Medical learner perspectives on elements of an educational rural generalist pathway: survey outcomes

Abstract

Introduction

The Northern Ontario School of Medicine University (NOSM U) continues to be challenged in meeting its social accountability mandate of addressing the rural health human resource crises in its catchment of Northern Ontario. Its new educational initiative, the Rural Generalist Pathway (RGP) aims to graduate family physicians specifically prepared for rural practice. This study elicits the perspective of NOSM U learners on the various components being considered for this educational pathway.

Methods

A mixed methods survey was created for each of two medical learner groups, undergraduate NOSM U students and its family medicine residents. Quantitative data was analyzed for frequencies and percentages and qualitative data underwent thematic analysis.

Results

With a response rate of 24.6% for undergraduates and 37.9% for residents, the survey discovered undergraduates consider rural clinical rotations as the most valuable experiences in rural medicine. Among the findings, both the majority of medical students and residents (87.3% and 87.9% respectively) agreed that support for a resident’s family well-being and community integration was the element of the pathway most likely to influence them in pursuing the RGP. Mentorship by a practicing rural physician was an element highly supported by 81% of undergraduate and 81.8% of postgraduate learners as likely to influence them to take the RGP.

Discussion

Incorporating learner perceptions into the development of the RGP could help focus institutional resources and enhance learner participation in this pathway, producing more rural family doctors to serve Northern Ontario.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-06225-0.

Introduction

In 2005 the Northern Ontario Medical School (NOSM) was launched with the foundational mandate of social accountability to contribute to improving the health of the peoples and communities of Northern Ontario [1]. Northern Ontario encompasses a vast Canadian geography of 806 708 km, this being 88% of the province of Ontario and a landmass larger than that of France and Germany combined. However, it contains a population of only approximately 855 000, or less than half the population of Paris. Rural communities, defined to be ones with a population of less than 30,000 that are greater than 30 min away in travel time from a community with a population of more than 30,000, contain over 50% of Northern Ontario’s population [2]. NOSM was expected to positively impact the chronic physician shortage of this region, particularly of its rural communities, by preferentially admitting students from Northern Ontario and training them locally. Unfortunately, 18 years later, the now NOSM University has yet to significantly improve the rural physician shortage in Northern Ontario. Graduating an average of 6 students per admission year into rural generalist practice in Northern Ontario [3], this output is unable to meet the current shortfall of 110 rural physicians in Northern Ontario [4] and much less the future increased demand arising from the retirement of the many baby boomer generation physicians that presently serve this geography [5]. It is incumbent on NOSM U to continue to innovate and evolve to meet its social accountability mandate and it has recently done so with the development of the Rural Generalist Pathway (RGP) [6].

A Rural Generalist education pathway was first developed in Queensland Australia, where it was recognized that particular training was required to best develop a physician workforce for its rural and remote communities, and this became formalized at the post graduate level [7]. Since 2006, the Queensland Health Rural Generalist Pathway that trains junior doctors in rural and remote medicine, offering a supported career pathway leading to certification and well remunerated rural clinical positions, has had significant positive impact on improving its rural physician workforce [8]. The success of the Queensland Health Rural Generalist Pathway has been noted and adapted by other countries. In 2008, the New Zealand Medical Council recognized Rural Hospital Medicine as a new vocational scope and its University of Otago developed the Rural Postgraduate Programme [9] while in 2017, the Rural Generalist Program Japan enrolled its first registrars in its training program strongly influenced by Australia’s model [10]. A 2018 scoping review found that scientific articles on rural generalism were being produced from Australia, Canada, U.S.A. and New Zealand, but as well from countries such as Kenya, Uganda, Rwanda, Ethiopia and India [11]. Though definitions of rural generalism and education programs may vary, many countries are trying to develop their own approach to the Rural Generalist Pathway in hopes of addressing their rural health human resource challenges.

NOSM U has looked to Queensland Australia’s successful example of developing a rural generalist physician specialty designation and associated training program [12] to bolster its number of rural doctors. This has been the inspiration to develop its own RGP. NOSM U has conceived the full aspirational pathway of developing generalist physicians for the rural North, one starting in high school through to rural practice, and has begun implementing educational elements of the pathway in its undergraduate education. While awaiting funding for the fulsome rural generalist pathway, the first trial cohort of 5 students entered NOSM U’s RGP in 2021 and a second cohort of 6 entered in 2022 [6]. If funding can be acquired, the plan is to greatly increase the student intake and implement further elements of the pathway starting in the first year of undergraduate training.

