Starting out rural: a qualitative study of the experiences of family physician graduates transitioning to practice in rural Ontario

Kathleen Walsh; Kara Passi; Nicola Shaw; Kerry Reed; Sarah Newbery

doi:10.9778/cmajo.20230041

Article Figures & Tables

Tables

View popup

Table 1:

Participant characteristics

Characteristic	No. of participants n = 18
General characteristics
Age during interview, yr
20–30	1
31–40	16
41–50	0
> 50	1
Gender
Female	10
Male	7
Nonbinary	1
No. of years in independent rural practice
1	2
1–2	3
2–3	8
3–4	3
4–5	2
Educational experiences
Medical school
Dalhousie University	1
NOSM University	3
University of Toronto	2
McMaster University	2
University of Ottawa	1
University of British Columbia	1
University of Saskatchewan	1
University of Montreal	1
Western University	4
Attended medical school internationally	2
Residency program
McGill University	1
McMaster University	2
NOSM University	7
University of Ottawa	2
University of Saskatchewan	1
University of Toronto	5
Rural exposure in medical school
1–4 wk	3
5 wk–3 mo	10
4–8 mo	2
> 8 mo	3
Rural exposure in residency
0 wk	1
5 wk–3 mo	7
4–8 mo	4
> 8 mo	0
Rural program	6
Optional third year of residency training (a.k.a. “plus one”)
Completed	0^*
Features of first year of practice
Partner when transitioning to practice
Yes	11
No	7
Children when transitioning to practice
Yes	4
No	14
Community population
< 5000	9
5000–10 000	6
10 000–30 000	2
> 75 000	1^†
Local Health Integration Network
Northwest	9
Northeast	4
Toronto Central	1
Southwest	2
Waterloo Wellington	1
North Simcoe Muskoka	2
Champlain	1
Central East	1
None listed	1
> 1 LHIN	3
Returned to rural community where they grew up to practise
Yes	2^‡
No	16
Practice format
Locum	8
Part-time	3
Full-time	10
Combination locum and full-time or part-time	4
Areas of practice (no. of areas of practice ranged from 1 to 7)
Primary care office	18
Hospitalist	15
Emergency department	14
Surgical assist	8
Palliative care	5
Addiction medicine	5
Long-term care	1
Obstetric care (clinic and delivery)	3
Teaching	9
Research	1
Hours per week
Average	47
Range	30–80^§
No. of days per month on call
Average	8
Range	0–20+

Note: NOSM = Northern Ontario School of Medicine.
↵* 2 participants completed a 3-month supplementary emergency medicine experience program.
↵† Individual practised in a larger centre for first year, but practised in a rural community within first 5 years.
↵‡ Not necessarily in first year of practice.
↵§ 1 worked only half of the year, and others worked a range.

View popup

Table 2:

Themes and subthemes

Theme	Subthemes
1. Choosing rural practice	Baseline interest in what rural has to offer Familiarity and comfort with a community Influence of practice incentives
2. Preparedness for practice	Lack of business knowledge for medical practice Adequacy of knowledge base for full-scope practice
3. Navigating work–life balance	Impact of overscheduling Distance to friends and family Conflict between career and family Importance of being integrated into the broader community
4. Navigating transition to practice	Developing confidence and managing uncertainty Role of mentorship Using other early-year physicians to bridge knowledge gaps
5. Challenges during transition to practice	Navigating community expectations and generational changes in practice styles Experiencing rural-specific challenges
6. Successes during transition to practice	Rewarding experiences and feeling fulfilled Collegiality
7. Locuming	Value of locuming
8. Rural emergency department practice	Unique challenges of emergency department practice Emergency department support and backup

View popup

Table 3:

Suggestions for interested parties

Group	Suggestions^*
Learners	Seek exposure to rural opportunities and especially any community one would considering practising in before committing Ask questions and seek training on billing and practice management Start planning for rural practice early and attempt to gain a broad skill set Make and maintain connections with other early-year physicians to support each other in both clinical and nonclinical contexts
Early-year physicians	Consider locuming before committing to a single practice or community Be conservative when planning your schedule in your first year and be cautious not to overschedule Work with the local physicians and the community to establish reasonable workload expectations early on Actively engage in the community outside of practice through social events and activities
Physician recruiters and rural communities	Consider nonfinancial incentives (e.g., nonfinancial logistical supports such as housing, child care and roles for spouses) Support physicians visiting their families with extended vacation periods and funding to travel or to bring family for key holiday dates Help physicians get connected with the local community by inviting them to events Manage workload expectations to support new graduates in terms of practice sizes and style Make your community attractive to locums as a pathway to future recruits Provide support for both children and spouses during transition to practice (including child care, job opportunities)
Medical education	Incorporate rural communities into curriculum and placements in medical school and residency Incorporate billing and practice management into curriculum and consider strategic continuing professional development to support practice management once in practice Allow residents flexibility in their training to tailor their skills for rural practice
Government	Invest in continuing education programs for skills development and maintenance beyond residency to increase confidence in broad generalist clinical practice, especially emergency medicine Provide funding such that new graduates can work in rural communities as a team to formalize the collegial support that benefits successful transition to practice Invest in rural health care systems and partner with communities to find solutions to local health care challenges Establish a user-friendly website for locuming opportunities that includes community profiles and what skills are expected
Clinicians in practice	Provide mentorship for new graduates Manage expectations for new graduates. Be mindful they may be unable to work at the same pace or style as a more experienced clinician Provide committed, easily accessible emergency department backup to early-year physicians

↵* Suggestions were created based on the authors’ interpretation of the themes discussed in the paper. They were inspired by examples provided by interviewees, and current knowledge of rural communities and medical school and postgraduate curricula.