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Annals of Internal Medicine: Clinical Cases

Clinical Cases on multiple devices

Annals of Internal Medicine: Clinical Cases (AIMCC) is an open access, peer-reviewed journal co-published by the American College of Physicians and the American Heart Association. AIMCC publishes case reports, case series, and image/video cases in subject areas across the spectrum of medicine.

The mission of Annals of Internal Medicine: Clinical Cases is to promote excellence in critical thinking around prevention, diagnosis, and management of challenging clinical situations by disseminating rigorously peer-reviewed reports of real clinical cases encountered by physicians and other medical professionals. 

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clinical case studies in internal medicine

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Clinical Cases - Resources for Faculty

  • Anatomy / Biochemistry Cases
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  • Writing Cases / Zoonotic Cases

Internal Medicine

  • 57-Year Old Woman with Fatigue: A Case-Based Exercise for Medical Students MedEd Portal
  • AccessMedicine: Pathophysiology of Disease Case Files Click on the Case File Tab on the AccessMedicine home page.
  • AccessMedicine: Toy Case Files Click on the Case File Tab on the AccessMedicine home page.
  • Blueprints Clinical Cases in Medicine Book can be requested via OhioLINK
  • Case Histories in Human Physiology
  • Case in Point Archive American College of Radiology
  • Cases for Teaching PICO or Literature Searching the EBM Librarian website
  • Clinical Case of the Month LSUHSC School of Medicine
  • Clinical Cases Loyola University School of Medicine
  • Clinical Correlations The NYU Internal Medicine Blog
  • CME Case Presentations A resource on the Medscape website
  • Color Atlas of Family Medicine AccessMedicine electronic textbook. See textbook tab in AccessMedicine
  • Common Clinical Cases: a Guide to Internship Book can be requested via OhioLINK
  • Core Clinical Cases in Medical and Surgical Specialities: a Problem-solving Approach Book can be requested via OhioLINK
  • Grand Rounds - A Case Report Journal for the Internet
  • Harvard University: Lieberman's Learning Lab
  • Headache and Chronic Pain Syndromes: The Case-Based Guide to Targeted Assessment and Treatment OhioLINK e-book
  • The Internal Medicine Casebook: Real Patients, Real Answers Book can be requested via OhioLINK
  • Internal Medicine I NEOMED Library book
  • Internal Medicine II NEOMED Library book
  • Jawetz, Melnick & Adelberg's Medical Microbiology e-book available via AccessPharmacy. See chapter 48.
  • Level II Case Discussions Loyola University Medical Education Network
  • Macrocytosis Case MedEdPortal
  • Medscape Clinical Cases
  • New England Journal of Medicine Clinical Case Articles Some articles are free full text. Articles requiring a subscription can be ordered by NEOMED Library registered patrons via inter-library loan. See clinical cases type of articles.
  • The NNT: Quick Sumaries of Evidence-Based Medicine
  • PharmacyLibrary: Case Studies from: Handbook of Nonprescription Drugs NEOMED Library online resource. See Case Studies Section
  • PharmacyLibrary: QuEST/SCHOLAR-MAC Case Studies NEOMED Library online resource. See Case Studies Section. Supplemental to Handbook of Nonprescription Drugs, 17th Edition.
  • PharmacyLibrary: University of Iowa College of Pharmacy Teaching Cases NEOMED Library online resource. See Case Studies Section
  • Quizzes in Internal Medicine MedNet HELLAS
  • VirginiaGeriatrics.org
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  • Last Updated: Oct 27, 2020 9:37 AM
  • URL: https://libraryguides.neomed.edu/ClincialCaseResources

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Search the world's largest collection of clinical case reports

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Global health case reports.

These are case reports that focus on the causes of ill health, the social determinants of health and access to healthcare services, prevailing local and national issues that affect health and wellbeing, and the challenges in providing care to vulnerable populations or with limited resources.

Read the full collection now

Images in… :

20 April 2023

18 April 2023

Case Reports: Findings that shed new light on the possible pathogenesis of a disease :

7 February 2023

10 March 2023

Case Reports: Unusual association of diseases/symptoms :

13 April 2023

17 February 2023

Case Reports: Reminder of important clinical lesson :

17 March 2023

Case Reports: Unusual presentation of more common disease/injury :

16 May 2023

Case Reports by specialty

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Global Health Competition

Every year BMJ Case Reports selects authors of global health case reports to join our editorial team as a global health associate editor.

This is an opportunity to gain some editorial experience or join our team on research and educational projects. Students and graduates may apply.

Simply select Global Health Competition when you submit.

Latest Articles

19 February 2024

Case Reports: Rare disease :

21 February 2024

Case Reports: Learning from unexpected outcome (positive or negative) :

Book cover

  • © 1988

Contemporary Internal Medicine

Clinical Case Studies

  • Juan Bowen 0 ,
  • Ernest L. Mazzaferri 1

The Ohio State University, Columbus, USA

You can also search for this editor in PubMed   Google Scholar

Part of the book series: Contemporary Internal Medicine (COIM, volume 1)

1805 Accesses

1 Citations

3 Altmetric

  • Table of contents

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Table of contents (25 chapters)

Front matter, chronic liver disease and neurologic abnormalities.

  • Fred B. Thomas

Dyspnea and Rapidly Enlarging Goiter

  • Ernest L. Mazzaferri

Atheroembolic Disease Mimicking Systemic Vasculitis

  • Fernando G. Cosio

Erythrocytosis

  • Stanley P. Balcerzak

Obstructive Sleep Apnea

  • Eric R. Pacht

Dyspnea and Cirrhosis

  • Mark D. Wewers

Chest Pain in a Young Man

  • James M. Ryan

A Reactive Arthropathy

  • N. Paul Hudson

Community-Acquired Pneumonia

  • Joseph F. Plouffe

Lens Subluxation and Tall Stature

Breast cancer in a premenopausal woman.

  • Jane M. Leiby, Earl N. Metz

Recurrent Fever, Chills, Pyuria, and Bacteriuria in an Adult Male Following Urinary Catheterization

  • Calvin M. Kunin

Fever and Bloody Diarrhea

  • William E. Maher

Chest Pain and Heart Murmur in a Young Woman

  • Mary E. Fontana

Peptic Ulcer Disease

  • James H. Caldwell

Microcytic Anemia

  • Pierre L. Triozzi

Recurrent Abdominal Pain and Edema

  • Donald L. McNeil

Hepatitis in a Chinese Student

  • Robert Kirkpatrick

A Woman with Rheumatoid Arthritis

  • Seth M. Kantor
  • Internal medicine

Juan Bowen, Ernest L. Mazzaferri

Book Title : Contemporary Internal Medicine

Book Subtitle : Clinical Case Studies

Editors : Juan Bowen, Ernest L. Mazzaferri

Series Title : Contemporary Internal Medicine

DOI : https://doi.org/10.1007/978-1-4615-6713-4

Publisher : Springer New York, NY

eBook Packages : Springer Book Archive

Copyright Information : Plenum Publishing Corporation 1988

Softcover ISBN : 978-1-4615-6715-8 Published: 12 December 2012

eBook ISBN : 978-1-4615-6713-4 Published: 06 December 2012

Edition Number : 1

Number of Pages : 336

Topics : Internal Medicine , General Practice / Family Medicine

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Clinical Cases

Litfl clinical cases database.

The LITFL Clinical Case Collection includes over 250 Q&A style clinical cases to assist ‘ Just-in-Time Learning ‘ and ‘ Life-Long Learning ‘. Cases are categorized by specialty and can be interrogated by keyword from the Clinical Case searchable database.

Search by keywords; disease process; condition; eponym or clinical features…

Compendium of Clinical Cases

LITFL Top 100 Self Assessment Quizzes

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50 Studies Every Internist Should Know

50 Studies Every Internist Should Know

50 Studies Every Internist Should Know

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This online resource presents key studies that have shaped the practice of internal medicine. Selected using a rigorous methodology, the studies cover various specialty areas, including preventative medicine, endocrinology, hematology and oncology, musculoskeletal diseases, nephrology, gastroenterology, infectious diseases, cardiology, pulmonology, geriatrics and palliative care, and mental health. For each study, a concise summary is presented with an emphasis on the results and limitations of the study, and its implications for practice. An illustrative clinical case concludes each review, followed by brief information on other relevant studies.

