A framework for enhancing continuing medical education for rural physicians: A summary of the literature

Abstract

Background: Recruitment and retention of rural physicians is vital for rural health care. A key deterrent to rural practice has been identified as professional isolation and access to continuing medical education/continuing professional development (CME/CPD).

Aims: The purpose of this article is to review and synthesize key themes from the literature related to CME/CPD and rural physicians to facilitate CME/CPD planning.

Methods: A search of the peer-reviewed English language literature and a review of relevant grey literature (e.g., reports, conference proceedings) was conducted.

Results: There is robust evidence demonstrating that the CME/CPD needs of rural physicians are unique. Promising practices in regional CME/CPD outreach and advanced procedural skills training and other up-skilling areas have been reported. Distance learning initiatives have been particularly helpful in increasing access to CME/CPD. The quality of evidence supporting the overall effect of these different strategies on recruitment and retention is variable.

Conclusion: Supporting the professional careers of rural physicians requires the provision of integrated educational programs that focus on specific information and skills. Future research should examine the linkage between enhanced CME/CPD access and its effect on factors related to retention of physicians in rural communities. A proposed framework is described to aid in developing CME/CPD for rural practitioners.

Introduction

The problem of recruiting and retaining physicians is particularly troublesome for rural communities and a key challenge to sustaining rural healthcare systems (Hutten-Czapski 1998; Kermode-Scott 1999; Tepper & Rourke 1999; Mennin & Kaufman 2000; Ramsey et al. 2001). The issues influencing rural physician recruitment and retention are varied and include: individual factors (such as rural background); family issues of spouse and children; community lifestyle and integration; educational factors such as rural exposure during medical training; and professional, economic, and organizational issues (Crouse 1995; National Rural Health Association 1998; MacIsaac et al. 2000; Curran & Rourke 2004; Gagnon et al. 2007). Kamien and Buttfield (1990) suggest that a main factor in attracting doctors to rural areas and keeping them there is related to the professional satisfaction they obtain from feeling needed and practicing a highly personalized form of comprehensive care. A number of professional factors believed to have a particular influence on reasons for leaving rural practice include: work hours; professional back-up; specialty services; additional training; hospital services; earning potential, and ease of access to continuing medical education/continuing professional development (CME/CPD) (Rourke 1993; Pathman et al. 1996; Florizone 1997). Bhatara et al. (1996) have suggested that rural physicians’ sense of professional isolation, because of a lack of continuing education opportunities, influences feelings of job dissatisfaction with rural practice. Several authors and reports have suggested that improving the professional lives of rural physicians can encourage their retention (Howe et al. 1994; WONCA 1995; Adams 1998; Kiroff 1999; White et al. 2007; Stenger et al. 2008). Access to appropriate and meaningful CME/CPD opportunities has been identified as a key factor in retaining medical practitioners in rural and remote communities (Jackson & Jackson 1991; Canadian Association of Interns and Residents 1992; Canadian Medical Association 1992; Zollo et al. 1999; Alexander & Fraser 2005; Kotzee & Couper 2006; White et al. 2007). Lifelong learning is critical in maintaining competence and confidence to function effectively. It is important that CME/CPD planners are aware of the unique needs and challenges of rural physicians to better meet their needs.

Table

Practice points

Robust evidence demonstrates that the CME/CPD needs of rural physicians are unique and that professional isolation and access to CME/CPD are key factors affecting recruitment and retention. Rural physicians are often expected to perform a generalist role in every aspect of clinical practice and because of this must develop and maintain a strong knowledge base and technical skill in a variety of clinical areas. Emerging evidence suggests that eclectic strategies addressing CME/CPD access and professional isolation factors at multiple policy and program levels can affect rural physician satisfaction and reduce perceptions of professional isolation. Promising practices in regional CME/CPD outreach, CME in advanced procedural skills training, and distance learning programming have been found to be particularly helpful in enhancing access to CME and reducing professional isolation. Further investigation of the direct linkage between strategies to enhance CME/CPD access and rural physician recruitment and retention is needed.

In this article, we review the literature related to rural physicians and relevant CME/CPD. We attempt to synthesize key themes emerging from the literature related to the CME/CPD needs of rural physicians, the challenges and barriers in providing appropriate CME/CPD for rural areas, and strategies to enhance relevant CME/CPD for rural physicians. We adapt a framework, first developed by Davis et al. (2009), to the rural setting. This rural CME/CPD framework can be of use to CME/CPD planners as well as to rural physicians themselves in identifying relevant CME/CPD.

