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Table 1 Description of intervention, costing and outcomes

From: A systematic review of strategies to recruit and retain primary care doctors

Study, (year) location Study type sample size Description of intervention (year) Costs Effect of intervention on recruitment and retention
Financial initiatives
1 A contract-based training system for rural physicians: follow-up of Jichi Medical University graduates (1978–2006)
Matsumoto et al. (2008) [21]
Japan
Long term effect of the Home prefecture Recruiting Scheme of Jichi Medical University,
Matsumoto et al. (2008) [22]
Japan
Longitudinal follow up comparative between groups = 2988
Longitudinal follow up comparative between groups
n = 1255
Aims to recruit rural doctors and distribute them nation-wide.
Jichi Medical University (1972- onwards) mission to produce rural doctors. “Home-prefecture recruiting scheme”. 9 year obligation service, 6 of those in rural practice after graduating – in their home prefecture. In exchange all undergraduate fees are waived.
If in breach of contract – all medical school expenses must be repaid in a lump sum (US $183,333), plus 10 % per year in interest. By 2004 JMU graduates (post obligation) were 4.2 times more likely than non JMU grads to work in rural areas-
• In 1994 post obligation JMU Graduates were 3.9 times more likely to work in rural areas than non JMU graduates.
• Rural upbringing and primary care speciality were positively associated with ‘having a rural address at least 1 year post obligation phase.
• 69.8 % of JMU graduates settled in their home prefecture after the obligation period
• The rates varied from 45.5 to 93.3 % amongst the prefectures (p < 0.001)
• Prefectures with relative shortage of physicians had higher settlement rates.
2 US department of Health and Human Services: The National Health Service Corps (NHSC) (2012) [23] (Webpage)
USA
The Comparative Retention of National Health Service Corps and Other Rural Physicians Results of a 9 year follow up study Pathman (1992) [24]
USA
The National Health Service Corps: Rural Physician Service and retention
Cullen et al. (1997) [25]
USA
Longitudinal follow up non comparative
n = not reported
Longitudinal follow up comparative between groups
n = 304
Cross sectional - non comparative
n = 2903
The National Health Service Corps (NHSC) (1970 onwards)
3 financial incentives: Loan Repayment: Up to $50,000 to repay their health profession student loans in exchange for a two-year commitment to work at an approved NHSC site in a high-need, underserved area. Scholarships: pays tuition fees, other educational costs, and provides a living stipend in return for a commitment to work at least 2 years at an approved outpatient facility in a medically underserved community. The scholarship can be awarded for up 4 years. Service begins upon graduation. Students to Service Program Loan Repayment Program (S2S LRP) provides up to $120,000 to medical students in their final year of school in return for a commitment to provide primary health care full time for at least 3 years at an approved NHSC site in a Health Professional Shortage Area of greatest need. NB length of obligations changed throughout the program history
Loan repayment up to $50,000
Bond of $120,000
Evaluation 1 from 2012:
• 82 % of NHSC ‘clinicians continued to practice in the short term; (1 years after duration) 55 % continue to practice in underserved area 10 years after completing their service commitment. (does not specify by which specific programme they were involved in)
• Primary Care Physicians who completed their NHSC commitment >10 years ago had a 60 % retention rate.
Evaluation 2 from 1992
• Poor retention at 8 years employment retention rates for NHSC VS NON NHSC 29 % 52 % in rural areas (p < 0.001)
• Hazard ratio for risk of leaving rural practice altogether was 1.74 (95 % CI 1.43-2.11).
• 7/93 (7.5 %) of NHSC physicians re-enlisted in the NHS following their initial terms of obligation (mean additional years of service was 2.1 years)
Evaluation 3 from 1997
• 69.8 % of the 2903 initially assigned to a rural area who entered program before 1975 had a urban practice address in 1991 27.2 % were located in their initial assignment counties.
3 Voluntary Bonding Scheme
New Zealand Ministry of Health (2012) [26] (webpage)
New Zealand
Cross sectional - non comparative
n = 115
For postgraduate doctors intending to train as GPs (2009- present) or allied health professionals who are prepared to train in rural or provincial area can enter the scheme when they enter vocational training. Incentive scheme with no upfront bonding agreement to sign – after being accepted you begin working or continue to work in an eligible hard to staff community specialty or profession. If you abide by the terms and conditions of your intake year, for at least 3 years you are eligible to apply for payments after year 3, 4 and 5 years. $10,000 annual after tax payment for up to 5 years. Incentive of $10,000 In 2009 115 doctors entered.
• By 2012 102 (89 %) had opted out of the scheme.
• In a survey of the 2009 cohort showed 9/37 (35 %); stated they planned to work in a hard to staff location in both the short and long term.
• Significant attrition; no penalty for opting out.
