Pathways to rural family practice at Memorial University of Newfoundland.

OBJECTIVE: To assess Memorial University of Newfoundland's (MUN's) commitment to a comprehensive pathways approach to rural family practice, and to determine the national and provincial effects of applying this approach. DESIGN: Analysis of anonymized secondary data. SETTING: Canada. PARTICIPANTS: Memorial's medical degree (MD) graduates practising family medicine in Newfoundland and Labrador as of January 2015 (N = 305), MUN's 2011 and 2012 MD graduates (N = 120), and physicians who completed family medicine training programs in Canada between 2004 and 2013 and who were practising in Canada 2 years after completion of their postgraduate training (N = 8091). MAIN OUTCOME MEASURES: National effect was measured by the proportion of MUN's family medicine program graduates practising in rural Canada compared with those from other Canadian family medicine training programs. Provincial effect was measured by the location of MUN's MD graduates practising family medicine in Newfoundland and Labrador as of January 2015. Commitment to a comprehensive pathways approach to rural family practice was measured by anonymized geographic data on admissions, educational placements, and practice locations of MUN's 2011 and 2012 MD graduates, including those who completed family medicine residencies at MUN. RESULTS: Memorial's comprehensive pathways approach to training physicians for rural practice was successful on both national and provincial levels: 26.9% of MUN family medicine program graduates were in a rural practice location 2 years after exiting their post-MD training from 2004 to 2013 compared with the national rate of 13.3% (national effect); 305 of MUN's MD graduates were practising family medicine in Newfoundland and Labrador as of 2015, with 36% practising in rural areas (provincial effect). Of 114 MD students with known background who graduated in 2011 and 2012, 32% had rural backgrounds. Memorial's 2011 and 2012 MD graduates spent 20% of all clinical placement weeks in rural areas; of note, 90% of all first-year placements and 95% of third-year family medicine clerkship placements were rural. For the 25 MUN 2011 and 2012 MD graduates who also completed family medicine residencies at MUN, 38% of family medicine placement weeks were spent in rural communities or rural towns. Of the 30 MUN 2011 and 2012 MD graduates practising family medicine in Canada as of January 2015, 42% were practising in rural communities or rural towns; 73% were practising in Newfoundland and Labrador and half of those were in rural communities and rural towns. CONCLUSION: A comprehensive rural pathways approach that includes recruiting rural students and exposing all medical students to extensive rural placements and all family medicine residents to rural family practice training has resulted in more rural generalist physicians in family practice in Newfoundland and Labrador and across Canada.

From pipelines to pathways: the Memorial experience in educating doctors for rural generalist practice.

CONTEXT: This report describes the community context, concept and mission of The Faculty of Medicine at Memorial University of Newfoundland (Memorial), Canada, and its 'pathways to rural practice' approach, which includes influences at the pre-medical school, medical school experience, postgraduate residency training, and physician practice levels. Memorial's pathways to practice helped Memorial to fulfill its social accountability mandate to populate the province with highly skilled rural generalist practitioners. Programs/interventions/initiatives: The 'pathways to rural practice' include initiatives in four stages: (1) before admission to medical school; (2) during undergraduate medical training (medical degree (MD) program); (3) during postgraduate vocational residency training; and (4) after postgraduate vocational residency training. Memorial's Learners & Locations (L&L) database tracks students through these stages. The Aboriginal initiative - the MedQuest program and the admissions process that considers geographic or minority representation in terms of those selecting candidates and the candidates themselves - occurs before the student is admitted. Once a student starts Memorial's MD program, the student has ample opportunities to have rural-based experiences through pre-clerkship and clerkship, of which some take place exclusively outside of St. John's tertiary hospitals. Memorial's postgraduate (PG) Family Medicine (FM) residency (vocational) training program allows for deeper community integration and longer periods of training within the same community, which increases the likelihood of a physician choosing rural family medicine. After postgraduate training, rural physicians were given many opportunities for professional development as well as faculty development opportunities. Each of the programs and initiatives were assessed through geospatial rurality analysis of administrative data collected upon entry into and during the MD program and PG training (L&L). Among Memorial MD-graduating classes of 2011-2020, 56% spent the majority of their lives before their 18th birthday in a rural location and 44% in an urban location. As of September 2016, 23 Memorial MD students self-identified as Aboriginal, of which 2 (9%) were from an urban location and 20 (91%) were from rural locations. For Year 3 Family Medicine, graduating classes 2011 to 2019, 89% of placement weeks took place in rural communities and 8% took place in rural towns. For Memorial MD graduating classes 2011-2013 who completed Memorial Family Medicine vocational training residencies, (N=49), 100% completed some rural training. For these 49 residents (vocational trainees), the average amount of time spent in rural areas was 52 weeks out of a total average FM training time of 95 weeks. For Family Medicine residencies from July 2011 to October 2016, 29% of all placement weeks took place in rural communities and 21% of all placement weeks took place in rural towns. For 2016-2017 first-year residents, 53% of the first year training is completed in rural locations, reflecting an even greater rural experiential learning focus. LESSONS LEARNED: Memorial's pathways approach has allowed for the comprehensive training of rural generalists for Newfoundland and Labrador and the rest of Canada and may be applicable to other settings. More challenges remain, requiring ongoing collaboration with governments, medical associations, health authorities, communities, and their physicians to help achieve reliable and feasible healthcare delivery for those living in rural and remote areas.

Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes.

INTRODUCTION: Rural recruitment and retention of physicians is a global issue. The Faculty of Medicine at Memorial University of Newfoundland, Canada, was established as a rural-focused medical school with a social accountability mandate that aimed to meet the healthcare needs of a sparse population distributed over a large landmass as well as the needs of other rural and remote areas of Canada. This study aimed to assess whether Memorial medical degree (MD) and postgraduate (PG) programs were effective at producing physicians for their province and rural physicians for Canada compared with other Canadian medical schools. METHODS: This retrospective cohort study included medical school graduates who completed their PG training between 2004 and 2013 in Canada. Practice locations of study subjects were georeferenced and assigned to three geographic classes: Large Urban; Small City/Town; and Rural. Analyses were performed at two levels. (1) Provincial level analysis compared Memorial PG graduates practicing where they received their MD and/or PG training with other medical schools who are the only medical school in their province (n=4). (2) National-level analysis compared Memorial PG graduates practicing in rural Canada with all other Canadian medical schools (n=16). Descriptive and bivariate analyses were performed. RESULTS: Overall, 18 766 physicians practicing in Canada completed Canadian PG training (2004-2013), and of those, 8091 (43%) completed Family Medicine (FM) training. Of all physicians completing Canadian PG training, 1254 (7%) physicians were practicing rurally and of those, 1076 were family physicians. There were 379 Memorial PG graduates and of those, 208 (55%) completed FM training and 72 (19%) were practicing rurally, and of those practicing rurally, 56 were family physicians. At the national level, the percentage of all Memorial PG graduates (19.0%) and FM PG graduates (26.9%) practicing rurally was significantly better than the national average for PG (6.4%, p<0.000) and FM (12.9%, p<0.000). Among 391 physicians practicing in Newfoundland and Labrador (NL), 257 (65.7%) were Memorial PG graduates and 247 (63.2%) were Memorial MD graduates. Of the 163 FM graduates, 148 (90.8%) were Memorial FM graduates and 118 (72.4%) were Memorial MD graduates. Of the 68 in rural practice, 51 (75.0%) were Memorial PG graduates and 31 (45.6%) were Memorial MD graduates. Of the 41 FM graduates in rural practice, 39 (95.1%) were Memorial FM graduates and 22 (53.7%) were Memorial MD graduates. Two-sample proportion tests demonstrated Memorial University provided a larger proportion of its provincial physician resource supply than the other four single provincial medical schools, by medical school MD for FM (72.4% vs 44.3%, p<0.000) and for overall (63.2% vs 43.5% p<0.000), and by medical school PG for FM (90.8 % vs 72.0%, p<0.000). CONCLUSION: This study found Memorial University graduates were more likely to establish practice in rural areas compared with the national average for most program types as well as more likely to establish practice in NL compared with other single medical schools' graduates in their provinces. This study highlights the impact a comprehensive rural-focused social accountability approach can have at supplying the needs of a population both at the regional and rural national levels.

A randomized controlled trial of the effect of an intensive 1-year care management program on measures of health status in independent, community-living old elderly: the Eldercare project.

BACKGROUND: Primary care practitioners are familiar with the frail elderly and commonly have to deal with their multi-morbidity and their functional decline, both physically and mentally. However, there are well elderly with high quality of life and very few co-morbidities who seldom seek medical care. OBJECTIVE: To determine if a nurse-based program of home-delivered care, linked directly with the primary care practitioner or primary care team, would improve quality of life, symptoms, satisfaction with care and utilization of community and medical services, in independent community living old elderly. DESIGN: Randomized controlled trial. SETTING: St. John's, Newfoundland, Canada. PARTICIPANTS: Two hundred and thirty-six independent, community-dwelling, cognitively functioning, people aged 80 years and older. INTERVENTION: A nurse-based program of care, carried out in the patients home, that involved a detailed assessment of needs, the development of a plan to meet the needs, and up to eight visits to the patients home during a 1-year period to facilitate the meeting of those needs. CONTROL GROUP: Usual care MAIN OUTCOME MEASUREMENTS: Quality of Life measured using the SF-36 and the CASP-19 scales; symptomology using the Comorbidity Symptom Scale; patient satisfaction using the PSQ-18; and assessment of health care services (community services, emergency room visits, hospitalizations, use of diagnostic services and family doctor visits) through patient recall, family physician chart review and assessment of hospitalization records. RESULTS: There were no statistical or meaningful differences between the intervention and control groups in any of the outcomes measured. CONCLUSION: The intensive, home-delivered, program of care for the well old elderly did not have an impact on the outcomes measured.

