical school were also collected. In total, 129 students responded to the survey, with 97 complete responses for analysis. Hierarchical regression was utilized to compare nested models and interpret interactions.

RESULTS

Of the 97 survey respondents, 34.0 % described themselves as first-year students, 37.1 % as second-year students, 16.5 % as third-year students, and 12.4 % as fourth-year students. Linear regression modeling indicated that for female medical students at Arkansas Colleges of Health Education, having a rural background had no relationship with their attitude toward practicing in a rural setting, β=-0.97, standard error (SE)=1.96, t=-0.49, p>0.05, CI [-4.86, 2.92]. Civic-mindedness had a positive relationship with their attitude toward practicing in a rural setting, β=0.17, SE=0.07, t=2.44, p=0.016, CI [0.03, 0.31], accounting for 4.57 % of its variance. Plan to practice family medicine was positively associated with a student's attitude toward practicing in a rural setting, β=4.38, SE=0.85, t=5.15, p<0.001, CI [2.69, 6.07], accounting for 20.25 % of its variance. Civic-mindedness appeared to moderate the relationship between planning to practice family medicine and attitudes toward practicing in a rural setting, F(1, 91) = 3.91, p=0.05, R 2=0.31. The p value for this interaction term was 0.05, but its effect size measure and graphical representation revealed a substantive effect.

CONCLUSIONS

The regression analysis showed that, for the women in this study, the greater the student's civic-mindedness, the more favorable her attitude toward practicing in a rural setting. Additionally, the stronger the student's plan to practice family medicine, the more favorable her attitude toward eventual rural practice was. Lastly, the student's civic-mindedness influenced the predictive value of having a plan to practice family medicine.

Social accountability in a medical school: is it sufficient? A regional medical school curriculum and approaches to equip graduates for rural and remote medical services

BACKGROUND

Social accountability is increasingly integral to medical education, aligning health systems with community needs. Universitas Pattimura's Faculty of Medicine (FMUP) enhances this through a curriculum that prepares graduates for rural and remote (RR) medical practice, exceeding national standards. The impact of this curriculum on graduate readiness in actual work settings remains unassessed.

OBJECTIVE

This study was conducted to capture the perspectives of FMUP medical graduates in a rural-centric curriculum, focusing on the teaching and learning opportunities afforded to them during their medical education. These insights are crucial for evaluating the accountability of regional medical schools in delivering quality service, particularly in underserved areas.

METHODS

Semistructured interviews were conducted with nine FMUP graduates employed in the RR areas of Maluku Province. A qualitative analysis was employed to examine graduates' views on the curriculum concerning medical school accountability.

RESULTS

The FMUP curriculum, informed by social accountability principles, partially prepares graduates to work under Maluku's RR conditions. However, it was reported by participants that their skills and preparedness often fall short in the face of substandard working environments.

CONCLUSIONS

The FMUP curriculum supports the government's aim to develop an RR medical workforce. However, the curriculum's social accountability and rural emphasis fall short of addressing community health needs amid inadequate practice conditions. Political investment in standardizing medical facilities and equipment is essential for enhancing graduates' effectiveness and health outcomes in RR communities.

Are early career family physicians prepared for practice in Canada? A qualitative study

BACKGROUND

In Canada, the College of Family Physicians of Canada (CFPC) introduced Competency Based Medical Education to prepare and train family medicine residents to be competent to enter and adapt to the independent practice of comprehensive family medicine. Despite its implementation, the scope of practice is narrowing. This study aims to understand the degree to which early career Family Physicians (FPs) are prepared for independent practice.

METHOD

A qualitative design was used for this study. A survey and focus groups were conducted with early-career FPs who completed residency training in Canada. The survey and focus groups examined the degree of preparedness of early career FPs in relation to 37 core professional activities identified by the CFPC's Residency Training Profile. Descriptive statistics and qualitative content analysis were conducted.