4 Postgraduate medical placements in rural areas: their impact on the rural medical workforce. Dunbabin (2006) [27] Australia Longitudinal follow up non comparative
n = 82
Cadetship Program (1988 onwards) offering bonded scholarships to provide financial support for medical students (residents of NSW and from 2005 the Australian Capital territory) during their final 2 years of undergraduate study. In return cadets are contracted to complete 2 of their first 3 postgraduate years in the NSW rural hospital network. Bond amount not reported • 33/77 (43 %) of cadets entering the program before 1999 were working in rural locations in 2004 (compared with 20.5 % of medical practitioners nationally)
• 17/22 (77 %) GPs were in a practice location closely related to where they completed rural service.
• 44 % had chosen to specialise in GP and made up 70 % of those working in rural areas in 2004
5 A Comparative assessment of West Virginias Financial Incentive Programs for Rural Physicians
Jackson et al. (2003) [28]
USA
Cross Sectional - comparative between groups
n = 251
West Virginias 4x financial incentive programs (1991 onwards): Community Scholarship Program (CSP) Average scholarship = $42,500 for students from a Health professional shortage area (HPSA) to commit to go back and serve 1 year for every year of funding received back in their home HPSA.
Health Science Scholarship Program (HSSP) for fourth year medical students. $20,000 one-time award for a minimum of 2 years’ service in an underserved area.
Recruitment and Retention Community Project (RRCP) : for medical residents up to $20,000 each year for up to 6 years (one year service required for each year of funding).
State loan repayment program for physicians up to $40,000 for 2 year commitment contract (may be extended for 2 additional years at $25,000 a year), for minimum 2 years’ service at a non-profit site in a HPSA. Must repay the funding back in full if they default.
See individual programme After obligations were completed – n = 14 (32 %) of all obligated physicians reported that they were no longer at their first service rural practice site compared to n = 41 (38 %) of the comparison group. (Similar retention patterns).
• Obligated physicians who remained in their initial rural practice anticipated to remain an average of 18 more years in rural practice. Non-obligated physicians had similar expectations.
• 6/14 (42 %) of the obligated respondents left their practice for another West Virginia rural site compared to 34/41 (82 %) of the comparison group
6 Evaluation of Physician Return for service Agreement in Newfoundland and Labrador
Mathews et al. (2013) [29]
USA
Longitudinal follow up comparative between groups
n = 134
Special funded residency positions – administered by Memorial University of Newfoundland-(1997–2006) Offers funding to medical students and to postgraduate residents training in family medicine and other specialist programmes in which physician shortages were identified (the funding is gained in return for service).
A Family Medicine bursary is also available to 3rd and 4th year medical students intending to pursue family medicine
Those who accept the funding are expected to work in Newfoundland for 1 year for each year of funding received. They can also pay the money back (with interest).
Not reported • Retention of Return For Service vs Non Return For Service physicians who first started practice between 2000 and 2005
• 11/60 (19 %) of Return For Service graduates had left the province, compared to 28/67 (42 %) of non-Return For Service graduates
• RFS physicians were 3.2 times less likely compared to Non Return For Service physicians to leave the province.
7 Evaluation of the Arizona Medical student Exchange Program.
Navin TR and Nichols AW (1977) [30]
USA
Cross sectional - non comparative
n = unclear
Students from 11 states which lack training facilities are given financial assistance to attend graduate programs in the health sciences.(1969-onwards) The cost that an Arizona student faces in attending an out of state medical school is covered ($500 in 1953) for return of service to Arizona: 2 years’ service for every year of participation in the program. (Reduced to 1:1 years in 1958 due to low uptake) The accepting school is also offered an ‘additional sum’ of $6000 as an inducement to accept more Arizona students in the future. The students were given the option to repay the debt in cash Sending state paid receiving school $6000 In 1953 the first medical students were assisted by the program:
• From 1953 to 1967 the program failed to the raise the number of medical school applications from Arizona.
• Between 1955 and 1965 there was a consistent decline in the physician- population ratio (NB time lag whilst students are at medical school)
Out of 149 program graduates
• 21/149 (14 %) chose service repayment in a rural area within Arizona.
Out of the 143 who have started discharging their obligation
• 55/143 (38 %) chose cash repayment instead of service.
• 67/143 (47 %) chose service in a metropolitan area within Arizona
As of 1975
• 62 % of participants repaid there loan obligation through service in the state- but not specifically to rural areas.
8 Outcomes of states' scholarship, loan repayment, and related programs for physicians
Pathman, et al. (2004) [31]
USA
Cross sectional - comparative between groups
n = 1157
5 Program types which were operating in 1996 (onwards) were compared :
Scholarships- obligate medical students early in their training many years before they serve their obligations, firmly expected to provide service, hefty penalties are used to discourage them from buying out of the obligation
Service option loans- targeted to medical students – can perform a service or repay the loans at standard interest rates
Loan repayment – commit physicians later, nearing the end of residency. Provide assistance to repay loans accrued earlier in medical school. Minimal penalties on physicians who fail to provide a period of service.
