Storylines of family medicine XII: family medicine and the healthcare system.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XII: Family medicine and the future of the healthcare system', authors address the following themes: 'Leadership in family medicine', 'Becoming an academic family physician', 'Advocare-our call to act', 'The paradox of primary care and three simple rules', 'The quadruple aim-melding the patient and the health system', 'Fit-for-purpose medical workforce', 'Universal healthcare-coverage for all', 'The futures of family medicine' and 'The 100th essay.' May readers of these essays feel empowered to be part of family medicine's exciting future.

Social responsiveness: The key ingredient to achieve social accountability in education and health care.

While social accountability (SA) is regarded as an obligation or mandate for medical school administration, it runs the danger of becoming a bureaucratic checkbox. Compassion which leads to social responsiveness (SR), in contrast, is often recognized as an individual characteristic, detached from the public domain. The two, however, complement each other in practice. Institutions must be truly socially accountable, which is possible if there is spontaneous SR to the needs, and is fueled by compassion. Compassion in this article is defined as a "feeling for other people's sufferings, and the desire to act to relieve the suffering." Compassion has a long history, whereas SA is more recently described concept that follows the historical development of social justice. SR is the moral or ethical duty of an individual to behave in a way that benefits society. Not everyone feels the need to do something for others. Even if the need is felt, there may be a lack of will to act for the needs or to act effectively to fulfill the needs of society. The reasons are many, some visible and others not. SR provides the basis for being compassionate; hence, medical schools need to include SR as a criterion in their admissions process for student recruitment and inculcate compassion in health professions education and health care. By fostering SR and engaging compassion and self-compassion to achieve SA, we can humanize medical education systems and health care.

Staffing rural emergency departments in Ontario: The who, what and where.

Introduction: The emergency department (ED) in rural communities is essential for providing care to patients with urgent medical issues and those unable to access primary care. Recent physician staffing shortages have put many EDs at risk of temporary closure. Our goal was to describe the demographics and practices of the rural physicians providing emergency medicine services across Ontario in order to inform health human resource planning. Methods: The ICES Physician database (IPDB) and Ontario Health Insurance Plan (OHIP) billing database from 2017 were used in this retrospective cohort study. Rural physician data were analysed for demographic, practice region and certification information. Sentinel billing codes (i.e., a billing code unique to a particular clinical service) were used to define 18 unique physician services. Results: A total of 1192 physicians from the IPDB met inclusion as rural generalist physicians out of a total of 14,443 family physicians in Ontario. From this physician population, a total of 620 physicians practised emergency medicine which accounted for 33% of their days worked on average. The majority of physicians practising emergency medicine were between the ages of 30 and 49 and in their first decade of practice. The most common services in addition to emergency medicine were clinic, hospital medicine, palliative care and mental health. Conclusion: This study provides insight into the practice patterns of rural physicians and the basis for better targeted physician workforce-forecasting models. A new approach to education and training pathways, recruitment and retention initiatives and rural health service delivery models is needed to ensure better health outcomes for our rural population.

Résumé Introduction: Le service d'urgence des communautés rurales est essentiel pour la prise en charge des patients présentant des problèmes médicaux urgents et de ceux qui ne peuvent accéder aux soins primaires. En raison de la récente pénurie de médecins, de nombreux services d'urgence risquent de fermer temporairement. Notre objectif était de décrire les caractéristiques démographiques et les pratiques des médecins ruraux qui fournissent des services de médecine d'urgence en Ontario afin d'éclairer la planification des ressources humaines en santé. Méthodes: La base de données des médecins de l'ICES (IPDB) et la base de données de facturation de l'assurance-santé de l'Ontario (OHIP) de 2017 ont été utilisées dans cette étude de cohorte rétrospective. Les données sur les médecins ruraux ont été analysées pour obtenir des renseignements sur la démographie, la région de pratique et la certification. Les codes de facturation sentinelle (c'est-à-dire un code de facturation unique pour un service clinique particulier) ont été utilisés pour définir 18 services médicaux uniques. Résultats: Sur un total de 14 443 médecins de famille en Ontario, 1 192 médecins de l'IPDB ont été inclus en tant que médecins généralistes ruraux. Parmi cette population de médecins, 620 pratiquaient la médecine d'urgence, ce qui représentait 33% de leurs jours de travail en moyenne. La majorité des médecins qui pratiquaient la médecine d'urgence étaient âgés de 30 à 49 ans et en étaient à leur première décennie de pratique. Les services les plus courants en plus de la médecine d'urgence étaient la clinique, la médecine hospitalière, les soins palliatifs et la santé mentale. Conclusion: Cette étude permet de mieux comprendre les modes de pratique des médecins ruraux et de jeter les bases de modèles de prévision des effectifs médicaux mieux ciblés. Une nouvelle approche des parcours d'éducation et de formation, des initiatives de recrutement et de rétention et des modèles de prestation de services de santé en milieu rural est nécessaire pour garantir de meilleurs résultats en matière de santé pour notre population rurale. Mots-clés: Médecine d'urgence, médecins ruraux, planification des ressources humaines en santé.

