To stay or leave: An integrative review of factors, personas, and recommendations for retaining family physicians in Canada

To stay or leave: An integrative review of factors, personas, and recommendations for retaining family physicians in Canada | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article To stay or leave: An integrative review of factors, personas, and recommendations for retaining family physicians in Canada Udoka Okpalauwaekwe, Brian K MacPhee, Lindsay Balezantis, Vivian R Ramsden, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7222819/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Dec, 2025 Read the published version in BMC Primary Care → Version 1 posted 11 You are reading this latest preprint version Abstract Introduction: Family physicians are the cornerstone of primary health care in Canada. Yet, retention remains a growing concern particularly in rural, remote, and underserved communities. Currently, 25% of Canadians do not have a primary care provider. While much attention has been given to recruitment, less is known about the multifaceted and intersecting factors that influence whether practicing family physicians and family medicine trainees (including Canadian Medical Graduates (CMGs) and International Medical Graduates (IMGs)), remain in sustained comprehensive practice in Canada. This review synthesizes the literature to identify key drivers of family physician retention and offers evidence-based recommendations. Methods: We conducted an integrative review of peer-reviewed literature published between January 1, 2000, and March 30, 2025, following Whittemore and Knafl’s five-stage methodology. A systematic search was carried out across five electronic databases. Included studies were assessed for quality and thematically analyzed using a five-domain coding framework: personal, family, community, professional, and structural/systemic. Composite personas were developed to illustrate recurring physician retention trajectories and evidence-based recommendations were thematized across our five-domain coding framework. Results: Of the 1,613 records screened, 23 studies met inclusion criteria. Factors influencing retention were identified across all five domains. Structural and professional barriers, including licensure restrictions, administrative burden, and limited autonomy, emerged as the most consistent deterrents. Facilitators included strong community ties, spousal support, team-based practice environments, and access to continuing professional development. We idenitified and developed seven physician personas to create a portrait of the diverse experiences of family physicians in Canada. Key recommendations included reforming licensure and payment models, enhancing mentorship and CME access, supporting spousal integration, and fostering culturally safe, community-rooted team-based practice models. Conclusion: Retaining family physicians in Canada is a relational challenge that requires collaborative, multi-level change. Tailored, context-specific retention strategies co-designed with physicians and communities can enhance sustainability and health equity especially in rural, remote and underserved communities. Family Physicians physician retention Canada rural medicine primary care International Medical Graduate community integration Workforce Planning Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Retention of family physicians (FPs) in Canada remains a persistent and complex challenge, with serious implications for healthcare accessibility, continuity, and equity. The impacts of family physician shortages are particularly noticeable in rural, remote, and underserved communities (these includes inner city areas with provider shortages, Indigenous communities, and urban or rural areas with high social vulnerability and communities with systemic barriers to care) (1-3). Despite intensified recruitment efforts, the ability to retain both Canadian Medical Graduates (CMGs are physicians who completed their medical training in Canada) and International Medical Graduates (IMGs are physicians who obtained their medical degrees outside of Canada)in comprehensive family practices continues to pose challenges, often resulting in cycles of physician turnover and care disruption (2, 3). Recent reports from the College of Family Physicians of Canada (CFPC) in 2023 estimated that more than 6.5 million Canadians were without a regular family physician, while nearly one in five family doctors were considering reducing or leaving comprehensive practice altogether (1). This widening gap in access to primary care was further underscored by the Canadian Medical Association’s (CMA) 2023 Physician Workforce Survey which reported rising burnout among family physicians and a declining interest in family medicine as a long-term career–both contributing to physician migration, particularly among early-career and rural physicians (4). Additionally, in 2022 the Canadian Institute for Health Information (CIHI) documented that the effects of poor physician retention were disproportionately borne by Indigenous communities and structurally marginalized populations, where disruptions to care continuity could exacerbate already existing health inequities (5). Since 2000, numerous strategies have been implemented in various Canadian provinces to attract physicians to family medicine and rural practice (3). While some initiatives (e.g., enhanced rural training tracks, community-based onboarding, and team-based care models) have shown success in improving retention in rural and underserved areas (7, 9), others, such as return-of-service agreements and one-size-fits-all licensure pathways, have often fallen short due to limited alignment with physician goals and inflexibility across career stages or geographic mobility (6, 8, 10). A core limitation in workforce planning has been the tendency to approach retention as a linear, one-size-fits-all issue; overlooking the complex and evolving interplay of personal, family, professional, systemic, and community-level factors that shape physicians’ decisions to stay or leave (1, 3, 11, 12). Notable challenges include administrative burden (9), excessive workloads (13), limited autonomy (3), and strained work-life balance (14), as well as issues related to training background, lack of team-based care, and how well physicians fit into the communities they serve (i.e., community integration) (3, 13-17). While CMGs and IMGs share some of these challenges, IMGs particularly face unique challenges linked to licensing processes (9), cultural integration (3), and gaps in career support systems to aid integration into the workforce (3, 18, 19). Recognizing these dynamics, we undertook this integrative review to provide a comprehensive, system-wide understanding of the factors influencing the retention of family physicians in Canada. Our objective was to move beyond narrow or single-domain perspectives by synthesizing evidence from across geographies, training pathways, and stages of medical practice to identify common and divergent factors shaping physician retention. This approach enabled the development of simulated physician personas grounded in real-world retention narratives, which helped illustrate divergent career trajectories and informed the generation of context-specific recommendations. Unlike our prior work that focused primarily on the experiences of International Medical Graduates (IMGs)(3), this review includes the perspectives of both Canadian Medical Graduates (CMGs) and IMGs across eight provinces. Drawing on empirical research and peer-reviewed policy discourse, we aimed to construct a panoramic view of why family physicians choose to stay, leave, or disengage from comprehensive family medicine in Canada. Ultimately, this review offers a more integrated lens to interpret retention dynamics across time, geography, and training background, and identifies critical leverage points for sustainable health workforce reforms. Study Objectives This integrative review was guided by the following objectives: To identify and synthesize personal, family, professional, community, and systemic factors that influence the retention or attrition of family physicians (both CMGs and IMGs) within Canadian locations between 2000 and 2025. To examine how personal, family, professional, community, and systemic factors interact across domains and over time, shaping physicians’ decisions to stay in or leave family practice, particularly in rural, remote, and underserved areas. To identify and develop conceptual physician personas that illustrate patterns of experience, motivation, and vulnerability related to retention. To map evidence-informed recommendations to specific personas and contexts, offering practical strategies for improving retention across varied physician backgrounds and practice environments. To reflect upon the gaps in current Canadian retention policies and contribute to a systems-level understanding of sustainable family physician workforce planning in Canada. METHODOLOGY AND METHODS Study Design An Integrative Review design was employed to systematically synthesize diverse forms of evidence (i.e., quantitative, qualitative, and mixed methods) related to family physician retention in Canada between January 01, 2000, and March 30, 2025. Integrative reviews allowed for the synthesis of diverse types of evidence (quantitative, qualitative, theoretical, and empirical) to provide a more comprehensive understanding of complex phenomenae (20, 21). Unlike Systematic Reviews, which typically focus on a narrowly defined question using primarily empirical studies (22), or Scoping Reviews, which aim to map the breadth and extent of literature on a topic without deep synthesis (23, 24), Integrative Reviews go further by critically analyzing, comparing, and conceptually integrating findings from multiple methodologies and sources; applying broad and more flexible approaches (20, 21). We chose an integrative approach to go beyond description and mapping, allowing for conceptual synthesis, identification of cross-domain interactions, and the development of personas that illustrate distinct patterns of retention challenges and opportunities among family physicians in Canada (including CMGs and IMGs). We adhered to the Whittemore and Knafl’s (20) methodological framework for Integrative Reviews (which includes problem identification, literature search, data evaluation, data analysis, and data presentation) using it as our guiding methodological framework. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (23) as our reporting guideline (see Supplementary File A ). Protocol and Registration No protocol registration was required prior to the commencement of this study. Eligibility Criteria Studies were included if they had been: 1) peer-reviewed journal articles that reported associations, predictors and relationships between Canadian family physicians and determinants that influence their decision to stay or leave their practice 2) peer-reviewed journal articles carried out in all areas and settings in Canada including urban, metropolitan, cities, rural or remote areas, and 3) peer-reviewed journal articles (including other synthesis material–reviews, policy analyses, meta-analyses, mixed method synthesis, data synthesis, etc.) published in English between January 01, 2000 to March 30, 2025. Study protocols, conference abstracts, theses/dissertations, historical and grey literature were excluded. Table 1 provides a descriptive summary of the eligibility criteria for this study. Information Sources and Search Strategy We collaborated with an academic librarian at the University of Saskatchewan to design a comprehensive search strategy that identified relevant groups of terms. Key search terms were organized into three conceptual groups: “family physician” (and synonyms), “Retention” (and synonyms), geography (and synonyms) and “Canada”. The following electronic databases were searched: MEDLINE (Ovid), PubMed, Scopus, Web of Science and ERIC (Education Resource Information Center). Searches were conducted for articles published from January 1, 2000, to March 30, 2025. Reference lists of included articles were also hand-searched for additional sources. The full search syntax for each database can be found in Table 2 . Selection of Sources of Evidence All identified records were imported into Covidence–a web-based collaboration software platform that streamlines the production of systematic and other literature reviews (Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). Thereafter, duplicate records were removed. We applied two iterative stages to select articles for this review. They were: 1) title and abstract screening, using our predefined eligibility criteria; and 2) full-text article (FTA) review, where eligibility was further confirmed or rejected with documented reasons. Two reviewers (UO and BKM) independently reviewed in both stages and where we had conflicts, resolved them through consensus or arbitration by a third reviewer (LB). The selection process was summarized in the PRISMA-ScR Flow Diagram in Figure 1 . Data Charting and Extraction We created a structured data extraction template within Covidence to capture and extract data under the following title fields: article title, citation and study objective; study type, study design, location, and setting; physician population focus (CMGs, IMGs, or both); main retention-related findings categorised as barriers and/or facilitators; and recommendations/policy implications. These were then exported into Microsoft Excel (Microsoft Corporation, Version 16) for cleaning, coding, and data synthesis. Data Analysis and Synthesis Barriers and Facilitators of Physician Retention A thematic analysis was undertaken using an abductive approach (i.e., using a deductive coding framework) informed by the domains that have been shown to influence physician retention (3, 11, 12) in Canada, viz-a-viz: personal, family, community, professional, structural (or systemic, organizational, or institutional) . We then coded each study’s findings into these domains to allow for themes to emerge, and synthesized them into barrier-facilitator matrices. Where relevant, we double-coded studies also, to reflect cross-domain influences. Persona Development To further illustrate the dynamic interplay across personal, family, community, and systemic domains (and facilitate knowledge translation of our somewhat abstract retention factors into relatable patterns grounded in real physician lived experiences), conceptual personas were constructed that captured recurrent retention profiles observed across included studies. While not exhaustive, the personas reflected the diverse migration pathways, motivations to stay or leave, and the vulnerabilities of Canadian family physicians practicing in various areas. These personas served in this study, as narrative tools to help interpret the findings, uncover systemic gaps, and inform the development of context-specific retention strategies. We constructed these conceptual personas by: a) identifying clusters of co-occurring themes (e.g., burnout + isolation + spousal dissatisfaction); then b) mapping them to demographic and professional traits (e.g., IMG status, early career stage, rural exposure); and finally, c) synthesizing them into narrative personas, by including motivators, barriers, likely outcomes, and/or targeted policy levers. These personas were validated to ensure credibility and relevance through both informal (personal and group discussions) and formal discussions with practicing family physicians across urban, rural, and remote settings in Saskatchewan and other provinces in Canada (British Columbia, Ontario, Nova Scotia and Manitoba) whom the first author (UO) had interactions with at conferences, symposiums, and meetings where early findings of this work were presented. We also sought feedback from these engagements to iteratively refine the personas, ensuring consistency with observed patterns across the data sources (enhancing their applicability through informal triangulation and content validation). Recommendations to Enhance Physician Retention A thematic analysis of data extracted from included studies on recommendations to enhance physician retention in Canada was conducted and data were mapped with our coding framework across the five domains (i.e., personal, family, community, professional, and systemic). Quality Assurance and Critical Appraisal of Included Studies Using the Joanna Briggs Institute (JBI) Critical Appraisal Toolkit (25), we evaluated the methodological quality of each included article. Two reviewers (UO and BKM) independently assessed the studies, and any discrepancies were resolved through discussion and consensus. A summary of the critical appraisal process and results is provided in Supplementary File B. Reflexivity and Trustworthiness of Study UO is an IMG and primary care researcher with the Department of Family Medicine, College of Medicine, University of Saskatchewan; BKM and LB are medical trainees (undergraduate health sciences student and family medical resident respectively) in the College of Medicine, University of Saskatchewan; VRR is a participatory primary care researcher and Director of Research with the Department of Family Medicine, College of Medicine, University of Saskatchewan; and AB is a practicing family physician, and clinical researcher with the Department of Family Medicine, College of Medicine, University of Saskatchewan. As a team, we met regularly to collaboratively interpret, validate, and refine the findings, ensuring we were providing a synthesis that was informed by the diversity of perspectives in the literature and enriched by insights from practicing family physicians and primary care researchers. Additionally, during these debriefing meetings, we critically reflected on how our respective roles and affiliations might have introduced interpretive biases into the analyses/findings. RESULTS Selection of Sources of Evidence Our initial search across five electronic databases and hand-searching yielded a total of 1,613 records. After removing 376 duplicates, 1237 articles were screened based on titles and abstracts. Of these, 254 full-text articles (FTAs) were reviewed in detail. Following FTA screening, 23 studies were included in the final synthesis. The most common reasons for exclusion at the full-text review stage included more focus on recruitment rather than retention, studies not addressing family physicians specifically, lack of relevance to the Canadian context, and non-original research (e.g., protocols, dissertations, conference abstracts, etc). We illustrated the process of article identification, selection and inclusion in the PRISMA Flow Diagram in Figure 1. Characteristics of Sources of Evidence The included studies employed a diverse range of methodologies: 11 (47.8%) were qualitative, 9 (39.1%) were quantitative, and 3 (13%) used mixed-methods. Most studies (65.2%) were published between 2010 and 2019. With regards to geographical scope, 9 of 23 studies (39.1%) had a national or multi-provincial focus, while the remainder concentrated on specific provinces including Alberta (4/23; 17.4%), Newfoundland and Labrador (4/23; 17.4%), Ontario (4/23; 17.4%), Saskatchewan (3/23; 13%), Quebec (3/23; 13%), Nova Scotia (2/23; 8.7%), and Manitoba (2/23; 8.7%). These studies covered a range of settings including urban, rural, and remote practice environments. While three studies (13%) focused exclusively on either International Medical Graduates (IMGs) or Canadian Medical Graduates (CMGs), the majority (17/23; 73.9%) included both groups. A summary of the methodological and descriptive characteristics of the included studies can be found in Table 3. Results of Individual Sources of Evidence A summary of the unique sources of evidence for this study can be found in Table 4 . Articles were included based on their relevance to addressing one or more of the research objectives. Synthesis of Findings Thematic analyses across studies revealed retention factors which were mapped across the deductive coding framework of inter-related domains: personal, family, community, professional, and structural/systemic. Within each domain, both facilitators and barriers to physician retention were identified. A total of 16 major themes and over 30 sub-themes were classified and examined. See Table 5 and Figure 2 , in which the findings from the synthesis are summarized. Barriers and Facilitators to Retention Barriers to retention were most frequently concentrated in the professional and structural domains. Studies cited physician burnout, high workloads, poor access to locum coverage, limited scope of practice, and few opportunities for Continuing Medical Education (CME) as significant deterrents to long-term practice, particularly in rural settings (8, 11, 18, 26-33). While rural areas are often assumed to offer broad scope opportunities, several studies (8, 11, 18, 26-33) revealed that structural constraints (such as restrictive billing codes, limited team supports, or administrative oversight) paradoxically narrowed practice scope, leaving physicians underutilized or unsupported in delivering comprehensive care. For IMGs especially, the challenge was not the scope itself, but the lack of mentorship and sustainable infrastructure to manage their scope of practice effectively. Structural or systemic challenges such as licensing constraints (especially for IMGs), restrictive return-of-service (RoS) agreements, insufficient infrastructure, and lack of inter-provincial licensure mobility further compounded dissatisfaction (13, 14, 18, 26, 31, 34-36). These challenges (professional and structural), were often interwoven with family-related concerns, including limited spousal employment opportunities and poor access to quality education for the physician’s children (10, 32, 37, 38). In several studies (7, 8, 10, 11, 29, 31, 34, 37, 39), community-level barriers were identified, including social isolation, cultural disconnection, and perceived or experienced discrimination, a lack of amenities (i.e., non-medical services and facilities that contribute to quality of life in community, e.g., gyms, parks, community centers, etc), poor infrastructure (i.e., foundational healthcare and community systems that support clinical practice, e.g., well resourced hospitals, clinics, emergency departments, diagnostic services, telehealth reliability, etc), and fragmented support systems (i.e., social and professional networks and services that buffer stress and support physician wellbeing, e.g., peer/collegial support networks (formal or informal), mental health support services, locum relief, childcare, spousal and family integration supports, etc). At the personal level, lifestyle preferences (e.g. a desire for urban living for those in rural communities), reluctance to relocate (i.e., an underlying intent to leave in cases of physicians who had accepted rural placements due to RoS obligations or other limited options but were not invested in long-term practice integration) also played a role in attrition, especially among younger and early-career physicians (18, 27, 28, 31, 34, 40). Gendered spousal roles, as well as spousal career sacrifices (particularly for female IMGs) (18) and career dissatisfaction (31, 32) emerged as a recurrent theme under the personal domain. In contrast, factors identified to have facilitated physician retention were often rooted in a strong sense of community belonging (8, 11, 34, 37), family integration (10, 32, 37), professional autonomy (18, 27-32), and meaningful patient relationships (8, 11, 26, 39). Physicians who reported feeling valued and supported by their communities (either through gestures of appreciation, social engagement, or access to cultural institutions) were more likely to stay (8, 11, 26, 39). Spousal support, employment opportunities, and access to childcare and quality schooling were also positively associated with retention (10, 32, 37, 38). On the professional front, opportunities for broad-scope practice, collegiality, affiliation with academic institutions, supportive team environments, access to mentorship and CME; as well as team-based models of care were frequently cited as enablers of long-term engagement (18, 27-32). Structural supports such as flexible contracts, supportive Return-of-Service (RoS) agreements, streamlined licensure processes for IMGs, alternate payment models (APMs), and well-resourced rural practices emerged as key facilitators (14, 26, 31, 34, 37). Persona-Based Synthesis A series of conceptual physician personas were created based on the recurring themes across included studies. These personas described how combinations of facilitators and barriers may have shaped decisions to stay or leave. Each persona represented a composite of lived experiences drawn from included studies in this review and several stakeholder validation sessions. For example, “The Frustrated IMG” represented early- to mid-career physicians navigating restrictive licensing pathways, family integration challenges, and community isolation. Without structural reform and spousal support, this persona faced a high risk of attrition. In contrast, “The Rural-Rooted Generalist” was a Canadian-trained physician aligned with rural life and community values, but vulnerable to burnout without adequate CME, mentorship, or locum support. Other personas included the “Mobile Urbanist,” who valued lifestyle flexibility and was unlikely to remain in rigid or isolated practice models, and finally the “Community-Aligned Practitioner” was one who thrived on relational continuity but required ongoing professional growth opportunities to remain engaged (see Figure 3 ). These personas provided a narrative lens to get a glimpse of understanding on how cross-domain interactions (e.g. spousal dissatisfaction combined with professional stagnation) compounded retention risks. They could also served as tools for policymakers to tailor solutions that aligned with the unique needs of different physician profiles. A summary of the personas and the retention strategies aligned to each can be seen in Figure 3. Recommendations for Retention We identified a set of evidence-informed recommendations mapped to the five domains (see Table 6 ). These included the need to