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Study of rural physician supply : practice location decisions and problems in retention Kazanjian, A.; Pagliccia, N.; Apland, L.; Cavalier, S.; Wood, L. Jun 30, 1991

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Centre for Health Servicesand Policy ResearchSTUDY OF RURAL PHYSICIAN SUPPLY:PRACTICE LOCATION DECISIONS ANDPROBLEMS IN RETENTIONHHRU91:2 JUNE 1991(Health Human Resources UnitResearch ReportsTHE UNIVERSITY OF BRITISH C O LU M B I ASTUDY OF RURAL PHYSICIAN SUPPLY:PRACTICE LOCATION DECISIONS AND PROBLEMS IN RETENTIONHHRU91:2Health Human Resources UnitCentre for Health Services and Policy ResearchThe John F. McCreary Health Sciences CentreThe University of British ColumbiaVancouver, British Columbia V6T 1Z3A. KazanjianN. PaglicciaL. AplandS. CavalierL. WoodJune 1991This document is one of a series describing the distribution of health human resources in the Province ofBritish Columbia. These reports are working documents, prepared for the Health Human Resources WorkingGroup of the Ministry of Health, and comments or suggestions are welcome.THE UNIVERSITY OF BRITISH COLUMBIAHealth Human Resources UnitCentre for Health Servicesand Policy Research429 - 2194 Health Sciences MallVancouver, B.C. Canada V6T 126Tel: (604) 228-4810Fax: (604) 228-2495June 11, 1991Dr. D. BigelowChairHealth Human Resources Working GroupMinistry of Health1515 Blanshard StreetVictoria, s.c. V8W 3C8Dear Dr. Bigelow:It gives us great pleasure to be able to transmit to you and the members of the Health HumanResources Working Group the first report of the project "Study of Rural Physician Supply: PracticeLocation Decisions and Problems in Retention."The project was formulated as a response to a request from the Provincial Medical Manpower AdvisoryCommittee in 1989; a small working group, comprised of representatives from the Committee and theresearchers, collaborated in the development of the research protocol.We believe this to be the first of this type of study, focusing on key characteristics of long-term ruralpractice, and examining professional practice location decisions from the perspective of the family unit.More detailed analyses are currently underway, but this general descriptive overview already indicatesthat the approach has produced some very useful planning information.We look forward to comments and suggestions from users of this report regarding the future phases ofthe analysis.Sincerely yours,Arminee Kazanjian, Dr.Soc.Associate DirectorAK:daEncl.A Research Unit Funded by the Ministry of Health, British ColumbiaTABLE OF CONTENTSPageList of TablesList of AppendicesPart A: Description of the Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1I. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1II. Literature Review 2III. Research Design and Methods 5Part B:I.II.III.IV.V.VI.VII.Part C:I.II.III.IV.V.VI.Part D:I.II.III.IV.V.Part E:I.II.III.IV.Practising Non-Postgraduate PhysiciansIntroduction .Profile of Respondents .Education .Practice .Community .Overall Satisfaction .Concluding Remarks ..Spouses of Practising PhysiciansIntroduction .Profile of Respondents .Education .Occupation .Satisfaction Levels .Concluding Remarks .Residents and InternsIntroduction ..Profile of Respondents .Education .Community .Concluding Remarks .Inter-Group Comparisons and ConclusionThe Scope and Structure of Medical Practice .Profile of Practising Physicians and their Spouses .Profile of Residents and Interns .Concluding Remarks .1111111729364851555555626366717373747882889191919496ReferencesiiiLIST OF TABLESPART A DESCRIPTION OF THE RESEARCHPageTable A-I Survey Group and Response Rate 8PART B PRACTISING NON-POSTGRADUATE PHYSICIANSTable B-1Table B-2Table B-3aTable B-3bTable B-4Table B-5aTable B-5bTable B-5cTable B-5dTable B-6Table B-7Table B-8Table B-9Table B-lOTable B-l1Table B-12Respondents by Age and Sex .Respondents by Marital Status and Sex .Rural Respondents by Size of Community of Birth,Elementary, and Secondary School .Urban Respondents by Size of Community of Birth,Elementary, and Secondary School .Father's Profession/Field of Employment .Respondents by Preference for Indoor vs. Outdoor LeisureActivities .Respondents by Preference for Active vs. Spectator LeisureActivities .Respondents by Preference for Sporting vs. Cultural LeisureActivities .Respondents by Preference for Group vs. Non-Group LeisureActivities .Respondent General Practitioners by FP Residency and CCFPCertificate .Most Common Specialties: Clinical, Surgical, and Laboratory. Respondents by Period of Graduation .Respondents by Province of Graduation (Canada)Respondents by Place of Graduation (Outside Canada) .Respondents by Length of Time Practising MedicineRespondents by Mean Level of Influence on PracticeLocation Decisions .iii12131414151616161618202223242527Table B-13aTable B-13bTable B-14Table B-15Table B-16Table B-17Table B-18Table B-19Table B-20Table B-21Table B-22Table B-23Table B-24Table B-25Table B-26Table B-27Table B-28Table B-29Table B-30Table B-31Other Physicians in Group Practice: General Practitionersby Specialists - Rural .Other Physicians in Group Practice: General Practitionersby Specialists - Urban .Respondents by Patients Seen per Average Day .Respondents by Nights per Week On Call .Respondents by Weekend Days Off per MonthRespondents by Weeks of Annual Holidays .Finding a LocumGeneral Practitioners by Time Spent in Various Areas ofMedicine .Type of Payment .Respondents by Years in Current Geographic AreaRespondents by Plans to Continue Practising in CurrentGeographic Area .Respondents by Time in Past Rural Practice .Respondents by Reasons for Leaving Rural Practice .Respondents by Medical Support Services Provided in TheirCommunities .Type of Hospital Nearest to/Based in the Community .Respondents by Medical Back-up Within 100 KilometresRespondents by Mean Satisfaction Levels for Professional,Community and PersonallFamily Lives .Respondents by Intent to Move .Respondents by Factors Related to Intended MoveRespondents Interested in Doing a Rural Locum .3030313232333334363838394041424348495051PART C: SPOUSES OF PRACTISING PHYSICIANSTable C-1 Respondents by Age and Sex .iv56Table C-2aTable C-2bTable C-3Table C-4aTable C-4bTable C-4cTable C-4dTable C-5Table C-6Table C-7Table C-8Table C-9Table C-lOTable C-llTable C-12Table C-13Table C-14Table C-15Rural Respondents by Size of Community of Birth,Elementary, and Secondary School .Urban Respondents by Size of Community of Birth,Elementary, and Secondary School .Father's Profession/Field of Employment .Respondents by Preference for Indoor vs. Outdoor LeisureActivities .Respondents by Preference for Active vs. Spectator LeisureActivities .Respondents by Preference for Sporting vs. Cultural LeisureActivities .Respondents by Preference for Group vs. Non-Group LeisureActivities .Number of Children of Respondents .Number of Children Currently Living in Respondents'Households .Age Range of Children (if any) Living with RespondentsRespondents by Highest Level of EducationRespondents by Employment StatusIf Not Employed, Is This By Choice?Respondents by Type of EmploymentRespondents by Activities Other than Family/JobResponsibilities .Extent of Contribution to Families' Decisions to Stay inSpouses' Current Practice Location .Respondents by Mean Satisfaction Level for Specific.Professional, Community, and Personal/Family ConcernsRespondents by Mean Satisfaction Levels for Professional,Community, and Personal/Family Lives .575758606060606161626363646465666770Part D: RESIDENTS AND INTERNSTable D-1 Respondents by Age and Sexv75Table D-2Table D-3aTable D-3bTable D-4Table D-5aTable D-5bTable D-5cTable D-5dTable D-6Table D-7Table D-8aTable D-8bTable D-9Table D-lORespondents by Marital Status and Sex .Responding Residents by Size of Community of Birth,Elementary, and Secondary School .Responding Interns by Size of Community of Birth,Elementary, and Secondary School .Father's Profession/Field of Employment .Respondents by Preference for Indoor vs. Outdoor LeisureActivities .Respondents by Preference for Active vs. Spectator LeisureActivities .Respondents by Preference for Sporting vs. Cultural LeisureActivities .Respondents by Preference for Group vs. Non-Group LeisureActivities .Responding Residents and Interns by Province of Graduation(Canada) .Responding Residents and Interns by Place of Graduation(Outside Canada) .Undergraduate Medical Training in Rural AreasPost-graduate Medical Training in Rural AreasFirst Choice for Location of PracticeResidents and Interns by Enjoyment of Rural Experience(Rural/Semi-Rural-bound vs. Urban-bound) .vi7576767779797979818283838485Appendix AAppendix BAppendix CAppendix DAppendix EAppendix FAppendix GAppendix HLIST OF APPENDICESMembers of the Project Working Group and Collaborating OrganizationsQuestionnairesCorrespondenceRural General Practitioners by Percentage of Time in Various Areas of MedicineUrban General Practitioners by Percentage of Time in Various Areas of MedicineRespondents by Medical Back-Up within 100 KilometresRespondents by Mean Satisfaction Level for Specific Professional, Community, andPersonallFamily ConcernsResidents and Interns by Specialties/Professional GoalsResidents and Interns by Mean Influence Level for Professional, Community, andPersonal/Family Factors Relating to Intended Practice Location DecisionsviiPART A: DESCRIPTION OF THE RESEARCHI. IntroductionWhile invoking a sense of national immediacy in many Canadians, the problems involved in attractingphysicians to and retaining them in rural areas are international in scope. Although they have been studiedin various other provinces and countries, the factors influencing practice location decisions and retentionof physicians undoubtedly will be subject to unique local conditions. Accordingly, a decision was made tostudy the problems as they specifically related to British Columbia. Furthermore, unlike other studies, thisresearch was designed to take a more positive approach to the problems of rural physician supply. It notonly sought to examine why physicians leave rural areas, but also attempted to identify those who stay andtheir reasons for doing so. In other words, the research was intended to track the general movement ofphysicians between rural and urban areas, not simply to document rural exodus.The project was formulated with assistance from the British Columbia Ministry of Health MedicalManpower Advisory Committee, the British Columbia Medical Association, and the Rural ResidencyProgram of the Department of Family Practice at the University of British Columbia. The stake-holderssponsored and supported the research as a positive response to concerns about the uneven distribution ofphysicians within British Columbia. It was their view that the information thus gained would be useful inthe development of appropriate policies to achieve a more even distribution and to eliminate the need forpolicies built on disincentives. A small working group, which was formed in June 1989, participated in thedevelopment of the research protocol. The group was comprised of representatives from the collaboratingorganizations (Appendix A). The research was undertaken to examine the supply of physicians in ruralpractice in British Columbia and related problems of recruitment and retention. Practice location decisionsof British Columbia physicians and the professional, community, and personal/family factors related to thesewere the focus for analysis. In order to estimate future supply, those currently completinginternships/residencies were also surveyed. The intent of this survey was to describe current post-graduatephysicians and their career plans. Thus the two surveys would allow a comparison of the practice profilesof current supply and the career expectations of future supply. The identification, from these profiles, ofkey characteristics pertaining to long-term rural practice could, therefore, facilitate successful recruitment,beginning at the residency level. Spouses of practising physicians also were surveyed, in recognition of therole that spouses and families play in influencing practice location decisions.II. Literature ReviewThe problem of rural physician supply has been publicly recognized for many decades. Accordingly, ithas become a focus of concern for policy-makers, academics, interest groups, government, and media,both in canada and internationally. This has been especially true since the early 1970s, after which timethere has been a proliferation of scholarly articles on health and health care delivery in rural areas and, atleast in canada, a series of Royal Commissions and Provincial Advisory Committees on provincial healthcare systems. A number of these studies and reports provided guidance in the development of the surveyquestionnaires that were sent to participants in the study described in this paper.In large part, the various studies of physician practice location decisions have produced consistent butnot always identical results. Cooper et al. noted that items which have been identified as affecting physicianpractice location decisions can be classified into three groups: physician background, professionalconsiderations, and community factors. Of those factors relating to the physician's background:the best documented seems to be the community background of the physician. Practice in a smallcommunity is more likely to be the choice of doctors who grew up in small communities than ofthose who did not ... [Furthermore] wives of rural physicians, like their husbands, are more likelyto have a rural background (Cooper et al., 1972, p. 940).Skipper and Gliebe (1977) studied the influence of spouses on the practice location decisions of studentsat the Medical College of Ohio with results supportive of this last contention. Cooper et a/. (1977)reiterated, after their first study, the positive influence of a physician's rural background on the choice ofa rural practice location. As well, they departed from the common view that physician supply was ahomogeneous pool, arguing instead that the observation of trends pertaining to each kind of physician wouldbe useful in physician human resources planning.2However, Parker and Sorensen (1978, p. 159) found that a number of factors, reported in other studiesto be related to rural practice location decisions, "were important to a relatively small proportion of...[participating] physicians... [Rather.] within everysubgroup, respondents consistently emphasized those factorsrelating to good professional support, especially a good community hospital, a nearby medical center, andmedical consultants in various fields." According to Cordes (1978, p. 366), a study of rural physicians inWashington state found that physicians were most frequently frustrated with:the "excess work, responsibility, demands and expectations by patients and community." Contraryto expectations, professional isolation, inadequate professional support, and the disadvantages ofsmall-town living were infrequently mentioned as sources of frustration.Wilensky (1979, p. 154) suggested that there were two trends of thought that had emerged fromprevious studies. First, as noted previously, "there is a relationship between the location of events in thephysician's past such as birth, medical school, residency, etc., and the place that the physician decides tolocate his practice... The second trend to emerge," Wilensky noted, "...involves the use of a more expliciteconomic model to explain physician location choices." Wilensky's study of a sample of Michigan-trainedphysicians concluded that the probability of locating in that state varied "according to the number andrecency of contacts, ...to attitudes about climate and the importance of being near friends and family andaccording to several measures of expected returns such as relative physician income and net migration rates(Wilensky, 1979, p. 176)."Following a model based on supply and demand estimation, Newhouse et a1. (1982, p. 2396) argued that"the availability of primary services in small towns should increase over time as the number of familypractitioners increases and competitive pressures become more intense." Indeed, Langwell et a1. (1985)concluded that as supply increases, the geographic diffusion of physicians into "attractive" non-metropolitanareas is occurring. However, Madison (1980, p. 853) argued that "because of the trend to centralizationwithin rural areas - of services, not necessarily of people - strategies that predispose physicians toward non-metropolitan America and rely on laissez-faire forces to guide their settlement will do little for the criticalproblem areas." To this end, Anderson and Rosenberg (1990, p. 43) noted that physician distribution iscommonly treated as a supply and demand issue. "Where governments have recognized the mismatch of3supply and demand," they argue, "intervention has generally taken the form of increased financial incentivesto locate in under-serviced areas." They conclude, however:physicians and policy makers alike need to add a humanist perspective to a problem that for themost part has been approached with statistics and financial incentives in hand. Quality of lifeconsiderations for both those demanding and those supplying health services should be of primeimportance to everyone in resolving the problem of medically underserved areas (Anderson andRosenberg, 1990, p. 44).While the literature on physicians' practice location decisions is largely consistent, the significanceattributed to particular influences varies among studies. These variations may be crucial in view of theirimplications for priorities in terms of public policy and programs directed at the problems of the geographicdistribution of physicians in a particular region. In addition, the degree to which particular issues are aproblem may vary from region to region. Based on a 1988 study of physicians in rural Saskatchewan, forinstance, Lepnurm and Trowell (1989, p. 19) argued that the geographic dispersion of the province'seconomic activity required the replacement "of outmoded solo practices and tiny hospitals with a regionalizednetwork of group practices and modern community hospitals." Jennett and Hunter (1988, pp. 155-163), intheir study of Alberta medical graduates over the period 1973 - 1985, report that drawing physicians to ruralcommunities will require programs to allow rural physicians access to consultants as well as to opportunitiesfor continuing professional education. The Alberta Medical Association seems to have concurred with thatassessment. Their 1989 Task Force on Rural Medical care stressed, among other recommendations: a) theneed to convince governments and universities of the requirements in rural areas for physicians withspecialty skills, b) the need in residency and university training programs for an emphasis on the distinctrequirements and characteristics of rural medical practice, and c) the need for innovative means by whichto provide back-up and support to practising rural physicians. From a planning perspective, only a region-specific analysiswill identify the particular problems facing the particular region and will provide insight intowhat solutions should be adopted.4III. Research Design and MethodsThree separate but similar surveys were designed, one each for practising non-postgraduate physicians,spouses or live-in partners of practising non-postgraduate physicians, and interns/residents. Interns andresidents were surveyed in order to better understand the decision-making processes of those who soonwould be establishing practices, as well as of those already established in practices. Spouses of practisingphysicians were surveyed in recognition that, to a greater or lesser extent, locational decisions are likely tobe made jointly by physicians and their spouses. Figure 1 illustrates the sample design described in detailbelow.Sample DesignA listing of practising non-postgraduate physicians from the register of the College of Physicians andSurgeons of British Columbia and population distribution figures for 1989 from Statistics Canada were usedas the bases for determining the survey group; physicians were stratified, first, by the population size of thecommunity in which they practised, and then by their general area of specialty - clinical, surgical, orlaboratory. Because the relatively smaller number of physicians practising in rural areas of the province wasthe focus of the study, 100 percent of this group was targeted for the survey; rural communities were definedas those with fewer than 10,000 people. Urban physicians were proportionally selected based onstratification by their area of specialty, while an increased sample size was taken for strata where populationswere considered too small for accurate representation. The result was that 11.6 percent of physicianspractising in urban areas were targeted for the survey. The survey's overall target population accounted for21.2 percent of the province's 6,459 non-postgraduate physicians as at September 1989 (ROLLCALL 89, pp.201-221).11 The figure used to determine the survey sample (6,460) includes one osteopath who, whiledirectory active, is included in a separate listing in ROLLCALL. However, three additional osteopathswere excluded from the survey population due to a clerical error.5Since the marital or cohabitation status of the practising physicians included in the study was notverified, a questionnaire addressed to the physician's spouse was included in the mailings. It was notpossible to determine how many spouses actually received a questionnaire, so it is not possible to determinea response rate for spouses. The numbers in the boxes entitled "spouses' response" in Figure 1 only indicatethe number of spousal questionnaires that were returned.Because of their small numbers, 100 percent of residents and interns on the temporary (at hospital)register with the College of Physicians and Surgeons of British Columbia, as at September 1989, weretargeted for the survey. Excluded from the resident and intern population-frame were residents on the fullregister with the College. Accordingly, 292 residents and interns on the temporary register were originallytargeted for the survey, instead of the total 534 reported by the Office of the Associate Dean, ResidencyPrograms, Faculty of Medicine (Production 89, p. 369 erratum's.Ten physicians were selected to take part in a pretest of the questionnaire. Efforts were made to ensurethat members of the pretest group had at least some rural experience, and that the questionnaire would bescrutinized from both a rural and an urban perspective. In accordance with the results of the pretest, thequestionnaire was then revised before being distributed to the selected survey group.In November 1989, self-administered, mail-in surveys were sent to 1,370 physicians (and their spouses)and 292 residents/intems.F Of 702 rural physicians who were sent questionnaires, 414 responded. Of the668 urban physicians targeted, 335 responded. A sample of practising physicians of this size will estimatethe proportion of physicians practising in urban areas with an error as small as ±0.034, 95 times out of 100.Rates of response and information on the survey group are detailed in Table A-I.For the purposes of the preliminary analysis, the surveyed physician and physician spouse groups weredivided into two subsets, based on the size of the community within which the respondents practised orresided. Rural respondents were identified as those practising or residing in communities of fewer than10,000 people.2 This figure was later reduced to 290 when two respondents returned the questionnaires and notedthat they were neither residents nor interns. Consequently, any analysis of this data is conducted on thebasis of a target population of 290 individuals.6Figure 1: Diagram of Sampling ProcedureTotal Population of Practising Res ide n t s /I n te r n sPhysicians in B.C. (1989) in B.C. (1989)N • 6460 N • 292II IIn Rural In UrbanCommun ities Commun ities(Pop. ~ 10,000) (Pop. > 10,000)N • 702 N • 5758I100% Selection 11.6% Random Sample 100% SelectionQuestionnaire sent to Stratified by CommunitySize & S p e cia I t y (1)Physicians & Spouses Questionnaire sent toPhysicians & Spouses (2)N • 702 N • 668 N • 290I r IIPhysicians' Spouses' Spouses' Ph ys i cia n s ' Res/Interns'Response Response Response Response Response(59'll,) (50%) (40.7%)N • 414 N • 334 N • 274 N • 335(3) N • 118ITo t a I N u m be r ofRespondent SpousesN • 608Total Number of RespondentPractising Physicians(55'll,)N • 749(1) Community size: 10,001 to 50,000 50,001 to 100,000 >100,000Specialties: General Practice Clinical Surgical LaboratorySample size required to estimate the proportion of physicians practising in urban areaswith an error of + 0.02. 95 times out of 100.(2) Survey population was reduced to 290 when 2 respondents returned questionnairesnoting they were neither interns nor residents.