The Limerick Declaration on Rural Health Care 2022.

The 19th World Rural Health Conference, hosted in rural Ireland and the University of Limerick, with over 650 participants coming from 40 countries and an additional 1600 engaging online, has carefully considered how best rural communities can be empowered to improve their own health and the health of those around them. The conference also considered the role of national health systems and all stakeholders, in keeping with the commitments made through the Sustainable Development Goals and the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being. This conference declaration, the Limerick Declaration on Rural Healthcare, is designed to inform rural communities, academics and policymakers about how to achieve the goal of delivering high quality health care in rural and remote areas most effectively, with a particular focus on the Irish healthcare system. Congruent with current evidence and best international practice, the participants of the conference endorsed a series of recommendations for the creation of high quality, sustainable and cost-effective healthcare delivery for rural communities in Ireland and globally. The recommendations focused on four major themes: rural healthcare needs and delivery, rural workforce, advocacy and policy, and research for rural health care. Equal access to health care is a crucial marker of democracy. Hence, we call on all governments, policymakers, academic institutions and communities globally to commit to providing their rural dwellers with equitable access to health care that is properly resourced and fundamentally patient-centred in its design.

Teaching compassion for social accountability: A parallaxic investigation.

BACKGROUND: In an arts integrated interdisciplinary study set to investigate ways to improve social accountability (SA) in medical education, our research team has established a renewed understanding of compassion in the current SA movement. AIM: This paper explores the co-evolution of compassion and SA. METHODS: The study used an arts integrated approach to investigate people's perceptions of SA in four medical schools across Australia, Canada, and the USA. Each school engaged approximately 25 participants who partook in workshops and in-depth interviews. RESULTS: We began with a study of SA and the topic of compassion emerged out of our qualitative data and biweekly meetings within the research team. Content analysis of the data and pedagogical discussion brought us to realize the importance of compassion in the practice of SA. CONCLUSIONS: The cultivation of compassion needs to play a significant role in a socially accountable medical educational system. Medical schools as educational institutions may operate themselves with compassion as a driving force in engaging partnership with students and communities. Social accountability without compassion is not SA; compassion humanizes institutional policy by engaging sympathy and care.

Ten years of graduates: A cross-sectional study of the practice location of doctors trained at a socially accountable medical school.

INTRODUCTION: The study predicted practice location of doctors trained at a socially accountable medical school with education programs in over 90 communities. METHODS: A cross-sectional study examined practice location 10 years after the first class graduated from the Northern Ontario School of Medicine (NOSM), Canada. Exact tests and logistic regression models were used to assess practice location in northern Ontario; northern Canada; or other region; and rural (population <10,000) or urban community. RESULTS: There were 435 doctors with 334 (77%) practising as family doctors (FPs), 62 (14%) as generalist specialists and 39 (9%) as other medical or surgical specialists. Approximately 92% (128/139) of FPs who completed both UG and PG at NOSM practised in northern Ontario in 2019, compared with 63% (43/68) who completed only their PG at NOSM, and 24% (30/127) who completed only their UG at NOSM. Overall, 37% (23/62) of generalist specialists and 23% (9/39) of other specialists practised in northern Ontario. Approximately 28% (93/334) of FPs practised in rural Canada compared with 4% (4/101) of all other specialists. FP northern Ontario practice was predicted by completing UG and PG at NOSM (adjusted odds ratio = 46, 95% confidence interval = 20-103) or completing only PG at NOSM (15, 6.0-38) relative to completing only UG at NOSM, and having a northern Ontario hometown (5.3, 2.3-12). Rural Canada practice was predicted by rural hometown (2.3, 1.3-3.8), completing only a NOSM PG (2.0, 1.0-3.9), and age (1.4, 1.1-1.8). CONCLUSION: This study uniquely demonstrated the interaction of two mechanisms by which medical schools can increase the proportion of doctors' practices located in economically deprived regions: first, admit medical students who grow up in the region; and second, provide immersive UG and PG medical education in the region. Both mechanisms have enabled the majority of NOSM-trained doctors to practise in the underserved region of northern Ontario.