streamline licensure processes across provinces (14, 32, 37), revise RoS agreements for better alignment with physician goals (27, 29), and strengthen spousal and family support systems (10, 32, 38), invest in community-based onboarding and cultural inclusion programs (8, 11, 34, 37); as well as developing flexible, team-based models of care (13, 26, 34). While it is possible that pan-Canadian licensure could increase physician mobility between provinces, our review findings suggested that simplifying licensure requirements may also encourage retention by reducing administrative burden (e.g., redundant paperwork, fees, background checks and delays), enhancing professional autonomy (delimiting physicians’ ability to respond flexibly to evoliving caeer goals, personal needs and short term relocations), and improving access to short-term locum or cross-provincial practice opportunities. For many early-career physicians, particularly IMGs, the ability to engage in temporary practice outside their home province without reapplying for licensure offered a sense of flexibility and control that supported long-term engagement in their primary practice location (14, 32, 37). As such, rather than driving attrition, streamlining licensure was viewed as a way to reduce that frustration by enabling an environment for professional growth, and support, to remain in underserved areas while staying connected to broader networks of care. See Table 6 for more description of identified recommendations. DISCUSSION Retention of family physicians in Canada is more than a workforce issue; it is a lens through which we can see the strengths and fractures in our healthcare system. The decision to stay or leave, particularly in Family Medicine, is never made in a vacuum. It is often a decision shaped by the delicate interplay of personal aspirations, systemic conditions, community dynamics, and the professional eco-systems they find themselves in (41). In this study, we set out to explore the interplay of these various factors, drawing on 25 years of literature, to illuminate the conditions under which family physicians (both Canadian and internationally trained) either build long-term careers or leave the systems that trained or welcomed them. Much has been written about the factors that influence retention (e.g., workload, remuneration, spousal employment, burnout, community integration, and more). However, most of these publications tend to examine these factors in isolation. Very few provide a holistic or synthesized picture of how these factors interact in real-world contexts to shape physicians’ decisions to stay or leave. The power of our integrative approach (20, 21) lies in its ability to trace how systemic and structural policies impact professional fulfillment, how community engagement influences family decisions, and how personal identities and/or determinants intersect with institutional recognition. Additionally, our integrative approach enabled us to identify how alignment (or misalignment) across personal, family, community, professional, and structural domains shapes a family physician’s sense of belonging, purpose, and sustainability in their vocation, rather than simply generating a checklist of retention problems. Such an approach is relevant because physician retention is deeply relational: it depends on the strength and quality of relationships between physicians and their patients, colleagues, support staff, administrators, and the communities they serve. Where these relationships thrive (i.e., fostering a sense of belonging and connectedness) so does long-term sustainability (3, 42-44). Retention matters because family physicians are the backbone of Canadian primary health care system (3, 45). Family physicians are often the first point of contact with the health care system, providing oversight in chronic disease management and a relational thread that weaves together a patient’s healthcare journey (46-49). As such, when retention falters, the consequences ripple far beyond the patient or the primary care provider (45, 50). As continuity of care is lost (51), access to care can be lost, preventive services interrupted (46), Emergency Departments overwhelmed (46, 50), patient outcomes decline including mental health (46), and the integrity of the health systems suffers (46, 52). These critical factors are why retention is not just a human resources issue; it is a systemic integrity issue. It is an indicator of how well we are caring for those who care for us, the significance of which cannot be overstated in the context of primary care’s centrality to health equity (15). Canada, like many other Nations, formally committed to the principles of primary care as outlined in the 1978 Alma Ata Declaration (53), the 1986 Ottawa Charter for Health Promotion (55), the 2018 Astana Declaration (54) and the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) (55). These foundational frameworks emphasized that health is a state of holistic well-being, pursued through accessible, community-grounded primary care, facilitated by relationships between patients and regulated health professionals within health systems (53-58). As such, when the very physicians tasked with delivering this kind of care are unable to remain in practice, it signals a retreat from Canada’s commitment to delivering on these principles of equitable, relationship-centered, and community-responsive primary health care. Our findings have also shown that retention of family physicians is a relational and relationship-driven process. Physicians stayed where they felt connected; either to their communities or their colleagues, to a sense of duty or purpose, and to systems or structures that valued their work. Conversely, they left when these connections and/or relationships were frayed. Based on findings from this study and anecdotal evidence from an initial environmental scan (59), this factor was especially true for physicians working within rural or remote areas in Saskatchewan. In such locations, the departure of even one physician could collapse a clinic, destabilize a regional area, and leave patients with no option but to travel hours to receive primary care (7, 13, 59-61). These communities (often with a more Indigenous or marginalized community presence) bear the compounded weight of systemic neglect, under-investment, and coloniality (i.e., the lingering structures and power dynamics established during colonialism that persist today) (62), which make them more likely to face health disparities and service disruptions when physicians leave (59, 63-65). Within rural and remote settings, retention is not just a matter of adequate staffing, but also that of relational equity for providers who face disproportionately high clinical loads, limited specialist support, and professional isolation compared to that of their urban counterparts (14, 37, 41, 66). In this light, physician retention becomes part of a broader struggle for equity, reconciliation, and relational accountability (67-69). Based on findings from this study, it was found that family physicians were deeply frustrated when leaving these communities; not because they lack commitment or sense of moral/fiduciary duty, but rather because the community, professional or structural-systemic conditions necessary for them to thrive were lacking (3, 59). As such, this integrative review illuminates the urgent need to rethink how we approach retention, not only as an operational necessity, but as a matter of fairness, inclusion, and reparative investment in rural, remote and Indigenous communities (5, 67, 68, 70, 71). One of the unique contributions of this review was the development of physician “personas” (i.e., conceptual profiles grounded in the synthesis of retention narratives across the included studies). These personas (ranging from the “ Frustrated IMG ” facing the usual licensing hurdles and family isolation, to the “ Burned-Out Rural Physician ” managing years of practice with vacillating support) brought humanity into the discussion. Often times, the discussion around physician retention, tends to create an abstract picture or caricature of the typical family physician in Canada. It is believed that the physician “personas” are not caricatures but composite portraits of “real” and lived physician experiences that reveal the emotional, and identity-based dynamics that shape physician life, family and career trajectories (32, 34, 41, 45, 48, 72). More importantly, these personas also revealed how generic, one-size-fits-all policies have often reinforced (rather than alleviated) the challenges faced by physicians across Canada. Thus, we can now appreciate that a one-size-fits-all approach for retention cannot address the divergent realities of a young CMG parent seeking urban flexibility, or an IMG navigating integration challenges, or a mid-career rural physician on the verge of exhaustion and so on. Each of these physicians needs something different. On the other hand, it cannot be assumed that the personae framework offers a perfect solution in itself; we believe it proposes a way to think more carefully, more empathetically, and more practically about what different family physicians need in order to stay in their home province or in Canada to practice. It is believed that our study findings may assist decision-makers to shift from the usual reactive workforce planning to an intentional design of retention in Canada (and by extension similar primary care systems globally). For example, a well-functioning retention ecosystem, might include bundled supports such as flexible licensure pathways across provinces, locally tailored onboarding and peer mentorship programs, spousal employment supports, access to locum coverage, and embedded community engagement efforts, each calibrated to the physician’s career stage and practice context (opposed to a generic often lobsided strategy). Building on this foundation, our study also revealed how deeply interconnected the factors (i.e., personal, family, community, professional and structural) influencing physician retention are. For example, structural constraints (e.g., restrictive licensure pathways, fee-for-service payment models, or return-of-service contracts), often collide with professional challenges such as lack of autonomy, poor access to Continuing Medical Education (CME), and low levels of professional and interprofessional supports. One of the most frequently cited structural barriers was the fee-for-service payment model. These models often fail to compensate for the complexity, continuity, and coordination that family physicians provide, particularly in comprehensive or rural practice settings. Remodelling remuneration structures to better reflect the time, relational work, and scope of care delivered by family physicians may improve job satisfaction and autonomy, and serve as a powerful lever to reduce attrition. Structural and professional influences, in turn, shape family decisions, influence personal well-being, and affect community engagement. When one or more of the domains misalign, physician retention becomes fragile. What was especially concerning was that many of these tensions were predictable and therefore preventable . To prevent them, however, we must move beyond transactional and short-term solutions (e.g., salary top-ups and other financial incentives, or compliance-based contracts) to long-term retention strategies that attend to the relational alignment across a physician’s full experience. This approach is inclusive of not only what happens in the clinic, but also what happens outside of work (e.g., meaningful work opportunities for spouses, access to quality education for children, presence of mentorship and peer support, and/or adequate support and integration of physicians into the communities). These factors have been known for decades (37, 41, 45, 48, 63), and health systems that ignore them puts individuals and communities at risk due to less-than-optimal sustainability of health care resources (42, 73-79) Alas, the consequences of less-than-optimal physician retention in Canada threatens the very viability of family medicine as a discipline (15, 56). For example, fewer medical students are choosing Family Medicine as a career(80-83). Furthermore, early-career family physicians are gravitating towards more focused practices that allow for more control and flexibility (84-86). Comprehensive, community-based generalist care is increasingly perceived as unrewarded and unsustainable (86-88). This unfortunate trajectory undermines the core principles of the Patient’s Medical Home (89, 90), and the broader vision of universal, relational primary care that Canada has long been espoused (89, 90). Without a course correction, we risk creating a healthcare system in which continuity is the exception rather than the norm (56, 91). However, there are glimmers of hope and reform for retention strategies, such as the expansion of interdisciplinary teams (89-92), the re-design of alternate payment models (34, 56), the strengthening of IMG assessment pathways (including the CMA’s proposal for a Pan-Canadian licensure pathway) (18, 93, 94), and the emergence of wellness and mentorship initiatives aimed at supporting physicians (95, 96). Notably, the CFPC’s Patient’s Medical Home (PMH) Model offers a compelling vision for team-based, community-grounded care (89, 90). In addition, the Canadian Medical Association’s advocacy for Pan-Canadian licensure proposes regulatory reforms to reduce interprovincial barriers to practice (94). Province-specific strides are being made, which can be used as models for optimizing primary care delivery across the country. In Nova Scotia, expanded team-based care and centralized physician recruitment have been implemented (97). British Columbia introduced a new longitudinal payment model to support comprehensive care (98). Alberta is modernizing its Primary Care Networks to facilitate primary care team attachment and access (99). Saskatchewan recently rolled out a new remuneration model to strengthen physician retention in urban, rural and remote communities(100), has ongoing participation in provincially-funded primary care innovation specific to individual clinic and community needs, and is working to re-align primary care delivery among networks (ref) . Manitoba has rolled out rural mentorship and retention bonuses for primary care teams and the health workforce (101), and Newfoundland and Labrador are developing Family Care Teams alongside incentive structures (102). These provincial efforts represent important steps toward a sustainable primary care workforce. While these strategies are an important step forward, we believe these strategies should be co-created “with” (and not “on”) the relevant participants (e.g., physicians, nurses, patients, other regulated health practitioners, Indigenous communities, and decision makers), spread contextually, and evaluated rigorously to ensure long-term sustainability. Overall, the present integrated review invites each of us to re-imagine retention as a collective responsibility rather than someone else’s responsibility. Physicians do not stay in place because of contracts or financial incentives alone. They stay because the systems they work within are conducive, compassionate, and responsive to their personal and professional expectations (44). Family physicians remain in their practice location because they are embedded in communities that care not just about access, but about belonging (72). They stay because they are supported not just to survive, but to thrive (50). If we want to build a primary care system that reflects the commitments of the Alma Ata Declaration, the Ottawa Charter, the Astana Declaration and the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), then we should start by actively listening to those tasked with delivering that care. We believe that this integrated review offers a framework for doing just that (i.e., understanding not just the policies that shape physician retention, but the people those policies effect). In the end, the question will not be whether Canadian physicians will stay or leave; it will be whether we are building a system that encourages them to stay. CONCLUSION In conclusion, through this integrative review, we have identified a range of inter-related factors that influence the retention of family physicians in Canada across five domains: structural/systemic, professional, family-related, community, and personal. Structural and professional barriers such as administrative burden, restrictive licensure, and limited autonomy, emerged as the most significant roadblocks to retention. Facilitators were often grounded in family and community support, collegial work environments, and physicians having a sense of belonging. By synthesizing findings across 23 studies and mapping them to conceptual physician personas, this review underscored the importance of co-creating tailored and context-specific physician retention strategies, including, but not limited to, reforming remuneration models, implementing team-based primary care, creating Pan-Canadian licensure pathways, and enhancing community-driven integration efforts. Overall, this review provides actionable insights for health practitioners, policymakers and health system leaders that would strengthen sustainability of the primary care workforce in Canada. Abbreviations APMs – Alternate Payment Models CCFP – Certification in the College of Family Physicians CIHI – Canadian Institute for Health Information CMG – Canadian Medical Graduate CME – Continuing Medical Education CSA – Canadian Studied Abroad CFPC – College of Family Physicians of Canada CMA – Canadian Medical Association ERIC – Education Resources Information Center IMG – International Medical Graduate JBI – Joanna Briggs Institute LFP – Longitudinal Family Physician MMG – Memorial University Medical Graduate MUN – Memorial University of Newfoundland NPS – National Physician Survey PMH – Patient’s Medical Home PGME – Postgraduate Medical Education PRISMA-ScR – Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews RoS – Return-of-Service SIPPA – Saskatchewan International Physician Practice Assessment SRPC – Society of Rural Physicians of Canada UoS – University of Saskatchewan Declarations Ethics approval: Not applicable. Data Availability: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Consent for publication: Not applicable Competing interests: The authors report no Conflicts of Interest. Funding: Funding provided by the Saskatchewan Health Research Foundation (SHRF) Align Grant held by Dr. Baerwald. Acknowledgements: Northern Medical Services (NMS) , Saskatchewan College of Family Physicians (SCFP), Saskatchewan Health Authority (SHA), Saskatchewan Health Research Foundation (SHRF), Saskatchewan International Physician Practice Assessment (SIPPA), Saskatchewan Medical Association (SMA), Saskatchewan Ministry of Health, University of Saskatchewan’s Department of Academic Family Medicine (DAFM) and the Align Primary Care Working Group Members: Brenda Andreas, Erin Brady, Jessica Campbell, Selene Daniel-Whyte, Coralie Darcis, Diana Ermel, Fei Ge, John Gordon, Jackie Hanson, Carla Holinaty, Jason Hosain, Max Karnitsky, Melissa Kimens, Matthew Kushneriuk, Kathy Lawrence, Bryan MacLean, Cathy MacLean, Veronica McKinney, Andries Muller, Cassandra Opikokew-Wajuntah, Meric Osman, Olivia Reis, Johann Roodt, Ginger Ruddy, Sheila Smith, Kent Stobart, Stuart Stone, Janet Tootoosis, Felicia Watson, Jon Witt, Matthew Wong, and Julie Yu. 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Tables Table 1: Eligibility criteria for review study Criteria Inclusion Exclusion Population Canadian Family Physicians Other health professionals such as specialists, nurse practitioners, nurses, etc. Place of study Canada Any country other than Canada Geography All areas including urban, metro urban, cities, and rural All areas outside of Canada Healthcare areas Retention, decision to move out from any area in primary care settings Secondary or tertiary care, medical education, medical training Language English Non-English Time period 2000-2023 < 2000 Study type Original studies and other synthesis material (reviews, policy analysis, meta-analysis, mixed method synthesis, data synthesis, etc.) published in a peer-reviewed journal Opinion pieces, study protocols, case reports, dissertations, historical and grey literature. Table 2: Keyword search syntax used for library search. Population/ Family adj1 physicians* OR general adj1 practitioner$ OR nurse adj1 practitioner* OR International adj1 medical adj1 graduate* OR Foreign adj1 medical adj1 graduate OR Migrant adj1 physician* OR oversea* adj1 trained adj1 physician* OR oversea* adj1 trained adj1 health adj1 professional.ti.ab* Retention Physician adj3 retention OR stay OR exit OR turnover OR attrition OR job adj2 retention OR job adj2 satisfaction OR fulfilment OR career adj2 advancement OR contentment OR workforce stability OR job adj2 dissatisfaction.ti.ab Practice geography/ Urban OR Metro* OR Rural adj2 medicin* OR rural adj1 population* OR rural adj1 communit* OR rural adj1 practice OR rural adj2 practice or rural adj2 health OR rural adj2 health adj1 servic*.ti.ab Location/ Canada OR Alberta OR British adj1 Columbia OR Manitoba OR New adj1 Brunswick OR Newfoundland adj1 and abj1 Labrador OR Northwest adj1 Territor* OR Nova adj1 Scotia OR Nunavut OR Ontario OR Prince adj1 Edward adj1 Island OR Quebec OR Saskatchewan OR Yukon.ti.ab #2 AND #4 AND #6 AND #8 Table 3: General and methodological descriptive characteristics of included studies (n=23) Publication year n (%) Article citation 2000- 2009 4 (17.4) (9, 30, 36, 37) 2010- 2019 15 (65.2) (7, 8, 10, 11, 13, 18, 26, 28, 29, 31-33, 38-40) 2020- 2025 4 (17.4) (14, 27, 34, 35) Provinces* AB 4 (17.4) (8, 10, 11, 34) BC 2 (8.7) (27, 35) MB 2 (8.7) (38, 39) NFL 4 (17.4) (9, 29-31) NS 2 (8.7) (27, 35) ON 4 (17.4) (27, 32, 35, 40) SK 3 (13.0) (7, 13, 31) QC 3 (13.0) (28, 33, 40) Pan-Canadian/Multiple provinces 9 (39.1) (14, 18, 26, 27, 32, 35-37, 40) Family Physician category CMGs focused 3 (13.0) (28, 31, 36) IMG focused 3 (13.0) (27, 37, 38) Both IMGs and CMGs 17 (73.9) (7-11, 13, 14, 18, 26, 29, 30, 32-35, 39, 40) Region Urban 0 (0.0) -- Rural 13 (56.5) (8, 10, 11, 13, 14, 26-29, 31, 34, 36, 37) Both 10 (43.5) (7, 9, 18, 30, 32, 33, 35, 38-40) Study type Quantitative 9 (39.1) (9, 18, 26, 30, 32, 36, 38-40) Qualitative 11 (47.8) (7, 8, 11, 27-29, 31, 33-35, 37) Mixed Methods Research 3 (13.0) (10, 13, 14) Data collection type Primary data 16 (69.6) (7, 8, 10, 11, 13, 14, 26-28, 31, 33-36, 38, 39) Secondary data (Data Registry/reviews/admin data) 7 (30.4) (9, 18, 29, 30, 32, 37, 40) * Multiple overlap for cited studies Table 4: Characteristics of included studies (n=23) Author (citation) Study Objective Study type, Design, Location, Setting, and Physician focus Relevant Findings Practical implications and indications to enhance workforce retention Barriers Facilitators Ampofo-Addo et al. 2016 (13). To understand factors that influence location decision of family physicians in Saskatchewan (SK), Canada Study type: mixed methods research Design: Surveys and Interviews Location: Saskatchewan, Canada. Setting: Rural Physician focus: IMGs and Canadian Medical Graduates (CMGs). Family: lack of spousal and family supports. Community: Lack of community support, community disintegration Professional: Burnout, high call rotation, few staff, lack of team support and educational opportunities Structural/systematic: Non-sustainable model of care delivery, poor infrastructure/working conditions Personal: preference for rural life, friendly climate and rural activities. Family: Spousal employment/family support, access to children’s education Community: social integration Professional: Good workload, collegiality, scope of work and financial compensation Match physicians with communities that align with their family, work-life, and lifestyle expectations. Provide financial incentives only to communities that cannot meet those requirements. Foster collaboration among small communities for viable group practices Asghari et al., 2017 (28). To identify factors influencing decisions to work in rural or remote areas. Study type: Qualitative Design: Interviews with rural physicians. Location: Quebec, Canada. Setting: Rural Physician focus: CMGs (implied). Personal: lack of extracurricular activities. Family: lack of spousal employment and children's education. Community: remoteness, cultural or language barriers, and absence of spiritual or cultural centers. Professional: difficulty accessing continuing education and specialists, burnout from high turnover and long hours, social challenges like maintaining a social life and anonymity. Poor collegial support and treatment from urban physicians. Personal: preference for rural life, previous education or life experience in rural area Family: spousal support to settle rurally, access employment opportunities. Community: community appreciation, friendliness, security, privacy, intimacy. Professional: wide scope of practice, access to CME, collegiality, positive working environment, and strong practice team Structural: additional financial incentives to stay, and reimbursement for travels outside rural area Providing opportunities for professional development, creating a supportive work environment, enhancing collegial and personal support systems, Ensuring a healthy work-life balance, providing adequate education for children, offering employment opportunities for spouses, and fostering community integration. Supporting and creating specific competencies targeting rural skills and supportive training environment. Bosco et al, 2024 (14). To understand factors influencing physicians' decisions to leave/stay in rural practice and assess perspectives on national licensure Study type: mixed methods Design: Environmental scan of 25 reports + qualitative and quantitative analysis of 2 national physician surveys (SRPC and CMA) Location: national focus Canada. Setting: Rural Physician focus: Both CMGs and IMGs Family: Family dissatisfaction Community: limited community integration. Professional: burdensome licensure requirements and fees for cross-provincial work. Poor work-life balance and burnout Structural: Lack of infrastructure