Training and practising in small communities

Due to the shortage of family physicians in many Canadian communities, the location and type of practice of graduating family medicine residents is of great interest. Godwin and colleagues provide important information on the choices of Ontario family medicine residents who completed their training in 1996 and 1997.¹ This work, along with previous research, suggests that medical schools and residency programs influence the practice locations of their graduates.^2-3

I was surprised that the authors and editorial staff chose to highlight the number of graduates practising in “smaller communities of 50 000 people or fewer” instead of the more accepted definition of rural communities with populations of fewer than 10 000 people.⁴ When the study data are examined using a more appropriate definition of smaller communities (less than 15 000 people), large differences between the percentage of family medicine graduates in these communities become apparent: Family Medicine North, 64.3%; University of Ottawa, 36.4%; Queen’s University, 22.9%; University of Western Ontario, 22.2%; Northeastern Ontario Family Medicine Residency Program, 15.0%; McMaster University, 13.2%; and University of Toronto, 10.8%. Thus, the proportion of graduates practising in communities of fewer than 15 000 varies six-fold among Ontario programs.

Hutten-Czapski had similar findings when examining the practice locations of Canadian family medicine residency graduates from 1994 to 1998.³ Fifty-one percent of Family Medicine North graduates located to communities with fewer than 10 000 people, compared with 24.6% of Queen’s University graduates, 12.0% of Northeastern Ontario Family Medicine Residency Program and University of Ottawa graduates, 11.4% of McMaster University graduates, 10.8% of University of Western Ontario graduates, and 4.6% of University of Toronto graduates.

This raises an important question: If programs can influence the practice locations of their residents, what are the important features of Family Medicine North that encourage graduates to practise in smaller rural communities? Some related factors include use of communities across northwestern Ontario as training sites, an overall program goal to provide training appropriate for northern and rural practice, selection of residents who possess similar educational desires, family medicine rotations in rural centres of 5000 to 15 000 people (16 weeks) and in smaller communities of fewer than 5000 people (8 weeks), specialty rotations with family medicine—friendly specialists who work collaboratively with family physicians, and academic seminars that provide strategies for handling clinical problems where on-site specialists might not be available.⁵

As educators, it is crucial that we determine how and where our graduates practise. It is also important that we examine the key components of family medicine training that influence graduates’ choosing specific practice locations.