As presently defined, the rural generalist pathway is constructed of core educational experiences, supports and privileges. Several constituent elements of the pathway are already long established in the regular curriculum, such as rural rotations, rural electives and rural physician lecturers. With the initiation of the pathway there is now also rural physician mentorship for the involved students, and it is being considered for the residents. Further educational experiences planned to enhance the pathway include education on Indigenous people and rural simulation-based workshops. Supports being suggested for residents on the pathway include family well-being and community integration programs. A privilege being considered for those on the RGP is priority placement to undergraduate rural rotation sites. The development of reserved rural post-graduate residency positions, which would bypass the traditional process of competitively matching students to residency positions through the Canadian Resident Matching Service (CaRMs), is an element also being considered.

It could be of benefit for new programs, such as the Rural Generalist Pathway at NOSM U, to seek out and integrate student perspectives and values in creating the reality that will shape their educational experience and potentially career decisions. Student engagement is becoming understood as a process of investment by the students and their institutions to “optimize the student experience and enhance the learning outcomes and development of students and the performance, and reputation of the institution” [13]. Beyond traditional forms of student engagement, this approach can include student participation in curriculum development and provision of the educational program. Unfortunately, there is little literature on the best pragmatic practices for this engagement [14]. Given the lack of best practices, a mixed-methods survey was developed and applied to enhance the student voice in the continuing development of the components of NOSM U’s Rural Generalist Pathway.

This article describes the outcomes of an effort to seek student input on NOSM U’s Rural Generalist Pathway through a survey approach of its undergraduate and postgraduate student body. Such input has the potential to enhance the pathway development, increase learner participation and, ultimately, lead to more rural practitioners and improved access to health care for rural Northern Ontarians.

Methods

The present study used a combination of qualitative and quantitative methods. It was felt that this combination of approaches would provide for a richer understanding of the student perspectives around which experiences to rural medicine and elements of the RGP were perceived as important and why.

Two novel surveys were developed for this study. The surveys, one for undergraduate (UG) medical students (see appendix 1) and another slightly different one for postgraduate (PG) family medicine residents (see appendix 2), consisted of multiple-choice items which covered demographics, rural upbringing, practice intent, experiences with rural medicine through particular elements of their program (UG survey only) and the perceived relative value of rural medicine experiences. Likert response items were used to determine respondents’ perceptions of the value for each of 16 elements being considered for the Rural Generalist Pathway (1- very unimportant to 5-very important) and to define to what degree each element would influence them to pursue the RGP (1 -strongly disagree to 5 -strongly agree). Further items asked that the most and least important elements of the RGP be chosen, and finally, short answer questions allowed for students to further expound on their perspectives of the proposed elements of the RGP. Both surveys were piloted to test for clarity of questions and time taken to complete.

An invitation to participate in the study and survey links were emailed to all NOSM’s undergraduate students and family medicine residents in March 2022. Two weeks later the survey links were emailed once again and the survey closed May 2022. Completion of surveys was encouraged by the option of entering a raffle for the possibility of winning one of six 50 Canadian dollar Visa cards. Informed consent to participate was obtained from all the participants in the surveys.

The surveys were constructed in Qualtrics. Quantitative data from completed questionnaires was analyzed to determine frequencies and percentages using SPSS (IBM SPSS Statistics for Windows, version 26, IBM Corp., Armonk, N.Y., USA). Responses to open ended questions were reviewed to identify main themes. Qualitative data were extracted, and a comprehensive list of codes was developed iteratively using a thematic analysis approach [15]. Coded data were cross-referenced among two team members to establish consensus and credibility [16]. Collapsed codes were then combined with corresponding survey citations as a means of source triangulation thus adding to rigour [17]. Qualitative rigor was also ensured by employing several strategies to strengthen credibility including method triangulation (using both quantitative and qualitative data) and investigator triangulation (having multiple researchers).

This study received research ethics approval from Lakehead University’s Research Ethics Board (Romeo #1468604).

Results

Response rates and demographics

The surveys were fully or partially completed by 63 of approximately 256 undergraduate medical students and 33 of 87 postgraduate medical students for response rates of 24.6% and 37.9% respectively. Characteristics of the survey respondents are summarized in Table 1.

Table 1.