and locum coverage in rural areas. Community: community integration and team-based practice support. Professional: National licensure enabling interprovincial mobility. Locum flexibility for semi-retired/retired physicians. Ability to access educational and locum opportunities across provinces. Implement national (pan-Canadian) licensure to reduce administrative barriers Improve locum availability and infrastructure in rural areas. Create turnkey, team-based rural practices. Address family and community integration needs Cameron et al., 2010 (8). To explore community factors that promote physician retention in rural Alberta communities Study type: Qualitative Design: Interview, Collective case-study design. Location: Alberta, Canada. Setting: Rural Physician focus: Both CMGs and IMGs None identified in study Community: Community appreciation (thank-yous, gifts, verbal praise). Personal and family connection to the community. Active support (advocacy, welcoming efforts, local fundraising). Appealing physical/recreational infrastructure (parks, activities). Mutual respect and reciprocity between community and physicians Strengthen community-physician relationships, Involve communities in physician support, both socially and professionally. Consider community-based interventions (e.g., welcome programs, community appreciation). Promote reciprocal contributions between physicians and communities Cameron et al. 2012 (11). To explore professional, personal, and community factors influencing physician retention in rural Alberta. Study type: Qualitative Design: Interview, Collective case-study design. Location: Alberta, Canada. Setting: Rural Physician focus: Both CMGs and IMGs Personal: lack of sufficient recreational assets, dissatisfaction of a physician's spouse with the community. Community: supply leading to burnout. Lack of community support Professional: inadequate physician Preserving status quo. Lack of innovative drive from management Personal: goodness-of-fit, individual choice. Family: spousal and family support. Community: appreciation, connection, active support, physical and recreational assets, reciprocity Professional: physician supply, dynamics, scope of practice, practice set-up, innovation, management and support. Advanced innovation and management support Considering the interplay between professional, personal, and community factors, Linking recruitment with retention efforts, Fostering positive doctor-patient relationships, promoting strong communities, and encouraging collaborative retention strategies led by both physicians and communities. Chan et al., 2005 (36). To examine influences on rural practice entry among physicians with different backgrounds. Study type: Quantitative Design: Cross-sectional survey. Location: National scope, Canada. Setting: Rural. Physician focus: CMGs. Family: the influence of spouses' preferences and proximity to family. Structural: limited effectiveness of financial incentives for long-term retention, the small number of rural students entering medical school. Financial incentives are less effective for long-term retention. Personal: enjoyment of a rural lifestyle, and rural education during medical training Family: Spouses' preferences and proximity to family, Encouraging rural applicants to apply for medicine, Making exposure to rural practice available during training, Promoting the challenges and lifestyle of rural practice, and Targeting both urban and rural students for recruitment and retention in rural areas. Chauban et al., 2010 (26). To assess incentives, satisfaction, future migration plans, and retention strategies among rural physicians in Canada Study type: Quantitative Design: National cross-sectional survey. Location: National scope, Canada. Setting: Rural. Physician focus: IMGs and CMGs. Family: Inadequate family support or child education options Professional: Lack of locum coverage (60% dissatisfaction). Poor professional backup (43%). Poor satisfaction with relief and on-call workload. Personal: Liking rural lifestyle (82%). Match with career interests (75%). Positive rural training experiences Community: sense of community appreciation (84%) and belonging (76%). Professional: Full scope of practice (84%). Improve access to locums and professional relief. Maintain and promote full scope of practice in rural settings. Invest in structured rural training experiences. Address family and community integration. Support intra-professional collaboration and use of technology for specialist support. Dove N. 2009 (37). To assess the potential of IMGs in addressing rural physician shortages in Canada. Study type : Review/Policy Analysis Design : Policy perspective analysis and narrative critical discourse Location : Pan-Canadian and rural focused Setting : Rural Physician focus: IMGs only. · Personal: Preference for urban migration. · Family: Limited spousal integration, job opportunities, and educational support for families. · Community: Lack of engagement, social and cultural isolation, discrimination, and high turnover. · Professional: Heavy workload, burnout, limited mobility, restricted practice scope, low compensation, and lack of training support. · Structural: Poor infrastructure, inconsistent licensing policies, short retention periods, and lack of national coordination in IMG recruitment. · Personal: Attraction to rural life, previous rural training, and community appreciation. · Family: Spousal employment, family integration, and educational opportunities. · Community: Strong local support, cultural/religious networks, and diverse environments. · Professional: Balanced workload, career growth opportunities, full licensure, financial incentives, and access to continuing education. · Structural: Institutional support, clear contracts, well-equipped facilities, coordinated licensing, and ethical recruitment policies. Integrate IMGs into long-term workforce planning. Enhance spousal and family support. Focus on career development, community integration, and systemic workforce strategies beyond licensing. Ensure access to mentorship, training, and career pathways. Improve financial incentives, relocation support, and flexible payment models. · Adopt a national approach to IMG recruitment, licensing, and retention to improve workforce stability. Grudniewicz et al., 2023 (35). To identify the key factors that influence the practice choices of early-career family physicians in Canada Study type: Qualitative Design: Framework Analysis using semi-structured interviews Location: BC, Ontario and Nova Scotia, Canada. Setting: Rural and Urban Physician focus: IMGs and Canadian Medical Graduates (CMGs). Family: personal responsibilities (e.g., childcare). Professional: Lack of flexibility in practice models. Lack of mentorship or poor training experiences; overwork; limitations in payment models or scope Community: community connection; group practices; affiliation with other health professionals Professional: positive training experiences; mentorship; supportive team environments; flexibility in practice schedule. Align training with desired practice models. improve policy and payment systems to support flexibility and comprehensiveness. Support family responsibilities and work-life balance. Recognize diverse personal and professional goals Lavesque et al., 2018 (33). To explore factors influencing physician retention in Quebec, Canada Study type: Qualitative Design: Semi-structured interviews. Location: Quebec, Canada. Setting: Rural Physician focus: IMGs and CMGs. Professional: Burnout, limited mobility, or scope of practice Structural: issues with continuity of care. Family: Spousal employment, family integration, opportunities for children Professional: Opportunities to advance career, physician wellness, and work environment, large scope of practice, autonomy, and care continuity. Focusing on improving the work environment and professional life quality through Regional Medical Campuses (RMCs), which contribute to regional development, healthcare quality, and economic impacts. Creating teaching opportunities. Mathews et al., 2007 (30). To assess whether IMGs trained at Memorial University of Newfoundland (MUN) are as likely as MUN and other Canadian medical graduates to work in Canada and Newfoundland and Labrador (NL) Study type: Quantitative. Design: Linked administrative data (MUN postgraduate database; and Scott's Medical Database) Location: Newfoundland, Canada Setting: Both Rural and Urban Physician focus: IMGs and CMGs. Community: Cultural and social isolation, Professional: Limited professional mobility, fewer residency opportunities in preferred fields, and difficulty securing long-term employment. Personal: Familiarity with training location, Professional: Integration into the healthcare system, and supportive practice environments. Institutional: Residency matching process disadvantaging IMGs, lower likelihood of IMGs remaining in Canada or NL compared to MUN graduates, limited effectiveness of MUN residency programs in retaining IMGs. Enhance professional support, Create structured career pathways, Provide incentives beyond training and develop targeted retention policies for IMGs. Mathews et al., 2008 (9). To compare retention rates between provisionally licensed IMGs, fully licensed Memorial University Medical graduates (MMGs) and other fully licensed CMGs. Study type: Quantitative. Design: Linked administrative data (Newfoundland College of Physicians and Surgeons; and Scott's Medical Database 1997-2004) Location: Newfoundland, Canada Setting: Both Rural and Urban Physician focus: IMGs and CMGs. Personal: physician background and training (IMGs had lower retention rates although not different from CMGs) Community: Social and cultural isolation in NL. Professional: Not having a CCFP designation. Personal: MMGs retention rates were more due to ties with NL. Community: Having cultural, religious or social ties to community. Professional: Having a CCFP designation. Local: NL was an entry point for most IMGs which increase recruitment but didn’t guarantee retention. Enhance cultural, social and professional supports. Provide clear incentives and mobility options for IMGs. Recruitment should focus on long-term retention goals rather than temporary workforce fixes. Mathews et al., 2012 (31). To examine generational differences in work location choices among physicians, Study type: Qualitative Design: Interviews with physicians from different generations. Location: Newfoundland and Saskatchewan, Canada. Setting: Rural. Physician focus: CMGs only. · Personal: Preference for urban settings with better career options and social opportunities. Work-life balance concerns, particularly among younger physicians who desire more flexible work conditions. · Family: Distance from family and social networks. Limited employment opportunities for spouses. Lack of quality education options for children · Community: Lack of community appreciation and engagement. Cultural and religious isolation. · Professional: Poor work environment. Limited access to medical resources, staff and updated equipment. High workload and burnout. · Systemic/institutional: lower remuneration. Billing restrictions and contract limitations. High physician turnover rates. Political instability and health policy changes especially from older generation physicians. Personal: Attraction to rural lifestyles particularly among those with prior exposure to rural life. Strong professional identity and commitment to patient care. Family: available employment and education opportunities for spouse and children. Community: community appreciation and engagement fostering a sense of belonging. Presence of cultural and religious networks. Professional: positive collegial relationships and mentorships. Access to continuing medical education and career advancement opportunities. Structural: Competitive remuneration and flexible incentive programs to make rural more attractive. Improved administrative and policy support. Developing long-term retention strategies for physicians, particularly in rural areas. Strengthening collegial and administrative support . Increasing investment in medical infrastructure Mathews et al., 2013 (29). To examine and compare retention patterns among return-for-service (RFS) type physicians and non-RFS physicians Study type: Quantitative Design: Administrative data (1997-2009) analysis on physicians with RFS and non-RFS agreements. Location: Newfoundland (NL), Canada. Setting: Rural. Physician focus: IMGs and CMGs. Family: Unavailability of suitable locations for family Structural: Low bursary amounts, poor recruitment from sites, changes in personal priorities, lower completion rates for Special Funded RFS agreements, and lack of choice in accepting RFS agreements and work locations. Structural: Bursary-linked RFS agreements, allowing physician choice in work location, and alignment of individual preferences with provincial needs. Improve tracking to monitor RFS fulfillment of service obligations and implement penalties for defaulting Alignment of provincial and federal RFS programs to maximize physician distribution in rural areas. Encourage voluntary participation in RFS programs rather than enforcing RFS agreements with limited flexibility. Mathews et al., 2017 (18). To examine and compare the retention patterns of Canadians who study abroad (CSAs) and immigrant IMGs who completed post-graduate medical education (PGME) training in Canada. Study type: Quantitative. Design: Registry data (National IMG Database and Scott's Medical Database) Location: Canada (national scope). Setting: Both Rural and Urban Physician focus: Canadian IMGs or CSAs and immigrant IMGs. Personal: Gender (female IMG with a non-physician male spouse). Community: lack of cultural networks in rural areas. Professional: limited mobility in practice Structural: Unclear return-of-service agreements. Personal: Gender (male IMGs with non-physician female spouse). Community: Presence of cultural communities Professional: Specialty type (family medicine vs. specialist). Family physician more likely to stay compared with specialist. Structural: Eligibility for a full license Treating all IMGs equally in PGME selection, improving IMG PGME training to enhance credentialing for independent practice, Conducting further research to improve IMG performance and utilizing comprehensive data sets for informed policy-making and workforce planning. Mathews et al., 2022 (27). To explore the influence of residency match and ROS agreements on early-career decisions of IMGs. Study type: Qualitative Design: Interview of early career IMGs Location: Canada (BC, Ontario, Nova Scotia). Setting: Rural Physician focus: IMGs Professional: Limited career choices, delayed preferred practice choices, and high turnover due to misalignment with location preferences. Structural: Lack of autonomy in accepting ROS agreements, uncertainty about practice location and nature, inability to practice in preferred ways. Professional/Structural: Alignment of ROS requirements with personal and professional goals, such as desired practice location or family ties, facilitates retention. Revise ROS agreements to allow for flexibility with IMGs, Provide flexibility in residency placements. McDonald et al., 2012 (40). To study the geographic mobility and retention of immigrant and non-immigrant physicians in Canada, with emphasis on the role of spousal characteristics. Study type: Quantitative. Design: Geographic mobility analysis using Canadian Census data (1991-2006) Location: Canada (Provinces: Ontario, Quebec, Atlantic Provinces, Prairies, Alberta, British Columbia). Setting: Both Rural and Urban Physician focus: Both IMGs and CMGs Personal: Isolation in rural communities. Family: Limited spousal integration in rural areas. Community: High outmigration of physicians in rural areas making it more likely for new ones to migrate. Higher likelihood of outmigration among immigrant physicians. Personal: Proximity to urban amenities Family: Spousal employment opportunities. Higher education level of spouse Improve spousal support systems. Address isolation in rural areas. Consider spousal employment in retention policies. Mou et al., 2015 (32). To explore determinants of inter-provincial migration intentions among rural and urban family physicians in Canada. Study type: Quantitative Design: Analysis of National Physician Survey (2010) Location: Canada (Provinces: Newfoundland, Saskatchewan, Atlantic provinces, Ontario, British Columbia. Setting: Both Rural and Urban Physician focus: Both IMGs and CMGs Personal: Personal dissatisfaction with professional life and relationships. Family: Spousal preferences and employment opportunities Community: small population size and lack of urban-like amenities, language and communications barriers Professional: Burnout from excessive on-call duties, and lack of time off for vacations or continuing medical education. Systemic: insufficient impact of financial incentives and overhead cost of running clinics. Personal: Older aged, married physician. Family: Spousal supports and opportunities for educational and professional advancements for spouse. Community: Community appreciation, connection, active support, and physical/recreational assets; as well as larger community population size. Professional: Collegiality among professional and social peer groups. Systemic/organizational: Flexible primary care delivery models, favorable levels of compensation. Focusing on retaining IMGs, especially in rural areas. Avoiding reliance on fee increases, addressing rural physician migration. implementing flexible primary care models like Collaborative Emergency Centers (CEC) to enhance physician retention. Implement strategies to mimic urban conditions such as spousal hire programs and professional development support Mowat et al. 2017 (38). To examine the retention and predictors of internationally trained family physicians in Manitoba. Study type: Quantitative Design: Cohort study using Logistic regression. Location: Manitoba, Canada. Setting: Both Rural and Urban Physician focus: IMGs only. Family: Spousal employment, educational facilities for kids. Community: Small community size and community disintegration. Professional: Limited mobility due to conditional licenses, challenges in transitioning to remote areas, higher compensation and cultural diversity in other provinces (compared to Manitoba), and dissatisfaction with return-of-service contracts. Systemic/Institutional: Removal of the Manitoba residency requirement before program entry, family relocation issues, the ineffectiveness of their mentorship program. Personal: Factors related to being established in Manitoba Family: Spousal employment, appropriate educational facilities for children, Community: Community integration both professionally and non-professionally, cultural diversity and access to cultural and religious institutions in community. Professional: Licensure type and certification status with unlimited scope and mobility. Financial compensation. Institutional: Manitoba residency at the time of application is a facilitator to retention, as it significantly increased the likelihood of IMGs remaining in Manitoba. Reinstating the requirement for applicants to reside in Manitoba before entering the program, Exploring and potentially redesigning mentorship programs, Considering factors beyond return-of-service contracts, such as community integration and family considerations, to enhance physician retention. Myroniuk et al., 2016 (10). To explore the influence of spouses on rural physician recruitment and retention. Study type: Mixed Design: Surveys and interviews with physicians and their spouses, Location: Alberta, Canada. Setting: Rural Physician focus: Both CMGs and IMGs. Family: isolation, lack of job opportunities for spouses. Difficulty accessing higher education for spouse. Community: Lack of social and cultural experiences. Cultural differences. Difficulty integrating into the community. Privacy/lack of anonymity concerns (for small areas) Professional: Challenges with dual relationships in small communities. Personal: Proximity to work Family: Supportive spouses, strong education system for children, spousal opportunities for employment, networking, and professional development Community: Opportunities for cultural engagement, community support, safety, access to recreational activities, and community -directed retention efforts. Finding a good fit between personal and community culture Professional: Collegiality, affiliation to academic center, broad scope of practice and specialist support. Personal and professional satisfaction. Continuing medical education (CME) support Institutional: Greater academic and CME support. Academic and CME support, Ensuring a good fit between physician skills and community needs, Creating a centralized database of rural practice opportunities, Enhancing the role of governing bodies in supporting physician spouses, and Forming partnerships with private industry to support spousal employment. Ogundeji et al., 2021 (34). To explore the role of alternative payment models (APMs) in recruiting and retaining rural physicians. Study type: Qualitative Design: Interviews Location: Alberta, Canada. Setting: Rural Physician focus: Both CMGs and IMGs Community: severe extremes in climate. Cultural and ideological differences, community pressures and lack of support Professional: complex patient panel, limited access to specialist, poor work-life balance, and burnout Structural: old and outdated equipment, lack of institutional support and access to specialist. Payment models/contracts that could lead to a) potential to earn less; b) fear of loss of autonomy and flexibility Personal: attraction to rural lifestyle, previous rural experience Family: spousal employment, support and access education and childcare. Professional: variety in scope of practice, good patient-physician relationship, collegiality, valued contribution to work, autonomy, independence, and financial compensation to stay. Structural: relocation support and retirement plans Making APMs attractive through nonmonetary incentives, Fostering a collaborative relationship between physicians and government, Involving physicians in payment model design, ensuring fairness in workload and remuneration, and Implementing accountability mechanisms to prevent perverse incentives. Wasko, et al., 2014 (7). To identify factors motivating physicians to select rural practice locations and remain in those communities. Study type: Qualitative Design: interview based. Location: Saskatchewan, Canada. Setting: Both Rural and Urban Physician focus: Canadian Medical Graduates (CMGs) and IMGs Community: Community disintegration and discrimination. Professional: Limited scope of practice, lack of independence and autonomy. Feeling unappreciated and alienated at work. Institutional: Lack of financial incentives Family: Physician and/or spouse having an attraction to rural lifestyle or having a rural background. Physicians and or spouse having ties to specific communities. Having friends and family living close to rural area. Spousal supports and opportunities for employment. Professional: Broad scope and freedom of practice. Group practice. Positive work environment Institutional: Adequate amount and mode of remuneration. Regional support (i.e., easy access to larger centers, specialist support. Having an attractive work schedule (e.g., with vacation time, locum relief, manageable call schedules, and opportunity for continuing medical education). Focusing on practice and lifestyle factors, Improving work conditions such as more reasonable hours, better availability of locum tenens, and professional backup, Providing educational opportunities for children, Optimizing intra-professional collaboration, using technology to improve professional backup, and Promoting the advantages of rural practice to younger physicians. Witt, J. 2017 (39). To investigate the opinions of physicians in Manitoba, Canada regarding rural jobs. Study type: Quantitative Design: cross-sectional study. Location: Manitoba, Canada. Setting: Both Rural and Urban Physician focus: Canadian Medical Graduates (CMGs) and IMGs Professional: intense workloads, difficulty taking time off, professional isolation, lack of specialized education, lack of professional support, dissatisfaction with after-hours work, rural training, community incentives, clinic technology, inadequate work-life balance, and less preferred locations. Structural: Financial incentives alone are insufficient for retention. Community: community incentives, Professional: work-life balance, professional and social inclusion (e.g., group practice, Structural: access to clinic technology), adequate housing availability, location preference (medium-sized towns within a 3-hour drive of Winnipeg), and appropriate financial compensation for on-call duties. Focusing on work-life balance, using nonpecuniary incentives such as professional and social inclusion (e.g., group practices, community incentives, access to telehealth), Ensuring adequate housing availability and understanding the monetary value of compensating for undesirable job attributes. Financial incentives alone are insufficient for retention. Table 5: Factors Influencing Physician Retention in Canada. A. Barriers codified by domains Factor Theme Description Citation Personal Lifestyle preference Preference for urban life, dissatisfaction with rural lifestyle (18, 27, 31, 34) Isolation Loneliness, lack of amenities, and distance from support networks (28, 31, 40) Gender/relationship dynamics Gender-related differences in spousal satisfaction and influence on location decisions (18) Career satisfaction Dissatisfaction with career path and/or misalignment with personal goals (31, 32) Family Spousal employment Lack of job opportunities for spouses in rural areas (8, 10, 11, 32, 37) Children’s education and integration Limited access to quality schools, educational disruption, social exclusion (10, 28, 38) Community Social/cultural isolation Lack of community engagement, cultural disconnect, absence of social networks (10, 29, 31, 37) Discrimination Experiences of racism, exclusion, or cultural insensitivity (7, 34, 37) Community disintegration Lack of amenities, poor infrastructure, fragmented support systems (8, 11, 34, 39) Professional