Direct financial incentives: “golden hello” to work in rural area; usually no penalty or minimal penalty for failure to complete minimal service.
Resident support – financial assistance; scholarships, loan repayment and direct financial incentive- service begins 1–2 years after commitment at the end of residency.
Not reported Obligated physicians remained longer in their Practices than non-obligated physicians (p = 0.03) 71 % vs 61 % at 4 years and 55 % vs 52 % at 8 years
• Obligated physicians worked in underserved areas (low physician to population ratio) more often than non-obligated physicians 37 % vs 11 % p < 0.001
• Obligated physicians remained longer in their service practices than non-obligated physicians in their first jobs after training (HR for leaving 0.70; 95 % CI 0.51-0.96 P = 0.029)
• Longest group retention was seen for loan repayment scheme .66 % of whom remained in their service sites for 8 years.
• Service option loans reported the lowest average service completion rate (44.7 %)
• Scholarship programs had a service completion rate of (66.5 %)
• The highest buy out rate was for service option loan programs (49.2 %) and scholarship program (27.2 %)
Recruit rural students
9 Long Term Retention of Graduates from a program to increase the Supply of rural Family Physicians
Rabinowitz (2005) [32]
USA
Cross sectional - comparative between groups
n = 1937
The Physician Shortage Area Programme (PSAP) (1974 onwards). Recruited applicants with a rural background, eligible for financial aid (payable loans). Undertake rural family medicine placements in rural areas in their 3rd and 4th years. Not reported 1937 Jefferson graduates from classes of 1978–1986 (148 PSAP graduates) 38 PSAP graduates identified.
• After 11–16 years 26/38 (68 %) PSAP graduates were still practicing family medicine in the same rural area compared to 25/54 (46 %) of their non-programme peers (p = 0.03) in 2002
10 The Contribution of Memorial University’s medical school to rural physician supply
Mathews (2008) [33]
Canada
Cross sectional non comparative
n = 1322
Long standing ‘med quest’ program (1973 onwards) to encourage secondary school students to a heath professional career. More than 30 % of memorial medical students are from rural origin compared with 1 % of other Canadian medical schools Medical school tuition is half the Canadian average Not reported Practice locations in 2004 were determined for graduates from 1973 to 1998.
• In 2004 81/1322 (6.1 %) of graduates were working in a rural community in Newfoundland making up (20.8 %) of the rural physicians in the province.
• n = 167 (12.6 %) graduates worked in Rural Canada making up 4.9 % of the rural physicians in Canada.
• Predictors of primary care doctors working in the area included having a rural background (OR 2.52 95 % CI 1.72-3.71) being from the area (OR 5.90, 95 % 1.80-19.36).
11 Influencing residency choice and practice location through a longitudinal rural pipeline program
Quinn (2011) [34]
USA
Cross sectional non comparative
n = 1046
The Missouri University Rural Track Pipeline Program (MU RTPP) (1995 onwards) has a preadmission program for rural students (rural scholars). Summer community programs for second year students: students participate in a clinical program in a rural community setting; participating hospital or clinic sponsors students and the student receives a stipend ($1000 –$2000). Aim to increase knowledge of rural medicine, improve clinical skills
Six month Rural Track Clerkship (RTC) for third year medical students: students live and work in a rural community
Rural track elective for 4th year medical students- one month primary care or specialty electives in a rural setting
Not reported 48 rural scholars were tracked from 2002 and compared to non-participants and RTC participants
• 18/20 (90 %) of rural scholars are practicing in Missouri
• 37/75 (49.3 %) of RTC are practicing in Missouri.
• 57.4 % of students who participated in the RTC program chose a rural location for their first practice
• Rural Scholars more than twice as likely to ‘match’ into family medicine
12 Improving the recruitment and retention of doctors by training medical students locally
Landry et al. (2011) [35]
Canada
Cross sectional non comparative
n = 390
New Brunswick does not have a medical school. It’s the only Canadian bilingual province. Places reserved for New Brunswick (NB) residents in three French medical schools in Quebec since 1967 students may also undertake part of their training in their home province, and opportunity to study in first language within home province provided since 2006. Not reported Odds Ratios for current practice in NB by exposure to the province during training, stratified by year of undergraduate training
• 4th Year OR 9.3 (95 % CI 1.4-60.)
• 3rd Year OR 9.3 (95 % CI 1.5 -56.9)
• 184/263 (70 %) of all graduates were currently practicing medicine in New Brunswick
13 Rural doctor recruitment: does medical education in rural districts recruit doctors to rural areas? Magnus et al. (1993) [36]
Norway
Cross sectional non comparative
n = 417
Established a medical school in northern Norway (1972) with the hypothesis of ‘homecoming salmon.’ Educating young people from the rural areas of northern Norway are likely to stay in these remote areas. Not reported Questionnaire sent to all graduates from 1979 to 1989
234/417 (56.1 %) of The University of Tromso graduates are retained in Northern Norway.