The healthy aged: Descriptive analysis by sex of cognitively functioning elderly patients 80 years and older living independently in the community.

OBJECTIVE: To describe a population of cognitively functioning seniors aged 80 years and older who are livingin dependently in the community. DESIGN: Descriptive cross-sectional study based on the enrolment cohort of a randomized controlled trial. SETTING: St John's, Nfld. PARTICIPANTS: A total of 236 cognitively functioning seniors aged 80 years and older living independently in the community. MAIN OUTCOME MEASURES: Demographic characteristics including age, sex, marital status, and education; health status and quality of life measured by the Short Form-36 and the CASP-19 (control, autonomy, self-realization,and pleasure); use of formal and informal community services;satisfaction with family physician care as measured by the Patient Satisfaction Questionnaire-18; and use of health care resources (family physician visits, emergency department visits,hospitalizations, and laboratory and diagnostic imaging tests). RESULTS: Overall, 66.5% of those in the group were women and the average age was 85.5 years. A quarter had postsecondary diplomas or degrees; 54.7% were widowed (69.4% of women and 25.3% of men). The cohort scored well in terms of health status and quality of life, with a range of scores on the Short Form­36 from 57.5 to 93.5 out of 100, and a score of 44 out of 57 on the CASP-19; they were satisfied with the care received from family physicians, with scores between 3.8 and 4.3 out of 5 on the Patient Satisfaction Questionnaire-18; and use of health services was low-70% had no emergency department visits in the previous year and 80% had not used any laboratory or diagnostic services. CONCLUSION: Seniors aged 80 years and older living in dependently are involved in the social fabric of society. They are generally well educated, slightly more than half are widowed,and two-thirds are female. They score well on scales that measure well-being and quality of life, and they use few health services. They are the healthy aged. TRIAL REGISTRATION NUMBER: NCT00452465 (ClinicalTrials.gov).

The Validity of Scores From the New MCAT Exam in Predicting Student Performance: Results From a Multisite Study.

PURPOSE: The new Medical College Admission Test (MCAT) was introduced in April 2015. This report presents findings from the first study of the validity of scores from the new MCAT exam in predicting student performance in the first year of medical school (M1). METHOD: The authors analyzed data from the national population of 2016 matriculants with scores from the new MCAT exam (N = 7,970) and the sample of 2016 matriculants (N = 955) from 16 medical schools who volunteered to participate in the validity research. They examined correlations of students' MCAT total scores and total undergraduate grade point averages (UGPAs), alone and together, with their summative performance in M1, and the success rate of students with different MCAT scores in their on-time progression to the second year of medical school (M2). They assessed whether MCAT scores provided comparable prediction of performance in M1 by students' race/ethnicity, socioeconomic background, and gender. RESULTS: Correlations of MCAT scores with summative performance in M1 ranged from medium to large. Although MCAT scores and UGPAs provided similar prediction of performance in M1, using both metrics provided better prediction than either alone. Additionally, students with a wide range of MCAT scores progressed to M2 on time. Finally, MCAT scores provided comparable prediction of performance in M1 for students from different sociodemographic backgrounds. CONCLUSIONS: This study provides early evidence that scores from the new MCAT exam predict student performance in M1. Future research will examine the validity of MCAT scores in predicting performance in later years.

Physicians as parents: parenting experiences of physicians in Newfoundland and Labrador.