Method

MEDLINE was the primary database used for the literature search. MESH search terms included: CME; rural population; rural hospital; and rural health services. Inclusion criteria included English language articles that were relevant to rural physicians and access to CME/CPD, and discussed issues, research and/or initiatives related to rural and remote CME/CPD delivery. There were no limits placed on study design and/or methodology. Articles were included that described the specific CME/CPD needs of rural physicians and discussed barriers and/or solutions to the problems of rural CME/CPD access. The literature review also included a number of relevant published and unpublished reports, conference proceedings and discussion papers.

Results

CME needs of rural physicians

A number of authors have reported on the unique and varied CME/CPD needs of rural physicians and how these needs differ from those of urban physicians (Rosenthal & Miller 1982; Rourke 1988; Kamien & Buttfield 1990; Woolf 1991; Gill & Game 1994; Lott 1995; Curran et al. 2000; Allan & Schaefer 2005; Curran et al. 2007). Two unique features of rural medicine practice are the scope of practice and the distance from major urban areas with specialist support and referral services (Rourke & Strasser 1996; Rourke 1997; Rourke et al. 2000).

Scope of rural medical practice

In rural areas with a small hospital, the rural physician's scope of practice can include not only office-based family practice, house calls, and nursing home visits, but also a large component of hospital-based medicine with a broad range of illness. This may include admission and ongoing care of high acuity in-hospital patients, emergency medicine shifts, obstetric deliveries, and sometimes GP anesthesia and surgery (Rourke 1991; Britt et al. 1993; Hamilton 1995; Rourke 1997; Pope et al. 1998).

Rural physicians also report practicing a wider range of procedural skills than their urban counterparts and this requires rural physicians to maintain competency in a number of advanced clinical areas, working more independently without ready access to the latest medical technology and specialist consultation (Al-Turk & Susman 1992; Hays et al. 1994; Rourke 1994; Wise et al. 1994; Baldwin et al. 1995; Kingsmill 1997; Hoyal 2000; Strasser 2001; Glazebrook & Harrison 2006).

Physicians entering rural practice often do not feel sufficiently prepared in relevant clinical skills and procedures which are drawn from many fields including: anesthetics; surgery; obstetrics; gynecology; emergency medicine; radiology; radiography; ophthalmology; dermatology; psychiatry; pediatrics; and ultrasonography (Glazebrook et al. 2004; Glazebrook & Harrison 2006).

Rural physicians play a key role in the initial emergency management of trauma (Lopez et al. 2006) and report a higher need than urban physicians for CME/CPD in emergency medicine, including advanced clinical procedural skills for the seriously injured patient (Curran et al. 2000). These include: pediatric and infant emergencies and procedures; airway, circulatory, and respiratory emergencies and procedures; management of neurological, toxicological, and orthopedic emergencies; and management of drowning, near drowning, multiple trauma, and spinal cord injuries (Tolhurst et al. 1999). It has been suggested that rural physicians should receive basic training in all of the procedural disciplines and skills needed to provide emergency care in communities remote from regional support services (Wise et al. 1994).

Rural physicians also need a special knowledge of aspects of medical care pertinent to their unique locations, which may include aboriginal healthcare, as well as wilderness, industrial, or agricultural medicine (Alexander & Fraser 2005). Barnabe and Kirk (2002) have also identified palliative care training as being important to rural physicians, especially in rural areas with aging populations.

Accessibility issues for rural physicians

In many instances, rural physicians are remote from specialist support and referral services, and also from a variety of CME/CPD opportunities. In a rural environment, access to CME/CPD may be limited because of a lack of locum coverage and distance factors such as time, expense, and travel issues (Rourke 1988; Rourke 1994; Pope et al. 1998). Rural physicians, some of whom are the sole providers of healthcare in their communities, simply cannot leave their communities to attend an educational session, regardless of how beneficial it might be to their patients and their practices (Lott 1995). While CME/CPD programs, meetings, and workshops in urban settings are often accessible to urban physicians, offerings of similar programs in rural settings are limited. A number of studies report that rural physicians perceive their opportunities for participation in traditional CME/CPD activity as inadequate (Rubenstein et al. 1975; Rosenthal & Miller 1982; Blackwood & McNab 1991; Woolf 1991; Gill & Game 1994; Lott 1995; Pathman et al. 1996; Curran et al. 2000; Alexander & Fraser 2007; White et al. 2007).