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Announcing 50 New Case-Based Questions in NEJM Knowledge+ Internal Medicine Board Review

New Case-Based Questions for Internal Medicine Board Review

At NEJM Knowledge+, we’re committed to ensuring that our products cover the breadth of knowledge that clinicians need for both clinical practice and Internal Medicine Board Exam preparation. NEJM Knowledge+ Internal Medicine Board Review already contains more than 1600 case-based questions on the most relevant and important topics in medicine today. We’re adding another 50 case-based questions now (and 50 more in December 2016) to further expand that knowledge base.

Most of the 50 new questions we’ve added relate to the following  topics:

  • Infectious Disease
  • Dermatology

Each year, we plan to add at least 100 new questions to NEJM Knowledge+ Internal Medicine Board Review — this is in addition to continually updating our content when guidelines change and in response to user feedback. Our goal is to become increasingly comprehensive in the learning we provide while remaining as clinically relevant and up-to-date as possible.

Covering the ABIM Blueprint with New Learning Objectives

In June 2015, ABIM rolled out a revised blueprint for the Maintenance of Certification (MOC) exam that not only listed the topics and subtopics but also showed the likelihood of which aspects of the subtopic will be on the exam, such as diagnosis, testing, and treatment.

Our editorial team analyzed the new ABIM blueprint and are prioritizing development of new IM questions that map to topics in the blueprint that are highly likely to be on the MOC exam.

We have derived learning objectives from the topic/task combinations in the blueprint; for example, ABIM lists six subtopics under “ischemic heart disease”:

Internal Medicine Blueprint for Cardiovascular Disease

These subtopics mostly fall into the “highly likely to be on the exam” bucket (green), so we recruited physician experts to write case-based questions that test those learning objectives that we did not already have at least one question on in our question bank. Here are some examples of the learning objectives we just added to the IM question bank:

  • Choose an optimal initial testing strategy for a patient with a prior acute anterior myocardial infarction who presents with a transient ischemic attack that has a suspected cardioembolic source.
  • Choose an appropriate treatment for improving the likelihood of survival in a patient who has depressed left ventricular systolic function after an acute myocardial infarction.
  • Choose appropriate evaluation for suspected heart failure with reduced ejection fraction.
  • Choose the most appropriate pharmacologic management for a patient who has a recent diagnosis of heart failure with reduced ejection fraction and is already taking an angiotensin-converting enzyme inhibitor.
  • Recognize heart failure with reduced left ventricular ejection fraction, secondary to ischemic cardiomyopathy.

Using this process for content development ensures that our question bank covers what you need to know for the board exam.

Case-Based Questions, Free from Outside Influence

All the questions we develop for NEJM Knowledge+ Internal Medicine Board Review meet the same high-quality standards you’ve come to expect from NEJM Group. The content was written by more than 300 clinicians from academic programs across the country and was subjected to a rigorous editorial process that included review by highly respected professional educators, leading specialists in their fields, generalists, PAs, and NEJM Group editors . You can be sure that what you’re learning in NEJM Knowledge+ is accurate, evidence-based, and relevant to your daily practice.

NEJM Knowledge+ offers a comprehensive question bank that reflects the breadth of primary care cases that physicians encounter in their practices today.

Personalized Learning, Tailored to You

NEJM Knowledge+ uses adaptive learning technology that tailors your learning to your needs. This adaptive learning technology continuously assesses the subjects you know and identifies the areas where you need reinforcement. It then delivers questions based on what you know already, what you need to study more, what you are struggling to master, what you think you know better than you do, and what you might be forgetting.

With the addition of these 50 new questions, NEJM Knowledge+ Internal Medicine Board Review now includes:

  • more than 1680 case-based questions
  • more than 4500 total questions tied to 2500 learning objectives

With the ability to earn:

  • CME credits
  • ABIM MOC points

All in all, we are strengthening one of the most comprehensive solutions available for continuous learning and board exam preparation.

More on NEJM Knowledge+ Content:

Roadmap to Great Content Work Less and Learn More: Here’s How in NEJM Knowledge+ Content Updates

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Having only a partial point of view of Cases Based Questins,I can see that you tried to do the best work in this section.I am totally sure, that the Clinical Cases presented will be carefully prepared.But, the problem that I see, in ER,Clinics-Hospitals-and in Home , it is that the patient, many times has not the Diagnostics written in his/her Chest.Many times, we have to do an intense work,trying to know what happen with the patients and trying to find(if we are in ER or Hospital) his/her medical record. Being agree with the way you prepared the questions,but I think that in Real Life,we have to face with patients, whose Diagnostics, we do not know,but we have to start with some measuresEx=relieving pain-giving IV solutions (if they are needed)-taking Exams, like Blood-Urina and others-XRay-CT Scan-Ultrasound and calling to others Physicians(Specialists=Cardiologists-Neurologists-Nephrologists etc-etc= so I suggest to add(if if is possible) some Complete Clinical Cases, where Students or Residents, must choose since the beginning the possible diagnostics-type of Blood-Urine -Bacteriologic Exams-Ultrasound-CT-Scan etcetcThis type of Questions(that NEJM sometimes present)are one of the best technique to know what the

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does anyone know of any journal/quis cme’s that are accepted for moc points in internal medicine? Also it seems like it varies from state to state. For example, JAMA articles/cme quizzes for some reason aren’t accepted in NY. I left my email if anyone should have any information. Thanks much

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Outcomes of Various Classes of Oral Antidiabetic Drugs on Nonalcoholic Fatty Liver Disease

  • 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
  • 2 Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
  • 3 Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
  • 4 Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea

Question   Among sodium-glucose cotransporter 2 (SGLT2) inhibitors, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, and sulfonylureas, which class of oral antidiabetic drugs (OADs) is the preferred therapeutic option for patients with both nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2D)?

Findings   In this nationwide cohort study involving 80 178 patients diagnosed with T2D and concurrent NAFLD in Korea, spanning 219 941 person-years, SGLT2 inhibitors were associated with a higher likelihood of NAFLD regression and lower incidence of adverse liver-related outcome parameters when compared with other OADs.

Meaning   The results from this study suggest that SGLT2 inhibitors may be the preferred choice among OADs for individuals with both NAFLD and T2D, highlighting the need for additional research to determine whether a shift in prescribing practices is warranted.

Importance   Several oral antidiabetic drug (OAD) classes can potentially improve patient outcomes in nonalcoholic fatty liver disease (NAFLD) to varying degrees, but clinical data on which class is favored are lacking.

Objective   To investigate which OAD is associated with the best patient outcomes in NAFLD and type 2 diabetes (T2D).

Design, Setting, and Participants   This retrospective nonrandomized interventional cohort study used the National Health Information Database, which provided population-level data for Korea. This study involved patients with T2D and concomitant NAFLD.

Exposures   Receiving either sodium-glucose cotransporter 2 (SGLT2) inhibitors, thiazolidinediones, dipeptidyl peptidase-4 (DPP-4) inhibitors, or sulfonylureas, each combined with metformin for 80% or more of 90 consecutive days.

Main Outcomes and Measures   The main outcomes were NAFLD regression assessed by the fatty liver index and composite liver-related outcome (defined as liver-related hospitalization, liver-related mortality, liver transplant, and hepatocellular carcinoma) using the Fine-Gray model regarding competing risks.

Results   In total, 80 178 patients (mean [SD] age, 58.5 [11.9] years; 43 007 [53.6%] male) were followed up for 219 941 person-years, with 4102 patients experiencing NAFLD regression. When compared with sulfonylureas, SGLT2 inhibitors (adjusted subdistribution hazard ratio [ASHR], 1.99 [95% CI, 1.75-2.27]), thiazolidinediones (ASHR, 1.70 [95% CI, 1.41-2.05]), and DPP-4 inhibitors (ASHR, 1.45 [95% CI, 1.31-1.59]) were associated with NAFLD regression. SGLT2 inhibitors were associated with a higher likelihood of NAFLD regression when compared with thiazolidinediones (ASHR, 1.40 [95% CI, 1.12-1.75]) and DPP-4 inhibitors (ASHR, 1.45 [95% CI, 1.30-1.62]). Only SGLT2 inhibitors (ASHR, 0.37 [95% CI, 0.17-0.82]), not thiazolidinediones or DPP-4 inhibitors, were significantly associated with lower incidence rates of adverse liver-related outcomes when compared with sulfonylureas.

