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PURPOSE Physician shortages and maldistribution, particularly within family medicine, have led many medical schools worldwide to create regional medical campuses (RMCs) for clerkship training. However, Canadian medical schools have developed a number of RMCs in which all years of training (i.e., a combined model that includes both preclerkship and clinical training) are provided geographically separate from the main campus. This study addresses the question: Are combined model RMC graduates more likely to enter postgraduate training in family medicine and rural-focused programs relative to main campus graduates? METHOD The authors used a quasi-experimental research design and analyzed 2006-2016 data from the Canadian Resident Matching Service (CaRMS). Graduating students (N = 26,525) from 16 Canadian medical schools who applied for the CaRMS match in their year of medical school graduation were eligible for inclusion. The proportions of graduates who matched to postgraduate training in (1) family medicine and (2) rural-focused programs were compared for combined model RMCs and main campuses. RESULTS Of RMC graduates, 48.4% matched to family medicine (95% confidence interval [CI] = 46.1-50.7) compared with 37.1% of main campus graduates (95% CI = 36.5-37.7; P < .001). Of RMC graduates, 23.9% matched to rural-focused training programs (95% CI = 21.8-25.9) compared with 10.4% of main campus graduates (95% CI = 10.0-10.8; P < .001). Subanalyses ruled out a variety of potentially confounding variables. CONCLUSIONS Combined model RMCs, in which all years of training take place away from the medical school's main campus, are associated with greater proportions of medical students entering family medicine postgraduate training and rural-focused training programs. These findings should encourage policymakers, health services agencies, and medical schools to continue seeking complements to academic medical center-based medical education.

Background and Objectives: There is a limited evidentiary base on the development of family medicine in different contexts and countries. The lack of evidence impedes our ability to compare and characterize family medicine models and identify areas of success that have led to the effective provision of care. This paper offers a comparative compilation and analysis of the development of family medicine training programs in seven countries: Brazil, Canada, Ethiopia, Haiti, Indonesia, Kenya, and Mali. Methods: Using qualitative case studies, this paper examines the process of developing family medicine programs, including enabling strategies and barriers, and shared lessons. An appreciative inquiry framework and complex adaptive systems thinking inform our qualitative study. Results: Committed partnerships, the contribution of champions, health policy, and adaptability were identified as key enablers in all seven case studies. The case studies further reveal that some enablers were more salient in certain contexts as compared to others, and that it is the interaction of enablers that is crucial for understanding how and why initiatives succeeded. The barriers that emerged across the seven case studies include: (1) resistance from other medical specialties, (2) lack of resources and capabilities, (3) difficulty in sustaining support of champions, and (4) challenges in brokering effective partnerships. Conclusions: A key insight from this study is that the implementation of family medicine is nonlinear, dynamic, and complex. The findings of this comparative analysis offer insights and strategies that can inform the design and development of family medicine programs elsewhere.