RESULTS

Seventy-five participants from across Canada participated in the survey, and 59 participated in the focus groups. Early career FPs reported being well prepared to provide continuous and coordinated care for patients with common presentations and deliver various services to different populations. FPs were also well prepared to manage the electronic medical record, participate in team-based care, provide regular and after-hours coverage, and assume leadership and teaching roles. However, FPs reported being less prepared for virtual care, business management, providing culturally safe care, delivering specific services in emergency care hospitals, obstetrics, self-care, engaging with the local communities, and conducting research activities.

CONCLUSIONS

Early career FPs do not feel fully prepared for practice in all 37 core activities in the Residency Training Profile. As part of the introduction of the three-year program by the CFPC, the postgraduate family medicine training should consider providing more exposure to learning opportunities and developing curricula in the areas where FPs are unprepared for practice. These changes could facilitate the production of a FP workforce better prepared to manage the dynamic and complex challenges and dilemmas faced in independent practice.

Ten years of graduates: A cross-sectional study of the practice location of doctors trained at a socially accountable medical school

Introduction

The study predicted practice location of doctors trained at a socially accountable medical school with education programs in over 90 communities.

Methods

A cross-sectional study examined practice location 10 years after the first class graduated from the Northern Ontario School of Medicine (NOSM), Canada. Exact tests and logistic regression models were used to assess practice location in northern Ontario; northern Canada; or other region; and rural (population <10,000) or urban community.

Results

There were 435 doctors with 334 (77%) practising as family doctors (FPs), 62 (14%) as generalist specialists and 39 (9%) as other medical or surgical specialists. Approximately 92% (128/139) of FPs who completed both UG and PG at NOSM practised in northern Ontario in 2019, compared with 63% (43/68) who completed only their PG at NOSM, and 24% (30/127) who completed only their UG at NOSM. Overall, 37% (23/62) of generalist specialists and 23% (9/39) of other specialists practised in northern Ontario. Approximately 28% (93/334) of FPs practised in rural Canada compared with 4% (4/101) of all other specialists. FP northern Ontario practice was predicted by completing UG and PG at NOSM (adjusted odds ratio = 46, 95% confidence interval = 20–103) or completing only PG at NOSM (15, 6.0–38) relative to completing only UG at NOSM, and having a northern Ontario hometown (5.3, 2.3–12). Rural Canada practice was predicted by rural hometown (2.3, 1.3–3.8), completing only a NOSM PG (2.0, 1.0–3.9), and age (1.4, 1.1–1.8).

Conclusion

This study uniquely demonstrated the interaction of two mechanisms by which medical schools can increase the proportion of doctors’ practices located in economically deprived regions: first, admit medical students who grow up in the region; and second, provide immersive UG and PG medical education in the region. Both mechanisms have enabled the majority of NOSM-trained doctors to practise in the underserved region of northern Ontario.

Factors associated with the rural and remote practice of medical workforce in Maluku Islands of Indonesia: a cross-sectional study

BACKGROUND

Many factors contribute to engagement in rural and remote (RR) medical practice, but little is known about the factors associated with rural and remote medical practice in such remote locations as the Maluku Province of Indonesia. This study describes factors associated with actual RR practice, preferred RR practice, and intention to remain practice in Maluku Province.

METHODS

An online survey of work-related experience and intentions for future rural work was administered to 410 doctors working in the Maluku province of Indonesia. Participant characteristics were described using descriptive statistics, associations between the independent variables with the location of the workforce, intention to remain practice in Maluku, preference for future RR practice in Maluku were analysed using Chi-square tests and logistic regression.

RESULTS

A total of 324 responses (79% response rate) were recorded, comprising 70% females and 30% Pattimura University graduates of doctors employed in Maluku. Doctors working in RR areas were more likely to be a GP (OR 3.49, CI 1.03-11.8), have a monthly salary of more than IDR 6 million (OR 11.5, CI 4.24-31.1), and have no additional practice (OR 2.78, CI 1.34-5.78). Doctors intended to stay practice in Maluku were more likely to be born in Maluku (OR 7.77, CI 3.42-17.7) and have graduated from Pattimura University (OR 3.06, CI 1.09-8.54), and less likely to be a temporary employee (OR 0.24, CI 0.10-0.57). Doctors who prefer future RR practice in Maluku were more likely to experience rural living (OR 2.05 CI 1.05-3.99), have a positive indication of the impact of community exposure during medical schools on their current practice (OR 2.08, CI 1.06-4.09), currently practising in RR Maluku (OR 8.23, CI 3.27-20.8); and less likely to have bigger take-home pay (OR 0.30, CI 0.13-0.70).

