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OBJECTIVE: To explore rural physician-community engagement through three case studies in order to understand the role that these relationships can play in increasing community-level resilience to climate change and ecosystem disruption. DESIGN: Qualitative secondary case study analysis. SETTING: Three Canadian rural communities (BC n = 2, Ontario n = 1). PARTICIPANTS: Rural family physicians and community members. METHODS: Twenty-eight semi-structured virtual interviews, conducted between November 2021 and February 2022, were included. Communities were selected from the larger data set based on data availability, level of physician engagement and demographic factors. Thematic analysis was completed in NVivo using deductive coding. MAIN FINDINGS: The presented qualitative case studies shed light on the strategies employed by physicians to establish and foster relationships within rural communities during challenging circumstances. In Community A, the implementation of a Primary Care Society (PCS) not only addressed physician shortages but also facilitated the development of strong continuity of care through proactive recruitment efforts. Community B showcased the adoption of an 'intentional physician community' model, emphasising collaboration and community consultation, resulting in effective communication of public health directives and innovative interdisciplinary action during the COVID-19 pandemic. In Community C, engaged physicians and community advocates are aligned to contribute to the long-term sustainability of the rural community, particularly in the context of food security and climate change vulnerabilities. CONCLUSION: These findings underscore the significance of trust building, transparent communication and collaboration in addressing health care challenges in rural areas and emphasise the need to recognise and support physicians as agents of change.

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A robust workforce of locum tenens (LT) physicians is imperative for health service stability. A systematic review was conducted to synthesize current evidence on the strategies used to facilitate the recruitment and retention of LT physicians. English articles up to October 2023 across five databases were sourced. Original studies focusing on recruitment and retention of LT's were included. An inductive content analysis was performed to identify strategies used to facilitate LT recruitment and retention. A separate grey literature review was conducted from June-July 2023. 12 studies were retained. Over half (58%) of studies were conducted in North America. Main strategies for facilitating LT recruitment and retention included financial incentives (83%), education and career factors (67%), personal facilitators (67%), clinical support and mentorship (33%), and familial considerations (25%). Identified subthemes were desire for flexible contracts (58%), increased income (33%), practice scouting (33%), and transitional employment needs (33%). Most (67%) studies reported deterrents to locum work, with professional isolation (42%) as the primary deterrent-related subtheme. Grey literature suggested national physician licensure could enhance license portability, thereby increasing the mobility of physicians across regions. Organizations employ five main LT recruitment facilitators and operationalize these in a variety of ways. Though these may be incumbent on local resources, the effectiveness of these approaches has not been evaluated. Consequently, future research should assess LT the efficacy of recruitment and retention facilitators. Notably, the majority of identified LT deterrents may be mitigated by modifying contextual factors such as improved onboarding practices.

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Introduction Physician shortages are a persisting issue in rural regions around the world, and rural Northern Ontario, Canada, is no exception. Even with significant government interventions, financial incentives, and rural-specific contracts, physician recruitment to the region remains an ongoing challenge. Refining recruitment strategies based on specific factors that attract physicians to rural practice could help address staffing shortages and, ultimately, enhance healthcare access and outcomes in rural communities. However, the draw to rural practice among physicians is poorly defined. Therefore, this study aims to bridge this knowledge gap and, in doing so, offers insight to better inform recruitment strategies for rural communities. Methodology As part of a larger qualitative study on physician retention and recruitment, semi-structured interviews were conducted with 12 physicians who had previously practiced in rural Northern Ontario communities. Interviews captured information about their individual experiences, including perspectives on factors that attracted them to establish a practice in rural Northern Ontario. Transcribed interviews were analyzed to identify recurring themes associated with the factors that affect the decision to practice in rural Northern Ontario. Results Participants described the draw to rural practice as being multifactorial and based on overlapping motivations. Key motivations described by participants could be categorized into three broad themes, including rural community connection and exposure, lifestyle and personal preferences, and career considerations. Specifically, participants emphasized the importance of pro-rural mentors and gaining firsthand experience in rural communities as important facilitators that created a connection with these areas. Interest in exploring new parts of the country, alignment with life plans, support of family, and the challenge of rural practice also played pivotal roles in the decision to pursue rural practice. Finally, the opportunity to have a broad scope of practice and serve a need in the healthcare system while receiving fair compensation within the framework of a flexible and supportive contract was also cited as a draw to practice. Conclusion The draw to rural practice is multifactorial and based on a wide array of motivations. As a result, recruitment strategies should move beyond single-pronged approaches and recognize the need to design strategies that address the multifaceted motivations and considerations that drive physicians towards rural practice. Designing and implementing recruitment approaches that consider the diverse factors influencing physicians interest in rural career paths is likely to enhance recruitment initiatives and more effectively address shortage of physicians in the region.