Commentary: Burning Platforms, Icebergs and Tipping Points - Canada Needs a Single Socially Accountable Healthcare System.

Leslie et al.'s (2022) article caused me to reflect on the complexities and contradictions that are Canada. Healthcare in Canada is a hodgepodge of different health systems all assembled under the umbrella of the Canada Health Act (1985). Canadians expect medicare to deliver high-quality healthcare close to home wherever they live. For this aspiration to become a reality, there needs to be a single pan-Canadian health system focussed on the health needs of the populations being served. This socially accountable healthcare system is likely to be achieved only if there is a chorus of support across Canada for meaningful pan-Canadian health reforms.

Addressing rural and Indigenous health inequities in Canada through socially accountable health partnerships.

BACKGROUND: There are few examples of the practical application of the concepts of social accountability, as defined by the World Bank and WHO, to health system change. This paper describes a robust approach led by First Nations Health Authority and the Rural Coordination Centre of British Columbia. This was achieved using partnerships in British Columbia, Canada, where the health system features inequities in service and outcomes for rural and Indigenous populations. Social accountability is achieved when all stakeholders come together simultaneously as partners and agree on a path forward. This approach has enabled socially accountable healthcare, effecting change in the healthcare system by addressing the needs of the population. INNOVATION: Our innovative approach uses social accountability engagement to counteract persistent health inequities. This involves an adaptation of the Boelen Health Partnership model (policymakers, health administrators, health professionals, academics and community members) extended by addition of linked sectors (eg, industry and not-for-profits) to the 'Partnership Pentagram Plus'. We used appreciative inquiry and deliberative dialogue focused on the rural scale and integrating Indigenous ways of knowing along with western scientific traditions ('two-eyed seeing'). Using this approach, partners are brought together to identify common interests and direction as a learning community. Equitable engagement and provision of space as 'peers' and 'partners' were key to this process. Groups with varying perspectives came together to create solutions, building on existing strengths and new collaborative approaches to address specific issues in the community and health services delivery. A resulting provincial table reflecting the Pentagram Plus model has fostered policies and practices over the last 3 years that have resulted in meaningful collaborations for health service change. CONCLUSION: This paper presents the application of the 'Partnership Pentagram Plus' approach and uses appreciative inquiry and deliberative dialogue to bring about practical and positive change to rural and Indigenous communities.

Distributed education enables distributed economic impact: the economic contribution of the Northern Ontario School of Medicine to communities in Canada.

BACKGROUND: Medical schools with distributed or regional programs encourage people to live, work, and learn in communities that may be economically challenged. Local spending by the program, staff, teachers, and students has a local economic impact. Although the economic impact of DME has been estimated for nations and sub-national regions, the community-specific impact is often unknown. Communities that contribute to the success of DME have an interest in knowing the local economic impact of this participation. To provide this information, we estimated the economic impact of the Northern Ontario School of Medicine (NOSM) on selected communities in the historically medically underserviced and economically disadvantaged Northern Ontario region. METHODS: Economic impact was estimated by a cash-flow local economic model. Detailed data on program and learner spending were obtained for Northern Ontario communities. We included spending on NOSM's distributed education and research programs, medical residents' salary program, the clinical teachers' reimbursement program, and spending by learners. Economic impact was estimated from total spending in the community adjusted by an economic multiplier based on community population size, industry diversity, and propensity to spend locally. Community employment impact was also estimated. RESULTS: In 2019, direct program and learner spending in Northern Ontario totalled $64.6 M (million) Canadian Dollars. Approximately 76% ($49.1 M) was spent in the two largest population centres of 122,000 and 165,000 people, with 1-5% ($0.7 M - $3.1 M) spent in communities of 5000-78,000 people. In 2019, total economic impact in Northern Ontario was estimated to be $107 M, with an impact of $38 M and $36 M in the two largest population centres. The remaining $34 M (32%) of the economic impact occurred in smaller communities or within the region. Expressed alternatively as employment impact, the 404 full time equivalent (FTE) positions supported an additional 298 FTE positions in Northern Ontario. NOSM-trained physicians practising in the region added an economic impact of $88 M. CONCLUSIONS: By establishing programs and bringing people to Northern Ontario communities, NOSM added local spending and knowledge-based economic activity to a predominantly resource-based economy. In an economically deprived region, distributed medical education enabled distributed economic impact.