CONCLUSION

This study indicates that special attention should be given to recruiting doctors with a rural background and ongoing support through attractive opportunities to build a sustainable RR workforce. Since a regional medical school helps supply doctors to the RR areas in its region, a sustained collaboration between medical schools and local government implementing relevant strategies are needed to widen participation and improve the recruitment and retention of RR doctors.

Comprehensiveness of distributed medical education systems: a regional population-based perspective

BACKGROUND

The core business of medical schools includes clinical (education and service) and academic (research) activities. Our objective was to assess the degree to which these activities exist in a distributed medical education system in Canada.

METHODS

A population-based design was utilized. Programs were contacted and public records were searched for medical trainees and faculty positions within a province in Canada during the 2017/2018 academic year. Data were expressed as positions per 100,000 residents within the Lower Mainland, Island, and Northern and Southern interior geographical regions.

RESULTS

Substantial differences in the distribution of medical students by region was observed with the highest observed in the Northern region at 45.5 per 100,000 as compared to Lower Mainland, Island, and Southern regions of 25.4, 16.8, 16.0 per 100,000, respectively. The distribution of family medicine residents was less variable with 14.9, 10.7, 8.9, and 5.8 per 100,000 in the Northern, Island, Southern, and Lower Mainland regions, respectively. In contrast, there was a marked disparity in distribution of specialty residents with 40.8 per 100,000 in the Lower Mainland as compared to 7.5, 3.2, and 1.3 per 100,000 in the Island, Northern, and Southern regions, respectively. Clinical faculty were distributed with the highest observed in the Northern region at 180.4 per 100,000 as compared to Southern, Island, and Lower Mainland regions of 166.9, 138.5, and 128.4, respectively. In contrast, academic faculty were disproportionately represented in the Lower Mainland and Island regions (92.8 and 50.7 per 100,000) as compared to the Northern and Southern (1.4 and 1.2 per 100,000) regions, respectively.

CONCLUSIONS

While there has been successful redistribution of medical students, family medicine residents, and clinical faculty, this has not been the case for specialty residents and academic faculty.

Twelve tips for establishing a new medical school

Many new medical programs have been established during the last 20 years, and this trend seems set to continue as the health care needs of the world's populations become more complex and demand increases for more physicians to provide the necessary health care. In this paper, we address how best to establish a new medical school, based on our experiences in new ventures in several countries. Success requires a combination of boldness of vision, support from many stakeholder groups, adequate financial and human resources, educational expertise, confidence, patience, and persistence.

The do's, don'ts and don't knows of establishing a sustainable longitudinal integrated clerkship

INTRODUCTION

The longitudinal integrated clerkship is a model of clinical medical education that is increasingly employed by medical schools around the world. These guidelines are a result of a narrative review of the literature which considered the question of how to maximize the sustainability of a new longitudinal integrated clerkship program.

METHOD

All four authors have practical experience of establishing longitudinal integrated clerkship programs. Each author individually constructed their Do's, Don'ts and Don't Knows and the literature that underpinned them. The lists were compiled and revised in discussion and a final set of guidelines was agreed. A statement of the strength of the evidence is included for each guideline.

RESULTS

The final set of 18 Do's, Don'ts and Don't Knows is presented with an appraisal of the evidence for each one.

CONCLUSION

Implementing a longitudinal integrated clerkship is a complex process requiring the involvement of a wide group of stakeholders in both hospitals and communities. The complexity of the change management processes requires careful and sustained attention, with a particular focus on the outcomes of the programs for students and the communities in which they learn. Effective and consistent leadership and adequate resourcing are important. There is a need to select teaching sites carefully, involve students and faculty in allocation of students to sites and support students and faculty though the implementation phase and beyond. Work is needed to address the Don't Knows, in particular the question of how cost-effectiveness is best measured.