Conclusions and Relevance   The results of this cohort study suggest that physicians may lean towards prescribing SGLT2 inhibitors as the preferred OAD for individuals with NAFLD and T2D, considering their potential benefits in NAFLD regression and lower incidences of adverse liver-related outcomes. This observational study should prompt future research to determine whether prescribing practices might merit reexamination.

Read More About

Jang H , Kim Y , Lee DH, et al. Outcomes of Various Classes of Oral Antidiabetic Drugs on Nonalcoholic Fatty Liver Disease. JAMA Intern Med. Published online February 12, 2024. doi:10.1001/jamainternmed.2023.8029

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Nick Seiferth

Theresa wilhelm, christopher holzmann-littig.

2 Department of Nephrology, Hospital Klinikum Rechts Der Isar of the Technical University of Munich, Munich, Germany

Veit Phillip

3 Department of Internal Medicine II, Hospital Klinikum Rechts Der Isar of the Technical University of Munich, Munich, Germany

Marjo Wijnen-Meijer

Associated data.

The datasets during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

In response to students´ poor ratings of emergency remote lectures in internal medicine, a team of undergraduate medical students initiated a series of voluntary peer-moderated clinical case discussions. This study aims to describe the student-led effort to develop peer-moderated clinical case discussions focused on training cognitive clinical skill for first and second-year clinical students.

Following the Kern Cycle a didactic concept is conceived by matching cognitive learning theory to the competence levels of the German Medical Training Framework. A 50-item survey is developed based on previous evaluation tools and administered after each tutorial. Educational environment, cognitive congruence, and learning outcomes are assessed using pre-post-self-reports in a single-institution study.

Over the course of two semesters 19 tutors conducted 48 tutorials. There were 794 attendances in total (273 in the first semester and 521 in the second). The response rate was 32%. The didactic concept proved successful in attaining all learning objectives. Students rated the educational environment, cognitive congruence, and tutorials overall as “very good” and significantly better than the corresponding lecture. Students reported a 70%-increase in positive feelings about being tutored by peers after the session.

Peer-assisted learning can improve students´ subjective satisfaction levels and successfully foster clinical reasoning skills. This highlights successful student contributions to the development of curricula.

The SARS-CoV2-pandemic´s strain on medical schools has been hard [ 1 – 3 ] since many stakeholders in medical education are both caregivers and instructors. With limited staff available for teaching [ 4 ] and reduced on-campus presence, many classes were moved to emergency remote teaching courses [ 5 , 6 ]. Emergency remote teaching is the “alternate delivery mode due to crisis circumstances” as opposed to well-planned online teaching [ 7 ].

At Technical University of Munich (TUM) most lectures, seminars, and bedside teachings werecanceled or moved to emergency remote teaching in the spring semester of 2020. Within the student council, the notion quickly gained traction that a peer-assisted learning (PAL) program ought to be established to alleviate pressure on faculty staff while providing students with a safe environment for the acquisition and training of their clinical reasoning skills.

Several universities have promoted PAL programs. It refers to the “development of knowledge and skill through explicit active helping and supporting among status equals” [ 8 ] . Benefits of PAL are i) a similar knowledge base and an understanding of obstacles while studying (cognitive congruence) [ 9 , 10 ], ii) a positive learning environment void of complicated student-instructor relationships due to similar social status (social congruence) [ 9 , 10 ] and iii) relieving pressure on faculty staff [ 11 ]. PAL has been employed in teaching anatomy, physiology, and biochemistry [ 12 ], as well as communication [ 13 ], physical examination [ 14 ], and other procedural skills [ 15 , 16 ]. There students have been shown to assume the roles of lecturers [ 17 ], clinical or practical teachers [ 18 ], mentors [ 19 ], learning facilitators [ 20 , 21 ], role models [ 21 ], and assessors [ 22 ]. In our study, we wish to introduce a curriculum that was fully designed, delivered, and evaluated by undergraduate students based on the Kern Cycle [ 23 ] with minimum intervention by faculty staff. We thus empower students to holistically assume all of the twelve roles of a teacher as proposed by Harden and Crosby in 2000 [ 24 ].

Targeted at students in the clinical phase of their studies, we developed the novel Integrated Clinical Case Discussions (ICCD) that emphasize the training of clinical reasoning skills that are at the heart of the recently released second edition of the competence-based German Medical Training Framework (GMTF) [ 25 ]. In accordance with the GMTF three central learning objectives were identified: i) transfer of clinical knowledge, ii) fostering of diagnostic management skills, and iii) enabling students to discuss findings and procedures in a team. Clinical Case Discussions (CCD) have been shown to enhance clinical and scientific reasoning skills [ 20 , 26 ], self-directed learning [ 26 ], and exchange with colleagues [ 27 ].

This study seeks to explore whether a peer-moderated clinical case discussion can improve students´ subjective satisfaction level with learning opportunities in case of emergency remote teaching.

Setting and participants

For their studies of internal medicine students at TUM attend two series of lectures in two consecutive semesters: In the spring semester of their first clinical year, there is a series of lectures on the cardiovascular and hematologic systems. In the subsequent fall semester, they hear a series of lectures on nephrology, gastroenterology, and endocrinology. Students are routinely requested to evaluate all lectures on a five-point Likert scale. When in the spring semester of 2020 all lectures were moved to an emergency remote teaching format, the mean evaluation of lectures on internal medicine dropped by 1.44 points as opposed to the six years prior (from 1.96 to 3.4, where 1 denoted the greatest and 6 the lowest level of satisfaction).

To provide their peers with an additional opportunity to review the lectures´ content, three students initiated the peer-moderated Integrated Clinical Case Discussions. In the ICCDs we applied a lecture´s content to a patient´s case with special emphasis on diagnostic and management skills in accordance with GMTF level 2 (i.e. clinical reasoning skills).

We prepared ICCDs for 12 topics in the fall semester of 2020 and 12 topics in the spring semester of 2021. For each topic we allocated two 90-min sessions in the week immediately following the general lecture on the topic. We were able to offer one face-to-face and one online tutorial for 11 topics. Due to hygiene regulations, the remaining 13 topics were discussed exclusively online twice a week. The time resources needed for one tutorial included i) 18 h for the tutor to prepare and hold the ICCD, ii) 3.5 h for the organizing students to recruit and mentor tutors as well as to evaluate and advertise the sessions and iii) 1.5 h of supervision by the physician (Fig.  1 ). The remuneration was 250€ per tutor and tutorial and 246.66€ for each organizing student per month (In the first year: authors JR and NS—15 months, TW—5 months. This was later reduced to one organizing student only.). Tutors were trained and supervised by specialist physicians as part of their regular teaching duties (1.5 h per session). Physicians were not reimbursed by the ICCD team. ICCDs were completely voluntary. We advertised ICCDs through weekly email alerts and a note in students´ schedules.

