Medical education interventions influencing physician distribution into underserved communities: a scoping review

Inequitable distribution of physicians is a global problem [1, 2]. Half of the world’s population resides in rural areas but are served by less than a quarter of the physician workforce [1]. Consequently, rural-residing individuals have lower access to primary healthcare services [3‐6], which contributes to higher incidence of chronic disease, injury, and mortality [7‐9]. These disparities are even more pronounced amongst vulnerable and minority populations, including Indigenous and Francophone populations [10, 11]. Challenges of accessing primary care are also experienced in urban areas by individuals who are unhoused [12], recent immigrants [13‐15] from certain ethnic or racial backgrounds [14, 16, 17], with low socioeconomic status [13‐15, 18], individuals who are uninsured [19] and/or without full-time employment [14, 20].

There are few levers to encourage physicians to arrange practices in a way that offsets this maldistribution; however, medical education does present an opportunity. In the past, a variety of policy interventions have been implemented in response to the health disparities that are exacerbated by physician maldistribution. These include investments in ehealth and telemedicine to overcome communication and distance barriers in remote communities [5], increases in health human resources such as nurse practitioners and physician assistants, and the introduction of financial incentives to attract and retain physicians working in rural regions. However, evidence of the effectiveness of interventions such as these are limited [21, 22]. It is essential to find effective ways to address inequitable physician distribution, especially as the number of people challenged in accessing primary care continues to rise [23, 24].

There has been much discussion about the role health professions education can play in responding to healthcare and health system challenges. For instance, the World Health Organization (WHO) champions the importance of social accountability in medical schools, which it defines as “the obligation to direct their education, research, and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public” [25]. Accordingly, over the last two decades, the Canadian government has worked to expand medical school enrollment, assuming that graduating more physicians will improve overall access to care [26]. This has been accompanied by support for distributed medical education (DME) that accommodates the influx of new learners while also enhancing their exposure to authentic community-based learning environments in rural, remote, and other underserved areas [27]. Nevertheless, the challenge of access to primary care physicians persists.

Canadian medical education needs to expand its approach to influencing physician distribution and numerous interventions have been suggested [28]: the development of pipeline programs, enhanced admissions pathways, diversified learning contexts, and an increased emphasis on generalism throughout all stages of training [27, 29]. Many of these approaches have been tried and developing a strong understanding of those that are successful in influencing physician distribution is crucial. The objective of this scoping review is thus to understand the current literature pertaining to medical education initiatives designed to promote the uptake of family physicians in underserved areas. Through this review we intend to describe the education interventions that have been reported, their outcomes with respect to downstream physician practice in underserved areas, and any prevailing research gaps related to the relationship between education and physician distribution. This work differentiates from previous literature reviews, which were constrained to undergraduate training interventions [30, 31] or geographic regions [32, 33], inclusive of all types of primary care physicians [34], or relevant to the choice of family medicine specialty [35]. Specifically, this review adopts a global perspective considerate of interventions relevant to all stages of the medical training and maintains a specific focus on the distribution of family physicians.

We employed Levac and colleagues’ [36] interpretation of Arksey and O’Malley’s scoping review framework [37] which is useful for covering a body of literature, identifying knowledge gaps, and informing future research or practice implications [38, 39]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist guided translation of the results [40].

Database searching was completed in June 2021, identifying 692 potentially relevant articles. After duplicate removal, screening, and addition of new references, 130 eligible articles were included (Fig. 1).

This review mapped the literature reporting on educational interventions designed to influence family physicians to practice in underserved areas. The review highlights that many training institutions around the world have made such efforts—with a particular focus on increasing the uptake of practitioners in rural areas. Summarily, the literature outlines preferential admissions policies, placements in relevant practice settings during undergraduate and postgraduate training, financial support in exchange for time-limited-service agreements, and various combinations of these approaches as relevant. Overall, the majority of studies report positive outcomes associated with these interventions.

