Exploring the effects of telehealth on medical human resources supply: a qualitative case study in remote regions

Background The availability of medical human resource supply is a growing concern for rural and remote communities in many countries. In the last decade, various telehealth experiences in Canada have highlighted the potential impact of this technology on professional practice. The purpose of this study was to explore physicians' and managers' perceptions regarding the potential of telehealth to support recruitment and retention of physicians in remote and rural regions. Methods A case study in Eastern Quebec was performed to explore this complex phenomenon. The analytical framework was based on two literature reviews and a Delphi study. Data were collected from semi-structured interviews with 41 physicians and 22 managers. Transcripts were produced and interview content was coded independently by two judges and validated by an expert panel. Results Interviews have highlighted the potential impact of telehealth on several factors influencing the recruitment and retention of physicians in rural and remote regions. The potential effects of telehealth on physicians' choice of practice location could be seen at the professional, organizational, educational and individual levels. For instance, telehealth could improve work satisfaction by allowing a regional on-call duty system and a better follow-up of patients. However, there are also certain limits related to telehealth, such as the fear that it would eventually replace all continuing medical education activities and onsite specialists in remoteregions. Conclusion Telehealth is likely to have an impact on several factors related to medical workforce supply in remote and rural regions. However, the expected benefits will materialize if and only if this technology is properly integrated into organizations as a support to professional practice.


Background
The uneven distribution of medical human resources between regions constitutes a problem in many countries. Physician supply in several rural and remote regions and shortages in certain medical specialties are particularly problematic in Canada [1]. The recent National Physician Survey [2] shows that physician shortage limits access to health care, especially in rural and remote areas and small cities. This situation is of major concern for decision-makers as well as the general population [3,4]. In Canada, various measures of medical human resources planning have been implemented both at the federal and provincial levels. In the Province of Quebec, the Ministry of Health and Social Services is currently assessing the impact of different strategies to favor physicians' attraction and retention in remote and rural regions [5]. The training, planning and distribution of health care workforce is a top priority for health services research in Canada [6].
Historically, strategies to increase physician supply in rural and remote areas have mostly included financial incentives, such as premiums and bursaries, but also recruitment of rural students in medicine, specific training program in rural medicine, and promotion campaigns [1]. However, the impact of various recruitment and retention strategies is changing over time. Shifts in values and lifestyles, as well as the changing profile of the new generation of physicians -women now outnumber men in US and Canada's medical schools -call for innovative recruitment and retention strategies. Work satisfaction is thus becoming an important factor of retention among physicians [7].
Over the last decade, new information and communication technologies (ICT) -such as telehealth -have entered the sphere of medical practice. Different studies suggest that telehealth could have a positive impact on medical practice [8,9]. The Quebec Ministry of Health has also identified telehealth as an effective strategy contributing to improve accessibility of health services in remote regions [5]. However, could telehealth also be part of the strategy for influencing recruitment and retention of the new generation of physicians?
A research project was conducted to explore the potential of telehealth as a strategy to improve the practice of health care professionals in rural and remote regions of Eastern Quebec. One of the particularities of this project is that it involved decision-makers in its different phases in order to facilitate knowledge sharing and utilization. This article reports on a qualitative study that was conducted in four remote regions of Eastern Quebec to explore physicians and managers' perceptions regarding the potential of tele-health to support recruitment and retention of physicians in remote and rural regions. Approval from the ethics committee of the Quebec University Medical Centre was received for this research project.