• n = 192 (82 %) of these doctors were brought up in northern Norway.
14 Illinois RMED: A Comprehensive Program to Improve the Supply of Rural Family Physicians
Stearns et al. (2000) [37]
USA
Cross sectional non comparative
n = 39
Rural Medical Education (RMED) (1993 onwards): longitudinal, multi-dimensional program with a focus on family practice.
RMED provides a focused curriculum for 4 years focusing on family medicine, rural health issues and community based medicine peer support, a 16 week rural preceptorship. Students recruited – must demonstrate an orientation towards rural practice and family practice Students sign a pledge promising to complete the 4 year rural curriculum (no obligation/)
Not reported After 6 years 39 physicians have graduated
• 27/39 (69 %) of RMED alumni are in family practice residencies
• 32/39 (82 %) are working in primary care
International recruitment
15 From Spain to County Durham: experience of cross cultural general practice recruitment
Bregazzi et al.(2005) [38]
UK
Cross sectional - non comparative
n = 7
‘The Durham Initiative’ Spanish General Practitioners (2002–2003) were recruited to under-doctored areas in Durham. They undertook a 4 month induction program of language training, supervised learning in the GP training environment. After induction they began their first post, continuing to meet weekly for peer group sessions facilitated by a GP trainer + Spanish born GP. Not reported Of the 7 GPs recruited (1 dropped out part way through the year)
• 5/7 (71 %) have continued to work beyond the initial years contract
• 3/7 (43 %) expect to continuing practice for between 1 and 3 years
16 Retention of J1 Visa Waiver Program physicians in Washington States Health Professional Shortage Areas.
Kahn et al. (2010) [39]
USA
The Effect of the Physician J-1 Visa Waiver on Rural Wisconsin
Crouse (2006) [40]
USA
Cross sectional - non comparative
n = 141
Cross sectional - comparative between groups
n = 145
Conrad J-1 Visa Waiver Program: (1994 onwards) International medical graduates can agree to serve in an officially designated rural or urban underserved area in an exchange for a J-1 visa waiver; removing the usual commitment to leave the United States for a minimum of two years on completion of training.
The doctors on this program are obligated to work for an approved J-1 waiver employer for the duration of their commitment period (in Washington = 3 years)
J-1 Visa Waiver in Rural Wisconsin (1996 onwards)
As above and commitment period (3 years).
Not reported
Not reported
All J-1 Visa waiver physicians assigned to employers in Washington between 1995 and 2003 were identified
77/141 responded (55 %)
• These remained with their employers a median of 23 months (0–120 months) longer than their commitment period (3 years for physicians)
• 65/7 (84 %) remained with their waiver employers longer than their commitment.
• 32/77 (23 %) are still working for their assigned j-1 waiver employers.
• 38 % felt employers should have shown them more respect.
All J-1 Visa waiver physicians assigned to employers in Wisconsin between 1996 and 2002 were identified n = 145, 72 responded (69 %)
• 30 % of these did not complete the 3 year obligation period in the assigned community
17 Choice or chance! The influence of decentralized training on GP retention in the Bogong region of Victoria and New South Wales
Robinson et al. (2013) [41]
Australia
Cross sectional - non comparative
n = 61
Decentralization of GP training (1998 onwards) to regional training providers to attract Australian born GPs + IMG’s to rural areas. Moratorium introduced in 1997 which allowed IMG and overseas born Australian trained doctor’s access to a Medicare provider number & access to government funded rebates if they trained in an accredited GP training program and practiced in ‘areas of need’ for up to 10 years. Regional training providers train GP registrars. Not reported • 7/26 (27 %) of the doctors subject to the moratorium who had completed their vocational training stayed in rural practice.
• 24/57 (42 %) of all GPs who had completed their vocational training remained in rural general practice. 32 % (n = 18) remaining in Bogong region.
• 73 % (n = 16) of the Australian born respondents and n = 8 (23 %) of the overseas born respondents remain in rural practice.
Rural/primary care focused placements for undergraduates
18 Recruitment and retention of rural physicians: outcomes from the rural physician associate program of Minnesota
Halaas et al. (2008) [42]
USA
Cross sectional - non comparative
n = 1175
Rural Physician Associate Programme (RPAP)(1971 onwards)
3RD year medical students assigned to rural communities for 9 months. Hands on participation, one-one teaching, online curriculum participate in online discussion with fellow students meet with RPAP faculty 6 times/9 months.
Communities make a financial commitment paying $4000 to have a student for the year Since 1971 (1175) medical students have completed the RPAP experience.
• 448/901 (49.7 %) of currently practicing graduates do so in rural settings
• 44 % currently practice in rural setting 100 % of the time (compared to 9 % of physicians nationally practice in rural areas)
• 14 % spend 50 % of their time in a rural practice and 50 % of their time in metropolitan city
• 64 % of all graduates practice in Minnesota and 36 % in rural areas of the state
• 160/410 (40 %) graduates raised in metropolitan areas currently practice within rural area.
