At the foundation of research concerned with professional training is the idea of an assumed causal chain between the policies and practices of education and the eventual behaviours of those that graduate these programs. In medicine, given the social accountability to ensure that teaching and learning gives way to a health human resource that is willing and able to provide the healthcare that patients and communities need, it is of critical importance to generate evidence regarding this causal relationship. One question that medical education scholars ask regularly is the degree to which the unique features of training programs and learning environments impact trainee achievement of the intended learning outcomes. To date, this evidence has been difficult to generate because data pertaining to learners is only rarely systematically brought together across institutions or periods of training. We describe new research which leverages an inter-institutional data-driven approach to investigate the influence of school-level factors on the licensing outcomes of medical students. Specifically, we bring together sociodemographic, admissions, and in-training assessment variables pertaining to medical trainee graduates at each of the six medical schools in Ontario, Canada into multilevel stepwise regression models that determine the degree of association between these variables and graduate performances on the Medical Council of Canada Qualifying Examinations (Part 1, n = 1097 observations; Part 2, n = 616 observations), established predictors of downstream physician performance. As part of this analysis, we include an anonymized school-level (School 1, School 2) independent variable in each of these models. Our results demonstrate that the largest variable associated with performance on both the first and second parts of the licensing examinations is prior academic achievement, notably clerkship performance. Ratings of biomedical knowledge were also significantly associated with the first examination, while clerkship OSCE scores and enrollment in a family medicine residency were significantly associated with the Part 2. Small significant school effects were realized in both models accounting for 4

Introduction: Enhanced recovery after surgery (ERAS) programmes include pre-operative, intraoperative and post-operative clinical pathways to improve quality of patient care while reducing length of stay (LOS) and readmission. This study assessed the feasibility and outcomes of an ERAS protocol for colorectal surgery implemented over 2 years in a small, resource-challenged rural hospital.Methods: A prospective cohort study used retrospectively matched controls to assess the effect of ERAS on LOS in patients undergoing colorectal surgery in a small rural hospital in northern Ontario, Canada. ERAS patients were matched to two patients in the control group based on diagnosis, age and gender. Patients had open or laparoscopic colorectal surgeries, with those in the intervention group treated per ERAS protocol and given instructions on pre- and post-operative self-care.Results: Most of the 47 ERAS patients recruited to the study reported adherence to ERAS protocols before surgery. Adherence to protocol was strongest for chewing gum in the days after surgery. Most patients were sitting in a chair for their afternoon meal by the 1st day and most were walking down the hallway by the 2nd day. The control group had significantly higher (P < 0.001) malignant neoplasm of the colon (C18, 69% vs. 35%) and significantly lower malignant neoplasm of the rectum (C20, 0% vs. 5%). The control group had an average ln-transformed LOS that was significantly longer (exponentiated as 1.7 days) than ERAS patients (t-test, P < 0.001).Conclusion: This study found that ERAS could be implemented in a small rural hospital and provided evidence for a reduced LOS of approximately 2 days.