Geographic Distribution of Regional Quota Program Graduates of Japanese Medical Schools: A Nationwide Cohort Study

PURPOSE

To show the practice location of graduates from two Japanese programs recruiting physicians to rural areas: a regional quota program of medical schools and a prefecture scholarship program (a prefecture is an administrative geographic division). Graduates of each program must work in a designated rural prefecture for a fixed period.

METHOD

A nationwide cohort study was conducted for three groups of participants graduating between 2014 and 2016: quota graduates without scholarship (quota alone), nonquota graduates with scholarship (scholarship alone), and quota graduates with scholarship. A questionnaire was sent via medical school or prefecture office to each potential subject to collect baseline individual data, including home prefecture and graduation year. Data were connected through physician identification number to the Physician Census 2016 of the Ministry of Health, Labour and Welfare to identify the subjects' practice location and compared with data for other physicians in the census. Comparisons were conducted with Mann-Whitney and chi-square tests.

RESULTS

The proportion of physicians working in nonmetropolitan municipalities for quota alone (185/244; 75.8%), scholarship alone (305/363; 84.0%), and quota with scholarship (341/384; 88.8%) was significantly higher than for other physicians (13,299/22,906; 58.1%). Median population density of the municipalities where subjects worked for quota alone (1,042.4 persons per square kilometer), scholarship alone (613.5), and quota with scholarship (547.4) was significantly lower than that for other physicians (3,214.0). These disparities increased with number of years since graduation.

CONCLUSIONS

The regional quota and prefecture scholarship programs succeeded in producing physicians who practiced in rural areas of Japan.

Emigration of regional quota graduates of Japanese medical schools to non-designated prefectures: a prospective nationwide cohort study

OBJECTIVES

This study examined the retention of regional quota graduates of Japanese medical schools and prefecture scholarship recipients within their designated prefectures where they are obliged or expected to work and revealed the personal and regional characteristics associated with their emigration to non-designated prefectures. Regional quota and prefecture scholarship are two of the most ambitious policies ever conducted in Japan for recruiting physicians to practice in rural areas.

DESIGN

Prospective cohort study.

SETTING

Nationwide.

PARTICIPANTS

Regional quota graduates with prefecture scholarship, quota graduates without scholarship and non-quota graduates with scholarship of Japanese medical schools who obtained their physician license between 2014 and 2016.

PRIMARY OUTCOME

The emigration in 2016 of the participants from the designated prefectures.

RESULTS

Total participants were 991 physicians, three of whom were excluded due to the missing values of crucial items, leaving 988 participants for analysis (quota with scholarship 387, quota alone 358 and scholarship alone 243). The percentage of those who emigrated was 11.9% (118/988). The mean (±SD) proportion of subjects who emigrated was 11.7% (±10.3) among all prefectures and the proportion varies widely among prefectures (0%-44.4%). Multilevel logistic regression analysis showed those who received prefecture scholarship (OR 0.23; 95% CI 0.08 to 0.67) and whose designated prefecture has an ordinance-designated city (ie, large city) were less likely to emigrate (OR 0.47; 95% CI 0.24 to 0.90). In contrast, graduates from a medical school outside the designated prefecture (OR 4.20; 95% CI 2.20 to 7.67) and who have a right to postpone their obligatory service (OR 3.42; 95% CI 1.52 to 7.67) were more likely to emigrate.

CONCLUSIONS

A substantial proportion of regional quota graduates and prefecture scholarship recipients emigrated to non-designated prefectures. Emigrations should be reduced by improving the potential facilitators for emigration such as discordance in location between medical school and designated prefecture.

Factors affecting access and use of preventive and weight management care: A public health lens

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.