Methods
Studying the impact of telehealth on physician recruitment and retention in remote and rural regions represented a challenge given that this technology is still relatively new. Consequently, a case study was chosen as the appropriate methodological approach since it allows exploring a complex phenomenon in close relation to its context [10].
Several research methods were used to develop the analytical framework. First, two literature reviews were conducted: the first on the factors influencing physician recruitment and retention and the second on the effects of telehealth. These reviews allowed identifying which factors associated with physician recruitment and retention could be impacted by the implementation of telehealth. A series of hypotheses regarding the potential impact of telehealth on physician recruitment and retention was then generated. Second, a Delphi study was conducted by the research team to get a consensus from Canadian telehealth experts on the proposed hypotheses [11]. Finally, an analytical framework was developed to illustrate the hypothesized relationships between telehealth and recruitment and retention factors.
In-depth semi-structured interviews were conducted individually and in small groups with 41 physicians (general practitioners and specialists) and 22 managers (hospital managers, recruitment specialists, and regional health managers) of Eastern Quebec. The characteristic of the respondent are presented in Table 1. Eastern Quebec was selected for the present study because several wide-scale telehealth projects have taken place there over the last decade [22][23][24]. Initial respondents for the interviews were selected through the network contact method [25]. Then a snowball sampling strategy [26] was used by asking ini-tial respondents to refer us potential participants among their contacts. In order to accommodate respondents' busy schedule, interviews were conducted at their practice location, either individually or in small groups. Using principles of data saturation and information redundancy, data collection ended when additional interviews did not bring new information or opinion [27]. Interviews lasted 40 minutes on average. All interviews were tape-recorded with the consent of respondents and verbatim transcripts of the interviews were done.
Two interview schemas were elaborated from the analytical framework: one for clinicians and one for managers. Interview schemas were validated with four extern collaborators of the research team who are experts on recruitment/retention and/or telehealth.
The interview schema for physicians was divided into three parts. The first part comprised questions about actual practice: work satisfaction; motivations for setting practice in the remote region; motivations for staying in the region; and potential factors that could make one leave the region. The second part covered perceptions on the effects of telehealth on clinical practice; as well as the benefits and limitations of telehealth use in one's practice. If respondents did not have access to telehealth, perceptions concerning its possible applications to their practice were gathered. The last part of the interview dealt with the possible effect of telehealth on recruitment and retention.
Managers from hospitals and health regions were also interviewed about the nature of their work and the strategies they were using to attract and keep medical workforce in their region. Managers were also asked questions dealing with their perception of telehealth benefits and limitations, and its effects on clinical practice, organization of care and recruitment/retention.
A qualitative iterative strategy was adopted for data analysis, based upon the method proposed by Huberman & Miles [28]. In a first step, all interview transcripts were read independently by two researchers to extract general impressions and preliminary classification categories based on the analytical framework. Classification categories were then compared and adjusted after a consensus discussion with the research team. In a second step, content of the interviews was codified according to this emerging classification. Data was then grouped into five broad categories: 1) recruitment factors; 2) retention factors; 3) work satisfaction factors; 4) potential impact of telehealth on recruitment and retention; and 5) potential impact of telehealth on work quality.

Physician recruitment and retention factors
As shown in Table 2, participants' opinions regarding recruitment and retention factors have been classified into seven categories (individual, family, community lifestyle, professional, organizational, educational and economic), corresponding to those identified in the analytical framework. Professionals (occupational well-being) and organizational (critical mass) factors were the most frequently mentioned.
Potential impact of telehealth on physician recruitment and retention factors When asked directly, interviewees generally agreed that telehealth could have a potential effect on their recruitment and retention. However, telehealth alone was not perceived as a direct recruitment/ retention strategy, but rather as an element having an impact on important recruitment/retention factors. Furthermore, interviews with physicians and managers showed that telehealth's impact on recruitment and retention in remote/rural regions would principally concern four of the categories identified in the analytical frame-work: professional, organizational, educational and individual factors

Professional factors
Favour occupational well-being and decrease workload Occupational well-being is the factor on which telehealth could have an impact that was mentioned most often. "For it [telelhealth] to have an impact on retention, it is necessary that it has an impact on the quality of life or the quality of life at work" (physician, region 2). Telehealth is also perceived as a way to decrease workload, by allowing on-call duties to be done from home or shared on a regional basis. This allows the coverage of specialties such as radiology to be shared by specialists from several hospitals rather than those of a single hospital. "Since at least six months, we have implemented a regional on-

Organizational factors
Access to specialized human resources Many physicians underscored the importance of having a critical mass of specialized human resources as a factor of recruitment/retention. In fact, it is difficult to recruit new physicians if the number of physicians working in the hospital is already low since potential recruits will fear huge workloads. Some interviewees mentioned that telehealth could be a temporary solution to this situation by facilitating regional or at home on-call duty systems.

Stabilization of services
Telehealth could also contribute to decrease workload by a stabilization of services. For instance, an interviewee described the possibility of using telepathology to secure access to pathology services when the local pathologist is away, thus allowing the continuity of the surgery service. "Let's take telepathology. In regions with small teams of specialists who will necessarily take holidays and will go away, if the links are functional and allow us to keep the service in place even if there is nobody on the spot, well, I think that yes, because in surgery, when there is no pathologist, it doesn't go very well." (manager, region 2). Another similar example is the use of teleradiology to maintain 24/7 emergency services in small hospitals.

Avoid patient transfer
Participants who used telehealth considered that it can have a benefit for patients by avoiding unnecessary transfers. This benefit gives physicians the possibility to answer patients' needs in the region and to avoid some frustration. "We have a radiologist and when he's not there, we have to transfer our cases to the regional center for echography.