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Introduction: This study examines the state of Rural and Northern Physician Group Agreement (RNPGA) physician teams in rural Northern Ontario in terms of demographics, intent to stay, length of stay, number of physicians relative to the RNPGA-designated complement and perceptions of various workplace and community factors. Materials and Methods: Data were based on a survey mailed, in 2018, to Ontario physicians in RNPGA communities having a designated complement of 2 or more physicians. Physicians reported on aspects of the work environment, community and intentions to stay. Results: Sixty-five percent of all practices and 91.7% of those with a designated complement of 2 physicians were at or above their government-designated complement. Intent to stay was higher in groups below complement. The mean length of stay was 11.3 years. More physicians were male (58.7%). Older physicians were more represented in smaller practice groups. Physicians reported positive ratings on several aspects of their work environment, community and intentions to stay. Length of stay in the community was related to strong family ties and was a predictor of intent to stay. Many physicians had neither strong family ties (65.3%) nor a rural upbringing (57.3%). Conclusion: The results show positive outcomes in terms of: high intentions to stay, satisfaction with workplace and community factors, and full recruitment into RNPGA groups designated for a complement of two physicians. Further research is needed to understand the role of family ties to length of stay, and the role of level of physician complement and group size in retention and recruitment.

Résumé Introduction: Cette étude examine l'état des équipes de médecins de l'Entente relative au groupe de médecins en milieu rural et dans le Nord (EGMMRN) dans les régions rurales du Nord de l'Ontario en termes de données démographiques, d'intention de rester, de durée, de nombre de médecins par rapport à l'effectif désigné par l'EGMMRN, ainsi que de perceptions de divers facteurs liés au milieu de travail et à la communauté. Méthodes: Les données sont fondées sur un sondage envoyé par courrier en 2018 aux médecins de l'Ontario dans les communautés associées à l'EGMMRN ayant un effectif désigné de 2 médecins ou plus. Les médecins ont fait état des aspects du milieu de travail, de la communauté et de leurs intentions de rester. Résultats: Soixante-cinq pour cent de tous les cabinets et 91,7% de ceux dont l'effectif désigné est de 2 médecins se situaient au niveau ou au-dessus de leur effectif désigné par le gouvernement. L'intention de rester était plus élevée dans les groupes en dessous de l'effectif. La durée moyenne de présence était de 11,3 ans. Plus de médecins étaient des hommes (58,7%). Les médecins plus âgés étaient plus représentés dans les petits groupes de pratique. Les médecins ont attribué des notes positives à plusieurs aspects de leur environnement de travail, de leur communauté et de leur intention de rester. La durée de présence dans la communauté était liée à des liens familiaux forts et constituait un facteur prédictif de l'intention de rester. De nombreux médecins n'avaient ni des liens familiaux forts (65,3%) ni une éducation en milieu rural (57,3%). Conclusion: Les conclusions montrent des résultats positifs en termes d'intentions élevées de rester, de satisfaction à l'égard du lieu de travail et des facteurs communautaires, ainsi qu'un recrutement complet dans les groupes désignés de l'EGMMRN pour un effectif de 2 médecins. D'autres recherches sont nécessaires pour mieux comprendre le rôle des liens familiaux sur la durée de présence, ainsi que le rôle du niveau d'effectif de médecins et de la taille du groupe en matière de rétention et de recrutement. Mots-clés: Recrutement, rétention, rural.