OBJECTIVE: To investigate the experiences of physicians as parents and to see if there were any differences in the parenting challenges perceived by male and female physicians. DESIGN: Mailed survey. SETTING: Newfoundland and Labrador. PARTICIPANTS: The survey was mailed to 180 male and 180 female licensed physicians, with a response rate of 60% (N = 216). MAIN OUTCOME MEASURES: Self-reported experiences of being a parent and a physician. RESULTS: Female physicians reported spending significantly more time on child care activities and domestic activities than their male counterparts did (P < .001). There was no significant difference in the number of professional hours between the 2 sexes, but income was significantly lower for female physicians (P < .001). More women than men had positive physician-parent role models, although very few physicians of either sex had such role models. Female physicians reported bearing the most responsibility for the day-to-day functioning of the family; male physicians relied on their female partners to carry out the main family responsibilities. Women reported feeling guilty about their performance as mothers and as doctors. Male physicians reported regrets about the lack of time with family. CONCLUSION: Although women make up an increasing percentage of the physician work force in Canada, they still face challenges as they continue to take primary responsibility for child care and domestic activities. Women are torn between their careers and their families and sometimes feel inadequate in both roles. Male physicians regret having a lack of time with family. Strategies need to be employed in both the workplace and at home to achieve an acceptable balance between being a physician and being a parent.

Traditional Panel Interview versus Multiple Mini-Interview (MMI) in Medical School Admissions: Does Performance differ by Age, Gender, Urban or Rural, or Socioeconomic Status (Findings from one medical school).

This article was migrated. The article was marked as recommended. INTRODUCTION: Globally, medical schools are trying to widen access and to increase the diversity of their student body to be more representative of the population and to meet the future heath care needs of society. Selection methods must not disadvantage the applicants from priority groups. In Memorial University's Faculty of Medicine, rural applicants and applicants from low socioeconomic status are priority groups. Methods: Since 2013, Memorial University has used a combination of traditional panel interviews and MMIs to interview candidates for medical school. We wondered whether applicants who participate in this medical school interview process perform differently on the MMIs compared to the traditional panel interview process and whether performance differs on either of the two interview processes based on age, sex, origin(urban or rural), or socioeconomic status. RESULTS: The mean score on the traditional panel interview was higher than that on the MMI. Females scored higher than males on both the traditional panel interview and the MMI. Applicants aged 22 and younger performed worse on both the traditional panel interview and the MMI than the other age groups. Neighborhood socioeconomic status, and urban/rural living status were not significantly related with applicants' performance on the traditional panel interview or MMI. DISCUSSION: The type of interview is not disadvantaging applicants from Memorial University's priority areas.

Physicians as mothers: breastfeeding practices of physician-mothers in Newfoundland and Labrador.

OBJECTIVE: To determine the initiation rate and duration of breastfeeding among female physicians in Newfoundland and Labrador, and to identify demographic factors that might influence duration of breastfeeding in this population. DESIGN: Mailed survey. SETTING: Newfoundland and Labrador. PARTICIPANTS: One hundred eighty licensed female physicians. MAIN OUTCOME MEASURES: Self-reported initiation of breastfeeding for each baby born, duration of breastfeeding in number of months, and reasons for ending breastfeeding. RESULTS: The response rate was 68%. The breastfeeding initiation rate among respondents was 96.6%. More physicians who graduated in 1980 or later breastfed for longer periods (63.9% vs 33.3%, P = .008). More family doctors than specialists breastfed their babies for longer periods (65.5% vs 33.3%, P = .004). More physicians whose partners were working part-time breastfed for longer periods than physicians whose partners were working full-time (83.3% vs 50.8%, P = .037). Other factors, such as age, income, maternity leave and benefits, part-time or full-time work, and urban or rural practice, did not affect duration of breastfeeding. Personal issues accounted for 51% of respondents' ending breastfeeding; baby issues accounted for 38%, practice issues for 33%, medical school issues for 4%, and societal issues for 1%. CONCLUSION: The breastfeeding initiation rate among female physician respondents in Newfoundland and Labrador was 96.6%; more than 50% of these physicians breastfed for longer than 7 months. Physicians graduating in 1980 or later breastfed their babies for longer.

A comparative analysis of the perceived continuing medical education needs of a cohort of rural and urban Canadian family physicians.

OBJECTIVE: To assess the perceived continuing medical education (CME) needs of a cohort of Canadian family physicians. METHODS: We distributed a questionnaire survey to Canadian family physicians who became Certificant members of the College of Family Physicians in 2001 and practised outside the province of Quebec. Main outcome measures were self-reported CME needs, professional development needs and preferences for CME delivery methods. RESULTS: We distributed 482 surveys and 197 questionnaires were returned for a response rate of 40.9%. Significant differences between rural and urban respondents' self-reported CME needs were found in the clinical areas of dermatology, endocrinology, emergency medicine, musculoskeletal, ophthalmology, otolaryngology, psychiatry and urology. Generally, a greater proportion of rural respondents reported significantly higher CME needs in emergency medicine. Urban respondents reported a significant preference for consulting colleagues as a method of CME, while rural respondents reported a significant preference for videoconferencing. CONCLUSION: Self-reported CME needs and preferences for CME delivery methods differ on the basis of region of practice and size of the community in which family physicians' practise.