Growing a Learning Health Care Community: reflections from the 6for6 rural research journey

Rural health systems face resource constraints, geographic barriers, and workforce shortages that demand new ways to learn, adapt, and deliver care.¹ Traditional research and policy often miss the realities of rural practice and under engage rural communities. The Learning Health Care Community (LHCC) offers a different approach by bringing together clinicians, researchers, decision makers, patients, and community members to learn from daily practice and implement timely improvements.^2,3 It is more than a system of feedback loops or clinical trials. It represents a culture of inquiry, collaboration, and responsiveness rooted in lived experience and shaped by community voices: research that matters.²

For rural health systems, LHCCs are not just ideal, they are essential. Rural settings, by virtue of scale, culture, and flexibility, are uniquely positioned to implement iterative change, yet face disproportionate barriers to doing so in traditional research systems. The small-scale and close-knit nature of rural practice make it possible to identify meaningful questions, quickly implement changes, and evaluate them in context. However, rural systems often lack the infrastructure, training, and support to activate this model.

The 6for6 program was developed to fill this gap; not simply to teach rural physicians how to conduct research, but to help them become agents of change within their health systems. By providing mentorship, peer support, and research and writing skills, 6for6 enables rural physicians to become leaders in translating clinical questions into action.

6for6 is a longitudinal faculty development program in foundational research and writing skills for rural and remote physicians.^4-7 Six physicians attend 6 sessions about research, writing, and information dissemination while developing research projects with the support of peers, a research team, and mentor. Through its flexible, learner-centred design, 6for6 addresses the realities of rural practice. It encourages physicians to pursue questions rooted in clinical experience and grounded in the voices of their patients and communities. These inquiries evolve into impactful research projects that inform practice, shape policy, and lead to local and regional change.

6for6 supports the core elements of LHCCs, particularly the often-overlooked component of stakeholder and community engagement.³ With physicians as crucial stakeholders, 6for6 supports physicians to ask meaningful research questions relevant to their patients and communities. It transforms them from passive recipients of evidence into leaders who can produce and mobilize knowledge, building rural health systems that are reflective, adaptive, and patient centred. The vision of a LHCC requires more than a shift in systems. It requires a shift in how individuals participate in those systems. Here, we explore how 6for6 is planting the seeds of LHCCs by equipping physicians to lead learning from within.

6for6 as a seed for LHCC development: key contributions

The 6for6 program goes beyond teaching research skills. It catalyzes key features of a LHCC in rural health care systems. Below, we reflect on 4 interrelated ways 6for6 participants put this model into action.

Research as practice transformation. Participants begin with questions rooted in daily clinical challenges: inefficient patient flow, gaps in continuity of care, or barriers to access that are especially pronounced in rural settings. Many questions arise from listening to patients, noticing recurring issues, and conversing with community members. 6for6 helps physicians turn these realities into focused research questions—an LHCC starting point where evidence is generated in real-world care and returned to improve it.

It’s a great initiative to bring, actually, medicine where it should be, back to basics to the actual life in the community. (6for6 participant)

The resulting studies lead to tangible changes. For example, Dr Sarah Lesperance’s project⁸ on resilience emerged from her experience with the emotional demands of isolated rural practice. Lesperance explored how to better support physician wellness and sustainability in rural practice. Similarly, Dr Margo Wilson examined communication gaps between rural physicians and urban specialists, highlighting the need for better understanding of rural contexts.⁹ Wilson’s findings offered practical ways to strengthen collaboration and continuity of care, showcasing the 6for6 program’s role in driving system-level improvement.

Another example of this change is the SurgeCon project,¹⁰ developed by 6for6 alumnus Dr Chris Patey in response to persistent overcrowding and inefficiencies in hospital emergency departments. What began as a single-site intervention became a scalable quality improvement initiative across multiple hospitals in Newfoundland and Labrador.^11,12 SurgeCon combined real-time patient flow data, process redesign, and staff engagement to reduce wait times and improve care. Together, these examples show research as a practical tool for learning and improving rural care, which is core to any LHCC.