Burnout & workload Excessive work hours, high call frequency, lack of relief or locum coverage (26, 28, 32, 34) Limited mobility Restricted license, return-of-service constraints (18, 29) Restricted scope of practice Unable to fully utilize training or practice independently (7, 8, 11, 37) Lack of career development Limited access to CME, mentorship, and opportunities for specialization (31, 32) Systemic Licensing and policy constraints Complex, inconsistent licensure across provinces; unclear ROS agreements (9, 27, 37) Infrastructure and system instability Underfunded health systems, outdated facilities, lack of backup (34, 38, 39) Administrative burden Excessive non-clinical workload limiting satisfaction and efficiency (32, 34) B. Facilitators codified by domains Factor Theme Description Citation Personal Lifestyle alignment Alignment with rural values, preference for slower pace, love for natural environment (9, 18, 27-32) Sense of purpose Feeling valued, having autonomy in care delivery, having meaningful patient relationships (8, 9, 11, 18, 27, 29-31, 34) Family Spousal satisfaction Spouses find meaningful work and feel welcome in community (10, 32, 37) Children’s education and integration Positive schooling options and social opportunities for children (10, 38) Community Sense of belonging Strong social connections, cultural fit, inclusion in community life (8, 11, 34, 37) Community appreciation Physicians feel respected and appreciated by community members (8, 11, 26, 39) Professional Supportive team environment Collegial relationships, collaborative practice, reduced isolation (13, 32, 34) Full scope of practice Opportunity to work to full potential with varied cases and independence (8, 11, 26) Career development Access to CME, professional mentorship, having academic affiliations (18, 27-32) Systemic Pan-Canadian licensure Interprovincial mobility and flexibility in practice location (14, 34) Flexible work arrangements Blended payment models, locum supports, manageable workloads (26, 34) Residency and training alignment Training in rural settings increases retention likelihood (26, 31) Table 6: Recommendations to Enhance Physician Retention in Canada (codified by domains) Factor Theme Description Citation Personal Align with values and lifestyle Recruit and retain physicians whose values align with rural practice (e.g., autonomy, slower pace, community-focused care) (9, 28, 30, 31) Family Support for spouses and children Develop dual-career recruitment policies, offer family integration supports, and invest in schooling and social amenities (10, 32, 38) Community Community onboarding and inclusion Develop welcoming strategies, cultural safety training, and long-term engagement efforts for physicians and their families (8, 11, 34, 37) Professional Mentorship and career development Strengthen CME access, mentorship networks, academic affiliations, and rural teaching opportunities (28, 31, 32) Team-based and flexible care models Implement collaborative practices, group models, and reduce isolation through peer and specialist support (13, 26, 34) Systemic Pan-Canadian licensure and mobility Adopt national licensing models to reduce barriers and enhance locum support and career flexibility (14, 32, 37) Sustainable ROS and payment models Make ROS agreements flexible and value-aligned; use blended or capitation payment models to ensure work-life balance (27, 29) Data-driven planning and evaluation Monitor long-term retention trends, especially among IMGs, and use integrated data for workforce planning (10, 27, 34) Reduce administrative burden Cut non-clinical workload and streamline documentation to improve physician satisfaction and efficiency (11, 32) Additional Declarations No competing interests reported. Supplementary Files SupplementaryFiles.docx Cite Share Download PDF Status: Published Journal Publication published 01 Dec, 2025 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 03 Nov, 2025 Reviews received at journal 31 Oct, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviews received at journal 26 Aug, 2025 Reviewers agreed at journal 03 Aug, 2025 Reviewers agreed at journal 01 Aug, 2025 Reviewers invited by journal 01 Aug, 2025 Editor invited by journal 01 Aug, 2025 Editor assigned by journal 30 Jul, 2025 Submission checks completed at journal 30 Jul, 2025 First submitted to journal 26 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7222819","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494984910,"identity":"7c777eb5-8df1-43d6-90ea-02ec350237dc","order_by":0,"name":"Udoka Okpalauwaekwe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYFCCBGYQwcDADubZgAhmIrVA1KWRruUwYS0Gx5MPG/yoSMvjb2Z+wMxTcT5xfvvxxwYMNXa4tZx5lpzYcyanWOIwmwEzz5nbiRvO5BgnMBxLxq3lRo7xAd62isSGwwwGzLxtQC0MOcwHGBtwOw6k5eBfoJb5h9k/ALWcS5zf//wxUEs9Xi3JvG05iRsO84BsOZDYcCPBOIGx4TBOLZJAvxjLnEkrNjzMU3Bwzplk4w033hgbJBw7jlMLHzDEJN9UJOfJHW/f+OBNhZ3s/P70xxIfaqpxaoGBBBBxAJVLjJZRMApGwSgYBVgBAKHVWMq3G/YzAAAAAElFTkSuQmCC","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":true,"prefix":"","firstName":"Udoka","middleName":"","lastName":"Okpalauwaekwe","suffix":""},{"id":494984912,"identity":"9fd943d5-5d17-40b9-8c44-66b63eafebaf","order_by":1,"name":"Brian K MacPhee","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"K","lastName":"MacPhee","suffix":""},{"id":494984914,"identity":"d2f7dd47-389f-4d4d-9a63-2dfdcefbc7e1","order_by":2,"name":"Lindsay Balezantis","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Lindsay","middleName":"","lastName":"Balezantis","suffix":""},{"id":494984915,"identity":"77b2f8dd-ec80-4aa4-851e-1cd156ea2fd1","order_by":3,"name":"Vivian R Ramsden","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Vivian","middleName":"R","lastName":"Ramsden","suffix":""},{"id":494984916,"identity":"58a3981a-5700-4c42-82d7-63db9b6cf036","order_by":4,"name":"Angela Baerwald","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Baerwald","suffix":""}],"badges":[],"createdAt":"2025-07-26 18:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7222819/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7222819/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-025-03128-x","type":"published","date":"2025-12-01T15:58:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88763373,"identity":"661ac09e-20c2-4816-af34-717157d11899","added_by":"auto","created_at":"2025-08-11 08:26:18","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":331898,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flowchart showing selection of articles for integrative review.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7222819/v1/5263e9794b76210df65c46bb.jpeg"},{"id":88763901,"identity":"9d705146-b081-4de5-ac0e-a6d4a7fbceb9","added_by":"auto","created_at":"2025-08-11 08:34:18","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":368891,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSummary of Factors InfluencingPhysician Retention in Canada.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7222819/v1/3925c6894276cdfb10ac6dba.jpeg"},{"id":88763902,"identity":"d7325f43-406f-4794-95bf-e64fddf7938c","added_by":"auto","created_at":"2025-08-11 08:34:18","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":635305,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual Physician Personas Constructed from the Study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7222819/v1/b2282872917b3b22a41193b1.jpeg"},{"id":97723989,"identity":"8b30df7b-0a2f-4e85-8662-12955aade428","added_by":"auto","created_at":"2025-12-08 16:10:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4121575,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7222819/v1/347b1f1e-d738-45d7-bd30-14c3f25b3f02.pdf"},{"id":88763376,"identity":"59ac3c7b-a8e4-4f4f-8032-47b678edfa1a","added_by":"auto","created_at":"2025-08-11 08:26:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":36346,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-7222819/v1/67ad3d3c5bb404a832e0c6bf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTo stay or leave: An integrative review of factors, personas, and recommendations for retaining family physicians in Canada\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eRetention of family physicians (FPs) in Canada remains a persistent and complex challenge, with serious implications for healthcare accessibility, continuity, and equity. The impacts of family physician shortages are particularly noticeable in rural, remote, and underserved communities (these includes inner city areas with provider shortages, Indigenous communities, and urban or rural areas with high social vulnerability and communities with systemic barriers to care) (1-3). Despite intensified recruitment efforts, the ability to retain both Canadian Medical Graduates (CMGs are physicians who completed their medical training in Canada) and International Medical Graduates (IMGs are physicians who obtained their medical degrees outside of Canada)in comprehensive family practices continues to pose challenges, often resulting in cycles of physician turnover and care disruption (2, 3). Recent reports from the College of Family Physicians of Canada (CFPC) in 2023 estimated that more than 6.5 million Canadians were without a regular family physician, while nearly one in five family doctors were considering reducing or leaving comprehensive practice altogether (1). This widening gap in access to primary care was further underscored by the Canadian Medical Association\u0026rsquo;s (CMA) 2023 Physician Workforce Survey which reported rising burnout among family physicians and a declining interest in family medicine as a long-term career\u0026ndash;both contributing to physician migration, particularly among early-career and rural physicians (4). Additionally, in 2022 the Canadian Institute for Health Information (CIHI) documented that the effects of poor physician retention were disproportionately borne by Indigenous communities and structurally marginalized populations, where disruptions to care continuity could exacerbate already existing health inequities (5).\u003cbr\u003e\u003cbr\u003eSince 2000, numerous strategies have been implemented in various Canadian provinces to attract physicians to family medicine and rural practice (3). While some initiatives (e.g., enhanced rural training tracks, community-based onboarding, and team-based care models) have shown success in improving retention in rural and underserved areas (7, 9), others, such as return-of-service agreements and one-size-fits-all licensure pathways, have often fallen short due to limited alignment with physician goals and inflexibility across career stages or geographic mobility (6, 8, 10). A core limitation in workforce planning has been the tendency to approach retention as a linear, one-size-fits-all issue; overlooking the complex and evolving interplay of personal, family, professional, systemic, and community-level factors that shape physicians\u0026rsquo; decisions to stay or leave (1, 3, 11, 12). Notable challenges include administrative burden (9), excessive workloads (13), limited autonomy (3), and strained work-life balance (14), as well as issues related to training background, lack of team-based care, and how well physicians fit into the communities they serve (i.e., community integration) (3, 13-17). While CMGs and IMGs share some of these challenges, IMGs particularly face unique challenges linked to licensing processes (9), cultural integration (3), and gaps in career support systems to aid integration into the workforce (3, 18, 19).\u003cbr\u003e\u003cbr\u003eRecognizing these dynamics, we undertook this integrative review to provide a comprehensive, system-wide understanding of the factors influencing the retention of family physicians in Canada. Our objective was to move beyond narrow or single-domain perspectives by synthesizing evidence from across geographies, training pathways, and stages of medical practice to identify common and divergent factors shaping physician retention. This approach enabled the development of simulated physician personas grounded in real-world retention narratives, which helped illustrate divergent career trajectories and informed the generation of context-specific recommendations. Unlike our prior work that focused primarily on the experiences of International Medical Graduates (IMGs)(3), this review includes the perspectives of both Canadian Medical Graduates (CMGs) and IMGs across eight provinces. Drawing on empirical research and peer-reviewed policy discourse, we aimed to construct a panoramic view of why family physicians choose to stay, leave, or disengage from comprehensive family medicine in Canada. Ultimately, this review offers a more integrated lens to interpret retention dynamics across time, geography, and training background, and identifies critical leverage points for sustainable health workforce reforms.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis integrative review was guided by the following objectives:\u003c/p\u003e\n\u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003eTo identify and synthesize personal, family, professional, community, and systemic factors that influence the retention or attrition of family physicians (both CMGs and IMGs) within Canadian locations between 2000 and 2025.\u003c/li\u003e\n \u003cli\u003eTo examine how personal, family, professional, community, and systemic factors interact across domains and over time, shaping physicians\u0026rsquo; decisions to stay in or leave family practice, particularly in rural, remote, and underserved areas.\u003c/li\u003e\n \u003cli\u003eTo identify and develop conceptual physician personas that illustrate patterns of experience, motivation, and vulnerability related to retention.\u003c/li\u003e\n \u003cli\u003eTo map evidence-informed recommendations to specific personas and contexts, offering practical strategies for improving retention across varied physician backgrounds and practice environments.\u003c/li\u003e\n \u003cli\u003eTo reflect upon the gaps in current Canadian retention policies and contribute to a systems-level understanding of sustainable family physician workforce planning in Canada.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"METHODOLOGY AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn Integrative Review design was employed to systematically synthesize diverse forms of evidence (i.e., quantitative, qualitative, and mixed methods) related to family physician retention in Canada between January 01, 2000, and March 30, 2025. Integrative reviews allowed for the synthesis of diverse types of evidence (quantitative, qualitative, theoretical, and empirical) to provide a more comprehensive understanding of complex phenomenae (20, 21). Unlike Systematic Reviews, which typically focus on a narrowly defined question using primarily empirical studies (22), or Scoping Reviews, which aim to map the breadth and extent of literature on a topic without deep synthesis (23, 24), Integrative Reviews go further by critically analyzing, comparing, and conceptually integrating findings from multiple methodologies and sources; applying \u0026nbsp;broad and more flexible approaches (20, 21). We chose an integrative approach to go beyond description and mapping, allowing for conceptual synthesis, identification of cross-domain interactions, and the development of personas that illustrate distinct patterns of retention challenges and opportunities among family physicians in Canada (including \u0026nbsp;CMGs and IMGs).\u003cbr\u003e\u003cbr\u003eWe adhered to the Whittemore and Knafl\u0026rsquo;s (20) methodological framework for Integrative Reviews (which includes problem identification, literature search, data evaluation, data analysis, and data presentation) using it as our guiding methodological framework. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (23) as our reporting guideline (see \u003cstrong\u003eSupplementary File A\u003c/strong\u003e).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProtocol and Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo protocol registration was required prior to the commencement of this study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudies were included if they had been: 1) peer-reviewed journal articles that reported associations, predictors and relationships between Canadian family physicians and determinants that influence their decision to stay or leave their practice 2) peer-reviewed journal articles carried out in all areas and settings in Canada including urban, metropolitan, cities, rural or remote areas, and 3) peer-reviewed journal articles (including other synthesis material\u0026ndash;reviews, policy analyses, meta-analyses, mixed method synthesis, data synthesis, etc.) published in English between January 01, 2000 to March 30, 2025. Study protocols, conference abstracts, theses/dissertations, historical and grey literature were excluded. \u003cstrong\u003eTable 1\u003c/strong\u003e provides a descriptive summary of the eligibility criteria for this study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformation Sources and Search Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe collaborated with an academic librarian at the University of Saskatchewan to design a comprehensive search strategy that identified relevant groups of terms. Key search terms were organized into three conceptual groups: \u0026ldquo;family physician\u0026rdquo; (and synonyms), \u0026ldquo;Retention\u0026rdquo; (and synonyms), geography (and synonyms) and \u0026ldquo;Canada\u0026rdquo;. The following electronic databases were searched: MEDLINE (Ovid), PubMed, Scopus, Web of Science and ERIC (Education Resource Information Center). Searches were conducted for articles published from January 1, 2000, to March 30, 2025. Reference lists of included articles were also hand-searched for additional sources. The full search syntax for each database can be found in \u003cstrong\u003eTable 2\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection of Sources of Evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll identified records were imported into Covidence\u0026ndash;a web-based collaboration software platform that streamlines the production of systematic and other literature reviews (Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). Thereafter, duplicate records were removed. We applied two iterative stages to select articles for this review. They were: 1) title and abstract screening, using our predefined eligibility criteria; and 2) full-text article (FTA) review, where eligibility was further confirmed or rejected with documented reasons. Two reviewers (UO and BKM) independently reviewed in both stages and where we had conflicts, resolved them through consensus or arbitration by a third reviewer (LB). The selection process was summarized in the PRISMA-ScR Flow Diagram in \u003cstrong\u003eFigure 1\u003c/strong\u003e.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Charting and Extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We created a structured data extraction template within Covidence to capture and extract data under the following title fields: article title, citation and study objective; study type, study design, location, and setting; physician population focus (CMGs, IMGs, or both); main retention-related findings categorised as \u0026nbsp;barriers and/or facilitators; and recommendations/policy implications. These were then exported into Microsoft Excel (Microsoft Corporation, Version 16) for cleaning, coding, and data synthesis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis and Synthesis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBarriers and Facilitators of Physician Retention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A thematic analysis was undertaken using an abductive approach (i.e., using a deductive coding framework) informed by the domains that have been shown to influence physician retention (3, 11, 12) in Canada, viz-a-viz: personal, family, community, professional, structural (or systemic, organizational, or institutional) . We then coded each study\u0026rsquo;s findings into these domains to allow for themes to emerge, and synthesized them into barrier-facilitator matrices. Where relevant, we double-coded studies also, to reflect cross-domain influences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePersona Development\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;To further illustrate the dynamic interplay across personal, family, community, and systemic domains (and facilitate knowledge translation of our somewhat \u0026nbsp;abstract retention factors into relatable patterns grounded in real physician lived experiences), conceptual personas were constructed that captured recurrent retention profiles observed across included studies. While not exhaustive, the personas reflected the diverse migration pathways, motivations to stay or leave, and the vulnerabilities of Canadian family physicians practicing in various areas. These personas served in this study, as narrative tools to help interpret the findings, uncover systemic gaps, and inform the development of context-specific retention strategies. We constructed these conceptual personas by: \u0026nbsp;a) identifying clusters of co-occurring themes (e.g., burnout + isolation + spousal dissatisfaction); then b) mapping them to demographic and professional traits (e.g., IMG status, early career stage, rural exposure); and finally, c) synthesizing them into narrative personas, by including motivators, barriers, likely outcomes, and/or targeted policy levers. These personas were validated to ensure credibility and relevance through both informal (personal and group discussions) and formal discussions with practicing family physicians across urban, rural, and remote settings in Saskatchewan and other provinces in Canada (British Columbia, Ontario, Nova Scotia and Manitoba) whom the first author (UO) had interactions with at conferences, symposiums, and meetings where early findings of this work were presented. We also sought feedback from these engagements to iteratively refine the personas, ensuring consistency with observed patterns across the data sources (enhancing their applicability through informal triangulation and content validation).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecommendations to Enhance Physician Retention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A thematic analysis of data extracted from included studies on recommendations to enhance physician retention in Canada was conducted and data were mapped with our coding framework across the five domains (i.e., personal, family, community, professional, and systemic).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality Assurance and Critical Appraisal of Included Studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Using the Joanna Briggs Institute (JBI) Critical Appraisal Toolkit (25), we evaluated the methodological quality of each included article. Two reviewers (UO and BKM) independently assessed the studies, and any discrepancies were resolved through discussion and consensus. A summary of the critical appraisal process and results is provided in \u003cstrong\u003eSupplementary File B.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexivity and Trustworthiness of Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUO is an IMG and primary care researcher with the Department of Family Medicine, College of Medicine, University of Saskatchewan; BKM and LB are medical trainees (undergraduate health sciences student and family medical resident respectively) in the College of Medicine, University of Saskatchewan; VRR is a participatory primary care researcher and Director of Research with the Department of Family Medicine, College of Medicine, University of Saskatchewan; and AB is a practicing family physician, and clinical researcher with the Department of Family Medicine, College of Medicine, University of Saskatchewan. As a team, we met regularly to collaboratively interpret, validate, and refine the findings, ensuring \u0026nbsp;we were providing a synthesis that was informed by the diversity of perspectives in the literature and enriched by insights from practicing family physicians and primary care researchers. Additionally, during these debriefing meetings, we critically reflected on how our respective roles and affiliations might have introduced interpretive biases into the analyses/findings.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eSelection of Sources of Evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur initial search across five electronic databases and hand-searching yielded a total of 1,613 records. After removing 376 duplicates, 1237 articles were screened based on titles and abstracts. Of these, 254 full-text articles (FTAs) were reviewed in detail. Following FTA screening, 23 studies were included in the final synthesis. The most common reasons for exclusion at the full-text review stage included more focus on recruitment rather than retention, studies not addressing family physicians specifically, lack of relevance to the Canadian context, and non-original research (e.g., protocols, dissertations, conference abstracts, etc). We illustrated the process of article identification, selection and inclusion in the PRISMA Flow Diagram in \u003cstrong\u003eFigure 1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics of Sources of Evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe included studies employed a diverse range of methodologies: 11 (47.8%) were qualitative, 9 (39.1%) were quantitative, and 3 (13%) used mixed-methods. Most studies (65.2%) were published between 2010 and 2019. With regards to geographical scope, 9 of 23 studies (39.1%) had a national or multi-provincial focus, while the remainder concentrated on specific provinces including Alberta (4/23; 17.4%), Newfoundland and Labrador (4/23; 17.4%), Ontario (4/23; 17.4%), Saskatchewan (3/23; 13%), Quebec (3/23; 13%), Nova Scotia (2/23; 8.7%), and Manitoba (2/23; 8.7%). These studies covered a range of settings including urban, rural, and remote practice environments. While three studies (13%) focused exclusively on either International Medical Graduates (IMGs) or Canadian Medical Graduates (CMGs), the majority (17/23; 73.9%) included both groups. A summary of the methodological and descriptive characteristics of the included studies can be found in \u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults of Individual Sources of Evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA summary of the unique sources of evidence for this study can be found in \u003cstrong\u003eTable 4\u003c/strong\u003e. Articles were included based on their relevance to addressing one or more of the research objectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSynthesis of Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThematic analyses across studies revealed retention factors which were mapped across the deductive coding framework of inter-related domains: personal, family, community, professional, and structural/systemic. Within each domain, both facilitators and barriers to physician retention were identified. A total of 16 major themes and over 30 sub-themes were classified and examined. See \u003cstrong\u003eTable 5\u003c/strong\u003e and \u003cstrong\u003eFigure 2\u003c/strong\u003e , in which the findings from the synthesis are summarized.