The decentralization of medical education has distributed some aspects of the medical school structure; however, specialty resident trainees and academic faculty are disproportionately concentrated in urban centers. In a distributed medical education system, undergraduate medical students and family medicine resident trainees are distributed across three satellite sites. Clinical faculty make up the majority (94%) of the workforce and make significant contributions to the teaching of medical students and family medicine residents. In contrast, the concentration of academic faculty (95%) and specialty resident trainees (94%) are observed in urban centers. Failing to distribute some of the core activities of service, research and education in the medical school structure consequently creates disadvantages for learners, faculty and limits opportunities for patients to benefit from specialist services and research advances.
Distributed medical education systems, where medical trainees conduct much or most of their training in smaller satellite or branch sites of a large traditional medical school has evolved in several countries in order to address the limitations of the traditional model 12,18−20. Previous work has focused on the distribution of undergraduate medical education and family medicine programs and finds positive outcomes in experiences and perceptions of learners in regional and rural sites, benefits to communities and acquisition of competencies tailored to broader population needs 2, 7–9,18, 21–23. A number of important social and economic benefits related to enrichment of the medical community by a distributed system have been identified 2,21,24,25. However, the shortage of family practice physicians in smaller communities has propelled distributed medical education systems forward; and the establishment of longitudinal rural and regional campuses have led to physician migration from urban centers, addressing shortages in smaller communities 8,9,18,20,24−29. This is evident in British Columbia; since 2004, the University of British Columbia, Faculty of Medicine implemented 3 satellite sites and distributed undergraduate and family medicine residency training. The successful distribution of practicing family physicians in 2018 is observed in the small variation across regions, with highest on Island at 176.6 per 100,000 as compared to Northern, Southern and Lower Mainland of 155.1, 150.2, and 122.7, respectively 30.
Physician specialists, however, are underrepresented in smaller communities and there is little evidence of specialty residency training programs and/or academic faculty distribution. The dominant discipline-specific rotations in smaller communities continues to be used for specialty residency programs and although clinical rotations are perceived to be valuable and increase self-identified likelihood of regional practice, there are limited data to indicate any shift in interest towards living in a smaller site 22,31,32. For example, in the distributed model in British Columbia, only 6% (79/1312) of subspecialty residents are based outside the Lower Mainland, despite, specialty services being provided in regional centers. This follows observed differences in practicing specialty physicians across British Columbia with highest observed in Lower Mainland and Island at 130.8 and 117.5 per 100,000, as compared to Southern and Northern, at 97.6 and 63.0, respectively 30.
In a distributed medical education system, human resources would be allocated to match the clinical and academic infrastructure. Clinical faculty make up the majority of the workforce and volunteer to supervise and teach learners in the clinical setting. For these faculty, teaching is tied to clinical revenue and the distribution of medical students is labour intensive, can decrease productivity and limit the number of trainees in a community 33–35. Juxtaposed, as observed in the findings, academic faculty predominately reside in an urban center and supervise the majority of resident trainees. For academic faculty, these trainees may significantly decrease workload and provide more time to conduct research and compete for national funding. Senior residents, for example, allocate a quarter of their time teaching interns and medical students; and they act as mentors, providing leadership, guidance and learning 13. As follows, with few residency programs, there are fewer opportunities for residents to teach at distributed sites as compared to their urban colleagues 34. It helps that medical students are distributed to increase opportunities for teaching, however, urban residents participate in broad community consistent with multiple learners, and more opportunities to supervise and teach while working as a team in the context of clinical practice 2,34.
An equal balance between service and medical education may be indicated by resident research 14. Residents that undertake research are competitive for subspecialty fellowships or careers in academia. Active participation in research exposes residents to scientific methods, improves critical appraisal of literature, nurtures critical thinking and generates new medical knowledge 13. The medical community can then support environments of inquiry and scholarship in which residents participate in the development of new knowledge, evaluate research findings and translate knowledge at the bedside 14. However, major barriers exist that limit resident participation in research outside urban centers. Few distributed specialty residency programs provide less opportunity for clinicians to be exposed to research, develop research skills, and grow specialty careers; and clinical faculty are at a disadvantage to conduct and support resident research because they have inadequate protected time, less research training, access to granting agencies, office and administrative support. There are well documented impediments to research activity in residency training programs, including, time, interest, qualified mentors and cost; however, trained faculty and their involvement have shown to increase research activity 35–37. Research training is identified as important for clinicians to conduct research and mentor trainees; however, research productivity and development is tied to protected time, research career development and mentorship 35,36. The participation in research sets medical education apart from other health professional training. Research attracts funding, improves patient care and influences career pathways. Research in tertiary large centers often lacks real world application, and residents that participate and conduct research during their fellowship are more likely to devote working time and future careers to clinical research 35. The redistribution of residency programs and academic faculty will support research programs that address population health needs.