Inequities in the distribution of human resources in health around the world have long been a topic of concern and discussion. There is an absolute shortage of health care providers in many parts of the world, notably in sub-Saharan Africa and parts of the Asia–Pacific region.1 However, here and in other areas the problem is that the available health care workforce is maldistributed, both geographically and in terms of specialty.2, 3 Understanding these issues and their drivers is an important step in developing, implementing and evaluating potential solutions, but both the understanding and the solutions need to be contextualised to region and circumstance.3 Health professional educational institutions can be important engines in driving social and educational change and innovation to ensure that their products (medical, nursing and other health professional graduates) are fit for purpose in terms of meeting the needs of the populations that they serve.4 Recognition of this potential has led the World Health Organization to focus on its agenda of transformative health professional education, to consciously improve access to health services by distributing the health workforce and aligning its competencies with evolving health needs on the way to addressing the broader social determinants of health.5 Importantly, to deliver socially accountable health professional education, educational institutions must hold themselves accountable for delivering appropriate health professionals, and for working in partnership to strengthen the health system and the quality of care that it delivers. Investment in training of the health workforce and strong primary health care delivers real economic value.6 The Training for Health Equity Network (THEnet; thenetcommunity.org), which was founded in 2008, is a community of practice that now includes 13 medical and health professional schools, selected on the basis of their commitment to social accountability. Located primarily in rural and underserved areas of nine countries (low and high income), they share a commitment to producing and supporting health workforces that will meet the needs of the communities they serve (Box 1). These schools share the aims of: recruiting students from underserved and under-represented populations; providing primary care-focused curricula; delivering medical programs mainly in underserved areas and within communities; and providing postgraduate training to address local health workforce needs.7, 8 * Reproduced from Murray et al7 under a CC BY 4.0 license. † Founding school; recently withdrew from THEnet. THEnet is a collaborative learning network, where members share challenges across sectors and countries, and partner schools learn from and share with other innovative schools worldwide. Research and evaluation using a self-critical lens helps members to understand how best to improve health equity and how to maintain accountability for outcomes.7, 8 As a learning network that aims to influence health systems and share lessons between partners, THEnet considered how best to measure progress towards, and outcomes of, social accountability in its early work. Collaborative creation of THEnet's Evaluation Framework for Socially Accountable Health Professional Education was its foundational work, which involved careful attention to the use of plain language and definitions that can be used and adapted across many contexts.8, 9 This work has since been adapted and expanded to create other widely used frameworks, such as the Indicators for Social Accountability Tool, and has been incorporated into medical accreditation standards worldwide.10, 11 THEnet partner schools share a commitment to finding out where graduates work and the difference that they make. Measuring impact is important. The THEnet evidence group conducts a program of research, including the THEnet Graduate Outcome Study — a prospective cohort study of more than 6000 learners enrolled across partner schools, from which data have been received from nine schools in seven countries.12 The THEnet Evidence Group designed the study to correlate learner characteristics and practice intentions at entry to and exit from medical school, and then follow these graduates into postgraduate practice for up to 10 years, to determine the location and discipline of their actual practice. In recognition of our work in this area, THEnet has contributed to white papers for the Pan American Health Organization and a recent WHO handbook on the rationale and strategies for graduate tracking.13 These data have highlighted that, relative to other medical schools, THEnet partner schools deliberately use diverse selection processes to ensure that their learner cohort has sociodemographic characteristics that are much more similar to the population they serve.12 Data have confirmed the association between rural or low socio-economic background and intention to practise in rural and remote areas, and that this is maintained from entry to exit from medical school.14, 15 Importantly, for learners in low and middle income schools in South Africa, Sudan and the Philippines, these demographic determinants are significantly associated with lower desire to emigrate after graduation, and thus contribute to a desire to meet the health needs of their home country.15 In response to local need, THEnet members have also designed and collaborated on studies of work readiness of graduates, perceptions of social accountability among faculty and students, impact on the health system, impact on health outcomes, and social return on investment.16-21 The evidence base produced by THEnet collectively, from studies involving partnerships between two or more partner schools from different contexts, is summarised in Box 2. Larkins SL, et al (2013)8 (JCU, ELAM, Ghent U, UPM-SHS, ADZU, WSU, FU, NOSM U) THEnet's Evaluation Framework for Socially Accountable Health Professional Education was developed as a tool to assist schools in assessing progress towards social accountability. The framework considers three questions: Ross SJ, et al (2014)9 (JCU, FU, NOSM U, ADZU, UPM-SHS) Larkins S, et al (2015)12 (JCU, Ghent U, WSU, Gezira U, ADZU, NOSM U) Larkins S, et al (2018)14 (JCU, NOSM U, Ghent U, Gezira U, WSU, ADZU, FU, UPM-SHS) Johnston K, et al (2020)15 (JCU, ADZU, Gezira, WSU, UPM-SHS, PAHS, NOSM U, FU) Preston R, et al (2016)22 (FU, JCU, ADZU, UPM-SHS) Ellaway RH, et al (2018)17 (NOSM U, Ghent U, JCU, FU, UNM, Gezira U, UPM-SHS, WSU) Reeve C, et al (2017)23 (FU, JCU, ADZU, UPM-SHS) Halili S Jr, et al (2017)18 (ADZU, JCU, FU) Siega-Sur JL, et al (2017)19 (UPM-SHS, JCU, FU) Woolley T, et al (2018)20 (JCU, ADZU, UPM-SHS, FU) Woolley T, et al (2018)21 (JCU, ADZU, UPM-SHS, FU) Woolley T, et al (2019)16 (JCU, UNM, Gezira U) Woolley T, et al (2020)24 (JCU, NOSM U) Murray R, et al (2022)7 (JCU, ADZU, PAHS, UPM-SHS, NOSM U, Ghent U, UNM) Our research shows promising outcomes from THEnet partner schools in terms of: intending to practise and actually practising in rural, remote and underserved areas; practice in generalist disciplines rather than subspecialties; broadening health teams to include community-based health workers and other mid-level providers; and health professionals remaining in low and middle income countries rather than emigrating.15, 18 Longer term data from some schools suggest that practice intentions translate well into actual practice.25 By summarising and integrating evidence from our collective work and the experience of partner schools in diverse locations, we identified consistent findings that may help produce a fit-for-purpose global health workforce (Box 2). Locating health professional education institutions in remote, rural and regional areas is a key factor in terms of producing a fit-for-practice rural and remote health workforce. In addition, providing a contextualised primary care-focused curriculum to a diverse body of students who are largely from remote, rural and regional areas themselves is important. Using these approaches has become known as training health professionals "from, in, with and for" the rural and remote communities that we would like them to serve.4 However, lessons from pioneering schools suggest that these approaches are necessary but not sufficient — that the building blocks necessary for success are broader still.26 A vital common factor is a clearly expressed and widely understood mission for each school, which is linked to meeting the health needs of the population served. Also, committed and charismatic leadership that conveys each school's mission to its faculty and students is essential. Likewise, schools need diversity among the staff and the teaching body, including a wide variety of inspiring community-based and primary care practitioners or generalists, to mitigate against the hidden hospital-centric curriculum that often deters students from pursuing careers in primary care.27 In addition, exposing learners to a wide variety of inspirational rural and remote service providers provides motivation and encouragement to both mentors and mentees. Two further critical elements for producing a fit-for-purpose global health workforce are: learning in and with rural communities; and recognising the role of community members as teachers, particularly with respect to the social and cultural determinants of health. Working alongside community extension officers, Aboriginal or Torres Strait Islander health workers and practitioners, community nurses, or other mid-level health professionals is critical for these aspects of learning.28 In all of these areas, increasing skills in telehealth and digitally assisted education — accelerated by the coronavirus disease 2019 (COVID-19) pandemic — can help build a rural and remote health workforce.7 However, we believe that nothing can replace the impact of a rural longitudinal placement. THEnet's partner schools have cooperated to produce a significant collective contribution to the evidence base on approaches to education that can help build a rural and remote health workforce. They have highlighted important factors which can help ensure that we deliver on our collective social accountability mandate. However, there is still much work to do as we strive to measure and critically reflect on the impact of our activities on the health of individuals, communities and populations, and on strengthening the health system. We have started to develop and apply novel approaches to measure social return on investment — in settings within Australia, the Philippines and Canada — with a view to extending this to a broader range of schools. It is important to measure the economic and social impact of school activities and outcomes for communities. Current work is also focused on measuring the impact of a learning health system and is looking at how we can build a chain of association from health professional education activities to accessibility of health services (and other markers of quality of care) through to improved health outcomes. Despite marked differences in the settings where THEnet's partner schools operate, similarities in approach provide lessons that may support more equitable distribution of the health and medical workforce into the future. We acknowledge all members of THEnet's Evidence Group and their valuable contributions to research synthesised in this article. Open access publishing facilitated by James Cook University, as part of the Wiley - James Cook University agreement via the Council of Australian University Librarians. No relevant disclosures. Commissioned; externally peer reviewed.