• 1/2 of the RPAP class spend 2 years of medical school on a campus which actively recruits from a rural background
• 896/1175 (82 %) of RPAP graduates have chosen primary care 742/1175 (68.1 %) family medicine
19 An Evaluation of the Rural Education program of the state university of New York Upstate Medical University 1990–2003
Smucny (2005) [43]
USA
Cross sectional - comparative between groups
n = 2101
Voluntary. 36 week clinical experience in rural communities for medical students that began in 1989.
Until 2001 they also received a $10,000 stipend for participating in RMED. Clinical training is completed in rural communities
Until 2001 received a $10,000 stipend for participating in RMED Between 1989 and 2003; 130 students have completed RMED:
• 22/86 (26 %) of RMED programme graduates (excluding residents) practiced in rural locations vs non programme students 95/1307 (7 %) [p < 0.0001]
• 64/76 84 % believed RMED was important in helping them choose ?A3B2 show $10#?>location
20 Geographic and Speciality Distributions of WAMI program Participants and Nonparticipants
Adkins et al. (1987) [44]
USA
Cross sectional - comparative between groups
n = 2704
WAMI Program (1975 onwards) The states of, Alaska, Montana and Idaho, which lack training facilities entered into a cooperative medical education program- with The University of Washington. It would accept 20 students each from Montana and Idaho and 10 from Alaska each year. It has a decentralized medical school program where teaching occurs in rural areas. In 1982 the programme cost the 4 states $4.8 million collectively. Graduates from 1975 to 1981 included:
In 1984:
• n = 156/677 (23 %) of graduates with programme experience were working in a non-metropolitan area compared to n = 32/260 (12 %) of graduates without programme experience.
Rural/underserved postgraduate placement
21 Where are they Now
The Career paths of Remote Vocational training scheme registrars
Wearne (2010) [46]
Australia
Cross sectional -non comparative
n = 24
The remote vocational- training scheme (1999–2005) trains doctors in remote communities using distance education and supervision. Standard program was 3 years duration. Contact with supervisors is minimal (a minimum of 1 h per week in the first 6 months, 1 h per fortnight in the second 6 months, and 1 h per month thereafter using telephone, text, fax, email or internet videoconferencing). Registrars attend weekly tele-tutorials and develop their clinical and procedural skills needed for the extended scope of remote clinical practice at 2 yearly face to face workshops Not reported • 24 doctors graduated from the training scheme
• 6 graduates (25 %) work in the same location as they trained.
• 17/21 (81 %) in rural areas
• 20/21 (95 %) still work in Australia
22 Experiences of female General practice registrars: are Rural attachments encouraging them to stay?
Charles et al. (2005) [45]
Australia
Cross sectional - non comparative
n = 83
Mandatory minimum of 6 months training in a rural area for GP registrars on the General Practice Education and Training Program (2002). Not reported • 21/65 (32 %) of registrars reported being more likely to work in a rural area as a direct result of the attachment
• 9/65 (14 %) were influenced against it as a direct result of the attachment.
• Plans to work in a rural area were positively associated with prior rural residence
• Registrars on specific rural pathway training had more intention of working in a rural location after graduation 49 % compared to 22 % of general pathway registrars (p < 0.05)
23 Training family physicians in community health centres: a health workforce solution
Morris et al. (2008) [48]
USA
Cross sectional - comparative between group
n = 1312
Community health care centres (1980 onwards) federally funded primary care clinics that provide care for underinsured and uninsured patients trained family medicine graduates– with the hope that they will be better prepared and more likely to meet the health workforce demands Not reported OR’s for current practice in underserved area based on training exposure:
• Family physicians training in a programme OR 2.7 (95 % CI 1.6-4.7) compare to non-programme trained physicians
• 63.9 % of CHC trained physicians working in underserved area compared to 37.3 % non-programme physicians.
Well-being/peer support initiatives
24 Impact of support initiatives on retaining rural general practitioners
Gardiner et al. (2006) [48]
Australia
Longitudinal Study comparative (before and after)
n = 221
The DR DOC programme introduced in 1999 (onwards) as a rural workforce support programme offering both social and emotional support strategies as well as practical interventions to help improve primary care doctors health and wellbeing including peer supported networks, emergency support lines and rural retreats, and health check-ups for rural doctors and their families. Not reported Followed up in 2001 (time 1) and 2003 (time 3)
• Moderate reduction of 5 % of those considering on leaving rural General Practice after the Course
‘’Time 1”: 98/187 (52.7 %) to ‘’Time 2” : 102/221 (46.1 %)
25 Postgraduate training at the ends of the earth - a way to retain physicians?
Straume et al. (2010) [50]
Norway
Internship at the ends of the earth - a way to recruit physicians?