White et al. (2007) examined aggregate evaluation data collected from CME/CPD workshop attendees over a 3-year period. Data from 429 respondents indicated that 94% agreed or strongly agreed that access to CME/CPD contributed to confidence in practicing in rural and/or remote locations. Ninety-three percent (93%) agreed or strongly agreed that access to CME/CPD alleviated professional isolation and 80% agreed or strongly agreed that they were less likely to remain without access (White et al. 2007).

While it has long been recognized that CME/CPD is important for recruitment and retention, it is also becoming increasingly necessary for practicing physicians to fulfill their license requirements. Revalidation of certification and/or licensure is becoming the gold standard for many regulatory bodies (Hayes 2005; Levinson 2008; Lake 2009). As such, the ability to access and partake in relevant and meaningful CME/CPD activities, regardless of one's place of practice, will be essential. With a possible increased emphasis on chart audits and peer review assessments, access to CME/CPD must be easily accomplished from any geographic location.

Strategies to enhance CME/CPD access for rural physicians

There is evidence that these identified barriers can be addressed, at least in part, by increased support for flexible CME/CPD such as specific rural skills training programs (Glazebrook & Harrison 2006). The World Organization of Family Doctors (WONCA) Working Party on Training for Rural Practice (1995) has recommended the provision of CME/CPD and professional development programs (PDPs) that meet the identified needs of rural family physicians.

Support from medical education institutions

Several studies insist that the continuum of rural practice education and training, referred to as a “pipeline to practice”, should not end after undergraduate or postgraduate training, but rather should be ongoing to encourage and facilitate CME/CPD among rural physicians (Council on Graduate Medical Education 1998; Rourke 2010). Barer and Stoddart (1999) have recommended greater opportunities for rural physicians to upgrade their skills and if necessary, re-enter training programs to specialize in areas of need for their communities. Iglesias and Thompson (1998) suggest that there is an onus on medical schools to take responsibility for the education of appropriately skilled doctors to meet the needs of their general geographic region, including underserved areas. Modifiable factors related to professional development and post-licensure skills enhancement include: increased support for CME/CPD; study leaves; and expanded training opportunities in procedural skills, and basic life support (i.e., ACLS, ATLS, OLS and neonatal resuscitation) (Rourke 1993; Adams 1998). According to Glazebrook and Harrison (2006), the use of outreach educational teams who provide onsite rural CME/CPD is a useful strategy. Kaufman (1990) has also suggested that medical schools should encourage faculty and residents to provide services and educational outreach to rural communities. This could take the form of expanded community-based CME/CPD courses concurrent with the provision of consultation services to rural practices.

Rural CME/CPD workshops

According to White et al. (2007), professional support through the provision of rurally relevant workshop-delivered CME/CPD is an effective strategy in retaining doctors in rural and remote communities. For example, a Rural Advanced Life Support Update Course offered rural physicians the opportunity to learn key components from advanced trauma life support (ATLS); pediatric advanced life support (PALS); advanced cardiac life support (ACLS); and Toxicology (Rourke 1994). Another example is a comprehensive Rural Critical Care course developed by the Society of Rural Physicians of Canada that provides eight hands-on workshops including the insertion of chest tubes, paracentesis and peritoneal lavage, pediatric crises, transport, electrocardiography, radiology, central and arterial lines, ventilators, and rapid sequence induction (Kingsmill 1997).

Distance CME/CPD

Distance education has been identified as a useful method for providing CME/CPD to rural physicians (World Organization of Family Doctors 1995). Distance learning enables rural physicians to enhance their knowledge of new clinical advances and learn new skills, and can foster communication and networking with colleagues via telephone, video, or over the Internet, all without leaving their communities. The use of such technology has the potential to alleviate some of the isolation felt by rural physicians and to reduce the costs, travel time, and staff absences associated with distant on-site CME/CPD programming (Zollo et al. 1999).

Audio teleconferencing has been used as a continuing education delivery mode for health professionals, and in particular rural physicians, since the 1960 s (House et al. 1981; Meyer 1983; Lockyer et al. 1987; Curran 2006). For example, the “Wednesday at Noon” program at Memorial University of Newfoundland Canada has been running continuously since 1979 (Elford 1998). In locales with challenges in the cost, availability, and reliability of more modern and complex forms of distance education, audio teleconferencing still allows the delivery of CME/CPD with the opportunity for live two-way interaction.