INTRODUCTION An understanding of the contextual, professional, and personal factors that affect choice of practice location for physicians is needed to support successful strategies in addressing geographic maldistribution of physicians. This study compared two categories of predictors of family practice location in non-metropolitan areas among undergraduate medical students: individual characteristics (nature), and the rural program component of their training program (nurture). The study aimed to identify factors that predict the location of practice 2 years post-residency training and determine the predictive value of combining nature and nurture variables using administrative data from two undergraduate medical education programs. METHODS Databases were developed from available administrative sources for a retrospective analysis of two undergraduate medical education programs in Canada: Universite de Sherbrooke (UdeS) and University of British Columbia (UBC). Both schools have a strong mandate to evaluate the impact of their programs on physician distribution. The dependent variable was location of practice 2 years after completing postgraduate training in family medicine. Independent variables included individual and program characteristics. Separate analyses were conducted for each program using multiple logistic regression. RESULTS The nature and nurture variables considered in the models explained only 21% to 27% of the variance in the eventual location of practice of family physician graduates. For UdeS, having an address in a rural/small-town environment at application to medical school (OR=2.61, 95% CI: 1.24-6.06) and for UBC, location of high school in a rural/small town (OR=4.03, 95% CI: 1.05-15.41), both increased the chances of practicing in a non-metropolitan area. For UdeS the nurture variable (ie length of clerkship in a non-metropolitan area) was the most significant predictor (OR=1.14, 95% CI: 1.067-1.22). For both medical schools, adding a single nurture variable to the model using only nature variables significantly increased the amount of variation accounted for in predicting location of practice in non-metropolitan areas. CONCLUSIONS Aspects of graduates' rural background increase the chances of practicing in a non-metropolitan area. A third-year clerkship experience in a rural area may increase the chances of non-metropolitan practice. Although the total variation predicted by both nature and nurture variables in this study was small, adding a nurture variable significantly improves the prediction of individuals who will practice in a non-metropolitan area. The fact that total variation predicted was small is likely to be due to the limitations of the administrative databases used. Different strategies are being implemented in each university to improve the quality of existing administrative databases, as well as to collect relevant data about intent-to-practice, training characteristics, and the attitudes, beliefs and backgrounds of students.

ContextStandards for licensure are designed to provide assurance to the public of a physician's competence to practice. However, there has been little assessment of the relationship between examination scores and subsequent practice performance.ObjectiveTo determine if there is a sustained relationship between certification examination scores and practice performance and if licensing examinations taken at the end of medical school are predictive of future practice in primary care.Design, Setting, and ParticipantsA total of 912 family physicians, who passed the Quebec family medicine certification examination (QLEX) between 1990 and 1993 and entered practice. Linked databases were used to assess physicians' practice performance for 3.4 million patients in the universal health care system in Quebec, Canada. Patients were seen during the follow-up period for the first 4 years (1993 cohort of physicians) to 7 years (1990 cohort of physicians) of practice from July 1 of the certification examination to December 31, 1996.Main Outcome MeasuresMammography screening rate, continuity of care index, disease-specific and symptom-relief prescribing rate, contraindicated prescribing rate, and consultation rate.ResultsPhysicians achieving higher scores on both examinations had higher rates (rate increase per SD increase in score per 1000 persons per year) of mammography screening (β for QLEX, 16.8 [95% confidence interval {CI}, 8.7-24.9]; β for Medical Council of Canada Qualifying Examination [MCCQE], 17.4 [95% CI, 10.6-24.1]) and consultation (β for QLEX, 4.9 [95% CI, 2.1-7.8]; β for MCCQE, 2.9 [95% CI, 0.4-5.4]). Higher subscores in diagnosis were predictive of higher rates in the difference between disease-specific and symptom-relief prescribing (β for QLEX, 3.9 [95% CI, 0.9-7.0]; β for MCCQE, 3.8 [95% CI, 0.3-7.3]). Higher scores of drug knowledge were predictive of a lower rate (relative risk per SD increase in score) of contraindicated prescribing for MCCQE (relative risk, 0.88; 95% CI, 0.77-1.00). Relationships between examination scores and practice performance were sustained through the first 4 to 7 years in practice.ConclusionScores achieved on certification examinations and licensure examinations taken at the end of medical school show a sustained relationship, over 4 to 7 years, with indices of preventive care and acute and chronic disease management in primary care practice.