Educational factors Regional medical training
With respect to educational factors influencing physician recruitment and retention, receiving training in a remote or rural region was the most frequently mentioned by the respondents. Thus, telehealth could support the organization of joint training programs between several rural and remote locations. Such programs could also give exposure to the regions and their medical teams."With the joint educational programs, people know you more, which means new recruits!" (physician, region 4) Moreover, telehealth could be used to provide training from experienced rural/remote physicians to medical students. "Tele education could enable us to transmit our knowledge and to better adapt the training of students. That would make it possible to increase their qualification level." (physician, region 1)

Access to continuing medical education
Respondents also acknowledged the importance of continuing medical education (CME) on physician recruitment and retention. Telehealth could improve access to CME by eliminating travel time since physicians could access CME from their home or office at the moment of their convenience. Also, telehealth allows equal access to CME activities for all professionals from a department.

Recruitment/retention
Seven broad categories of factors that influence the recruitment and retention of physicians in remote and rural regions were identified through the analytical framework. Interviews with physicians and hospital managers have highlighted the importance of many of these factors in the specific context of our study. We are thus confident that the present findings would apply to other jurisdictions with similar characteristics. Interviews conducted with physicians and managers indicate that telehealth could have an impact on four of the seven categories of factors described in the literature (professional, organizational, educational and individual) as shown in Figure 1.
More specifically, telehealth could have a positive impact on professional factors influencing physician recruitment and retention by increasing quality of life at work, supporting professional practice, and giving access to high technology.
Telehealth is also likely to have a positive impact on organizational factors that influence recruitment and retention by providing support to medical centers which do not have a critical mass of specialized physicians. Conversely, telehealth could have a negative impact by giving the image of a poorly equipped hospital.
With respect to educational factors, telehealth could have several positive effects. First, it can be used as a tool for providing adapted rural/remote medical training to students and residents. Second, tele-education increases access to CME which is an important factor of physician retention. However, one must make sure that tele-education will not replace all CME activities.
Finally, telehealth can have a positive impact on individual factors related to recruitment by increasing the feeling of security among new recruits, but this might have a negative impact on retention. Nevertheless, participants drew attention to the fact that such effects will be possible only if telehealth is better known and more used. Hence, the benefits reported here have to be taken as assumptions rather than as affirmations.

Occupational well-being
The iterative approach used for analyzing qualitative data has allowed the development of a conceptual framework of the potential of telehealth to influence factors related to physician recruitment and retention. Study findings indicate that telehealth is likely to have a major impact on the concept of occupational well-being. This concept was used as a synonym to psychosocial work quality described in Petterson and Arnetz's model [29]. This model pro-poses six categories of factors that significantly impact psychosocial work quality: 1) Competence and personal development, 2) Work strain-pressure 3) Organisational climate 4) Demands from people around 5) Goal clarity 6) Optimal work load. Therefore, several of the telehealth benefits mentioned by respondents could have an impact on five of those factors, as shown in Figure 2. By facilitating access to CME and updated knowledge, telehealth could stimulate professional development and offer possibility to advance oneself. It could diminish work pressure by giving access to expertise and technologies that would not be easily available without telehealth. This technology could also improve the medical decision-making process by giving access to a second opinion. Moreo-ver, telehealth could improve cooperation with colleagues form other hospitals by allowing multi-center meetings through videoconference. Together, these two factors are likely to improve the organizational climate. The stabilization of services and avoided transfers associated with the use of telehealth could also increase physicians' capacity to satisfy demands from their patients. Finally, telehealth could decrease physicians' workload by implementing on-call duty systems on a regional basis and from home.

Conclusion
A number of observations can be drawn from this study. Obviously, telehealth could have an important impact on Perceptions of respondents regarding telehealth impact on recruitment/retention factors Figure 1 Perceptions of respondents regarding telehealth impact on recruitment/retention factors. Legend: + : perceived positive impact; -: perceived negative impact; +/-: perceived positive and negative impacts.
a set of professional, organizational, educational and individual factors related to medical workforce supply in remote and rural regions. However, the potential benefits of telehealth will materialize if and only if this technology is properly integrated into organizations and fits professional practices. Telehealth could improve occupational well-being, but to do so it has to be as easy and efficient as a phone call, as mentioned by many respondents. It can thus take several years before the effects described in this study can be measured. Nevertheless, this study has shown that even if telehealth can be seen as an asset for recruitment and retention of physicians, this technology alone cannot solve workforce shortages in remote regions. Finally, this comprehensive field study provides a framework to assess the potential influence of telehealth on medical human resources planning in the future. Thus, it could be interesting to estimate the weight of various recruitment and retention factors in the Quebec health system context. As telehealth technologies are becoming more present in the health care system, it would be important to follow the evolution of these various effects over time and in various settings through longitudinal studies.