(3) Error of estimation of proportion of physicians practising in urban areas is + 0.034,95 times out of 100.7Table A-ISurvey Group and Response RatePhysicians Spouses IntemslResidentsGroup Total Response Response Total ResponseN % N % N % N % N %Rural 702 100.0 414 59.0 334 - - - - -Urban 668 11.6 335 50.1 274 - - - - -Totals 1370 21.2 749 54.7 608 - 290 100.0 118 40.7Urban respondents were identified as those who practised or resided in communities of more than 10,000people. Rural and urban designations were based on census figures for respondents' community of residenceor practice. While these population figures are employed in Statistics Canada's designations of rural andurban, they are relatively subjective and arbitrary from a qualitative standpoint. Invariably, some mayconsider a community of more than 10,000 people to be rural, while a community that has a population offewer than 10,000 may be considered urban by others. Further analyses of more narrowly focused researchquestions will include more complex definitions and/or more detailed breakdowns of regional distributions.The rural-urban analytic designations used in this report cannot be applied to interns and residents sincethese individuals, of necessity, almost always will be based in urban teaching hospitals.On a cautionary note, Madison suggested that a distinction be drawn between rural and under-served."Fifty-five percent of Americans," Madison (1980, p. 853) noted, "live in communities of less than 25,000population, but it is the 6 percent in medically underserved rural America... that feel the physician shortagemost critically." In an analysis of physician choices between rural and urban practice locations, however, thesubjective nature of these designations may be less of an issue than when health care itself is assessed.Questionnaires and AnalysisThe questionnaire that was developed for practising physicians provided the foundation for slightlyshorter versions that were used to survey physicians' spouses and residents/interns. Each of the8questionnaires, therefore, was similar, except for variations intended to accommodate differing professionalbackgrounds and current activities. The questionnaire for practising physicians was divided into four basicareas. In part one, personal biographic and demographic information was sought. Part two inquired as tothe respondent's educational background, including areas of specialization and the year training wascompleted. Information on the nature and scope of the physician's practice was sought in part three. Thecommunity in which the respondent's practice was located was the focus of the final part of thequestionnaire. Also included in this part were questions regarding respondents' satisfaction in relation toprofessional, community, and personal/family life. Samples of the questionnaires and accompanyingcorrespondence are contained in Appendices Band C.Throughout this report, tables displaying data may not add up to 100.0 percent due to rounding. Wheremean scores were calculated for survey items that required response on a five point Likert-type scale, a two­tailed r-test of significance was conducted to test the equality of means for rural and urban respondents.The two practising physician groups were weighted to reflect the province's more than 8:1 ratio of urbanto rural physicians. In this test and others, the pooled-variance r-test was used in the two groups underscrutiny, and the separate-variance z-test was used in the case of unequal population variance. The equalityof population variance hypothesis was based on the F-test. In the majority of cases, the hypothesis of equalvariances was not rejected.The questionnaire for residents/interns was similar to that sent to practising physicians except thatquestions regarding respondents' practices were excluded. This section was also excluded from the spousalquestionnaire and, instead, questions regarding the home lives and occupations of physicians' spouses wereincluded. The data acquired for residents/interns and physicians' spouses will be discussed in later sectionsof this report.910PART B: PRACTISING NON-POSTGRADUATE PHYSICIANSI. IntroductionAs noted previously, this part of the study targeted practising non-postgraduate physicians. This groupwas stratified, first, by the population size of the community in which they practised, and then by theirgeneral area of specialty - clinical, surgical, or laboratory. All of the relatively smaller number of physicianspractising in rural areas of the province were included in the survey population. Urban physicians wereproportionally selected based on stratification by their area of specialty, while an increased sample size wastaken for strata where populations were considered too small for accurate representation. Slightly more thaneleven percent of physicians practising in urban areas (11.6%) were targeted for the survey. The survey'soverall target population accounted for 21.2 percent of the province's 6,459 non-postgraduate physicians.The response rate for rural practising physicians (59.0%) was greater than that for urban (50.1%).There were 286 rural non-respondents, of whom 86.0 percent were male and 14.0% were female. Ruralrespondents included a slightly greater proportion of females (17.0%). Just over twenty percent of urbannon-respondents (20.2%) were female and 79.8 percent were male. This compares with an urban responsethat was 18.3 percent female and 81.7 percent male.II. Profile of RespondentsIn the following section, sociodemographic characteristics, including background information andpreferences for leisure time are discussed.Age and SexWhile there were rural respondents from each age category, the majority (58.1%) were younger than45 years. A lesser proportion of urban respondents fell into this group (51.0%). The modal age categoryfor rural respondents was the under-35-years group (22.9%). The age category into which the single largestnumber of urban respondents fell was the 40 to 44 years group (18.6%). The modal age category for femalerespondents, both from rural (42.9%) and urban (36.1%) areas, was the under-35-years group. In both11cases, the percentage of women under-35 was more than double the percentage of men. Table B-1 presentsa breakdown of rural and urban respondents by age and sex.Table B-1Respondents by Age and Sex(Total N = 749)Rural UrbanAge Male Female Total Male Female TotalN % N % N % N % N % N %< 35 64 18.8 30 42.9 94 22.9 38 14.0 22 36.1 60 18.035-39 62 18.2 13 18.6 75 18.2 38 14.0 10 16.4 48 14.440-44 56 16.4 14 20.0 70 17.0 52 19.1 10 16.4 62 18.645-49 44 12.9 4 5.7 48 11.7 25 9.2 11 18.0 36 10.850-54 38 11.1 4 5.7 42 10.2 43 15.8 1 1.6 44 13.255-59 29 8.5 2 2.9 31 7.5 23 8.5 5 8.2 28 8.4> 59 48 14.1 3 4.3 51 12.4 53 19.5 2 3.3 55 16.5Totals* 341 100.0 70 100.0 411 100.0 272 100.0 61 100.0 333 100.0(%) (83.0) (17.0) (100.0) (81.7) (18.3) (100.0)* Non-respondents: Rural =3; Urban =2.As indicated in Table B-2, there was little overall difference in the marital status of rural and urbanrespondents. The proportions of rural (86.9%) and urban (88.0%) respondents who were married or livingwith a partner were almost identical. However, while the proportion of males and females was equal amongsingle urban respondents, there was a slightly greater proportion of single males among rural respondents.Although not explicitly stated in the table, 22.9 percent of female respondents in rural areas and 22.6percent in urban were single, while only 7.9 percent of male respondents from rural areas and 5.2 percentfrom urban areas were single.12Table B-2Respondents by Marital Status and SexRural UrbanMarital Male Female Total Male Female TotalStatus N % N % N % N % N % N %Single 27 6.6 16 3.9 43 10.4 14 4.2 14 4.2 28 8.4Married 309 75.0 49 11.9 358 86.9 250 75.1 43 12.9 293 88.0Other 6 1.5 5 1.2 11 2.7 7 2.1 5 1.5 12 3.6Totals* 342 83.0 70 17.0 412 100.0 271 81.4 62 18.6 333 100.0* Non-respondents: Rural =2; Urban =2.Community of Residence as a YouthRespondents were asked to identify the size of the communities in which they were born and hadattended elementary and secondary school. This information is outlined in Tables B3a and B3b. Ruralrespondents tended to have been born and educated (at the primary and secondary levels) either incommunities with populations of more than 100,000 (ie. a range of 40.1% to 46.6% for the three locationsof interest), or in communities of up to 10,000 people (ie. a range of 24.3% to 32.0% for the three locationsof interest).Approximately one-half of all responding urban physicians were born and educated in communities withmore than 100,000 people (a range of 49.7% to 54.1% for the three variables). Their higher representationamong this group, compared with rural respondents, appears to coincide with correspondingly lowerrepresentation from communities of up to 10,000 people.13Table B-3aRural Respondents by Size of Communityof Birth, Elementary, andSecondary SchoolPopulation Birth Elementary SecondaryN % N % N %Up to 10,000 122 29.8 130 32.0 98 24.310,001 - 50,000 64 15.6 74 18.2 79 19.650,001 - 100,000 33 8.0 39 9.6 45 11.2More than 100,000 191 46.6 163 40.1 181 44.9Totals* 410 100.0 406 100.0 403 100.0* Non-respondents: Birth = 4; Elementary = 8; Secondary = 11.Table B-3bUrban Respondents by Size of Communityof Birth, Elementary, andSecondary SchoolPopulation Birth Elementary SecondaryN % N % N %Up to 10,000 74 22.4 69 21.3 53 16.610,001 - 50,000 52 15.8 65 20.1 55 17.250,001 - 100,000 39 11.8 29 9.0 39 12.2More than 100,000 165 50.0 161 49.7 173 54.1Totals* 330 100.0 324 100.0 320 100.0* Non-respondents: Birth = 5; Elementary = 11; Secondary = 15.Father's Field of EmploymentRespondents were then asked to indicate their fathers' fields of employment or professions. Since thevast majority of respondents' families were likely to have been characterized by male, single-income earners,mothers' fields of employment or professions were considered to have been of lesser influence inrespondents' career choices and accordingly were not included in the questionnaire.14The most frequently selected professional/employment category for both rural and urban respondents'fathers was "Managerial/Administrative" (17.0% and 16.7% respectively). Rural respondents whose fatherswere physicians were the third largest group (15.6%), closely following those whose fathers had come fromother, unspecified fields (15.8%). The order of these was reversed for urban respondents (15.8% for"Physicians" and 15.5% for the all encompassing "Other" category). Only 3.9 percent of rural and 4.2 percentof urban respondents indicated that their fathers had been involved in "Other Medicine/Health" relatedfields. If "Other Medicine/Health" related fields are combined with "Physician," however, the rankings areslightly altered. This grouping would be the most frequent professional/employment category for the fathersof both rural (19.5%) and urban (20.0%) respondents, followed by "Managerial/Administrative" and the"Other" category. Regardless, the results indicate similar employment/professional backgrounds for fathersof respondents in both the rural and urban survey groups. Table B-4 outlines this information in moredetail.Table B-4Father's ProfessionIField of EmploymentProfession Rural UrbanN % N %Managerial!Administrative 70 17.0 55 16.7Physician 64 15.6 52 15.8Teaching 36 8.8 22 6.7Farming/Ranching 29 7.1 21 6.4Sales 26 6.3 31 9.4Services 18 4.4 16 4.8Other Medicine/Health 16 3.9 14 4.2ProcessinglManufacturing 14 3.4 9 2.7ForestrylMining 13 3.2 9 2.7Construction 11 2.7 10 3.0Clerical 11 2.7 8 2.4Social ScienceslLaw 10 2.4 9 2.7Religion 8 1.9 7 2.1Machining 6 1.5 8 2.4TransportJEquipment Operation 6 1.5 3 0.9ArtisticlLiterary 6 1.5 2 0.6Sport/Recreation 1 0.2 2 0.6Fishing/Hunting 1 0.2 1 0.3Other 65 15.8 51 15.5Totals* 411 100.0 330 100.0* Non-respondents: Rural =3; Urban =5.15Preferences for Leisure Time ActivitiesThere appears to be some difference in the kinds of leisure time activities enjoyed by rural and urbanrespondents. A slightly greater proportion of rural respondents preferred outdoor leisure time activities overindoor activities (Table B-5a), participatory versus spectator activities (Table B-5b), sporting over culturalactivities (Table B-5c), and non-group over group activities (Table B-5d). The difference between the ruraland urban response to these four survey items, however, varied between a maximum of 7.7 percent (foroutdoor versus indoor activities) and a minimum of only 0.7 percent (for non-group over group activities).Table B-SaRespondents by Preference forIndoor vs, Outdoor Leisure ActivitiesActivities Rural UrbanN % N %Indoor 53 13.2 67 20.9Outdoor 348 86.8 253 79.1Totals* 401 100.0 320 100.0* Non-respondents: Rural = 13; Urban = 15.Table B-ScRespondents by Preference forSporting vs. Cultural Leisure ActivitiesActivities Rural UrbanN % N %,iSporting 314 78.7 234 75.5Cultural 85 21.3 76 24.5Totals* 399 100.0 310 100.0* Non-respondents: Rural = 15; Urban = 25.16Table B-ShRespondents by Preference forActive vs. Spectator Leisure ActivitiesActivities Rural UrbanN % N %Active 387 96.3 297 92.5Soectator 15 3.7 24 7.5Totals* 402 100.0 321 100.0* Non-respondents: Rural =12; Urban =14.Table B-SdRespondents by Preference forGroup vs, Non-Group Leisure ActivitiesActivities Rural UrbanN % N %Group 119 30.2 97 30.9Non-Group 275 69.8 217 69.1Totals" 394 100.0 314 100.0* Non-respondents: Rural = 20; Urban = 21.III. EducationOf the rural physicians who responded to the survey, 74.2 percent (307 physicians) indicated that theirprimary area of training was general practice. However, a number of respondents indicated more than oneprimary area of training. Further examination revealed that 281 rural respondents indicated they wereprimarily trained as general practitioners only. Of these, three were actually licensed as specialists - onefrom each of clinical, surgical, and laboratory areas - with the College of Physicians and Surgeons of BritishColumbia.P Twenty-six rural respondents stated that they were general practitioners and reported at leastone other specialty," According to the registry of the College of Physicians and Surgeons, however, two ofthese twenty-six respondents were surgical specialists. The other twenty-four in this group were registeredwith the College as general practiuoners," These figures are in marked contrast to respondents from theurban sample, of whom 47.2 percent (158 physicians) indicated that they had been trained primarily as GPs.One hundred and forty of these respondents indicated general practice as the only area in which they hadbeen primarily trained. One of these, however, was registered with the College of Physicians and Surgeonsas having a clinical specialty. Eighteen other urban respondents reported general practice and at least onespecialty as their primary areas of training." Only six of these general practice respondents were licensed3 Specialist certification by the College of Physicians and Surgeons of British Columbia does notprohibit a physician from being active as a general practitioner.4 In addition to general practice, specialties noted by these 26 rural respondents include:anaesthesia (4); geriatric medicine (1); internal medicine (1); cardiology (1); general surgery (2);obstetrics (4); ophthalmology (2); orthopaedics (6); otolaryngology (2); general pathology (1); anaesthesiaand general surgery (1); and internal medicine and general surgery (1). Twenty-four of theserespondents were licensed as general practitioners with the College of Physicians and Surgeons.5 A time-lag can occur between successful completion of specialist training and formal recognitionof certification in the registry of the College of Physicians and Surgeons of British Columbia, which mayexplain some of these inconsistencies. As well, it is possible for general practitioners to do partialresidencies in a specialty area without receiving specialist certification from the College.6 In addition to general practice, the specialties noted by these 18 urban respondents include:anaesthesia (3); community medicine (1); emergency medicine (1); psychiatry (1); general surgery (1);obstetrics/gynaecology (2); ophthalmology (1); orthopaedics (2); otolaryngology (1); urology (1); generalpathology (1); community medicine and obstetrics (1); psychology and obstetrics (1); dermatology,general surgery, and a laboratory specialty (1). Twelve of these respondents were registered as generalpractitioners with the College of Physicians and Surgeons.17as specialists with the College.Respondents who indicated that they were general practitioners were then asked to indicate whetherthey had completed a residency in family practice and whether they held a CCFP Certificate. Table B-6displays a breakdown of this information. According to the survey results, a slightly greater proportion ofresponding urban general practitioners did residencies in FP or were CCFP certificants. A number of rural(N = 33) and urban (N = 22) respondents possessed a CCFP Certificate but had not completed a familypractice residency. This is possible because, until 1989, there were two routes to become eligible to sitthe exam for a CCFP certificate. Until then, physicians who had spent five years or longer in what couldbe defined as a family practice were eligible to sit the exam. The other option, and since 1989 the onlyavenue to the CCFP certificate, was to undertake a residency in family practice. CCFP re-certification isrequired every five years. Of the thirteen rural general practitioners who had done residencies in familypractice but did not hold CCFP certificates, ten were graduates from foreign universities. Four of the tenurban practitioners who had completed family practice residencies but did not hold CCFP certificates werefrom foreign universities.Table B-6Respondent General Practitioners byFP Residency and CCFP Certificate(Total N: Rural =307; Urban =158)General Practitioners Rural UrbanN % N %FP Residency Only 13 4.3 10 6.5CCFP Certificate Only 33 11.0 22 14.4Both 51 17.1 20 13.1Neither 202 67.6 101 66.0Totals* 299 100.0 153 100.0* Non-respondents: Rural =8; Urban =5.18Overall, rural practitioners were more apt both to have done a residency in family practice and to holda CCFP Certificate. Equal proportions of the two groups (approximately two-thirds of each) neither haddone an FP Residency, nor had acquired a CCFP Certificate.Areas of SpecialtyTwo hundred and forty-nine physicians (33.2% of all respondents) noted that they had completed theirtraining primarily in a specialty area. These figures exclude respondents who indicated that they weregeneral practitioners but who also claimed to have been trained in one or more specialty areats). Onehundred and sixty-three (65.5%) of these individuals were from urban areas, 34.5 percent (N = 86) fromrural. Of the rural respondents reporting specialty training, 51.7 percent were trained primarily in clinicalareas, 47.1 percent were trained primarily in surgical specialties, and only one individual (1.1%) in laboratorymedicine. Clinical specialties were noted by 60.8 percent of urban respondents with specialty training; 34.9percent noted surgical specialties and another 4.2 percent noted laboratory specialties. However, becauseof the methods used to determine the survey population, caution should be exercised when comparing thesefigures."Among responding rural physicians who indicated specialty training only, most clinical specialties werenot represented. Those not represented included: cardiology, clinical immunology and allergy, communitymedicine, endocrinology and metabolism, gastroenterology, geriatric medicine, haematology, infectiousdisease, medical oncology, nephrology, neurology, nuclear medicine, physical medicine and rehabilitation,radiation oncology, respiratory medicine, and rheumatology. Only clinical immunology and allergy, geriatricmedicine, infectious disease, nephrology, and nuclear medicine were unrepresented among responding urbanphysicians with clinical specialties.Table B-7 presents the most common clinical, surgical, and laboratory specialties, in ranked order, forrural and urban areas. The table is based on a total of 253 responses (rural N = 87; urban N = 166),rather than 249 physicians, because of double counting in some specialties. One rural respondent indicated7 As noted earlier, 100 percent of rural physicians were included in the survey population, while asample of 11.6 percent of urban physicians was targeted.19Table B-7Most Common Specialties: Clinical, Surgical, and Laboratory(Total N: Rural =87; Urban =166)SPECIALTIES N % N % N %CLINICAL Rural (I) Urban (2) TotalAnaesthesia 11 24.4 21 20.8 32 12.6Internal Medicine 10 22.2 16 15.8 26 10.3Psychiatry 8 17.8 18 17.8 26 10.3Radiology (Diagnostic) 8 17.8 15 14.9 23 9.1Paediatrics 6 13.3 8 7.9 14 5.5Emergency Medicine 1 2.2 5 5.0 6 2.4Other Clinical (3) 1 2.2 18 17.8 19 7.5Clinical Subtotal 45 100.0 101 100.0 146 57.7SURGICAL Rural (4) Urban (5) TotalGeneral 14 34.1 8 13.8 22 8.7Obstetrics & Gynaecology 10 24.4 12 20.7 22 8.7Ophthalmology 6 14.6 15 25.9 21 8.3Orthopaedic 4 9.8 8 13.8 12 4.7Otolaryngology 3 7.3 4 6.9 7 2.8Other Surgical (6) 4 9.8 11 19.0 15 5.9Surgical Subtotal 41 100.0 58 100.0 99 39.1LABORATORY Rural (7) Urban (8) TotalGeneral Pathology 1 100.0 3 42.9 4 1.6Anatomical Pathology - - 2 28.6 2 0.8Haematological Pathology - - 2 28.6 2 0.8Laboratory Subtotal 1 100.0 7 100.0 8 3.2SPECIALTY TOTALS 87 (9) 34.4 166 (0) 65.6 253 100.0(1) Excluded from these totals are eight rural respondents who indicated being trained primarily in general practice.but who also noted having clinical specialties. These include: anaesthesia (5); geriatric medicine (1) andinternal medicine (2).(2) Excluded from these totals are nine urban respondents who indicated being trained primarily in general practice,but who also noted having clinical specialties. These include: anaesthesia (3); community medicine (2);dermatology (1); emergency medicine (1); and psychiatry (2).(3) Includes, for rural: dermatology (1); for urban: cardiology (3); community (1); dermatology (1); medicaloncology (2); neurology (2); physical/rehabilitation (2); radiation oncology (2); endocrinology/metabolism (1);gastroenterology (1); haematology (1); respiratory medicine (1); and rheumatology (1).(4) Excluded from these totals are 19 rural respondents who indicated being trained primarily in generalpractice. but who also noted having surgical specialties. These include: cardiovascular and thoracic surgery (1);general surgery (4); obstetrics and gynaecology (4); ophthalmology (2); orthopaedics (6); and otolaryngology (2).(5) Excluded from these totals are 11 urban respondents who indicated being trained primarily in generalpractice. but who also noted having surgical specialties. These include: general surgery (2); obstetrics andgynaecology (4); ophthalmology (1); orthopaedics (2); otolaryngology (1); and urology (1).(6) Includes, for rural: urology (3); plastics (1); for urban: plastics (5); urology (3); neurosurgery (2); andcardiovascular and thoracic (1).(7) Excluded from these totals is one rural respondent who indicated being trained primarily in general practice.but who also noted having a laboratory specialty in general pathology.(8) Excluded from these totals are two urban respondents who indicated being trained primarily in generalpractice, but who also noted having laboratory specialties. These include: general pathology (1); and medicalmicrobiology (1).(9) Figures include the double counting of one rural respondent who indicated both a psychiatry/psychologyand an orthopaedic specialty.(10) Figures include the double counting of three urban respondents who indicated dual specialties: internalmedicine and haematological pathology (1); and radiology and obstetrics/gynaecology (1).20both a psychiatry/psychology and an orthopaedic specialty. Three urban respondents indicated dualspecialties: one noted internal medicine and orthopaedics; one noted internal medicine and haematologicalpathology; one noted radiology and obstetrics and gynaecology. Accordingly, the total N value for the tableis inflated by four. At this point, specialties rather than individuals are counted in the table since anappropriate basis for selecting one specialty over another for classification and analysis, where more thanone has been reported, has yet to be established.The rural and urban listings are similar for clinical specialties, except for internal medicine andpsychiatry, which are ranked second and third, respectively, in rural areas, but were in reverse order in urbanones. The "other" category in the urban listing also reflects a wider range of clinical specialties. The mostcommon clinical specialty, for both rural (24.4%) and urban (20.8%) physicians with specialty training, wasanaesthesia. There were no respondents with paediatric general, thoracic, or vascular surgery specialties.The most common area of surgical training for rural respondents was general surgery (34.1%), followed byobstetrics and gynaecology (24.4%), ophthalmology (14.6%), orthopaedics (9.8%), and otolaryngology (7.3%).For urban respondents the most common surgical specialties were ophthalmology (25.9%), followed byobstetrics and gynaecology (20.7%). These were followed by orthopaedics and general, at 13.8 percent each,plastic surgery (which is included in the "other" category), at 8.6 percent, and otolaryngology at 6.9 percent.Specialties in neuropathology, medical microbiology, and medical biochemistry were absent from bothgroups. In addition, there were no rural respondents with specialties in anatomical pathology orhaematological pathology. The one rural respondent who indicated having completed training primarilyin general pathology was the only laboratory specialist represented among rural respondents. Generalpathology also was the most common area of laboratory training for urban respondents. Three of the sevenurban respondents who noted a laboratory specialty indicated general pathology as their primary area oftraining.21Completion of TrainingTable B-8 displays the number of rural and urban respondents by the period in which they completedtheir primary area of training. For both rural and urban respondents, the modal category for year ofgraduation was the period between 1976 and 1985; one hundred and forty (34.6%) of rural respondents andone hundred and nine (33.3%) of urban ones completed their training during this period. The proportionof urban respondents who had graduated during the period before 1966 was slightly larger than rural ones;the reverse was true for those graduating since 1966.TableB-8Respondents by Period of GraduationPeriod of Rural UrbanGraduation N % N %Before 1956 28 6.9 29 8.91956-1965 56 13.9 47 14.41966-1975 123 30.4 97 29.71976-1985 140 34.6 109 33.3After 1985 57 14.1 45 13.8Totals* 404 100.0 327 100.0* Non-respondents: Rural =10; Urban =8.Undergraduate Medical TrainingRespondents were asked to indicate the Canadian or foreign university from which they received theirundergraduate medical training. Tables B-9 and B-lO present, in ranked order, the number of rural andurban respondents according to the province or country in which they graduated from university; in addition,they list the existing 1989 data for these variables (Cavalier et al., pp. 86-95). Similar proportions of rural(68.4%) and urban (69.5%) respondents reported having received their undergraduate training from22Canadian universities. One hundred and thirty rural (31.4%) and ninety-nine urban (29.6%) respondentsreceived their undergraduate training from foreign universities. These percentages closely reflect the actualpercentages of 68.9 percent domestic-trained, and 31.1 percent foreign-trained, as outlined in existing data.a) Canadian UniversitiesThe proportions of respondents graduating from universities in each of the provinces appear to be anaccurate reflection of actual proportions as indicated by existing physician data. For both rural and urbanrespondents educated in Canada, more than one-third received their training at the University of BritishColumbia. Outside British Columbia, the single greatest Canadian source of responding physicians, rural(23.0%) and urban (14.2%), was the province of Alberta. More than two-thirds (71.0%) of Canadian-trained rural respondents and nearly two-thirds of urban ones (61.1%) received their undergraduate trainingat universities west of the Ontario-Manitoba border. Francophone universities accounted for only three ofthe 13 rural respondents and two of the 25 urban respondents who graduated from universities in Quebec.There were no rural respondents who had undergraduate training in Newfoundland.TableB-9Respondents by Province of Graduation (Canada)Province Rural Urban Group Total Actual 1989 (1)N % N % N % N %British Columbia 98 34.6 81 34.8 179 34.7 1521 34.2Alberta 65 23.0 33 14.2 98 19.0 768 17.2Ontario 59 20.9 54 23.2 113 21.9 998 22.4Manitoba 19 6.7 16 6.9 35 6.8 361 8.1Saskatchewan 19 6.7 12 5.2 31 6.0 243 5.5Quebec 13 4.6 25 10.8 38 7.4 376 8.4Nova Scotia 10 3.5 8 3.4 18 3.5 141 3.2Newfoundland 0 0.0 4 1.7 4 0.8 45 1.0Totals 283 100.0 233 100.0 516 100.0 4453 100.0(1) Source: Cavalier, S., Kerluke, K., and Wood, L. (1990), "Place of Graduation for Selected HealthOccupations - 1989", HMRU 90:7, Health Human Resources Unit, University of British Columbia,p.93.23b) Foreign UniversitiesWhile the proportion of non-Canadian-trained respondents was also an accurate reflection of actual1989 licensing data, the total respondent group contained a slightly larger number of physicians who hadbeen educated in the United Kingdom, South Africa, the Irish Republic, and Australia/New Zealand.Physicians from the United States, other European countries, Hong Kong and India were slightly under-represented among the respondents.Table B-lORespondents by Place of Graduation (Outside Canada)Place of Graduation Rural Urban Group Total Actual 1989 (1)N % N % N % N %United Kingdom 85 65.4 45 45.5 130 56.8 988 49.3South Africa 16 12.3 9 9.1 25 10.9 137 6.8Irish Republic 8 6.2 11 11.1 19 8.3 143 7.1AustralialNew Zealand 8 6.2 4 4.0 12 5.2 94 4.7United States 6 4.6 3 3.0 9 3.9 111 5.5Other Europe 3 2.3 3 3.0 6 2.6 180 9.0Hong Kong - - 4 4.0 4 1.7 51 2.5India - - 1 1.0 1 0.4 77 3.8Other 4 3.1 19 19.2 23 10.0 225 11.2Totals 130 100.0 99 100.0 229 100.0 2006 100.0(1) Source: Cavalier, S., Kerluke, K., and Wood, L. (1990), "Place of Graduation for Selected HealthOccupations - 1989", HMRU 90:7, Health Human Resources Unit. University of British Columbia,pp. 93 - 95.Of the 130 rural respondents who had received their undergraduate training outside Canada, almost two-thirds (85) graduated from universities in the United Kingdom. South African universities provided trainingfor 12.3 percent of rural respondents, while universities in the Irish Republic and Australia/New Zealandeach accounted for 6.2 percent. Slightly less than half (45.5%) of foreign-trained urban respondentsindicated having been trained in the United Kingdom. The second greatest source of urban respondentswas the Irish Republic, an additional 11.1 percent having received their training in universities there. SouthAfrican universities were the third greatest source of urban respondents (9.1%).24Time Practising MedicineTable B-11 displays respondents by the length of time they have been practising medicine. Accordingto the data, rural respondents tended to have practised for shorter lengths of time than urban respondents.One hundred and forty-eight (35.9%) rural respondents indicated having practised medicine for fewer than11 years, while only 29.4 percent of urban respondents were in this category; however, among the groupedyears of tenure, the greatest difference seems to be between rural and urban respondents who have beenpractising for six to ten years, where the proportion of rural respondents was 5.4 percent larger than theproportion of urban respondents. Further, a smaller proportion of rural respondents (34.2%) than urban(38.8%) indicated having practised for more than 20 years.Table B-llRespondents by Length ofTime Practising MedicineNumber of Years Rural UrbanN % N %Less than 6 years 77 18.7 58 17.66 to 10 years 71 17.2 39 11.811 to 15 years 65 15.8 58 17.616 to 20 years 58 14.1 47 14.2More than 20 years 141 34.2 128 38.8Totals* 412 100.0 330 100.0* Non-respondents: Rural = 2; Urban = 5.Respondents were asked to indicate on a five-point scale, where (1) denoted "no influence" and (5) "verymuch influence: the degree to which selected factors, people, or events were influential in the choice oflocation for their current practice. The mean influence level attributed to each survey item, as calculatedfor rural and urban respondents (Table B-12), should be interpreted relative to the sliding scale from whichit is derived. Standard deviations indicating how much, on average, individual values differ from each meanscore are also included in the table. The results appear to indicate that respondents did not consider factorsrelated to their medical training to be very influential in their practice location decisions. More important25in these decisions, it seems, were personal considerations such as the respondent's spouse. From among theitems provided, this factor was identified both by the rural and urban groups as the single most influentialin their practice location decisions (rural 3.02; urban 3.24) although it was more important for urbanphysicians. A two-tailed t-test revealed that the difference in mean scores of rural and urban respondentsfor this item was statistically significant," The desire to live or raise a family in an environment similar tothat in which the respondent grew up was identified by both the rural (2.49) and urban (2.86) as the secondmost influential factor. In both cases, however, it appears to have been only of moderate influence inpractice location decisions. And while locum experience was reported as the first professional influence(although third overall, with an average value of 2.43) among rural respondents, urban respondents indicatedpeers/friends (2.65) as the third most influential factor. Although locum experience (2.35) was also notedby urban respondents as the most influential professional concern in practice location decisions, it rankedfifth overall after four factors related to spouse, friends, relatives, and personal environment. The differencebetween rural and urban respondents' average influence values attributed to locum experience was found notto be statistically significant.The high number of responses and the high influence values in the "other" category led to a decisionto examine those responses more thoroughly. Upon review, factors indicating influence that had beenwritten in by respondents were found to fall into four general categories: employment availability, preferencefor a particular lifestyle (rural or urban), preference for the geography or climate of a particular area, andprofessional considerations. Accordingly, additional variables were created to accommodate these responses,and average influence levels were calculated.While average influence levels for each of the newly created variables are considerably higher than thosefor the itemized categories provided, N values are much smaller.8 In this test and others, as mentioned earlier, the pooled-variance t-test was used for the twogroups, and the separate-variance r-test was used in the case of unequal population variance. Theequality of population variance hypothesis was based on the F-test. In the majority of cases, thehypothesis of equal variances was not rejected. The t-tests indicate the statistical significance of thedifference between the mean scores calculated for each survey sub-group.26TableB-12Respondents by Mean Level of Influenceon Practice Location Decisions(1 = not at all ... 