Characteristics of undergraduate and postgraduate respondents

	Undergraduate	Postgraduate
	Freq (%)	Freq (%)
Age group
• Under 25  • 25–29  • 30–34  • 35–39  • 40+	14 (22.2) 37 (58.7) 9 (14.3) 2 (3.2) 1 (1.6)	0 14 (42.4) 11 (33.3) 7 (21.2) 1 (3.0)
Gender
• Female  • Male  • No response	42 (66.7) 18 (28.6) 3 (4.8)	23 (69.7) 10 (30.3)
Raised primarily in northern Ontario	49 (77.8)	22 (66.7)
Raised primarily rural	29 (46.8)	21 (63.6)
Learner year
• 1  • 2  • 3  • 4	11 (17.7) 21 (33.9) 12 (19.4) 18 (29.0)	17 (51.5) 16 (48.5) NA NA
In a rural family medicine program	NA	21 (75)

Rural and northern living, training and future plans

Fifty-two (82.5%) of undergraduate and 30 (90.9%) of postgraduate respondents had experience living in a rural community. Of those students with rural living experience, the vast majority (92% of undergraduate and 90% of postgraduate students) somewhat or strongly agreed that the experience was positive. The number of months of rural learning ranged from 0 to 18 (mean 5.9 SD 5.5) for undergraduate students and from 2 to 38 (mean 14.6 SD 9.5) for postgraduate students. 95% of undergraduate and 94% of postgraduate students who had had rural medical training somewhat or strongly agreed that these experiences were positive. The majority of postgraduate (72.7%) and undergraduate (75.8%) students reported that they somewhat or strongly agreed that they were interested in a career in rural medicine. However, less than a third of respondents indicated that they wanted to work in a community of less than 10 000 people (Table 2).

Table 2.

Size of community most likely to practice in

Size of community	Undergraduate Percent (n = 63)	Postgraduate Percent (n = 33)
very large (urban,100 000+)	20.6	12.1
Large (urban, 30 K-99 999)	27.0	30.3
Moderate (rural, 10 K-29 999)	25.4	27.3
Small (rural, 1 K – 9 999)	22.2	30.3
very small (rural, < 1 000)	4.8

The most common postgraduate program that undergraduate students planned to pursue was rural family medicine (29.5%) followed by family medicine (23.0%) then emergency and internal medicine (8.2% each) and pediatrics (6.6%). Half of the postgraduate students had no intention of completing a third year, while 18.8% were undecided. Of those 10 respondents (31.3%) who planned to complete a third year, the most common program they planned to complete was emergency medicine (36.4%) followed by anesthesia (27.3%), geriatrics (9.1%) and obstetrics (9.1%).

Rural medicine experiences

Undergraduate

All UG students reported some rural experiences, the specific types of which are summarized in Table 3. The proportion of students reporting the various experiences among their top three most important are summarized in Table 4.

Table 3.

Experiences in rural medicine during NOSM undergraduate education (n = 62)

Experiences (See Appendix 3 for definition of educational elements below)	Freq	%	Experiences	Freq	%
Through small group learning topics	46	74.2	Rural Elective during phase 3	14	22.6
Through lecture topics	42	67.7	Special education experience	12	19.4
2nd year February rural placement (Module 110)	42	67.7	Academic leadership training	8	12.9
Rural physicians as facilitators of small group sessions or lecturers	39	62.9	Workshops of sim-based ed on rural medicine topics	6	9.7
Rural placements (Integrated Community Experience (Modules 106, 108, 110), Comprehensive Community Clerkship)	34	54.8	Rural elective after year 2	5	8.1
2nd year November rural placement (Module 108)	33	53.2	Summer studentships in research	3	4.8
3rd year Comprehensive Community Clerkship	27	43.5	Other: conferences, information sessions, rural generalist program, medical career advising program	3	4.8
First year placement in Indigenous community (Module 106)	27	43.5	NOSM rural summer job placements	2	3.2
Rural medicine interest group	18	29.0	I have not been exposed to rural medicine though my undergrad education at NOSM	0	0

Table 4.