Videoconferencing technology has rapidly emerged as an increasingly useful tool for improving patient care delivery and expanding access to CME/CPD for health professionals seeking improved interactive, real-time two-way communication. Videoconferencing systems have experienced significant growth in recent years because of increased digital transmission options at reduced costs, vast improvements in video compression technologies, and improvements in the systems with an associated decrease in their cost. Several studies have demonstrated that CME/CPD videoconferencing is popular with rural physicians (Langille et al. 1998; Davis & McCracken 2002; Klein et al. 2005; Ricci et al. 2005; Greenwood & Williams 2008), and is as effective, if not better, than face-to-face CME/CPD in increasing knowledge in a variety of clinical topic areas (Hampton et al. 1994; Ricci et al. 2005; Rossaro et al. 2007; Miller et al. 2008).

Internet-based learning has become an increasingly popular approach to medical education (Casebeer et al. 2002; Curran & Fleet 2005; Fordis et al. 2005; Bergeron 2006; Cook et al. 2008), and on-line CME/CPD has grown steadily in the recent past (Olson & Shershneva 2004; Wearne 2008). The Internet has expanded opportunities for the provision of a flexible, convenient, and interactive form of CME/CPD for busy practitioners who have difficulty attending formal education sessions (Casebeer et al. 2003; Sly et al. 2006). A consortium of the Canadian medical school CME/CPD departments has developed MDcme.ca, an Internet-based CME portal which provides College of Family Physicians of Canada (CFPC) accredited online CME courses (Curran et al. 2004). A large number of registrants and participants in these Internet-based CME/CPD courses are rural physicians. Evaluation data indicate that such courses are a highly satisfactory CME/CPD format, effective in enhancing knowledge and increasing confidence, and participants report significant change in clinical practice as a result of participation (Curran et al. 2004, 2006).

Examples of innovative rural CME/CPD initiatives

There have been a number of innovative rural CME/CPD initiatives described in the literature. Several examples that have not been described earlier are listed below.

In 1994, the Department of Family Medicine at the University of British Columbia, Canada established an Enhanced Skills Program to meet the needs of primary care physicians, especially those who practiced in rural areas, with regards to special skills. Practicing physicians from rural communities were offered the paid opportunity, for up to a year, to train in areas such as psychiatry, anesthesia, surgery, obstetrics, and emergency medicine (Whiteside 1996; Whiteside & Newbery 1997). CME/CPD sessions were also offered to isolated communities throughout the province. Each session was one hour long and case-based, and interaction was possible between presenters and participants. Another exciting current Canadian initiative is the Enrichment Program of the rural physician action plan (RPAP) in Alberta, Canada which uses rural physician “skills brokers” and support from regional medical directors to facilitate individually tailored skills training programs for rural physicians (Gorsche & Hnatuik 2006).

The Western Australian Center for Rural and Remote Medicine (WACRRM), established in 1990, introduced a number of initiatives in an attempt to address the inadequate provision of CME/CPD for rural physicians (Jackson & Jackson 1991). Its initiatives included assisting physicians who wanted to upgrade their skills by providing them with locums and arranging exchange opportunities between rural and urban physicians. A pilot journal club had also been started amongst rural GPs. Doolan and Nichols (1994) described the establishment of the Directorate of Rural Education and Training. One of its key objectives was the advancement of rural CME/CPD, including re-skilling opportunities for rural physicians. Another Australian CME/CPD initiative connected internationally known speakers with a rural GP panel and moderator by satellite link to hundreds of rural hospitals around the country (Rourke & Strasser 1996).

The Australian College of Rural and Remote Medicine (ACRRM) has introduced several initiatives to enhance access to CME/CPD for rural physicians. The ACRRM has introduced a mandatory Professional Development Program (PDP) for its Fellows with a range of continuing education activities that enhance their clinical, management, and professional skills. Participation is mandatory but the program is designed to be flexible and responsive to the range of rural practice characteristics as well as to individual needs (Crampton & Wilkinson 2002). In 2000, ACRRM also developed a national radiology quality assurance (QA) and CME/CPD program for rural and remote non-specialist Australian doctors (Glazebrook et al. 2005a). The Support Scheme for Rural Specialists has also been introduced in Australia to reduce professional isolation among rural medical specialists and has supported new formats for CME/CPD (Kurzydlo et al. 2005; McLean 2006).