5 = very much)Rural UrbanFactors Standard StandardN Mean Deviation N Mean DeviationSpouse* 332 3.02 1.481 268 3.24 1.539Similar to Childhood Environment** 345 2.49 1.600 278 2.86 1.641Locum Experience 316 2.43 1.656 237 2.35 1.657Peers/Friends** 340 2.40 1.441 269 2.65 1.434Postgrad. Rural Experience** 308 2.40 1.556 222 1.99 1.438Undergrad. Rural Experience** 320 2.18 1.421 234 1.74 1.230Location of Internship** 338 1.72 1.233 274 2.10 1.562Closeness to Parents** 332 1.68 1.140 263 2.41 1.545Professor/Mentor** 311 1.57 1.101 244 1.80 1.374Location of Residency** 286 1.51 1.059 229 2.32 1.628Other 187 4.64 0.794 116 4.60 0.844Breakdown of Other: (1)Professional Reasons 54 4.87 0.339 29 4.79 0.491Preferred Lifestyle 79 4.73 0.499 34 4.74 0.511Needed a Job 19 4.37 1.257 17 4.53 0.514Preferred Geography 18 4.33 0.840 14 4.50 1.092Other Reasons 23 4.61 0.583 20 4.65 0.933* Significant (p < 0.05)** Highly significant (p < 0.01) (2)(1) N value in "Other" category is not equal to total N values in the "Breakdown of Other"because some respondents indicated more than one factor of influence in the choice oftheir practice location.(2) Based on a 2-tailed t-test after the practising physician groups were weighted to reflectthe province's more than 8:1 ratio of urban to rural physicians.27Respondents who wrote a particular factor into the "other" category were fewer in number, but the levelof influence they attributed to these factors tended to be much greater. Accordingly, the averages wereloaded with the highest influence values (4 or 5). In addition, because the items were not listed in thesurvey questionnaire for all respondents to see, those respondents who otherwise may have indicated thatthe written-in factors were "not at all" influential in their decision making (a value of 1) were not given theopportunity to do so. Average influence values for factors derived from the "other" category, therefore,were not reduced by the inclusion values at the low end of the influence scale. Thus the average influencelevels are higher for the factors derived from the "other" category than for those that were itemized in thesurvey questionnaire.Responses such as "needed a job," "preferred lifestyle," and "preferred climate or geography" do notnecessarily indicate why a particular choice was made. Indeed, if taken at face value, "needed a job" seemsto indicate a choice between working and not working, but not between rural and urban areas. Responsessuch as "lifestyle" and "geography" invite some explanation of how they came to be influential factors in thefirst place. The specific responses that are encompassed in "professional considerations," however, suggestthat respondents made a locational choice on the basis of their perception of the characteristics of rural andurban medical practices. Rural practices were often preferred since, in the view of a number of respondents,they allowed for a wider variety of medical treatment, sometimes because referrals were less of an option.For some urban respondents, "professional considerations" included the view that rural practice was "tooboring."However, none of the differences in average values calculated for the categories created from the"other" category was found to be significant. In comparison, all of the differences in average influencevalues for the listed items, except "locum experience" (not statistically significant) and spouse (significant atp < 0.05), were found to be highly significant (p < 0.01).28IV. PracticeDetailed information about the scope and structure of respondents' practices was sought in part threeof the questionnaire.Solo vs. Group PracticeNearly two-thirds (65.5%) of rural respondents, compared with approximately half of urban ones(49.9%), reported working in group practice. Tables B-13a and B-13b list these respondents by the numberof general practitioners and specialists with whom they were in group practice. The tables do not indicatewhether respondents themselves were general practitioners or specialists.The proportion of urban respondents in a group practice with at least five general practitioners and fivespecialists (7.6%) was almost twice that of their rural counterparts (3.9%). A greater proportion of ruralrespondents, however, were in group practice with five or more GPs and two or fewer specialists (rural36.7%; urban 19.9%). Only 5.0 percent of rural respondents indicated being in practices without generalpractitioners, while 19.1 percent of their urban counterparts were in such practices. The proportions of rural(62.9%) and urban (58.8%) respondents in group practices without specialists, however, were relatively equal.Although noting that they were in group practice, three rural respondents went on to indicate that therewere no other general practitioners or specialists in that practice.Other Practices in the CommunityOver one-third (34.5%) of rural respondents reported that theirs was the only practice in thecommunity, while only a tenth (10.1%) of urban respondents indicated that there were no other practicesin the community. Of those who reported competition from other practices in their communities, 76.5percent of those from rural and 76.0 percent from urban areas believed that the competition did not affecttheir patient retention or, more generally, their practices.29Table B-13aOther Physicians in Group Practice:General Practitioners by Specialists - Rural(N =271)General Specialists (1)Practitioners (2) 5+ 3-4 1 - 2 None TotalsN % N % N % N % N %5+ 10 3.9 15 5.8 38 14.7 57 22.0 120 46.33-4 3 1.2 4 1.5 13 5.0 48 18.5 68 26.31-2 1 0.4 1 0.4 1 0.4 55 21.2 58 22.4None 4 1.5 1 0.4 5 1.9 3 1.2 13 5.0Totals* 18 6.9 21 8.1 57 22.0 163 62.9 259 100.0* Non-respondents =12.(l) Excluded from these figures are eight rural respondents who indicated that theirs were solo practices but who reportedworking in a group with other specialists. Two of these respondents reported working in a group with more than five otherspecialists; one reported working with three or four specialists; and five others reported working with one to two specialists.(2) Excluded from these figures are eight rural respondents who indicated that theirs were solo practices but who reportedworking in a group with other general practitioners. Three of these respondents reported working in a group with more thanfive other general practitioners; two reported working with three to four GPs; and three others reported working with one totwo GPs.TableB-13bOther Physcians in Group Practice:General Practitioners by Specialists - Urban(N = 167)General Specialists (1)Practitioners (2) 5+ 3-4 1 - 2 None TotalsN % N % N % N % N %5+ 10 7.6 3 2.3 6 4.6 20 15.3 39 29.83-4 1 0.8 1 0.8 5 3.8 23 17.6 30 22.91 - 2 1 0.8 1 0.8 1 0.8 34 26.0 37 28.2None 15 11.5 8 6.1 2 1.5 - - 25 19.1Totals* 27 20.6 13 9.9 14 10.7 77 58.8 131 100.0* Non-respondents =36.(1) Excluded from these figures are four urban respondents who indicated that theirs were solo practices but who reportedworking in a group with other specialists. Two of these respondents reported working in a group with more than five otherspecialists; one reported working with three to four specialists; and one other reported working with one to two specialists.(2) Excluded from these figures are three urban respondents who, while indicating that theirs were solo practices, reportedworking in a group with one to two other general practitioners.30Patient Volnme and WorkloadTable B-14 displays rural and urban respondents according to the number of patients they see in anaverage working day. The data suggest that rural physicians, on average, have a greater patient load thantheir urban counterparts. While only a quarter of rural respondents (25.6%) reported seeing fewer than 21patients per day, 42.5 percent of urban respondents reported that this was the case. Conversely, 74.7 percentof rural respondents, compared with only 57.6 percent of urban ones, noted seeing more than an averageof 20 patients per day.Table B·14Respondents by Patients Seen per Average DayNumber of Rural UrbanPatients N % N %Up to 10 37 9.3 84 26.811- 20 65 16.3 49 15.721- 30 159 39.8 96 30.731- 40 109 27.3 57 18.241 - 50 22 5.5 14 4.551 - 60 3 0.8 4 1.3Over 60 5 1.3 9 2.9Totals* 400 100.0 313 100.0* Non-respondents: Rural = 14; Urban =22.The data summarized in Table B-15 suggest that rural physicians spend more time on-call than urbanphysicians. Only a quarter of rural physicians (24.0%), compared with almost a third of urban respondents(32.3%), spent one night per week or less on-call. Almost half of rural respondents (47.1%) spent two ormore nights per week on-call. This compared with only 37.0 percent for urban respondents.The number of weekend days off per month, as displayed in Table B-16, was relatively equal for ruraland urban respondents except at the lowest and highest ends of the scale; 21.1 percent of rural respondents,compared with only 12.7 percent of urban ones, reported having no weekend days free of medicalresponsibility in the average working month.31Table B-ISRespondents by Nights per Week On CallNights Per Rural UrbanWeek N % N %Less than 1 94 24.0 101 32.31 113 28.8 96 30.72 84 21.4 52 16.63 35 8.9 22 7.04 13 3.3 5 1.65 53 13.5 37 11.8Totals* 392 100.0 313 100.0* Non-respondents: Rural =22; Urban=22.Table B-I6Respondents by Weekend Days Off per MonthWeekend Days Rural UrbanPer Month N % N %None 86 21.1 41 12.71 22 5.4 16 5.02 74 18.2 52 16.13-4 104 25.6 84 26.05-6 96 23.6 78 24.17-8 25 6.1 52 16.1Totals* 407 100.0 323 100.0* Non-respondents: Rural =7; Urban = 12.At the other end of the scale, 16.1 percent of urban respondents noted having, on average, seven to eightweekend days per month with no medical responsibilities. This was the case for only 6.1 percent of ruralrespondents.While the data reviewed to this point seem to suggest a heavier and, perhaps, more intense work loadfor rural physicians, it appears some may find compensation in the holidays they take. Although rural andurban respondents take approximately the same number of holidays, seemingly minor differences exist32between their patterns. As summarized in Table B-17, a majority of rural respondents (51.6%) reportedhaving more than four weeks holidays in the past year. The percentage of urban respondents who took thisamount of holiday time was appreciably smaller (44.1%). Conversely, the proportion of rural physicians whotook one week or less was 5.4 percent, while only 3.4 percent of urban physicians reported such limitedholiday time.Table B·I7Respondents by Weeks of Annual HolidaysWeeks of Rural UrbanHolidavs N % N %None 9 2.2 6 1.91 13 3.2 5 1.52 37 9.1 42 13.03 48 11.8 48 14.84 90 22.1 80 24.7More than 4 210 51.6 143 44.1Totals* 407 100.0 324 100.0* Non-respondents: Rural =7; Urban =11.TableB-I8Finding a LocumMethods Rural UrbanN % N %Covered by Members of Group Practice 69 23.4 47 24.1Word of mouth 83 28.1 77 39.5Journals 14 4.7 1 0.5Co-operation With Other Doctors 34 11.5 34 17.4Department of Family Practice Residents 7 2.4 5 2.6"Matchbox" 3 1.0- -College Listing Service 32 10.8 3 1.5Private Service 3 1.0 2 1.0RelativesIFriends 7 2.4 8 4.1Other 43 14.6 18 9.2Totals* 295 100.0 195 100.0* Non-respondents: Rural =54; Urban =48. Totals also exclude 65 ruraland 92 urban responses that were "Not Applicable".33Finding a LocumRespondents were then asked to indicate how they went about finding a locum (Table B-18). In largepart, both rural and urban physicians found locums through word of mouth, through co-operation with otherdoctors in the same town or in neighbouring towns, or by virtue of their coverage in a group practice. TheListing Service provided by the College of Physicians and Surgeons of British Columbia was used by asubstantially greater proportion of rural respondents (10.8%) than urban ones (1.5%).Breakdown of General Practitioners' Medical Work TimeGeneral practitioners were asked to indicate the percentage of their work time spent involved in variousmedical areas. The complete results of this question are provided in Appendix D. However, Table B-19displays, for rural and urban respondents, the number (N) and percentage (%) of general practitioners whospend at least some time in various medical areas, the modal percentage category for the amount of timespent in that area (Modal % Time), the frequency for the modal percentage category (Modal n), and thepercentage of responding GPs that comprise the modal category (Modal %).Table B-19General Practitioners by Time Spent inVarious Areas of Medicine(rota! N: Rural = 307; Urban = 158)Rural UrbanAreas of Medicine Modal ModalN % % Time n % N % %Time n %Internal Medicine 268 87.3 11- 20 83 31.0 128 81.0 21 - 30 33 25.8Paediatrics 266 86.6 11- 20 109 41.0 125 79.1 11 - 20 48 38.4Psychiatry/CounsellinglPsychology 264 86.0 11-20 102 38.6 128 81.0 1 - 10 42 32.8Obstetrics & Gynaecology 262 85.3 1 -10 106 40.5 121 76.6 1 - 10 48 39.7Dermatology 255 83.1 1 - 10 165 64.7 121 76.6 1 - 10 68 56.2House Calls 222 72.3 1 - 10 197 88.7 114 72.2 1 - 10 90 78.9Geriatrics 213 69.4 11-20 80 37.6 104 65.8 1 - 10 36 34.6General Surgery 137 44.6 1 - 10 104 75.9 63 39.9 1 - 10 47 74.6Public Health/Community Medicine 109 35.5 1 - 10 87 79.8 42 26.6 1 - 10 27 64.3Physical Medicine & Rehabilitation 88 28.7 1 - 10 62 70.5 47 29.7 1 - 10 32 68.1Anaesthesia 81 26.4 1- 10 49 60.5 16 10.1 1 - 10 10 62.5Radiology 74 24.1 1 - 10 59 79.7 25 15.8 1 - 10 21 84.0Medical Subspecialty 59 19.2 1 - 10 38 64.4 34 21.5 I - 10 19 55.9Pathology & Lab Medicine 43 14.0 1- 10 38 88.4 20 12.7 1 - 10 17 85.0Surgical Subspecialty 42 13.7 1 - 10 38 90.5 23 14.6 1 - 10 16 69.6Other 39 12.7 1 - 10 19 48.7 34 21.5 1 - 10 12 35.334The medical area in which both rural (87.3%) and urban (81.0%) general practitioners most frequentlyspent time was internal medicine. For respondent rural general practitioners involved in internal medicine,the modal response category was the 11 to 20 percent range, with 31.0 percent devoting this amount of timeto it. The modal response category for urban GPs was the 21 to 30 percent range, with 25.8 percentindicating that internal medicine required this portion of their time. Compared with urban respondents,therefore, a greater proportion of rural GPs spent a lesser amount of their time involved in internalmedicine.After internal medicine, paediatrics (86.6%), followed closely by psychiatry/counselling psychology(86.0%) were the areas in which rural general practitioners were most frequently involved. Forty-onepercent of responding rural GPs were involved in paediatrics for between 11 and 20 percent of their time,and 38.6 percent spent a similar amount of time in psychiatry/psychology. The proportion of urban GPsworking in these areas was slightly smaller (paediatrics 79.1%; psychiatry/psychology 81.0%). As well, whilethe modal response category for paediatrics was the same for urban respondents as it was for rural (11 to20%), the modal category for psychiatry/psychology was 1 to 10 percent for urban respondents; 32.8 percentof responding urban GPs spent between 1 and 10 percent of their work-time in psychiatry/counsellingpsychology.For most of the medical areas listed, the proportion of rural respondents working in each was greaterthan the proportion of urban respondents so occupied. For 26.4 percent of rural GPs, compared with only10.1 percent of urban ones, anaesthesia was an area of medicine to which they devoted some time in theirpractices. A large majority of rural GPs (85.3%) spent some time in obstetrics and gynaecology, whilesomewhat smaller proportion of responding urban GPs reported such work (76.6%), and 35.5 percent ofrural GPs, compared with 26.6 percent of urban ones, were involved to some extent in public health.Relatively equal portions of rural and urban respondents spent some time in geriatrics, but the modalamount of time spent by rural GPs (11 to 20%) was greater than that for urban GPs (1 to 10%). Thepercentage of urban GPs was slightly greater than rural GPs only in rehabilitation and physical medicine,medical subspecialties, and surgical subspecialties. The proportions of each spending time on house calls35were almost exactly the same - approximately 72 percent. Only in other unlisted areas of medicine did asubstantially greater percentage of urban respondents (21.5%) indicate involvement, as opposed to 12.7percent of rural respondents.Type of PaymentThe final question regarding respondents' practice inquired as to methodes) of payment (Table B-20).A slightly greater percentage of responding rural physicians (94.7%) than urban (92.5%) reported paymentat least partly on a fee-for-service basis. Payment at least partly on a salaried basis was somewhat moreprevalent among urban respondents (11.7%) than rural ones (8.1%), perhaps due to the presence of agreater number of alternative models of health care delivery in urban areas. This may also explain why norural respondents indicated payment at least partly on a sessional basis.Table B-20Type of PaymentType of Payment Rural UrbanN % N %Fee-far-Service Only 335 85.2 228 74.0Salary Only 21 5.3 11 3.6Sessional Only 0 0.0 10 3.2Fee-far-Service and Salary 11 2.8 20 6.5Fee-far-Service and Sessional 26 6.6 34 11.0Salary and Sessional 0 0.0 2 0.6Fee-for-Service, Salary and Sessional 0 0.0 3 1.0Totals* 393 100.0 308 100.0* Non-respondents: Rural =21; Urban =27.V. CommunityIn this section, respondents were asked to provide information on the community in which they practice,the health services available there, and their level of satisfaction with professional, community, andpersonal/family concerns. While respondents' town/city information and census figures were used to place36them objectively into previously defined rural and urban categories", respondents were asked to notewhether, by their own definition, their community of practice was urban, semi-rural, or rural. Only half(53.4%) of those respondents identified by the research team as practising in rural areas indicated that theybelieved that they were practising in rural areas. About thirty-nine percent of those identified as being ruralrespondents considered their community of practice to be semi-rural, and a further 7.4 percent consideredtheir community of practice to be urban. Of the respondents deemed urban by the research team, 78.4percent subjectively agreed with the urban designation of their community of practice; 16.5 percent, however,considered their communities to be semi-rural, and 5.2 percent considered them to be rural.The discrepancies between the population-based designations and physicians' subjective perceptions ofrural and urban were anticipated and, indeed, pose interesting questions for future study. The population-based designations, however, provide a more stable and appropriate foundation for most of the analysis thatfollows. Since the basis of physicians' perceptions of rural and urban perceptions of rural and urban isessentially unknown, these perceptions are used as a foundation for analysis only where survey questions aredirectly related to specific subjective issues and items.Respondents were asked to indicate how long they had practised in their current geographical area.Table B-21 summarizes this information. The data for rural and urban respondents appear to be fairlysimilar, except that a greater proportion of rural respondents (24.6%) than urban (15.4%) had lived in theircommunities for between six and ten years, and a greater proportion of urban respondents (21.1%) thanrural (12.3%) had lived in their communities more than twenty years.Table B-22 lists respondents by the length of time that they were planning to remain in their thencurrent communities of practice. Similar proportions of rural (27.3%) and urban (26.8%) respondents wereplanning to stay. in their respective communities for one to five years. However, fewer rural than urbanrespondents (62.5% vs. 68.9%) were planning to remain there more than five years.9 As noted earlier, rural communities were defined as having fewer than 10,000 people, while urbancommunities were defined as those with populations of over 10,000.37Table B-21Respondents by Years in CurrentGeographic AreaNumber of Years Rural UrbanN % N %Less than 1 year 43 10.6 31 9.31 year 26 6.4 11 3.32 - 3 years 43 10.6 40 12.04 - 5 years 42 10.3 32 9.66 - 10 years 100 24.6 51 15.411 - 15 years 66 16.2 59 17.816 - 20 years 37 9.1 38 11.4More than 20 years 50 12.3 70 21.1Totals* 407 100.0 332 100.0* Non-respondents: Rural::: 7; Urban « 3.Table B-22Respondents by Plans to Continue Practisingin Current Geographic AreaNumber of Years Rural UrbanN % N %Less than 1 year 41 10.3 14 4.31 year 18 4.5 11 3.42 - 3 years 55 13.8 42 12.94 - 5 years 36 9.0 34 10.5More than 5 years 250 62.5 224 68.9Totals* 400 100.0 325 100.0* Non-respondents: Rural::: 14; Urban « 10.A greater proportion of rural respondents (10.3%) than urban (4.3%) were planning to leave theircommunities in less than one year. The data suggest that, in both the short and long terms, rural areas willcontinue to experience an outflow of physicians.38Respondents who had indicated that they did not consider their present community of practice to berural were asked if they had ever practised in a rural setting (Table B-23). Of those who indicated thatthey had practised in a rural setting at one time, over half (56.5%) had been there for one year or less.Only 12.9 percent reported having practised in a rural area for more than five years before leaving.TableB-23Respondents by Time inPast Rural Practice(Total N = 211)Number of Years N %Less than 1 year 85 40.71 year 33 15.82 - 3 years 41 19.64 - 5 years 23 11.0More than 5 years 27 12.9Totals* 209 100.0* Non-respondents = 2.When asked to indicate some of the reasons for leaving, the results displayed in Table B-24 wereobtained. For almost two-thirds of the respondents (61.6%), the main reasons reported for leaving ruralpractice were related primarily to personal or family considerations. However, less than half of these 130respondents indicated only personal or family considerations; for the rest, there were also other reasons forleaving. The second most common reasons for leaving, reported by just under half of the respondents, wererelated to professional considerations. Less than one-quarter of the respondents left rural practices becauseof dissatisfaction with the community in which they were located. No respondents reported communityfactors as their only reasons for leaving. Only 10.4 percent cited financial reasons for moving their practicefrom a rural area.39Table B-24Respondents by Reasons forLeaving Rural Practice(Total N = 211)Reasons N* %**PersonallFamily Reasons 130 61.6Professional Dissatisfaction 95 45.0Dissatisfaction with Community 45 21.3Financial Dissatisfaction 22 10.4* Number of responses; multiple answers werepermitted.