Most valuable experiences in rural medicine during NOSM undergraduate education

Experiences (see Appendix 3 for definition of educational elements below)	Ranked as one of 3 most valuable experiences
	All respondents (n = 60) freq (%)	Respondents with experience freq/n experience (%)
2nd year February rural placement (Module 110)	30 (50.0)	30/42 (71.4)
2nd year November rural placement (Module 108)	24 (40.0)	23/33 (69.7)
3rd year Comprehensive Community Clerkship (CCC)	23 (38.3)	23/27 (85.2)
Rural physicians as facilitators of small group sessions or lecturers	13 (21.7)	13/39 (33.3)
Rural placements (Integrated Community Experience (Module 106, 108, 110), Comprehensive Community Clerkship)	13 (21.7)	13/34 (38.2)
Through small group learning topics	13 (21.7)	12/46 (26.1)
Through lecture topics	9 (15.0)	7/42 (16.7)
First year placement in Indigenous community (Module 106)	6 (10.0)	5/27 (18.5)
Rural medicine interest group	6 (10.0)	5/18 (27.8)
Rural Elective during phase 3	5 (8.3)	5/14 (35.7)
Special education experience (SEE)	3 (5.0)	2/12 (16.7)
Academic leadership training	4 (6.7)	3/9 (37.5)
Rural elective after year 2	2 (3.3)	2/5 (40.0)
Summer studentships in research	2 (3.3)	1/3 (33.3)
Other: conferences, information sessions, rural generalist program, medical career advising program	1 (1.7)	1/3 (33.3)
NOSM rural summer job placements	1 (1.7)	1/2 (50)
I have not been exposed to rural medicine though my undergrad education at NOSM	1 (1.7)	0/0 (0)
Workshops of sim-based ed on rural medicine topics	0	0/5 (0)

Postgraduate

The proportion of PG learners who ranked each of the rural medicine training experiences as most and then least valuable are summarized in Table 5.

Table 5.

Experiences during Post Graduate family medicine training that were most and least valuable in increasing interest in rural medicine

Experience that was MOST valuable in increasing interest in rural medicine	Freq (%) n = 32	Experience that was LEAST valuable in increasing interest in rural medicine	Freq (%) n = 31
Core rural rotations	15 (46.9)	Academic leadership training	10 (32.2)
Elective rural rotations	8 (25.0)	Rural medicine topics – academic half day sessions	8 (25.8)
Rural generalist mentor	5 (15.6)	Sim-based education workshops focused on rural medicine topics	7 (22.6)
Other: living there, personal experience growing up, personal experience	3 (9.4)	Rural physicians as lecturers or academic half day presenters	6 (19.5)
Sim-based education workshops focused on rural medicine topics	1 (3.1)	Core rural rotations	3 (9.7)
Academic leadership training	0	Community leadership training	2 (6.5)
Community leadership training	0	Rural generalist mentor	1 (3.2)
Rural medicine topics - half day academic sessions	0	Specific education related to Indigenous communities/people	1 (3.2)
Rural physicians as lecturers or academic half day presenters	0	Elective rural rotations	0
Specific education related to Indigenous communities and people	0
I have not been exposed	0

Undergraduate and postgraduate thematic analysis

Two main themes emerged from the analysis of comments about why respondents felt that experiences in rural medicine were valuable or not in terms of increasing their interest in rural medicine: (1) the degree of hands-on, real-world experience and (2) the one-to-one interactions with rural generalist mentors.

Students indicated the value of the rural rotations was to get to know what rural generalism is like, to see the broad scope of practice, and become more comfortable with all that is involved.

I believe that in order to truly understand rural medicine, you need to practice it. I absolutely loved my rural summer electives in 2nd year and my rural CCC experience. It is a great opportunity to informally chat with rural physicians about their lifestyles, practice model, scope of practice, remuneration and hours worked. Not only that, but we get exposure to rural specialists like general surgeons, general internists and rural emerg docs. (undergraduate student)

Undergraduate comments also reflected how valuable these experiences were for allowing students to see the challenges and rewards of working in rural communities.

I felt that being able to live and train in small rural communities was great hands-on exposure to rural medicine and really allowed for a full appreciation of the joys and challenges of rural medicine. (undergraduate student)

Similarly, post graduate students described rural rotations as providing direct “real world” experience where they were able to see the broad scope of practice. Postgraduates commented that core rotations were inspiring. They also felt that they resulted in increased comfort in general practice and provided an opportunity for them to see the rural lifestyle. One commented that “it opened my eyes to all that RG can do in terms of scope and was the first thing to pique my interest”, while another stated rural rotations “enhanced my already high interest and developed comfort in general practice and practicing at the edge of competency, hence clinical courage”.