Rural physicians in the United States have benefited from the establishment of Area Health Education Centres (AHEC) (Rhoades et al. 1995; Whitfield 1998; Ramsey et al. 2001). These centres have worked with local medical schools to train physicians about ever-changing rural health science trends. They have arranged CME/CPD courses, maintained learning resource centres and worked to strengthen local healthcare systems in order to further develop the skills of rural physicians. The AHECs and offices of rural health also served to link communities with healthcare professionals seeking new locations and advising towns on recruitment.

Discussion

A framework for developing effective CME/CPD for rural physicians

Davis et al. (2009) outline a 4-step process to make CME/CPD more effective: knowing the audience; knowing the topic; knowing the format; and knowing the outcome. Using this framework, Table 1 summarizes the key thematic findings which emerged from the current review and synthesis of the literature for CME/CPD for rural physicians. A content analysis (Springer 2010) was used to identify the key themes with respect to each of the steps of the Davis et al. (2009) framework. This process involved comparing and contrasting themes emerging from the literature, and synthesizing these themes as categories to fit within the framework.

Table 1.  Key themes related to effective CME/CPD for rural physicians

Four steps for effective CME/CPD (Davis et al. 2009)	Identified rural physician themes
Know the audience	1. Isolation – from colleagues, consultants, locums
	2. Rural physician needs assessments
	3. Adult learning principles and styles
	4. Retention factors for rural physicians
Know the topic	1. Wide and sometimes different scope of practice, including:
	• Procedural skills
	• Care of high acuity patients that would be managed by consultants if available
	• Wilderness medicine
	• Occupational medicine (e.g., mines, farming, fishing, etc.)
	• Unique population characteristics (e.g., genetic, cultural, socioeconomic, etc.)
	2. Self-study – to identify needed CME
Know the format	1. Face-to-face formats
	• Location: urban, regional/centralized, local
	• Types: lecture, workshop, panel discussion, etc.
	2. Distance formats
	• Synchronous vs. asynchronous
	• Medium used: video, audio, internet, PDA compatible, etc.
	3. Point-of-care CME/CPD – timeliness, especially in urgent clinical situations
	4. Traineeships
	5. Self-study
Know the outcomes	Dixon's four outcomes (from least to most complex):
	1. Perception of the learning event
	2. Competence
	3. Performance change
	4. Healthcare outcome

Davis et al. (2009) suggest that knowing the audience involves understanding the various attributes and characteristics of the target audience which might influence learning needs, interests, and participation in CME/CPD. Isolation from colleagues, consultants, and locums must be considered when developing appropriate CME/CPD for rural physicians. As for any target audience, rural or urban, it is important to have an accurate needs assessment when planning CME/CPD and also to be familiar with the principles of adult learning (Knowles 1980). CME/CPD is more likely to be valued if it incorporates and addresses known rural physician retention factors (e.g., individual, lifestyle, family, professional, educational, economic, and organizational). Examples include increased support for CME/CPD, such as assistance with reimbursement of travel, accommodation, program costs, provision of locums, and increased time off for study (Rourke 1993; Adams 1998).

Knowing the topic refers to the importance of identifying both subjective and objective needs which may inform the development and implementation of CME/CPD activities and approaches. Subjective needs are expressed by the learner, whereas objective needs reflect areas in which clinical evidence has not been effectively translated into practice. CME/CPD programs should be attentive to the wide scope of clinical and procedural skills practiced in rural settings. The availability of CME/CPD on topics identified by self-study is desirable for all physicians.

Knowing the format emphasizes the importance of the educational intervention and thinking about the best ways to make the CME/CPD activity effective and enabling the transfer of information into the rural practice setting. The use of information and communication technologies (ICTs) to support the CME/CPD needs of rural physicians has been discussed and presented in the literature as key program delivery options. A number of distance learning program initiatives have been successful in enhancing knowledge and skill levels of rural physicians and study findings indicate a high level of satisfaction with such initiatives. The urgency of conditions managed by rural physicians can often demand accessible point-of-care CME/CPD. Initiatives which provide opportunities for consultation with peers at a distance have also demonstrated some success in addressing professional isolation issues. It is important, however, that these “distance” initiatives support rural professional practice rather than diminish local outreach by visiting consultants and other resources (Gagnon et al. 2007). CME/CPD outreach programming in the form of regional or community-based CME/CPD courses, clinical traineeships and visiting consultant initiatives are all possible strategies to increase access to CME/CPD. Relevant urban-based CME/CPD can also provide opportunities for rural physicians and their families; the chance to meet widely disbursed colleagues, to communicate directly with consultants to whom they refer patients, and to have time away from practice obligations.