Integrated clinical learning: team teaching and team learning in primary care.

Developed in Northern Ontario, Canada, Integrated Clinical Learning (ICL) involves a team of clinical teachers from a range of health professions teaching a team of students and trainees together in common community and clinical settings. It is the balanced integration of educational strategies to develop healthcare providers and team-based competencies focused on improving the quality of care. Learning outcomes are developed with and in consideration of the goals of patients or the community through relational learning that mirrors patient-centred care. Implementing ICL requires a systematic approach that addresses the practical issues and enhances the quality of experience for all involved. These practicalities include academic institutions valuing ICL through the appointment and support of primary care clinicians as academic staff with protected time; the provision of physical space, as well as clinical and teaching equipment; and the appointment of local administrative coordinators. The team approach shares the teaching load with the multiple students actually teaching each other so that the load on individual clinicians is less than for one student at a time. Through ICL, students are learning from patients and developing a service-oriented professional identity. The patient and family centred nature of ICL helps bridge the primary care-secondary care divide as students follow their patients into and out of hospital services. This is positive for patients and specialists and provides authentic learning for students. ICL enhances the quality of care; the quality of learning; and the quality of professional satisfaction for primary care clinical teachers.

Lessons learned from adapting a remote area health placement from physical to virtual: a COVID-19-driven innovation.

OBJECTIVES:  To investigate the acceptability and the effectiveness of a virtual adaptation of a well-established, mandatory, community-based pre-clinical remote area health placement in which medical students learn about the social and environmental determinants of health in remote Australia; and make recommendations to guide the delivery of future learning experiences. METHODS: A mixed-methods convergent design was used. All 99 students, 36 placement hosts and 10 staff were invited to complete an online survey and 27(27%), 12(33%) and 10(100%), respectively, contributed data.  Qualitative data were collected via semi-structured interviews from four students, four hosts and six staff. Survey data were analysed using descriptive statistics (frequency and percentage) and open-ended responses summarised to provide supporting contextual evidence. Interview transcripts were analysed and coded independently, then corroborated to identify and summarise common themes using thematic analysis. RESULTS: Survey and interview data indicated that the virtual placement was acceptable to students and hosts and enabled students to achieve intended learning objectives.   Virtual activities enabled students and hosts to develop authentic, genuine interpersonal relationships, which in turn were facilitated when hosts and students had practiced videoconferencing beforehand with good high-speed internet connections via mobile devices. Pastoral care and access to IT support were essential. CONCLUSIONS: Virtual placements can be used in combination with and are an option for students and hosts who cannot attend/courses that cannot fund physical placements. Careful design and further research is required to ensure that virtual placements enable "head, heart and hands" learning and do not create/reinforce inequities.

Plan, recruit, retain: a framework for local healthcare organizations to achieve a stable remote rural workforce.

BACKGROUND: Recruiting and retaining a skilled health workforce is a common challenge for remote and rural communities worldwide, negatively impacting access to services, and in turn peoples' health. The research literature highlights different factors facilitating or hindering recruitment and retention of healthcare workers to remote and rural areas; however, there are few practical tools to guide local healthcare organizations in their recruitment and retention struggles. The purpose of this paper is to describe the development process, the contents, and the suggested use of The Framework for Remote Rural Workforce Stability. The Framework is a strategy designed for rural and remote healthcare organizations to ensure the recruitment and retention of vital healthcare personnel. METHOD: The Framework is the result of a 7-year, five-country (Sweden, Norway, Canada, Iceland, and Scotland) international collaboration combining literature reviews, practical experience, and national case studies in two different projects. RESULT: The Framework consists of nine key strategic elements, grouped into three main tasks (plan, recruit, retain). Plan: activities to ensure that the population's needs are periodically assessed, that the right service model is in place, and that the right recruits are targeted. Recruit: activities to ensure that the right recruits and their families have the information and support needed to relocate and integrate in the local community. Retain: activities to support team cohesion, train current and future professionals for rural and remote health careers, and assure the attractiveness of these careers. Five conditions for success are recognition of unique issues; targeted investment; a regular cycle of activities involving key agencies; monitoring, evaluating, and adjusting; and active community participation. CONCLUSION: The Framework can be implemented in any local context as a holistic, integrated set of interventions. It is also possible to implement selected components among the nine strategic elements in order to gain recruitment and/or retention improvements.