** Percentage calculations are based on total number ofrespondents.The N value (211) for Tables B-23 and B-24 is comprised of 126 urban respondents who noted havingspent some time in the past in a rural practice, as well as 85 respondents who, while deemed rural by theresearch team, considered their present practice location to be semi-rural or urban and had indicatedspending some time in rural practice. From these responses and responses to other of the survey questions,the subjective nature of rural and urban designations has become increasingly evident. As a result, it wasdecided that the experiences and perceptions of these individuals, particularly in relation to leaving what theyconsidered rural practice, would be no less valid and should be included in the data analysis whereappropriate.Medical Support Services and BackupRespondents were provided with an itemized list of medical support services and then asked to indicatethose which were based in their communities. Table B-25 displays the number and percentage ofrespondents by the services that were available in their communities. Less than half of the ruralrespondents, compared with over 90 percent of urban respondents, reported that all of the medical services40itemized were provided in their communities. Rural and urban respondents reported high and relativelyequal availability of ambulance, laboratory, public health and pharmacy services. While social andpsychological counselling and radiology services were available to approximately 80 percent of ruralrespondents, over 90 percent of urban respondents reported these services were provided in theircommunities. Approximately two-thirds or less of rural respondents indicated that dietetic or rehabilitationservices were available in their communities. Less than half of rural respondents reported access to podiatryservices in their communities.Table B-25Respondents by Medical Support ServicesProvided in Their Communities(Rural N = 414; Urban N = 335)Medical Support Services Rural UrbanN % N %Ambulance Service 404 97.6 324 96.7Laboratory 393 94.9 322 96.1Public Health Service 390 94.2 321 95.8Pharmacy 382 92.3 323 96.4Social/Psych. Counselling 339 81.9 315 94.0Radiology 333 80.4 321 95.8Dietetics 282 68.1 316 94.3Rehabilitation Service 250 60.4 306 91.3Podiatry 195 47.1 307 91.6Other (1) 29 7.0 6 1.8(1) Includes five rural and three urban respondents who indicated thatall itemized services were provided in their communities, but notedthat other services that were not listed also were provided.Respondents were asked to indicate the type of hospital closest to or based in their communities.Definitions of each of these designations were not provided to respondents, under the assumption thatBritish Columbia Ministry of Health definitions would be applied. As illustrated in Table B-26, the resultsfor rural areas were essentially the reverse of those for urban areas. Over two-thirds of rural respondents(69.0%) reported a primary care facility closest to or based in their communities. Only 3.4 percent of ruralrespondents reported being nearest a tertiary hospital. Most urban respondents (50.2%), on the other hand,41were closest to a tertiary hospital. Only 18.1 percent of urban respondents reported closest proximity to aprimary care facility. Regional hospitals appeared to be more equitably distributed, with 27.6 percent ofrural and 31.7 percent of urban respondents noting these as the type of hospital nearest their communities.Table B-26Type of Hospital Nearest tolBased in the CommunityType of Hospital Rural UrbanN % N %Primary 280 69.0 57 18.1Regional 112 27.6 100 31.7Tertiary (referral) 14 3.4 158 50.2Totals* 406 100.0 315 100.0* Non-respondents: Rural = 8; Urban = 20.When asked to identify all of the medical specialist back-up available within 100 kilometres of theirarea, less than one-quarter of rural respondents (24.2%), as compared with over three-quarters of urban ones(77.3%), reported that all of the services on the itemized list were available.Appendix E lists respondents by the types of medical specialist back-up that were available within 100kilometres of their communities. To provide a summary of this information, Table B-27 displays the topfive specialty services in each of clinical, surgical, and laboratory areas, and the number and percentage ofrespondents who reported each of them available within 100 kilometres of their community of practice.Over 90 percent of urban respondents indicated access within 100 kilometres to the top five clinical andsurgical specialties. More than 85 percent of them reported similar access to all of the top five laboratoryspecialties. In comparison, the only specialty back-up that was available within 100 kilometres to more than80 percent of rural respondents was general surgery.42Less than 75 percent of rural respondents had access to most of the top five specialties in each of theareas indicated. In some cases, less than half of rural respondents were within 100 kilometres of wherethese services could be found.Table B-27Respondents by Medical Back-upWithin 100 Kilometres(Rural N = 414; Urban N = 335)Type of Medical Back-Up Rural UrbanN % N %CLINICAL SPECIALTIES:Radiology (Diagnostic) 315 76.1 319 95.2Anaesthesia 311 75.1 314 93.7Internal Medicine 306 73.9 320 95.5Paediatrics 299 72.2 314 93.7Psychiatry 281 67.9 313 93.4SURGERY SPECIALTIES:General 340 82.1 324 96.7Obstetrics/Gynaecology 291 70.3 321 95.8Urology 290 70.0 315 94.0Ophthalmology 284 68.6 312 93.1Otolaryngology 280 67.6 314 93.7LABORATORY SPECIALTIES:General Pathology 272 65.7 317 94.6Medical Biochemistry 202 48.8 290 86.6Medical Microbiology 200 48.3 293 87.5Anatomical Pathology 195 47.1 296 88.4Haematoloaical Pathology 185 44.7 289 86.3Satisfaction LevelsRespondents were presented with a series of 42 survey items in order to identify their level ofsatisfaction with various aspects of their professional, community, and personal/family lives. Using the five-point scale provided, respondents were asked to indicate whether they were (1) "very unsatisfied", (3)"indifferent", or (5) "very satisfied" with the various survey items. Once again, the mean values that werecalculated for these items should be interpreted in the context of the scale from which they were derived.43Appendix F displays the mean satisfaction levels for rural and urban respondents as calculated from thesurvey results.As noted earlier, two-tailed t-tests were conducted to test the equality of means for rural and urbansatisfaction averages, after the practising physician groups were weighted to reflect the province's more than8:1 ratio of urban to rural physicians. The t-tests indicated that the differences between mean satisfactionlevels for the majority of survey items were either significant (p < 0.05) or highly significant (p < 0.01).There is a possibility that the statistical significance for those survey items may at least partly be due to thelarge sample size. However, because of the sample size, even large differences in mean satisfaction levelsthat were not statistically significant are without much doubt truly lacking in significance.a) Professional ItemsOn average, both rural and urban respondents were quite highly satisfied (a value of approximately fouror greater) with a number of professional concerns. The t-tests for the following items indicated nosignificant differences between average values for rural and urban groups:i) the variety in the medical problems to be treated (rural 4.46; urban 4.45);ii) opportunity to provide complete package of medical services (rural 3.95; urban 4.01);iii) opportunities for continuity of care (rural 4.18; urban 4.15);iv) opportunity to practice the kind of medicine they wish (rural 4.16; urban 4.17).While both rural and urban groups appeared to be quite highly satisfied with the professional concernsitemized below, t-tests indicated that the relatively small differences in their average satisfaction scores weresignificant for the first two cases that follow, and highly significant for the third:i) acuteness of diseases seen (rural 4.37; urban 4.26);ii) challenge of practice (rural 4.33; urban 4.22);iii) level of responsibility (rural 4.31; urban 4.43).44Rural and urban respondents were, on average, relatively equal in being somewhat satisfied (rural 3.11;urban 3.40) with their caseloads in relation to their incomes. They also were equally less satisfied (rural2.75; urban 2.88) regarding the ease with which they could relocate their practices.There were a number of other profession-related concerns for which levels of satisfaction varied betweenrural and urban respondents. In every case, except one, urban respondents were more satisfied, or lessunsatisfied, than their rural counterparts. Only when asked to comment on the "opportunity to practiceas a family doctor" were rural respondents (4.36), on average, more satisfied than urban ones (3.83).Although the average levels of satisfaction for the "availability of clinical support" and "free and informalcommunication with peers" were fairly high among rural respondents (3.83 and 3.97, respectively), there wasconsiderably higher satisfaction among urban respondents (4.57 and 4.43 respectively) in regard to theseitems. In each of these cases, the differences tested as highly significant.There were four professional points in relation to which rural respondents were only somewhat satisfiedwhile urban respondents were quite highly satisfied. The differences, in each of these cases, were found tobe highly significant:i) access to specialist expertise (rural 3.69; urban 4.54);ii) availability of medical facilities (rural 3.65; urban 4.08);iii) ease of transfer to an appropriate level of care of the acutely ill/injured patient (rural 3.60; urban4.14);iv) specific training for the appropriate medical services in their geographic area of practice (rural 3.55;urban 4.01).In relation to the question of satisfaction with "length of working hours (on-call)," rural respondents(3.19) were somewhat less satisfied than urban ones (3.85). Once again, the difference in mean values wasfound to be highly significant.There were five survey items about professional concerns with which rural respondents were somewhatunsatisfied, while urban respondents tended to be relatively satisfied. Of these, rural respondents were leastsatisfied with research opportunities (2.49). Rural respondents were also somewhat unsatisfied with45academic opportunities (2.80), while this was not much of a concern for urban respondents (3.65). Ruralrespondents were somewhat more unsatisfied than their urban counterparts with "opportunities forinvolvement in RCM.A, CM.A, or other related activities" (rural 2.84; urban 3.49), their "ability to secureuninterrupted free time from work" (rural 2.85; urban 3.44), and the "availability of locum relief" (rural 2.89;urban 3.43). The difference in average values for each of these items was found to be highly significant.b) Community ItemsLevels of satisfaction in relation to community concerns were relatively equal among rural and urbanrespondents, with two exceptions. The largest difference between rural and urban average satisfaction levels,for any of the satisfaction items, was received for the "availability of cultural activities." For this item, ruralrespondents indicated indifference (3.04), while urban respondents indicated a relatively high level ofsatisfaction (4.25). And while both rural and urban respondents reported a satisfaction with the "availabilityof recreational facilities," urban respondents (4.51) indicated a notably greater satisfaction than rural ones(4.04). In both cases, r-tests indicated that the different satisfaction values were highly significant.Both rural and urban respondents indicated relatively equal satisfaction with eight community surveyitems, although rural respondents were slightly more satisfied with half of the items, while urban respondentswere slightly more satisfied with the other half. Those items with which rural respondents were slightlymore satisfied were:i) quality of environment (rural 4.33; urban 4.05);ii) own personal safety in the community (rural 4.50; urban 4.26);iii) sense of community (rural 4.00; urban 3.83);iv) possibility for community involvement/leadership (rural 4.04; urban 3.85);Items with which urban respondents, on average, were slightly more satisfied were:i) size of community (rural 4.05; urban 4.33);ii) life-style in the community (rural 4.12; urban 4.22);46iii) resources with which to enjoy leisure time (rural 4.02; urban 4.25);iv) financial/economic security in the community (rural 3.86; urban 4.00).For all but one of the items relating to community concerns, there were highly significant differencesbetween rural and urban respondents; the mean value of "life-style in the community" was found to besignificant.c) Personal/Family ItemsMean levels of satisfaction for at least half of the personal/family related survey items were relativelyequal among rural and urban respondents. In every case, however, levels of satisfaction were higher, if onlyslightly, among urban respondents than rural ones.Both rural (4.38) and urban (4.44) respondents, on average, expressed a fairly high degree of satisfactionrelating to their "own preference for practising" where they do; however, the r-test indicated that thedifference in means for this variable was not significant. The quality of life for respondents' children (rural4.04; urban 4.34), the quality of housing (rural 4.16; urban 4.30), and the contentment of respondents'spouses in the community (rural 3.95; urban 4.32) were other items in regard to which a fairly high degreeof satisfaction was expressed. In each of these cases, the difference between rural and urban averages wasfound to be highly significant. Both rural and urban respondents expressed relatively equal satisfaction with"opportunities to earn the kind of income [they] require" (rural 3.79; urban 3.87). While rural and urbanrespondents were both somewhat satisfied with their time for family life, recreation, and leisure (rural 3.47;urban 3.75), the difference in mean values in favour of urban respondents was found to be highly significant.Levels of satisfaction differed most, as with community items, in relation to the "availability of culturalopportunities for self and family," where rural respondents indicated indifference (3.05), while urbanrespondents expressed a fairly high level of satisfaction (4.12). Concern over quality of education forrespondents' children also differed considerably, with rural respondents expressing relative satisfaction (3.30)and urban respondents being quite satisfied (4.21). Urban respondents (3.30) were slightly less unsatisfied47than rural ones (2.70) regarding their proximity to relatives and extended family. In each of these cases, thedifferences between rural and urban average satisfaction levels were found to be highly significant.VI. Overall SatisfactionRespondents were surveyed to determine their overall satisfaction or contentment with theirprofessional, community, and personal/family lives. Once again, respondents were asked to indicate theirresponses on a five-point scale: (1) "strongly disagree"; (3) "indifferent"; (5) "strongly agree." Averages ofthese responses were calculated for rural and urban respondents, and are displayed in Table B-28.Responses from both rural and urban physicians were comparable, but as with the majority of the moredetailed items regarding their professional, community, and family/personal lives, urban satisfaction levelswere slightly higher.TableB-28Respondents by Mean Satisfaction Levels forProfessional, Community and Personal/Family Lives(l = strongly disagree ... 3 = indifferent ... 5 = strongly agree)Rural UrbanStandard StandardN Mean Deviation N Mean DeviationProfessional 412 3.68 1.148 334 3.84 1.128Community 407 4.01 0.986 328 4.14 0.937PersonallFamilv 407 4.16 0.995 325 4.27 0.929As a general indicator of professional satisfaction, respondents were asked to indicate their level ofagreement with the following statement: "When I think of my professional career I am quite satisfied withit and there is very little I would like to change." In responding to this statement, urban respondents (3.84)expressed slightly greater agreement than rural ones (3.68).The following statement was used as an indicator of respondents' overall level of satisfaction with theirlives in relation to their communities: "When I look at the community where I live I think that it greatlycontributes to my overall quality of life." Once again, while agreement among both groups was relatively48high, urban respondents (4.14) were slightly more satisfied than rural respondents (4.01) with life in theircommunities.As an indicator of overall satisfaction with their personal/family lives, respondents were asked to recordthe degree to which they agreed or disagreed with the following statement: "When I look at mypersonal/family life I am quite satisfied with the quality of those relationships." While the whole surveygroup indicated basic agreement with this statement, on average, urban respondents (4.27) reported a slightlyhigher degree of agreement than rural ones (4.16).The differences between the overall satisfaction levels for professional and community concerns werefound to be highly significant (p < 0.01); testing indicated that the difference between rural and urbansatisfaction in relation to overall family/personal life was statistically significant (p < 0.05).10Respondents were then asked to indicate whether they intended to move their practices within the nextfive years and, if so, to indicate the type of area they were considering: urban, semi rural, or rural. Theresponses to this question are displayed in Table B-29.Table B-29Respondents by Intent to MoveIntent to Move Rural UrbanN % N %Yes, to an Urban Area 35 8.9 17 5.4Yes, to a Semi-Rural Area 34 8.7 14 4.4Yes, to a Rural Area 9 2.3 7 2.2No Intent to Move 315 80.2 278 88.0Totals* 393 100.0 316 100.0* Non-respondents: Rural =21; Urban = 19.Reflecting their greater overall satisfaction, a greater proportion of urban respondents (88.0%) thanrural (80.2%) reported no intent to move their practices in the immediate future. Only 6.6 percent of urban10 As noted earlier: based on a two-tailed z-test after the practising physician groups were weightedto reflect the province's more than 8:1 ratio of urban to rural physicians.49respondents expressed an intent to move to other than an urban area. Almost nine percent of ruralrespondents indicated an intent to move their practices to urban areas. Eleven percent of rural respondentsindicated that they intended to move their practices to other rural or semi-rural areas, while 5.4 percent ofurban respondents intended to move to other urban areas.Respondents who reported that they intended to move their practices within the next five years wereasked to indicate whether, or how much, factors related to community, professional, personal/family, andincome were involved in their decisions to relocate (Table B-30). Once again, family/personal followed byprofessional reasons were primary among factors related to moving. Reasons related to community andincome tended to be of lesser importance in decisions to relocate.TableB-30Respondents by Factors Related to Intended Move(1 =not at all ... 5 =very much)(Total N: Rural = 78; Urban= 38)Rural UrbanFactors Standard StandardN Mean Deviation N Mean DeviationPersonal/Family 72 3.94 1.362 36 3.81 1.348Professional 71 3.31 1.379 34 3.53 1.502Community 70 2.54 1.380 35 2.71 1.506Income 71 2.21 1.372 34 2.03 1.337Respondents who considered themselves to be currently practising in an urban or semi-rural area wereasked if they would be interested in doing a locum in a rural area within the next three years (Table B-31). Only urban respondents are included in this table, since rural respondents who answered the questionwere already practising in rural areas. Ninety-two urban respondents (27.5% of the urban survey population)indicated that they would be interested in a rural locum. Almost a quarter of these (23.1%) indicated awillingness to take on a locum of between one and three months. Almost half (47.3%) indicated that theywould do a locum of between three and four weeks. Another quarter (24.2%) reported they would accept50a rural locum of one to two weeks. Only 5.5 percent of urban respondents who were willing to do a rurallocum indicated they would do so for more than six months.Table B-31Respondents Interested in Doinga Rural LocumPreferredLengthof Locum N %1- 2 Weeks 22 24.23 - 4 Weeks .43 47.31 - 3 Months 21 23.14 - 6 Months 1 1.17 - 9 Months 2 2.210 - 12 Months 0 0.0> 1 Year 2 2.2Totals* 91 100.0* Non-respondents =1.VII. Concluding RemarksThe survey group appeared to be a reasonable reflection of British Columbia's physician populationdespite a less than ideal response rate. Responding rural physicians were fairly representative of the ruralphysician population in British Columbia, in terms of age, sex, place of graduation, and area of specialty.According to these criteria, urban respondents were also quite representative of the urban target populationas identified in the sampling procedure.While some differences between the responding rural and urban physicians exist, a significant findingof the survey was the extent to which the two groups displayed similar characteristics and indicated similarattitudes. Regarding background characteristics such as age, sex, father's field of employment, andpreferences for leisure time activity, the differences between the two groups appear to be relatively minor.Interestingly, for both groups, the proportion of female respondents who were single was considerably largerthan the proportion of male respondents who were single.51In support of the literature on physician practice location decisions, a greater proportion of ruralphysicians noted having been born and educated in less populous communities. Also clearly supported bythe survey results was the idea that physicians' spouses are a significant influence in the practice locationdecisions of their partners.A slightly larger proportion of rural than urban physicians completed their training in the years since1966. A greater proportion of urban respondents graduated before that time. Reflecting these differences,rural physicians tended to have been practising medicine for shorter lengths of time.Findings on respondents' primary area of training proved to have been more complex than had beenanticipated, particularly when the results of these questions were compared with registration data from theCollege of Physicians and Surgeons of B.c. In some cases, the information on primary area of trainingprovided by the respondents did not match with College registry data. This may have been due to differinginterpretations of what was being asked or to registry data that were not as current as the survey. Withinthe confines of this analysis, however, it raises several interesting research questions regarding physicianeducation and training.According to the survey results, rural practitioners appeared to have seen more patients per day andspent more time on-call. Rural practices also appear to be more varied in terms of the amount of timephysicians spend in different medical areas; the proportion of rural respondents working in most of themedical areas listed was greater than the proportion of urban respondents. An appreciably greaterproportion of rural respondents reported taking more than four weeks of annual holidays.The proportion of rural respondents who had access in their communities to a full list of medicalsupport services and back-up was almost half that of their urban counterparts. Further, while almost allurban respondents had access within 100 kilometres to a range of clinical, surgical, and laboratory specialties,only three-quarters of responding rural physicians had the same access.Rural respondents tended to be more satisfied with professional concerns such as the challenge of theirpractices, opportunities to practice as a family doctor, and the acuteness of diseases that they treat. Thecommunity item with which urban respondents were appreciably more satisfied was the availability of cultural52activities; both groups appeared equally satisfied with various aspects of life in their communities. They alsoappeared to be relatively equally satisfied with their personal and family lives.Overall, rural and urban respondents tended to express general satisfaction with their personal,professional, and community lives. Urban respondents may have been slightly more satisfied. This pointmay be reflected in the greater proportion of rural respondents who were planning, either in the short termor the long term, to leave rural areas. The proportion of rural respondents planning to leave theircommunities within a year was more than double the proportion of urban respondents planning to leavetheirs. Interestingly, while much. is made in the literature of the professional isolation that can discouragephysicians from rural practice, respondents seemed more likely to cite personal/family reasons for thedecision to leave rural areas.5354PART C: SPOUSES OF PRACTICING PHYSICIANSI. IntroductionIn recognition of the likelihood that locational decisions will be made jointly by physicians and theirspouses, a spousal questionnaire was included with those sent to practising physicians. The questionnairewas divided into four basic areas. In part one, personal biographic and demographic information was sought.Part two inquired as to the respondent's educational level; part three requested information on therespondent's occupational status. Part four was comprised of questions regarding the respondent'ssatisfaction in relation to professional, community, and personal/family life.A total of 608 spouses answered the survey. For the purposes of analysis, the respondents were dividedinto two subsets (as are the physicians) based on the size of the community within which their physician­spouses practised or resided. Rural respondents (N = 334) were identified as those from communities offewer than 10,000 people, and urban respondents (N = 274) from communities of more than 10,000 people.Since the marital status of the practising physicians included in the study was previously unverified, it wasnot possible to calculate an appropriate response rate for the spousal respondents. However, 651 of thephysicians who responded to the questionnaire indicated that they were married. For a detailed discussionof sample design, see Part A, Section III: Research Design and Methods. The information which followsis a preliminary descriptive analysis of the data which were obtained from the spouses' questionnaires.II. Profile of RespondentsAge and SexOf the 334 responding spouses in rural communities, 87.4 percent were female and 12.6 percent weremale; of the 273 urban respondents, 84.6 percent were female and 15.4 percent were male (a slightly greaterproportion of males than their rural counterparts). While there were rural respondents from each agecategory (from under 35 years to 60 years or over), a majority of these (61.7%) were less than 45 yearsold. A smaller proportion of urban respondents fell into this group (50.9%). The modal age category of55rural male respondents (31.0%) was the younger-than-35 age-group, while that of rural female respondents(22.6%) was the 35-to-39-years group. The modal age category for both male and female urban respondents(23.8% and 21.2%, respectively) was 35 to 39 years. Thus, rural respondents were slightly younger than theirurban counterparts, with a higher proportion of males who were younger than 40. Table C-l presentsrural and urban respondents by age and sex.Table C-IRespondents by Age and Sex(Total N =608)Age Rural UrbanMale Female Total Male Female TotalN % N % N % N % N % N %< 35 13 31.0 65 22.3 78 23.4 9 21.4 35 15.2 44 16.135 - 39 12 28.6 66 22.6 78 23.4 10 23.8 49 21.2 59 21.640 - 44 5 11.9 45 15.4 50 15.0 8 19.0 28 12.1 36 13.245 - 49 1 2.4 22 7.5 23 6.9 3 7.1 22 9.5 25 9.250 - 54 5 11.9 44 15.1 49 14.7 7 16.7 45 19.5 52 19.055 - 59 2 4.8 30 10.3 32 9.6 1 2.4 29 12.6 30 11.060+ 4 9.5 20 6.8 24 7.2 4 9.5 23 10.0 27 9.9Totals* 42 12.6 292 87.4 334 100.0 42 15.4 231 84.6 273 100.0* Non-respondents: Urban = 1 Female.Community of Residence as a YouthRespondents were asked to identify the size of the communities in which they were born and hadattended elementary and secondary school. This information is outlined in Tables C-2a and C-2b. A higherpercentage of rural respondents were either born or attended school in communities of 50,000 or fewerpeople than their urban counterparts (53.6% of rural respondents were born in communities of such size,compared with 42.7% of urban respondents; 55.4% of rural respondents attended elementary school incommunities of 50,000 or fewer people, compared with 43.5% of urban respondents; and, 48.3% of ruralrespondents attended secondary school in communities of that size, compared with 37.6% of their urbancounterparts). In contrast, between 42 and 48 percent of all responding urban spouses were born and56Table C·2aRural Respondents by Size of Communityof Birth, Elementary, and Secondary SchoolPopulation Birth Elementary SecondaryN % N % N %Up to 10,000 114 34.3 125 38.5 91 28.210,001 - 50,000 64 19.3 55 16.9 65 20.150,001 - 100,000 36 10.8 31 9.5 43 13.3More than 100,000 118 35.5 114 35.1 124 38.4Totals* 332 100.0 325 100.0 323 100.0* Non-respondents: Birth =2; Elementary =9; Secondary =11.Table C·2bUrban Respondents by Size of Communityof Birth, Elementary, and Secondary SchoolPopulation Birth Elementary SecondaryN % N % N %Up to 10,000 65 24.3 74 27.5 55 20.710,001 - 50,000 49 18.4 43 16.0 45 16.950,001 - 100,000 37 13.9 39 14.5 38 14.3More than 100,000 116 43.4 113 42.0 128 48.1Totals* 267 100.0 269 100.0 266 100.0* Non-respondents: Birth =7; Elementary =5; Secondary =8.57educated in communities of more than 100,000 people (43.4% birth; 42.0% elementary; 48.1% secondary).However, when compared with the physician survey, these figures show that a higher proportion of bothrural and urban spousal respondents came from smaller communities (of 50,000 or fewer people).Father's Field of EmploymentRespondents were asked to indicate their father's profession or field of employment (Table C-3). Themost frequently cited professional/occupational category for both rural and urban respondents' fathers was"Managerial/Administrative" (16.3% and 19.2%, respectively). Rural respondents whose fathers' fields ofemployment were "FarminglRanching" comprised the second largest group (12.6%), followed by those in"Sales" (8.9%). The order of these was reversed for urban respondents (9.1% for "Sales"; 7.5% for"Farming/Ranching"), If the categories of "Physician" and "Other Medicine/Health" are combined, they takethird place among rural and second place among urban respondents (9.8% for both rural and urban). Otherunspecified fields of employment account for 12.3 percent of the father's professional/employment categoryfor rural respondents, and 19.2 percent for urban respondents.TableC·3Father's ProfessionIField of EmploymentProfession Rural UrbanN % N %ManageriaIJAdministrative 53 16.3 51 19.2FanninglRanching 41 12.6 20 7.5Sales 29 8.9 24 9.1Physician 27 8.3 19 7.2Services 21 6.5 8 3.0ProcessingIManufacturing 16 4.9 13 4.9Forestry/Mining 15 4.6 8 3.0Construction 15 4.6 14 5.3Teaching 14 4.3 13 4.9Machining 11 3.4 5 1.9Clerical 9 2.8 4 1.5TransportJEquipment Operation 9 2.8 12 4.5Social Sciences/Law 8 2.5 7 2.6ArtisticlLiterary 5 1.5 I 0.4Other MedicinelHealth 5 1.5 7 2.6Religion 4 1.2 5 1.9FishinglHunting 3 0.9 2 0.8SportlRecreation 0 0.0 I 0.4Other 40 12.3 51 19.2Totals* 325 100.0 265 100.0* Non-respondents: Rural = 9; Urban = 9.58The distribution of these responses differed from those of the physicians, for whom the most frequentlyreported category was that of "Physician" and "Other Medicine/Health" combined. "Managerial/Administrative" comprised