Retention of visa-trainee post-graduate residents in Canada: a retrospective cohort study.

BACKGROUND: Visa trainees (international medical graduates [IMG] who train in Canada under a student or employment visa) are expected to return home after completing their training. We examine the retention patterns of visa trainee residents funded by Canadian (regular ministry and other), foreign, or mixed sources. METHODS: We linked data from the Canadian Post-MD Medical Education Registry with Scott's Medical Database for a retrospective cohort study. Eligible trainees were IMG visa trainees as of their first year of training, started their residency program no earlier than 2000, and exited training between 2006 and 2016. We used Cox regression to compare the retention of visa trainees by funding source. RESULTS: Of 1,913 visa trainees, 431(22.5%), 1353 (70.7%) and 129 (6.8%) had Canadian, foreign, or mixed funding, respectively. The proportion of trainees remaining in Canada decreased over time, with 35.5% (679/1913); 17.7% (186/1052); 10.8% (11/102) in Canada one, five, and ten years, respectively after their exit from PGME training. Trainees who remained on visas (HR: 1.91; [95% CI 1.59, 2.30]), were funded exclusively by foreign sources (HR: 1.46; [95% CI 1.25, 1.69]), and who had graduated from 'Western' countries (HR: 1.39; [95% CI 1.06, 1.84]) were more likely to leave Canada compared to trainees who became citizens/permanent residents, were funded by Canadian sources, or were visa graduates of Canadian medical schools, respectively. CONCLUSIONS: Most visa trainees leave Canada following their training. Trainees with Canadian connections (funding and/or change in legal status) were more likely to remain in Canada.

From pipelines to pathways: the Memorial experience in educating doctors for rural generalist practice.

CONTEXT: This report describes the community context, concept and mission of The Faculty of Medicine at Memorial University of Newfoundland (Memorial), Canada, and its 'pathways to rural practice' approach, which includes influences at the pre-medical school, medical school experience, postgraduate residency training, and physician practice levels. Memorial's pathways to practice helped Memorial to fulfill its social accountability mandate to populate the province with highly skilled rural generalist practitioners. Programs/interventions/initiatives: The 'pathways to rural practice' include initiatives in four stages: (1) before admission to medical school; (2) during undergraduate medical training (medical degree (MD) program); (3) during postgraduate vocational residency training; and (4) after postgraduate vocational residency training. Memorial's Learners & Locations (L&L) database tracks students through these stages. The Aboriginal initiative - the MedQuest program and the admissions process that considers geographic or minority representation in terms of those selecting candidates and the candidates themselves - occurs before the student is admitted. Once a student starts Memorial's MD program, the student has ample opportunities to have rural-based experiences through pre-clerkship and clerkship, of which some take place exclusively outside of St. John's tertiary hospitals. Memorial's postgraduate (PG) Family Medicine (FM) residency (vocational) training program allows for deeper community integration and longer periods of training within the same community, which increases the likelihood of a physician choosing rural family medicine. After postgraduate training, rural physicians were given many opportunities for professional development as well as faculty development opportunities. Each of the programs and initiatives were assessed through geospatial rurality analysis of administrative data collected upon entry into and during the MD program and PG training (L&L). Among Memorial MD-graduating classes of 2011-2020, 56% spent the majority of their lives before their 18th birthday in a rural location and 44% in an urban location. As of September 2016, 23 Memorial MD students self-identified as Aboriginal, of which 2 (9%) were from an urban location and 20 (91%) were from rural locations. For Year 3 Family Medicine, graduating classes 2011 to 2019, 89% of placement weeks took place in rural communities and 8% took place in rural towns. For Memorial MD graduating classes 2011-2013 who completed Memorial Family Medicine vocational training residencies, (N=49), 100% completed some rural training. For these 49 residents (vocational trainees), the average amount of time spent in rural areas was 52 weeks out of a total average FM training time of 95 weeks. For Family Medicine residencies from July 2011 to October 2016, 29% of all placement weeks took place in rural communities and 21% of all placement weeks took place in rural towns. For 2016-2017 first-year residents, 53% of the first year training is completed in rural locations, reflecting an even greater rural experiential learning focus. LESSONS LEARNED: Memorial's pathways approach has allowed for the comprehensive training of rural generalists for Newfoundland and Labrador and the rest of Canada and may be applicable to other settings. More challenges remain, requiring ongoing collaboration with governments, medical associations, health authorities, communities, and their physicians to help achieve reliable and feasible healthcare delivery for those living in rural and remote areas.

Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes.