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OBJECTIVE: To examine how rural physician team effectiveness predicts outcomes of team performance, team commitment, and intentions to stay. DESIGN: Surveys measuring team climate, team efficacy, and team performance were sent to rural physician team members. Surveys measuring team performance were sent to external observers in supervisory positions. SETTING: Northern Ontario communities. PARTICIPANTS: Rural physicians and external observers, the latter including hospital chief executive officers, family health team executive directors, and clinic managers. MAIN OUTCOMES MEASURES: Total scale scores were generated using mean substitution. Cronbach α was used to assess internal consistencies of team member-level measures. Team-level measures were created by averaging the responses across team members, and intraclass correlation coefficients for each scale of each team of 2 or more members were calculated to yield a measure of rating consistency. A t test was used to assess the possible difference between team performance ratings by team members and external observers. Team-level relationships within the team effectiveness model were assessed using mediated regression, and generalized estimating equations were used to assess the relationships in the model between team-level (team efficacy) and individual-level (affective team commitment and intentions to stay) variables to address the nonindependence of these data. RESULTS: Overall, 70 rural physicians from 26 Rural and Northern Physician Group Agreement communities with 2 or more physicians and 25 external observers from 19 of the 26 Rural and Northern Physician Group Agreement communities participated in the study. The findings showed that team climate (composed of decision making, communication, and conflict resolution measures) positively predicted team efficacy, which in turn positively predicted team performance. This fully mediated set of relationships held whether team performance was rated by the physicians themselves or by the external observers. Team efficacy significantly predicted affective team commitment (b value=0.69, standard error=0.08, Wald =13.89, P<.001) in the first analysis and intentions to stay (b value=0.34, standard error=0.15; Wald =5.42, P=.020) in the second analysis. However, when the other variables impacting physician retention were added to the model in predicting intentions to stay, team efficacy did not predict it above and beyond these additional predictors. CONCLUSION: The findings support initiatives that attempt to enhance physician team effectiveness in rural physician teams by influencing team decision making, communication, and conflict resolution to improve team performance, physician attitudes, and commitment.

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Introduction: Rural maternity care services matter. Obstetrical care in rural Canada has seen concerning trends of service closures and decreasing numbers of family physicians who predominantly provide this service. Such reductions have been shown to have a serious impact on maternal/foetal well-being. Methods: This study investigated the present state of obstetrical services in Northern Ontario, comparing results to those of the last similar survey in 1999. All 40 Northern Ontario communities with hospitals were surveyed, as were the 16 midwife practices in the region. Results: : Of the 35 rural and 5 urban hospitals surveyed, the number not offering obstetrical care has risen from 37.5% in 1999 to 60% in 2020, with all the closures having been rural sites. There have been no re-openings of obstetrics in hospitals that did not offer obstetrics in 1999. Women in the 9 communities that had offered maternity services in 1999, but no longer do in 2020, now travel an average of over 1.5 h to access these services. In those communities that continue obstetrics, but stopped offering caesarean sections, women now travel 2.5 h for this surgery. Although the total number of general physicians remains at the 1999 level, the number offering intrapartum care has dropped by 65% in urban centres and by 49% in rural ones still providing maternity care. Conclusions: Like much of the rural United States, rural Northern Ontario is well on its way to becoming a maternity care desert. As proven in Southern Australia, supportive government policies and programmes should be established and education reform enacted to reverse this concerning trend.

Résumé Introduction: Les services de maternité en région rurale comptent. On observe une tendance préoccupante de fermeture des services d'obstétriques et de réduction du nombre de médecins de famille qui offrent surtout des soins obstétriques dans les régions rurales du Canada. Ces réductions ont montré avoir un impact grave sur le bien-être de la mère et du fœtus. Méthodes: Cette étude s'est penchée sur l'état actuel des services d'obstétriques au nord de l'Ontario, et a comparé ses résultats à ceux de la dernière enquête semblable réalisée en 1999. Les 40 communautés du nord de l'Ontario dotées d'un hôpital ont été incluses dans l'enquête, tout comme les 16 pratiques de sages-femmes de la région. Résultats: Sur les 35 hôpitaux ruraux et les 5 hôpitaux urbains interrogés, le nombre qui n'offrait pas de soins obstétriques est passé de 37,5 % en 1999 à 60 % en 2020, et toutes les fermetures ont eu lieu dans des centres ruraux. Aucun hôpital sans soins obstétriques en 1999 n'avait ouvert un service en 2020. Les femmes des 9 communautés qui offraient des services de maternité en 1999, mais pas en 2020, doivent maintenant faire 1,5 heure de route en moyenne pour accéder à ces services. Dans les communautés qui offrent toujours des services d'obstétrique, mais ne réalisent plus de césariennes, les femmes doivent maintenant faire 2,5 heures de route pour recevoir cette intervention. Même si le nombre total de généralistes demeure le même qu'en 1999, le nombre qui offre des soins périnataux a chuté de 65 % dans les centres urbains et de 49 % dans les centres ruraux qui offrent toujours des soins de maternité. Conclusion: Tout comme dans la majorité des régions rurales des États-Unis, les soins de maternité dans les régions rurales du nord de l'Ontario brilleront sous peu par leur absence. Comme l'a démontré le sud de l'Australie, des politiques et programmes de soutien gouvernemental doivent être mis sur pied et une réforme de l'éducation doit être mise de l'avant pour inverser cette tendance préoccupante. Mots-clés: Soins primaires, première ligne, sage-femme, obstétriques et gynécologie, recherche axée sur les patients, santé et médecine rurale.

