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The Romanow report noted that, although Canada has one of the world’s best health care systems, there is a huge disparity of services between those living in urban areas and those residing in smaller or more remote areas of the country. Moreover, the report argued that geography has become a determinant of the level of health care, because these communities struggle to attract and retain health care professionals (1). Further, Strasser noted that, internationally, access to care is the number one rural health issue (2). Proposed solutions encompass a wide range of tactics, from recruitment campaigns, financial incentives, and early rural exposure to changes in both academic and social policies (3–9). In 1996, Ontario called for greater attention to rural and northern training exposure during medical school and residency (10). The creation of the MOHLTC UAP also led to a source of support for northern and rural clinical service and education, particularly outreach consultation from larger centres to underserved areas. Finally, in the 1980s and 1990s, several university- and community-based organizations were created to support and encourage northern and rural education. This included the ECP at the University of Western Ontario, the Northern Ontario Francophone Psychiatric Program at the University of Ottawa, NOMP, NOMEC, and the Rural Ontario Medical Program. In 1995, the University of Toronto established its own psychiatric outreach program to provide clinical consultation and education to underserviced areas. In the first phase, between 1995 and 2001, UTPOP also created opportunities for residents to participate in outreach consultation clinics. In a second phase, launched in 2001, UTPOP expanded its program to give residents living in northern sites the opportunity to complete long-term core rotations in their home communities. This paper investigates those who graduated from the University of Toronto Department of Psychiatry between January 1990 and June 2002 (the first phase of the program only) to assess where they located and whether such factors as age, sex, and place of birth influenced their decision. Second, we assessed what factors discriminate those who were active in outreach as a resident and those who are still active in outreach consultation. MethodWe distributed self-administered questionnaires to all psychiatrists who graduated from the University of Toronto between January 1990 and June 2002. In total, our sampling frame comprised 314 graduates who were listed on the College of Physicians and Surgeons of Ontario Web site (11) or in the Annual Canadian Medical Directory (12). Between October and December of 2002, we mailed up to 3 questionnaires at monthly intervals. Of the 314 eligible respondents, 14 questionnaires were returned as undeliverable, and 153 respondents provided completed questionnaires (51% response rate). The sample surveyed by this study includes those who had access to UTPOP outreach electives between 1994 and 2002 but does not include those who participated in northern core rotations developed after 2001. The first members of this latter group did not graduate until 2003. This cohort now includes at least 8 residents and will be the subject of a subsequent study. A self-administration questionnaire was developed on the basis of a literature review of the factors related to the recruitment and retention of health professionals in rural and underserved areas. The final 7-page , 61-item instrument was based on input by consultants and residents who are part of the UTPOP. This project was approved by the joint CAMH University of Toronto Research Ethics Committee. The 2 key outcomes assessed in this paper include items related to practice location and outreach activities. Determinants of practice location were assessed by the question, “How important were the following factors in your professional environment in determining your choice of your main practice location?” The respondents were asked to rate 20 items (for example, professional challenge and level of interest in the position) as “very important,” “important,” or “not important.” For the second key outcome, outreach activities, we asked those with outreach experience as a resident the question, “How important were the following factors in influencing your decision to do outreach?” Again, the respondents were asked to rate 14 items (for example, high quality of supervision) as “very important,” “important,” or “not important.” Similarly, those currently involved in outreach consultation were asked to rate the importance of 8 items in the question, “How important were the following factors in motivating you to do outreach?” (for example, type of experience offered). In addition, our analysis included age, sex, and region, based on 5 regions derived from the Ontario Learning Disabilities Resource Directory area maps (13). Some key sample characteristics are shown in Table 1. As noted, men and women were equally represented in the sample (51% and 49%), and just over one-half the sample (53%) were aged 40 years or under. Regionally, over 97% of respondents resided in Ontario, with 76% in Toronto. Of the remainder, 3.4% (n = 5) practised in Eastern Ontario; only 1 respondent practised in the north. Additional analyses indicated that 80% practised in large urban centres with populations of 300 000 or more, and only 6 (4%) reported that they provided service to populations of less than 10 000. About two-thirds (61%) reported involvement in a single practice location, 27% reported having practices in 2 locations, 8% in 3, and 4% in more than 3 locations. Fourteen percent indicated they practised general psychiatry, 49% practised subspecialties, and 34% reported practising both general and subspecialty psychiatry practice. The most frequently cited subspecialties were child (n = 31), schizophrenia (n = 18), geriatrics (n = 17), forensics (n = 16), mood disorders (n = 14), medical psychiatry and (or) consultation (n = 13), substance abuse (n = 10), and eating disorders (n = 9).