Introduction The study predicted practice location of doctors trained at a socially accountable medical school with education programs in over 90 communities. Methods A cross-sectional study examined practice location 10 years after the first class graduated from the Northern Ontario School of Medicine (NOSM), Canada. Exact tests and logistic regression models were used to assess practice location in northern Ontario; northern Canada; or other region; and rural (population <10,000) or urban community. Results There were 435 doctors with 334 (77%) practising as family doctors (FPs), 62 (14%) as generalist specialists and 39 (9%) as other medical or surgical specialists. Approximately 92% (128/139) of FPs who completed both UG and PG at NOSM practised in northern Ontario in 2019, compared with 63% (43/68) who completed only their PG at NOSM, and 24% (30/127) who completed only their UG at NOSM. Overall, 37% (23/62) of generalist specialists and 23% (9/39) of other specialists practised in northern Ontario. Approximately 28% (93/334) of FPs practised in rural Canada compared with 4% (4/101) of all other specialists. FP northern Ontario practice was predicted by completing UG and PG at NOSM (adjusted odds ratio = 46, 95% confidence interval = 20-103) or completing only PG at NOSM (15, 6.0-38) relative to completing only UG at NOSM, and having a northern Ontario hometown (5.3, 2.3-12). Rural Canada practice was predicted by rural hometown (2.3, 1.3-3.8), completing only a NOSM PG (2.0, 1.0-3.9), and age (1.4, 1.1-1.8). Conclusion This study uniquely demonstrated the interaction of two mechanisms by which medical schools can increase the proportion of doctors' practices located in economically deprived regions: first, admit medical students who grow up in the region; and second, provide immersive UG and PG medical education in the region. Both mechanisms have enabled the majority of NOSM-trained doctors to practise in the underserved region of northern Ontario.