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Workflow for the preparation of one ICCD session. Three parties are involved in the preparation and implementation of an ICCD session: an administrative unit consisting of the organizing undergraduate students (*) and the TUM Medical Education Center (†) (bottom row), tutors (middle row) and clinical supervisors (top row). Their respective tasks are indicated at the relative time points for the preparation of one ICCD. The allotted time frame for each task per one ICCD session is included in round brackets. For their first meeting tutors and supervisors are provided with a checklist (‡), i.e. to i) define content-focal points, ii) select an appropriate clinical case iii) define a clinical skill essential for the successful completion of the case, and to iv) provide the tutor with important clinical findings (e.g. laboratory findings, images)

Conception of the didactic concept

ICCDs followed cognitive learning theory. Each session was set as an interactive problem-based learning scenario ( Clinical Case Discussion ), that facilitated learners´ active participation to organize and conceptualize information [ 28 ]. To prompt students to access pre-existing knowledge ICCD sessions started with a voluntary entry-exam of five multiple-choice questions. The prefix Integrated reflects the close alignment of student-led tutorials and the lectures conducted by faculty staff. ICCDs did not seek to introduce new facts but to offer a platform for reviewing and applying the lecture’s contents to a clinical case. Each ICCD comprised two clinical cases in which at least one skill apart from history taking was trained (usually the interpretation of laboratory findings). Tutors and lecturers chose a clinical case from the lecturer´s clinical experience that matched the lecture. Tutors then prepared a powerpoint presentation (Microsoft Corp., Redmond, Washington, USA) to facilitate the case discussion, which was checked by the lecturer for medical content and by the organizing students for the didactic concept. Tutors delivered online sessions through a university zoom account (Zoom Video Communication Inc., 5.7.7, San Jose, California, USA) and—if under the Covid-regulations permissible—face-to-face in the lecturing hall. We instructed tutors to follow a modified version of Linsenmeyer´s approach [ 27 ] (Fig.  2 ). Briefly, tutees´ participation and teamwork were gradually increased by moving from anonymous multiple-choice questions to group discussions in breakout rooms and finally to discussing the ideal diagnostic procedures in the plenary session. An example of one case can be found in the supplementary material S1.

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Typical outline of an ICCD session. We modified Linsenmeyer´s approach to stimulating interaction between students (Linsenmeyer, 2021). One ICCD session propagates along the x-axis from left to right. Several layers along the y-axis indicate the roles a tutor assumes at each time point, the teaching techniques they employ (examples provided below), and the level of interaction this is likely to be incentivize between tutees. A: Each session starts with a knowledge probe intended to activate students´ prior knowledge by asking five multiple-choice questions that participants must solve individually and anonymously. As indicated by the green triangle at the bottom of the figure this requires only a minimum level of interaction between students. B: Subsequently, tutors introduce the session´s clinical case and moderate a plenum discussion in which participants collectively take a patient´s history, determine an appropriate diagnostic algorithm, and list differential diagnoses. This gradually raises the level of interaction (upward slope of the triangle). C: In the next stage participants are assigned to break-out groups of two to four students in which they practice interpreting patient-specific clinical findings, lab results or different image modalities. Tutors switch from group to group to help if needed. D: Finally, the breakout groups meet back in the plenum and discuss their findings and differential diagnoses under the tutor´s moderation. We rated this as the most demanding level of interaction as it requires students to present in front of a larger group. At this point, tutors are oscillating between facilitating the discussion as different groups present their findings and providing direct instruction when explaining the meaning behind lab results/images, etc. Under the tutor’s guidance differential diagnoses are eliminated and the final diagnosis emerges. E: Lastly the tutor outlines treatment options. Due to time constraints, this was predominantly done in direct instruction

Recruitment and training of tutors

Tutors were recruited from the student body of those students who had completed the lecture on internal medicine and passed the exam. The recruitment process was based on Engel´s approach [ 17 ] and included a publicly shared application form and a job interview in which a shared decision was made on the topic best suited to the tutor´s interests and experience. A standardized curriculum was designed for tutors and delivered by a joint group of clinicians, the TUM Medical Education Center, and the organizing students who provided the impetus for ICCDs (Fig.  1 ). Mandatory training consisted of an introductory seminar on the ICCD´s didactic concept and a lecture on how to teach clinical reasoning skills and stimulate group interaction. Tutors then prepared their tutorial with their clinical supervisor as described above.

Questionnaire

Tutee evaluations were collected online at the end of each session using EvaSys V8.1 (evasys GmbH, Lueneburg, Germany). The survey comprised 50 self-report questions (supplementary material S2). Items were rated on a five-point Likert scale from 1 (strongly agree) to 5 (strongly disagree). For selected items, we also asked open-ended questions.

The underlying concept of the evaluation tool was modeled on the Student´s Evaluations of Educational Quality Questionnaire (SEEQ), a validated and reproducible evaluation tool proposed by Marsh in 1982 [ 29 ]. Designed for summative assessment of faculty-administered teaching, the SEEQ had to be adapted to our specific needs. We adopted evaluation items “I Learning/Value”, “IV Group Interaction” and all applicable items of “III Organisation” and “V Individual Raport”, yet omitted items VI-IX, since participation was completely voluntary, and examinations were not part of the ICCDs. Following the SEEQ category “I Learning/Value” we compared students´ subjective assessments of gain in knowledge, skill, motivation, and overall grade [ 30 ] after attending only the general lecture with attending both lecture and ICCD. We excluded SEEQ-section “II Enthusiasm” since tutors would have to proactively volunteer to teach in addition to their regular workload. Instead, we wanted to measure tutors´ performance as levels of cognitive congruence and educational environment. The tutor intervention profile by De Grave [ 31 ]and the Student Course Experience Questionnaire by Paul Ginns [ 32 ] reflected the aforementioned categories in more detail than the SEEQ and served as a reference. (Appendix Table 1 ). We also asked tutees to identify roles the tutor had assumed for them as proposed by Bulte et al. [ 21 ]. Learning outcomes were assessed as comparative self-assessment (CSA) for aggregated data [ 33 ]. The questions´ wording was based on the GESIS survey guidelines [ 34 ].

We handed tutors a short survey that asked them to rate the helpfulness of the introductory seminar, their understanding of the overall concept, and their difficulties in preparing the ICCD and enjoyment of the process on a five-point Likert scale.

Statistical analysis

We analyzed data using SPSS Statistics for Windows version 27 (IBM Corp., Armonk, New York, USA) and Microsoft Excel (Microsoft Corp., Redmond, Washington, USA). We included all surveys that had answers to more than 50% of all questions. If a student visited multiple sessions, only their first response to each question was included in the analysis. Learning outcomes and shifts in attitude toward peer teachers were computed as the CSA-gain as proposed by Raupach et al. (2011) [ 33 ]. Briefly, at the end of each session students were asked to retrospectively rate their expertise in the item before and after attending an ICCD session. The average net increase in self-assessment was then displayed as a percentage-wise increase over the average initial self-assessment. Qualitative, descriptive data were measured on a five-point Likert scale and analyzed using mean, mode, and standard deviation. Testing for statistical significance was performed using a two-tailed exact Chi-Square Test for categorical variables. Mann–Whitney-U-test was used for the comparison of metric variables with non-normal distribution between two groups (learning outcome). A p-value of 0.05 was chosen a priori. Effect size was calculated using Cramer´s V for descriptive data and correlations were computed using Spearman Correlation. Cronbach´s alpha was computed to test for internal consistency for the categories “cognitive congruence” and “educational environment”. Answers to open-ended questions were analyzed according to qualitative content analysis by Mayring [ 35 ]. Author JR developed the major categories deductively based on probable answers and supplemented them with subcategories inferred from students´ final responses. Another author, NS, checked categories for traceability. Finally, a category tree with specific anchor examples and defined subcategories emerged. The frequency of items and total number of student comments were recorded.

In the fall semester of 2020, a total of 335 students enrolled in the general lecture, 149 (44.5%) of whom attended at least one ICCD session. In the subsequent spring semester, 334 students enrolled in the general lecture and 237 (71.0%) took part in at least one ICCD session. Some tutees attended multiple sessions throughout the semesters. In sum, we counted 273 student attendances in the first and 521 in the second semester, respectively.

We received evaluations from 32.4% of all participants ( n  = 125). 91 (72.8%) tutees were aged 25 or under and 96 tutees (76.8%) identified as female. This approximately reflected the general student population (female/male: 65/35; mean age: 24 years). Questionnaires without informed consent were excluded from further analysis.

We employed 19 tutors for the implementation of 48 ICCD sessions covering a total of 24 topics. Eleven (57.8%) of those tutors identified as female and 12 (63.1%) had gained previous experience in front-line tertiary teaching.