Table 1 also provides some comparisons between respondents and nonrespondents for sex, age, and region. There was no significant difference between respondents and nonrespondents for sex. However, the sample tends to overrepresent younger respondents and underrepresent respondents from outside Ontario. Fortunately, among those living in Ontario, the differences between the respondents and nonrespondents was not significant (c2 = 3.84, df 3; P = 0.280). In sum, the sample appears to have good characteristics, including a response rate that exceeds or is comparable with other physician surveys (14–16), and minimal differences between respondents and nonrespondents on key demographic variables. ResultsChoice of Practice Location To assess the underlying dimensions of the 20 items related to choice of practice location, we performed exploratory factor analysis for categorical data (17). An examination of the data suggested the presence of 3 dominant factors: professional, community, and family ties and lifestyle. These 3 factors displayed a meaningful factor structure and had an acceptable goodness-of-fit (root mean square residual = 0.089). In Table 2, the first 9 items represent the professional domain (eigenvalue = 4.50). As indicated by the factor loadings, the most highly correlated items were work opportunities, patient population, professional challenge, and supervisor influence. Collegial presence and contact, opportunity for advancement, university affiliation, and multidisciplinary opportunities were also moderately important. The next 4 items represent the community and family ties domain (eigenvalue = 3.39). Proximity to extended family, desire to return to hometown, community ties, and children’s education are part of this domain. The lifestyle domain (eigenvalue = 1.60) is represented by 3 items: lifestyle, recreational activities, and community size and diversity. The 4 items, level of administrative and psychosocial support provided in the position, autonomy and freedom to run own practice, spousal work, and income did not clearly load on any of the 3 dominant factors. As noted in other studies, Table 2 shows that practice location ratings are not significantly associated with either sex or age. Indeed, of the 20 factors, only 3 showed significant differences. Those aged 40 years and under were more likely to cite personal contacts and influence of supervisors as very important for choosing their practice location, compared with those aged over 40 years (43% and 28%; 30% and 13%, respectively), whereas those aged over 40 years were more likely than younger respondents to cite community ties as a very important factor in choosing practice location (41% and 22%, respectively).
We also assessed whether community size was associated with choice of practice location. Only 2 factors showed any degree of significance. Sixty-four percent of those living in communities over 100 000 rated professional challenge and level of interest in the position as very important, compared with 23% of those in communities with a population of 100 000 or under (c2 = 8.16, df 1; P = 0.004). Forty-five percent of those in communities with a population over 100 000 listed size and diversity as important, compared with 15% in communities under 100 000 (c2 = 4.30, df 1; P = 0.038). Prior Connection to Current Practice Location We also investigated whether factors such as early community connections or later medical training were associated with current practice location. Unfortunately, owing to a printing error, only 91 questionnaires provided data on this question. Table 3 indicates that few respondents returned or remained in their home communities after graduation. Although less than one-third were born or raised or did their postsecondary education in the community in which they now practise (21% and 32%, respectively), after graduation, almost one-half (52%) remained in proximity to their place of residency.