\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBarriers and Facilitators to Retention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers to retention\u003c/strong\u003e were most frequently concentrated in the professional and structural domains. Studies cited physician burnout, high workloads, poor access to locum coverage, limited scope of practice, and few opportunities for Continuing Medical Education (CME) as significant deterrents to long-term practice, particularly in rural settings (8, 11, 18, 26-33). While rural areas are often assumed to offer broad scope opportunities, several studies (8, 11, 18, 26-33) revealed that structural constraints (such as restrictive billing codes, limited team supports, or administrative oversight) paradoxically narrowed practice scope, leaving physicians underutilized or unsupported in delivering comprehensive care. For IMGs especially, the challenge was not the scope itself, but the lack of mentorship and sustainable infrastructure to manage their scope of practice effectively. Structural or systemic challenges such as licensing constraints (especially for IMGs), restrictive return-of-service (RoS) agreements, insufficient infrastructure, and lack of inter-provincial licensure mobility further compounded dissatisfaction (13, 14, 18, 26, 31, 34-36). These challenges (professional and structural), were often interwoven with family-related concerns, including limited spousal employment opportunities and poor access to quality education for the physician\u0026rsquo;s children (10, 32, 37, 38). In several studies (7, 8, 10, 11, 29, 31, 34, 37, 39), community-level barriers were identified, including social isolation, cultural disconnection, and perceived or experienced discrimination, a lack of amenities (i.e., non-medical services and facilities that contribute to quality of life in community, e.g., gyms, parks, community centers, etc), poor infrastructure (i.e., foundational healthcare and community systems that support clinical practice, e.g., well resourced hospitals, clinics, emergency departments, diagnostic services, telehealth reliability, etc), and fragmented support systems (i.e., social and professional networks and services that buffer stress and support physician wellbeing, e.g., peer/collegial support networks (formal or informal), mental health support services, locum relief, childcare, spousal and family integration supports, etc). At the personal level, lifestyle preferences (e.g. a desire for urban living for those in rural communities), reluctance to relocate (i.e., an underlying intent to leave in cases of physicians who had accepted rural placements due to RoS obligations or other limited options but were not invested in long-term practice integration) also played a role in attrition, especially among younger and early-career physicians (18, 27, 28, 31, 34, 40). Gendered spousal roles, as well as spousal career sacrifices (particularly for female IMGs) (18) and career dissatisfaction (31, 32) emerged as a recurrent theme under the personal domain.\u003c/p\u003e\n\u003cp\u003eIn contrast, \u003cstrong\u003efactors identified to have facilitated physician retention\u003c/strong\u003e were often rooted in a strong sense of community belonging (8, 11, 34, 37), family integration (10, 32, 37), professional autonomy (18, 27-32), and meaningful patient relationships (8, 11, 26, 39). Physicians who reported feeling valued and supported by their communities (either through gestures of appreciation, social engagement, or access to cultural institutions) were more likely to stay (8, 11, 26, 39). Spousal support, employment opportunities, and access to childcare and quality schooling were also positively associated with retention (10, 32, 37, 38). On the professional front, opportunities for broad-scope practice, collegiality, affiliation with academic institutions, supportive team environments, access to mentorship and CME; as well as team-based models of care were frequently cited as enablers of long-term engagement (18, 27-32). Structural supports such as flexible contracts, supportive Return-of-Service (RoS) agreements, streamlined licensure processes for IMGs, alternate payment models (APMs), and well-resourced rural practices emerged as key facilitators (14, 26, 31, 34, 37).\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePersona-Based Synthesis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA series of conceptual physician personas were created based on the recurring themes across included studies. These personas described how combinations of facilitators and barriers may have shaped decisions to stay or leave. Each persona represented a composite of lived experiences drawn from included studies in this review and several stakeholder validation sessions. For example, \u0026ldquo;The Frustrated IMG\u0026rdquo; represented early- to mid-career physicians navigating restrictive licensing pathways, family integration challenges, and community isolation. Without structural reform and spousal support, this persona faced a high risk of attrition. In contrast, \u0026ldquo;The Rural-Rooted Generalist\u0026rdquo; was a Canadian-trained physician aligned with rural life and community values, but vulnerable to burnout without adequate CME, mentorship, or locum support. Other personas included the \u0026ldquo;Mobile Urbanist,\u0026rdquo; who valued lifestyle flexibility and was unlikely to remain in rigid or isolated practice models, and finally the \u0026ldquo;Community-Aligned Practitioner\u0026rdquo; was one who thrived on relational continuity but required ongoing professional growth opportunities to remain engaged (see \u003cstrong\u003eFigure 3\u003c/strong\u003e). These personas provided a narrative lens to get a glimpse of understanding on how cross-domain interactions (e.g. spousal dissatisfaction combined with professional stagnation) compounded retention risks. They could also served as tools for policymakers to tailor solutions that aligned with the unique needs of different physician profiles. A summary of the personas and the retention strategies aligned to each can be seen in \u003cstrong\u003eFigure 3.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecommendations for Retention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe identified a set of \u003cstrong\u003eevidence-informed recommendations\u003c/strong\u003e mapped to the five domains (see \u003cstrong\u003eTable 6\u003c/strong\u003e). These included the need to streamline licensure processes across provinces (14, 32, 37), revise RoS agreements for better alignment with physician goals (27, 29), and strengthen spousal and family support systems (10, 32, 38), invest in community-based onboarding and cultural inclusion programs (8, 11, 34, 37); as well as developing flexible, team-based models of care (13, 26, 34).\u003c/p\u003e\n\u003cp\u003eWhile it is possible that pan-Canadian licensure could increase physician mobility between provinces, our review findings suggested that simplifying licensure requirements may also encourage retention by reducing administrative burden (e.g., redundant paperwork, fees, background checks and delays), enhancing professional autonomy (delimiting physicians\u0026rsquo; ability to respond flexibly to evoliving caeer goals, personal needs and short term relocations), and improving access to short-term locum or cross-provincial practice opportunities. For many early-career physicians, particularly IMGs, the ability to engage in temporary practice outside their home province without reapplying for licensure offered a sense of flexibility and control that supported long-term engagement in their primary practice location (14, 32, 37). As such, rather than driving attrition, streamlining licensure was viewed as a way to reduce that frustration by enabling an environment for professional growth, and support, to remain in underserved areas while staying connected to broader networks of care. See \u003cstrong\u003eTable 6\u003c/strong\u003e for more description of identified recommendations.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eRetention of family physicians in Canada is more than a workforce issue; it is a lens through which we can see the strengths and fractures in our healthcare system. The decision to stay or leave, particularly in Family Medicine, is never made in a vacuum. It is often a decision shaped by the delicate interplay of personal aspirations, systemic conditions, community dynamics, and the professional eco-systems they find themselves in (41). In this study, we set out to explore the interplay of these various factors, drawing on 25 years of literature, to illuminate the conditions under which family physicians (both Canadian and internationally trained) either build long-term careers or leave the systems that trained or welcomed them. \u003c/p\u003e\n\n\u003cp\u003eMuch has been written about the factors that influence retention (e.g., workload, remuneration, spousal employment, burnout, community integration, and more). However, most of these publications tend to examine these factors in isolation. Very few provide a holistic or synthesized picture of how these factors interact in real-world contexts to shape physicians\u0026rsquo; decisions to stay or leave. The power of our integrative approach (20, 21) lies in its ability to trace how systemic and structural policies impact professional fulfillment, how community engagement influences family decisions, and how personal identities and/or determinants intersect with institutional recognition. Additionally, our integrative approach enabled us to identify how alignment (or misalignment) across personal, family, community, professional, and structural domains shapes a family physician\u0026rsquo;s sense of belonging, purpose, and sustainability in their vocation, rather than simply generating a checklist of retention problems. Such an approach is relevant because physician retention is deeply relational: it depends on the strength and quality of relationships between physicians and their patients, colleagues, support staff, administrators, and the communities they serve. Where these relationships thrive (i.e., fostering a sense of belonging and connectedness) so does long-term sustainability (3, 42-44).\u003c/p\u003e\n\n\u003cp\u003eRetention matters because family physicians are the backbone of Canadian primary health care system (3, 45). Family physicians are often the first point of contact with the health care system, providing oversight in chronic disease management and a relational thread that weaves together a patient\u0026rsquo;s healthcare journey (46-49). As such, when retention falters, the consequences ripple far beyond the patient or the primary care provider (45, 50). As continuity of care is lost (51), access to care can be lost, preventive services interrupted (46), Emergency Departments overwhelmed (46, 50), patient outcomes decline including mental health (46), and the integrity of the health systems suffers (46, 52). These critical factors are why retention is not just a human resources issue; it is a systemic integrity issue. It is an indicator of how well we are caring for those who care for us, the significance of which cannot be overstated in the context of primary care\u0026rsquo;s centrality to health equity (15). Canada, like many other Nations, formally committed to the principles of primary care as outlined in the 1978 Alma Ata Declaration (53), the 1986 Ottawa Charter for Health Promotion (55), the 2018 Astana Declaration (54) and the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) (55). These foundational frameworks emphasized that health is a state of holistic well-being, pursued through accessible, community-grounded primary care, facilitated by relationships between patients and regulated health professionals within health systems (53-58). As such, when the very physicians tasked with delivering this kind of care are unable to remain in practice, it signals a retreat from Canada\u0026rsquo;s commitment to delivering on these principles of equitable, relationship-centered, and community-responsive primary health care.\u003c/p\u003e\n\n\u003cp\u003eOur findings have also shown that retention of family physicians is a relational and relationship-driven process. Physicians stayed where they felt connected; either to their communities or their colleagues, to a sense of duty or purpose, and to systems or structures that valued their work. Conversely, they left when these connections and/or relationships were frayed. Based on findings from this study and anecdotal evidence from an initial environmental scan (59), this factor was especially true for physicians working within rural or remote areas in Saskatchewan. In such locations, the departure of even one physician could collapse a clinic, destabilize a regional area, and leave patients with no option but to travel hours to receive primary care (7, 13, 59-61). These communities (often with a more Indigenous or marginalized community presence) bear the compounded weight of systemic neglect, under-investment, and coloniality (i.e., the lingering structures and power dynamics established during colonialism that persist today) (62), which make them more likely to face health disparities and service disruptions when physicians leave (59, 63-65). Within rural and remote settings, retention is not just a matter of adequate staffing, but also that of relational equity for providers who face disproportionately high clinical loads, limited specialist support, and professional isolation compared to that of their urban counterparts (14, 37, 41, 66). In this light, physician retention becomes part of a broader struggle for equity, reconciliation, and relational accountability (67-69). Based on findings from this study, it was found that family physicians were deeply frustrated when leaving these communities; not because they lack commitment or sense of moral/fiduciary duty, but rather because the community, professional or structural-systemic conditions necessary for them to thrive were lacking (3, 59). As such, this integrative review illuminates the urgent need to rethink how we approach retention, not only as an operational necessity, but as a matter of fairness, inclusion, and \u003cem\u003ereparative\u003c/em\u003e investment in rural, remote and Indigenous communities (5, 67, 68, 70, 71). \u003c/p\u003e\n\n\u003cp\u003eOne of the unique contributions of this review was the development of physician \u0026ldquo;personas\u0026rdquo; (i.e., conceptual profiles grounded in the synthesis of retention narratives across the included studies). These personas (ranging from the \u0026ldquo;\u003cem\u003eFrustrated IMG\u003c/em\u003e\u0026rdquo; facing the\u003cem\u003e usual\u003c/em\u003e licensing hurdles and family isolation, to the \u0026ldquo;\u003cem\u003eBurned-Out Rural Physician\u003c/em\u003e\u0026rdquo; managing years of practice with vacillating support) brought humanity into the discussion. Often times, the discussion around physician retention, tends to create an abstract picture or caricature of the typical family physician in Canada. It is believed that the physician \u0026ldquo;personas\u0026rdquo; are not caricatures but composite portraits of \u0026ldquo;real\u0026rdquo; and lived physician experiences that reveal the emotional, and identity-based dynamics that shape physician life, family and career trajectories (32, 34, 41, 45, 48, 72). More importantly, these personas also revealed how generic, one-size-fits-all policies have often reinforced (rather than alleviated) the challenges faced by physicians across Canada. Thus, we can now appreciate that a one-size-fits-all approach for retention cannot address the divergent realities of a young CMG parent seeking urban flexibility, or an IMG navigating integration challenges, or a mid-career rural physician on the verge of exhaustion and so on. Each of these physicians needs something different. On the other hand, it cannot be assumed that the personae framework offers a perfect solution in itself; we believe it proposes a way to think more carefully, more empathetically, and more practically about what different family physicians need in order to stay in their home province or in Canada to practice. It is believed that our study findings may assist decision-makers to shift from the\u003cem\u003e usual\u003c/em\u003e reactive workforce planning to an \u003cem\u003eintentional\u003c/em\u003e design of retention in Canada (and by extension similar primary care systems globally). For example, a well-functioning retention ecosystem, might include \u003cem\u003ebundled\u003c/em\u003e supports such as flexible licensure pathways across provinces, locally tailored onboarding and peer mentorship programs, spousal employment supports, access to locum coverage, and embedded community engagement efforts, each calibrated to the physician\u0026rsquo;s career stage and practice context (opposed to a generic often lobsided strategy).\u003c/p\u003e\n\n\u003cp\u003eBuilding on this foundation, our study also revealed how deeply interconnected the factors (i.e., personal, family, community, professional and structural) influencing physician retention are. For example, structural constraints (e.g., restrictive licensure pathways, fee-for-service payment models, or return-of-service contracts), often collide with professional challenges such as lack of autonomy, poor access to Continuing Medical Education (CME), and low levels of professional and interprofessional supports. One of the most frequently cited structural barriers was the fee-for-service payment model. These models often fail to compensate for the complexity, continuity, and coordination that family physicians provide, particularly in comprehensive or rural practice settings. Remodelling remuneration structures to better reflect the time, relational work, and scope of care delivered by family physicians may improve job satisfaction and autonomy, and serve as a powerful lever to reduce attrition. Structural and professional influences, in turn, shape family decisions, influence personal well-being, and affect community engagement. When one or more of the domains misalign, physician retention becomes fragile. What was especially concerning was that many of these tensions were \u003cem\u003epredictable\u003c/em\u003e and therefore \u003cem\u003epreventable\u003c/em\u003e. To prevent them, however, we must move beyond transactional and short-term solutions (e.g., salary top-ups and other financial incentives, or compliance-based contracts) to long-term retention strategies that attend to the \u003cem\u003erelational alignment\u003c/em\u003e across a physician\u0026rsquo;s full experience. This approach is inclusive of not only what happens in the clinic, but also what happens outside of work (e.g., meaningful work opportunities for spouses, access to quality education for children, presence of mentorship and peer support, and/or adequate support and integration of physicians into the communities). These factors have been known for decades (37, 41, 45, 48, 63), and health systems that ignore them puts individuals and communities at risk due to less-than-optimal sustainability of health care resources (42, 73-79)\u003c/p\u003e\n\n\u003cp\u003eAlas, the consequences of less-than-optimal physician retention in Canada threatens the very viability of family medicine as a discipline (15, 56). For example, fewer medical students are choosing Family Medicine as a career(80-83). Furthermore, early-career family physicians are gravitating towards more focused practices that allow for more control and flexibility (84-86). Comprehensive, community-based generalist care is increasingly perceived as unrewarded and unsustainable (86-88). This unfortunate trajectory undermines the core principles of the Patient\u0026rsquo;s Medical Home (89, 90), and the broader vision of universal, relational primary care that Canada has long been espoused (89, 90). Without a course correction, we risk creating a healthcare system in which continuity is the exception rather than the norm (56, 91). However, there are glimmers of hope and reform for retention strategies, such as the expansion of interdisciplinary teams (89-92), the re-design of alternate payment models (34, 56), the strengthening of IMG assessment pathways (including the CMA\u0026rsquo;s proposal for a Pan-Canadian licensure pathway) (18, 93, 94), and the emergence of wellness and mentorship initiatives aimed at supporting physicians (95, 96). Notably, the CFPC\u0026rsquo;s Patient\u0026rsquo;s Medical Home (PMH) Model offers a compelling vision for team-based, community-grounded care (89, 90). In addition, the Canadian Medical Association\u0026rsquo;s advocacy for Pan-Canadian licensure proposes regulatory reforms to reduce interprovincial barriers to practice (94). Province-specific strides are being made, which can be used as models for optimizing primary care delivery across the country. In Nova Scotia, expanded team-based care and centralized physician recruitment have been implemented (97). British Columbia introduced a new longitudinal payment model to support comprehensive care (98). Alberta is modernizing its Primary Care Networks to facilitate primary care team attachment and access (99). Saskatchewan recently rolled out a new remuneration model to strengthen physician retention in urban, rural and remote communities(100), has ongoing participation in provincially-funded primary care innovation specific to individual clinic and community needs, and is working to re-align primary care delivery among networks (ref) . Manitoba has rolled out rural mentorship and retention bonuses for primary care teams and the health workforce (101), and Newfoundland and Labrador are developing Family Care Teams alongside incentive structures (102). These provincial efforts represent important steps toward a sustainable primary care workforce. While these strategies are an important step forward, we believe these strategies should be co-created \u0026ldquo;with\u0026rdquo; (and not \u0026ldquo;on\u0026rdquo;) the relevant participants (e.g., physicians, nurses, patients, other regulated health practitioners, Indigenous communities, and decision makers), spread contextually, and evaluated rigorously to ensure long-term sustainability.\u003c/p\u003e\n\n\u003cp\u003eOverall, the present integrated review invites each of us to re-imagine retention as a collective responsibility rather than \u003cem\u003esomeone else\u0026rsquo;s\u003c/em\u003e responsibility. Physicians do not stay in place because of contracts or financial incentives alone. They stay because the systems they work within are conducive, compassionate, and responsive to their personal and professional expectations (44). Family physicians remain in their practice location because they are embedded in communities that care not just about access, but about belonging (72). They stay because they are supported not just to survive, but to thrive (50). If we want to build a primary care system that reflects the commitments of the Alma Ata Declaration, the Ottawa Charter, the Astana Declaration and the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), then we should start by actively listening to those tasked with delivering that care. We believe that this integrated review offers a framework for doing just that (i.e., understanding not just the policies that shape physician retention, but the people those policies effect). In the end, the question will not be whether Canadian physicians will stay or leave; it will be whether we are building a system that encourages them to stay.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, through this integrative review, we have identified a range of inter-related factors that influence the retention of family physicians in Canada across five domains: structural/systemic, professional, family-related, community, and personal. Structural and professional barriers such as administrative burden, restrictive licensure, and limited autonomy, emerged as the most significant roadblocks to retention. Facilitators were often grounded in family and community support, collegial work environments, and physicians having a sense of belonging. By synthesizing findings across 23 studies and mapping them to conceptual physician personas, this review underscored the importance of co-creating tailored and context-specific physician retention strategies, including, but not limited to, reforming remuneration models, implementing team-based primary care, creating Pan-Canadian licensure pathways, and enhancing community-driven integration efforts. Overall, this review provides actionable insights for health practitioners, policymakers and health system leaders that would strengthen sustainability of the primary care workforce in Canada.