Background Medical schools with distributed or regional programs encourage people to live, work, and learn in communities that may be economically challenged. Local spending by the program, staff, teachers, and students has a local economic impact. Although the economic impact of DME has been estimated for nations and sub-national regions, the community-specific impact is often unknown. Communities that contribute to the success of DME have an interest in knowing the local economic impact of this participation. To provide this information, we estimated the economic impact of the Northern Ontario School of Medicine (NOSM) on selected communities in the historically medically underserviced and economically disadvantaged Northern Ontario region. Methods Economic impact was estimated by a cash-flow local economic model. Detailed data on program and learner spending were obtained for Northern Ontario communities. We included spending on NOSM’s distributed education and research programs, medical residents’ salary program, the clinical teachers’ reimbursement program, and spending by learners. Economic impact was estimated from total spending in the community adjusted by an economic multiplier based on community population size, industry diversity, and propensity to spend locally. Community employment impact was also estimated. Results In 2019, direct program and learner spending in Northern Ontario totalled $64.6 M (million) Canadian Dollars. Approximately 76% ($49.1 M) was spent in the two largest population centres of 122,000 and 165,000 people, with 1–5% ($0.7 M – $3.1 M) spent in communities of 5000–78,000 people. In 2019, total economic impact in Northern Ontario was estimated to be $107 M, with an impact of $38 M and $36 M in the two largest population centres. The remaining $34 M (32%) of the economic impact occurred in smaller communities or within the region. Expressed alternatively as employment impact, the 404 full time equivalent (FTE) positions supported an additional 298 FTE positions in Northern Ontario. NOSM-trained physicians practising in the region added an economic impact of $88 M. Conclusions By establishing programs and bringing people to Northern Ontario communities, NOSM added local spending and knowledge-based economic activity to a predominantly resource-based economy. In an economically deprived region, distributed medical education enabled distributed economic impact.

Introduction: The objective of this study was to identify commonalities between one regionally based medical school in Australia and one in Canada regarding the association between postgraduate training location and a doctor's practice location once fully qualified in a medical specialty. Methods: Data were obtained using a cross-sectional survey of graduates of the James Cook University (JCU) medical school, Queensland, Australia, who had completed advanced training to become a specialist (a 'Fellow') in that field (response rate = 60%, 197 of 326). Medical education, postgraduate training and practice data were obtained for 400 of 409 (98%) fully licensed doctors who completed undergraduate medical education or postgraduate training or both at the Northern Ontario School of Medicine (NOSM), Ontario, Canada. Binary logistic regression used postgraduate training location to predict practice in the school's service region (northern Australia or northern Ontario). Separate analyses were conducted for medical discipline groupings of general/family practitioner, general specialist and subspecialist (JCU only). Results: For JCU graduates, significant associations were found between training in a northern Australian hospital at least once during postgraduate training and current (2018) northern Australian practice for all three discipline subgroups: family practitioner (p <0.001; prevalence odds ratio (POR)=30.0; 95% confidence interval (CI): 6.7-135.0), general specialist (p=0.002; POR=30.3; 95%CI: 3.3-273.4) and subspecialist (p=0.027; POR=6.5; 95%CI: 12-34.0). Overall, 38% (56/149) of JCU graduates who had completed a Fellowship were currently practising in northern Australia. For NOSM-trained doctors, a significant positive effect of training location on practice location was detected for family practice doctors but not for general specialist doctors. Family practitioners who completed their undergraduate medical education at NOSM and their postgraduate training in northern Ontario had a statistically significant (p<0.001) POR of 36.6 (95%CI: 16.9-79.2) of practising in northern Ontario (115/125) versus other regions, whereas those who completed only their postgraduate training in northern Ontario (46/85) had a statistically significant (p<0.001) POR of 3.7 (95%CI: 2.1-6.8) relative to doctors who only completed their undergraduate medical education at NOSM (28/117). Overall, 30% (22/73) of NOSM's general speciality graduates currently practise in northern Ontario. Conclusion: The findings support increasing medical graduate training numbers in rural underserved regions, specifically locating full specialty training programs in regional and rural centres in a 'flipped training' model, whereby specialty trainees are based in rural or regional clinical settings with some rotations to the cities. In these circumstances, the doctors would see their regional or rural centre as 'home base' with the city rotations as necessary to complete their training requirements while preparing to practise near where they train.