A Narrative Literature Review Considering the Development and Implementation of Longitudinal Integrated Clerkships, Including a Practical Guide for Application

Hailed by supporters as the answer to many challenges facing medical schools and the wider health care system, longitudinal integrated clerkships (LICs) offer a practical and sustainable alternative to more traditional block rotational models. Given this, their popularity as a curricular measure is increasing, although such clerkships remain relatively novel within the United Kingdom. This narrative literature review of international work provides a comprehensive introduction to developing and implementing LICs within medical education. This review generates a practical guide for medical educators with a focus on the development and implementation of LICs within the United Kingdom, on which there is little work. Using illustrated examples and with reference to contemporary literature, it outlines the rationale for considering an LIC within a curriculum, the different types of LIC, barriers and enabling factors to LIC implementation and considers the contemporary application of LIC models within the United Kingdom. The practical guide details key questions educators must consider when developing and implementing an LIC, particularly within the landscape of UK medical education.

Needs of the many: Northern Ontario School of Medicine students' experience of generalism and rural practice

OBJECTIVE

To explore the Northern Ontario School of Medicine (NOSM) student and graduate experience of generalism in rural practice, in the context of a growing discourse on generalism.

DESIGN

Qualitative analysis.

SETTING

Northern Ontario School of Medicine in multiple sites across northern Ontario, which is the NOSM campus.

PARTICIPANTS

A total of 37 graduating medical students and 9 practising NOSM graduates.

METHODS

The Centre for Rural and Northern Health Research and NOSM tracking studies use mixed methods drawing on data from various sources. This paper reports on an arts-based study using semistructured interviews.

MAIN FINDINGS

Key themes from student observations include an affinity for the northern Ontario environment and a recognition that rural medicine involves a broad scope of practice. Students from NOSM consider generalist care to be a comprehensive service with a strong focus on responding to the health needs of the communities they serve. Beyond primary care, a rural medicine "true generalist" is viewed as a complete package-a physician who provides care ranging from promoting prevention to performing specialist tasks.

CONCLUSION

Rural practitioners, particularly in family medicine, are extended generalists with a broad scope of practice guided by the health needs of the communities they serve. The NOSM students' and graduates' experience of rural generalism is positive and highly influential in determining their career directions, including specialty, scope, and location of practice. The generalist approach of NOSM might be effective beyond rural applications and an advantageous approach for foundational medical education. Students and graduates report that NOSM's distributed community-engaged learning prepares them well for rural generalist practice.

Community engagement: A central feature of NOSM's socially accountable distributed medical education

BACKGROUND

Northern Ontario School of Medicine (NOSM) serves as the Faculty of Medicine of Lakehead and Laurentian Universities, and views the entire geography of Northern Ontario as its campus. This paper explores how community engagement contributes to achieving social accountability in over 90 sites through NOSM's distinctive model, Distributed Community Engaged Learning (DCEL).

METHODS

Studies involving qualitative and quantitative methods contribute to this paper, which draws on administrative data from NOSM and external sources, as well as surveys and interviews of students, graduates and other informants including the joint NOSM-CRaNHR (Centre for Rural and Northern Health Research) tracking and impact studies.

RESULTS

Community engagement contributes throughout the lifecycle stages of preadmission, admission, and undergraduate medical education. High school students from 70 Northern Ontario communities participate in NOSM's week-long Health Sciences Summer Camps. The MD admissions process involves approximately 128 volunteers assessing written applications and over 100 volunteer interviewers. Thirty-six Indigenous communities host first year students and third-year students learn their core clinical medicine in 15 communities, throughout Northern Ontario. In general, learners and communities report net benefits from participation in NOSM programs.

CONCLUSION

Community engagement makes a key contribution to the success of NOSM's socially accountable distributed medical education.

The Canadian Otolaryngology–Head and Neck Surgery Workforce in the Urban-Rural Continuum: Longitudinal Data from 2002 to 2013

Objectives

To evaluate the proportion of otolaryngology–head and neck surgery (OHNS) providers who are rural versus urban based from 2002 to 2013. Secondary objective was to present perspectives of rural primary care providers on unmet needs for OHNS services.

Study Design

Mixed methods database analysis and prospective survey.

Setting

National administrative database.

Subjects and Methods

The Canadian Medical Association OHNS provider Masterfile and the Statistics Canada postal code file were used to determine provincial, urban, rural, and Aboriginal group care coverage. The Society of Rural Physicians of Canada was surveyed to explore care delivery and unmet needs for OHNS and audiology. Descriptive statistics and linear regression were used to describe results.

