1 New Brunswick is a rural province that has a population of approximately 750,000, but is more than twice the size of the Netherlands (Statistics Canada, Annual Demographic Estimates).1 According to the New Brunswick Medical Society’s “Finding a Doctor” article, nearly 50,000 New Brunswick residents currently do not have access to a personal family physician, and the province has twenty-nine vacancies in family medicine.2 As of 2015, Statistics Canada estimates that 19.0% of New Brunswick residents are over the age of sixty-five, higher than anywhere else in Canada (Annual Demographic Estimates). The literature indicates that adults over the age of sixty-five generally utilize health care to a greater extent than younger individuals, exacerbating difficulties regarding access to primary care.3 In addition, Statistics Canada reports that nearly half (47.5%) of the New Brunswick population lives in rural areas (“Population, Urban and Rural”). Rural medicine presents unique challenges, such as the increased burden of travel in a province with poor public transportation;4 professional challenges for physicians, such as lack of resources (Miedema et al. 1141); and clinical challenges related to the high turnover of family physicians.5 This can be an expensive problem for rural communities that must continually invest in recruitment and retention with limited long-term success (Audas et al. 21–24). Similarly, although financial incentives are effective in the short term, they are less effective in terms of long-term retention (Sempowski 82–88).

2 Access to primary care is a critical component of the Canadian health care system, as patient access to specialist care is facilitated through the family physician referral system. Primary care in Canada is the responsibility of the individual provincial governments, resulting in different health care models between the provinces.6 The lack of timely access to primary care can lead to a cascade of problems and culminate in long wait times for health care.7 It is therefore prudent to consider factors that might influence physicians’ choice of practice locations and what this choice means for aging and rural populations.

3 Family physicians report choosing family medicine because of family, lifestyle, and professional reasons (Gill et al. 649–57). Several medical schools have created programs to emphasize the importance of family medicine and to recruit medical students from rural areas, with the expectation that they will be more likely to practice in rural areas. Dalhousie Medical New Brunswick (DMNB), an expansion of Dalhousie Medical School associated with the University of New Brunswick, has been training medical students and residents from New Brunswick since 2010 (Dalhousie University, “About Dalhousie Medicine New Brunswick”). Programs such as DMNB have been somewhat successful in Canada and the United States.8 For instance, a study examining the retention of francophone doctors in New Brunswick demonstrated that family physicians with a rural background are more likely to set up practice in a rural area as compared to their urban colleagues (Beauchamp 44–48). However, this study also found that setting up a rural practice was not predictive of family doctors remaining in rural areas. In a more recent study, Giberson et al. polled medical students to determine their willingness to practice in New Brunswick (25–31). Their results showed that being female, living in New Brunswick prior to medical school, attending one of the satellite medical schools (Université de Sherbrooke), completing preceptorship in New Brunswick, and having a desire to practice family medicine predicted willingness to stay in the province. Although findings such as these underscore the need for homegrown talent, other factors may play a role as to where physicians ultimately settle down.

4 Medical students often choose family medicine residency programs that suit their family and lifestyle preferences (Lee et al. 113–21; Lu et al.). After two years of residency, many prefer to stay flexible before settling into their career and establishing a practice in a permanent location (Beaulieu et al. 14–20), choosing to do locums to gain experience before establishing their own practice (Lu et al.). In other cases, residents take a liking to the location of their residency program and establish their first practice in the community.9 According to the Canadian Resident Matching Services (CaRMS), in 2015 more Canadian medical graduates applied to family medicine residency programs as their first choice (38.5%) than have in the past twenty-two years. Each year the Dalhousie family medicine residency program (Anglophone) trains approximately twenty family physicians at Dalhousie’s three New Brunswick residency sites, with the hope and expectation that many will remain in the province to establish a permanent practice. Retaining these physicians is crucial, as research shows that retention is more effective than recruitment (see Chauban et al. 101–7). Thus, knowledge of what specifically influences family physician retention in New Brunswick is vital to effective recruitment and retention efforts. For instance, Wasko et al.’s study on family physicians in Saskatchewan found that retention was more likely when physicians and their spouses and families were happy and felt integrated into the community, and when physicians felt appreciated by their patients and had a desirable scope of practice (93–98).

5 The primary goal of this study is to explore the retention of a ten-year cohort of Dalhousie University family medicine residents in New Brunswick and the reasons behind their decisions as to where to establish their first practice. In particular, our study investigates why some family physicians who completed their residency in New Brunswick remained in the province and why some decided to leave. Finally, our study examines whether the location of their residency training had an influence on their choice. This study was guided by three research questions: (1) What factors influence physicians’ choice of first practice location? (2) What factors specifically influence physicians who decide to leave New Brunswick to establish their first practice? (3) Does the location of the residency site attended relate to physicians’ decisions to stay in or leave New Brunswick to establish their first practice? The study thus expands on Giberson et al., which assessed willingness of medical school students who lived in New Brunswick before attending medical school to remain in New Brunswick after graduating (25–31). The current study uses a larger number of factors over a longer period of time, recruiting any physicians who completed their residency in New Brunswick regardless of where they lived prior to attending medical school, and is thus more comprehensive.