From novice researchers to knowledge leaders. Many physicians enter the 6for6 program uncertain about their ability to conduct research. Over time, they recognize daily clinical experiences are rich sources of inquiry. This shift from care provider to knowledge generator helps influence teaching, regional planning, and policy with community-informed evidence: “I’m a different practitioner now.... Scholarly work has woven itself into my life. I’m hooked.”

This shift in identity is important in rural contexts where physicians are often expected to assume multiple roles beyond providing clinical care. Rural physicians mentor colleagues, teach and supervise students, participate in regional planning, and contribute to discussions about health care systems. The 6for6 program builds physician confidence and provides tools to drive meaningful change. Through this process, participants develop core research and quality improvement skills, including how to formulate a research question, apply qualitative and quantitative methodologies, and use data to guide practice change. They also gain experience in community-engaged research, scholarly writing, and knowledge translation, enabling a shift from informal problem recognition to structured inquiry and improvement.

We’re generalists and we’re in a great position, and we’re connected to the community, but I’ve never had the language or muscles to use that position to start influencing change in a mindful way. (6for6 participant)

It also gave me a lot of value for my voice as a rural family physician. Realizing the value of what I know, and what I can bring to not only research. (6for6 participant)

Through this transformation, the 6for6 program cultivates not only research competence but also leadership, empowering rural physicians to shape systems and advocate for communities. Participants find and affirm their voices as clinicians and champions of rural realities in care and policy.

From isolation to connection through peer learning networks and communities. Rural physicians often work in isolation, which can make research feel inaccessible or disconnected from community needs. The 6for6 program counters this by fostering connection among peers, the communities they serve, and researchers and academic mentors who provide guidance and support.¹³ As a 6for6 participant put it, “I’m not alone in this.” Relationships often outlast the program. Alumni continue to support each other, collaborate, share ideas, and connect with mentors and academics from the program, which supports ongoing research and quality improvement.

The group we had was great and the peer support and feedback and the different perspectives, I thought was super helpful. We’re all in fairly similar situations, so you know, knowing that we’re all sort of trying to balance it all and learn from each other has been really great. (6for6 participant)

We also encourage alumni to co-present and co-write with members of the 6for6 program and participate in events like the 6for6 Come Home Year Summit. This culture of connection is further strengthened through initiatives like Rural360, developed by 6for6 members to support community-driven research in northern Newfoundland and coastal Labrador. Building on the 6for6 program, it provides alumni with funding, mentorship, and project support, and has since expanded to other rural regions in Newfoundland and Labrador, the Northwest Territories, Nunavut, Prince Edward Island, and Nepal.¹⁴ Similarly, the Carbonear Institute for Rural Reach and Innovation by the Sea (CIRRIS), founded by a 6for6 program alumnus, offers a space for rural professionals to share research and engage communities through creative, local events.¹⁵

Participants of the 6for6 program noted the tension between engaging in research and meeting the demands of clinical care in resource-limited rural settings.

It encourages me to do my research and although it takes a lot of time and you’re doing your full-time job and the rest of your life, it is very rewarding and satisfying and there’s so many important questions in primary care. (6for6 participant)

Despite this, many participants described how research enhanced their clinical practices by helping them better understand patient needs and identify gaps in care. Together, these efforts form a growing community of practice, with clinicians improving rural health care through collaborative, community-informed inquiry. This culture of connection, reflection, and responsiveness is a defining characteristic of a LHCC.

Mobilizing knowledge and closing the loop. The 6for6 program emphasizes translating research findings into local action. Participants are encouraged to think beyond academic publication and consider how their work can inform change in their clinics, communities, and regions. The core part of the program is supporting participants in returning research findings to those who shaped them: the patients, colleagues, and community members whose voices inspired the research questions.

One example of this is how community concerns about contamination and access to testing informed a research project about well water safety in rural Newfoundland and Labrador. The physician researcher, guided and supported by the 6for6 team, responded to these concerns and helped translate research findings into local health promotion strategies and practical recommendations that informed practice and decision making.^16,17 This locally rooted knowledge mobilization exemplifies the LHCC model: research grounded in community priorities that leads to change.