In contrast, the rural medicine experiences that were less highly ranked, or selected as least valuable, were in many cases viewed this way because they were not hands-on. It was noted that “lectures are good for delivering factual info, but not always the best means for inspiring people”, “there were not enough RG focussed teaching sessions” and that half day sessions “were slightly less specific to the rural context than other experiences”. Those residents who found the sim-based workshops to be least valuable indicated that these sessions did not accurately represent rural medicine, that other experiences were more enjoyable and that the “daunting and complex” cases may deter people from wanting to practice rural medicine. Having rural physicians as lecturers or academic half day presenters were selected as least valuable as they did not involve hands-on experience and often the lecture was not specifically related to rural health. For a number of undergraduate student respondents, experiences in rural medicine through the small group learning session, lectures and having a RG as a facilitator or lecturer were the only experiences that they had had so far to rural medicine. The comments about these non-hands-on experiences did indicate that they provided insight into rural generalism, including the lifestyle, scope of practice and skill requirements, and that they were a source of some great discussions. Academic leadership training was described as being of least interest, not relevant for career goals, and not reflective of rural medicine. The academic half day sessions were described as “not useful” and “a waste of time”.

Both undergraduate and postgraduate respondents commented about the positive experiences of having one-on-one time with welcoming rural mentors/preceptors and developing insight into the rural generalist lifestyle while experiencing supportive rural communities. Postgraduate respondents described RG mentors as being impactful on learning, providing experiences to many skills and areas of medicine as well as their quality of life.

Importance and influence of RGP elements

Support for resident’s family well-being and community integration was the element for which the highest proportion of students in both undergraduate and postgraduate programs somewhat or strongly agreed would influence them to pursue RPG (87.3% and 87.9% respectively) while the element of additional leadership training for PG learners had the lowest proportions (44.4% and 36.4% respectively) (Tables 6 and 7). Mentorship with practicing rural physicians was considered important/very important by the highest proportion of undergraduate students (98.3%) while support for resident’s family well-being and community integration was considered important/very important by the highest proportion of postgraduate students (97%).

Table 6.

Importance and influence of existing and proposed elements of RGP: undergraduate student responses

Element P = proposed E = existing	Important/Very Important		Influence me to pursue RGP: somewhat/strongly agree
	n	freq (%)	n	freq (%)
Support for resident’s family well-being and community integration (P)	54	52 (96.3)	55	48 (87.3)
Guaranteed Funding for PGY3 training months (P)	54	51 (94.4)	54	46 (85.1)
Mentorship with practicing rural physicians (E)	58	57 (98.3)	58	47 (81.0)
Priority access to relevant non-core rotations/electives (P)	54	47 (87.0)	55	43 (78.2)
Reserved spot/direct entry to total PG residency1(P)	55	43 (78.2)	55	40 (72.7)
Learning on how to thrive in rural practice (P)	54	47 (87.0)	54	38 (70.3)
Annual rural scenario sim-based workshop (P)	55	47 (85.5)	55	37 (67.3)
Priority access to rural sites for placements1(P)	57	47 (82.5)	57	39 (68.4)
Practicing rural physicians as lecturers and facilitators in undergrad medical education1(E)	55	44 (80.0)	56	36 (64.3)
Specific education related to Indigenous communities and people (P)	54	42 (77.8)	55	33 (60.0)
Opportunity for further rural exposure (Special Education Experience, research)1(E)	55	40 (72.7)	55	34 (61.8)
Extra support/opportunities to pursue teaching, learning, research (P)	54	38 (70.4)	54	30 (55.6)
Rural medicine interest group1(E)	59	42 (71.2)	59	27 (45.8)
Additional leadership training for PG learners (P)	54	35 (68.4)	54	24 (44.4)

1 Elements on undergraduate survey only

Table 7.

Importance and influence of existing and proposed elements of RGP: Postgraduate student responses

Element P = proposed E = existing	Important/Very Important (n = 33) freq (%)	Influence me to pursue RGP Somewhat/strongly agree (n = 33) freq (%)
Support for resident’s family well-being and community integration (P)	32 (97.0)	29 (87.9)
Mentorship with practicing rural physicians (P)	31 (93.4)	27 (81.8)
Priority access to relevant non-core rotations/electives (P)	29 (87.9)	25 (75.8)
Guaranteed funding for PGY3 training months (P)	26 (78.8)	24 (72.7)
Learning on how to thrive in rural practice (P)	29 (87.9)	22 (66.7)
Annual rural scenario sim-based workshop (P)	24 (72.7)	21 (63.6)
Extra support/opportunities to pursue teaching, learning, research (P)	19 (57.6)	17 (51.5)
Specific education related to Indigenous communities and people (P)	21 (63.6)	15 (45.5)
Additional leadership training for PG learners (P)	18 (54.5)	12 (36.4)