the second largest employment category (rural 17.0%; urban 16.7%), followed by"Teaching" (8.8%) for the rural physicians' fathers and "Sales" (9.4%) for those of the urban group.Preferences for Leisure Time ActivitiesRespondents were asked to indicate their preferences for leisure time activities. Both rural and urbanrespondents expressed a preference for outdoor over indoor activities (Table C-4a), for active over spectatoractivities (Table C-4b), for sporting over cultural activities (Table C-4c), and for non-group over groupactivities (Table C-4d). A larger proportion of rural respondents indicated these preferences in eachinstance although the rural/urban difference with respect to group/non-group activities was small.The spousal group appeared to prefer the same activities as the physician group but in lesserproportions. For example, while 64.4 percent of the spouses in rural areas preferred sporting to culturalactivities, 78.7 percent of the physicians in rural areas preferred sporting over cultural activities. This maybe explained, in part, by the gender difference between the two respondent groups; the physicians werepredominantly male (approximately 82%), while the spouses were predominantly female (approximately86%). It also seemed to be related to location; both rural physician and spouse respondents seem morelikely to prefer outdoor, active and sporting activities than did their urban counterparts.ChildrenReporting spouses were asked to indicate the number of children they had (Table C-5). The majority(rural 61.1%; urban 56.2%) had two to three children; a small proportion had none (rural 12.0%; urban13.5%). Table C-6 shows the number of children living in the respondents' households. Significantproportions of both rural and urban respondents had no children living with them (34.9% and 30.3%,respectively).59sTable C-4aRespondents by Preference forIndoor vs. Outdoor Leisure Time ActivitiesActivities Rural UrbanN % N %Indoor 88 27.4 96 36.4Outdoor 233 72.6 168 63.6Totals* 321 100.0 264 100.0* Non-respondents: Rural = 13; Urban = 10.Table C-4cRespondents by Preference forSporting vs. Cultural Leisure Time ActivitiesActivities Rural UrbanN % N %Sporting 203 64.4 150 57.7Cultural 112 35.6 110 42.3Totals* 315 100.0 260 100.0* Non-respondents: Rural = 19; Urban = 14.Table C-4bRespondents by Preference forActive vs, Spectator Leisure Time ActivitiesActivities Rural UrbanN % N %Active Participation 292 91.0 224 84.8Spectator 29 9.0 40 15.2Totals* 321 100.0 264 100.0* Non-respondents: Rural =13; Urban =10.Table C-4dRespondents by Preference forGroup vs, Non-Group Leisure Time ActivitiesActivities Rural UrbanN % N %Group 118 37.2 100 39.4Non-Group 199 62.8 154 60.6Totals* 317 100.0 254 100.0* Non-respondents: Rural =: 17; Urban =: 20.Only 4.5 percent of rural respondents and 4.1 percent of urban respondents had more than three childrenliving in their households. The majority (rural 60.6%; urban 65.7%) had between one and three childrenresiding at home.Table C-SNumber of Children of RespondentsNumber of Rural UrbanChildren N % N %None 40 12.0 37 13.5One 38 11.4 30 10.9Two 106 31.9 84 30.7Three 97 29.2 70 25.5More than three 51 15.4 53 19.3TotaIs* 332 100.0 274 100.0* Non-respondents: Rural = 2; Urban = O.Table C-6Number of Children Currently Livingin Respondents' HouseholdsNumber of Rural UrbanChildren N % N %None 116 34.9 82 30.3One 62 18.7 59 21.8Two 81 24.4 70 25.8Three 58 17.5 49 18.1More than three 15 4.5 11 4.1TotaIs* 332 100.0 271 100.0* Non-respondents: Rural = 2; Urban = 3.The 216 rural (65.1%) and 189 urban (69.7%) respondents who currently had children living with themwere next asked to identity the ages of the youngest and oldest children in their households (Table C-7).The most dramatic difference between the rural and urban groups appeared in the over-18 age category.While only 2.8 percent of rural respondents reported that their youngest child was in this group, 16.161percent of urban respondents had youngest children at home who were older than 18. Data for the oldestchild's age show a similar rural/urban difference; 9.2 percent of rural respondents and 23.3 percent of urbanrespondents reported that the oldest child in their household was over eighteen years old. The contrastbetween the rural and urban groups may be related to age differences; both the rural physicians and spousestended to be younger than their urban counterparts and so had less time to have children. The data inTable C-7 support this view; a higher proportion of rural respondents reported that their youngest (oronly) child was under one year of age and that their oldest child was between one and five.Table C-7Age Range of Children (if any) Living with RespondentsYoungest Oldest*Age Range Rural Urban Rural UrbanN % N % N % N %< 1 34 15.8 19 10.2 0 0.0 0 0.01-5 66 30.7 62 33.3 32 20.9 20 15.56 - 12 71 33.0 41 22.0 62 40.5 49 38.013 - 18 38 17.7 34 18.3 45 29.4 30 23.318+ 6 2.8 30 16.1 14 9.2 30 23.3Totals** 215 100.0 186 100.0 153 100.0 129 100.0* If only 1 child was reported, response was included in "Youngest".** Non-respondents: Youngest - Rural :::: 1, Urban:::: 3; Oldest - Urban :::: 1.III. EducationHighest level of education information is reported in Table C-8. The largest single proportion of ruralrespondents reported trade/vocational training as their highest level of education (26.7%); the largest singleproportion of urban respondents had completed university graduate education (32.1%). More urbanrespondents reported having obtained undergraduate (24.7%) and graduate (32.1%) degrees than their ruralcounterparts (undergraduate 20.0%; graduate 22.4%). As previously noted, the urban respondents tendedto be older than their rural counterparts; this may explain in part their higher level of education. In62general, though, the overwhelming majority of both rural and urban respondents had completed some formof post-secondary education (91.5% and 95.1%, respectively).Table C-SRespondents by Highest Level of EducationHighest Level of Education Rural UrbanN % N %Primary School 1 0.3 0 0.0Some Secondary School 4 1.2 4 1.5Completed Secondary School 23 7.0 9 3.3TradeNocational Training 88 26.7 47 17.3Some University, Undergraduate 59 17.9 48 17.7Completed University, Undergraduate 66 20.0 67 24.7Some University, Graduate Level 15 4.5 9 3.3Completed University, Graduate Level 74 22.4 87 32.1TotaIs* 330 100.0 271 100.0* Non-respondents: Rural = 4; Urban = 3.IV. OccupationThe majority of both rural and urban respondents were employed although more urban than ruralspouses reported employment (63.7% and 66.9%, respectively) (Table C-9).Table C-9Respondents by Employment StatusEmployment Status Rural UrbanN % N %Employed 212 63.7 182 66.9Not Employed 121 36.3 90 33.1TotaIs* 333 100.0 272 100.0* Non-respondents: Rural = 1; Urban = 2.63Of those who were unemployed (Table C-lO), 15.4 percent of the rural respondents reported that theirunemployment was not by choice, while only 9.3 percent of urban respondents so replied.Table e-reIfNot Employed, Is This By Choice?By Choice? Rural UrbanN % N %Yes 99 84.6 78 90.7No 18 15.4 8 9.3Totais* 117 100.0 86 100.0* Non-respondents: Rural =4; Urban = 4.The majority of the spouses who were employed (Table C-ll) worked in health care (rural 62.9%; urban60.6%). An appreciably larger proportion of rural respondents were nurses (22.9%) than were their urbancounterparts (11.1%). While 14.3 percent of rural respondents reported employment as physicians (eithersalaried or self-employed), a larger proportion (20.6%) of urban respondents stated that as their profession.Table C-llRespondents by Type of EmploymentPosition Rural UrbanN % N %Physician - Salaried 4 1.9 5 2.8Physician - Self-Employed 26 12.4 32 17.8Nurse 48 22.9 20 11.1Other Health Care Worker 54 25.7 52 28.9Other than in Health Care 49 23.3 56 31.1Self-Employed (Non-Phvsician) 29 13.8 15 8.3Totais* 210 100.0 180 100.0* Non-respondents: Rural =2; Urban =2.64Respondents were asked to identify those activities, other than family/job responsibilities, in which theywere participating (Table C-12). This question was intended to determine the extent of their involvementin community work. Approximately 46 percent of rural respondents reported being engaged in volunteerwork in the community, while only 36.1 percent of urban respondents so answered. In addition, 15.8 percentof rural respondents and 11.6 percent of urban respondents stated that they developed activities within alocal social/recreational group.Table C-12Respondents by Activities Other ThanFamily/Job ResponsibilitiesActivity Rural UrbanN % N %Do Volunteer Work in Community 145 45.7 90 36.1Develop SociallRecreational Group Activities 50 15.8 29 11.6Have Other Activities 122 38.5 130 52.2Totals* 317 100.0 249 100.0* Non-respondents: Rural = 17; Urban = 25.Respondents were then asked about the extent of their contribution to practice location decisions.Using the 5-point scale provided, respondents were asked to indicate whether they had contributed from (1)"not at all" to (5) "to a great extent" in the decision-making process. Table C-13 displays the meancontribution level for rural and urban respondents as calculated from the survey results. The meancontribution level of rural spouses was slightly larger than that of urban spouses, but the majority of allspouses believed that their input was significant in deciding practice location (an average of 3.7 or greateron the scale provided). A two-tailed t-test was conducted in relation to the difference between rural andurban contribution averages; it was not found to be statistically significant.65Table C-13Extent of Contribution to Families'Decisions to Stay in Spouses' Current Practice Location(1 =not at all ... 5 =to a great extent)Rural UrbanStandard StandardN Mean Deviation N Mean Deviation325 3.85 1.260 268 3.69 1.351V. Satisfaction LevelsRespondents were presented with a series of survey items in order to identify their level of satisfactionwith various aspects of their professional, community, and personal/family lives. Using the five-point scaleprovided, respondents were asked to indicate whether they were (1) "very unsatisfied" to (5) livery satisfied"with the survey items. Table C-14 displays the mean satisfaction levels for rural and urban respondents ascalculated from the survey results. Two-tailed t-tests were performed to assess the differences between meansatisfaction levels of rural and urban respondents for each item below. Highly significant differences inmean satisfaction levels were found for 13 out of 22 items (p < 0.01).a) Professional ItemsIn all areas of professional concern, rural respondents showed lower mean satisfaction levels than theirurban counterparts, with t-tests indicating that these differences were highly significant. The area of greatestconcern for rural spouses was "professional/work advancement," where the mean level of satisfaction was only3.12 (compared with 3.77 for their urban counterparts). The difference in level of satisfaction for the twogroups was also highly significant with regard to "opportunities for employment" and "opportunity to use[one's] skills." Rural respondents showed satisfaction levels of 3.36 and 3.53, respectively, for these twoareas, compared with 3.89 and 3.91 for urban respondents. A comparison of the mean levels of professionalsatisfaction of the physicians and spouses is difficult because of the work-specific content of the 22 questions66Table C-14Respondents by Mean Satisfaction Level forSpecific Professional, Community, and PersonallFamily Concerns(l =very unsatisfied ... 5 =very satisfied)Rural UrbanProfessional, Community, Personal! Standard StandardFamily Concerns N Mean Deviation N Mean DeviationPROFESSIONAL:Opportunity to Use One's Skills** 303 3.53 1.252 249 3.91 1.051Opportunities for Employment** 295 3.36 1.332 244 3.89 1.091ProfessionaI/Work Advancement** 293 3.12 1.302 237 3.77 1.073COMMUNITY:Personal Safety in the Community** 325 4.55 0.733 262 4.16 0.893Quality of Environment** 325 4.18 1.007 267 3.91 1.044FinanciallEconomic Security in the Community 322 4.14 0.896 262 4.08 0.929Possibility for Community Involvement/Leadershij 318 4.11 0.945 260 4.01 0.913Life-style in the Community 328 4.05 1.094 268 4.06 0.981Sense of Community** 325 4.01 1.063 268 3.76 1.081Size of Community 326 3.99 1.118 269 4.16 1.010Resources With Which to Enjoy Leisure Time** 322 3.93 1.119 266 4.22 0.946Availability of Recreational Facilities** 324 3.90 1.193 268 4.32 0.961Availability of Cultural Activities** 323 2.84 1.220 267 4.03 1.165PERSONALIFAMILY:Quality of Housing 324 4.28 0.947 256 4.25 0.899Spouse's Contentment in the Community 325 4.15 0.896 261 4.18 0.942Quality of Life for One's Children 272 4.11 0.963 231 4.22 0.873Time for Family Life (Recreation & Leisure) 326 3.69 1.165 264 3.65 1.082Opportunity to Earn Required Income** 302 3.54 1.293 251 3.90 1.063Quality of Education for One's Children** 275 3.34 1.120 226 4.03 1.039Availability of Cultural Opportunities** 327 2.93 1.178 267 3.93 1.067Proximity to Relatives & Extended Family** 321 2.73 1.508 259 3.20 1.451Other 31 2.48 1.730 11 3.18 1.834** Highly significant (p < 0.01).67answered by physician respondents (Appendix F). In general, however, the physicians were found to bemore satisfied with their professional lives than were the respondent spouses.b) Community ItemsThere were many areas of community concern for which t-tests indicated highly significant differencesin levels of satisfaction between the rural and urban groups. The most notable of these was "availability ofcultural activities," where the mean level of satisfaction for urban respondents was 4.03, compared with only2.84 for those in rural areas. Rural respondents were also less satisfied with the "availability of recreationalfacilities" (rural 3.90; urban 4.32) and the "resources with which to enjoy leisure time" (rural 3.93; urban4.22). Rural respondents were more satisfied than their urban counterparts with "sense of community"(rural 4.01; urban 3.76), "quality of environment" (rural 4.18; urban 3.91), and their "own personal safetyin the community" (rural 4.55; urban 4.16). These findings are similar to those of the physician groupalthough mean levels of satisfaction were generally higher for rural physician respondents than for ruralspouses.There were only four statements of community concern for which differences in levels of satisfactionbetween the rural and urban spouses were not statistically significant. However, the physician respondentsshowed either significant or highly significant differences for these four items, which were:i) financial/economic security in the community (rural 3.86; urban 4.00);ii) possibility for community involvement/leadership (rural 4.04; urban 3.85);iii) life-style in the community (rural 4.12; urban 4.22);iv) size of community (rural 4.05; urban 4.33).For all but the item about community involvement or leadership, urban communities scored higher on thesatisfaction scale.68c) Personal/Family ItemsFour items on the personal/family satisfaction scale were highly significant for differences in mean levelsof satisfaction between rural and urban groups. In all four cases, rural respondents were less satisfied thantheir urban counterparts. Once again, the largest difference in level of satisfaction was seen with "availabilityof cultural opportunities for self and family" (rural 2.93; urban 3.93). Although only 35.6 percent of ruralspouses indicated a preference for cultural activities (Table C-4c), no difference was found in the satisfactionlevels pertaining to availability of cultural opportunities between spouses who preferred cultural activitiesand those who preferred sporting activities. Rural physician respondents showed a similar degree ofdissatisfaction with the two questions regarding availability of cultural activities although their meansatisfaction levels were slightly higher (3.04 and 3.05).Rural spouses were also significantly less satisfied with the quality of their children's education (rural3.34; urban 4.03). These results were similar to those of the physician group. However, there was nostatistically significant difference between rural and urban spouses' satisfaction with the quality of life fortheir children (rural 4.11; urban 4.22). This differs from the results of the physicians' survey, in which highlysignificant differences were found between the rural and urban groups (rural 4.04; urban 4.34) in responseto this statement.Rural spouses were significantly less satisfied with "proximity to relatives and extended family" (rural2.73; urban 3.20). Physicians showed similar levels of dissatisfaction with their proximity to family. Ruraland urban physicians differed from the spousal respondents in being somewhat satisfied with their incomeopportunities (rural 3.79; urban 3.87). Mean satisfaction levels were lower for the spouses, with a highlysignificant difference between the rural and urban respondents (rural 3.54; urban 3.90).For the item "spouse's contentment in the community", both rural and urban spousal respondentsshowed similar mean levels of satisfaction (rural 4.15; urban 4.18) with the contentment of the physicianrespondents. In contrast, rural and urban physician respondents differed significantly in their mean levelsof satisfaction with the contentment of the spousal respondents (rural 3.95; urban 4.32). Spouses showedno significant differences in mean levels of satisfaction with "quality of housing" in their communities nor69with "time for family life.tt On the other hand, the physician respondents showed highly significantdifferences for these areas (quality of housing: rural 4.16, urban 4.30; family time: rural 3.47, urban 3.75).Overall SatisfactionLastly, respondents were surveyed to determine their overall satisfaction or contentment with theirprofessional, community, and personal/family lives. Once again, the spouses were asked to indicate theirresponses on a 5-point scale, ranging from (1) "strongly disagree" to (5) "strongly agree." Averages for theseresponses were calculated for rural and urban respondents and are displayed in Table C-15. The resultsshowed a highly significant difference between rural and urban respondents' satisfaction with theirprofessional careers (rural 3.03; urban 3.38), but no significant differences in community or personal/familysatisfaction levels. The mean score for satisfaction with their communities was slightly higher for urbanrespondents (3.94) than for rural respondents (3.80). For personal/family satisfaction levels, the mean scoresfor rural and urban respondents were almost identical (rural 4.30; urban 4.28).Table C-tSRespondents by Mean Satisfaction Levels forProfessional, Community, and PersonallFamily Lives(l =strongly disagree ... 5 =strongly agree)Rural UrbanStandard StandardN Mean Deviation N Mean DeviationProfessional 278--3.03 1.207 236 3.38 1.151Community 325 3.80 1.115 267 3.94 0.993PersonallFamilv 327 4.30 0.859 265 4.28 0.809When these results were compared with those of the physician group, both rural and urban spouseswere found to have been considerably less satisfied with their professional lives than were the rural (3.68)and urban (3.84) physician respondents. In addition, they were slightly less satisfied with their communitylives than were the physician respondents (rural 4.01; urban 4.14). However, rural and urban spouses were70slightly more satisfied with their personal/family lives than physician respondents in either location (rural4.16; urban 4.27).VI. Concluding RemarksIn summary, the majority of the spousal respondents were female; half the urban respondents andalmost two-thirds of the rural respondents were under 45 years old. A higher proportion of both ruraland urban spouses came from communities of 50,000 or fewer people than did the physician respondents.The most frequently cited employment group for spouses' fathers was "Managerial/Administrative," followedby "Farming/Ranching" for rural spouses, and combined "Physician" and "Other Medicine/Health" for urbanspouses. In contrast, the most frequently cited employment group for the physicians' fathers was thecombined category of "Physician" and "Other Medicine/l-Iealth," followed by "Managerial/Administrative."Both the physicians and the spouses had similar interests in leisure time activities, preferring outdoor overindoor, active over spectator, sporting over cultural, and non-group over group activities. Some respondentshad no children living with them, but the majority had between one and three children residing at home.The most dramatic difference between the rural and urban groups in the numbers of children appeared inthe over-18 age-category. Five times more urban than rural respondents had a youngest child aged 18 orolder living with them.In general, the overwhelming majority of spousal respondents had completed some form of post­secondary education. The largest single proportion of rural spouses reported trade/vocational training astheir highest level of education, while the largest single proportion of urban respondents had completeduniversity graduate education.The majority of both rural and urban spouses was employed. Of those who were unemployed,significantly more rural than urban respondents reported that their unemployment was involuntary. Mostof the spouses who were employed worked in health care; twice as many rural spouses were employed asnurses. Approximately 14 to 21 percent of spouses reported employment as physicians (either salaried orself-employed). A higher percentage of rural than urban spouses reported being engaged in volunteer work71in their communities and in development of local social/recreational activities. The majority of all spousesbelieved that their input was important in the decision to stay in their spouses' current practice location.In all areas of professional concern, rural spouses showed lower mean satisfaction levels than theirurban counterparts, and both groups of spouses were less satisfied than the physician respondents withprofessional life. Both rural physicians and spouses showed dissatisfaction with the availability in theircommunities of cultural activities, recreational facilities, and the resources with which to enjoy leisure time.Rural respondents were more satisfied than their urban counterparts with community, the quality ofenvironment, and community safety levels. In matters of personal/family concern, rural spouses were lesssatisfied than their urban counterparts with the quality of their children's education, proximity to relativesand extended family, and opportunities to earn required income. These results are similar to those of thephysician group although the physicians were somewhat more satisfied than the spousal respondents withincome opportunities. In terms of overall satisfaction, it was observed that although rural spouses wereless satisfied with their professional careers than were urban spouses, no statistically significant differencesbetween the two groups existed in overall community or personal/family satisfaction levels. When theseresults are compared with those of the physicians, both rural and urban spouses were found to have beenless satisfied with their professional and community lives, but more satisfied with their personal/family lives,than were the physician respondents.72PART D: RESIDENTS AND INTERNSI. IntroductionThe target population for this part of the survey included those residents and interns on the temporary(at hospital) register with the College of Physicians and Surgeons of British Columbia as of September 1989.As a result, the survey group was originally comprised of 207 residents and 85 interns. The total figure waslater revised to 290 individuals when two respondents returned questionnaires and noted that they wereneither residents nor interns.Forty-one interns and 77 residents returned questionnaires, making a total of 118 respondents and anoverall response rate of 40.7 percent. The response rate for interns (41 out of 85,48.2%) was higher thanthat for residents (77 out of 207, 37.2%). Among resident non-respondents, 30.5 percent were female and69.5 percent male; the sex distribution of resident respondents was approximately the same. Intern non­respondents were 53.5 percent female and 46.5 percent male, while intern respondents included a largerproportion of males (58.5%) and a smaller proportion of females (41.5%). Of the 207 questionnaires mailedto residents, 15 (7.2%) were undeliverable after two mailings. None of the intern questionnaires wasundeliverable after the second mailing. Thus, while interns constituted only 29.1 percent of the totalresident and intern survey population, they accounted for 34.7 percent of the respondents.Unlike the practising physician and practising physician spouse survey groups, interns and residents werenot divided into rural and urban sub-groups for the purpose of description and analysis. This was partlybecause of the nature of the group under scrutiny and partly a result of their intentions regarding practicelocations upon graduation. First, a division into rural and urban sub-groups is not appropriate sincevirtually all residencies are based in urban teaching hospitals. While the intended location of respondents'practices might have been another basis of comparison, only eight (6.8%) of the 118 interns and residentswho responded to the survey indicated that their first choice would be to establish practices in ruralcommunities. Accordingly, this method of classification is not useful for comparative purposes. Acomparison of respondents based on an urban and rural/semi-rural split, however, is undertaken in theanalysis. This is made possible since an additional 31 respondents declared that it was their intention to73establish their practices in semi-rural areas. This basis of analysis, however, is somewhat problematic foracross-group comparison, since interns and residents were provided with specific definitions of urban andrural while practising physicians and spouses were not. For some questions in the resident and internquestionnaire, urban areas were defined as "having all necessary specialty backup services readily available"and rural areas were "over 100 kilometres or more than 1.5 hours from a secondary or tertiary hospital."For the purposes of analysis, practising physicians and their spouses were sub-divided according to the sizeof the community in which their practices were located: rural (communities of up to 10,000 people) andurban (communities of more than 10,000 people). In any direct comparison of the different survey groups,therefore, these varying definitions of rural and urban must be considered.For the first part of the analysis, the interns/residents will generally be described without disaggregationinto rural and urban groups. In large part, resident or intern status provides the basis for comparison.Residents and interns are subsequently divided into those intending to establish practices in rural or semi­rural areas and those intending to practise in urban areas.II. Profile of RespondentsAge, Sex and Marital StatusTable D-1 provides a breakdown of respondents' age and sex. The table indicates that there was agreater proportion of female respondents among interns. While 70.1 percent of responding residents weremale, the corresponding figure for the intern group was only 58.5 percent. The interns who responded tothe survey were slightly younger than their resident counterparts. Only one of the responding interns (2.4%)was over thirty-nine, while 6.5 percent of responding residents fell into this category. Female residents andinterns were also slightly more likely to be older than their male counterparts.74Table D-IRespondents by Age and Sex(Total N = 118)Residents InternsAge Male Female Total Male Female TotalN % N % N % N % N % N %< 35 45 83.3 17 73.9 62 80.5 22 91.7 15 88.2 37 90.235 - 39 7 13.0 3 13.0 10 13.0 1 4.2 2 11.8 3 7.340 -44 1 1.9 2 8.7 3 3.9 1 4.2 - - 1 2.445 - 49 1 1.9 1 4.3 2 2.6 - - - - - -Totals 54 100.0 23 100.0 77 100.0 24 100.0 17 100.0 41 100.0(%) (70.1) (29.9) (100.0) (58.5) (41.5) (100.0)The information displayed in Table D-2 indicates that a greater proportion of interns (55.0%) than ofresidents (46.8%) were single. In addition, in both the resident and intern groups, the proportion of femaleswho were single (residents 60.9%; interns 68.8%) was greater than the proportion of single males (residents40.7%; interns 45.8%). However, just over half (51.9%) of the resident group were married (or living witha partner), while only 45.0 percent of the intern group were married (or living with a partner). Theproportion of single female interns was larger than the proportion of single female residents; thisrelationship also held for male interns and residents although the difference between these two groups wasnot as large as in