INTRODUCTION: Rural recruitment and retention of physicians is a global issue. The Faculty of Medicine at Memorial University of Newfoundland, Canada, was established as a rural-focused medical school with a social accountability mandate that aimed to meet the healthcare needs of a sparse population distributed over a large landmass as well as the needs of other rural and remote areas of Canada. This study aimed to assess whether Memorial medical degree (MD) and postgraduate (PG) programs were effective at producing physicians for their province and rural physicians for Canada compared with other Canadian medical schools. METHODS: This retrospective cohort study included medical school graduates who completed their PG training between 2004 and 2013 in Canada. Practice locations of study subjects were georeferenced and assigned to three geographic classes: Large Urban; Small City/Town; and Rural. Analyses were performed at two levels. (1) Provincial level analysis compared Memorial PG graduates practicing where they received their MD and/or PG training with other medical schools who are the only medical school in their province (n=4). (2) National-level analysis compared Memorial PG graduates practicing in rural Canada with all other Canadian medical schools (n=16). Descriptive and bivariate analyses were performed. RESULTS: Overall, 18 766 physicians practicing in Canada completed Canadian PG training (2004-2013), and of those, 8091 (43%) completed Family Medicine (FM) training. Of all physicians completing Canadian PG training, 1254 (7%) physicians were practicing rurally and of those, 1076 were family physicians. There were 379 Memorial PG graduates and of those, 208 (55%) completed FM training and 72 (19%) were practicing rurally, and of those practicing rurally, 56 were family physicians. At the national level, the percentage of all Memorial PG graduates (19.0%) and FM PG graduates (26.9%) practicing rurally was significantly better than the national average for PG (6.4%, p<0.000) and FM (12.9%, p<0.000). Among 391 physicians practicing in Newfoundland and Labrador (NL), 257 (65.7%) were Memorial PG graduates and 247 (63.2%) were Memorial MD graduates. Of the 163 FM graduates, 148 (90.8%) were Memorial FM graduates and 118 (72.4%) were Memorial MD graduates. Of the 68 in rural practice, 51 (75.0%) were Memorial PG graduates and 31 (45.6%) were Memorial MD graduates. Of the 41 FM graduates in rural practice, 39 (95.1%) were Memorial FM graduates and 22 (53.7%) were Memorial MD graduates. Two-sample proportion tests demonstrated Memorial University provided a larger proportion of its provincial physician resource supply than the other four single provincial medical schools, by medical school MD for FM (72.4% vs 44.3%, p<0.000) and for overall (63.2% vs 43.5% p<0.000), and by medical school PG for FM (90.8 % vs 72.0%, p<0.000). CONCLUSION: This study found Memorial University graduates were more likely to establish practice in rural areas compared with the national average for most program types as well as more likely to establish practice in NL compared with other single medical schools' graduates in their provinces. This study highlights the impact a comprehensive rural-focused social accountability approach can have at supplying the needs of a population both at the regional and rural national levels.

Early-career work location of Memorial University medical graduates: Why the decline in rural practice?

INTRODUCTION: In a previous study, we found a decline in the proportion of Memorial University of Newfoundland (MUN) medical alumni practising in rural areas, particularly in Newfoundland and Labrador. The current study focused on the work location of recent graduates and examined the predictors of working in rural Canada and in rural Newfoundland and Labrador within the first 15 years following graduation. METHODS: We linked data from graduating class lists and the alumni and postgraduate databases with Scott's Medical Database to create a record of all graduates from 1973 to 2008, including their work location. We identified differences and significant predictors for each outcome and then described and compared the characteristics of 4 cohorts of graduating classes. RESULTS: In their early career, 127/1113 (11.4%) MUN medical graduates were working in rural Canada, and 57 (5.1%) were working in rural Newfoundland and Labrador. Having a rural background and being a family physician were predictors of working in rural Canada, and having a rural background, doing at least part of the residency at MUN, being from Newfoundland and Labrador and being a family physician were predictors of working in rural Newfoundland and Labrador. Seventy-four (13.6%) and 33 (6.1%) of 1989-1998 graduates worked in rural Canada and rural Newfoundland and Labrador, respectively, compared to 53 (9.3%) and 24 (4.2%), respectively, of 1999-2008 graduates. CONCLUSION: The proportion of MUN medical graduates who worked in rural communities early in their career decreased among recent cohorts. The results show the impact of changes in the characteristics of MUN medical graduates, who increasingly opt for specialist practice and residency training outside the province, and the important role of local postgraduate training.