Acceptance of ICCD

The nature of the ICCD being an add-on to the standard curriculum, we aimed to create additional value to the core curriculum that could not be attained with lectures and seminars alone. Evaluation of the ICCD shall therefore be displayed in direct comparison to the corresponding lecture (Fig.  3 ). ICCDs were generally rated as excellent and significantly better than lectures for all categories: knowledge, skill, attitude, and overall grade. Effect size was greatest for overall grade (V = 0.58; p  < 0.01) and smallest for gain in knowledge (V = 0.37; p  < 0.01) in ICCDs as opposed to the lecture. We observed that gain in knowledge correlated with gain in skills (r = 0.56; p  < 0.01) and overall evaluation of the ICCD session (r = 0.61; p  < 0.01).

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Evaluation of ICCD vs. lecture. A Kiviat diagram representing students´ mean subjective assessment after attending lectures alone (round dots) and after attending both lectures and ICCD (long dashes) in categories knowledge, skill, attitude, and overall grade each represented on one of the axes of the diagram. Students were asked to rate their gain in each of the categories for both tutorial and the respective lecture on a five-point Likert scale with 1 denoting the greatest and 5 the lowest degree of satisfaction. Questionnaires were administered immediately after each tutorial. Tutorials took place one week after the general lecture. All differences are significant ( p  < .01). Effect size was calculated using Cramer´s V

When asked how comfortable tutees felt about being tutored by peers for an ICCD, tutees indicated a 70% increase in positive feelings after the intervention (CSA gain = 69.57%, n  = 111).

We received 57 answers to the open-ended questions on satisfaction and improvement suggestions (Table ​ (Table1). 1 ). In these answers, a total of 123 text segments (k) were identified and grouped into four categories. Most test segments praised the general format of the ICCD (k = 45). The second most frequent category included individual feedback on tutors (k = 40). The third category addressed learning value (k = 24) and the last category included improvement suggestions (k = 14).

Qualitative Content Analysis of Open-Ended Questions on Student Satisfaction

* test segments that were categorized

Overview of the categories and subcategories of the open-ended questions. Statements ( n  = 57, k = 123) provided further information on the acceptance of ICCD and improvement suggestions for future semesters

Evaluation of Tutors

Mean cognitive congruence and educational environment for all sessions were rated as excellent at 1.26 ( n  = 121) and 1.35 ( n  = 107) respectively. Most tutees ascribed the roles “information provider” ( n  = 106, 84.4%) and “facilitator” ( n  = 87, 69.6%) to their tutors. Several tutees also rated their tutors as “role models” ( n  = 68,54.4%) and “assessors” ( n  = 51, 40.8%).

Learning outcome

CSA of learning outcomes revealed an increase in the ability to apply the correct diagnostic algorithm to a given case by 74.65% ( n  = 115). Ability to interpret the findings of diagnostic procedures increased by 70.31% ( n  = 114).

The end-of-course examination on internal medicine in the fall semester of 2020/21 consisted of 70 questions with a mean score of 85%. 30 (43%) questions have been previously discussed only during ICCD sessions, and 40 questions (57%) only during lectures. ICCD questions were answered with a higher score compared to lecture questions (90.3% vs. 82.4%, p  = 0.074). Although not statistically significant, students’ overall performance measured as a grade in the end-of-course examination was improved by material produced during ICCD sessions.

15 of 18 eligible tutors (83.33%) completed the survey. One tutor (author JR) conceived the questionnaire and was thus excluded to prevent potential bias.

Tutors rated the introductory seminar as helpful (mean 1.20) and indicated that the concept of the ICCD had been clearly communicated to them (mean 1.07). They did not report extreme difficulties conceiving a clinical case (mean 1.4) and indicated enjoying the process (mean 1.33).

This study aimed to report on an undergraduate students´ initiative to facilitate the core curriculum on internal medicine by developing and implementing the novel Integrated Clinical Case Discussions to train cognitive clinical skills relevant to the pertaining lecture. This information can help develop further student-led initiatives to address emergency remote teaching or other perceived curricular deficits with the expressed goal of training cognitive clinical skills.

The direct comparison of ICCDs and lectures versus emergency remote lectures alone revealed tutees´ subjective increased proficiency in clinical reasoning (determining diagnostic algorithm and interpreting findings). Similarly, students´ satisfaction levels rose. Tutees expressed positive feelings about being tutored by peers and high cognitive congruence.

We recorded increased participation rates in the second semester of ICCDs. The participation rate was 44.5% in the first and 71.0% in the second semester respectively. These participation rates merit special consideration, as the compulsory curriculum at TUM fulfils the legally required minimum number of classes and is supplemented with a broad range of voluntary courses (There are another 72 elective and extracurricular courses). This results in a competitive curricular environment in which students may be less intent on yet another learning opportunity, though the ICCDs are the only course covering the full spectrum of the lectures on internal medicine. The above-mentioned and increasing participation rates indicate that there is a target group that welcomes the offer of ICCDs, especially in the second semester on the cardiovascular and hematologic systems. We conclude, that a peer-moderated ICCD in response to emergency remote teaching can improve students´ subjective satisfaction level with learning opportunities and is in line with previous research [ 36 ]. Student satisfaction is important to consider, as it is one of the five pillars of Quality Online Education [ 37 ] and is positively correlated with student performance [ 38 ].

Our results support other studies highlighting the effectiveness of peer-teaching [ 39 , 40 ] and CCD [ 41 , 42 ] in teaching cognitive clinical skills. We found that students attending ICCDs in addition to the lecture benefitted from a gain in skill, overall satisfaction, motivation, and knowledge. This aligns with the ICCD´s goal of generating added value to the core curriculum.

Second, we conclude empowering students to organize and execute courses provides an effective way to create custom-tailored and widely accepted teaching formats. The excellent ratings of subjective learning outcomes, educational environment, and cognitive congruence support the notion that student leadership can be useful for curricular development [ 36 , 43 , 44 ].

We described the human and time resources for preparing one ICCD session. With student teachers contributing the most hours to an ICCD we are aware that additional teaching responsibilities might act as an additional stressor on tutors. However, our results suggest that tutors enjoy the process, feel well instructed and mentored in the workflow we proposed. Similarly, previous research has highlighted the benefits of being a peer teacher [ 10 , 45 ]. Furthermore, students who agree to tutor have been shown to have the necessary resources to cope with the additional stress at their command [ 46 ].

It has been repeatedly demonstrated that voluntary courses receive better feedback than compulsory courses [ 47 ]. This study was limited by the ICCD´s voluntary nature, too. Selection bias in the evaluation may be introduced by the self-selection of students who are highly motivated to attend an ICCD session on top of the lecture in comparison to those who attended the general lecture alone. The modest overall response rate of 32% also suggests that certain opinions are likely to be overrepresented while others may be missing. However, with the respondent demographics reflecting the general student population at TUM, we believe our study provides worthwhile data. Response rates of approximately 30% have been reported before in the context of voluntary peer teachings [ 21 ]. A study by Bahous et al. (2018) suggests that the reliability between voluntary questionnaires with a low response rate and compulsory questionnaires with a high response rate is comparable [ 48 ]. To allow for a more comprehensive interpretation of results we also reported the maximum number of possible and de-facto attendances as demonstrated earlier [ 33 ]. The study design does not allow for a follow-up to assess the long-term impact on knowledge, skill, and attitude. Since our findings are based on data from one medical school in Germany they cannot be extrapolated to other medical schools without further consideration. However, the German model of medical education being common in Europe, we have reason to believe that study populations at other medical schools may be similar and our findings of value to their curricular designers [ 49 ].

Empowering students to design their own add-on learning opportunities can improve learning outcomes, teach clinical reasoning skills beyond the scope of the core curriculum and increase satisfaction ratings with learning opportunities. We believe that our concept provides an easy-to-implement and up-scalable format to alleviate pressure on faculty staff and physicians with teaching capabilities for other schools, too.

For future optimization, we propose to advance the beneficial effect of social and cognitive congruence by inviting lecturers to facilitate ICCD sessions in person as we are now planning at TUM for the fall semester of 2022/23. This ultimately leads to a triangularized teaching format in which a student-tutor moderates the discussion, lecturers support discussions with more in depth-knowledge and clinical experience, and tutees engage in an instructive discussion.