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INTRODUCTION: This study seeks to explore influential factors leading to physician turnover in designated Rural Northern Physician Group Agreement (RNPGA) communities in Northern Ontario, as well as physician's perceptions of the RNPGA contract and effects of the Northern Ontario School of Medicine (NOSM) on physician retention in these communities. METHODS: Twelve qualitative semi-structured interviews were completed with rural physicians who had RNPGA contracts within the past 5 years but had left their practice community. Data collected from recorded interviews were analysed using a thematic analysis approach in order to identify common themes. RESULTS: A range of factors influencing physician's decisions to leave were identified including lack of partner career prospects, burnout and lack of opportunities and amenities. Common challenges were sometimes also perceived as rewards of rural practice. The concern of lack of flexibility of the RNPGA contract was identified, as well as a perceived lack of presence of NOSM graduates in RNPGA communities. CONCLUSION: A variety of factors influence physician turnover in RNPGA communities. These may be considered by communities hoping to inform recruitment and retention policy. Renewal of the RNPGA contract may require consideration for availability of part-time positions, increasing the number of physicians funded and incentivising physician wellness. NOSM may consider mandatory postgraduate programme placements in RNPGA communities and further development of infrastructure in these communities to improve learner, graduate and institutional engagement.

Résumé Introduction: Cette étude visait à examiner les facteurs qui influent sur le roulement des médecins dans les communautés désignées du groupe de médecins en milieu rural et dans le Nord (GMMRN) du Nord de l'Ontario, ainsi que la perception qu'on les médecins du contrat du GMMRN et des effets de l'École de médecine du Nord de l'Ontario (ÉMNO) sur la rétention des médecins dans ces communautés. Méthodes: On a réalisé 12 entrevues semi-structurées auprès de médecins ayant travaillé sous contrat avec le GMMRN dans les 5 dernières années, mais qui avaient quitté leur communauté de pratique. Une approche d'analyse thématique a servi à analyser les données recueillies dans les entrevues enregistrées afin de cerner les thèmes communs. Résultats: Absence d'occasion de faire carrière avec un partenaire, épuisement professionnel et absence d'occasions et d'équipement font partie de la gamme de facteurs qui influent sur la décision des médecins de partir. Les difficultés courantes étaient parfois aussi perçues comme la récompense de la pratique rurale. Des préoccupations quant à la rigidité du contrat avec le GMMRN ont été soulevées, ainsi que l'absence perçue de diplômés de l'ÉMNO dans les communautés du GMMRN. Conclusion: Une gamme de facteurs influencent le roulement des médecins dans les communautés du GMMRN. Les communautés qui espèrent éclairer le recrutement et la politique de rétention pourraient en tenir compte. Le renouvellement du contrat avec le GMMRN pourrait nécessiter d'envisager d'ouvrir des postes à temps partiel, d'augmenter le nombre de médecins financés et de favoriser le bien-être des médecins. L'ÉMNO pourrait envisager des placements dans les communautés du GMMRN dans le cadre du programme obligatoire de 2e cycle et le développement plus poussé de l'infrastructure dans ces communautés afin d'améliorer l'engagement de l'apprenant, des diplômés et de l'établissement. Mots-clés: recrutement des médecins ruraux, rétention des médecins ruraux.

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OBJECTIVE: This study sought to understand the beliefs and perspectives of women in northern Ontario and their obstetrical providers with respect to water birthing as access to this service is limited in this region METHODS: All midwives, family physicians (FPs), and obstetricians providing labour and delivery services in northern Ontario were surveyed, as were a sample of labour and delivery nurses in the region and convenience samples of regional women. RESULTS: Of the 362 women who completed the survey (a 90.5% response rate), 81.8% (95% CI 77.5-85.4) believed water births to be safe, 40.9% (95% CI 35.9-46) were interested in having a water birth, and 76.5% (95% CI 71.8-80.5) wanted to have the option of a hospital-based water birth. Perceptions of water birth safety varied significantly by provider type (χ2P < 0.001) with 100% (95% CI 89.6-100) of midwives but 0% (95% CI 52.3-94.9) of obstetricians considering them to be safe. Perceptions of the specific risks and benefits of water birth also varied significantly by provider type, as did understanding of consumer interest. Reflecting these perceptions, 97.1% (95% CI 85.1-99.5) of midwives and 0% (95% CI 0-27.8) of obstetricians would consider assisting in or providing hospital-based water births. CONCLUSIONS: Women in northern Ontario are interested in water birth and in having this service available in hospitals. However, given the widely divergent views of the professional groups providing labour and delivery care in the region, hospitals should be strongly encouraged to explore interprofessional development opportunities to enable patient-centred care in this context.