Equity in health outcomes for rural and remote populations in low- and middle-income countries (LMICs) is limited by a range of socio-economic, cultural and environmental determinants of health. Health professional education that is sensitive to local population needs and that attends to all elements of the rural pathway is vital to increase the proportion of the health workforce that practices in underserved rural and remote areas. The Training for Health Equity Network (THEnet) is a community-of-practice of 13 health professional education institutions with a focus on delivering socially accountable education to produce a fit-for-purpose health workforce. The THEnet Graduate Outcome Study is an international prospective cohort study with more than 6,000 learners from nine health professional schools in seven countries (including four LMICs; the Philippines, Sudan, South Africa and Nepal). Surveys of learners are administered at entry to and exit from medical school, and at years 1, 4, 7, and 10 thereafter. The association of learners' intention to practice in rural and other underserved areas, and a range of individual and institutional level variables at two time points—entry to and exit from the medical program, are examined and compared between country income settings. These findings are then triangulated with a sociocultural exploration of the structural relationships between educational and health service delivery ministries in each setting, status of postgraduate training for primary care, and current policy settings. This analysis confirmed the association of rural background with intention to practice in rural areas at both entry and exit. Intention to work abroad was greater for learners at entry, with a significant shift to an intention to work in-country for learners with entry and exit data. Learners at exit were more likely to intend a career in generalist disciplines than those at entry however lack of health policy and unclear career pathways limits the effectiveness of educational strategies in LMICs. This multi-national study of learners from medical schools with a social accountability mandate confirms that it is possible to produce a health workforce with a strong intent to practice in rural areas through attention to all aspects of the rural pathway.

PURPOSE:To describe the admissions process and outcomes for Indigenous applicants to the Northern Ontario School of Medicine (NOSM), a Canadian medical school with the mandate to recruit students whose demographics reflect the service region's population.METHOD:The authors examined 10-year trends (2006-2015) for self-identified Indigenous applicants through major admission stages. Demographics (age, sex, northern and rural backgrounds) and admission scores (grade point average [GPA], preinterview, multiple mini-interview [MMI], final), along with score-based ranks, of Indigenous and non-Indigenous applicants were compared using Pearson chi-square and Mann-Whitney tests. Binary logistic regression was used to assess the relationship between Indigenous status and likelihood of admission outcomes (interviewed, received offer, admitted).RESULTS:Indigenous qualified applicants (338/17,060; 2.0%) were more likely to be female, mature (25 or older), or of northern or rural background than non-Indigenous applicants. They had lower GPA-based ranks than non-Indigenous applicants (P < .001) but had comparable preinterview-, MMI-, and final-score-based ranks across all admission stages. Indigenous applicants were 2.4 times more likely to be interviewed and 2.5 times more likely to receive an admission offer, but 3 times less likely to accept an offer than non-Indigenous applicants. Overall, 41/338 (12.1%) Indigenous qualified applicants were admitted compared with 569/16,722 (3.4%) non-Indigenous qualified applicants.CONCLUSIONS:Increased representation of Indigenous peoples among applicants admitted to medical school can be achieved through the use of socially accountable admissions. Further tracking of Indigenous students through medical education and practice may help assess the effectiveness of NOSM's social accountability admissions process.

Background: Northern Ontario School of Medicine (NOSM) serves as the Faculty of Medicine of Lakehead and Laurentian Universities, and views the entire geography of Northern Ontario as its campus. This paper explores how community engagement contributes to achieving social accountability in over 90 sites through NOSM’s distinctive model, Distributed Community Engaged Learning (DCEL). Methods: Studies involving qualitative and quantitative methods contribute to this paper, which draws on administrative data from NOSM and external sources, as well as surveys and interviews of students, graduates and other informants including the joint NOSM-CRaNHR (Centre for Rural and Northern Health Research) tracking and impact studies. Results: Community engagement contributes throughout the lifecycle stages of preadmission, admission, and undergraduate medical education. High school students from 70 Northern Ontario communities participate in NOSM’s week-long Health Sciences Summer Camps. The MD admissions process involves approximately 128 volunteers assessing written applications and over 100 volunteer interviewers. Thirty-six Indigenous communities host first year students and third-year students learn their core clinical medicine in 15 communities, throughout Northern Ontario. In general, learners and communities report net benefits from participation in NOSM programs. Conclusion: Community engagement makes a key contribution to the success of NOSM’s socially accountable distributed medical education.

