Jasmine C. Mah, MD, PhD1, Tharsan Kanagalingam, MD, MSc2, Sarah Best, MHM3, Sallie Elhayek, MSc3, Jenny Thain, MD4, José A. Morais, MD5, Marianne Lamarre, MD6, Jaspreet Bhangu, MD4, Michael J. Borrie, MD4, Luxey Sirisegaram, MD, MASc7
1Division of Geriatric Medicine, Dalhousie University, Halifax, NS
2Schulich School of Medicine and Dentistry, Western University, London, ON
3Lawson Health Research Institute, London, ON
4Division of Geriatric Medicine, Department of Medicine, Western University, London, ON
5Division of Geriatric Medicine, McGill University, Montreal, QC
6Quebec Network Geriatric Program
7Department of Geriatric Medicine, University of Toronto, University Health Network and Sinai Health Systems, Toronto, ONDOI: https://doi.org/10.5770/cgj.27.774
ABSTRACT
Background
There is a projected and growing gap of geriatricians in Canada. Geriatricians play a crucial role in addressing the health needs of older adults. We aimed to understand the factors that influence the choice of first-practice location for new geriatricians in the context of an aging Canadian population.
Methods
We distributed an online survey to geriatric medicine subspecialty residents and recently licensed geriatricians in Canada. The survey was developed through expert opinions, career planning sessions, and a literature review. There were nine survey sections: general characteristics, location determinants, practice determinants, colleague determinants, support and space, non-clinical opportunities, income models, lifestyle factors, and recruitment determinants. The data were analyzed descriptively.
Results
A total of 61 respondents (51 English, 10 French) completed the survey. The respondents were new practicing geriatricians (37) and geriatric medicine residents (24). Most planned to practice in Ontario (26.2%) or Quebec (27.9%), and 75.4% were women. Flexibility in work-life balance (95.1%), collegiality (93.4%) and reasonable call schedules (93.4%) were the most important factors influencing first practice location. Income did not rank among the highest priorities for choosing the first practice location relative to other factors but was mentioned in open-ended responses to recruitment questions.
Conclusions
This is the first survey identifying the determinants of first practice location in geriatric medicine in Canada. Work-life balance and collegial support are a priority for new geriatricians and may be the strongest incentives a program can provide. For recruitment, income incentives may be beneficial to building new specialized geriatric services. Future research will examine determinants of first practice location among Care of the Elderly clinicians.
Key words: geriatrics, practice location, geriatric residents, geriatricians, survey, Canadian, recruitment, rural medicine
The Canadian Geriatric Society’s Human Resources Committee projects a national deficit of geriatricians in Canada by 2030.(1,2) Estimations in 2019 revealed a substantial shortage of geriatricians, approximately 61.2% below a benchmark of 1.25 geriatricians per 10,000 individuals aged over 65, resulting in a deficit of 504.1 geriatricians.(2) In Canada, geriatricians are fellows of the Royal College of Physicians and Surgeons of Canada (RCPSC) and complete a three-year internal medicine residency prior to subspecializing in geriatrics for two more years. In 2018, there were only 304 Canadian geriatricians, yet there is limited understanding of how new geriatricians choose practice locations, making it difficult to effectively guide workforce planning for this scarce and important specialty.(3)
The shortage of geriatricians has implications for the health outcomes of the aging population. Geriatricians support specialized geriatric services that are associated with shorter hospitalization and lower hospitalization costs for adults older than 75 years.(4) In the pre-operative and post-operative setting, consultation and co-management by geriatrician services with surgical services results in a lower probability of post-operative outcomes. For example, in a large American cohort of older adults undergoing cancer-related surgeries, there was a reduction in the 90-day mortality rate with concurrent geriatric care (4.3% versus 8.9 % with only surgical services).(5)
Geriatricians are also the experts in administering and using Comprehensive Geriatric Assessments (CGAs), which improve post-hospitalization health outcomes, decrease the likelihood of being discharged to long-term care homes, and decrease mortality at home post-discharge.(6) A CGA is a standardized assessment encompassing the full health status and function of an older adult with the purpose of facilitating tailored management strategies.(6) CGAs are also a key practice to inform the management of cognitive impairment.(7) Given that the number of people with dementia is projected to triple by 2050, limited access to CGAs has implications for early identification of people with dementia, appropriate management in the community, and identifying sufficient home care and long-term care home supports.(8)
Beyond the limited number of physicians specializing in caring for older adults, there is disproportionate geographic distribution in the Canadian geriatric workforce. Rural and remote regions have the greatest disparity, defined as an area with fewer than 10,000 people.(9) Furthermore, between 2020 and 2030, more retirements may occur in academic centres, which may reduce teaching and research capacity but also provide opportunities to actively recruit new geriatricians seeking an academic career.(2) This highlights the need to understand the factors that influence a geriatrician’s choice of their first practice location whether it is in an academic centre, the urban community, or rural and remote regions.(10) Therefore, this paper aims to investigate the determinants influencing the choice of first-practice location among geriatric subspeciality residents and newly practicing geriatricians in Canada, with implications for personal and system-level workforce planning.