Straume et al. (2010) [49]
Norway
Longitudinal study non comparative
n = 36
Cross sectional - comparative between group
n = 233
Special tutorial group started in 1997 (onwards) for postgraduates serving a 18 month medical internship in rural area (normal in Norwegian training program) to enhance retention, decrease professional and social isolation Not reported 29/36 (80 %) family doctors were still working in Finnmark In 2003/4, 6 years after completing their tutorial.
• Overall 5 year retention rate of 65 %
• Interns bought up in the north were 8 times more likely to take their first job in the north as those from a southern background (C1 2.2-29.6)
• Interns who graduated from the University of Tromso were 3.6 times more likely to take a job in the north than their counterparts from the southern universities.
Marketing
26 The Effects of Video Advertising on Physician Recruitment to a Family Practice Residency Program
Barclay (1994) [51]
USA
Longitudinal follow up comparative between group
n = 248
A promotional video (1992–1993) described the University of Maryland family practice program- highlighted intellectual challenges/scope of family practice. The video was sent to half of all persons inquiring about the residency programme. The remaining inquiries received all standard application materials and the residency brochure but not the video tape. Not reported 120 people received the video
• 35 (29 %) of those who received the video completed the application process compared to 69 (54 %) who did not receive the video
• Controls (applicants who did not receive the video) were 2.86 x more likely (95 % CI 1.6- 5.0) to apply to the programme (p < 0.0001)
• After interview 0 of the 120 persons who received the video matched with the residency program (p <0.005).
27 The Effect of a Blog on Recruitment to GPST in the north of Scotland
Green (2015) [52]
UK
Cross sectional - non comparative
n = unclear
Online Blog (2012–2013) static pages and a dynamic blog section to feed information on GP training programme in the north of Scotland. Five existing GP trainees blogged about their experiences of GP training in the north of Scotland. Newly qualified GPs wrote articles describing their time in training and subsequent careers- to demonstrate the variety of career paths in GP. Not reported Survey of year 1 GP trainees in Aug 2013 and 2014, 76 % of those surveyed had viewed the blog
• 48 % of those surveyed the blog had influenced the choice of location for training.
• The fill rate at the end of round 1 was up to 71 % in 2013 and 81 % in 2014 from an average of 60 % in the years prior to the blog. (At this time the overall recruitment in Scotland remained static.)
Mixed approach
28 Recruiting and Retaining GP’s to remote areas in Northern
The Senja Doctor Project.
Conference presentation (2010) [53]
Norway
Cross sectional non comparative
n = unclear
Project aimed to develop a collaborative model for GP services in the four Senja Municipalities (2007–2009). Establish a new main GP office where all doctors meet one a week.
All doctors part of a professional network with a fixed wage
Driving to local offices included in working time, organized scientific activity, no public health responsibilities and continued medical education programs
Not reported • One municipality had recruited and lost 73 GPs in 10 years prior to this scheme
• 2 years from the start of the programme in Feb 2007 4 of 10 GP applicants signed a job contract, 2 with GP specialist qualifications and 2 residents.
29 The Chilean Rural Practitioner Programme: a multidimensional strategy to attract and retain doctors in rural areas
Pena (2010) [54] Bulletin of the World Health Organization
Chile
Longitudinal follow up non comparative
n = unclear
The Rural practitioner Programme launched in 1955; four domains of incentives and a competitive application process
Education – voluntary rural clerkship- 4 week clerkship with physicians from the RPP
Financial – direct and indirect incentives; direct = salary + tuition fees paid for increments full time compensation of 23 %, indirect e.g. installation and departure kit – double salary for 1st and last month transport tickets and a removal van
Management, environment and social support incentives to engage in hospital and community work, continuous professional development, increased holiday and leave allocation.
External incentives – internship during medical school
Double salary for 1st and last month plus travel allowance 58 % of rural practitioners are retained for the maximum period (6 years)
• High degree of satisfaction with the program >90 % considered it a positive experience
• Applications exceed the number of available positions by at least 2.5 times
30 Alberta Rural Physician Action Plan : an integrated approach to education, recruitment, and retention
Wilson (1998) [55],
Canada
Rural Incentive Programs a failing report card
Czapski (1998) [56]
Canada
Cross sectional - non comparative
n = unclear
Cross sectional - non comparative
n = unclear
Alberta Rural Physician Action Plan: (1991 onwards) Addresses recruiting and retaining rural physicians at the medical student, resident and current physician levels.
Undergraduate medical students and residents
Rural rotations
Special skills program
Student loan remission program
Mandatory four week Family Medicine rotation (most students in rural Alberta)
Physicians currently practicing in rural Alberta
CME initiatives
Enrichment program
Rural locum program
Government provided RPAP with funding of £3.11 million per year • 1995 - 35 % of 285 responding physicians indicated the RPAP had a critical or moderate on their decision to move to or stay in rural Alberta.