16 Bringing residency training to more rural provinces that have traditionally not had medical schools was developed to not only provide more training options for medical students, but also in the hope that some of these students would stay to practice after completing their training. This study has revealed that a combination of personal and professional factors influence family physicians when deciding where to establish their first practice. The findings broadly align with the extant literature that demonstrates personal preferences (e.g., proximity to family) and employment opportunities for a partner influence establishment of first practice.19 Similar to findings in the literature, opportunities for research was ranked low on the list of factors influencing first practice location.11

17 Based on the results of this survey, personal reasons are paramount when newly graduated family physicians leave the province; therefore recruitment strategies cannot be uncoupled from the family circumstances. Although there are other barriers to retention, family factors were identified as being important not only by those who left but also by those who remained. This suggests that recruiting more local residents may aid physician retention, which is consistent with the literature regarding the efficacy of recruitment programs for rural and underserved areas in Canada.12 An examination of the short- and long-term career choices of DMNB-trained physicians, the first cohort of whom graduated in 2014, could provide further insights. However, creating more training spaces is only one component of recruitment strategies. Physicians are a mobile group, owing to the highly marketable nature of their skills. Coupled with the Fraser Institute’s findings regarding an ongoing shortage of physicians in Canada (see Esmail, Canada’s Physician Supply), this means physicians can afford to choose positions that not only meet their professional needs, but that are also in locations that suit their personal preferences. This includes accommodating the current and future needs of their spouses and families. These findings are also consistent with previous studies (see Gill et al.; Lee et al.; Lu et al.) and may be indicative of regional characteristics that cannot specifically be countered with a recruitment strategy.

18 Professional reasons for leaving the province mainly involved system barriers, which also relate to regional characteristics. Physicians in Canada providing insured health care are paid through provincial health insurance plans, typically through a fee-for-service payment structure. In New Brunswick, this means family physicians must obtain a location-based billing number from the province in order to receive payment through Medicare (see the New Brunswick Medical Society’s “Fast Facts about Practicing in NB” for more information). Difficulties encountered when attempting to acquire a billing number were articulated by a number of physicians, both among those who stayed and those who left, highlighting an area for process improvement that may facilitate retention.

19 New Brunswick is a largely rural province, with half of the population living outside of urban areas (Statistics Canada “Population, Urban and Rural”). Previous work has demonstrated that family physicians may face unique challenges in rural areas (see Miedema et al.’s study detailing the problems of professional isolation and lack of resources [1141]). However, previous studies also found there can be many rewards in rural practice, such as getting to know patients. Wasko et al., for example, found that rural physicians enjoyed being able to practice the full scope of family medicine. New Brunswick has relatively high unemployment rates (9.9 per cent) compared to the national average (7.3 per cent), an aging population, and high rates of chronic disease and health risk factors.13 However, Statistics Canada’s “Police-Reported Crime Rate” demonstrates that New Brunswick also offers low crime rates, and the Canadian Real Estate Association’s “National Average Price Map” shows that New Brunswick enjoys lower real estate costs compared to the rest of Canada, as well as an abundance of provincial parks and green spaces for outdoor recreation, historical and natural landmarks, festivals, and cultural events.14 Recruitment strategies should focus on these benefits to quality of life and emphasize that physicians can enjoy the advantages of rural practice with some of the drawbacks being mitigated by the proximity of larger urban centres. Shifting policies may also influence the retention of physicians in the coming years: for instance, initiatives from the New Brunswick Medical Society for doctors to join family health teams, permitting more same-day appointments, and team-based care (Pruss).

20 Although the response rate was good, this study focused on physicians who completed residency training in New Brunswick, thus limiting the generalizability of these results. In addition, the survey did not include questions about return-of-service or military obligations that would determine the location of first practices. The survey also did not capture specific information about physicians’ living situations prior to their post-secondary education, such as how long they lived in a particular province or whether they were living in a particular location out of preference or necessity (e.g., educational or employment opportunities, family obligations). Finally, physicians were not asked about the length of time between completing residency and the establishment of their first practice; thus the study failed to capture details regarding the timing of this choice.

21 Graduates of the Dalhousie family medicine residency program in New Brunswick choose the location of their first practice based on a variety of personal and professional reasons. When newly graduated physicians leave the province, it is primarily for personal reasons involving the needs of their spouses and families. Professional reasons for leaving the province largely relate to the provincial health care model. It should be noted that when newly graduated family physicians leave they are unlikely to return, whereas those who remain in the province tend to stay. Therefore, efforts to recruit and retain family physicians in New Brunswick that specifically address these factors may be beneficial to the long-term growth and retention of these physicians.