The surveys were sent to current Canadian geriatric medicine subspecialty residents in training (4th and 5th year trainees). The surveys were also sent to practicing geriatricians in their first or second year of practice. The period of survey collection took place from February 6, 2023, to May 28, 2023. This project is part of a larger study looking at the geriatric health-care workforce, and a separate survey is underway examining determinants of first clinical practice for Care of the Elderly trainees and graduates.
We distributed two anonymous online surveys, one in English and one in French, containing the same questions. We used an iterative approach whereby a literature review and evaluation of previously published surveys and career planning sessions informed the initial content of the survey.(11,12) Then, team members who were geriatricians and geriatric subspeciality residents reviewed it for content validity, given their expertise in geriatric workforce planning. An initial draft survey was piloted among geriatrician members of the research team. Next, a second pilot survey was reviewed by several geriatric subspeciality residents/geriatricians outside the study team to increase the validity and reliability of the survey instrument.
Following consent, the survey consisted of 67 (± 2) multiple choice, Likert scale, or open-ended questions divided into nine sections: general characteristics, location determinants, practice determinants, colleague determinants, support and space, non-clinical opportunities, income models, lifestyle factors, and recruitment determinants. Respondents were asked to rate on a 3-point Likert scale (not important, somewhat important, very important (and not applicable [NA]) each determinant of geriatric practice. In the last section of the survey on recruitment, respondents could also respond to open-ended questions. The wording of the questions differed slightly depending on whether the respondents identified as a trainee or a recent graduate. The survey was translated into French by two francophone geriatricians (JM, ML) who were also involved in the development of the survey to ensure that the nuances of the survey were intact. The online survey had REB approval at Western University (Western Research Ethics Board: REB# 121902). Survey responses were anonymized and entered directly into REDCap (Research Electronic Data Capture [REDCap], www.project-redcap.org) without requesting any direct identifying information. The data were only accessed by the research team, who are bound by confidentiality and are granted access to the anonymized data for analysis purposes. Data are to be stored for up to 15 years upon conclusion of this study. The full survey is in Appendix A, created using REDCap electronic data capture tools(13,14) hosted by Dalhousie University.
We employed several measures of survey distribution. First, surveys were sent to the program directors of all 13 post-graduate geriatric medicine education programs in Canada to distribute to their current subspecialty residents and recent graduates by email. Second, we recruited respondents using social media, specifically through the Canadian Resident Geriatrics Interest Group Twitter Account (@GeriInterestGp account had 1,468 followers on June 5th, 2024). Third, we used snowball sampling, asking colleagues to send the survey to respondents meeting our criteria. Finally, recent graduates or current geriatric residents attending the 42nd Canadian Geriatrics Society Annual Society Meeting in Vancouver, British Columbia in 2023 were asked to complete the survey.
The data were analyzed descriptively. We summarized continuous data with means and standard deviations, and categorical data with frequencies and proportions. We used t-tests and Chi-Square tests, to determine differences between trainees and recent graduates where appropriate. To synthesize the open-ended questions in the recruitment section of the survey, two team members (JM, TK) independently coded and categorized the responses into the pre-established sections (e.g., location determinants, practice determinants, colleague determinants, etc.) of the survey. Two meetings were held to refine, combine, and create sub-categories of responses and come to a consensus about any disagreements and interpretations. These categories and subcategories reflect themes of respondents’ perspectives on recruitment initiatives regarding geriatric practice.
A total of 61 respondents completed our survey: 51 completed the English survey and 10 completed the French survey. Overall, 63.9% were between the age of 30 and 34 years old and 75.4% identified as women. Most were practicing or planned to practice in the provinces of Ontario (26.2%) or Quebec (27.9%). Table 1 shows basic demographics by geriatric medicine subspecialty residents and recently graduated geriatricians; there were no significant differences in gender, language, provincial distribution, or rural living between the two groups.