Factors Associated With Involvement in Outreach Forty-five percent (n = 69) of respondents indicated they were involved in outreach as a medical student and 44% (n = 68) as a resident; 31% (n = 47) were involved in both. Table 4 shows that the 3 highest-rated motivational factors for those who did outreach as residents focused on types of experience offered. The next 2 factors are related to teaching style and enthusiasm and high quality of the supervisors. The item with the lowest rating, interest in a particular lifestyle (9%), suggests that outreach activities were undertaken for career experiences and not for lifestyle or location reasons. In a question directed at those who did no outreach as a resident, 48% cited university or hospital demands, and 27% reported lack of knowledge and familiarity with rural or underserviced areas as reasons for not participating.
There is an association between year of graduation and participation in rural or northern electives as a resident. Of the 56 respondents who graduated before 1995, 34% participated in resident electives, compared with 55% of those who graduated in 1995 or later (c2 = 5.85, df 1, P = 0.016). This increase suggests that the establishment of UTPOP in 1995 allowed more psychiatry residents the opportunity to experience rural medicine. In addition, among respondents who indicated they are currently involved in outreach (n = 37), 78% had rural or remote experience as a resident. Table 4 shows that this same group of respondents rated variety in work routine as the primary factor for doing outreach (51%) and positive role models during residency as the second (40%) for continuing outreach after graduation. Conversely, 17% (n = 27) of respondents said they did outreach in the past but dropped the program. Although family and professional commitments were cited as the 2 main reasons for stopping, there are some interesting differences between those who stopped doing outreach and those who continued. Among those who went on outreach electives in at least 3 or more years of their 5 years of resident training, 85% are still providing outreach service, compared with only 50% of those who participated for 2 years or less (c2 = 5.05, df 1; P = 0.025). Table 5 presents a logistic regression predicting current and past involvement in outreach activities. The analysis shows that age, sex, or outreach activities during medical school are not significantly associated with the odds of participating in outreach. The determining predictor is whether they had rural or northern exposure during their residency. This group was 10.2 times as likely as those who did not receive prior outreach residency experience to be currently involved in outreach. These findings did not hold for those who started but discontinued their involvement.
InterpretationBefore discussing the implications of our research, we should note the limitations of the study. First, we cannot rule out the possibility that differences between respondents and nonrespondents may bias our data. Nevertheless, our results are consistent with other research showing that sex and age are not significant predictors in determining a practice location (18). Second, we limited our study to those who completed their residency at the University of Toronto between January 1990 and June 2002, and we cannot know whether our findings generalize to other programs. Third, our data, based on self-reports of perceived influences on practice location, likely contain unknown measurement error. Fourth, our data are cross-sectional; thus, we are unable to interpret our findings as causal determinants. Despite these limitations, we believe our findings offer insight into how we might help address the gap in services between the rural or remote and urban areas. Our results suggest that rural exposure during residency may produce a cohort of psychiatrists with the experience to deliver outreach consultations. Today, approximately 50 psychiatrists are part of the University of Toronto’s psychiatric outreach fly-in, drive-in programs that provide clinical services, education, and training on a rotating basis to local mental health workers in the north and underserviced areas of the south. The University of Ottawa, The University of Western Ontario, McMaster University, and Queen’s University also offer similar services. However, in the first 5 years of the outreach program, it is evident that simple rural exposure in itself has failed to encourage location of our graduates out of the urban centres. As important as our existing outreach programs are, we need to move beyond this type of model and leverage the results of our data to show