Medical student clerkships a pipeline to creating more rural physicians: study

Towns throughout rural Alberta perennially struggle with the problem of attracting family physicians to their community. A University of Alberta education program might hold some of the answers.

A recently published study in the Canadian Medical Education Journal tracked over a thousand university medical grads between 2009 and 2016. The cohort who went through U of A's Rural Integrated Community Clerkship (ICC) Program in their third year of med school were more likely to choose rural or family practice after graduation than those who did a rounds-based placement in an urban hospital.

"For those that have done the ICC, we found that 45 per cent of the total group of ICC grads went into rural practice, whether they chose family medicine or another specialty," said co-author and chief investigator Jill Konkin. Before becoming a professor of family medicine at the U of A, Konkin was a family doctor in Sundre and Jasper.

Conventional wisdom in education indicates students with rural backgrounds are more inclined to return to rural communities after graduation. Participation in the ICC program proved to be an even stronger predictor of whether students would choose careers in rural medicine. About 27 per cent of students with rural backgrounds who did their third year placement in an urban centre ended up in a rural practice, while rural students who went through the ICC were nearly twice as likely to choose rural medicine.

Even students from urban centres who had chosen the ICC Program were also more likely to end up in a rural practice than rural students who had not.

"So how we see this is that the ICC program helps to support the rural students' interest in likelihood to return to rural as well as increasing those who are urban origin and potentially interested in rural to consider it and do it," Konkin said.

Konkin said the program's influence on students' career paths has a lot to do with the relationships they form with patients, their physician-teachers, and other healthcare workers during the ten-month placement.

"They actually feel like they belong in that community and that they are members of [the] health team in that community. Which one would then theorize helps them understand that this might be something that is an appealing way of practicing and that that sense of belonging is hugely important for decisions about where you might practice," Konkin said.

The ICC Program started in 2007 with just seven students, and now normally has more than 20. Konkin said the goal is to keep increasing the number of students over time, but the decline of rural health services and loss of physicians greatly limits the opportunities ICC participants have for their placement.

To ensure that students in the rural program meet all the same objectives as those who stayed in the city, communities need to have a regular clinic, a hospital with inpatient emergency care, labour and delivery, and minor surgeries. It has always been difficult to find communities with the breadth of services required, Konkin said, and it has only become more a challenge.

"If one looks at rural health since Klein's 90s, rural has lost significant services," Konkin said. "That was, in a sense, the beginning of a decline in the extent of the delivery of services in rural communities."

"And that before the latest round of sort of insecurity or fluidity in the workforce was one of the limitations on where we could go. But most recently with the significant loss of physicians from rural it has been a challenge to expand the program."

Konkin said there is a core group of 10 communities in central and north Alberta, and they have negotiated a few more locations further south, being careful not to impinge the University of Calgary, which runs a similar program.

"But we've also had communities that have had to take a pause from the program who are still very committed to the program. But for instance, two years ago, I think was two years ago now. There was a community that had had 10 to 12 full-time positions that in a couple of months, went to four," she said.

Without the commitment of rural physicians who are willing to teach, the success of the program wouldn't be possible, Konkin said. Education programs can take years to show a difference. With this study ICC has hard numbers to point to, and will continue working toward their goal of getting 30 med students through clerkships each year.

"The challenge is, health services changes, government changes, or physician recruitment and retention, all of those kinds of things have a significant impact on rural medical education programs that we have to keep trying to work around and keep our programs robust and functional," Konkin said.

Brett McKay, Local Journalism Initiative Reporter, St. Albert Gazette