INTRODUCTION: Une étude antérieure a révélé une baisse du nombre de diplômés en médecine de l'Université Memorial de Terre-Neuve (MUN) exerçant en région rurale, plus particulièrement à Terre-Neuve-et-Labrador. L'étude actuelle portait sur le lieu de travail de diplômés récents et sur les prédicteurs du travail en milieu rural au Canada et dans la province de Terre-Neuve-et-Labrador dans les 15 premières années suivant l'obtention du diplôme. METHODS: Nous avons établi un lien entre les listes de diplômés, les bases de données des anciens et des postdoctorants et la Base de données médicales Scott's afin de créer un dossier de tous les diplômés de 1973 à 2008, y compris de leur lieu de travail. Nous avons établi des différences et des prédicteurs importants pour chaque résultat et avons ensuite décrit et comparé les caractéristiques de 4 cohortes de classes de diplômés. RESULTS: Au début de leur carrière, 127 sur 1113 (11,4 %) diplômés en médecine de MUN travaillaient en région rurale au Canada et 57 (5,1 %) en région rurale à Terre-Neuve-et-Labrador. Le fait de venir d'un milieu rural et d'être un médecin de famille était des prédicteurs de travail en milieu rural au Canada alors que le fait de venir d'un commilieu rural, d'avoir fait au moins une partie de sa résidence à MUN, d'être originaire de Terre-Neuve-et-Labrador et d'être médecin de famille étaient des prédicteurs de travail en milieu rural à Terre-Neuve-et-Labrador. Soixante-quatorze (13,6 %) et 33 (6,1 %) diplômés de 1989 à 1998 travaillaient en milieu rural au Canada et en milieu rural à Terre-Neuve-et-Labrador, respectivement, par comparaison à 53 (9,3 %) et à 24 (4,2 %), respectivement, pour les diplômés de 1999 à 2008. CONCLUSION: La proportion de diplômés en médecine de MUN qui ont travaillé dans des localités rurales au début de leur carrière a diminué au sein des cohortes récentes. Les résultats de notre étude montrent l'incidence du changement des caractéristiques des diplômés en médecine de MUN, lesquels choisissent de plus en plus de se spécialiser et de faire leur résidence à l'extérieur de la province, ainsi que le rôle important de la formation médicale postdoctorale à l'échelle locale.

Work locations in 2014 of medical graduates of Memorial University of Newfoundland: a cross-sectional study.

BACKGROUND: Part of the mandate for social accountability of medical schools is to address physician needs at the local, regional and national levels. We determined the work locations in 2014 of medical graduates of Memorial University of Newfoundland (MUN) and identified the characteristics and predictors of working in urban and rural areas of Canada and the province of Newfoundland and Labrador (NL). METHODS: We linked data from class lists, and alumni and postgraduate databases with data from the Scott's Medical Database to determine work locations in 2014 of MUN medical graduates from 1973 to 2008. Multiple logistic regression analysis was used to identify predictors of working in urban and rural areas of Canada and NL. RESULTS: Of the 1864 graduates in our study, 1642 (88.1%) were working in Canada, 638 (34.2%) in NL, 217 (11.6%) in rural Canada and 92 (4.9%) in rural NL in 2014. Predictors of physicians working in Canada included having a rural background, being from NL and graduating in the 1980s, 1990s or 2000s. Predictors of physicians working in NL included having a rural background, being from NL, graduating in the 2000s and having done some or all of their residency training at MUN. Having a rural background and being a family physician were predictors of working in rural Canada. Having a rural background, being from NL, having done some or all residency training at MUN and being a family physician were predictors of working in rural NL. INTERPRETATION: Most MUN graduates were working in Canada in 2014, with about one-third remaining in NL and much smaller percentages working in rural communities, especially in rural NL. These findings have implications for the physician supply in NL.

Evaluation of physician return-for-service agreements in Newfoundland and Labrador.

INTRODUCTION: Despite the widespread use of physician return-for-service (RFS) programs in Canada, few have been evaluated. We examined two types of RFS agreements (Family Medicine Bursary and Special Funded Residency Position) and (a) describe the proportion of RFS physicians who complete their service obligation and identify the predictors of completion and (b) compare the retention of RFS physicians to that of non-RFS physicians. METHODS: Using administrative data on physicians with RFS agreements in Newfoundland and Labrador (NL), Memorial University's Postgraduate Medical Education Office and the Physician and Medical Practice Database, we calculated the proportion of RFS physicians (1997-2009) who fulfilled their service obligation and also identified predictors of completion. We then followed to 2010 a cohort of physicians who started practice in NL between 2000 and 2005 to compare the retention of RFS and non-RFS physicians. RESULTS: Ninety-six (71.6%) of 134 RFS physicians fulfilled the service obligation in full. Physicians who held Special Funding Residency Position RFS agreements were 11.1 times less likely (95% CI: 4.0-33.3) to complete their service commitment than physicians who held Family Medicine Bursary RFS agreements. In the cohort of 60 RFS and 67 non-RFS physicians, 16.9% of RFS versus 41.8% of non-RFS physicians left NL by 2010 (p=0.004). RFS physicians were 3.22 times less likely (95% CI: 1.41-7.14) than non-RFS physicians to leave the province. Four years after starting practice, roughly 90% of RFS versus 60% of non-RFS physicians remained in NL; after 10 years, 70% of RFS versus 60% of non-RFS physicians remained (p=0.006). CONCLUSION: The RFS program improves the retention of physicians in NL. Using RFS tied to bursaries rather than residency positions may increase service completion and retention rates.