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INTRODUCTION: The group practice physicians in Marathon, a small rural community in northwestern Ontario, discovered general lifestyle dissatisfaction with the traditional model for obstetric practice. The old model of doing the follow-up and delivery for one's own patients created perceived onerous on-call responsibilities. The providers created a new model of obstetric care. This involved the local providers of obstetric care each taking 1 month of the year in rotation and following up any woman due in that month for prenatal and intrapartum services. This study is an investigation of patient and provider satisfaction with this model. METHODS: Patient survey: We surveyed all 73 women who received obstetric care under the new model during its first 14 months of implementation. We collected data on patient demographics and patients' satisfaction with their obstetric experience using Likert scale, yes/no and short-answer questions. Physician survey: We surveyed the 9 physicians of Marathon Family Practice using Likert scale, yes/no and short-answer questions. We collected information on demographics, history of involvement with obstetric service, and comparison of old and new models with regard to patient care, and professional and personal issues. RESULTS: Patient survey: The response rate was 56%. Of the respondents, 97% reported their expectations for their obstetric care were met, if not surpassed, and 100% were satisfied with their obstetric care. Physician survey: All the physicians responded and found the new model to cause less disruption of their family practice (Wilcoxon signed rank test, p = 0.041), to improve scheduling of personal activities (p = 0.017) and to improve their satisfaction with on-call hours (p = 0.027). Overall, the physicians were satisfied with the new model and preferred it to the old model. CONCLUSION: This obstetric care model meets patients' expectations and provides patient satisfaction. It provides practitioners with an increased quality of life and greater satisfaction. It is a viable paradigm for the provision of obstetric care in the appropriate setting.

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OBJECTIVE: To investigate the factors that influence women to deliver their babies in small rural communities rather than in larger centres that have more comprehensive obstetric services, including cesarean section capability and epidural anesthesia. DESIGN: Self-administered survey. SETTING: Marathon, Ont, a rural community of 4500 in north western Ontario that offers low-risk obstetric services and has no local cesarean section capability. The closest referral centre, Thunder Bay, is 300 km away. PARTICIPANTS: Sixty-four women between 16 and 40 years old living in Marathon. MAIN OUTCOME MEASURES: The relative importance of personal and systemic factors and of beliefs that influence women to choose to give birth in Marathon rather than a larger centre. How well informed women are about local obstetric services. How likely women would be to choose to deliver in Marathon if they had low-risk pregnancies. RESULTS: Beliefs were more important than personal and systemic factors in influencing women's decisions. Respondents were moderately well informed about local obstetric services (mean proportion of correct responses was 66%). Most women with low-risk pregnancies would choose to deliver in Marathon (77.8%). CONCLUSION: For women in Marathon, beliefs are much more important than personal and systemic factors in influencing the decision to give birth in this small rural community.

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PROBLEM BEING ADDRESSED: Medical care in rural Canada has long been hampered by insufficient numbers of physicians. How can a rural community's physicians change the local medical culture and create a new approach to sustaining their practice? OBJECTIVE OF PROGRAM: To create a sustainable, collegial family practice group and address one rural community's chronically underserviced health care needs. PROGRAM DESCRIPTION: Elements important to physicians'well-being were incorporated into the health care group's functioning to enhance retention and recruitment. The intentional development of a consensus-based approach to decision making has created a supportive team of physicians. Ongoing communication is kept up through regular meetings, retreats, and a Web-based discussion board. Individual physicians retain control of their hours worked each year and their schedules. A novel obstetric call system was introduced to help make schedules more predictable. An internal governance agreement on an alternative payment plan supports varied work schedules, recognizes and funds non-clinical medical work, and pays group members for undertaking health-related projects. CONCLUSION: This approach has helped maintain a stable number of physicians in Marathon, Ont, and has increased the number of health care services delivered to the community.

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