BACKGROUND:Understanding the impact of selection and medical education on practice intentions and eventual practice is an essential component of training a fit-for-purpose health workforce distributed according to population need. Existing evidence comes largely from high-income settings and neglects contextual factors. This paper describes the practice intentions of entry and exit cohorts of medical students across low and high income settings and the correlation of student characteristics with these intentions.METHODS:The Training for Health Equity Network (THEnet) Graduate Outcome Study (GOS) is an international prospective cohort study tracking learners throughout training and ten years into practice as part of the longitudinal impact assessment described in THEnet's Evaluation Framework. THEnet is an international community of practice of twelve medical schools with a social accountability mandate. Data presented here include cross-sectional entry and exit data obtained from different cohorts of medical students involving eight medical schools in six countries and five continents. Binary logistic regression was used to create adjusted odds ratios for associations with practice intent.RESULTS:Findings from 3346 learners from eight THEnet medical schools in 6 countries collected between 2012 and 2016 are presented. A high proportion of study respondents at these schools come from rural and disadvantaged backgrounds and these respondents are more likely than others to express an intention to work in underserved locations after graduation at both entry and exit from medical school. After adjusting for confounding factors, rural and low income background and regional location of medical school were the most important predictors of intent to practice in a rural location. For schools in the Philippines and Africa, intention to emigrate was more likely for respondents from high income and urban backgrounds.CONCLUSIONS:These findings, from a diverse range of schools with social accountability mandates in different settings, provide preliminary evidence for the selection and training of a medical workforce motivated to meet the needs of underserved populations. These respondents are being followed longitudinally to determine the degree to which these intentions translate into actual practice.

OBJECTIVE:Opioid use disorder has been declared a public health crisis across North America and opioid agonist therapy (OAT) is the standard of care for these patients. Despite the increasing adoption of telemedicine as a delivery method for OAT, its effectiveness has not yet been evaluated against traditional in-person treatment. This study compared treatment outcomes for in-person versus telemedicine-delivered OAT. METHODS:We conducted a non-randomized cohort comparison study using an administrative database for patients who commenced OAT between 2011 and 2012 across 58 clinic sites in the province of Ontario, Canada. Patients were stratified by primary treatment modality as being: in-person (<25% appointments by telemedicine), mixed (25-75% by telemedicine), or via telemedicine (>75% appointments by telemedicine). The primary outcome was continuous retention in treatment as defined by one year of uninterrupted therapy, based on pharmacy dosing records. RESULTS:A total of 3733 OAT initiating patients were identified. Patients treated via telemedicine were more likely to be retained in therapy than patients treated in-person (n=1590; aOR=1.27; 95% CI 1.14-1.41; p<0.001). Telemedicine patients demonstrated a retention rate of 50% at one year whereas in-person patients were retained at a rate of 39%. The mixed group also had higher likelihood of retention than the in-person group (n=418; aOR=1.26; 95% CI 1.08-1.47; p=0.001) and had a retention rate of 47% at one year. CONCLUSION:Telemedicine may be an effective alternative to delivering in person OAT, and it has the potential to expand access to care in rural, remote, and urban regions.

INTRODUCTION:The Northern Ontario School of Medicine (NOSM) opened in 2005 with a social accountability mandate to address a long history of physician shortages in northern Ontario. The objective of this qualitative study was to understand the school's effect on recruitment of family physicians into medically underserviced rural communities of northern Ontario.METHODS:We conducted a multiple case study of 8 small rural communities in northern Ontario that were considered medically underserviced by the provincial ministry of health and had successfully recruited NOSM-trained physicians. We interviewed 10 people responsible for physician recruitment in these communities. Interview transcripts were analyzed by means of an inductive and iterative thematic method.RESULTS:All 8 communities were NOSM medical education sites with populations of 1600-16 000. Positive changes, linked to collaboration with NOSM, included achieving a full complement of physicians in 5 communities with previous chronic shortages of 30%-50% of the physician supply, substantial reduction in recruitment expenditures, decreased reliance on locums and a shift from crisis management to long-term planning in recruitment activities. The magnitude of positive changes varied across communities, with individual leadership and communities' active engagement being key factors in successful physician recruitment.CONCLUSION:Locating medical education sites in underserviced rural communities in northern Ontario and engaging these communities in training rural physicians showed great potential to improve the ability of small rural communities to recruit family physicians and alleviate physician shortages in the region.

Background The “rural pipeline” suggests that students educated in rural, or other underserviced areas, are more likely to establish practices in such locations. It is upon this concept that the Northern Ontario School of Medicine (NOSM) was founded. Our analysis answers the following question: Are physicians who were educated at NOSM more likely to practice in rural and northern Ontario compared with physicians who were educated at other Canadian medical schools? Methods We used data from the College of Physicians and Surgeons of Ontario. We compared practice locations of certified Ontario family physicians who had graduated from NOSM vs. other Canadian medical schools in 2009 or later. We categorized the physicians according to where they completed their undergraduate (UG) and postgraduate (PG) training, either at NOSM or elsewhere. We used logistic regression models to determine if the location of UG and PG training was associated with rural or northern Ontario practice location. Results Of the 535 physicians examined, 67 had completed UG and/or PG medical education at NOSM. Over two thirds of physicians with any NOSM education were practicing in northern areas and 25.4% were practicing in rural areas of Ontario compared with those having no NOSM education, with 4.3 and 10.3% in northern and rural areas, respectively. Physicians who graduated from NOSM-UG were more likely to have practices located in rural Ontario (OR = 2.57; p = 0.014) whereas NOSM-PG physicians were more likely to have practices in northern Ontario (OR = 57.88; p < 0.001). Conclusions NOSM education was associated with an increased likelihood of practicing in rural (NOSM-UG) and northern (NOSM-PG) Ontario.