Discussion

The results of our study highlight the types of experiences and elements of rural medical training that NOSM U undergraduate and postgraduate students perceive as being of value and influencing their decision to pursue rural medicine. Some of these components exist in the current programs at NOSM U and could be further developed, expanded, and promoted, while others may be prioritized for implementation into the RGP.

It is notable that the most valued experiences in rural medicine in the undergraduate curriculum have been part of NOSM U’s curriculum since its inception. These are its formal rural clinical rotations in second and third year, with the longest and most highly ranked being the eight-month Community Comprehensive Clerkship (see Table 3) which, for most students, takes place in rural centers. Several other rural clinical rotations, such as rural electives, were less valued for generating rural interest, but when ranked only by those that had experienced them became much more recognized in relative importance. The postgraduate family medicine respondents also ranked rural clinical rotations as most highly effective in generating interest in rural medicine (see Table 4). Rural clinical experiences are well known to significantly impact the future career choices of the students that undergo them, being an important factor in encouraging a rural career [18–20].

A few other experiences in rural medicine experienced by only a few respondents were also very highly ranked: NOSM summer job placements, academic leadership training, and summer studentship in research. Given the low number of students who engaged in leadership training and research in rural settings, it may be the lack of direct experience that contributed to the low percentages of UG and PG learners that felt these elements were important or influential in deciding to pursue RGP. It also may be that the learners do not see how these translate into the reality of rural practice.

Support for resident’s family well-being and community integration was the element that the highest proportion of both undergraduate and postgraduate respondents classified as important/very important in influencing them to pursue the RPG (see Tables 6 and 7. It would appear that even at an undergraduate level, years away from it having any direct impact on them, there is an awareness that the reality of rural practice can be challenging for family life and that this issue requires support. Evidence supports this as it indicates that a common cause for a rural physician to leave their practice is when their life partner is not meeting their own needs in the rural community [21].

Another element that was highly regarded as important and in generating interest in rural medicine was having a rural generalist mentor. The highest proportion (98%) of undergraduates classified having a mentor as important/very important and it had the third highest number indicating that it would influence them to pursue the RGP (Table 6). Among PG respondents, it had the second highest proportion of respondents who agreed that it would influence them to pursue the RGP and that it was important/very important (Table 7). This finding supports the continued inclusion of rural generalist mentors for the undergraduate RGP students and incorporating them for the postgraduate residents. In fact, mentorship has gained a much higher recognition and focus in the last decade as we now appreciate how it can be a powerful aid to inform, support and transition medical learners and practitioners into new scopes of practice [22, 23].

There are several proposed advantageous elements to the RGP, such as guaranteed funding and prioritized access to aspects such as residency positions and electives, that are valued by a high proportion of the respondents. 94% of undergraduates were already thinking ahead to the end of their family medicine residency when rating guaranteed funding for a third year of residency training in an area of specialty, as this is the third most common element to be rated as important/very important (Table 6). This element also has the second highest proportion of UG students (85.1%) indicating that it would influence them to pursue the RGP. Fourth most common is priority access to relevant non-core rotations/electives and fifth is direct entry through a reserved spot into rural family medicine residency. Priority access to these aspects of medical training is clearly valued by the undergraduate respondents, but less than might be expected. The Canadian Resident Matching Service (CaRMS) match is often a great source of effort and anxiety for undergraduate students though this element did not land as one of the most reported as important or influential. The postgraduate respondents also value priority access to non-core rotations (3rd) and guaranteed funding to PGY 3 positions (4th) (see Table 7).

Overall, based on the responses from those that did complete the survey, the results suggest that it is likely that the rural generalist pathway (RGP) at NOSM U will find traction with its students and residents; 72.7% of postgraduate and 75.8% of undergraduate respondents indicated interest in a rural medical career. However, a much lower proportion of respondents, 27% of undergraduates and 30.3% of postgraduates, were planning on practicing in communities of under 10 000. As many of Northern Ontario’s neediest communities are also its smallest and well below 10 000 in population, this may reduce the future rural recruitment potential of these students and is an area that needs to be addressed in the on-going development of NOSM U and the RGP.