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAPMs\u003c/strong\u003e \u0026ndash; Alternate Payment Models\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCCFP\u003c/strong\u003e \u0026ndash; Certification in the College of Family Physicians\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCIHI\u003c/strong\u003e \u0026ndash; Canadian Institute for Health Information\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCMG\u003c/strong\u003e \u0026ndash; Canadian Medical Graduate\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCME\u003c/strong\u003e \u0026ndash; Continuing Medical Education\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCSA\u003c/strong\u003e \u0026ndash; Canadian Studied Abroad\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCFPC\u003c/strong\u003e \u0026ndash; College of Family Physicians of Canada\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCMA\u003c/strong\u003e \u0026ndash; Canadian Medical Association\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eERIC\u003c/strong\u003e \u0026ndash; Education Resources Information Center\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIMG\u003c/strong\u003e \u0026ndash; International Medical Graduate\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJBI\u003c/strong\u003e \u0026ndash; Joanna Briggs Institute\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLFP\u003c/strong\u003e \u0026ndash; Longitudinal Family Physician\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMMG\u003c/strong\u003e \u0026ndash; Memorial University Medical Graduate\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMUN\u003c/strong\u003e \u0026ndash; Memorial University of Newfoundland\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNPS\u003c/strong\u003e \u0026ndash; National Physician Survey\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePMH\u003c/strong\u003e \u0026ndash; Patient\u0026rsquo;s Medical Home\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePGME\u003c/strong\u003e \u0026ndash; Postgraduate Medical Education\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRISMA-ScR\u003c/strong\u003e \u0026ndash; Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRoS\u003c/strong\u003e \u0026ndash; Return-of-Service\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSIPPA\u003c/strong\u003e \u0026ndash; Saskatchewan International Physician Practice Assessment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSRPC\u003c/strong\u003e \u0026ndash; Society of Rural Physicians of Canada\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUoS\u003c/strong\u003e \u0026ndash; University of Saskatchewan\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors report no Conflicts of Interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eFunding provided by the Saskatchewan Health Research Foundation (SHRF) Align Grant held by Dr. Baerwald.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNorthern Medical Services (NMS)\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003eSaskatchewan College of Family Physicians (SCFP), Saskatchewan Health Authority (SHA), Saskatchewan Health Research Foundation (SHRF), Saskatchewan International Physician Practice Assessment (SIPPA), Saskatchewan Medical Association (SMA), Saskatchewan Ministry of Health, University of Saskatchewan\u0026rsquo;s Department of Academic Family Medicine (DAFM) and the Align Primary Care Working Group Members: Brenda Andreas, Erin Brady, Jessica Campbell, Selene Daniel-Whyte, Coralie Darcis, Diana Ermel, Fei Ge, John Gordon, Jackie Hanson, Carla Holinaty, Jason Hosain, Max Karnitsky, Melissa Kimens, Matthew Kushneriuk, Kathy Lawrence, Bryan MacLean, Cathy MacLean, Veronica McKinney, Andries Muller, Cassandra Opikokew-Wajuntah, Meric Osman, Olivia Reis, Johann Roodt, Ginger Ruddy, Sheila Smith, Kent Stobart, Stuart Stone, Janet Tootoosis, Felicia Watson, Jon Witt, Matthew Wong, and Julie Yu.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eUO, AB and VRR contributed to the conceptualization, funding application, methodology and design of this review. UO, BKM, and LB contributed to the data collection, management, and data analysis of this work. UO, AB and VRR contributed the original draft of the manuscript. All authors (UO, BKM, LB, AB and VRR) contributed to the review and editing of several drafts of the manuscript. All authors (UO, BKM, LB, AB and VRR) read and approved the final draft of the manuscript for submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCollege of Family Physicians of Canada (CFPC). \u003cem\u003ePosition Statement on the Workforce Supply of Family Physicians in Canada: Ensuring Equitable Access to Comprehensive, Continuous Primary Care\u003c/em\u003e. College of Family Physicians of Canada; 2023. Available from: https://www.cfpc.ca/en/policy-innovation/health-policy-goverment-relations/cfpc-policy-papers-position-statements/position-statement-on-workforce-supply-for-family. 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Building general practice training capacity in rural and remote Australia with underserved primary care services: a qualitative investigation. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2019;19(1):338. doi:10.1186/s12913-019-4078-1.\u003c/li\u003e\n\u003cli\u003eMcKee ND, McKague MA, Ramsden VR, Poole RE. Cultivating interest in family medicine: family medicine interest group reaches undergraduate medical students. \u003cem\u003eCan Fam Physician\u003c/em\u003e. 2007;53(4):661-5.\u003c/li\u003e\n\u003cli\u003eAvinashi V, Shouldice E. Increasing interest in family medicine. \u003cem\u003eCMAJ\u003c/em\u003e. 2006;174(6):761-2. doi:10.1503/cmaj.050752.\u003c/li\u003e\n\u003cli\u003eGill H, McLeod S, Duerksen K, Szafran O. Factors influencing medical students\u0026apos; choice of family medicine: effects of rural versus urban background. \u003cem\u003eCan Fam Physician\u003c/em\u003e. 2012;58(11):e649-57.\u003c/li\u003e\n\u003cli\u003eRosser WW. The decline of family medicine as a career choice. \u003cem\u003eCMAJ.\u003c/em\u003e 2002;166(11):1419-20.\u003c/li\u003e\n\u003cli\u003eKabir M, Randall E, Mitra G, Lavergne MR, Scott I, Snadden D, et al. Resident and early-career family physicians\u0026apos; focused practice choices in Canada: a qualitative study. \u003cem\u003eBr J Gen Pract\u003c/em\u003e. 2022;72(718):e334-e41. doi:10.3399/bjgp.2021.0512.\u003c/li\u003e\n\u003cli\u003eAggarwal M, Abdelhalim R. Are early career family physicians prepared for practice in Canada? A qualitative study. \u003cem\u003eBMC Med Educ\u003c/em\u003e. 2023;23(1):370. doi:10.1186/s12909-023-04250-z.\u003c/li\u003e\n\u003cli\u003eCIHI. \u003cem\u003eChanges in practice patterns of family physicians in Canada 2024\u003c/em\u003e. Available from: https://www.cihi.ca/en/changes-in-practice-patterns-of-family-physicians-in-canada?utm_source=chatgpt.com. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eLavergne MR, Ahuja MA, Schultz A, Hedden L. Trends in comprehensive care among family physicians in British Columbia. CMAJ. 2023;195(3):E112-E8. doi:10.1503/cmaj.221352.\u003c/li\u003e\n\u003cli\u003eLavergne MR, Rudoler D, Peterson S, Stock D, Taylor C, Wilton AS, et al. Declining Comprehensiveness of Services Delivered by Canadian Family Physicians Is Not Driven by Early-Career Physicians. Ann Fam Med. 2023;21(2):151-6. doi:10.1370/afm.2945.\u003c/li\u003e\n\u003cli\u003eCollege of Family Physicians of Canada. \u003cem\u003eA new vision for Canada: Family Practice\u0026mdash;The Patient\u0026rsquo;s Medical Home 2019 Mississauga, ON2019\u003c/em\u003e. Available from: https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eWong ST, Thandi M, Martin-Misener R, Johnston S, Hogg W, Burge F. Transforming community-based primary health care delivery through comprehensive performance measurement and reporting: examining the influence of context. \u003cem\u003eBMC Prim Care\u003c/em\u003e. 2024;25(1):410. doi:10.1186/s12875-024-02659-z.\u003c/li\u003e\n\u003cli\u003eKiran T, Wang R, Handford C, Laraya N, Eissa A, Pariser P, et al. Family physician practice patterns during COVID-19 and future intentions: Cross-sectional survey in Ontario, Canada. \u003cem\u003eCan Fam Physician\u003c/em\u003e. 2022;68(11):836-46. doi:10.46747/cfp.6811836.\u003c/li\u003e\n\u003cli\u003eAggarwal M, Glazier RH. Toward a universal definition of provider-patient attachment in primary care. \u003cem\u003eCan Fam Physician\u003c/em\u003e. 2024;70(10):634-41. doi:10.46747/cfp.7010634.\u003c/li\u003e\n\u003cli\u003eRoyal College of Physicians and Surgeons of Canada. \u003cem\u003eRecruitment, retention and collaboration: Addressing Canada\u0026rsquo;s shortage of health professionals\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003e2024\u003c/em\u003e. Available from: https://www.royalcollege.ca/en/newsroom/posts/recruitment--retention-and-collaboration--addressing-canada-s-sh.html. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eCanadian Medical Association (CMA). \u003cem\u003eImproving accountability in health care for Canadians.\u003c/em\u003e Ottawa: The Association; 2023. Available from: https://digitallibrary.cma.ca/link/digitallibrary4. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eCollege of Family Physicians of Canada (CFPC). \u003cem\u003ePhysician Wellness+ Initiative 2023.\u003c/em\u003e Available from: https://www.cfpc.ca/en/education-professional-development/practice-tools-guidelines/physician-wellness-initiative. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eHernandez-Lee J, Pieroway A. Mentorship for early career family physicians: Is there a role for the First Five Years in Family Practice Committee and the CFPC? \u003cem\u003eCan Fam Physician\u003c/em\u003e. 2018;64(11):861-2.\u003c/li\u003e\n\u003cli\u003eNova Scotia Health. \u003cem\u003eStrengthening the Primary Health Care System in Nova Scotia. Evidence Synthesis and Guiding Document for Primary Care Delivery: Collaborative family practice team-based care \u0026amp; health homes\u003c/em\u003e 2023. Available from: https://www.nshealth.ca/sites/default/files/documents/Strengthening%20Primary%20Healthcare.pdf. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eBritish Columbia Ministry of Health. \u003cem\u003eMSC Longitudinal Family Physician (LFP) Payment Schedule 2024\u003c/em\u003e. Available from: https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/medical-services-plan/longitudinal-family-physician/lfp-paymment-schedule_april-2025.pdf?utm_source=chatgpt.com. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eGovernment of Alberta. \u003cem\u003eStrengthening Health Care 2023.\u003c/em\u003e Available from: https://open.alberta.ca/dataset/fe2a75b5-571b-4b44-8b04-66a6d81aaba4/resource/20f11317-cc2f-4468-95c3-dae61dd516ae/download/budget-2023-highlights-strengthening-health-care.pdf?utm_source=chatgpt.com. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eGovernment of Saskatchewan. \u003cem\u003eTransitional Payment Model (TPM) Information \u003c/em\u003eRegina, SK: Government of Saskatchewan; 2024. Available from: https://www.saskatchewan.ca/government/health-care-administration-and-provider-resources/transitional-payment-model-tpm-information. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eGovernment of Manitoba. \u003cem\u003eHealth Human Resource Action plan 2022\u003c/em\u003e. Available from: https://news.gov.mb.ca/news/?item=58225. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003cli\u003eGovernment of Newfoundland and Labrador. \u003cem\u003eHealth and Community Services 2025.\u003c/em\u003e Available from: https://www.gov.nl.ca/hcs/grantsfunding/bursaries/?utm_source=chatgpt.com. Accessed Feb 05, 2025.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Eligibility criteria for review study\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCriteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInclusion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExclusion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eCanadian Family Physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eOther health professionals such as specialists, nurse practitioners, nurses, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePlace of study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eCanada\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eAny country other than Canada\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eGeography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAll areas including urban, metro urban, cities, and rural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eAll areas outside of Canada\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eHealthcare areas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eRetention, decision to move out from any area in primary care settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSecondary or tertiary care, medical education, medical training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eLanguage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eNon-English\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eTime period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e2000-2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026lt; 2000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eStudy type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eOriginal studies and other synthesis material (reviews, policy analysis, meta-analysis, mixed method synthesis, data synthesis, etc.) \u0026nbsp; \u0026nbsp; published in a peer-reviewed journal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eOpinion pieces, study protocols, case reports, dissertations, historical and grey literature.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Keyword search syntax used for library search.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 623px;\"\u003e\n \u003col\u003e\n \u003cli\u003e\u003cstrong\u003ePopulation/\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eFamily adj1 physicians* OR general adj1 practitioner$ OR nurse adj1 practitioner* OR International adj1 medical adj1 graduate* OR Foreign adj1 medical adj1 graduate OR Migrant adj1 physician* OR oversea* adj1 trained adj1 physician* OR oversea* adj1 trained adj1 health adj1 professional.ti.ab*\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRetention\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003ePhysician adj3 retention OR stay OR exit OR turnover OR attrition OR job adj2 retention OR job adj2 satisfaction OR fulfilment OR career adj2 advancement OR contentment OR workforce stability OR job adj2 dissatisfaction.ti.ab\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePractice geography/\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eUrban OR Metro* OR Rural adj2 medicin* OR rural adj1 population* OR rural adj1 communit* OR rural adj1 practice OR rural adj2 practice or rural adj2 health \u0026nbsp;OR rural adj2 health adj1 servic*.ti.ab\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLocation/\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eCanada OR Alberta OR British adj1 Columbia OR Manitoba OR New adj1 Brunswick OR Newfoundland adj1 and abj1 Labrador OR Northwest adj1 Territor* OR Nova adj1 Scotia OR Nunavut OR Ontario OR Prince adj1 Edward adj1 Island OR Quebec OR Saskatchewan OR Yukon.ti.ab\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e#2 AND #4 AND #6 AND #8\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: General and methodological descriptive characteristics of included studies (n=23)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePublication year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eArticle citation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 2000- 2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(9, 30, 36, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e2010- 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(7, 8, 10, 11, 13, 18, 26, 28, 29, 31-33, 38-40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e2020- 2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(14, 27, 34, 35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvinces*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eAB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(8, 10, 11, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(27, 35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(38, 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eNFL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(9, 29-31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(27, 35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eON\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(27, 32, 35, 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eSK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(7, 13, 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eQC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(28, 33, 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003ePan-Canadian/Multiple provinces\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(14, 18, 26, 27, 32, 35-37, 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily Physician category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eCMGs focused\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(28, 31, 36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eIMG focused\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(27, 37, 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eBoth IMGs and CMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e17 (73.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(7-11, 13, 14, 18, 26, 29, 30, 32-35, 39, 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e13 (56.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(8, 10, 11, 13, 14, 26-29, 31, 34, 36, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(7, 9, 18, 30, 32, 33, 35, 38-40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eQuantitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(9, 18, 26, 30, 32, 36, 38-40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eQualitative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(7, 8, 11, 27-29, 31, 33-35, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eMixed Methods Research\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(10, 13, 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eData collection type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003ePrimary data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16 (69.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(7, 8, 10, 11, 13, 14, 26-28, 31, 33-36, 38, 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eSecondary data (Data Registry/reviews/admin data)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e(9, 18, 29, 30, 32, 37, 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eMultiple overlap for cited studies\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Characteristics of included studies (n=23)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"741\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(citation)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Objective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type, Design, Location, Setting, and Physician focus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelevant Findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractical implications and indications to enhance workforce retention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eAmpofo-Addo et al. 2016 (13).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo understand factors that influence location decision of family physicians in Saskatchewan (SK), Canada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e mixed methods research\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Surveys and Interviews\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Saskatchewan, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Rural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs and Canadian Medical Graduates (CMGs).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: lack of spousal and family supports.\u003c/li\u003e\n \u003cli\u003eCommunity: Lack of community support, community disintegration\u003c/li\u003e\n \u003cli\u003eProfessional: Burnout, high call rotation, few staff, lack of team support and educational opportunities\u003c/li\u003e\n \u003cli\u003eStructural/systematic: Non-sustainable model of care delivery, poor infrastructure/working conditions\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: preference for rural life, friendly climate and rural activities.\u003c/li\u003e\n \u003cli\u003eFamily: Spousal employment/family support, access to children\u0026rsquo;s education\u003c/li\u003e\n \u003cli\u003eCommunity: social integration\u003c/li\u003e\n \u003cli\u003eProfessional: Good workload, collegiality, scope of work and financial compensation\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eMatch physicians with communities that align with their family, work-life, and lifestyle expectations.\u003c/li\u003e\n \u003cli\u003eProvide financial incentives only to communities that cannot meet those requirements.\u003c/li\u003e\n \u003cli\u003eFoster collaboration among small communities for viable group practices\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eAsghari et al., 2017 (28).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo identify factors influencing decisions to work in rural or remote areas.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Interviews with rural physicians.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Quebec, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eRural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e CMGs (implied).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: lack of extracurricular activities.\u003c/li\u003e\n \u003cli\u003eFamily: lack of spousal employment and children\u0026apos;s education.\u003c/li\u003e\n \u003cli\u003eCommunity: remoteness, cultural or language barriers, and absence of spiritual or cultural centers.\u003c/li\u003e\n \u003cli\u003eProfessional: difficulty accessing continuing education and specialists, burnout from high turnover and long hours, social challenges like maintaining a social life and anonymity. Poor collegial support and treatment from urban physicians.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: preference for rural life, previous education or life experience in rural area\u003c/li\u003e\n \u003cli\u003eFamily: spousal support to settle rurally, access employment opportunities.\u003c/li\u003e\n \u003cli\u003eCommunity: community appreciation, friendliness, security, privacy, intimacy.\u003c/li\u003e\n \u003cli\u003eProfessional: wide scope of practice, access to CME, collegiality, positive working environment, and strong practice team\u003c/li\u003e\n \u003cli\u003eStructural: additional financial incentives to stay, and reimbursement for travels outside rural area\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eProviding opportunities for professional development, creating a supportive work environment, enhancing collegial and personal support systems,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEnsuring a healthy work-life balance, providing adequate education for children, offering employment opportunities for spouses, and fostering community integration. Supporting and creating specific competencies targeting rural skills and supportive training environment.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eBosco et al, 2024 (14).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo understand factors influencing physicians\u0026apos; decisions to leave/stay in rural practice and assess perspectives on national licensure\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e mixed methods\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Environmental scan of 25 reports + qualitative and quantitative analysis of 2 national physician surveys (SRPC and CMA)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e national focus Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eRural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Both CMGs and IMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: Family dissatisfaction\u003c/li\u003e\n \u003cli\u003eCommunity: limited community integration.\u003c/li\u003e\n \u003cli\u003eProfessional: burdensome licensure requirements and fees for cross-provincial work. Poor work-life balance and burnout\u003c/li\u003e\n \u003cli\u003eStructural: Lack of infrastructure and locum coverage in rural areas.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCommunity: community integration and team-based practice support.\u003c/li\u003e\n \u003cli\u003eProfessional: National licensure enabling interprovincial mobility. Locum flexibility for semi-retired/retired physicians. Ability to access educational and locum opportunities across provinces.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eImplement national (pan-Canadian) licensure to reduce administrative barriers\u003c/li\u003e\n \u003cli\u003eImprove locum availability and infrastructure in rural areas.\u003c/li\u003e\n \u003cli\u003eCreate turnkey, team-based rural practices.\u003c/li\u003e\n \u003cli\u003eAddress family and community integration needs\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eCameron et al., 2010 (8).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo explore community factors that promote physician retention in rural Alberta communities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Interview, Collective case-study design.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Alberta, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eRural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Both CMGs and IMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNone identified in study\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCommunity: Community appreciation (thank-yous, gifts, verbal praise). Personal and family connection to the community. Active support (advocacy, welcoming efforts, local fundraising). Appealing physical/recreational infrastructure (parks, activities). Mutual respect and reciprocity between community and physicians\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eStrengthen community-physician relationships,\u003c/li\u003e\n \u003cli\u003eInvolve communities in physician support, both socially and professionally.\u003c/li\u003e\n \u003cli\u003eConsider community-based interventions (e.g., welcome programs, community appreciation).\u003c/li\u003e\n \u003cli\u003ePromote reciprocal contributions between physicians and communities\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eCameron et al. 2012 (11).