Retaining graduates of non-metropolitan medical schools for practice in the local area: the importance of locally based postgraduate training pathways in Australia and Canada.

INTRODUCTION: The objective of this study was to identify commonalities between one regionally based medical school in Australia and one in Canada regarding the association between postgraduate training location and a doctor's practice location once fully qualified in a medical specialty. METHODS: Data were obtained using a cross-sectional survey of graduates of the James Cook University (JCU) medical school, Queensland, Australia, who had completed advanced training to become a specialist (a 'Fellow') in that field (response rate = 60%, 197 of 326). Medical education, postgraduate training and practice data were obtained for 400 of 409 (98%) fully licensed doctors who completed undergraduate medical education or postgraduate training or both at the Northern Ontario School of Medicine (NOSM), Ontario, Canada. Binary logistic regression used postgraduate training location to predict practice in the school's service region (northern Australia or northern Ontario). Separate analyses were conducted for medical discipline groupings of general/family practitioner, general specialist and subspecialist (JCU only). RESULTS: For JCU graduates, significant associations were found between training in a northern Australian hospital at least once during postgraduate training and current (2018) northern Australian practice for all three discipline subgroups: family practitioner (p<0.001; prevalence odds ratio (POR)=30.0; 95% confidence interval (CI): 6.7-135.0), general specialist (p=0.002; POR=30.3; 95%CI: 3.3-273.4) and subspecialist (p=0.027; POR=6.5; 95%CI: 1.2-34.0). Overall, 38% (56/149) of JCU graduates who had completed a Fellowship were currently practising in northern Australia. For NOSM-trained doctors, a significant positive effect of training location on practice location was detected for family practice doctors but not for general specialist doctors. Family practitioners who completed their undergraduate medical education at NOSM and their postgraduate training in northern Ontario had a statistically significant (p<0.001) POR of 36.6 (95%CI: 16.9-79.2) of practising in northern Ontario (115/125) versus other regions, whereas those who completed only their postgraduate training in northern Ontario (46/85) had a statistically significant (p<0.001) POR of 3.7 (95%CI: 2.1-6.8) relative to doctors who only completed their undergraduate medical education at NOSM (28/117). Overall, 30% (22/73) of NOSM's general speciality graduates currently practise in northern Ontario. CONCLUSION: The findings support increasing medical graduate training numbers in rural underserved regions, specifically locating full specialty training programs in regional and rural centres in a 'flipped training' model, whereby specialty trainees are based in rural or regional clinical settings with some rotations to the cities. In these circumstances, the doctors would see their regional or rural centre as 'home base' with the city rotations as necessary to complete their training requirements while preparing to practise near where they train.

It takes a community to train a future physician: social support experienced by medical students during a community-engaged longitudinal integrated clerkship.

BACKGROUND: Social support may be beneficial for medical students who must develop adaptive strategies to respond to the demands and challenges during third-year clerkship. We provide a detailed description of the supportive behaviours experienced by third-year students during a longitudinal integrated clerkship (LIC) in the context of rural family medicine. METHODS: Informed by a social constructivist research paradigm, we undertook a qualitative study to understand from the students' perspectives the presence and characteristics of social support available during a LIC. Data were collected from conversational interviews at three points during the eight-month clerkship year, pre-, during, and post-clerkship, to explore how 12 medical students experienced social support. We employed an innovative methodological approach, the guided walk method, to gain the students' stories in the contexts where they were taking place. RESULTS: The participants described the relationships they developed with various sources of social support such as (a) preceptors, (b) peers, (c) family, (d) health professionals, and (e) community members. CONCLUSION: Various individuals representing communities of practice such as the medical profession and community members were intimately related to the longitudinal aspects of the students' experiences. The findings lend credence to the view that it really does take a community to train a future physician.

