Recruitment & Retention of Health Care Providers in Remote Rural Areas: The View from Up Over

and Down Under

Professor Roger Strasser

Northern Ontario School of Medicine

Recruitment & Retention Strategies

• education and training

• regulatory initiatives

• financial incentives & rewards

• personal & professional support

• sustainable service models

access is the rural health issue

• resources concentrated in cities

• communication

and transport difficulties

• rural health workforce shortages

Rural Health Around the World

Rural Health Services

• access is the major issue• “safety net”• local services preferred• limited resources• workforce shortages• different from cities

Rural Health Care

•specialists’ support role

•partnership not putdown

•consultant support local service

•not assume patients will travel

Rural Practitioners

• wide range of services• high level of clinical

responsibility• relative professional

isolation• specific community health

role

“Extended Generalists”

Interprofessional Teamwork

- workforce shortages- community relationship- “do the necessary”

• Much talked about in the cities• Actually happens more in rural communities

Sustainable Rural Health Services

• health service authority/agency

• health care providers

• community participation

Recruitment Facilitators

for Rural Practice • rural upbringing• positive undergraduate rural clinical experiences• targeted postgraduate training for rural practice

Retention Factors

• academic involvement

• recognition and reward

• support from “the system”

• active community engagement

Rural Based Medical Education

• response to workforce shortages• specific knowledge and skills• high quality learning environment

Rural Clinical Education

• more hands-on experience• greater procedural competence• more common conditions

Impact of Rural Based Medical Education

• more skilled rural doctors

• enhanced rural health care

• improved rural health outcomes

• broader academic developments

• economic developments

Australia

• Rural and Remote GP Program

- Rural Workforce Agencies

• Retention Payments

• Rural Postgraduate Training

- GP and Specialist

• Rural Based Medical Education

Australian Rural Academic Initiatives

• Rural Undergraduate Support and Coordination• University Departments of Rural Health• Rural Clinical Schools

Canada

• Differs Province to Province

• Recruitment incentives

• Alternative funding models

• Rural postgraduate training

• Rural medical school programs

Northern Ontario School of Medicine

• Faculty of Medicine of Lakehead

• Faculty of Medicine of Laurentian

• Social Accountability mandate

• Commitment to innovation

In, by and for Northern Ontario

Northern Ontario

Southern Ontario

• Sioux Lookout

Doctor’s Life Cycle

• high schools program

• local premed programs

• undergraduate program

• postgraduate programs

• professional development

• graduate studies

Admissions 2005-201012,000 applications for 346 places

• 20% of applicants interviewed• 15% of interviewees enrolled

Class Profile• 91% Northern Ontario• 7% Aboriginal 22% Francophone• GPA 3.7• Age 26 (except 28 charter class)• 68% Female 32% Male

Distributed CommunityEngaged Learning

An instructional model that allows widely distributed human and instructional resources to be utilized independent of time and place in community partner locations across the North

Organization / Delivery

of NOSM CurriculumPhase 1 Phase 3

Year 1

101102103104105106

Residency

Year 2

107108109110111

Year 3

Comprehensive Community

Clerkship

Year 4

Clerkship&

Electives

Licensure Examination

Years 5, 6and Beyond

IndividualSpecialtyChoice

Case Based Modules

Phase 2

Elective

Patient CentredCase Based Learning

• complex “real life” scenarios

• structured discussion, analysis

and problem solving

• informed tutor / facilitator

Principles for Longitudinal Integrated Curricula

• comprehensive patient care over time• continuing learning relationships with clinicians• achieve core clinical competencies across multiple disciplines simultaneously

Rural Distributed Medical Education

• high quality clinical and educational experiences• electronic access to information and educational resources• maximum human contact

Integrated Clinical Learning

InterprofessionalLearners and

Providers

MedicalStudents

Clinical Teachers

PostgraduateResidents

Patient & Family

Context: •Clinical setting•Area of care•Physical environment•Practice culture•Community

Learning occurs at points of overlap –multiple overlap can lead to richer learning

Community Engagement

• community active participant - interdependent partnership• ensures student “at home”• contributes to student’s learning experience• education and research activities• community capacity building

NOSM Outcomes

• CaRMS - 100% matched• 63% rural family medicine• 33% general specialties• 11 medical schools (of 17)• 35% residency with NOSM• “deep roots” in Northern Ontario• >65% of NOSM residents stay

NOSM Charter Class

NOSM

NOSM Residents

Benefits of NOSM

• More generalist doctors• Enhanced healthcare access• Responsiveness to Aboriginal, Francophone, rural, remote• Interprofessional cooperation• Health research• Broader academic developments• Economic development

Essentials for Success

• Context counts• Community participation• Standards and quality• Definition of success • Challenge conventional wisdom• Vision, mission and values• Program blueprint

References• Strasser R. Rural Health Around the World: Challenges

and Solutions. Family Practice 2003; 20: 457-463.

• Strasser R., et al. Canada's new medical school: the Northern Ontario School of Medicine - social accountability through distributed community engaged learning. Academic Medicine. 2009; 84: 1459-1456

• Strasser, R. Community engagement: a key to successful rural clinical education. Rural and Remote Health 10: 1543. (Online), 2010. Available from: http://www.rrh.org.au

• Strasser R, Neusy, A-J. Context Counts: Training Health Workers in and for Rural Areas. Bull World Health Organ 2010; 88: 777 – 782