the case of females.Table D·2Respondents by Marital Status and SexResidents InternsStatus Male Female Total Male Female TotalN % N % N % N % N % N %Single 22 40.7 14 60.9 36 46.8 11 45.8 11 68.8 22 55.0Married 32 59.3 8 34.8 40 51.9 13 54.2 5 31.3 18 45.0Oilier - - 1 4.3 1 1.3 - - - - - -Totals* 54 100.0 23 100.0 77 100.0 24 100.0 16 100.0 40 100.0(%) (70.1) (29.9) (100.0) (60.0) (40.0) (100.0)* Non-respondents: Interns = 1.75Community of Residence as a YouthRespondents were asked to identify the size of the communities in which they were born and hadattended elementary and secondary school. This information is outlined in Tables D-3a and D-3b. Theoverwhelming majority of both residents and interns were born and educated at the elementary andsecondary levels in urban communities of over 10,000 people. However, the proportion of residents fromcommunities of 10,000 of fewer people was double that of interns in each case, except for community ofsecondary school. The proportion of interns who were born and educated in communities of between 10,001and 50,000 people was approximately double that of residents. Overall, almost two-thirds of residents andslightly over half of interns were born and educated in communities with populations larger than 100,000.Table D-3aResponding Residents by Size of Community ofBirth, Elementary, and Secondary SchoolPopulation Birth Elementary SecondaryN % N % N %Up to 10.000 13 17.1 13 16.9 12 15.810.001 - 50.000 9 11.8 10 13.0 7 9.250.001 - 100.000 5 6.6 5 6.5 7 9.2More than 100.000 49 64.5 49 63.6 50 65.8Totals* 76 100.0 77 100.0 76 100.0* Non-respondents: Birth =1; Secondary =1.Table D-3bResponding Interns by Size of Community ofBirth, Elementary, and Secondary SchoolPopulation Birth Elementary SecondaryN % N % N %Up to 10.000 3 7.3 3 7.3 5 12.210.001 - 50.000 10 24.4 9 22.0 10 24.450.001 - 100.000 3 7.3 5 12.2 5 12.2More than 100.000 25 61.0 24 58.5 21 51.2Totals* 41 100.0 41 100.0 41 100.076Father's Field of EmploymentAs with the practising physician group discussed earlier, the most frequently noted category for father'sfield of employment was "Managerial/Administrative" (22.1%) for responding residents. Among interns,"Physician" (14.6%) ranked first as a category of father's field of employment; among responding residents,"Physician" ranked second (14.3%). If "Other Medicine/Health" is combined with the "Physician" category,the rankings of the profession/field of employment categories remain unchanged for residents and internsas separate groups. For residents, however, the gap between the managerial/administrative and the physiciancategories is narrowed from an original difference of 7.8 percent to a 5.2 percent difference. For interns,the gap between the first ranking physician category and the second in rank teaching andmanagerial/administrative categories is widened considerably, from 2.4 percent to 14.6 percent. In the finalanalysis, 26.8 percent of interns noted father's field of employment as health care-related, either physicianor other medical or health-related fields.Table D-4Father's ProfessionlField of EmploymentProfession Residents InternsN % N %Managerial/Administrative 17 22.1 5 12.2Physician 11 14.3 6 14.6Teaching 8 10.4 5 12.2Social Sciences/Law 4 5.2 - -Sales 4 5.2 3 7.3Services 4 5.2 - -Farming/Ranching 4 5.2 2 4.9TransportlEquipment Operation 3 3.9 4 9.8Other Medicine/Health 2 2.6 5 12.2Artistic/Literary 2 2.6 - -Construction 2 2.6 - -Machining 2 2.6 - -Religion 1 1.3 - -Forestry/Mining 1 1.3 2 4.9Processing/Manufacturing 1 1.3 1 2.4Clerical - - 1 2.4Other 11 14.3 7 17.1Totals 77 100.0 41 100.077If residents and interns are examined as one group, and physician and other medicine/health arecombined, this category becomes the most frequently selected overall (20.3%). As with the practisingphysician group, the number of residents and interns who indicated that their fathers were employed in otherprofessions or fields of employment was nearly as large or larger than the listed items. Table D-4 displaysin more detail the profession and field of employment of each respondent's father.Preferences for Leisure Time ActivitiesWhen asked to indicate a preferred kind of leisure time activities, responding interns and residentsnoted a preference for outdoor (73.9%), active (85.5%), sporting (74.1%), and non-group (59.1%) activities,although interns were evenly divided, preferring group and non-group activities equally. In terms ofoutdoor activities (80.5%) and activities that require active participation (92.5%), responding interns werevery closely matched with practising urban physicians. In terms of a preference for sporting activities(79.5%), responding interns were more closely matched with practising rural physicians. Collectively, theinterns who responded to the survey were unique in the almost equal division of their preferences for groupand non-group activities (Table D-5d). Both interns and residents preferred non-group activities, but theproportion of residents that preferred such activities was greater than the corresponding proportion ofinterns. In each of the other leisure activity items, the proportion of responding residents was between 7.5and 10.5 percent smaller than the proportion of interns indicating similar preferences (Tables D-5a throughD-5d).III. EducationArea of Residency - Professional GoalsResidents were asked to indicate the specialty or professional discipline in which they were doing aresidency, while interns were asked their intended professional goal. Twenty eight residents and interns(23.9%) expressed an intention to pursue general and family practice. Eighty-nine residents and internsexpressed an intention to pursue specialty training.78~Table D-5aRespondents by Preference forIndoor vs, Outdoor Leisure ActivitiesActivities Residents InternsN % N %Indoor 22 28.9 8 19.5Outdoor 54 71.1 33 80.5Totals* 76 100.0 41 100.0* Non-respondents: 1 resident.Table D-5cRespondents by Preference forSporting vs, Cultural Leisure ActivitiesActivities Residents InternsN % N %Sporting 54 72.0 31 79.5Cultural 21 28.0 8 20.5Totals* 75 100.0 39 100.0* Non-respondents: 2 residents; 2 interns.TableD-5bRespondents by Preference forActive vs, Spectator Leisure ActivitiesActivities Residents InternsN % N %Active Participation 62 81.6 37 92.5Spectator 14 18.4 3 7.5Totals* 76 100.0 40 100.0* Non-respondents: 1 resident; 1 intern.Table D-5dRespondents by Preference forGroup vs, Non-Group Leisure ActivitiesActivities Residents InternsN % N %Group 28 37.8 19 48.7Non-Group 46 62.2 20 51.3Totals* 74 100.0 39 100.0* Non-respondents: 3 residents; 2 interns.Of this latter group, 58 (64.9%) planned to pursue clinical specialties, 24 (26.8%) planned to pursue surgicalspecialties, and seven (7.8%) planned to pursue laboratory specialties.Of the respondent residents, a total of 59.7 percent reported clinical residencies. A further 22.1 percentwere involved in surgical residencies, and 9.1 percent noted laboratory specialties. Finally, 9.1 percent ofresidents noted family practice (CCFP) as the area of their residency. Over half (52.5%) of respondinginterns indicated either general or family practice (CCFP) as their intended professional goal. A further30.0 percent intended to pursue clinical specialties. Surgical specialties were noted as professional goals by17.5 percent of interns. No interns indicated an intention to pursue laboratory specialties.Internal medicine was the most frequently chosen area of specialty among residents (13.0%) and amonginterns (7.5%), excluding those interns who intended to pursue either general practice or family practice(CCFP). Paediatrics was noted as the specialty of residency of 11.7 percent of residents. This was followedby 9.1 percent of residents who chose psychiatry as their area of residency. Ophthalmology was first amongsurgical specialties noted by residents (5.2%), followed by cardiovascular and thoracic (3.9%), andneurosurgery (3.9%). Interns indicating clinical specialties as intended professional goals selected, afterinternal medicine, anaesthesia and emergency medicine (at 5.0% each). Further details of residents'specialties and interns' professional goals are outlined in Appendix G.Undergraduate Medical TrainingAs with practising physicians, residents and interns were asked to indicate the Canadian or foreignuniversity from which they received their undergraduate medical training. Tables D-6 and D-7 present, inranked order, responding residents and interns according to the province or country in which they graduatedfrom university. The proportion of responding residents (66.2%) who received their undergraduate trainingfrom Canadian universities, while similar to the practising physician group, was different from the internpopulation. While 26 residents (33.8%) were trained at foreign universities, only one intern indicated havingreceived undergraduate training from a foreign university, in this case, India.80a) Canadian UniversitiesThe proportions of responding residents and interns who graduated from universities in each ofCanada's provinces did not compare directly with the actual place of graduation distribution of the practisingphysician survey group (see Cavalier et al., 1990). Residents and interns who were educated in BritishColumbia accounted for slightly more than one-quarter (26.7%) of responding Canadian educated internsand residents. The University of British Columbia was the single largest source of the intern/residentgroup. When examined separately, however, figures for residents vary somewhat from those for interns. Thesingle largest source of responding residents was Alberta, with the two universities in that provinceaccounting for 31.4 percent of those who responded. While 38.5 percent of interns had graduated from theUniversity of British Columbia, only 17.6 percent of residents received their training at UBC. As withpractising physicians, approximately two-thirds of responding Canadian-trained residents (68.6%) and interns(66.8%) received their undergraduate training at universities west of the Ontario-Manitoba border.Table D-6Responding Residents and Interns byProvince of Graduation (Canada)(Total N: Residents =51; Interns =40)Province Residents Interns Group TotalN % N % N %Alberta 16 31.4 6 15.4 22 24.4Ontario II 21.6 4 10.3 15 16.7British Columbia 9 17.6 15 38.5 24 26.7Saskatchewan 7 13.7 4 10.3 II 12.2Newfoundland 4 7.8 I 2.6 5 5.6Manitoba 3 5.9 I 2.6 4 4.4Quebec I 2.0 5 12.8 6 6.7Nova Scotia - - 3 7.7 3 3.3Totals* 51 100.0 39 100.0 90 100.0(56.7) (43.3) (l00.0)* Non-respondents: Interns = I.81b) Foreign UniversitiesOf the interns who responded to the survey, only one trained in a foreign university (India). Almosthalf (46.2%) of the 26 responding residents who had received their undergraduate medical education outsidecanada indicated training from universities in areas or countries not itemized in the survey questionnaire.Areas not itemized in the questionnaire included much of Asia, Africa, the Middle East, and Central andSouth America. Those residents who did select an itemized country or area reported training in the UnitedKingdom (15.4%), Australia/New Zealand (11.5%), South Africa (11.5%), and various other countries.Details of the results are provided in Table D-7.Table D-7Responding Residents and Interns byPlace of Graduation (Outside Canada)(Total N: Residents = 26; Interns = 2)Place of Graduation Residents Interns Group TotalN % N % N %United Kingdom 4 15.4 - - 4 14.8Australia/New Zealand 3 11.5 - - 3 11.1South Africa 3 11.5 - - 3 11.1Hong Kong 1 3.8 - - 1 3.7Other Europe 1 3.8 - - 1 3.7United States 1 3.8 - - 1 3.7India 1 3.8 1 100.0 2 7.4Other 12 46.2 - - 12 44.4Totals* 26 100.0 1 100.0 27 100.0(96.3) (3.7) (100.0)* Non-respondents: Interns = 1.IV. CommunityResidents and interns were asked to indicate if and for how long they had been in a rural communityduring their medical training. For the purposes of this question, rural communities were defined as thosewith populations of up to 10,000 people (Tables D-8a and D-8b). Close to half of all responding residents(48.7%) and interns (43.9%) did not spend time in a rural community during their undergraduate medical82training. Twenty-one percent of residents and 29.3 percent of interns spent one month or less in rural areasduring their undergraduate years. Over a quarter of residents (30.3%) and interns (26.8%), however, hadspent more than one month in rural communities during this time.Table D-SaUndergraduate Medical Trainingin Rural Areas(Total N: Residents =77; Interns =41)Length of Training Residents InternsN % N %Less than One Month 8 10.5 4 9.8One Month 8 10.5 8 19.5More than One Month 23 30.3 11 26.8Never 37 48.7 18 43.9Totals* 76 100.0 41 100.0* Non-respondents: Residents = 1.Table D-SbPost-graduate Medical Trainingin Rural Areas(Total N: Residents =77; Interns =41)Length of Training Residents InternsN % N %Twelve Months 3 4.3 - -Nine Months 4 5.7 - -Three Months 5 7.1 - -One Month 2 2.9 4 13.8Never 56 80.0 25 86.2Totals* 70 100.0 29 100.0* Non-respondents: Residents = 7; Interns = 12.83The proportion of residents and interns with any rural experience was reduced further during theirpost-graduate medical training. Eighty percent of residents and 86.2 percent of interns who responded tothe question reported never having spent time in a rural area during their post-graduate training. Onlythree residents who responded to the question (4.3%) had spent more than a year in a rural area duringtheir post-graduate medical training.Respondents were asked to indicate their first choices for location of practice following completion oftheir residency or internship program (Table D-9). Only 28.0 percent of residents, compared with 41.5percent of interns, chose rural or semi-rural areas as their area of first preference for establishing a practice.Table D-9First Choice for Location of Practice(Total N: Residents =77; Interns =41)Location of Choice Residents InternsN % N %Urban Area 54 72.0 24 58.5Semi-rural Area 18 24.0 12 29.3Rural Area 3 4.0 5 12.2Totals* 75 100.0 41 100.0* Non-respondents: Residents =2.For the analysis of residents and interns that follows, "rural," "rural/semi-rural," and "rural-bound" referto respondents who intended to establish practices in rural or semi-rural areas, while "urban" and "urban-bound" refer to those who intended to establish practices in urban areas. Accordingly, comparisons betweenresidents and interns based on the intended rural or urban location of their practices, and comparisons withphysicians based on their actual rural or urban practice locations, should be approached with caution becauseof the differing definitions of rural and urban provided to respondents and assumed in the analysis.Those residents and interns who had spent time in a rural area as part of their undergraduate or post-graduate medical training were asked to indicate on a scale from (1) "not at all" to (5) "very much" thedegree to which they had enjoyed a) "the practice of medicine in that community," b) "the community life,"84and c) their "personal/family life." Table 0-10 displays means and standard deviations for the levels ofenjoyment for the group, as well as for the type of area in which they were planning to set up practice.Because the cell for rural-bound contained only two respondents, the rural- and semi-rural-bound werecollapsed into one category for the purposes of analysis.Table D-IOResidents and Interns by Enjoyment of Rural Experience(RuraIlSemi-Rural-bound vs, Urban-bound)(l =not at all ... 5 =very much)(Total N = 53)Aspects of Intended Location of PracticeRural Experience Rural/Semi-rural Urban Total Group"Standard Standard StandardN Mean Deviation N Mean Deviation N Mean DeviationPractice** 18 4.33 0.767 28 3.61 1.066 46 3.89 1.016Community 18 3.50 0.985 28 2.96 1.170 46 3.17 1.122Personal 17 3.24 1.300 27 2.89 1.188 44 3.02 1.229* Non-respondents: Practice =7; Community =7; Personal =9.** Highly Significant (p < 0.01).Among responding residents and interns, there was a reasonably high average level of enjoymentregarding their experiences in rural medical practice, rural community life, and their personal lives in therural area, regardless of the type of area in which they intended to set up practice. In each case, however,the urban-bound residents and interns enjoyed these aspects of rural life less than those who planned to setup practice in rural or semi-rural areas. In particular, based on a two-tailed t-test, the difference in thedegree to which these two groups enjoyed the practice of medicine in that community was found to behighly significant. Furthermore, in each case, the mean level of enjoyment for the rural-bound was greaterthan the mean for the total survey group, while the enjoyment level of those intending to establish urbanpractices was lower than for the total group.85Satisfaction LevelsRespondents were asked to indicate, from a list of 35 survey items, the degree to which various factorswere influential motivators in the choice for the location of their future practice. These items wereessentially the same as those for which physician respondents were asked to indicate their levels ofsatisfaction regarding aspects of their professional, community, and personal/family lives. Using a five­point scale that ranged from (1) "not at all" to (5) "very much," residents and interns were asked to indicatethe extent to which the main reason for establishing a practice in rural, semi-rural or urban areas wasmotivated by factors directly related to the items listed. These items are ranked in the order of the meanscores of the rural-bound respondents in Appendix H.a) Professional ItemsThe professional factor of most importance to the practice location decisions of both residents andinterns was the "opportunity to practice the kind of medicine" they desired (rural 4.47; urban 4.24); thedifference between their mean scores was not statistically significant. For the rural-bound residents andinterns, the professional factors ranking next in importance in practice location decisions were "level ofresponsibility" (rural 4.28; urban 3.22) and "challenge of practice" (rural 4.24; urban 3.72). In both of thesecases, the differences in the mean scores for the two groups were highly significant. Items ranked low bythe rural-bound group, but relatively high by the urban-bound group were:i) research opportunities (rural 1.83; urban 3.32);ii) teaching and academic medicine opportunities (rural 2.61; urban 4.04);iii) access to specialist expertise (rural 3.27; urban 3.83).The differences in the means of each of these items were highly significant at the 0.01 level. The differencesin the means for "research opportunities" and "teaching and academic medicine opportunities" were thelargest among all the professional items measured. While those intending to establish urban practicesconsidered these items to be of substantial importance in their location decisions, rural-bound residents andinterns attributed much less importance to them.86"Opportunities for continuity of care," "opportunity to earn a good income," and "caseload in relationto income" were ranked higher in importance by rural-bound residents and interns than by those planningto practise in urban areas. The difference in the mean scores for the first item was highly significant at the0.01 level; for the other two items, the differences were significant at the 0.05 level.The "availability of medical facilities" (rural 3.54; urban 4.03) and the "availability of clinical support"(rural 3.30; urban 3.86) were each ranked higher in importance by those residents and interns intending toestablish urban practices. The differences in the mean scores for these items were statistically significantat the 0.05 level.The professional item accorded the least importance as a factor in the practice location decisions ofeither of the resident/intern groups was "opportunities for involvement in RCM.A., CM.A. or other relatedactivities" (rural 1.70; urban 1.76). The difference in the mean scores between these two groups was notstatistically significant. "Opportunity to practice as a family doctor" ranked fifteenth in importance as aninfluence in the practice location decisions of rural-bound residents and interns. With this item, thedifference between the means for the rural- and urban-bound groups was highly significant. This is an item,however, that ranked third among practising physicians in relation to their level of satisfaction withprofessional concerns. With this exception, the importance that residents and interns attributed toprofessional concerns appeared consistent with the satisfaction levels for corresponding items as noted bypractising physicians.b) Community ItemsRural-bound residents and interns ranked "quality of environment" of primary importance among thecommunity factors with influence on their practice location decisions. This is consistent with rural practisingphysicians who ranked this item as one of the community-related concerns with which they were mostsatisfied. As well, the difference between the rural mean score (4.47) and the urban mean (3.62) for thisitem was highly significant (p < 0.01).87"Lifestyle in the community" was ranked third among the community items of importance in the practicelocation decisions of those residents and interns intending to establish rural practices. Furthermore, thedifference in the mean scores for this group and those who were urban-bound was significant (p < 0.05).The community item for which there was the greatest difference in mean scores of rural- and urban-boundresidents and interns was "sense of community." This item ranked quite highly in importance among rural­bound residents and interns (4.16), but it was of only moderate importance to those intending to establishpractices in urban areas (2.94). A two-tailed r-test determined that this difference was highly significant.While of least importance among community items in the practice location decisions of both rural­(3.33) and urban-bound (2.57) residents and interns, the difference in the mean scores for the "possibilityfor community involvement/leadership" was highly significant. The only community item ranked lower byresidents and interns intending to establish rural practices than by their urban-bound counterparts was the"availability of cultural activities" (rural 3.70; urban 4.00); the difference in these means was found not tobe statistically significant.c) Personal/Family ItemsResidents and interns identified all of the personal/family items listed in the questionnaire except"proximity to relatives and extended family" to be of moderate to high influence in location decisions. Foreach of these items, the differences between the means of the urban-bound and the rural-bound were notstatistically significant. Those intending to establish urban practices attributed moderate importance (3.45)to "proximity of relatives and extended family," while rural-bound residents and interns ranked this item ofmuch lesser importance (2.36). The difference in the mean score was highly significant (p < 0.01).V. Concluding RemarksFor both residents and interns, the proportion of female respondents was greater than in the rural andurban practising physician groups. This was particularly true in the intern group, where 41.5 percent ofrespondents were female, in comparison with approximately 20 percent in the practising physician groups.88This may partly reflect a trend increasingly towards the breakdown of gender as a barrier to the study andpractice of medicine.As with the practising physicians, most respondent residents and interns were born and educated incommunities of more than 100,000 people. Indeed, the proportions for both interns and residents of the"city"-born and -educated sub-group exceeded the proportion of "city"-born and -educated seen among thephysician respondents.Among the items pertaining to community of birth and education, there was only one, that of secondaryschool, for which a smaller proportion of residents and interns, as compared with the proportions ofpractising physicians, noted being from communities of more than 100,000 people. Even in this case, theproportion of urban practising physicians who attended secondary school in communities of over 100,000people was only slightly larger than the corresponding proportion of interns. As with the practisingphysician group, the single most frequent response for "Father's field of employment" of the residents was"Managerial/Administrative." Although the proportions of interns and residents who chose "Physician" werecomparable to those in the practising physician groups, this response was the most frequently chosen amonginterns. Further, the proportion of interns who selected "Other Medicine/Health" as their fathers' field ofemployment was considerably higher than in the resident or practising physician groups.Over half of the interns who responded to the survey noted general practice or family practice (CCFP)as their intended professional goal; slightly more than one-tenth of responding interns (12.2%) intended toestablish practices in rural areas. An additional 29.3 percent, however, intended to establish practices insemi-rural areas.Few of the responding residents and interns had spent any of their post-graduate experience in ruralareas. A sizeable proportion of each group had no undergraduate medical experience in rural practice.Residents and interns who had previously worked in rural areas expressed moderate to fairly highenjoyment of their rural experiences. Only for the item describing enjoyment of their professional practicewas the difference in mean scores for rural- and urban-bound residents and interns statistically significant.89In terms of practice location decisions, rural-bound residents and interns appeared to place considerableimportance on professional items such as the level of responsibility that characterizes the practice, thechallenge of the practice, and the variety in medical problems to be treated. Those who were urban-boundappeared to place more importance on items that indicated a concern for professional support such asmedical facilities, clinical support, and access to specialists. Consistent with responses regarding satisfactionlevels of practising physicians, the only community item to which urban-bound residents and internsattributed greater importance than did those who were rural-bound was "availability of cultural activities."90PART E: INTER-GROUP COMPARISONS AND CONCLUSIONI. The Scope and Structure of Medical PracticeRural physicians were more likely than their urban counterparts to be practising in group settings.Theoretically, according to the literature on the practice of medicine in rural areas, this should reduce thedemands of rural practice on individual physicians because patient loads would be shared with otherphysicians. By extension, this would mean that rural physicians could spend more time with their families.Despite the greater proportion of group practices among rural physicians, however, their workloads, assuggested by the number of nights per week spent on-call, appeared to be heavier than those of urbanphysicians. Patient volumes also appeared to be larger than those of urban physicians; a large proportionof rural physicians saw from 21 to 40 patients in an average day, while the greatest proportion of urbanrespondents saw from 1 to 20 patients per day. The lower patient volumes of urban physicians may haveresulted from individual patient requirements for more time with urban specialists. Perhaps in compensationfor their apparently heavier patient loads, a greater proportion of the rural physicians took more than fourweeks of holidays in the year of the survey.In support of the contention that rural medical practice is more varied than urban practice, a greaterproportion of rural physicians spent at least some time in each of the medical areas itemized, except physicalmedicine and rehabilitation, medical subspecialties, and surgical subspecialties (Appendix D). This may berelated to the greater proportion of general practitioners who practice in rural communities and the fact thatspecialist practices are more likely to be located in urban areas.II. Profile of Practising Physicians and their SpousesThe vast majority of both the rural and the urban practising physician groups were male and married.Greater proportions of female practising physicians from these groups, however, were single.A statistical comparison of married physicians and spouses has not yet been undertaken. In general,however, rural physicians and spouses tended to be younger than their urban counterparts; this wassupported by the higher proportion of rural respondents who had children from younger age brackets.91Spouses of rural physicians were more likely than rural physicians to have been born and educated insmaller rural communities (10,000 or fewer