Context.—Clinical competence is a determinant of the quality of care delivered, and may be associated with use of health care resources by primary care physicians. Clinical competence is assumed to be assessed by licensing examinations, yet there is a paucity of information on whether scores achieved predict subsequent practice.Objective.—To determine if licensing examination scores were associated with selected aspects of quality of care and resource use in initial primary care practice.Design.—Prospective cohort study of recently licensed family physicians, followed up for the first 18 months of practice.Setting.—The Quebec health care system.Participants.—A total of 614 family physicians who passed the licensing examination between 1991 and 1993 and entered fee-for-service practice in Quebec.Main Outcome Measures.—All patients seen by physicians were identified by the universal health insurance board and all health services provided to these patients were retrieved for the 18 months prior to (baseline) and after (follow-up) the physicians' entry into practice. Medical service and prescription claims files were used to measure rates of resource use (specialty consultation, symptom-relief prescribing compared with disease-specific prescribing) and quality of care (inappropriate prescribing, mammography screening). Baseline data were used to adjust for differences in practice population.Results.—Study physicians saw a total of 1116389 patients, of whom 113535 (10.2%) were elderly and 83391 (7.5%) were women aged 50 to 69 years. Physicians with higher licensing examination scores referred more of their patients for consultation (3.8/1000 patients per SD increase in score; 95% confidence interval [CI], 1.2-7.0; P=.005), prescribed to elderly patients fewer inappropriate medications (−2.7/1000 patients per SD increase in score; 95% CI, −4.8 to −0.7; P =.009) and more disease-specific medications relative to symptom-relief medications (3.9/1000 patients per SD increase in score; 95% CI, 0.3 to 7.4; P=.03), and referred more women aged 50 to 69 years (6.6/1000 patients per SD increase in score; 95% CI, 1.2-11.9; P=.02) for mammography screening. If patients of physicians with the lowest scores had experienced the same rates of consultation, prescribing, and screening as patients of physicians with the highest scores, an additional 3027 patients would have been referred, 179 fewer elderly patients would have been prescribed symptom-relief medication, 912 more elderly patients would have been prescribed disease-specific medication, 189 fewer patients would have received inappropriate medication, and 121 more women would have received mammography screening.Conclusions.—Licensing examination scores are significant predictors of consultation, prescribing, and mammography screening rates in initial primary care practice.

Background : The World Health Organization advocates for faculties of medicine to orient health professional education toward the needs of the populations graduates are to serve and to include a greater emphasis on primary health care. It was in this framework that in 2007, the Faculty of Medicine and Health Sciences at the Universite de Sherbrooke (FMHS-UdeS) in Canada and the Facultad de Medicina de la Universidad de la Republica (FMUdelaR) in Montevideo, Uruguay developed a comprehensive collaboration to sustain the development of family medicine in both universities through education, practice and research. Activities and Outcomes : In addition to information sharing through email and teleconferencing, this five year collaboration has included 28 bilateral visits by the two institutions' teachers and leaders. During these visits, Uruguayan members participated in workshops and benefited from exchanges during educational and clinical activities. Interactions led to the improvement of their skills as teachers of family medicine with an emphasis on clinical teaching, supervision, feedback to learners in clinical evaluations, use of various educational methods, use of standardized patients for teaching and evaluation, and research. FMHS-UdeS members learned about the community aspects of family medicine in Uruguay and reflected on how these could be implemented to the benefit of Canadians. Conclusions : The international collaboration forged between the FMHS-UdeS and the FMUdelaR represents a socially responsible endeavor that has been highly rewarding for all involved. It represents a significant learning opportunity for each group aiming to better prepare physicians to serve as primary health care providers in their communities.

To look at how well residency directors in family medicine predict the performances of their candidates on the Quebec Licensing Examination (QLEx) for family physicians.The four family medicine program directors in Quebec were asked in the spring of 1992 to identify the ten residents from their own programs who would get the highest marks on the QLEx and the ten who would get the lowest marks. From the results of these candidates, and those of the intermediate groups defined by default, the prediction abilities of the program directors were assessed.Descriptive statistics showed that the program directors had difficulties discriminating among the different groups and tended to collapse the predicted scores toward the total mean. Analysis-of-variance studies confirmed the absence of difference between the predicted weak and intermediate groups as well as between the predicted intermediate and strong groups for each program and for each QLEx component. Regression analysis as well as eta 2 studies showed that the program directors' prediction abilities were low for all components and represented less than 25% of the explained variance of the QLEx scores.The residency directors did not accurately categorize their residents' performances on the QLEx. Both the evaluations of program directors and terminal examination results are complementary approaches to clinical competence assessment and should be used for licensure.