• By 1998 the number of rural primary care doctors had dropped 34 % from 1994 baseline figure
31 Ontarios Underserviced Area Program Revisited: an indirect analysis
Anderson et al. (1990) [57]
Canada
Cross sectional - non comparative
n = unclear
Ontarios Underserviced Area Program Started in 1969 (onwards) : To place physicians in areas on Ontario deemed to be medically underserved
36 bursaries of $5000 awarded annually to Ontario students.
Students are expected to return service to an underserved area following their training (if the student fails to fulfil the service, the bursary is refundable with interest) $40,000 incentive payment paid Quarterly over 4 years for physicians
$40,000 incentive payment paid quarterly over 4 years to physicians
$5000 student bursary
• Physician population ratios have improved
• Each northern country experienced between 35 and 80 % improvement in its ratio between 1956 and 1986
• The province improved its ratio from 971 people/physician in 1956 to 560/physician in 1986
Support for professional development and research
32 Developing primary care through education
Hilton et al. (1997) [58]
UK
Academic Training in London. GP Tomorrow (book)
Freeman et al. (2002) [59]
UK
Whole-system evaluation research of a scheme to support inner city recruitment and retention of GPs
Bellman (2002) [60]
UK
Cross sectional non comparative
n = not reported
Cross sectional non comparative
n = 49
Cross sectional non comparative
n = 14
The London Initiative Zone Educational Incentives Scheme (LIZEI) Aim of the programme was to improve recruitment, retention and refreshment of London GPs (1994–1999)
London Academic Training scheme (LATS) (1995–2000): To encourage GPs to remain in the London area each with a strong link to an academic department. 7 ½ day sessions/week for academic training, 2 sessions in general practice
GP Assistants/Research Associates: (time period not reported) recently vocationally trained GPs provide regular clinical cover to LIZ practitioners 7 clinical sessions + sessions for research and development.
LATS: Practice pay registrar £80 for medical defence subscription and travel
LATS: Total budget in the first year for 12 registrars = £600,000
LATS:
• 2 Years on: 75 % of the first cohort continue to practice in London, with academic links
LATS: In 2000 the 49 participants of the first 4 cohorts were contacted with 37 replies.
• 32/37 (86 %) were working in London
• 34/37 (92 %) In general practice.
• 20/37 (54 %) were current members of academic departments.
GP Assistants/Research Associates: Participants in the 9 month scheme and a previous years scheme were contacted,
• 7/14 (50 %) have become principals/partners
• 10/14 (71 %) chose to remain working in local practices
33 Positive Impact of Rural Academic Family Practice on Rural Medical Recruitment and Retention in South Australia.
Wilkinson et al. (2001) [61]
Australia
Longitudinal follow up non comparative
n = 17
Four rural academic family practices (1995–1999) Established with support of University of Adelaide.
Doctors work for fee-for service bases (no need for financial commitment). Strong academic component- teaching students, pursuing research.
Not reported From 1995 to 1999
• Recruitment: 17 doctors were recruited, 14 were placed in the 4 academic family practices
• Retention: 4 doctors left after an average of 20 months (6 months – 3 years and 6 months) mean duration of appointment = 15 months (range = 4 months to 3 years and 6 months)
• 5/17 (24 %) of the doctors were overseas trained, 4/5 expected to stay (80 %) permanently.
34 Making a difference: education and training retains and supports rural and remote doctors in Queensland.
White (2007) [62]
Australia
Longitudinal non comparative
n = 426
Continuing medical education opportunities (2004–2006) were provided in the aim to retain medical practitioners in rural and remote communities. Workshops on topics such as emergency cardiology. Travel, accommodation + locum support subsidised 341/426 (80 %) of respondents agreed or strongly agreed they were less likely to remain in rural practice without access to CME workshop
Retainer schemes
35 The GP Retainer Scheme: report of a national survey.
Lockyer et al. (2014) [65]
UK
Cross sectional non comparative
n = 318
The GP retainer scheme (1998-present) combines a service commitment and educational element.
It allows a limited number of sessions in clinical practice (1–4 sessions per week, 5 years max (unless in exceptional circumstances) to aid the retention of skills when taking time out
Retainer payment £59.18 per session
£310 for professional expenses
Of those who had left the scheme in the last 2 years (2012–2013) n = 105 were working as:
• 91/105 (86.3 %) GPs,
• 49/105 (47.1 %) in salaried GP posts.
• 25/105 (24 %) were working as GP principals/partners
• Future plans of current retainers: 93/105 (88.6 %) planned to continue as GPs.
36 Doctors' retainer scheme in Scotland: time for change?
Douglas et al. (1996) [66]
UK
Cross sectional; non comparative
n = 357
Doctors' retainer scheme in Scotland (1972–1998) allows a limited number of sessions in clinical practice to aid the retention of skills when taking time out.
Terms: Must subscribe to a professional journal, carry out a maximum of 2 sessions per week and at least 12 per year and attend a minimum of 7 education sessions per year.