Acknowledgements

We would like to thank all our tutors for their outstanding engagement and continuous feedback on improving ICCD as well as all the people who have provided useful productive feedback on earlier manuscripts. We would particularly like to thank the reviewers of this article for their encouragement and highly detailed feedback.

Abbreviations

Appendix Table 1. Cognitive Congruence and Educational Environment. The table gives an overview of the items used to compute the cognitive congruence between tutors and tutees using the mean of section “1. Cognitive Congruence”, where 1 denotes the greatest and 5 the lowest level of tutees´ satisfaction. Tutees´ perception of the educational environment was computed by calculating the mean of the items in section “2. Educational Environment”. Cronbach´s alpha for cognitive congruence was 0.76; for educational environment 0.83.

Authors’ contributions

JR conceived the didactic concept of the ICCD, developed the questionnaire, and oversaw the data acquisition. NS was chief exchequer, head of human resources, and coordinated cooperation with the lecturers. TW developed administered the online material, zoom-links, and monitored student commentaries for continuous improvement. CHL helped with conceiving the evaluation tool and data analysis. VP matched lecturers to the ICCD sessions, facilitated their communication with the tutors, and majorly revised the manuscript. MWM conducted the didactic lecture and majorly revised the manuscript. All authors have read and approved the manuscript.

Authors’ information

At the time of the study the following statements apply:

Johannes Reifenrath is a fifth-year medical student at Technical University of Munich, School of Medicine, and a student representative to the school´s committee on curricular development.

Nick Luca Seiferth is a fifth-year medical student at Technical University of Munich, School of Medicine, and a student envoy to the school´s faculty council.

Theresa Wilhelm is a sixth-year medical student at Technical University of Munich, School of Medicine, and a student representative to the school´s committee on curricular development.

Christopher Holzmann-Littig, MD, is a resident at Technical 482 University, School of Medicine, Department of Nephrology, and a 483 member of TUM Medical Education Center.483 member of TUM Medical Education Center.

Veit Phillip, MD, Instructor of Medicine, is a senior physician at Technical University, School of Medicine, Department of Gastroenterology and coordinates the lectures on internal medicine.

Marjo Wijnen-Meijer is head of innovation at the TUM Medical Education Center and specializes in curricular development.

Open Access funding enabled and organized by Projekt DEAL. This work was kindly supported by the Technical University of Munich under a grant for teaching-related projects of excellence at Technical University of Munich (TUM) (“Studienbezogene Exzellenstrategie der TUM”) and partly under a fund jointly handled by student representatives and the TUM Medical Education Center (“Planungsmittelkommission”).

Availability of data and materials

Declarations.

Informed consent was obtained from each participant and monitored and approved by the Ethics Review Board of the Technical University of Munich (grant number 701/20S).

Not applicable.

The authors declare no conflict of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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  • Published: 13 September 2023

Factors associated with the attraction and retention of family and community medicine and nursing residents in rural settings: a qualitative study

  • G. Tort-Nasarre 1 , 2 ,
  • Josep Vidal-Alaball 3 , 4 , 5 ,
  • M. J. Fígols Pedrosa 6 ,
  • L. Vazquez Abanades 6 ,
  • A. Forcada Arcarons 7 &
  • J. Deniel Rosanas 1  

BMC Medical Education volume  23 , Article number:  662 ( 2023 ) Cite this article

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A Correction to this article was published on 02 November 2023

This article has been updated

The current shortage of primary care doctors and nurses is causing difficulties in replacement, and this shortage is expected to increase. This situation is more pronounced in rural environments than in urban ones. Family and community care specialty training is a key component of both the transition to clinical practice and the retention of new professionals. The aim of this study is to explore the attitudes and perceptions of internal medicine residents and internal nurse residents trained in a rural teaching unit on factors associated with recruitment and retention, including the role of the specialty training programme.

A qualitative study was conducted. Purposive sampling was used, and thirteen residents from the central Catalonia teaching unit who were in their final year of training participated in semistructured interviews. The data were collected during 2022 and were subsequently analysed with thematic analysis. The study is reported using the COREQ checklist.

Six themes emerged from data related to perceptions and attitudes about the factors associated with recruitment and retention: training programme, characteristics of the family and community specialty, concept of rural life, family and relational factors, economic and resource factors , and recruitment and job opportunities.

Conclusions

Family and community medicine and nursing residents trained in rural settings expressed satisfaction with the specialty programme and most features of primary care, but they experienced a wide range of uncertainties in deciding on their professional future in terms of living in rural areas, family support, financial support and recruitment. This study identifies individual and structural factors that could be of great use to retain doctors and nurses in rural areas.

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Introduction

The shortage of health professionals in rural areas is a growing problem in many countries. This situation has important implications for the quality of health care provided in these areas as well as for the health of the people who live there. Lack of access to medical care, deficiencies of health personnel and a lack of organisation and coordination of services are barriers to access and the quality of health care in these areas.

The insufficient number of trained professionals and the growing shortage of doctors and nurses causes difficulties in replacement in primary care, and this shortage is forecasted to increase [ 1 , 2 ]. The WHO proposed as a global strategy the need to prioritise policies to improve the recruitment, development and retention of health care workers [ 3 , 4 ].

In recent years, the primary care specialty has been increasingly unattractive for some doctors’ specialisation [ 5 ]. There are important elements to consider when primary care residents choose not to join the primary care workforce after completing residency [ 6 ] or to retain physicians who have been working in primary care [ 7 ]. In nursing, there is a shortage of generalist nurses worldwide; however, there is an increase in the retention rates of new graduates who participate in residency programmes [ 8 ].

There is a wide range of initiatives and recommendations to promote the recruitment and retention of doctors and nurses in primary and community care. The WHO recently published a systematic review on health workforce retention in remote areas [ 9 ] and guidelines on health workforce development, attraction, recruitment and retention in rural and remote areas [ 10 ]. Among the recommendations, it is worth mentioning the establishment of specific education and training programmes for health personnel working in rural and remote areas to meet the needs of the rural population.

Strategies to retain doctors and nurses include ensuring professional growth, providing minimum and uniform economic incentives across areas, and ensuring good availability of social services and economic opportunities [ 11 ]. Primary care doctor retention has a strong relationship with knowledge acquisition, empathic personality profile and the possibility of continuous personal development in addition to factors related to adequate infrastructure, organisational climate and salary [ 7 ]. In Spain, security and stability, development opportunities within the organisation, learning opportunities and the degree of autonomy are seen as more important than aspects such as remuneration [ 12 ]. Concern for the retention of new nursing professionals has been studied through evaluation of the effectiveness of nurse residency programmes (NRPs), and specialty recognition, gratification, and environment-dependent relatedness have been identified as factors for retention [ 13 , 14 ].

In rural areas, attraction factors go beyond financial incentives; future professionals also value the quality of life in the rural environment, community support, nonmonetary incentives, previous family or professional experiences in a rural environment, autonomy and good professional-patient relationships [ 15 ]. Rural generalist medicine programmes are a strong point in the joint efforts to coordinate and strengthen the response to both the shortage of professionals and health needs in rural and remote areas [ 16 , 17 ]. In nursing, there are also broad and multifaceted factors that influence the recruitment and retention of practising nurses in rural areas [ 18 ]. Although there are several proposals from educators, practice administrators and political leaders to address this problem, the literature in this area is still developing, and there is a lack of robust studies that specifically focus on the retention of practising nurses [ 19 ]. Kaplan et al. argued that it is too early to draw definitive conclusions regarding the ability of rural nurse practitioner residencies to foster nurse practitioners’ involvement and investment in rural communities. Further research is necessary to assess their potential long-term impact on rural primary care practice [ 20 ]. To summarise, addressing the challenges in rural areas calls for fresh ideas and strategies that differ from those applied in urban areas and that consider primary health care across the entire system. Furthermore, it is crucial to translate empirical research findings into effective actions that can address the current issues.

Studies have reported that an organised, well-funded, rural placement or rural clinical school programme produces positive associations with increased rural intentions and actual rural employment for graduates [ 21 ] and that rural clinical rotations at universities influence rural medical career choices [ 22 , 23 ] but require further refining [ 24 ].