Introduction: Northern Ontario is a region in Canada with approximately 775,000 people in communities scattered across 803,000 km2. The Ontario Telemedicine Network (OTN) facilitates access to medical care in areas that are often underserved. We assessed how OTN utilization differed throughout the province. Materials and Methods: We used OTN medical service utilization data collected through the Ontario Health Insurance Plan and provided by the Ministry of Health and Long Term Care. Using census subdivisions grouped by Northern and Southern Ontario as well as urban and rural areas, we calculated utilization rates per fiscal year and total from 2008/2009 to 2013/2014. We also used billing codes to calculate utilization by therapeutic area of care. Results: There were 652,337 OTN patient visits in Ontario from 2008/2009 to 2013/2014. Median annual utilization rates per 1,000 people were higher in northern areas (rural, 52.0; urban, 32.1) than in southern areas (rural, 6.1; urban, 3.1). The majority of usage in Ontario was in mental health and addictions (61.8%). Utilization in other areas of care such as surgery, oncology, and internal medicine was highest in the rural north, whereas primary care use was highest in the urban south. Conclusions: Utilization was higher and therapeutic areas of care were more diverse in rural Northern Ontario than in other parts of the province. Utilization was also higher in urban Northern Ontario than in Southern Ontario. This suggests that telemedicine is being used to improve access to medical care services, especially in sparsely populated regions of the province.

Objective To assess the effect of different levels of exposure to the Northern Ontario School of Medicine's (NOSM's) distributed medical education programs in northern Ontario on FPs' practice locations.Design Cross-sectional design using longitudinal survey and administrative data.Setting Canada.Participants All 131 Canadian medical graduates who completed FP training in 2011 to 2013 and who completed their undergraduate (UG) medical degree or postgraduate (PG) residency training or both at NOSM.Intervention Exposure to NOSM's medical education program at the UG (n = 49) or PG (n = 31) level or both (n = 51).Main outcome measures Primary practice location in September of 2014.Results Approximately 16% (21 of 129) of FPs were practising in rural northern Ontario, 45% (58 of 129) in urban northern Ontario, and 5% (7 of 129) in rural southern Ontario. Logistic regression found that more rural Canadian background years predicted rural practice in northern Ontario or Ontario, with odds ratios of 1.16 and 1.12, respectively. Northern Canadian background, sex, marital status, and having children did not predict practice location. Completing both UG and PG training at NOSM predicted practising in rural and northern Ontario locations with odds ratios of 4.06 to 48.62.Conclusion Approximately 61% (79 of 129) of Canadian medical graduate FPs who complete at least some of their training at NOSM practise in northern Ontario. Slightly more than a quarter (21 of 79) of these FPs practise in rural northern Ontario. The FPs with more years of rural background or those with greater exposure to NOSM's medical education programs had higher odds of practising in rural northern Ontario. This study shows that NOSM is on the road to reaching one of its social accountability milestones.

INTRODUCTION:The Ontario Telemedicine Network (OTN) uses technology to help make medical services more accessible to people in medically underserved rural and remote parts of Ontario, Canada. We examined access to OTN-enabled health and medical services in Northern Ontario, which has 775,000 people in communities scattered across an area of 803,000 km(2).MATERIALS AND METHODS:We used ArcGIS Network Analyst (Esri, Redlands, CA) to conduct a service area analysis with travel time as a measure of potential access to care. We used road distance and speed limits to estimate travel time between Northern Ontario communities and the nearest OTN unit.RESULTS:In 2014 there were 2,331 OTN units, of which 552 (24%) were located in Northern Ontario. All seven communities in Northern Ontario with a population of 10,000 or greater had OTN units. Almost 97% of the 59 communities with 1,000-10,000 people were within 30 min of an OTN unit. The percentage of communities within 30 min steadily decreased with decreasing population size, to 58% for communities with fewer than 50 people. In total, 86% (690/802) of Northern Ontario communities were within an hour's drive of an OTN unit.CONCLUSIONS:This study showed that most Northern Ontario communities were within an hour's drive of an OTN unit. The current distribution of OTN units has the potential to increase access to medical services and to reduce the need for medically related travel for residents of these communities.