that choosing to locate in a less serviced community can be a viable and attractive option. Our findings suggest that some residents choose not to participate in outreach electives because they are unfamiliar with rural life. Indeed, a study done by the Canadian Psychiatric Association (19), as well as other studies, indicates that the practice of mental health care is different in rural areas than it is in urban centres and requires specialized training (6,20,21). Including the practice of rural mental health as part of the core curriculum may appeal to psychiatry graduates seeking a change in lifestyle. In addition to early exposure and specialized courses, research also highlights the importance of targeting and training students with strong rural ties as one of the key factors in any long-term recruitment strategy (2,18,20–27) As well, Loschen and others found that psychiatrists often set up practice in communities similar in size to their place of origin (28). Although our study does not capture the home communities of respondents, our findings suggest that graduates opt to practise where they trained. Positive impact on the number of graduates who choose to practise in underserviced areas may result from decentralizing and allowing residents from these communities the chance to train close to home. It is for this reason that, in 2001, UTPOP created long-term core rotations in the north and, in cooperation with NOMP and NOMEC, helped develop a dedicated northern stream position. Therefore, while our survey showed little movement of residents from south to north or urban to rural, with the advent of these core rotations, this is starting to change. In 2003, 2 residents who completed most of their training in the north have chosen to stay. Several more residents have elected to do their core rotations in Thunder Bay, Sault Ste Marie, and North Bay. As well, the establishment of the Northern Ontario School of Medicine and the development of a northern stream position offered through CARMS should also bring more psychiatrists to these underserviced areas. In summary, addressing the needs of underserviced areas from an educational perspective requires a 3-pronged approach. First, involving residents in outreach consultation appears to be effective in training a cohort of psychiatrists with the experience to continue to deliver outreach once in practice. For many small communities in rural and remote Ontario, this may be the most appropriate form of service. Second, only by creating more long-term, on-site core rotations and rural stream residencies can we expect a portion of our graduating psychiatrists to locate in the underserviced communities. Third, conceptually separating the goals and objectives of outreach consultation education from onsite rural or remote education may help us to develop the most appropriate elements for both of these essential educational programs. Funding and SupportUTPOP and the Ontario psychiatric outreach programs are supported by the UAP of the MOHLTC. References1. Romanow RJ. Building on values: the future of health care in Canada. Ottawa (ON): Canadian Government Publishing Communication Canada; 2002. 2. Strasser R. Education and research by rural practitioners, for rural practitioners in the rural setting. N Z Fam Physician 2002;29(2):86–8. 3. WONCA World Council Meeting. Policy on training for rural practice, 1995 Available: www.globalfamilydoctor.com/aboutWonca/working_groups/rural_training/training/WONCAP01.htm. Accessed 2004 Jun 7. 4. Barer ML, Stoddart GL. Improving access to needed medical services in rural and remote Canadian communities: recruitment and retention revisited. The University of British Columbia, Centre for Health Services and Policy Research; 1999. 5. Emmerson B, Brown P, Whiteford H, McVie N, Kuipers W. Recruitment and retention of psychiatrists in non-metropolitan public positions in Queensland: research on “Queensland’s health response.” Australian N Z J Psychiatry 1996;30:667–71. 6. Lau T, Kumar S, Thomas D. Practicing psychiatry in New Zealand’s rural areas: incentives, problems and solutions. Australasian Psychiatry 2002;10(1):33–8. 7. Pion GM, Kellere P, McCombs H. Mental health providers in rural and isolated areas. 1997 Available: www.mentalhealth.org/publications/allpubs/SMA98-3166/default.asp. Accessed 2004 Jun 23. 8. RPAP Coordinating Committee Working Group on Undergraduate Rural Medical Education. Undergraduate rural medical education. 2003. Available: www.rpap.ab.ca/pdf/URME%20Report%20FINAL%2016Sept2003.pdf. Accessed 2004 Mar 3. 