Through the 6for6 program, rural physicians show how listening to their communities, conducting focused research, and returning research results to the community can drive meaningful improvement. Learning health systems begin through community-grounded, practitioner-led inquiry.

I can’t imagine not incorporating this into my daily activities, monthly activities where I would say to my colleagues, you know, every second Friday I don’t see patients, but I work for the patients and the community by doing this stuff and getting better at it. (6for6 participant)

6for6 program as a systems change lever

While the 6for6 program builds individual research skills, its impact extends beyond participants. As rural physicians gain confidence, they become local champions for quality improvement and research integration, bringing credible, community-informed perspectives to regional planning and decision making. By grounding their work in the experiences of patients and needs of their communities, physicians shift the system toward more responsive, locally driven solutions. Early signs of system impact include alumni projects, such as Dr Yordan Karaivanov’s study¹⁸ on diabetes management, and Dr Charlene Fitzgerald’s work on centering pregnancy, which aligned with priorities in Labrador-Grenfell Health’s strategic plan¹⁹ and helped inform policy and resource allocation. These shifts point to the emergence of rural LHCCs: networks of clinicians, organizations, and communities using local evidence to drive continuous improvement.

Reflections from the journey

From the perspective of faculty and participants, 6for6 is more than a skills-building program. As 1 long-time team member noted, “What started as a skills program became something much larger—a quiet but powerful shift toward a rural Learning Health Care Community.”

Participants often describe feeling empowered and “seen,” that is, valued not just as clinicians but as researchers, problem solvers, and community leaders. This shift—from isolation to connection, from uncertainty to leadership—highlights 6for6’s deeper impact, affirming rural physicians’ capacity to shape the systems in which they work, in service of the communities they care for.

Looking to the future

The long-term promise of LHCCs is the ability to embed continuous improvement into daily care. When local knowledge generation, collaborative problem solving, and patient engagement become routine features of health systems, care becomes more resilient, responsive, and equitable, especially in rural communities with complex, underserved needs.

However, the transition from individual capacity to system-wide change does not happen in isolation. While rural physicians are essential leaders in this work, they cannot do it alone. The sustainability and spread of rural LHCCs depends on committed health system support including leadership, policy alignment, protected time for inquiry, and investment in local research infrastructure. Without sustained system support, there is a risk the momentum generated by programs like 6for6 will dissipate. Physician burnout, research fatigue, and lost opportunities for local innovation are all possible outcomes when structural support is lacking.

Programs like 6for6 lay the foundation for research by empowering physicians with the tools, mentorship, and networks needed to lead from within but these efforts must be matched by broader system commitments. Moving forward, the challenge is twofold: to support alumni of programs like 6for6 in sustaining research momentum, and to integrate the LHCC model into the core infrastructure of rural health care delivery. This requires not only funding for faculty development and applied research, but also for embedding research literacy, community engagement, and learning cycles into clinical education, health system operations, and policy frameworks.

Scaling and adapting initiatives like the 6for6 program, with aligned support from health systems, will ensure the seeds planted today grow into lasting systems of learning. These systems must reflect the voices of rural people and communities, and respond to their needs with intelligence, agility, and care. As described in CanMEDS 2025, adaptive expertise—the capacity to balance efficiency with innovation—is essential for physicians to deliver responsive, context-sensitive care in complex environments.²⁰

Conclusion

Rural health systems need to do more than deliver care. They must learn from it. The success of the 6for6 program demonstrates that when rural physicians are supported to ask the right questions, they generate solutions that improve care, strengthen systems, and build the foundation for rural LHCCs. Investing in programs like 6for6 is not a cost; it is a strategy to embed learning, evidence, and community voices into rural health care. Building LHCCs in rural areas is also a matter of equity, ensuring that all communities, regardless of geography, have the opportunity to shape the care they receive.