Retainer fee of £290 + salary
The practice receive a fee of £40.50 per session
Length of membership 1–17 years Former members who responded n = 104
• 76/104 (73 %) had left the scheme within 4 years
• 31/104 (29 %) were GP principals/partners
• 5/104 (4 %) were unemployed.
• 33/104 (32 %) stated it prevented them from leaving medicine
Of current members n = 152
• 69/152 (46 %) stated the scheme prevented them from leaving medicine
37 Special provisions for women doctors to train and practice medicine after graduation: a report of a survey
Beaumont (1979) [63]
UK
Review of the women’s doctors retainer scheme in Sheffield region 1972–1973 Eskin (1974) [64]
UK
Cross sectional non comparative
n = 2433
Cross sectional non comparative
n = 14
UK Women’s Doctors retainer scheme (1973–1976) for female doctors in hospital medicine, GP or that work in the local authority health service aged under 55; who are unemployed (or work ≤2 sessions per week)
Terms: As above and membership with a medical defence organisation
£ 50 retainer fee • 36/2433 (1.5 %) of respondents had been a member of the retainer scheme and 91 % of them were currently working; 5 (14 %) in full time posts
Evaluation 2:14 doctors on the scheme
• 10/14 (71 %) of these subsequently employed in the Sheffield region; (hospital doctors + GPs)
Re-entry scheme
38 Putting principals back into practice: an evaluation of a re-entry course for vocationally trained doctors
Baker et al. (1997) [67]
UK
Longitudinal follow up comparative between groups
n = 14
Re-entry course (3 day course March 1996) developed to help doctors to return to general practice. Rebuilding confidence and needs based. 8 tutorial sessions (rational prescribing, developments in therapeutics, recent advances, CPR, practice management, employment prospects) and simulated surgeries. Charge £450 per delegate 6 months post course
• 2/14 (14 %) have returned as principals/partners
• 7/14 (50 %) had made ‘positive steps’ to return to general practice
• Vs 1 in the control group (size of the control group not stated in text) had made plans to return to practice
Delayed partnership
39 Career Start in County Durham Tomorrow’s GP (Book)
Harrison et al. (2002) [68]
UK
Cross sectional - non comparative
N = unclear
GP Career Start Scheme: (1996)
2 year salaried GP Start Scheme ‘Give Vocationally trained practitioners a further level of training to aid the difficult transition between registrar and principal/partner + aid the personal and professional development of its doctors
Year 1 sessions in mentor practices + half day release for group education Year 2 50 % general practice locums in County Durham + 50 % Professional and personal development
Full time salary at 80 % of net intended GP principal/partner income. +/− a bonus of 10 % of final salary to join Durham Medical List Seven recruited (5 women, 2 men) in 1996 (since then 5 further cohorts have been recruited). 19 had left the scheme by 2002,Career destinations of the above 19:100 % remain working as a GP in some capacity
Remaining in County Durham:
• Principal/partner 6/19 (33 %), retained 3/19 (16 %), salaried post 2/19 (11 %)
Working in wider NHS
• Principal/partner 3/19 (16 %) retained 2/19 (11 %), Salaried Post 2/19 (11 %), Locum 1/19 (5 %)
40 South London Vocational Training Associate scheme seven years on
GP Tomorrow (book)
Delacourt et al. (2002) [69]
UK
Cross sectional - non comparative n = 50 An extra structured year of professional development (1994–2002) in general practice and to also allow this time as ‘cover’ for existing practitioners at the practice. Vocational Training Associate scheme 7 sessions working in 2 busy inner city practices + research and professional development time. Not reported Since 1994–2002 50 GPs have been on the scheme
• 7 years on 22/50 (44 %) still work as GP principals/partner/salaried doctors in the schemes locality
• 7/50 (14 %) remain as assistants or locums in the schemes locality
Specialised recruiter/case manager
41 Recruitment of rural health care providers: a regional recruiter strategy
Felix et al. (2003) [70]
USA
Cross sectional - non comparative
n = 8
Delta- based recruiter (DR) (2000–2002) to assist communities with health care provider recruitment and retention of uses a holistic approach + encourages community development activities – Nurtures new providers to ease their transition into their new community Salary and ‘fringe’ for 1 full time Delta recruiter $75,000 a year Average cost of $18, 750 per recruit In a 2 year period
  • DR was able to recruit 8 primary care providers (3 primary care physicians)
  • Previously only had access to a part time rural health clinic managed by a nurse practitioner
42 Case management: a model for the recruitment of rural general practitioners
MacIsaac, et al. (2000) [71]
Australia.
Cross sectional - non comparative
n = 17
The West Vic Model: (Feb 1997- May 1998) intensive case manager to identify potential doctors, assess any issues, define goals, support and motivate them and help ease the transition (national and international recruitment) $1000-$1500 cost of advertising in 2 newspapers per week.
Other costs not detailed.
Over 18 month period
  • 17 doctors placed into temporary or permanent placements
  • 4/17 (23 %) from UK/Ireland