Moving forward, NOSM U may consider the feedback from medical students in this study in the on-going development of the RGP to address the challenge of attracting medical graduates into these rural northern Ontario communities. How might the RGP incorporate real world, hands-on rural experiences into the first year of the program rather than waiting until second year? Are there ways to enhance and expand the valued role of rural generalist mentors? How might the program better illustrate how one might take on academic leadership, or research as part of a rural career? The positive impact on those who have experiences with these elements provides evidence for the RGP planners to consider making these elements more available to undergraduate students while investigating outcomes and value determinations by the students engaging with them. In addition, developing learners’ contextual understanding of rural career opportunities, and promoting them, could help them play an important role in the RGP. Given the importance of support for family well-being and community integration to learners, NOSM U would benefit from prioritizing and implementing ways to provide for these needs. Further research may help to identify initiatives that can successfully provide this much needed support for well-being and community integration, helping to attract and retain learners to the RGP. Establishing a priority approach to accessing rural clinical rotations and funding for PGY3 should also be considered by NOSM U for incorporation into the RGP. On-going tracking of recruitment into smaller rural northern communities and research into the role of new and existing elements of the RGP in influencing the choice to pursue rural medicine will help to assess the value of incorporating student feedback into the program.

Practicing rural generalist physicians appear to play an important role in encouraging medical learners to develop rural practice intentions, especially through their work as mentors as well as preceptors for rural rotations. There has been a recent learner request to integrate more rural generalist physicians in the undergraduate education of medical students at NOSM U [24] and this study supports answering this request. To recruit greater involvement from rural clinicians, NOSM U may benefit from letting their rural faculty know how valued their contributions are to learners in creating interest in the rural generalist educational pathway and in forming their rural practice career intentions.

This study has several limitations that may have had an impact on its results. It was carried out during the second year of COVID-19 pandemic when NOSM had canceled certain curriculum experiences such as rural placements and replaced them with online sessions. The lack of experience in several of the usual curriculum components would mean that the evaluation of these experiences would be more based on assumptions than lived experience for more of the respondents. Understanding the value of current experiences in rural medicine was based on ranking which could mean that lower ranked elements were still very valuable, and that their value was underrepresented in the results. Perhaps a scale of value could be the more appropriate interrogation tool for evaluating these experiences. Because the response rate to the survey was relatively low there may have been a very specific type of individual that was attracted to answering the survey and therefore the results may not be representative of the perceptions of NOSM U’s whole undergraduate body. Specifically, given that over 70% of the respondents somewhat or strongly agreed that they were interested in a career in rural medicine, the survey may have attracted more students with this interest and skewed results compared to a sample with more students uninterested in a rural medicine career.

Recently, the Rural Generalist Pathway at NOSM U has been paused due to a lack of funding and a need to focus present resources on the expansion of the student body that is underway. One hopes that this rural educational innovation will be recognized for the value it has been shown to have in other rural constituencies and that it will once again be supported to be an active pathway and further developed in the years to come by NOSM U.

Conclusion

The Northern Ontario School of Medicine University may better position itself to meet its social accountability mandate, in helping rural communities in Northern Ontario move out of their chronic physician shortage, by incorporating the feedback of students into its new Rural Generalist Pathway and moving forward with this innovation. There are elements of this pathway that are more important and meaningful to the student body and this student input could help further enhance the RGP’s utility and enrollment. We encourage NOSM U and other medical schools to continue innovating in rural medical education and to engage their medical learners in the process of development and improvement of new educational pathways and programs, as they have an important voice that should be heard, respected and incorporated.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

EO was responsible for the conception of the study. EO, MC and LN all made substantial contributions to study design. EO and LN executed the study and acquired the data. EO and MC analyzed and interpreted the data. EO wrote the first draft of the article while MC substantially revised it and LN reviewed it. All authors agreed to be accountable for the contents of the article.

Funding

No external funding sources supported this work.

Data availability

The results of the surveys are being safely stored, for at least 10 years, at the Marathon Family Health Team office in Marathon, Ontario, Canada. Parties interested in viewing these results can contact the corresponding author for access to this data.

Declarations

Ethics approval and consent to participate

This study received research ethics approval from Lakehead University’s Research Ethics Board (Romeo #1468604). Informed consent to participate was obtained from all participants in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.