#KeyLIMEPodcast 225: How ya gonna keep them down on the farm after they’ve seen Paree?

The lack of physicians in rural areas is a well known and long time issue. In order to try and rectify the shortage, the WHO has recommended that residents spend some of their clinical rotation time in rural areas, but how does this affect their choice of where to practice in the long run? This week’s paper examines the impact of rural rotations on urban-based residents and whether it is a cost-effective solution.  The authors used previously published manuscripts to inform their study — to learn what the co-hosts thought of this methodology, listen here.


KeyLIME Session 225

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Malhi et al., The impact of rural rotations on urban based postgraduate learners: A literature review. Medical Teacher. 2019 May 1:1-9


Linda Snell (@LindaSMedEd)


The maldistribution of physicians is a longstanding (Flexner refers to it over a century ago) and global issue, in both developed and developing countries. There’s even been a movie made about it.
The WHO has recognized that it’s hard to recruit and retain health workers in remote and rural areas and recommended clinical rotations in rural areas during studies.
In Canada the USA and Australia there are examples of undergraduate med ed rural placements, longitudinal clerkships in rural areas, even satellite med schools away from the urban mother ship.
In postgraduate med ed rural placements for residents are well developed, especially in family medicine, and standards exist. Although no formal costing has been done, the authors suggest that cost effectiveness has not been evaluated, and that ‘Rural rotations embedded in an urban-based program appear to be a resource-intensive mechanism to achieve the desired objective of increasing the supply of rural physicians’


This is a ‘comprehensive literature review ‘ to assess the published evidence for the impact of rural rotations on urban-based postgraduate learners in all disciplines.
Results could inform
– policy on physician rural recruitment,
– the design of postgraduate residency programs
– accreditation standards for urban based programs.

Key Points on the Methods

Searched MEDLINE between 1980 and 2017, articles about all learners (including med students), mandatory rotation (rural, regional, distributed) outcomes and impact; using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)guidelines.
Any methodology, in English, medicine only, residency (GME, PGME)
Screened, data extracted using a tool looking at study characteristics, participants, characteristics of rural rotation, outcomes.
Included papers subject to a quality assessment using Medical Education Research Study Quality Instrument (MERSQI) a 10-item tool to measure quality of studies in 6 domains: design, sampling, type of data, sophistication of data analysis, appropriateness of data analysis, outcome measures, and validity of the evaluation instrument. >14 /18 = high quality; all observational; half from one institution.

Key Outcomes

301 studies found – after exclusion 19 remained – 6 US, 4 Canadian, 9 Australian
Methods – surveys, program record review, program evaluations
Mean adjusted MERSQI = 11.95
~half examined impact of rural placements influence on subsequent practice – pooled OR 3.03:
Characteristics of placements vary widely, however longer experiences had more likely positive outcomes.
There was an ‘interplay between 3 factors: rural origin, rural rotations, intent to practice rurally’.

Key Conclusions

The authors conclude that ‘duration of a rural rotation in any discipline on eventual practice location appears to be the most consistent factor of influence’; ‘rural background of the learner also remains an important factor’; and ‘the evidence suggests that the reliance by medical educational systems on the rural rotation does not accurately reflect the complexity of the choice to practice in a rural community.’

Spare Keys – other take home points for clinician educators

Conclusions must be drawn from valid data –
This is especially true for any kind of review or meta analysis – the included studies have to be of high quality.

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