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo explore professional, personal, and community factors influencing physician retention in rural Alberta.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Interview, Collective case-study design.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Alberta, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eRural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Both CMGs and IMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: lack of sufficient recreational assets, dissatisfaction of a physician\u0026apos;s spouse with the community.\u003c/li\u003e\n \u003cli\u003eCommunity: supply leading to burnout. Lack of community support\u003c/li\u003e\n \u003cli\u003eProfessional: \u0026nbsp;inadequate physician Preserving status quo. Lack of innovative drive from management\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: goodness-of-fit, individual choice.\u003c/li\u003e\n \u003cli\u003eFamily: spousal and family support.\u003c/li\u003e\n \u003cli\u003eCommunity: appreciation, connection, active support, physical and recreational assets, reciprocity\u003c/li\u003e\n \u003cli\u003eProfessional: physician supply, dynamics, scope of practice, practice set-up, innovation, management and support. Advanced innovation and management support\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eConsidering the interplay between professional, personal, and community factors,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLinking recruitment with retention efforts,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFostering positive doctor-patient relationships, promoting strong communities, and encouraging collaborative retention strategies led by both physicians and communities.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eChan et al., 2005 (36).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo examine influences on rural practice entry among physicians with different backgrounds.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Cross-sectional survey.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e National scope, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Rural.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e CMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: the influence of spouses\u0026apos; preferences and proximity to family.\u003c/li\u003e\n \u003cli\u003eStructural: limited effectiveness of financial incentives for long-term retention, the small number of rural students entering medical school. Financial incentives are less effective for long-term retention.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: enjoyment of a rural lifestyle, and rural education during medical training\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFamily: Spouses\u0026apos; preferences and proximity to family,\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eEncouraging rural applicants to apply for medicine,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMaking exposure to rural practice available during training,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePromoting the challenges and lifestyle of rural practice, and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTargeting both urban and rural students for recruitment and retention in rural areas.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eChauban et al., 2010 (26).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo assess incentives, satisfaction, future migration plans, and retention strategies among rural physicians in Canada\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e National cross-sectional survey.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e National scope, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Rural.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs and CMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: Inadequate family support or child education options\u003c/li\u003e\n \u003cli\u003eProfessional: Lack of locum coverage (60% dissatisfaction). Poor professional backup (43%). Poor satisfaction with relief and on-call workload.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Liking rural lifestyle (82%). Match with career interests (75%). Positive rural training experiences\u003c/li\u003e\n \u003cli\u003eCommunity: sense of community appreciation (84%) and belonging (76%).\u003c/li\u003e\n \u003cli\u003eProfessional: Full scope of practice (84%).\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eImprove access to locums and professional relief.\u003c/li\u003e\n \u003cli\u003eMaintain and promote full scope of practice in rural settings.\u003c/li\u003e\n \u003cli\u003eInvest in structured rural training experiences.\u003c/li\u003e\n \u003cli\u003eAddress family and community integration.\u003c/li\u003e\n \u003cli\u003eSupport intra-professional collaboration and use of technology for specialist support.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eDove N. 2009 (37).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo assess the potential of IMGs in addressing rural physician shortages in Canada.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type\u003c/strong\u003e: Review/Policy Analysis\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e: Policy perspective analysis and narrative critical discourse\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e: Pan-Canadian and rural focused\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e: Rural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs only.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u003cstrong\u003ePersonal:\u003c/strong\u003e Preference for urban migration.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u003cstrong\u003eFamily:\u003c/strong\u003e Limited spousal integration, job opportunities, and educational support for families.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u003cstrong\u003eCommunity:\u003c/strong\u003e Lack of engagement, social and cultural isolation, discrimination, and high turnover.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u003cstrong\u003eProfessional:\u003c/strong\u003e Heavy workload, burnout, limited mobility, restricted practice scope, low compensation, and lack of training support.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u003cstrong\u003eStructural:\u003c/strong\u003e Poor infrastructure, inconsistent licensing policies, short retention periods, and lack of national coordination in IMG recruitment.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp;\u003cstrong\u003ePersonal:\u003c/strong\u003e Attraction to rural life, previous rural training, and community appreciation.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp;\u003cstrong\u003eFamily:\u003c/strong\u003e Spousal employment, family integration, and educational opportunities.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp;\u003cstrong\u003eCommunity:\u003c/strong\u003e Strong local support, cultural/religious networks, and diverse environments.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp;\u003cstrong\u003eProfessional:\u003c/strong\u003e Balanced workload, career growth opportunities, full licensure, financial incentives, and access to continuing education.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp;\u003cstrong\u003eStructural:\u003c/strong\u003e Institutional support, clear contracts, well-equipped facilities, coordinated licensing, and ethical recruitment policies.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eIntegrate IMGs into long-term workforce planning.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEnhance spousal and family support.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFocus on career development, community integration, and systemic workforce strategies beyond licensing.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEnsure access to mentorship, training, and career pathways.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eImprove financial incentives, relocation support, and flexible payment models.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp;\u003cstrong\u003eAdopt a national approach to IMG recruitment, licensing, and retention to improve workforce stability.\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eGrudniewicz et al.,\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;2023 (35).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo identify the key factors that influence the practice choices of early-career family physicians in Canada\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Framework Analysis using semi-structured interviews\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e BC, Ontario and Nova Scotia, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs and Canadian Medical Graduates (CMGs).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: personal responsibilities (e.g., childcare).\u003c/li\u003e\n \u003cli\u003eProfessional: Lack of flexibility in practice models. Lack of mentorship or poor training experiences; overwork; limitations in payment models or scope\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCommunity: community connection; group practices; affiliation with other health professionals\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProfessional: positive training experiences; mentorship; supportive team environments; flexibility in practice schedule.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAlign training with desired practice models.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eimprove policy and payment systems to support flexibility and comprehensiveness.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSupport family responsibilities and work-life balance.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRecognize diverse personal and professional goals\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eLavesque et al., 2018 (33).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo explore factors influencing physician retention in Quebec, Canada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Semi-structured interviews.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Quebec, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eRural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs and CMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eProfessional: Burnout, limited mobility, or scope of practice\u003c/li\u003e\n \u003cli\u003eStructural: issues with continuity of care.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: Spousal employment, family integration, opportunities for children\u003c/li\u003e\n \u003cli\u003eProfessional: Opportunities to advance career, physician wellness, and work environment, large scope of practice, autonomy, and care continuity.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFocusing on improving the work environment and professional life quality through Regional Medical Campuses (RMCs), which contribute to regional development, healthcare quality, and economic impacts.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCreating teaching opportunities.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMathews et al., 2007 (30).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo assess whether IMGs trained at Memorial University of Newfoundland (MUN) are as likely as MUN and other Canadian medical graduates to work in Canada and Newfoundland and Labrador (NL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Linked administrative data (MUN postgraduate database; and Scott\u0026apos;s Medical Database)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Newfoundland, Canada\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Both Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs and CMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCommunity: Cultural and social isolation,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProfessional: Limited professional mobility, fewer residency opportunities in preferred fields, and difficulty securing long-term employment.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Familiarity with training location,\u003c/li\u003e\n \u003cli\u003eProfessional: Integration into the healthcare system, and supportive practice environments.\u003c/li\u003e\n \u003cli\u003eInstitutional: Residency matching process disadvantaging IMGs, lower likelihood of IMGs remaining in Canada or NL compared to MUN graduates, limited effectiveness of MUN residency programs in retaining IMGs.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eEnhance professional support,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCreate structured career pathways,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProvide incentives beyond training and develop targeted retention policies for IMGs.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMathews et al., 2008 (9).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo compare retention rates between provisionally licensed IMGs, fully licensed Memorial University Medical graduates (MMGs) and other fully licensed CMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Linked administrative data (Newfoundland College of Physicians and Surgeons; and Scott\u0026apos;s Medical Database 1997-2004)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Newfoundland, Canada\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Both Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs and CMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: physician background and training (IMGs had lower retention rates although not different from CMGs)\u003c/li\u003e\n \u003cli\u003eCommunity: Social and cultural isolation in NL.\u003c/li\u003e\n \u003cli\u003eProfessional: Not having a CCFP designation.\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: MMGs retention rates were more due to ties with NL.\u003c/li\u003e\n \u003cli\u003eCommunity: Having cultural, religious or social ties to community.\u003c/li\u003e\n \u003cli\u003eProfessional: Having a CCFP designation.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLocal: NL was an entry point for most IMGs which increase recruitment but didn\u0026rsquo;t guarantee retention.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eEnhance cultural, social and professional supports.\u003c/li\u003e\n \u003cli\u003eProvide clear incentives and mobility options for IMGs.\u003c/li\u003e\n \u003cli\u003eRecruitment should focus on long-term retention goals rather than temporary workforce fixes.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMathews et al., 2012 (31).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo examine generational differences in work location choices among physicians,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Interviews with physicians from different generations.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Newfoundland and Saskatchewan, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Rural.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e CMGs only.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; Personal: Preference for urban settings with better career options and social opportunities. Work-life balance concerns, particularly among younger physicians who desire more flexible work conditions.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; Family: Distance from family and social networks. Limited employment opportunities for spouses. Lack of quality education options for children\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; Community: Lack of community appreciation and engagement. Cultural and religious isolation.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; Professional: Poor work environment. Limited access to medical resources, staff and updated equipment. High workload and burnout.\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; Systemic/institutional: lower remuneration. Billing restrictions and contract limitations. High physician turnover rates. Political instability and health policy changes especially from older generation physicians.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Attraction to rural lifestyles particularly among those with prior exposure to rural life. Strong professional identity and commitment to patient care.\u003c/li\u003e\n \u003cli\u003eFamily: available employment and education opportunities for spouse and children.\u003c/li\u003e\n \u003cli\u003eCommunity: community appreciation and engagement fostering a sense of belonging. Presence of cultural and religious networks.\u003c/li\u003e\n \u003cli\u003eProfessional: positive collegial relationships and mentorships. Access to continuing medical education and career advancement opportunities.\u003c/li\u003e\n \u003cli\u003eStructural: Competitive remuneration and flexible incentive programs to make rural more attractive.\u003c/li\u003e\n \u003cli\u003eImproved administrative and policy support.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDeveloping \u003cstrong\u003elong-term retention strategies\u003c/strong\u003e for physicians, particularly in rural areas.\u003c/li\u003e\n \u003cli\u003eStrengthening \u003cstrong\u003ecollegial and administrative support\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003eIncreasing \u003cstrong\u003einvestment in medical infrastructure\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMathews et al., 2013 (29).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo examine and compare retention patterns among return-for-service (RFS) type physicians and non-RFS physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Administrative data (1997-2009) analysis on physicians with RFS and non-RFS agreements.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Newfoundland (NL), Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Rural.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs and CMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: Unavailability of suitable locations for family\u003c/li\u003e\n \u003cli\u003eStructural: Low bursary amounts, poor recruitment from sites, changes in personal priorities, lower completion rates for Special Funded RFS agreements, and lack of choice in accepting RFS agreements and work locations.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eStructural: Bursary-linked RFS agreements, allowing physician choice in work location, and alignment of individual preferences with provincial needs.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eImprove tracking to monitor RFS fulfillment of service obligations and implement penalties for defaulting\u003c/li\u003e\n \u003cli\u003eAlignment of provincial and federal RFS programs to maximize physician distribution in rural areas.\u003c/li\u003e\n \u003cli\u003eEncourage voluntary participation in RFS programs rather than enforcing RFS agreements with limited flexibility.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMathews et al., 2017 (18).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo examine and compare the retention patterns of Canadians who study abroad (CSAs) and immigrant IMGs who completed post-graduate medical education (PGME) training in Canada.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Registry data (National IMG Database and Scott\u0026apos;s Medical Database)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Canada (national scope).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Both Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Canadian IMGs or CSAs and immigrant IMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Gender (female IMG with a non-physician male spouse).\u003c/li\u003e\n \u003cli\u003eCommunity: lack of cultural networks in rural areas.\u003c/li\u003e\n \u003cli\u003eProfessional: limited mobility in practice\u003c/li\u003e\n \u003cli\u003eStructural: Unclear return-of-service agreements. \u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Gender (male IMGs with non-physician female spouse).\u003c/li\u003e\n \u003cli\u003eCommunity: Presence of cultural communities\u003c/li\u003e\n \u003cli\u003eProfessional: Specialty type (family medicine vs. specialist). Family physician more likely to stay compared with specialist.\u003c/li\u003e\n \u003cli\u003eStructural: Eligibility for a full license\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTreating all IMGs equally in PGME selection,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eimproving IMG PGME training to enhance credentialing for independent practice,\u003c/li\u003e\n \u003cli\u003eConducting further research to improve IMG performance and utilizing comprehensive data sets for informed policy-making and workforce planning.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMathews et al., 2022 (27).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo explore the influence of residency match and ROS agreements on early-career decisions of IMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Interview of early career IMGs\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Canada (BC, Ontario, Nova Scotia).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Rural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eProfessional: Limited career choices, delayed preferred practice choices, and high turnover due to misalignment with location preferences.\u003c/li\u003e\n \u003cli\u003eStructural: Lack of autonomy in accepting ROS agreements, uncertainty about practice location and nature, inability to practice in preferred ways.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eProfessional/Structural: Alignment of ROS requirements with personal and professional goals, such as desired practice location or family ties, facilitates retention.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eRevise ROS agreements to allow for flexibility with IMGs,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProvide flexibility in residency placements.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMcDonald et al., 2012 (40).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo study the geographic mobility and retention of immigrant and non-immigrant physicians in Canada, with emphasis on the role of spousal characteristics.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Geographic mobility analysis using Canadian Census data (1991-2006)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Canada (Provinces: Ontario, Quebec, Atlantic Provinces, Prairies, Alberta, British Columbia).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Both Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Both IMGs and CMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Isolation in rural communities.\u003c/li\u003e\n \u003cli\u003eFamily: Limited spousal integration in rural areas.\u003c/li\u003e\n \u003cli\u003eCommunity: High outmigration of physicians in rural areas making it more likely for new ones to migrate. Higher likelihood of outmigration among immigrant physicians.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Proximity to urban amenities\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFamily: Spousal employment opportunities. Higher education level of spouse\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eImprove spousal support systems.\u003c/li\u003e\n \u003cli\u003eAddress isolation in rural areas.\u003c/li\u003e\n \u003cli\u003eConsider spousal employment in retention policies.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMou et al., 2015 (32).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo explore determinants of inter-provincial migration intentions among rural and urban family physicians in Canada.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Analysis of National Physician Survey (2010)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Canada (Provinces: Newfoundland, Saskatchewan, Atlantic provinces, Ontario, British Columbia.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eBoth Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Both IMGs and CMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Personal dissatisfaction with professional life and relationships.\u003c/li\u003e\n \u003cli\u003eFamily: Spousal preferences and employment opportunities\u003c/li\u003e\n \u003cli\u003eCommunity: small population size and lack of urban-like amenities, language and communications barriers\u003c/li\u003e\n \u003cli\u003eProfessional: Burnout from excessive on-call duties, and lack of time off for vacations or continuing medical education.\u003c/li\u003e\n \u003cli\u003eSystemic: insufficient impact of financial incentives and overhead cost of running clinics.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Older aged, married physician.\u003c/li\u003e\n \u003cli\u003eFamily: Spousal supports and opportunities for educational and professional advancements for spouse.\u003c/li\u003e\n \u003cli\u003eCommunity: Community appreciation, connection, active support, and physical/recreational assets; as well as larger community population size.\u003c/li\u003e\n \u003cli\u003eProfessional: Collegiality among professional and social peer groups.\u003c/li\u003e\n \u003cli\u003eSystemic/organizational: Flexible primary care delivery models, favorable levels of compensation.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFocusing on retaining IMGs, especially in rural areas.\u003c/li\u003e\n \u003cli\u003eAvoiding reliance on fee increases, addressing rural physician migration.\u003c/li\u003e\n \u003cli\u003eimplementing flexible primary care models like Collaborative Emergency Centers (CEC) to enhance physician retention.\u003c/li\u003e\n \u003cli\u003eImplement strategies to mimic urban conditions such as spousal hire programs and professional development support\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMowat et al. 2017 (38).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo examine the retention and predictors of internationally trained family physicians in Manitoba.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Cohort study using Logistic regression.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Manitoba, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eBoth Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e IMGs only.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: Spousal employment, educational facilities for kids.\u003c/li\u003e\n \u003cli\u003eCommunity: Small community size and community disintegration.