Effective training in various health science specialties, such as family and community care, plays a vital role in preparing professionals for clinical practice and retaining them in their fields. Family and community medicine and nursing specialty training programmes are common in the training systems of many countries but diverge in specific aspects. In Spain, the training for family and community medicine and nursing includes clinical skills and training in ethical values, commitment to patients, professional commitment to the specialty and to the National Health System, empathy and communication skills, new technologies and other aspects that may contribute to quality professional practice [ 25 , 26 ]. Both programmes include a training stay in a rural primary care setting.

Multiprofessional Teaching Units of Family and Community Care are responsible for the quality training of future doctors and nurses as well as for the promotion of the teaching and research profile. The Multiprofessional Teaching Unit of Family and Community Care of Central Catalonia has a diverse typology of centres in accordance with the characteristics of the region itself. Some of the centres are located in an urban environment, while the vast majority of them are located in rural areas with a population of less than 7500 inhabitants, a density of 100 inhabitants/km2 and specific population characteristics [ 27 ].

In Spain, the attraction and retention of health professionals in rural areas is also a major challenge. According to data from the General Council of Official Colleges of Physicians of Spain, in 2020, only 6.7% of registered doctors in Spain worked in rural areas, even though these areas represent approximately 30% of the Spanish territory and have significant populations requiring medical care (15.9% of the Spanish population was registered in rural municipalities in 2020) [ 28 , 29 ]. In Catalonia (Northwest Spain), the recruitment and retention situation of health professionals in rural areas is similar to that of the rest of Spain. In 2020, only 5.3% of registered doctors worked in municipalities with fewer than 5,000 inhabitants [ 30 ]. There are no studies in the territory that have analysed the reasons why, despite high satisfaction in the specialty programme [ 31 ], there is low retention. Knowing the reasons, motives and experiences of resident doctors and nurses who train in family and community care is useful when making recommendations for the implementation of effective strategies to improve the retention and loyalty of these professionals in the region where they completed their residency.

This study can provide valuable information on the factors that influence the decision of health care residents to work in rural areas as well as on the strategies that can be used to retain them. In addition, it can provide a complementary and novel perspective since the perspectives of doctors and nurses are combined in a single investigation, which can enrich the understanding of the phenomenon.

This study aims to explore the attitudes and perceptions of internal medicine residents and internal nurse residents trained in a rural teaching unit on factors associated with recruitment and retention, including the role of the specialty training programme.

Methodology

A qualitative study was conducted to explore and understand the issues based on the individual experiences of the participants. This design is suitable for obtaining a deeper understanding of practice in applied disciplines and is especially relevant when the goal is to understand the perspective and experience of participants [ 32 ]. It also allows us to obtain research data in a specific context [ 33 ].

Participants

The participants were resident doctors and nurses who were in their final year of training in family and community medicine from the teaching unit of central Catalonia. There were no exclusion criteria. Participants were selected using purposeful sampling [ 34 ] based on pragmatic and convenience criteria such as feasibility, interest and time until data saturation was obtained [ 35 ]. Participants of different ages, genders and geographic backgrounds were included to cover all ranges of experience [ 36 ].

Data collection

Data were collected using semistructured interviews. The research team prepared a set of interview questions relevant to the objectives of the study, including the following questions: Based on your experience, what barriers and facilitators do you identify regarding recruitment and retention in the centres of central Catalonia? In your opinion, how has the training process been in the family and community residency?

Recruitment of participants was carried out by the teaching unit that had data on the final-year residents. From these records, students were approached according to the criteria of access, their interest in participating and the relevance of the study topic to their experience. All residents (n = 29) were invited to participate, and 13 residents agreed to be included in the study. Residents who showed interest in participating were contacted by telephone to schedule the interview. Initially, 11 participants were interviewed. Then, two additional participants were interviewed until data saturation was achieved (n = 13), as we needed to ensure that we gathered sufficient information and insights for a comprehensive understanding of the research topic.

The interviews were carried out by the PI between April and May 2022. We chose to conduct interviews via videoconference due to the wide dispersion of the region and to facilitate accessibility. The interviews were recorded with the permission of the participants using the Microsoft Teams communication platform provided by the Catalan Institute of Health. During the interviews, follow-up questions were asked to encourage participants to provide additional details about their perspective. Participants were recommended to participate in the interview in a quiet place without interruptions to ensure confidentiality. The interviews lasted a minimum of 35 min and a maximum of 55 min. The interviews were conducted in Catalan or Spanish, the two official languages of Catalonia, and transcribed into Catalan. Subsequently, the interviews were returned to the participants for approval of the content. All of the participants accepted the content of the interview.

Data analysis

The data were analysed using thematic analysis [ 37 ] supported by Atlas.ti v. 9. Patterns were identified in the collected data, and themes were organised systematically to meet the research objectives [ 33 ]. The PI was responsible for analysing the data because of her experience in qualitative analysis. Likewise, the PI maintained a constant review process with a colleague external to the team and thus ensured the validity of the study. The entire process was explained to the research team, and consensus was obtained when necessary.

The process involved several steps. First, the PI familiarised herself with the data by listening to the recordings, transcribing them, and carefully reading and rereading the transcripts. Then, the PI identified meaning units that were relevant to the research objectives, generated codes, and explored relationships among them. Next, she grouped the codes into abstract themes and defined the boundaries of each theme. The PI identified six themes, which were composed of meaning units and formed the primary structure for the analysis. Finally, the research team organised the themes and subthemes and wrote the research report.

Rigor criteria and ethical considerations

This study met the criteria for credibility, transferability, dependability and confirmability to ensure trustworthiness in qualitative research [ 38 ]. The interviews were conducted by the PI, who was an RN, PHD in nursing. She worked in primary care and served as a lecturer in the Nursing Degree Program at the university. There was no prior relationship between the PI and the project participants. The PI had extensive experience in qualitative methodology. The PI recorded her impressions during the process of conducting the interviews and analysis to ensure maximum objectivity in the procedure. The research team made constant revisions to the analysis process to ensure qualitative validity. The COREQ checklist was used to run and evaluate the study [ 39 ].

The study was approved by the University Institute for Primary Care Research (IDIAP) Jordi Gol i Gurina Clinical Research Ethics Committee (Code 22/048-P). All participants signed an informed consent document. Data confidentiality and anonymity were ensured throughout the process by assigning each participant an alpha-numeric code.

Thirteen residents in their final year of training in the specialty of family and community medicine and nursing at the Central Catalonia Teaching Unit participated in the study. Table  1 shows the main sociodemographic characteristics of the participants. Of those interviewed, 5 (38%) stayed to work in central Catalonia.

The results of this study were based on six themes that emerged in the thematic analysis of the data (Table  2 ).

Factors related to the training programme

Participants highlighted the advantages of training in a rural area, such as individualisation in learning.

I chose Central Catalonia as an option. I had been told that the training of doctors was good because it has a smaller hospital and the family resident had more prominence in the different specialties, and that made me decide to come. P5 .

They had opportunities to be in a teaching unit with few residents.

Because it is small and rural, I am the only resident, and the teaching is at an individual level, and you see everything in first person. There is very good feedback that perhaps if there were more residents would not be so personalised, and you can get involved and participate a lot in the activities of each service where you go. P5 . You get individual treatment. I’m not just nurse number 130, but I’m XX, and I am valued and empowered. P2 .

The majority of residents, both doctors and nurses, positively assessed the mentoring process for their learning.

I have been fortunate to have a very good tutor on a personal and professional level. I have learned a lot, and she has given me a lot of confidence to discuss any questions I have. P5 .

However, they also explained how this relationship influenced retention.

If you don’t have a good relationship with the tutor, if you have a fairly negative experience, that makes you not want to stay. P6 .

Among the learning activities in the context of professional practice, the shifts in different hospital clinical units were highly appreciated by both doctors and nurses.

You learn a lot on shifts. It completes your training. And then on a day-to-day basis, because you’ve seen so much, you can deal with it. P1 .

They valued the purpose of the shifts to better understand the area’s resources.