people). At the same time, urban physicians were more likelythan urban spouses to have been born and educated in communities of more than 100,000 people.In terms of their preferences for leisure time activities, both the practising physician and spouse groupsexpressed a preference for outdoor over indoor activities; active over spectator activities; sporting overcultural activities; and non-group over group activities. In each case except the last, the proportion ofrural respondents who indicated these preferences was noticeably larger. The proportion of rural practisingphysicians who indicated these preferences was also somewhat larger than the proportion of rural spouseswho indicated likewise.Influence in Location DecisionsSpouses reported that, in family decision-making concerning whether to remain in current practicelocations, their contributions were important. In addition, regardless of geographic setting, practisingphysicians rated spousal influence as the most influential of a number of factors relating to location decision.However, mean scores of practising physicians for spousal influence were lower than the mean scores forthe extent to which spouses believed they influenced practice location decisions.Satisfaction With Specific Professional, Community, and Family/Personal ConcernsA comparison of practising physicians and spouses based on average satisfaction scores for specificprofessional concerns is not appropriate because all items were not applicable to both groups. However,most of the specific community and personal/family items for which physicians and spouses were asked toindicate their level of satisfaction are directly comparable. Physicians' and spouses' mean satisfaction scoresfor community items did not differ greatly and were relatively high.The mean scores for rural physician and rural spouse satisfaction with various community items differedby more than 0.10, on a scale of one to five, for only four items. Rural spouses' mean scores were morethan 0.10 higher than rural physician mean scores for satisfaction with the quality of the environment and92satisfaction with financial/economic security in the community. The difference in the mean scores for theformer item was statistically significant; for the latter item the difference in the mean scores was highlysignificant. Indeed, while rural spouses ranked as third the community item "financial/economic security,"practising physicians ranked it ninth among ten community items in terms of satisfaction. Rural physicians'mean satisfaction scores were greater than those of rural spouses in relation to the availability of culturalactivities (the difference in these scores was statistically significant) and recreational facilities in thecommunity.Urban physicians' mean satisfaction scores were larger than those of urban spouses for quality of theenvironment, lifestyle in the community, community size, and the availability of recreational facilities andcultural opportunities in the community. The mean satisfaction score of urban spouses was larger than thatof practising urban physicians only for the possibility for community involvementlleadership. Except forquality of the environment, each of these items showed statistically significant differences in mean scores.Among the personal/family items, rural spouses' mean satisfaction scores were larger than those of ruralphysicians for quality of housing, spouses' contentment in the community, and time for family life (orrecreation and leisure time). The differences in the mean scores for these items were statistically significantand highly significant, respectively. Rural physicians' mean satisfaction scores were higher than the spouses'for the opportunity to earn the kind of income they desired and the availability of cultural opportunities forthemselves and their families.None of the urban spouses' mean satisfaction scores for personal/family items exceeded the scores ofurban physicians by more than 0.10, nor were any of the differences in mean scores for these itemsstatistically significant. Urban physicians' mean scores, however, exceeded this margin for the followingitems: spouse's contentment in the community, quality of life and education for the respondent's children,and the availability of cultural opportunities for themselves and their families. Only for the last item wasthe difference in the mean satisfaction scores found to be statistically significant. The mean satisfactionscores of urban physicians and urban spouses differed by more than 0.10 for more community andpersonal/family items than did the scores of their rural counterparts. In terms of the relative ranking of93these items based on mean satisfaction scores, however, urban physicians and spouses were closer inagreement with each other than were rural physicians and spouses.Overall Satisfaction with Professional, Community, and FamilyJPersonal LifeIn terms of overall satisfaction with professional and community life, practising physicians in rural andin urban areas tended to have appreciably higher mean scores than rural and urban spousal groups. Foreach of these items, the difference in mean satisfaction scores of rural physicians and rural spouses washighly significant. The difference in the mean scores of urban physicians and urban spouses was statisticallysignificant for satisfaction with community life and highly significant for professional satisfaction. Amongboth the practising physician and the spousal groups, urban respondents had higher mean scores forprofessional satisfaction than their respective rural counterparts; at least part of the reason for the lowmean score among rural spouses may be the higher proportion of these respondents who are involuntarilyunemployed.The mean scores for overall satisfaction with personal/family life were almost equal for urban physiciansand urban spouses. For rural physicians, the mean score for overall satisfaction with personal/family life wasslightly smaller than that of rural spouses; the difference between these means was found to be statisticallysignificant.III. Profile of Residents and InternsThe proportion of women among the resident and intern group was somewhat larger than among theurban or rural practising physician groups. For the most part, residents and interns were more likely thaneither practising physicians or spouses of practising physicians to have been born and educated incommunities of more than 100,000 people. However, the proportion of urban physicians who attendedsecondary school in communities of more than 100,000 was greater than the proportion of interns whoattended secondary school in communities of that size. While the resident and intern group, on average,94expressed a preference for the same types of leisure activities as practising physicians, the proportion ofresidents and interns indicating such support in each case was not as large.Intended Areas of SpecializationA large proportion of residents and interns were either involved in or expressed intentions to pursuespecialty training. The proportion of this group that planned to pursue clinical specialties was larger thanthe proportion of practising specialists who had been trained in these areas. The proportion of interns andresidents interested in specialization and intending to pursue surgical specialties, however, was smaller thanthe proportion of responding specialists actually practising in these areas. The proportion of interns andresidents who intended to pursue laboratory specialties was more than double that of specialist respondentswho were practising in these areas.Professional, Community and PersonallFamily Items: Satisfaction and InfluenceWhen asked where they intended to establish their future practices, residents and interns overwhelminglychose non-rural areas. They were then presented with a series of professional, community, andpersonal/family items and asked to indicate the extent to which these had been influential in their choiceof practice location. Practising physicians had been presented with a similar but longer list and asked toindicate their level of satisfaction with these and other such items. While a cross-group statisticalcomparison of these items is not appropriate, given the different concepts involved in the questions, adescriptive comparison provides some indication of the degree to which some of the expectations of internsand residents may be borne out in the actual experiences of practising physicians. However, such acomparison cannot identity any causal relationship or even a correlation between elements of the decision­making of interns and residents and the experiences of practising physicians.Responding interns and residents indicated that, among professional items, the opportunity to practiceas a family doctor was not very influential in their practice location decisions. However, this was one of theprofessional factors with which practising physicians were most satisfied. In addition, while rural-bound95interns and residents rated the ability to secure uninterrupted free time as a factor of moderate importancein their practice location decisions, practising rural physicians indicated that this was an item with which theywere somewhat less than satisfied. Rural-bound interns and residents indicated that most of the communityitems were of moderate to high influence in their practice location decisions. Practising rural physiciansindicated mean satisfaction levels for these items that also ranged from moderate to high. While urban­bound interns' and residents' mean influence scores were relatively low for sense of community andpossibility for community involvement/leadership, practising urban physicians' mean satisfaction scores forthese items were relatively high.Among personal/family items, proximity to relatives and extended family was considered the factor ofleast influence by rural-bound residents and interns and of second least influence by their urban-boundcounterparts. This item was ranked as least satisfactory by practising physicians, both rural and urban.Practising rural physicians scored this item as less than satisfactory, while practising urban physicians scoredit as only moderately satisfactory.IV. Concluding RemarksFor physicians and for their spouses, the personal and professional demands and implications of ruralpractice are quite different from those that characterize the practice of medicine in urban areas. Anunderstanding of these demands and implications is essential, not only to the development of policies forthe successful recruitment and retention of physicians, but also to the development of educationalrecruitment policies for residents and interns and medical students interested in practising in rural areas.Given the importance of spousal influence on practice location decisions, knowledge of the perceiveddifferences in quality of life of rural and urban communities may provide a foundation upon which to basepolicies and programs to address spousal concerns. Rural medical practice must be better understood sothat it can be more effectively promoted and so that the concerns of those who value its distinct nature canbe addressed. While not itself a basis upon which to implement policy, this descriptive analysis hasidentified a number of issues and concerns that require further in-depth examination so that efforts to rectifythe geographic maldistribution of physicians can be better focused and, ultimately, more successful.96REFERENCESREFERENCESAlberta Medical Association (1989), Report of the Task Force on Rural Medical care, May.Anderson, M. and Rosenberg, M.W. (1990), "Ontario's Underserviced Area Program Revisited: AnIndirect Analysis," Social Science and Medicine, 30(1):35-44.cavalier, S., Kerluke, K, and Wood, L. (1990), Place of Graduation for Selected Health Occupations ­1989, HMRU Report 90:7, Health Manpower Research Unit, University of British Columbia, March.Cooper, J.K, Heald, K, and Samuels, M. (1972), "The Decision for Rural Practice," Journal of MedicalEducation, 6O(December):939-944.Cooper, J.K, Heald, K, and Samuels, M. (1977), "Affecting the Supply of Rural Physicians," AmericanJournal of Public Health, 67(8):756-759.Cordes, S.M. (1978), "Opinions of Rural Physicians About Their Practices, Community Medical Needs,and Rural Medical care," Public Health Reports, 93(4):362-368.Health Manpower Research Unit (1990), PRODUCTION 89: A Status Report on the Production ofHealth Personnel in the Province of British Columbia, HMRU Report 90:4, University of BritishColumbia, March.Health Manpower Research Unit (1990), ROLLCALL 89: A Status Report of Health Personnel in theProvince of British Columbia, HMRU Report 90:3, University of British Columbia, March.Jennett, P. and Hunter, KL. (1988), "career and Practice Profiles of Alberta Medical Graduates 1973­1985: Implications for Manpower Planning and Decision Making," in Physician Manpower in canada:Proceedings of the First and Second Annual Physician Manpower Conferences, Mamoru Watanabe (ed.).Association of canadian Medical Colleges, calgary: University of calgary Printing Services.Langwell, K, Nelson, KS., Calvin, D., and Drabek, J. (1985), "Characteristics of Rural Communities andthe Changing Geographic Distribution of Physicians," The Journal of Rural Health, 1(2):42-55.Lepnurm, R and Trowell, M. (1989), "Satisfaction of Country Doctors," Healthcare ManagementForum, 2(3):14-20.Madison, D.L. (1980), "Managing a Chronic Problem: The Rural Physician Shortage," Annals of InternalMedicine, 92(6):852-854.Newhouse, J.P., Williams, AP., Bennett, B.W., and Schwartz, Wm. B. (1982), "Where Have All theDoctors Gone?" Journal of the American Medical Association, 247(17):2392-2396.Parker, RC, Jr. and Sorensen, AA (1978), "The Tides of Rural Physicians: The Ebb and Flow, or WhyPhysicians Move Out of and Into Small Communities," Medical Care, XVI(2):152-166.Skipper, J.K, Jr. and Gliebe, W.A (1977), "Forgotten Persons: Physicians' Wives and their Influence onMedical career Decisions," Journal of Medical Education, 52(September):764-766.Wilensky, G.R (1979), "Retention of Medical School Graduates: A case Study of Michigan, Researchin Health Economics, Vol. 1:153-183.APPENDIX AMembers of the Project Working Group andCollaborating OrganizationsDr. Steve Gray (to April, 1990) and Dr. Rick Hudson (after May, 1990), Province of British Columbia,Ministry of HealthMs. Cheryl Jackson, Research Officer, Health Human Resources Unit, University of British ColumbiaDr. Arminee Kazanjian, Associate Director, Health Human Resources Unit, University of BritishColumbiaMr. Nino Pagliccia, Statistician, Health Human Resources Unit, University of British ColumbiaDr. Carl Whiteside, Family Practice Residency Program, University of British ColumbiaDr. Bob Woollard, Department of Family Practice, University of British ColumbiaAPPENDIXB--•-------Directions: Use a dark HB PENCll.., ONLY and FILL IN THE RESPONSE CIRCLE COM­PLETELY and darkly. If you wish to change your answer, erase all traces of the wrongmark, then darken the correct response. Do not make stray marks on the front or backof this page.Questionnaire for Practicing Physicians(PERSONAL )5. Please indicate the size and name of the communitywhere you attended:- 2. Please indicate the age group you belong to:1. Sex- C) Male• () Femalea) Elementary School b) Secondary School() Up to 10,000 () Up to 10,0000 10,001 - 50,000 0 10,001 - 50,000C) 50,001 - 100,000 () 50,001 - 100,0000 More than 100,000 C) More than 100,000------() Under 35 yearso 35 - 39o 45 - 49() 55 - 59o 40-44o 50- 54o 60 or overName of Community: Name of Community:6. Please indicate the field of employment or professionof your father: (please fill only one circle)More choiceson the next page...-----------------3. Marital Status() Single() Married/Living with partnerC) Other4. Please indicate the name and size of the communitywhere you were bornName of Community:Size of Community:C) Up to 10,000o 10,001 - 50,000C) 50,001 - 100,000o More than 100,0001989 EMRG/UBC • L9: 11:17:PROJECTS:RURAL]H:PHYS••oooC)o(J()oC)oooPhysicianOther Medicine/HealthManagerial/AdministrativeSocial Sciences/LawReligionTeachingArtistic/LiterarySport/RecreationClericalSalesServicesFarming/RanchingPage 1- a) () Indoor- 0 or Outdoor-7. Please indicate the kind of leisure time activities thatyou prefer (Check ONLY one from each pair)NeurologyNuclear MedicinePaediatricsPhysical Medicine and RehabilitationPsychiatryRadiation OncologyRadiology (Diagnostic)Respiratory MedicineRheumatologyCardiovascular & ThoracicGeneralNeurosurgeryObstetrics & GynaecologyOphthalmologyOrthopaedicOtolaryngologyPaediatric GeneralPlasticThoracicUrologyVascularCol2()C)()()()r.,.()ooDivision of Surgery SpecialtiesCot 1 Col2o 0(J ()o 0o 0C) l)o 0('; (-\o ()() C)O C_J-) ,-l (Jo 0Requiring active participationor as a spectatorGroup activitiesor Non-group activitiesSportingor Culturalb)d)c)('I Fishing/HuntingCJ Forestry/Mining~ ';( . I Processing/ManufacturingC) Construction( ) Transport/Equipment OperationC) MachiningC) Other-----------------Page 211. From which university did you receive your under­graduate medical training? (Please fill one only.)10. In what year did you complete your training indicatedin question 8?9. Using the list of specialties above, please indicate incolumn 2 other specialties in which you have had atleast six months of training. (please fill all that apply)Anatomical PathologyGeneral PathologyHaematological PathologyMedical BiochemistryMedical MicrobiologyNeuropathologyCol 2o('\~)ooC)oLaboratory SpecialtiesCoIlo(Joo()oo Before 1956o 1956 - 1965o 1966 - 1975() 1976 - 1980o 1981 - 1985(J After 1985If in Canada:o Alberta (j Memorial() British Columbia () Montrealo Calgary () OttawaMore choices on the next page...Yes () No() General PracticeIf general practice, did you do a resi­dency in FP?8. Please indicate in column 1 in which specialty orprofessional discipline you completed your training.(Check your primary area of training only)Are you a certificate CCFP?Coil••1989 EMRG/UBC - L9:11:17:PROJECTS:RURAL]H:PHYS() Yes 0 NoOinical SpecialtiesCoil Col2C) CJ Anaesthesia(J (J Cardiology() () Clinical Immunology and AllergyC) () Community MedicineC) (J Dermatology(J C) Emergency Medicine() C) Endocrinology and MetabolismC) () Gastroenterology() ()() (j ~:~~t~~l~~cineC) 0 Infectious Disease(j 0 Internal Medicineo 0 Medical Oncologyo 0 Nephrology--------------------------0 Dalhousie 0 Queen's-() Laval 0 Saskatchewan-0 Manitoba 0 Sherbrooke• 0 McGill 0 Toronto-0 McMaster 0 Western OntarioIf abroad:12. How long have you been practicing medicine?13. How much were you influenced by the followingpeople or events in the choice of location of yourcurrent practice? (leave blank if not applicable)1 =not at all5 = very much11 - 2031 - 4051 - 60o()(JNoNoYes 0Yes 0Up to 1021 - 3041 - 50Over 60o 5 or moreo 3-4o 1-2o noneb) How many specialists are there?o 5 or moreo 3-4o 1- 2o noneoo Less than 1o 1o 2() 3o 4o 5oo 0o 1o 2o 3-4o 5-6o 7-8C)8o20. How many weekend days do you have free of medicalresponsibilities in an average working month?19. How many nights are you on-call in an averageworking week?17. If no, does this affect your practice/patient retention?16. Is this the only practice in the community?18. How many patients do you see in an average workingday?Irish RepublicUnited StatesHong KongOtherLocation of internshipLocation of residencyUndergraduate rural experiencePostgraduate rural experienceLocum experienceProfessor/mentorPeers/friendsSpouseCloseness to parents/extended familyDesire to live/Raise a familyin a similar environmentto the one I grew up inOther (specify)I)Less than 6 years6 - 10 years11 - 15 years16 - 20 yearsMore than 20 yearsoooIndia 0Australia/New ZealandUnited KingdomOther EuropeSouth Africao()oooC)ooo()I 2 3 4 5()OOOO()OO"\(j'< L)~(JC)C)O()00000()C)OCjO00000(jOOOO00000(JOOOC)00000I 2 3 4 500000------------------------------14. What is the nature of your practice?15. If a group practice, excluding yourself,a) How many GP's/Family Physicians (CCFP)are there?21. How many weeks of holidays did you have in the lastyear?o I week() 3 weekso more than 4 weeksNone2 weeks4 weekso()oo Groupo Solo----19891!MRG/UBC • L9: 11:l7:PROIECTS:RURAL]H:PHYS-- •• •Page 322. How did you go about finding a locum?-(i Locum covered by members of group practice-,'OC_)Word of mouthl/.. () Journals-() Cooperation with other doctors in town or-neighbouring towns-() Department of Family Practice ResidentsLocum services:-a) 'Matchbox', College of Family-Physicians, B.C. Chapter-b) College of Physicians and Surgeons 0-B.c. Listing Service.. c) other private service--0 Relatives/Friends-(') Not Applicable"'_/-C) Other (specify)( COMMUNITY))25. By your own definition, do you consider the areawhere you practice() urbano semi-rural() rural26. How long have you practiced in your current geo­graphical area?o Less than 1 yearCJ 1 yearo 2 - 3 yearso 4 - 5 yearso 6 -10 yearso 11 - 15 yearso 16 - 20 yearso More than 20 years24. Are you paid on a (please fill as many as apply)23. If you are a General Practitioner what percentage ofyour work time is spent in the following areas ofmedicine? (do not fill bubbles for zero percent)1= 1% to 10% 2= 11% to 20% ... 10= 91% to 100%NoYes 0o27. How long do you plan to continue practicing in thisarea?C) Less than 1 yearo 1 year() 2 - 3 yearso 4 - 5 yearso More than 5 years29. If yes, how long did you practice in that rural area?28. If you do not consider the area where you practice asrural, have you ever practiced in a rural setting?o Professional dissatisfactiono Personal/Family reasonso Dissatisfaction with communityo Financial dissatisfaction30. Why did you leave? (fill as many as apply)o Less than 1 year() 1 yearo 2 - 3 yearsC) 4 - 5 yearso More than 5 years[IF YOU HAVB MARKED 'RURAL' IN QUESTION 25SKIP QUESTIONS 28 TO 30]AnaesthesiaDermatologyInternal MedicineMedical subspecialtyOb & GynaecologyPaediatricsPathology and Lab MedicinePhysical Medicine & Reha-bilitationPsychiatry/Counselling!PsychologyPublic Health/CommunityMedicineRadiologyGeneral SurgerySurgical subspecialtyGeriatricsHouse CallsOther (specify)Fee-for-service basisSalaried basisSessional basis()oo12345678910C.')(X XJC)CX)e)()()(Jex) /je}") .~) /)0 /J/ ,. ~/ C~ ~". C/( (j C.()C.)()C)()()e)()()U()OC)()()(j(jO()C)(J()(j(Xj()()(jeJ( -)()C()()CX)()()OO()(Je)Ci(X)C)()()(i()()OlJOOOOO()1 2 3 4 5 6 7 8 9 10()()(X)()(JCX-)(JO12345678910()()e)()()C)()e)(X)1 2 3 4 5 6 7 8 9 10(J()()()C)(X)C)CX)C)~)OC)C)OO(JC)C)( ..)CX)()C)(.)()()()()()C)OC)C)e)Cl(]C)O()()()O()e)(X)C)O()C)()()OO()OOC)1'---__--------------....................................1989 EMRG{UBC • L9: 11:17:PROJECfS:RURAL]H:PHYS-- •• •Page 4/1Division of Surgery Specialties35. Please indicate your level of satisfaction with yourpresent life and practice using the following 5-pointscale.1 = very unsatisfied 3 = indifferent 5 = very satisfied34.• Using the list above, indicate in column 2 thoseconsullant/resource services, not presently availableto you, that you feel would most help you in yourpractice of medicine. Select ONLY the three mostimportant.Cardiovascular & ThoracicGeneralNeurosurgeryObstetrics & GynaecologyOphthalmologyOrthopaedicOtolaryngologyPaediatric GeneralPlasticThoracicUrologyVascularavailability of clinical supportopportunities for free and informal communi-cation with peersvariety in medical problems to be treatedacuteness of diseases seenopportunity to provide complete package ofmedical servicesaccess to specialist expertiselevel of responsibilitylength of working hours (on call)caseload in relation to incomeability to secure uninterrupted free time fromworkopportunities for continuity of careavailability of medical facilitiesopportunity to practice as a family doctorease of transfer to an appropriate level of careof the acutely ill/injured patientContinued ...col. 2C)o()oo()o8C)o()col. 1()o()ooC)ooo()ooLaboratory Specialtiescol.1 col. 2(J C) Anatomical PathologyC) (J General Pathology() 0 Haematological PathologyC) C) Medical Biochemistryo 0 Medical Microbiologyo 0 NeuropathologyProfessionalI 2 3 4 5(JOOOC)00000I 2 3 4 50000000000()O()OOI 2 345(X)()O()CJOOOO()OOOO0000000000I 2 3 4 5(JOOOO()C)O()O00000C)O()C)O31. Please indicate which of the following medicalsupport services are based in your community.-(please fill all circles that apply)--0 All of the services below-0 Ambulance service-0 Public Health Service-0 Dietetics-0 Laboratory-() Rehabilitation Services-0 Pharmacy-C) Podiatry-0 Radiology-0 Social/Psych. counselling-0 Other (specify)-I-32. Please indicate the type of hospital closest to or based-in your community.--0 Primary-0 Regional-(j Tertiary (referral)33. Please indicate in column 1 all the medical specialistback-up available to you within 100 km of your area.col. 1-0 All of the specialties belowClinical Specialtiescol. 1 col. 2-0 0 Anaesthesia-() C) Cardiology-Cl 0 Clinical Immunology and Allergy-C) 0 Community Medicine-0 0 Dermatology-(J 0 Emergency Medicine-0 0 Endocrinology and Metabolism-0 0 Gastroenterology-0 0 Geriatric Medicine-C) 0 Haematology-C) () Infectious Disease-0 0 Internal Medicine-C) () Medical Oncology-0 0 Nephrology-() 0 Neurology-0 0 Nuclear Medicine-C) 0 Paediatrics-() 0 Physical Medicine and Rehabilitation-0 () Psychiatry-0 0 Radiation Oncology-0 0 Radiology (Diagnostic)-() 0 Respiratory Medicine-C) 0 Rheumatology1989 EMRGNBC - L9: II: 17:PROJECTS:RURAL]H:PI/YS-- •• •Page 537. In the near future (in the next 5 years, say), do youintend to move your practice to...39. If you are currently practicing in an urban or semi­rural area, would you be interested in doing a locumin a rural area within the next three years?NoYes 01 - 2 weeks3 - 4 weeks1- 3 months4 - 6 months7 - 9 months9 -12 monthsmore than one yearo()o()Q()o()40. If yes, for how long?38. If you intend to move your practice, to what extent isthe main reason for moving motivated by a factordirectly related to ...?l=not at all 5=very mucho an urban areaC) a semi-rural areao a rural areao In the near future I do not intend to move mypractice1 2 3 4 5(j()()/J('~ ~. __ ~_J When I look at my personal/family life I amquite satisfied with the quality of those rela­tionships.I 2 3 4 5()(JO()() the community you live in nowOOOO() strictly professional reasons00000 personal/family reasons()OQOO .. .income1 2 3 4 5C\ -- )~()(\L L_ _j When I look at the community where I live Ithink that it greatly contributes to my overallquality of life.36. Read the following statements and indicate to whatextent you agree or disagree:l=strongly disagree 3=indifferent 5=strongly agreeI 2 3 4 5C)()()()C) When I think of my professional career I amquite satisfied with it and there is very little Iwould like to change.I 234 5Community1 2 3 4 5()(i(Xi() size of communityC(~()()) availability of cultural activitiesCXXXJC) availability ofrecreational facilities()C=iC()C) sense of community()~)()CX) life-style in the community()(X)OC) resources with which to enjoy leisure time(JCxJe)e) financial/economic security in the communityC(~)C)OC) quality of environmentCXJOC)O possibility for community involvement!I 2 3 4 5 leadershipeX)(l()() own personal safety in the communityPersonal/FamilyI 2 3 4 5()()O()O own preference for practicing here()(",)()C)() spouse's contentment in the community( X )( )Oe )time for family life (recreation and leisureI 2 3 4 5 time)eXJ(J()() availability of cultural opportunities for self1 2 3 4 5 and familyeJ(X)(X) quality of education for my children (if any)CX)QQO quality of life for my children (if any)()()(J(J(J quality of housingCX)(J(JCJ proximity to relatives and extended family()( )( )()0 opportunity to earn the kind of income I~. 2_ ~ ~.. 5_ requireC)(X_XJ(J Other (specify)availability of locum reliefteaching and academic medicine opportunitiesresearch opportunitiesopportunities for involvement in B.C.M.A.,I 2 3 4 5 C.M.A. or other related activitiesCXX)()C) challenge of practice()(J()()(J specific training for the appropriate medicalservices in my geographic area ofI 2 3 4 5 practiceopportunity to practice the kind of medicine Iwish to practiceease to relocate practice-----------------------------------------1989 EMRG/UBC • L9: 11:17:PROJECTS:RURAL]H:PHYS•• •Page 6--(COMMENTS)1989 EMRO/UBC· L9:11:17:PROlECTS:RURAL]H:PHYS•• •Prepared by:Health Manpower Research UnitThe University of British ColumbiaPage 7--------OFFICE USE ONLYo CX)(J(J1 (Je)()()32 C)()CX]OC)CJC)4 (')()(i()5 ocj6b6 ()(X)()7 OeJeJC)8 C)CX)C)9 C)CXJODirections: Use a dark HB PENCIL ONLY and fill in the response circle completely anddarkly. If you wish to change your answer, erase all traces of the wrong mark, thendarken the correct response. Do not make stray marks on the front or back of this page.Questionnaire for Spouses ofPracticing Physicians(PERSONAL )4. Please indicate the size and name of the communitywhere you attended:a) Elementary School b) Secondary School() Up to 10,000 ( J Up to 10,0000 10,001 - 50,000 () 10,001 - 50,0000 50,001 - 100,000 () 50,001 - 100,0000 More than 100,000 () More than 100,0001. Sex-0 Male• CJ Female--2. Please indicate the age group you belong to:--(j Under 35 years-0 35 - 39 0 40 -44-0 45 - 49 0 50 - 54-0 55 - 59 0 60 or overName of Community: Name of Community:5. Please indicate the field of employment or professionof your father: (please fill only one circle)More choiceson the next page ...