The greatest proportion of very important ratings was flexibility in work-life balance (95.1%). Next, 93.4% of respondents rated their geriatric colleagues as most important. Of equal high importance were reasonable call schedules (93.4%). Support from allied health professionals was very important to 88.5% of respondents followed closely by administrative support and nearby family and friends (Figure 1). For 67.2% and 63.9% of respondents, incorporating other services or general internal medicine as part of their geriatric practice was not important. Funding models (such as Alternative Payment Plans or fee for service), a city with a high cost of living, research potential, and opportunities for supplementary income were relatively low when ranked on the importance for determining practice.
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FIGURE 1 Determinants of geriatric practice in ascending order of very important: combined subspecialty residents and recent graduates | ||
Of the recent graduates, most (58.3%) decided on their practice location during subspecialty training, 22.2% decided during medical school, 16.7% decided during internal medicine training, and 2.8% decided after subspecialty training. Of 28 new practicing geriatricians who responded to the question: “Did recruitment initiatives influence your decision?”, 10.7% felt recruitment was very important to their decision and 53.3% felt it was somewhat important. In comparison, 20 residents answered this question, and their responses were 35.0% and 30.0%, respectively, for very important and somewhat important. When asked which factor they wish they had more information about, 28% of the 52 respondents wanted more information on income models, lifestyle factors (21%), and type of clinical practice (17%).
The survey also explored whether trainees and graduates considered or were considering working in rural and remote regions. More than half (27/47) of respondents stated that coverage of costs was not important. However, as seen in Table 2, financial incentives did emerge as a recurrent response to the open-ended question: “What incentives would make you seriously consider practicing in a rural and/or remote location?” In addition to family considerations, allied health support, work-life balance, and reimbursements were the most frequently mentioned incentive in the open ended responses.
TABLE 2 Responses to the question: What incentives would make you seriously consider practicing in a rural and/or remote location?
There is an urgent need to recruit and train geriatricians to support our aging population across Canada and to understand which factors influence where geriatricians choose to practice. This survey was distributed to geriatric medicine subspecialty residents and new geriatricians nationwide to identify determinants that influence the decision-making process behind the choice of their first practice location. We identified that geographical factors (i.e., proximity to friends and family and location), lifestyle factors (i.e., work-life balance and flexible call schedules), and supports (i.e., allied health care and administrative assistance) were most important to new geriatricians and residents.
To date, most research on factors influencing first practice location choice has been completed in family medicine. Existing research explores both traditional non-modifiable factors (e.g., geographic upbringing) and modifiable factors (e.g., clinical practice format) that may influence the trainee’s practice choice. In a large cohort study of Manitoba medical school graduates, the top-ranked factors influencing practice location were non-modifiable, such as proximity to their partners, support systems, and opportunities for spouses.(15) Like family physicians, our survey indicated that geriatricians prioritize the location of family, friends, and partners. Family ties being a vital aspect in practice location determination is expected since Blachman et al. demonstrated that close relationships with older adults (likely from family exposure) early in life were a motivating factor to pursue the field of geriatrics.(16) Respondents also had a strong preference for work-life balance, which is in keeping with prior research that has demonstrated work-life balance as a driving factor in the choice of specialty among medical students and general internal medicine residents.(16)
The top determinants of first geriatric medicine practice location are primarily lifestyle, proximity to friends and family and support; these are not surprising. It is known that geriatricians routinely report high levels of career satisfaction and satisfaction with balancing commitments between personal and professional commitments.(17) Our findings reveal that these factors are crucial for new staff and trainees as well, highlighting their importance early on for consideration of first job postings; that is to say, work-life balance is sought early in a career, not something that is expected later in a career. In the context of the changing demographics of geriatricians, in particular the increasing number of women, this study highlights the determinants of practice that are relevant to today’s geriatrician.(3) This may explain the concentration of new geriatricians in certain areas that provide allied health and administrative support. Hesitancy to work in rural and remote areas may be partly due to location, but geriatricians may also avoid these regions due to a preference for collaborative work environments, as highlighted by our respondents.