The review highlights that allocating medical school seats to those from or predisposed to practice in underserved areas may be an effective approach to promoting practice in these areas; but also, that this may not be entirely sufficient. Specialized non-clinical curriculum focusing on rural-residing or traditionally underserved patients [50, 92], workshops and seminars [57], training at a rural medical school [86, 87], and rural experiences provided through short-term and long-term placements, were all also influential in promoting practice in rural and underserved areas. Through these interventions, students may develop positive perceptions about practice in underserved communities, develop the appropriate skills to do so [137], and receive important mentorship from those who have expertise in these communities [57, 119]. The review suggested that combinations of admissions, undergraduate and postgraduate placement, and financial incentives may be particularly effective; however, did not indicate which combination of interventions is most effective in graduating physicians into underserved areas. It is important to highlight that learning experiences may also discourage students from practice in underserved areas. For instance, they may develop perceptions that the work and lifestyle are overly challenging [50, 57, 74]. Personal reasons, such as those related to family planning and spousal preferences, may also push learners away from these practice locations [126]. Given this, medical schools should consider the interaction between educational and personal factors when developing experiences for learners. In this regard, the simple introduction of interventions can be thought of as having a potential positive effect on the hidden curriculum of medical education [178]. When experiences in rural and underserved communities are prioritized within admissions and teaching activities, supported by knowledgeable mentors, and encouraged with funding, this type of practice may be perceived as more valuable.

The review also elucidates how evaluations of these educational interventions are largely situated within the medical education context and do not consider how they interact with healthcare initiatives or policies that operate outside of the training environment. For instance, numerous underserved communities mount their own projects to influence physician recruitment and retention, including monetary and lifestyle incentives, offsetting overhead costs, housing support, and fundraising activities for recruitment campaigns [179‐183]. Future research may consider how these grassroots programs interact with educational interventions to promote the uptake of family physicians in underserved communities. Similarly, many medical schools now have admissions policies that contemplate applicant selection with respect to their equity, diversity, and inclusion commitments, with minimal focus on resolving the physician maldistribution challenge. In Canada, some examples include admissions pathways for Black [183‐187] and Indigenous [189‐195] applicants. With respect to the evidence demonstrating a relationship between physician social identity characteristics and eventual practice location or practice intentions [196‐200], there may be an unintended downstream relationship between these admissions processes and the practice intentions or locations of the matriculants. In this regard, we encourage evaluations of these policies to extend beyond the diversity of resulting medical school classes so as to also formally consider the eventual impacts on physician distribution. Considerations for medical schools to design and adopt mission statements that reflect the social responsibility of graduating physicians into underserved communities present another potential avenue for influencing the health workforce outcomes as medical schools’ social mission content was reported to be a significant predictor of physician output in medically underserved areas and populations [201]. However, it is unclear if this effect was a result of the institution’s orientation or if medical learners were predisposed to work in the underserved areas and subsequently self-selected into institutions that align with their practice intentions. The review also revealed that a vast majority of the studies have a singular focus on educational interventions situated to influence physician disposition in rural or remote areas, with less consideration for underserved communities in urban areas. Future program evaluations should consider designing curricula and medical education initiatives that expose learners to working in underserved urban communities as populations with certain ethnic, cultural and/or socioeconomic backgrounds residing in urban locations experience challenges with accessing primary care [12‐18, 20].

The review has some notable limitations. Included studies were heterogeneous with respect to designs, interventions, and definitions of underservedness. Accordingly, our findings were summarized on a broader level, which inherently suppresses some of the unique features of different approaches. Second, numerous studies were single cohort or cross-sectional in design and many used self-reported survey data. We recommend researchers in this area conduct more longitudinal studies [202]. This would strengthen the overall quality of the evidence. Furthermore, many studies did not account for student background or pre-existing interest in practicing in underserved areas, making it challenging to understand the true, independent impact of interventions. Finally, our review may also be beset by considerable publication bias. It is likely that the strong representation of positive findings emanates from a tendency for medical education scholars to only seek publication of evaluations that reveal positive outcomes vis-à-vis programmatic objectives. In this case, instances where educational interventions were not successful may not be captured within this review.

Medical education may play an important role in addressing the challenges underserved communities face in accessing primary care family physicians. Various educational interventions can influence physician practice location: preferential admissions criteria, rural experiences during undergraduate and postgraduate medical training, and financial incentives. Effective strategies must also consider the social identity, preferences, and motivations of aspiring physicians as they have considerable impact on the effectiveness of education initiatives designed to promote practice in underserved settings.