A rural practice affinity model: recognizing the role of emergency medicine competency

Rural Canadians have poorer health indices than their urban counterparts and struggle with worse access to care due to an undersupply of physicians. Research has identified personal factors, such as being raised in a rural environment, and traits, such as lower harm avoidance, among those drawn to rural practice. As well, the impact of aspects of medical training, such as rural rotations, have been recognized in creating rural practice intentions, but the role of specific clinical competencies here has yet to be determined. Emergency medicine is often one of the most challenging components of rural practice and thought by some to have its competencies poorly developed in family practice training. We hypothesized a model for rural practice affinity in which a strong sense of general self-efficacy would be independently mediated by the development of emergency medicine competence and rural practice self-efficacy, leading to stronger intentions to embark on a rural practice career.

This model was tested using the data from a survey of all family medicine residents nearing graduation from 14 of the 17 Canadian medical schools. Demographics and data on factors known to influence a rural career choice were collected and accounted for when determining the strength of the hypothesized relationships. Both existing and specifically designed survey tools were used to assess model components. A partial correlation matrix between the variables of interest (general self-efficacy, emergency medicine competency, rural practice self-efficacy, and rural practice intentions) - controlling for the effects of relationships, financial aspects, personal aspects, and social desirability - was created and subjected to a structural equation model.

Our initial rural practice affinity model resulted in a poor fit of the model to the data. However, the addition of a pathway from emergency medicine competence to rural practice self-efficacy improved the model to one showing significant paths as hypothesized as well as excellent measures of fit.

The importance of general self-efficacy is recognized and is itself mediated by the more specific rural practice self-efficacy to rural practice intentions, consistent with the literature. Emergency medicine competency has a central role in both mediating general self-efficacy to rural practice intentions, while also being mediated itself by rural practice self-efficacy to rural practice intentions. This provides new understanding in the development of rural practice self-efficacy. The link of emergency medicine competency to both rural practice self-efficacy and rural practice intentions suggests that this is a curricular area that deserves greater focus and consideration of how to ensure that residents are meeting emergency medicine requirements and receiving robust training in this area. This is especially important as there have been significant concerns from various groups on the efficacy of emergency medicine training in family medicine residency.

These findings will help inform residency program curriculum and pedagogies, underlining the critical role of emergency medicine competence to support rural physician identity formation and to improve physician recruitment to rural Canada.