All income determinants were in the bottom half of the factors that respondents felt were important when assessed with the Likert scale. However, when asked what would incentivize moving to a rural or remote practice, income was a prominent open-answer response. The paradox between reimbursement being the least important relative to other determinants in the survey, yet one of the most frequently mentioned incentives for rural and remote recruitment, deserves more exploration, perhaps using qualitative methods. This finding also may be due to the fact that the various income models across Canada for geriatricians were not represented appropriately in the survey. For example, geriatricians in Ontario (where the majority of the survey respondents were from) may not prioritize finances, since the “Enhanced Care of the Frail Elderly Funding Initiative” model began in 2010 and established a floor level of funding comparable to general internists.(10)
The findings of this first geriatric medicine survey may provide insights for communities wishing to recruit a geriatrician since most new practicing geriatrician respondents (61.1%) decided on their practice location during geriatric medicine subspecialty training or later. Recruitment initiatives prioritizing work-life balance and support from colleagues, allied health, and administrators might attract new geriatricians. Comprehensive geriatric care requires a collaborative team approach. The engagement and retention of allied health team members working with a geriatrician is a key component of a successful recruitment plan.(11) Providing supplementary income through loan repayment, higher on-call remuneration, and other income incentives may enhance recruitment in regions wanting to attract geriatricians.
One of the biggest challenges for recruitment is to support the physician’s ties to a community through family.(11) Our survey indicates that family ties are an important factor and a seemingly traditional non-modifiable factor; however, geriatricians may be attracted if communities highlight opportunities for families and partners in the community. Even respondents who deemed they would not practice in remote or rural locations were amenable to short-term practices with incentives. An interview of family medicine residency graduates determined that previously living in the community, the influence of a spouse, and comfort with practice expectations were the key variables in determining the choice of a rural practice location.(12) This is reiterated by a longitudinal cohort study that revealed that a rural background was vital in the decision of a rural practice location for both general and specialist physicians.(13) Providing opportunities for family members and creating incentives for short-term consistent practices may help in overcoming traditionally non-modifiable factors that deter from practicing in underserved communities.
There are several limitations of our study. First, in the survey itself, we did not include a definition of rural or remote for the respondents. Second, the sample included in our study should be taken into consideration. While we estimate between a 54–59% response rate using the Canadian Post-M.D. Education Registry (CAPER) and the Canadian Resident Matching Service (CARMS) data, the inability to compare respondents with non-respondents on key determinants does limit generalizability. For example, there was no strategy to target respondents who have decided to practice in rural and remote areas.
Our primary population of geriatric medicine subspecialty trainees and recent graduates does not include Care of the Elderly trainees who will be invited to respond to a separate survey. The training duration of RCPSC subspeciality residents in geriatric medicine is five years versus the three years for Family Medicine—Care of the Elderly (FM-CoE), which leaves more time to consider practice style and location. In 2019, geriatricians were mostly full-time equivalents whereas FM-COE were most often practicing part-time in specialized geriatric services.(2) These three factors are the main reasons why the two surveys were done separately. We agree there is a significant overlap in medical expertise between FM-CoE and geriatricians.(14) Learning about incentives for many of the current FM-COE physicians to increase their practice within specialized geriatric services could assist in the expansion of geriatric care in Canada.(2) The next step in this research is a study that is currently underway using similar methodologies to illuminate determinants of practice location of FM-CoEs.
This is the first study identifying factors that influence the choice of first practice location among geriatric residents and geriatricians. Non-modifiable factors such as friends, family, and partner location were the most important determinants, which is in line with previous research for family medicine. Modifiable factors, such as work-life balance, may be the most influential factor that recruitment programs can utilize to build specialized geriatric services in their region. Sufficient support from colleagues and allied health professionals would also be a priority for new geriatricians. Interestingly, financial incentives did not rank among the highest priorities for choosing the first practice location, but our survey did indicate that financial incentives would help recruitment to rural and remote areas specifically. Future research is underway to understand the determinants of Care of the Elderly trainees and graduates who also contribute to geriatric care across Canada.
The submission to the Western Research Ethics Board (REB) was facilitated by the Cognitive Clinical Trials Group, Parkwood Institute.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare there are none.
Funding for the publication was provided by the Canadian Geriatrics Society, Scholarship Foundation.
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Correspondence to: Luxey Sirisegaram md, masc, frcpc, University Health Network and Sinai Health Systems. Geriatric Medicine Office, 4th floor, Mount Sinai Hospital, 600 University Ave., Toronto, ON M5G1X5, E-mail: luxey.sirisegaram@uhn.ca
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 27, No. 4, DECEMBER 2024