\u003c/li\u003e\n \u003cli\u003eProfessional: Limited mobility due to conditional licenses, challenges in transitioning to remote areas, higher compensation and cultural diversity in other provinces (compared to Manitoba), and dissatisfaction with return-of-service contracts.\u003c/li\u003e\n \u003cli\u003eSystemic/Institutional: Removal of the Manitoba residency requirement before program entry, family relocation issues, the ineffectiveness of their mentorship program.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Factors related to being established in Manitoba\u003c/li\u003e\n \u003cli\u003eFamily: Spousal employment, appropriate educational facilities for children,\u003c/li\u003e\n \u003cli\u003eCommunity: Community integration both professionally and non-professionally, cultural diversity and access to cultural and religious institutions in community.\u003c/li\u003e\n \u003cli\u003eProfessional: Licensure type and certification status with unlimited scope and mobility. Financial compensation.\u003c/li\u003e\n \u003cli\u003eInstitutional: Manitoba residency at the time of application is a facilitator to retention, as it significantly increased the likelihood of IMGs remaining in Manitoba.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eReinstating the requirement for applicants to reside in Manitoba before entering the program,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eExploring and potentially redesigning mentorship programs,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConsidering factors beyond return-of-service contracts, such as community integration and family considerations, to enhance physician retention.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMyroniuk et al., 2016 (10).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo explore the influence of spouses on rural physician recruitment and retention.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Mixed\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Surveys and interviews with physicians and their spouses,\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Alberta, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eRural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Both CMGs and IMGs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFamily: isolation, lack of job opportunities for spouses. Difficulty accessing higher education for spouse.\u003c/li\u003e\n \u003cli\u003eCommunity: Lack of social and cultural experiences. Cultural differences. Difficulty integrating into the community. Privacy/lack of anonymity concerns (for small areas)\u003c/li\u003e\n \u003cli\u003eProfessional: Challenges with dual relationships in small communities.\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: Proximity to work\u003c/li\u003e\n \u003cli\u003eFamily: Supportive spouses, strong education system for children, spousal opportunities for employment, networking, and professional development\u003c/li\u003e\n \u003cli\u003eCommunity: Opportunities for cultural engagement, community support, safety, access to recreational activities, and community -directed retention efforts. Finding a good fit between personal and community culture\u003c/li\u003e\n \u003cli\u003eProfessional: Collegiality, affiliation to academic center, broad scope of practice and specialist support. Personal and professional satisfaction. Continuing medical education (CME) support\u003c/li\u003e\n \u003cli\u003eInstitutional: Greater academic and CME support.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAcademic and CME support,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEnsuring a good fit between physician skills and community needs,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCreating a centralized database of rural practice opportunities,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEnhancing the role of governing bodies in supporting physician spouses, and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eForming partnerships with private industry to support spousal employment.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eOgundeji et al., 2021 (34).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo explore the role of alternative payment models (APMs) in recruiting and retaining rural physicians.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Interviews\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Alberta, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eRural\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Both CMGs and IMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCommunity: severe extremes in climate. Cultural and ideological differences, community pressures and lack of support\u003c/li\u003e\n \u003cli\u003eProfessional: complex patient panel, limited access to specialist, poor work-life balance, and burnout\u003c/li\u003e\n \u003cli\u003eStructural: old and outdated equipment, lack of institutional support and access to specialist. Payment models/contracts that could lead to a) potential to earn less; b) fear of loss of autonomy and flexibility\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePersonal: attraction to rural lifestyle, previous rural experience\u003c/li\u003e\n \u003cli\u003eFamily: spousal employment, support and access education and childcare.\u003c/li\u003e\n \u003cli\u003eProfessional: variety in scope of practice, good patient-physician relationship, collegiality, valued contribution to work, autonomy, independence, and financial compensation to stay.\u003c/li\u003e\n \u003cli\u003eStructural: relocation support and retirement plans\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eMaking APMs attractive through nonmonetary incentives,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFostering a collaborative relationship between physicians and government,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eInvolving physicians in payment model design, ensuring fairness in workload and remuneration, and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eImplementing accountability mechanisms to prevent perverse incentives.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eWasko, et al., 2014 (7).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo identify factors motivating physicians to select rural practice locations and remain in those communities.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Qualitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e interview based.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Saskatchewan, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eBoth Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Canadian Medical Graduates (CMGs) and IMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCommunity: Community disintegration and discrimination.\u003c/li\u003e\n \u003cli\u003eProfessional: Limited scope of practice, lack of independence and autonomy. Feeling unappreciated and alienated at work.\u003c/li\u003e\n \u003cli\u003eInstitutional: Lack of financial incentives\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eFamily: Physician and/or spouse having an attraction to rural lifestyle or having a rural background. Physicians and or spouse having ties to specific communities. Having friends and family living close to rural area. Spousal supports and opportunities for employment.\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eProfessional: Broad scope and freedom of practice. Group practice. Positive work environment\u003c/li\u003e\n \u003cli\u003eInstitutional: Adequate amount and mode of remuneration. Regional support (i.e., easy access to larger centers, specialist support. Having an attractive work schedule (e.g., with vacation time, locum relief, manageable call schedules, and opportunity for continuing medical education).\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFocusing on practice and lifestyle factors,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eImproving work conditions such as more reasonable hours, better availability of locum tenens, and professional backup,\u003c/li\u003e\n \u003cli\u003eProviding educational opportunities for children,\u003c/li\u003e\n \u003cli\u003eOptimizing intra-professional collaboration, using technology to improve professional backup, and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePromoting the advantages of rural practice to younger physicians.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eWitt, J. 2017 (39).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTo investigate the opinions of physicians in Manitoba, Canada regarding rural jobs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Quantitative\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e cross-sectional study.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation:\u003c/strong\u003e Manitoba, Canada.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSetting:\u0026nbsp;\u003c/strong\u003eBoth Rural and Urban\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysician focus:\u003c/strong\u003e Canadian Medical Graduates (CMGs) and IMGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eProfessional: intense workloads, difficulty taking time off, professional isolation, lack of specialized education, lack of professional support, dissatisfaction with after-hours work, rural training, community incentives, clinic technology, inadequate work-life balance, and less preferred locations.\u003c/li\u003e\n \u003cli\u003eStructural: Financial incentives alone are insufficient for retention.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCommunity: community incentives,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProfessional: work-life balance, professional and social inclusion (e.g., group practice,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eStructural: access to clinic technology), adequate housing availability, location preference (medium-sized towns within a 3-hour drive of Winnipeg), and appropriate financial compensation for on-call duties.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFocusing on work-life balance, using nonpecuniary incentives such as professional and social inclusion (e.g., group practices, community incentives, access to telehealth),\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEnsuring adequate housing availability and understanding the monetary value of compensating for undesirable job attributes. Financial incentives alone are insufficient for retention.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cu\u003e\u003cbr\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Factors Influencing\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Physician Retention in Canada.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA. Barriers codified by domains\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCitation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePersonal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eLifestyle preference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003ePreference for urban life, dissatisfaction with rural lifestyle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(18, 27, 31, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIsolation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eLoneliness, lack of amenities, and distance from support networks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(28, 31, 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGender/relationship dynamics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eGender-related differences in spousal satisfaction and influence on location decisions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCareer satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eDissatisfaction with career path and/or misalignment with personal goals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(31, 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eFamily\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSpousal employment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eLack of job opportunities for spouses in rural areas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(8, 10, 11, 32, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eChildren\u0026rsquo;s education and integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eLimited access to quality schools, educational disruption, social exclusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(10, 28, 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSocial/cultural isolation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eLack of community engagement, cultural disconnect, absence of social networks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(10, 29, 31, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eDiscrimination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eExperiences of racism, exclusion, or cultural insensitivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(7, 34, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCommunity disintegration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eLack of amenities, poor infrastructure, fragmented support systems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(8, 11, 34, 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBurnout \u0026amp; workload\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eExcessive work hours, high call frequency, lack of relief or locum coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(26, 28, 32, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eLimited mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eRestricted license, return-of-service constraints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(18, 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eRestricted scope of practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eUnable to fully utilize training or practice independently\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(7, 8, 11, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eLack of career development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eLimited access to CME, mentorship, and opportunities for specialization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(31, 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eSystemic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eLicensing and policy constraints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eComplex, inconsistent licensure across provinces; unclear ROS agreements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(9, 27, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eInfrastructure and system instability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eUnderfunded health systems, outdated facilities, lack of backup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(34, 38, 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAdministrative burden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eExcessive non-clinical workload limiting satisfaction and efficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(32, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. Facilitators codified by domains\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCitation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePersonal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eLifestyle alignment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eAlignment with rural values, preference for slower pace, love for natural environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(9, 18, 27-32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSense of purpose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eFeeling valued, having autonomy in care delivery, having meaningful patient relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(8, 9, 11, 18, 27, 29-31, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eFamily\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSpousal satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eSpouses find meaningful work and feel welcome in community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(10, 32, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eChildren\u0026rsquo;s education and integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003ePositive schooling options and social opportunities for children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(10, 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSense of belonging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eStrong social connections, cultural fit, inclusion in community life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(8, 11, 34, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCommunity appreciation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003ePhysicians feel respected and appreciated by community members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(8, 11, 26, 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSupportive team environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eCollegial relationships, collaborative practice, reduced isolation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(13, 32, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eFull scope of practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eOpportunity to work to full potential with varied cases and independence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(8, 11, 26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCareer development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eAccess to CME, professional mentorship, having academic affiliations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(18, 27-32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eSystemic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003ePan-Canadian licensure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eInterprovincial mobility and flexibility in practice location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(14, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eFlexible work arrangements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eBlended payment models, locum supports, manageable workloads\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(26, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eResidency and training alignment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eTraining in rural settings increases retention likelihood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(26, 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Recommendations to Enhance Physician Retention in Canada (codified by domains)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCitation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePersonal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAlign with values and lifestyle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eRecruit and retain physicians whose values align with rural practice (e.g., autonomy, slower pace, community-focused care)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(9, 28, 30, 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eFamily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSupport for spouses and children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eDevelop dual-career recruitment policies, offer family integration supports, and invest in schooling and social amenities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(10, 32, 38)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCommunity onboarding and inclusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eDevelop welcoming strategies, cultural safety training, and long-term engagement efforts for physicians and their families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(8, 11, 34, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMentorship and career development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eStrengthen CME access, mentorship networks, academic affiliations, and rural teaching opportunities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(28, 31, 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eTeam-based and flexible care models\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eImplement collaborative practices, group models, and reduce isolation through peer and specialist support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(13, 26, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eSystemic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003ePan-Canadian licensure and mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eAdopt national licensing models to reduce barriers and enhance locum support and career flexibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(14, 32, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSustainable ROS and payment models\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eMake ROS agreements flexible and value-aligned; use blended or capitation payment models to ensure work-life balance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(27, 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eData-driven planning and evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eMonitor long-term retention trends, especially among IMGs, and use integrated data for workforce planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(10, 27, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eReduce administrative burden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eCut non-clinical workload and streamline documentation to improve physician satisfaction and efficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(11, 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Family Physicians, physician retention, Canada, rural medicine, primary care, International Medical Graduate, community integration, Workforce Planning","lastPublishedDoi":"10.21203/rs.3.rs-7222819/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7222819/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Family physicians are the cornerstone of primary health care in Canada. Yet, retention remains a growing concern particularly in rural, remote, and underserved communities. Currently, 25% of Canadians do not have a primary care provider. While much attention has been given to recruitment, less is known about the multifaceted and intersecting factors that influence whether practicing family physicians and family medicine trainees (including Canadian Medical Graduates (CMGs) and International Medical Graduates (IMGs)), remain in sustained comprehensive practice in Canada. This review synthesizes the literature to identify key drivers of family physician retention and offers evidence-based recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We conducted an integrative review of peer-reviewed literature published between January 1, 2000, and March 30, 2025, following Whittemore and Knafl’s five-stage methodology. A systematic search was carried out across five electronic databases. Included studies were assessed for quality and thematically analyzed using a five-domain coding framework: personal, family, community, professional, and structural/systemic. Composite personas were developed to illustrate recurring physician retention trajectories and evidence-based recommendations were thematized across our five-domain coding framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Of the 1,613 records screened, 23 studies met inclusion criteria. Factors influencing retention were identified across all five domains. Structural and professional barriers, including licensure restrictions, administrative burden, and limited autonomy, emerged as the most consistent deterrents. Facilitators included strong community ties, spousal support, team-based practice environments, and access to continuing professional development. We idenitified and developed seven physician personas to create a portrait of the diverse experiences of family physicians in Canada. Key recommendations included reforming licensure and payment models, enhancing mentorship and CME access, supporting spousal integration, and fostering culturally safe, community-rooted team-based practice models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Retaining family physicians in Canada is a relational challenge that requires collaborative, multi-level change. Tailored, context-specific retention strategies co-designed with physicians and communities can enhance sustainability and health equity especially in rural, remote and underserved communities.\u003c/p\u003e","manuscriptTitle":"To stay or leave: An integrative review of factors, personas, and recommendations for retaining family physicians in Canada","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 08:26:13","doi":"10.21203/rs.3.rs-7222819/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-03T05:32:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-31T18:31:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186826527182730042166229646469499396023","date":"2025-09-24T19:24:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T19:13:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59953467157039414960879071627471065230","date":"2025-08-03T20:15:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319515282816490551744727853417379188564","date":"2025-08-01T13:41:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-01T13:33:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-01T09:13:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-30T07:00:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-30T06:59:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-07-26T18:27:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"89b2df12-0df9-4932-b35b-613f9997825e","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:03:58+00:00","versionOfRecord":{"articleIdentity":"rs-7222819","link":"https://doi.org/10.1186/s12875-025-03128-x","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-12-01 15:58:18","publishedOnDateReadable":"December 1st, 2025"},"versionCreatedAt":"2025-08-11 08:26:13","video":"","vorDoi":"10.1186/s12875-025-03128-x","vorDoiUrl":"https://doi.org/10.1186/s12875-025-03128-x","workflowStages":[]},"version":"v1","identity":"rs-7222819","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7222819","identity":"rs-7222819","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}