Results

Ontario and Quebec had the largest annual OHNS physician growth (6.38 providers/year; r2 = 0.94) versus stagnant growth in the territories. The clear majority of OHNS providers are in urban centers, and rural OHNS coverage is decreasing annually (–0.33 providers/year, r2 = 0.28). There are no OHNS providers in 485 population centers where Aboriginal groups are located. A survey of 40 rural primary care providers reported that OHNS care is most commonly delivered through seasonal visits to a local facility, with otology (hearing loss, chronic ear disease) and rhinology (nonmalignant nasal or sinus conditions) as the most frequently reported unmet needs.

Conclusion

From 2002 to 2013, OHNS coverage showed a trend for urban consolidation. Most Aboriginal groups may have decreased access to care, as there are no OHNS providers in 485 population centers where reserves are located. There is an unmet need for specialized OHNS services reported by rural primary care physicians, especially otology and rhinology.

Milestones on the social accountability journey: Family medicine practice locations of Northern Ontario School of Medicine graduates

OBJECTIVE

To assess the effect of different levels of exposure to the Northern Ontario School of Medicine's (NOSM's) distributed medical education programs in northern Ontario on FPs' practice locations.

DESIGN

Cross-sectional design using longitudinal survey and administrative data.

SETTING

Canada.

PARTICIPANTS

All 131 Canadian medical graduates who completed FP training in 2011 to 2013 and who completed their undergraduate (UG) medical degree or postgraduate (PG) residency training or both at NOSM.

INTERVENTION

Exposure to NOSM's medical education program at the UG (n = 49) or PG (n = 31) level or both (n = 51).

MAIN OUTCOME MEASURES

Primary practice location in September of 2014.

RESULTS

Approximately 16% (21 of 129) of FPs were practising in rural northern Ontario, 45% (58 of 129) in urban northern Ontario, and 5% (7 of 129) in rural southern Ontario. Logistic regression found that more rural Canadian background years predicted rural practice in northern Ontario or Ontario, with odds ratios of 1.16 and 1.12, respectively. Northern Canadian background, sex, marital status, and having children did not predict practice location. Completing both UG and PG training at NOSM predicted practising in rural and northern Ontario locations with odds ratios of 4.06 to 48.62.

CONCLUSION

Approximately 61% (79 of 129) of Canadian medical graduate FPs who complete at least some of their training at NOSM practise in northern Ontario. Slightly more than a quarter (21 of 79) of these FPs practise in rural northern Ontario. The FPs with more years of rural background or those with greater exposure to NOSM's medical education programs had higher odds of practising in rural northern Ontario. This study shows that NOSM is on the road to reaching one of its social accountability milestones.

The role of distributed education in recruitment and retention of family physicians

BACKGROUND

Distributed medical education (DME) programmes, in which training occurs in underserviced areas, have been established as a strategy to increase recruitment and retention of new physicians following graduation to these areas. Little is known about what makes physicians remain in the area in which they train.

OBJECTIVES

To explore the factors that contributed to family physician's decisions to practice in an underserviced area following graduation from a DME programme.

METHODS

Semistructured inperson interviews were conducted with 19 family physicians who graduated from a DME residency training programme. Programme records were reviewed to identify practice location of DME programme graduates.

RESULTS

Of the 32 graduates to date from this DME programme, 66% (N=21) and all of the interview participants established their practices in this region after completing their residency training. Five key themes were identified from the interview analysis as impacting physicians' decisions to establish their practice in an underserviced area following graduation: familial ties to the region, practice opportunities, positive clerkship and residency experiences, established relationships with specialists and services in the area and lifestyle opportunities afforded by the location.

CONCLUSIONS

This study suggests that DME programmes can be an effective strategy for equalising the distribution of family physicians and highlights the ways in which these programmes can facilitate recruitment and retention in underserviced areas, including being responsive to residents' personal preferences and objectives for learning and shaping their residency experiences to meet to these objectives.