Community engagement: A central feature of NOSM's socially accountable distributed medical education.

BACKGROUND: Northern Ontario School of Medicine (NOSM) serves as the Faculty of Medicine of Lakehead and Laurentian Universities, and views the entire geography of Northern Ontario as its campus. This paper explores how community engagement contributes to achieving social accountability in over 90 sites through NOSM's distinctive model, Distributed Community Engaged Learning (DCEL). METHODS: Studies involving qualitative and quantitative methods contribute to this paper, which draws on administrative data from NOSM and external sources, as well as surveys and interviews of students, graduates and other informants including the joint NOSM-CRaNHR (Centre for Rural and Northern Health Research) tracking and impact studies. RESULTS: Community engagement contributes throughout the lifecycle stages of preadmission, admission, and undergraduate medical education. High school students from 70 Northern Ontario communities participate in NOSM's week-long Health Sciences Summer Camps. The MD admissions process involves approximately 128 volunteers assessing written applications and over 100 volunteer interviewers. Thirty-six Indigenous communities host first year students and third-year students learn their core clinical medicine in 15 communities, throughout Northern Ontario. In general, learners and communities report net benefits from participation in NOSM programs. CONCLUSION: Community engagement makes a key contribution to the success of NOSM's socially accountable distributed medical education.

Challenges of Capacity and Development for Health System Sustainability.

To achieve sustainability, remote and rural communities require health service models that are designed in and for these settings and are responsive to local population health needs. This paper draws on a panel discussion at the Rural and Indigenous Health Symposium held in Toronto, ON, on September 21, 2017. Active community participation is an important contributor to success in rural health system transformation, as well as health workforce recruitment and retention. Increasingly, communication technology is contributing to the quality and effectiveness of healthcare in remote rural community settings, particularly by ensuring that specialist expertise is accessible to and supportive of the local providers of care. Recent medical graduates bring life experiences and work expectations to rural primary care that are different from their senior colleagues. Successful recruitment and retention of the rural primary care workforce depend increasingly on offering a "turnkey" clinic work supported by a functioning electronic medical record. Rural health system sustainability occurs most frequently through ongoing collaboration and partnerships, partnerships, partnerships. It is through partnerships with communities, health services and healthcare providers that the Northern Ontario School of Medicine (NOSM) has been successful in producing medical graduates who provide care responsive to population health needs in previously underserved communities of northern Ontario. Sustainable healthcare in remote and rural communities is enhanced by active community participation and clustering these communities in local networks. An important key to success is shifting from hospital-centric to community-centric care.

Needs of the many: Northern Ontario School of Medicine students' experience of generalism and rural practice.

OBJECTIVE: To explore the Northern Ontario School of Medicine (NOSM) student and graduate experience of generalism in rural practice, in the context of a growing discourse on generalism. DESIGN: Qualitative analysis. SETTING: Northern Ontario School of Medicine in multiple sites across northern Ontario, which is the NOSM campus. PARTICIPANTS: A total of 37 graduating medical students and 9 practising NOSM graduates. METHODS: The Centre for Rural and Northern Health Research and NOSM tracking studies use mixed methods drawing on data from various sources. This paper reports on an arts-based study using semistructured interviews. MAIN FINDINGS: Key themes from student observations include an affinity for the northern Ontario environment and a recognition that rural medicine involves a broad scope of practice. Students from NOSM consider generalist care to be a comprehensive service with a strong focus on responding to the health needs of the communities they serve. Beyond primary care, a rural medicine "true generalist" is viewed as a complete package-a physician who provides care ranging from promoting prevention to performing specialist tasks. CONCLUSION: Rural practitioners, particularly in family medicine, are extended generalists with a broad scope of practice guided by the health needs of the communities they serve. The NOSM students' and graduates' experience of rural generalism is positive and highly influential in determining their career directions, including specialty, scope, and location of practice. The generalist approach of NOSM might be effective beyond rural applications and an advantageous approach for foundational medical education. Students and graduates report that NOSM's distributed community-engaged learning prepares them well for rural generalist practice.