Objective To assess the effect of different levels of exposure to the Northern Ontario School of Medicine’s (NOSM’s) distributed medical education programs in northern Ontario on FPs’ practice locations.Design Cross-sectional design using longitudinal survey and administrative data.Setting Canada.Participants All 131 Canadian medical graduates who completed FP training in 2011 to 2013 and who completed their undergraduate (UG) medical degree or postgraduate (PG) residency training or both at NOSM.Intervention Exposure to NOSM’s medical education program at the UG (n = 49) or PG (n = 31) level or both (n = 51).Main outcome measures Primary practice location in September of 2014.Results Approximately 16% (21 of 129) of FPs were practising in rural northern Ontario, 45% (58 of 129) in urban northern Ontario, and 5% (7 of 129) in rural southern Ontario. Logistic regression found that more rural Canadian background years predicted rural practice in northern Ontario or Ontario, with odds ratios of 1.16 and 1.12, respectively. Northern Canadian background, sex, marital status, and having children did not predict practice location. Completing both UG and PG training at NOSM predicted practising in rural and northern Ontario locations with odds ratios of 4.06 to 48.62.Conclusion Approximately 61% (79 of 129) of Canadian medical graduate FPs who complete at least some of their training at NOSM practise in northern Ontario. Slightly more than a quarter (21 of 79) of these FPs practise in rural northern Ontario. The FPs with more years of rural background or those with greater exposure to NOSM’s medical education programs had higher odds of practising in rural northern Ontario. This study shows that NOSM is on the road to reaching one of its social accountability milestones.

INTRODUCTION:The economic contribution of medical schools to major urban centres can be substantial, but there is little information on the contribution to the economy of participating communities made by schools that provide education and training away from major cities and academic health science centres. We sought to assess the economic contribution of the Northern Ontario School of Medicine (NOSM) to northern Ontario communities participating in NOSM's distributed medical education programs.METHODS:We developed a local economic model and used actual expenditures from 2007/08 to assess the economic contribution of NOSM to communities in northern Ontario. We also estimated the economic contribution of medical students or residents participating in different programs in communities away from the university campuses. To explore broader economic effects, we conducted semistructured interviews with leaders in education, health care and politics in northern Ontario.RESULTS:The total economic contribution to northern Ontario was $67.1 million based on $36.3 million in spending by NOSM and $1.0 million spent by students. Economic contributions were greatest in the university campus cities of Thunder Bay ($26.7 million) and Sudbury ($30.4 million), and $0.8-$1.2 million accrued to the next 3 largest population centres. Communities might realize an economic contribution of $7300-$103 900 per pair of medical learners per placement. Several of the 59 interviewees remarked that the dollar amount could be small to moderate but had broader economic implications.CONCLUSION:Distributed medical education at the NOSM resulted in a substantial economic contribution to participating communities.

OBJECTIVE To test predictors of practice location of fully qualified Monash University Bachelor of Medicine, Bachelor of Surgery (MBBS) graduates. DESIGN Cohort survey, 2011. SETTING Australia. PARTICIPANTS Rural (n = 67/129) and urban (n = 86/191) background doctors starting at Monash University 1992-1999. Approximately 60% female, 77% married/partnered, 79% Australian-born, mean age 34 years, 31% general practitioners, 72% fully qualified and 80% training/practising in major cities. MAIN OUTCOME MEASURES First and current practice location once fully qualified. Intended practice location in 5-10 years. RESULTS Logistic regression found that rural versus urban background was a significant predictor of rural (outside major city) first practice location (odds ratio (OR) 5.0, 95% confidence interval (CI) 1.3-19.2) and rural current practice location (OR 5.6, 95% CI 1.5-21.2) for fully qualified doctors. General practitioner versus other medical specialists significantly predicted first (OR 7.2, 95% CI 2.1-25.2) or current (OR 3.6, 95% CI 1.1-11.9) rural practice location. Preference for a rural practice location in 5-10 years was predicted by rural background (OR 4.4, 95% CI 1.6-11.8) and positive intention towards rural practice upon completing MBBS (OR 4.6, 95% CI 1.7-12.6). Surveyed in 2011, 28% of those who also responded to the 2006 survey shifted their preferred future practice location from rural to urban communities versus 13% shifting from urban to rural (McNemar-Bowker test, P = 0.02). CONCLUSION The majority of fully qualified Monash MBBS graduates practicing in rural communities have rural backgrounds. The rural-background effect diminished over time and may need continued support during training and full practice.