Knowing the outcome deals with evaluation of the effect and impact of the CME/CPD educational intervention. Outcomes from CME/CPD activities range from the most easily measured results of perception of and satisfaction with the activity, through to changes in competency (e.g., knowledge, skills or attitudes), performance change, and finally, and most challenging to measure, to improvements in healthcare outcomes (Dixon 1978; Davis et al. 2009). Given the need for further evidence to support the link between increased access to CME/CPD and retention, the effect of CME/CPD on rural physician's practice competencies and the increased attention to revalidation and CME/CPD participation, knowing the outcomes is very important in enhancing CME/CPD programming for rural physicians.

Although systematic reviews pertaining to the effectiveness of CME/CPD have been published (Davis et al. 1999, 2009; Marinopoulos et al. 2007), there appears to be limited research that has measured the actual impact of access to relevant CME/CPD on retention of rural physicians (White et al. 2007). A limited number of studies have focused specifically on the effect of CME/CPD on rural physician practice. A local ultrasound CME/CPD program for rural and remote Australian doctors resulted not only in self-reported increases in knowledge, confidence, and expertise in ultrasound, but also an objective increase in knowledge (Glazebrook et al. 2005b). Another Australian study found that rural CME/CPD was effective in increasing rural GPs’ knowledge and skills in the management of common palliative symptoms (Reymond et al. 2005). Two American studies described local ACLS training associated with improved initial resuscitation or survival rates in rural community hospitals or out-of-hospital cardiac arrests (Birnbaum 1994; Sanders et al. 1994). In developing countries, rural CME/CPD outreach has been effective in enhancing rural physician practice. A recent study of a rural CME/CPD outreach program on HIV/STI prevention and treatment in rural China found that rural physicians reported increased knowledge and improved patient outcomes including higher rates of HIV testing and improved condom usage (Wang et al. 2009). Rural CME/CPD outreach programs in trauma care in both India and Africa have also been effective in increasing participants’ knowledge and skills in trauma care, and enhancing the quality of care provided to patients in rural areas (Mock et al. 2005; Tchorz et al. 2007).

Evaluations of CME/CPD programming and initiatives for rural physicians need to consider innovative ways to incorporate the measurement of performance change, healthcare outcomes, and health system impacts including physician recruitment and retention. Such evaluation data are critical in enhancing CME/CPD programming for rural physicians and seeking increased resources and commitment for rural CME/CPD initiatives.

Conclusion

Recruitment and retention of rural physicians is an important issue in the sustainability of rural healthcare systems. The findings from this survey of the literature pertaining to rural physicians and access to CME/CPD indicate that there is robust evidence demonstrating that the CME/CPD needs of rural physicians are unique and that professional isolation and access to CME/CPD are key factors affecting recruitment and retention. No one format or location of CME/CPD is the answer; flexibility and variety to address different needs are key. According to Alexander and Fraser (2005), supporting the professional careers of doctors in a region requires the provision of integrated educational programs that focus on specific information and skills. There is emerging evidence that eclectic strategies addressing CME/CPD access and professional isolation difficulties at multiple policy and program levels can affect rural physician satisfaction and reduce perceptions of professional isolation. Promising practices in regional CME/CPD outreach, advanced procedural skills training and other up-skilling areas are reported. Distance learning programming has been found to be particularly helpful in increasing access to CME/CPD. The quality of evidence supporting the overall effect of these different strategies on recruitment and retention is variable. Future research should examine the linkage between enhanced CME/CPD access and effect on factors related to retention of physicians in rural communities, and ultimately to the effect on rural healthcare outcomes.

Acknowledgments

We thank Dr James Rourke for his review of the manuscript.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Notes on contributors

VERNON R. CURRAN, PhD is a professor of Medical Education and Director of Academic Research and Development, Professional Development and Conferencing Services, Faculty of Medicine, Memorial University of Newfoundland.

LESLIE ROURKE, MD, CCFP, MClinSc, FCFP, FRRMS is an associate professor of Family Medicine, past Academic Director (Family Physicians), Professional Development and Conferencing Services, Faculty of Medicine, Memorial University of Newfoundland, and former rural family physician.

PAMELA SNOW, MD, CCFP, FCFP is an assistant professor of Family Medicine and the current Academic Director (Family Physicians), Professional Development and Conferencing Services, Faculty of Medicine, Memorial University of Newfoundland.