9. Society of Rural Physicians of Canada, Professional Association of Internes and Residents of Ontario. PAIRO: from education to sustainability: a blueprint for addressing physician recruitment and retention in rural and remote Ontario, 1998. Available: www.srpc.ca/librarydocs/Susta.PDF. Accessed 2004 Jul 6. 10. Provincial Co-ordinating Committee on Community and Academic Health Science Centre Relations (PCCAR). Expert Panel on Physician Resources. 1996. 11. The College of Physicians and Surgeons of Ontario [Web site]. 2004. Available: www.cpso.on.ca. Accessed 2004 Jun 5. 12. Business Information Group. 48th Annual Canadian Medical Directory. Don Mills (ON): HCN Publications Company; 2002. 13. Learning Disabilities Association of Ontario [Web site]. Available: http://ldao.ca/directory/direct/ldaomap/ldaomap.html. Accessed 2004 Mar 3. 14. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50:1129–36. 15. Kellerman SE, Herold J. Physician response to surveys: a review of the literature. Am J Prev Med Elsevier Science Inc 2001;20(1):61–7. 16. Lin E, Woodside DB, Rhodes A. The Canadian Psychiatric Association practice profile survey: 1. Methods and general sample characteristics. Can J Psychiatry 2003;48:237–43. 17. Muthen LK, Muthen BO. Mplus: the comprehensive modeling program for applied researchers. Los Angeles (CA): Muthen and Muthen; 1998. 18. Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The role of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Acad Med 2002;77:790–8. 19. Bernston A, Goldner E, Leverette J, Moss P, Tapper M, Hodges B. Psychiatric training in rural and remote areas: increasing skills and building partnerships. Ottawa (ON): Canadian Psychiatric Association (CPA); August 2005. Position Paper nr 2005-46. 8 p. Available from CPA, 141 Laurier Avenue West, Suite 701, Ottawa, ON K1P 5J3. 20. Bachrach LL. Psychiatric services in rural areas: a sociological overview. Hosp Community Psychiatry 1983;34:215–26. 21. Merwin EI, Goldsmith HF, Manderscheid RW. Human resource issues in rural mental health services. Community Ment Health J 1995;31:525–37. 22. Dunbabin JS, Levitt L. Rural origin and rural medical exposure: their impact on the rural and remote medical workforce in Australia. Rural and Remote Health 2003;3:1–26 Available: http://rrh.deakin.edu.au/publishedarticles/article_print_212.pdf Accessed 2004 Mar 3. 23. Easterbrook M, Godwin M, Wilson R, Hodgetts G, Brown G, Pong R, and others. Rural background and clinical rural rotations during medical trainings: effect on practice location. CMAJ 1999;160:1159–63. 24. Greene J. Rural doctors often born not raised, not recruited. Am Med News 1999;42(34):1–4. 25. Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA 2001;286:1041–8. 26. Shack J, Baker AD. Keeping doctors north: recruiting and retaining physicians in underserved areas. Univ Toronto Med J 1999;76:174–8. 27. Tavernier LA, Connor PD, Gates D, Wan JY. Does exposure to medically underserved areas during training influence eventual choice of practice location? Med Educ 2003;37:299–304. 28. Loschen EL, D’Elia GM, Sheehan MP. Factors affecting selection of psychiatry and the distribution of psychiatrists. J Med Educ 1985;60:332–4. Author(s)Manuscript received March 2005, revised, and accepted September 2005. 1. Associate Professor and Vice Chair (Education), Department of Psychiatry, University of Toronto, Toronto, Ontario; Director, University of Toronto, Faculty of Medicine, Donald R Wilson Centre for Research in Education at the University Health Network, Toronto, Ontario; Director, Ontario Psychiatric Outreach Programs, Centre for Addiction and Mental Health, Toronto, Ontario; Centre for Addiction and Mental Health, Toronto, Ontario 2. Research Analyst and Program Evaluator, University of Toronto Psychiatric Outreach Program,Centre for Addiction and Mental Health, Toronto, Ontario. 3. Associate Professor, University of Toronto, Faculty of Medicine, Toronto, Ontario; Staff Psychiatrist, Moods and Disorder Program, Centre for Addiction and Mental Health, Toronto, Ontario; Director, University of Toronto Psychiatric Outreach Program, Toronto, Ontario. 4. Policy and Program Developer, Ontario Psychiatric Outreach Programs, Centre for Addiction and Mental Health,Toronto, Ontario. 5. Associate Professor, Department of Public Health Sciences and Department of Psychiatry, Faculty of Medicine, Toronto, Ontario; Head, Population and Life Course Studies, Centre for Addiction and Mental Health, Toronto, Ontario. Address for correspondence: Dr B Hodges, University Health Network, Toronto General Hospital, Donald R Wilson Centre For Research in Education, 200 Elizabeth Street, 1-565, Toronto, ON M5G 2C4 e-mail: brian.hodges@utoronto.ca
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