--------------3. Please indicate the name and size of the communitywhere you were born.Name of Community:Size of Community:o Up to 10,000o 10,001 - 50,000o 50,001 - 100,000(J More than 100,0001989 EMRG/UBC • L9:11:17:PROJECfS:RURAL1H:SPOUSB•••ooooooooooooPhysicianOther Medicine/HealthManagerial!AdministrativeSocial Sciences/LawReligionTeachingArtistic/LiterarySport/RecreationClericalSalesServicesFarrning/RanchingPage 1-(J- Fishing/Hunting-() Forestry/Mining-() Processing/Manufacturing-() Construction-C) Transport/Equipment Operation-0 Machining,-C) Other() 6 - 12o 13 - 18o 18+(EDUCATION ))7. How many children do you have?c) () Sporting() or Culturala) 0 Indooro orOutdoorb) (J Requiring active participation(J or as a spectatorNoNoYes 0Yes 0I am employed as a salaried physicianI am self employed as a physicianI am self employed (other than physician)I have a paid position as a nurseI have a paid position in the health care system(other than as a nurse or physician)I have a paid position other than in the healthcare systemprimary schoolsome secondary schoolcompleted secondary schooltrade/vocational trainingsome university, undergraduatecompleted university, undergraduatesome university, graduate levelcompleted university, graduate degreeooo()ooooooooo()o()12. Are you currently employed?14. If currently employed, which of the following appliesto you?11. What is your highest level of education?13. If no, is this by choice?( OCCUPATION ))None123More than 3Group activitiesor Non-group activitiesd)o Noneo 1o 2() 3(J More than 3o()Cl()o6. Please indicate the kind of leisure time activities thatyou prefer (Fill ONLY one circle from each pair)8. How many children are presently living in yourhousehold?-------------------------15. Aside from your family/job responsibilities, which ofthe following activities, if any, applies to you?-----9. In what age range is the youngest child (if any) livingwith you?< 11 - 56 - 1213 - 1818 +oooI do volunteer work in the communityI develop activities within a local social/recreational groupI have other activities----10. In what age range is the oldest child (if any) livingwith you?o <1o 1-51989 EMRG/UBC • L9: 11:17:PROJECTS:RURAL]H:SPOUSE••••16. To what extent have you contributed to your family'sdecision to stay in your spouse's current practicelocation? 1= Not at all '" 5= To a great extentI 2 3 4 5O()OOOPage 2'( PERSONAL SATISFACTIONJ 18. Read the following statements and indicate (whenapplicable) to what extent you agree or disagree:-17. Keeping in mind the geographical area where youlive, please indicate your feelings on the followingtopics:1 =Very Unsatisfied ... 5 =Very Satisfied---------------ProfessionalI 2 3 4 5()C)C)(X)()CXJl)l)C)CXJC)ClCommunity1 2 3 4 5ex))(y'"_ ~.. C_ ljeJC)C)()()OOOClC)( )()(XX)C)()Ci(JC)(;()()(;()I 2 3 4 5CXXXX)1 2 3 4 5'r xx ,~,l_ \~.l)UC-l(;ClCX"lI 234 5( XXX)()professional/work advancementopportunity to use my skillsopportunities for employmentsize of communityavailability of cultural activitiesavailability of recreational facilitiessense of communitylife-style in the communityresources with which to enjoy leisuretimefinancial/economic security in thecommunityquality of environmentpossibility for community involvement/leadershipown personal safety in the community1 =Strongly Disagree ... 5 =Strongly AgreeI 2 3 4 5(X)(X)() When I think of my professional career I amquite satisfied with it and there is very little I wouldlike to change.1 2 3 4 5OOOOe) When I look at the community where I live Ithink that it greatly contributes to my overall qualityof life.I 2 3 4 5()OO()() When I look at my personal/family life I amquite satisfied with the quality of those relationships.ICOMMENTS IPersonal/Family1 2 3 4 5- C)CJC)()(J spouse's contentment in the community- C)()()C)() time for family life (recreation andI 2 3 4 5 leisure time)- ('X~XJCXJ availability of cultural opportunities for1 2 3 4 5 self and family- C)OC)OC) quality of education for my children (ifI 2 3 4 5 any)- ()CXJ()C) quality of life for my children (if any)- ()C)()()C) quality of housing- (XX)(X) proximity to relatives and extendedI 2 3 4 5 family- ()()()()() opportunity to eam the kind of income II 2 3 4 5 require- CX)(JCX) other (specify)1989 EMRG/UBC - L9:11:17:PROJECIS:RURAkPH:SPOUSE-- ••• •Prepared by:Health Manpower Research UnitThe University of British ColumbiaPage 3--..-------OFFICE USE ONLYo OOC)O1 O()()()2 00003 C)()OC)4 OC)(JO5 ()()(X)6 OC)OC)7 ("'('(]('J~) ,~8 ()()()O9 ()()(JODirections: Use a dark HB PENCIL ONLY and fill in the response circle completely anddarkly. If you wish to change your answer, erase all traces of the wrong mark, thendarken the correct response. Do not make stray marks on the front or back of this page.Questionnaire for Interns/Residents(PERSONAL )5. Please indicate the size and name of the communitywhere you attended:- 2. Please indicate the age group you belong to:1. Sex- C) Male..- () Femalea) Elementary School b) Secondary School() Up to 10,000 () Up to 10,0000 10,001 - 50,000 () 10,001 - 50,0000 50,001 - 100,000 0 50,001 - 100,0000 More than 100,000 0 More than 100,000-----o Under 35 yearso 35 - 39o 45 -49o 55 - 59o 40-44o 50 - 54o 60 or overName of Community: Name of Community:6. Please indicate the field of employment or professionof your father: (please fill only one circle)More choiceson the next page...----------------3. Marital Statuso Singleo Married/Living with partnero Other4. Please indicate the name and size of the communitywhere you were bornName of Community:Size of Community:o Up to 10,000o 10,001 - 50,000() 50,001 - 100,000() More than 100,0001989E~RO/UBC - L9:1 I: 17:PROJECfS:RURAL]H:/NTERNooooooooooooPhysicianOther Medicine/HealthManagerial/AdministrativeSocial Sciences/LawReligionTeachingArtistic/LiterarySport/RecreationClericalSalesServicesFanning/RanchingPage 1- ..--- c) (J Sporting- 0 or CulturalNephrologyNeurologyNuclear MedicinePaediatricsPhysical Medicine and RehabilitationPsychiatryRadiation OncologyRadiology (Diagnostic)Respiratory MedicineRheumatologyCardiovascular & ThoracicGeneralNeurosurgeryObstetrics & GynaecologyOphthalmologyOrthopaedicOtolaryngologyPaediatric GeneralPlasticThoracicUrologyVascularDivision of Surgery Specialtiesooo(Jooooooooo8oooooooa) 0 Indooro orOutdooro- Fishing/Huntingo Forestry/Miningo Processing/Manufacturingo Constructiono Transport/Equipment Operation(~ ~achiningo Other7. Please indicate the kind of leisure time activities thatyou prefer (Fill ONLY one circle from each pair)- d) 0 Group activities- ( ) or Non-group activities- b) C) Requiring active participation- 0 or as a spectator------------Oinical Specialties8. Are you presently enrolled in:o a residency programo a rotating internship9. If you are a resident, indicate from the choices belowthe specialty or professional discipline in which youare doing your residency.If you are an intern, indicate below your intended pro­fessional goal.MemorialMontrealOttawaQueen'sSaskatchewanSherbrookeTorontoWestern OntarioIrish RepublicUnited StatesHong KongOther8()()oooo()()oIndia 0Australia/New ZealandAnatomical PathologyGeneral PathologyHaematological PathologyMedical BiochemistryMedical MicrobiologyNeuropathologyAlbertaBritish ColumbiaCalgaryDalhousieLavalManitoba~cGillMclvlasterUnited KingdomOther EuropeSouth AfricaIf in Canada:If abroad:Laboratory Specialtieso8oooooo8oo8oooo10. From which university did you receive your under­graduate medical training? (Please fill one only.)General PracticeFamily Practice (CCFP)() Anaesthesiao CardiologyC) Clinical Immunology and Allergyo Community Medicine() Dermatology() Emergency MedicineC) Endocrinology and Metabolismo Gastroenterologyo Geriatric Medicineo Haematologyo Infectious Disease() Internal Medicineo Medical Oncologyo()------------------------1989 BMRGjUBC· L9:11:17:PROJECfS:RURAL]H:INTBRN­... •• •Page 2(COMMUNITY))12. If you spent (are spending) any length of time in arural community, how much did you enjoy (are youenjoying):availability of locum reliefteaching and academic medicine opportuni­tiesresearch opportunitiesopportunities for involvement in B.C.M.A.,C.M.A. or other related activitieschallenge of practiceopportunity to practice the kind of medicineI wish to practicetime for family life (recreation and leisuretime)availability of cultural opportunities for selfand familyquality of education for my children (if any)quality of life for my children (if any)quality of housingproximity to relatives and extended familyOther (specify)size of communityavailability of cultural activitiesavailability of recreational facilitiessense of communitylife-style in the communityresources with which to enjoy leisure timefinancial/economic security in the commu-nityquality of environmentpossibility for community involvement/leadership1 2 3 4 5OOOC)O000001 2 3 4 500000(JOOOO1 2 3 4 5CJC)C)OO00000Personal/Family1 2 345OOOOC)I 2 3 4 5000001 2 3 4 5C)OOOC)00000()OOOO0000000000Community1 2 3 4 588888888880000000000000001 2 3 4 500000()OOOO(Rural is defined as over 100 kmor more than 1.5 hours from asecondary or tertiary hospital.)(Urban is defined as having allnecessary specialty backupservices readily available.)... an urban area... a semi-rural area... a rural areaC)C)()11. During your medical training, for how long were you(or have you been if still there) in a rural community(population less than 1O,000)?13. After you finish your residency/internship program doyou think your first choice for establishing yourpractice will be in ...14. To what extent is the main reason for establishingyour practice in the area you have indicated motivatedby a factor directly related to ..,Undergraduate: Postgraduate:0 Less than 1 month 0 Never() 1 month () 1 Month0 Over 1 month (J 3 Months() Never 0 9 Months() 12 Months1 =Not at all 5 =Very much1 2 3 4 5()CjOOC) the practice of medicine in that community?()()()CiO the community life?00000 your personal/family life?-----------------------------ProfessionalI 234 5- 00000 availability of clinical support- ()(X)()() opportunities for free and informal commu-1 2 3 4 5 nication with peers- OOooe) variety in medical problems to be treated- ()OC)C)C) opportunity to provide complete package ofI 2 3 4 5 medical services- C)OO()C) access to specialist expertise- 00000 level of responsibility- (X)CX)O length of working hours (on call)- oe]OOQ opportunity to eam a good income- ()OOOO caseload in relation to income- 00000 ability to secure uninterrupted free timet 2 3 4 5 from work- ()OOOO opportunities for continuity of care- ')OC)()O availability of medical facilities- \..-....:,)C)OC)C) opportunity to practice as a family doctor1 = Not at all 5 =very much11...---.__1ICOMrvIENTS IPrepared by:Health Manpower Research UnitThe University of British Columbia1989BMRGiUBC - L9: 11:17:PRomcrs:RURAL]H:INTBRN-- •• •Page 3APPENDIX CTHE UNIVERSITY OF BRITISH COLUMBIAOffice of the Co-ordinator,Health SciencesDivision of Health ServicesResearch and Development#400-2194 Health Sciences MallVancouver, B.C. Canada V6T lZ6Telephone (604) 228-4810November 27, 1989Dear Respondent:In collaboration with the Department of Family Practice, Community-basedResidency Program; the British Columbia Medical Association; and theMinisterial Medical Manpower Advisory Committee, we are currently undertakinga study of rural physician supply in B.C. A small working group, comprised ofrepresentatives from the collaborating organizations, was formed in June 1989,and has participated in the development of the research protocol.The main purpose of the project is to study the supply of physicians inrural practice and related problems in recruitment and in retention. Morespecifically, it is the intention of this survey to examine practice locationdecisions of B.C. physicians, the professional, community and personal/familyfactors related to these, as well as to estimate future supply, includingthose currently completing internships/residencies.Please find enclosed the specially designed questionnaire for practisingphysicians or for residents/interns. If you are a practising physician, youwill also find a separate questionnaire to be completed by your spouse/live-inpartner (if applicable). Practice location decisions are often made inconsultation with family members, therefore, this dimension is also importantfor a full understanding of problems in rural physician recruitment andretention.As you may be aware, a low response rate will undermine theinterpretation of results from this study. Therefore, your kind cooperationand that of your spouse (if applicable) is essential to the success of thisproject. While it goes without saying that you have every right to declineour invitation to participate, and this should in no way prejudice yourstanding with the above named organizations, we are hopeful that you willrecognize the importance of the study and will be willing to assist us.The amount of time required to complete the questionnaire is about 20minutes (less than 10 minutes for the spouse). The returned questionnaire inthe stamped, self-addressed envelope will be taken as your consent toparticipate in this study, and will also represent the total commitmentrequired of you.. .. / (continued)The John F. McCreary Health Sciences Centre- 2 -There will be no further contact or questionnaires. Your identity andthe information you provide will be held in strict confidence and will beaccessible only to the researchers directly involved in this study. Resultson individuals will not be published or appear in any working documents.If you have any questions please feel free to contact me at 228-4618 orNino Pagliccia at 228-5009.Thank you in advance for your cooperation.Sincerely yours,Pr,~~.s;!~c:..-:-Arminee Kazanjian, Dr.Soc.Associate DirectorDivision of Health ServicesResearch and DevelopmentAssistant ProfessorDepartment of Health Careand EpidemiologyAK:daEne1.IiBRITISHCOLUMBIAMEDICALASSOCIATION~ovember 12, 1989Dear Colleague:As a positive response to expressed concerns about the uneven distribution ofphysicians within British Columbia, the BC Medical Association and the HealthManpower Research Unit at the University of British Columbia are undertakinga joint study of the factors that determine why physicians establish practicein a given area and why they do or do not stay there. We hope that theinformation thus gained will be useful in the development of reasonablepolicies to achieve more even distribution and avoid policies built ondisincentives.You have been chosen as one of a statistically useful group of physicians intraining, physicians' spouses, or physicians in practice. It is mostimportant that we hear from you in order to ensure that we have an accuratepicture of the group you represent. We also wish to ensure that thisquestionnaire allows you to "tell your story", and hope that you will forwardcomments on any factors that may not be fully described in the questionnaire.Follow-up to improve the response rate is very expensive and so it would bevery helpful if you could complete and return the questionnaire as soon aspossible.I recognise that each of you is very busy, and express in advance myappreciation for the portion of your valuable time you take to respond tothis request. The compensation I can offer is the assurance that your effortswill make a positive contribution to the future of your colleagues andpatients within our health care system.hn B Anderson MD1,/ resident.r'/115 - 1665 West Broadway, Vancouver, B.C. V6J 5A4 Telephone [604/ 736-5551 FAX [604/ 736-4566THE UNIVERSITY OF BRITISH COLUMBIAJanuary 22, 1990Dear Respondent:Division of Health ServicesResearch and DevelopmentOffice of the Co-ordinator,Health Sciences400 - 2194 Health Sciences MallVancouver, B.C. Canada V6T 1Z6Tel: (604) 228-4810Fax: (604) 228-2495In early December we sent you a questionnaire soliciting information fora study on the supply of physicians in rural practice and related problems inrecruitment and retention. More specifically, it is the intention of thissurvey to examine practice location decisions of B.C. physicians,theprofessional, community and personal/family factors related to these, as wellas to estimate future supply, including those currently completinginternships/residences.If you have received the questionnaire please take the time to completeit and return it to us at your earliest convenience. We realize that this isa somewhat exacting request, given your busy schedule, but we trust that youwill recognize the importance of your cooperation to the health care deliverysystem and will be willing to assist us in achieving a very high response rateto the study.If you have just mailed your response, please disregard this reminder;your cooperation is greatly appreciated. If for some reason you have notreceived the questionnaire, please call Donna Abbott, collect, at 228-4810 andwe will immediately provide you with another one.If you have any questions, please feel free to contact me at 228-4618 orNino Pagliccia at 228-5009.Thank you for your cooperation.Arminee Kazanjian, Dr.Soc.Associate DirectorDivision of Health ServicesResearch and DevelopmentThe John F. McCreary Health Sciences CentreAPPENDIX DRural General Practitioners by Percentage of Timein Various Areas of MedicineArea of Medicine 1% - 20% 21%-40% 41% - 60% 61% - 80% 81% -100%N % N % N % N % N %Anaesthesia 67 82.7 11 13.6 2 2.4 0 0.0 1 1.2Dermatology 240 94.1 12 4.7 3 1.2 0 0.0 0 0.0Internal Medicine 115 42.9 94 35.1 45 16.8 11 4.1 3 1.1Medical Subspecialty 51 86.4 6 10.2 2 3.4 0 0.0 0 0.0Obstetrics & Gynaecology 187 71.4 55 21.0 12 4.6 6 2.3 2 0.8Paediatrics 171 64.3 80 30.1 12 4.5 3 1.1 0 0.0Pathology & Lab Medicine 43 100.0 0 0.0 0 0.0 0 0.0 0 0.0Physical Medicine & Rehabilitation 80 90.9 6 6.8 1 1.1 0 0.0 1 1.1Psychiatry/Counselling/Psychology 199 75.4 46 17.4 17 6.5 0 0.0 2 0.8Public Health/Community Medicine 97 89.0 5 4.6 2 1.8 3 2.8 2 1.8Radiology 66 89.2 2 2.8 1 1.4 0 0.0 5 6.8General Surgery 129 94.2 5 3.6 3 2.2 0 0.0 0 0.0Surgical Subspecialty 40 95.2 2 4.8 0 0.0 0 0.0 0 0.0Geriatrics 157 73.7 39 18.4 13 6.1 3 1.4 1 0.5House Calls 214 96.4 5 2.3 2 0.9 1 0.5 0 0.0Other 28 71.8 6 15.4 2 5.2 1 2.6 2 5.2Urban General Practitioners by Percentage of Timein Various Areas of MedicineArea of Medicine 1% - 20% 21%-40% 41% - 60% 61% - 80% 81% - 100%N % N % N % N % N %Anaesthesia 12 75.0 4 25.0 0 0.0 0 0.0 0 0.0Dermatology 107 88.4 12 9.9 2 1.7 0 0.0 0 0.0Internal Medicine 47 36.7 50 39.1 25 19.6 6 4.6 0 0.0Medical Subspecialty 26 76.5 7 20.5 1 2.9 0 0.0 0 0.0Obstetrics & Gynaecology 84 69.5 29 24.0 4 3.3 4 3.3 0 0.0Paediatrics 84 67.2 33 26.4 5 4.0 3 2.4 0 0.0Pathology & Lab Medicine 18 90.0 1 5.0 0 0.0 1 5.0 0 0.0Physical Medicine & Rehabilitation 39 83.0 5 10.6 2 4.3 1 2.1 0 0.0Psychiatry/Counselling/Psychology 81 63.3 32 25.0 10 7.8 4 3.1 1 0.8Public Health/Community Medicine 34 81.0 3 7.2 1 2.4 2 4.8 2 4.8Radiology 22 88.0 0 0.0 0 0.0 0 0.0 3 12.0General Surgery 57 90.5 6 9.5 0 0.0 0 0.0 0 0.0Surgical Subspecialty 21 91.3 1 4.3 0 0.0 0 0.0 1 4.3Geriatrics 64 61.5 22 21.2 12 11.5 4 3.9 2 1.9House Calls 107 93.9 6 5.3 0 0.0 1 0.9 0 0.0Other 21 61.8 8 23.5 1 2.9 1 2.9 3 8.8APPENDIX ERespondents by Medical Back-UpWithin 100 Kilometres(Rural N =414; Urban N =335)Medical Back-Up Rural UrbanN % N %CLINICAL SPECIALTIES:Radiology (Diagnostic) 315 76.1 319 95.2Anaesthesia 311 75.1 314 93.7Internal Medicine 306 73.9 320 95.5Paediatrics 299 72.2 314 93.7Psychiatry 281 67.9 313 93.4Neurology 204 49.3 299 89.3Cardiology 199 48.1 296 88.4Dermatology 196 47.3 305 91.0Nuclear Medicine 187 45.2 299 89.3Medical Oncology 182 44.0 294 87.8Nephrology 181 43.7 292 87.2Community Medicine 172 41.5 289 86.3Respiratory Medicine 170 41.1 294 87.8Gastroenterology 167 40.3 298 89.0Rheumatology 164 39.6 295 88.1Emergency Medicine 160 38.6 291 86.9Physical MedicinelRehabilitation 150 36.2 293 87.5Haematology 147 35.5 282 84.2Clinical Immunology & Allergy 132 31.9 282 84.2Geriatric Medicine 128 30.9 272 81.2Infectious Disease 121 29.2 278 83.0Endocrinology & Metabolism 119 28.7 279 83.3Radiation Oncology 113 27.3 266 79.4SURGICAL SPECIALTIES:General 340 82.1 324 96.7Obstetrics/Gynaecology 291 70.3 321 95.8Urology 290 70.0 315 94.0Ophthalmology 284 68.6 312 93.1Otolaryngology 280 67.6 314 93.7Orthopaedic 274 66.2 317 94.6Plastic 217 52.4 301 89.9Vascular 202 48.8 296 88.4Thoracic 164 39.6 284 84.8Paediatric General 161 38.9 286 85.4CardiovascularlThoracic 147 35.5 278 83.0Neurosurgery 135 32.6 296 88.4LABORATORY SPECIALTIES:General Pathology 272 65.7 317 94.6Medical Biochemistry 202 48.8 290 86.6Medical Microbiology 200 48.3 293 87.5Anatomical Pathology 195 47.1 296 88.4Haematological Pathology 185 44.7 289 86.3Neuropathology 107 25.8 269 80.3APPENDIX FRespondents by Mean Satisfaction Level forSpecific Professional, Community, and PersonallFamily Concerns(1 = very unsatisfied ... 3 = indifferent ... 5 = very satisfied)Rural UrbanProfessional, Community, PersonallFamily Concerns Standard StandardN Mean Deviatior N Mean DeviationPROFESSIONAL:Variety in Medical Problems to be Treated 407 4.46 0.820 323 4.45 0.760Acuteness of Diseases Seen* 404 4.37 0.848 322 4.26 0.889Opportunity to Practice as a Family Doctor** 356 4.36 0.849 214 3.83 I.l42Challenge of Practice* 406 4.33 0.854 318 4.22 0.904Level of Responsibility** 406 4.31 0.948 320 4.43 0.797Opportunities for Continuity of Care 406 4.18 0.938 309 4.15 0.988Opportunity to Practice the Kind of Medicine I Wish to Practice 404 4.16 0.997 320 4.17 0.971Opportunities for Free and Informal Communication With Peers** 406 3.97 1.236 323 4.43 0.911Opportunity to Provide Complete Package of Medical Services 400 3.95 I.l23 310 4.01 1.075Availability of Clinical Support** 403 3.83 1.058 322 4.57 0.791Access to Specialist Expertise** 407 3.69 I.l05 322 4.54 0.719Availability of Medical Facilities** 405 3.65 1.097 318 4.08 1.089Ease of Transfer to an Appropriate Level of Care of the Acutely IllJInjured Patient** 401 3.60 1.160 293 4.14 1.063Specific Training for the Appropriate Medical Services In My Geographic Area of Practice** 389 3.55 I.l49 297 4.01 1.023Length of Working Hours (On Call)** 403 3.19 1.366 321 3.85 I.l99Caseload in Relation to Income** 403 3.11 1.236 322 3.40 1.245Availability of Locum Relief** 383 2.89 1.291 263 3.43 1.308Ability to Secure Uninterrupted Free Time From Work** 405 2.85 1.343 318 3.44 1.325Opportunities for Involvement in BCMA, CMA or Other Related Activities** 383 2.84 0.997 304 3.49 1.096Teaching and Academic Medicine Opportunities** 391 2.80 1.174 314 3.65 1.193Ease to Relocate Practice** 378 2.75 1.123 292 2.88 1.263Research Opportunities** 380 2.49 1.016 307 3.20 I.l82COMMUNITY:Own Personal Safety in the Community** 403 4.50 0.802 323 4.26 0.866Quality of Environment** 409 4.33 0.868 324 4.05 1.020Life-style in the Community* 406 4.12 0.935 326 4.22 0.933Size of Community** 407 4.05 1.047 324 4.33 0.940Possibility for Community InvolvementlLeadership** 403 4.04 0.881 321 3.85 0.998Availability of Recreational Facilities** 407 4.04 I.l36 320 4.51 0.796Resources With Which to Enjoy Leisure Time** 409 4.02 1.012 320 4.25 0.973Sense of Cornmunity** 409 4.00 0.999 320 3.83 1.098FinancialJEconomic Security in the Community** 409 3.86 1.015 322 4.00 1.025Availability of Cultural Activities** 406 3.04 1.267 324 4.25 1.047PERSONALIFAMILY:Own Preference for Practicing Here 405 4.38 0.843 325 4.44 0.871Quality of Housing** 405 4.16 0.997 317 4.30 0.961Quality of Life for My Children (If Any)** 335 4.04 0.989 270 4.34 0.825Spouse's Contentment in the Cornmunity** 366 3.95 1.053 290 4.32 0.933Opportunity to Earn the Kind of Income I Require 405 3.79 1.081 320 3.87 1.066Time for Family Life (Recreation and Leisure Time)** 398 3.47 I.l91 321 3.75 1.108Quality of Education for My Children (If Any)** 332 3.30 I.l76 275 4.21 1.0l3Availability of Cultural Opportunities for Self and Family** 403 3.05 I.ln 323 4.12 1.007Proximity to Relatives and Extended Family** 395 2.70 1.425 311 3.30 1.438Other 27 3.41 1.907 17 3.59 1.661* Significant (p < 0.05)** Highly Significant (p < 0.01) (1)(1) Based on a 2-tailed t-test, after the practising physician groups were weighted to reflect the province's more than 8:1 ratio of urban to ruralphysicians.APPENDIX GResidents and Interns by SpecialtieslProfessional Goals(Total N: Residents =77; Interns =41)SpecialtylProfessional Goal Residents Interns TotalN % N % N %NON-SPECIALISTGeneral Practice- -14 35.0 14 12.0Family Practice (CCFP) 7 9.1 7 17.5 14 12.0Sub-total 7 9.1 21 52.5 28 23.9SPECIALISTCLINICALInternal Medicine 10 13.0 3 7.5 13 11.1Paediatrics 9 11.7 1 2.5 10 8.5Psychiatry 7 9.1 1 2.5 8 6.8Anaesthesia 5 6.5 2 5.0 7 6.0Radiology (Diagnostic) 4 5.2 - - 4 3.4Radiation Oncology 3 3.9- - 3 2.6Community Medicine 2 2.6- -2 1.7Cardiology 1 1.3 1 2.5 2 1.7Dermatology 1 1.3-- 1 0.9Gastroenterology 1 1.3 - - 1 0.9Geriatric Medicine 1 1.3 - - 1 0.9Respiratory Medicine 1 1.3 --1 0.9Rheumatology 1 1.3- -1 0.9Emergency Medicine- -2 5.0 2 1.7Clinical Immunology & Allergy - - 1 2.5 1 0.9Neurology- -1 2.5 1 0.9Clinical Sub-total 46 59.7 12 30.0 58 49.6SURGICALOphthalmology 4 5.2 2 5.0 6 5.1Cardiovascular/Thoracic 3 3.9 2 5.0 5 4.3Neurosurgery 3 3.9- - 3 2.6Obstetrics/Gynaecology 2 2.6 - - 2 1.7Orthopaedic 2 2.6 1 2.5 3 2.6Vascular 2 2.6 - - 2 1.7General 1 1.3 --1 0.9Paediatric General - - 2 5.0 2 1.7Surgical Sub-total 17 22.1 7 17.5 24 20.5LABORATORYAnatomical Pathology 3 3.9 - - 3 2.6Medical Microbiology 2 2.6 - - 2 1.7Haematological Pathology 1 1.3 - - 1 0.9Medical Biochemistry 1 1.3 - - 1 0.9Laboratory Sub-total 7 9.1 0 0.0 7 6.0Specialist Sub-totals 70 90.9 19 47.5 89 76.1TOTALS* 77 100.0 40 100.0 117 100.0(65.8) (34.2) (100.0)* Non-respondents: Interns =1.APPENDIX HResidents and Interns by Mean Influence Level forProfessional, Community, and PersonallFamily Factors Relating toIntended Practice Location Decisions(1 =not at all influential '" 5 =very much influential)Rural UrbanProfessional, Community, PersonaIlFamily Factors Standard StandardN Mean Deviation N Mean DeviationPROFESSIONAL:Opportunity to Practice the Kind of Medicine I Wish to Practice 38 4.47 0.830 76 4.24 1.031Level of Responsibility** 36 4.28 0.882 77 3.22 1.199Challenge of Practice** 37 4.24 0.760 76 3.72 1.138Variety in Medical Problems to be Treated 36 3.92 1.079 77 3.84 1.136Opportunity to Provide Complete Package of Medical Services 35 3.86 1.115 77 3.55 1.083Opportunities for Free and Informal Communication With Peers 36 3.69 1.091 77 3.90 0.882Opportunities for Continuity of Care** 38 3.68 1.118 77 3.00 1.288Ability to Secure Uninterrupted Free Time From Work 37 3.65 1.230 78 3.37 1.378Availability of Medical Facilities* 37 3.54 0.931 77 4.03 1.038Availability of Clinical Support* 37 3.30 1.199 78 3.86 1.125Access to Specialist Expertise** 37 3.27 1.018 77 3.83 1.031Length of Working Hours (On Call) 37 3.16 1.214 78 3.14 1.365Opportunity to Earn a Good Income* 37 3.16 1.191 78 2.67 1.266Caseload in Relation to Income" 37 3.00 1.354 77 2.52 1.071Opportunity to Practice as a Family Doctor** 37 2.68 1.765 72 1.74 1.151Teaching and Academic Medicine Opportunities** 36 2.61 1.271 75 4.04 1.202Availability of Locum Relief 36 2.58 1.251 72 2.49 1.547Research Opportunities** 36 1.83 1.082 74 3.32 1.491Opportunities for Involvement in BCMA, CMA or Other Related Activities 37 1.70 0.996 76 1.76 1.044"':OMMUNITY:Quality of Environment** 38 4.47 0.893 77 3.62 1.236Availability of Recreational Facilities 37 4.35 0.889 78 3.97 1.105Life-style in the Community* 37 4.32 0.852 77 3.92 1.244Resources With Which to Enjoy Leisure Time 36 4.25 0.937 77 4.08 1.167Sense of Community** 37 4.16 0.898 77 2.94 1.196Size of Community 37 4.00 0.882 76 3.95 1.057FinanciallEconomic Security in the Community 36 3.75 1.079 77 3.38 1.267Availability of Cultural Activities 37 3.70 1.151 78 4.00 1.162Possibility for Community InvolvementlLeadership** 36 3.33 1.287 76 2.57 1.170PERSONALIFAMILY:Time for Family Life (Recreation and Leisure Time) 38 4.29 1.137 77 3.88 1.246Quality of Life for My Children (If Any) 34 4.15 0.989 69 4.00 1.260Quality of Education for My Children (If Any) 34 3.76 1.304 70 4.19 1.183Availability for Cultural Opportunities for Self and Family 37 3.65 1.136 77 4.08 1.085Quality of Housing 37 3.65 1.207 77 3.43 1.261Proximity to Relatives and Extended Family** 36 2.36 1.291 78 3.45 1.420Other 4 4.00 2.000 14 4.57 1.089* Significant (p < 0.05)** Highly Significant (p < 0.01) (1)(1) Based on a 2-tailed t-tests, as previously described.

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