We have to go through the different services because we have to know what is acute or what is chronic and those that can be made acute, what we can do from the primary care centre. In the end, we are the ones who refer the different services, or we can also solve problems in the primary care centre. P5 .

They also pointed out that doing hospital on-call duty provided them with security to treat critical illnesses in rural areas.

Because then if I find a serious case in the primary care centre, we have a little more back-up. Because few come to me, but when they do, it’s good to know what to do. P6 .

Factors related to the characteristics of the family and community specialty and personal motivations

The participants explained their reasons for choosing the family specialty. All the nurses had studied primary care subjects during their nursing degree curriculum, and they explained how this previous training experience was crucial when choosing their specialty.

I was going to study mental health; it was my goal but for my last internship in my fourth year I went to a rural primary care centre and there I fell in love with primary. P2 .

On the other hand, not all the doctors had taken specific primary care subjects during their university training and believed that this could later influence them in not choosing this specialty.

You have cardiology, nephrology, and digestive medicine, but there is no family medicine. If everything that it covers were really explained, there would not be this kind of rejection, in inverted commas. I have to say that family medicine is the last thing to be chosen because it is for those who had bad results in the internal medicine residency. P8 .

The participants said that for a subject within the curriculum, it would help to have more doctors who would want that specialty.

If a course of study were made, we would lose the idea that the family doctor is the doctor who does not have a specialty because he or she touches upon everything and knows nothing in depth. P8 .

Another characteristic that the participants considered was the disrepute of family doctors and how this aspect may influence the poor recruitment of family professionals.

I think what has gone wrong is the belief that good doctors work in the hospital and bad doctors stay in primary care. P8 .

However, despite the discrediting of the specialty among the medical community and socially, this did not deter them from choosing the specialty.

There really is a lack of prestige, and I think it comes from the previous era, when people finished their degree and were already primary care doctors without a specialty. And people have kept this particular idea. It is not global, not everyone thinks so, but there is a kind of thinking that the primary care doctor is the idiot who did not want to do a specialty. P10 .

Therefore, although many of them already had previous experience in primary care and motivations for choosing the specialty, during the residency period, they identified characteristics of primary care that could be related to retention and willingness to practice, such as the generalist approach .

I wanted a specialty that covered a lot, not focusing on being an eye doctor, but something of the whole body, not just centred around one area. The variability that family medicine gives you, that you don’t know what you are going to get the next day. I like variety. P10 .

They discovered the extent of primary care as a specialty, including aspects such as professional independence and longitudinality .

In family medicine, you are lucky enough to have the chance to specialise in one thing or another, and then you also have all this part of minor surgery techniques, injections and ultrasound scans, which is also something this allows you to do. P8. We also have our independence to do things. So that’s what I take away most - I have been surprised in that sense. P3 . I must emphasise the importance of the relationship you have with the patient and the importance of following up with the patient, of knowing what has happened to them. I find this very important for health care because if you give them medication but the next day something happens because of the medication, for example, you give them an antihypertensive because they have low blood pressure, cramps in their legs or they sweat at night…. you can be reached, and you are accessible for them to call and say, look, I have not been doing well, or I want to stop taking the pills. Well, that is very important for you to know. P5 .

They specified the importance of the doctor‒patient relationship in primary care and of the holistic perspective of the person and the environment as an aspect that favours the relationship.

I have seen the doctor‒patient relationship at a later stage. The way you relate to the patient and know their family is very important. At a social level, this has been more of a discovery now in the residency. P13 . Seeing the environment where the patient lives helps you to understand more about what they sometimes explain. When you see them in the environment where they live, you can understand the difficulty, the other person’s problem, the experience of living with a disease, etc. I believe that what makes family medicine special is knowing the patient’s environment. P8 .

Both doctors and nurses emphasised the patient-centred model in the family and community setting.

I have seen that individualisation is kind of the essence because you know that not everything is as mechanical or as easy as the clinical practice guideline says, and it is more about adapting to the person and the context. P13 .

Furthermore, during the residency, both nurses and doctors talked about the need to improve teamwork .

I think teamwork is very important for me. We are a very individualistic group, especially doctors, and we do not know much about teamwork. I have seen now that the work is very hierarchical. In other words, there has been teamwork, but more than teamwork, it has been more group work, something that is essential, that we need to incorporate in our day-to-day life and even more so in primary school. It is about sharing knowledge and different visions. We should be more decisive as a team, and I think there is still a lot to do. P13 .

They also found negative aspects in daily tasks, such as the bureaucratic part of being a family doctor.

The bureaucratic part consumes a lot of your time and takes it away from the care part, and then you are also the gateway to all the frustrations of the patient with all the other specialists: if I have not been called by the traumatologist, I’ll take it out on you later. The ophthalmologist should have asked me for it, and he didn’t so I’ll take it out on you. And then there’s the issue of work discharges. I can’t deal with it. It’s beyond me. P12 .

They also felt limited by the little time that could be devoted to each patient.

In practice, I have found the time per patient to be totally insufficient. I find it practically impossible to monitor chronicity in 10 min. It gives me the feeling that I’m kind of postponing things I don’t know for later, for when I have time to look at the ones I’m not resolving because I don’t have time to think anymore. For me, it creates discomfort in my day-to-day life to know that I am not doing things right and that I no longer have time to deal with things calmly. P12 .

Factors related to the concept of rural life

The participants talked about their experience of living in a village in terms of adaptation and integration into the community.

Here in Osona, I have integrated very well and I feel very comfortable, both with the professional team and on a personal level, and that’s why I would like to stay. P5 . Most come, spend the four years and eventually integrate with the other residents but not with the community, not too much.

Some participants mentioned that they had come from a large city and were attracted to the rural environment.

I really like the rural lifestyle. I came from a super, super big city. There, you don’t know anyone, but here in the village, I really enjoy it because you get to know people and you become part of the community. P4 .

Additionally, the participants had different opinions about the attraction of rural medicine and consequently about practising professionally in these areas.

I like it. I prefer rural areas over the city. I suppose that because of the proximity of the patients and because it is a small team, there tends to be more communication. P6 . I prefer the idea of an urban area. Maybe the kind of people you have to deal with isn’t ideal, but I don’t see myself working alone in a rural area. I like the idea of having more co-workers, having a fairly large centre where there are more people and being able to talk about things. P9 .

Family and relational factors

One aspect that stood out notably was family ties as a reason for doctors and nurses to not stay and to return home.

They leave because they have family there. I understand it. P8

The issue of not finding a partner in the area was also prominent for doctors and nurses.

Either you marry someone from here, or you won’t get them to stay. It is the link that would make them stay, but that is very difficult. P6.

Economic and resource factors

Some doctors mentioned that salary was not a motivating factor in choosing the specialty.

It is very clear to me that I did not study family medicine for the money that is earned. P3 .

However, some participants stated that they had no economic incentives to remain in rural areas; therefore, they preferred to go abroad where the economic conditions were better.

Perhaps they could do it, I don’t know, as some places in the south of France do: for five years you don’t pay taxes, they offer you a house to stay in, and if you have any problem with the issue of the offices, they help you with everything. P8 .

In addition, some participants from other areas found that in the area where they studied, the cost of living was more expensive compared to the area they came from. They noted that the salary was not sufficient for living in this area.

The rent here is super expensive. Life is expensive here compared to where I am from, and the salary is not very high either. If you equate it with what you spend on rent and everything, it’s not that much. For example, in Murcia, they do earn much more. P1 . I need stability and to know that I am going to have a medium- or long-term contract that will allow me to sort out my life, not to be waiting. P3 .

Factors related to recruitment and job opportunities

The participants noted that deciding on the near future was a complex and uncertain process. This organisational situation put pressure on them to decide and was stressful.

The data showed a difference between medical and nursing staff in relation to the types of contracts. For example, doctors had more defined and clear contracts with more stable contractual conditions compared to nurses.

In principle, the offer is good; it is interim, and from what I have felt nursing is not that lucky. Nurses have very small contracts and are constantly having to see if they will be renewed, possibly because of the need for more medical professionals who offer us better conditions. P5 .

For nurses, the job offers were lacking or included short and uncertain contracts.

I would like to stay in the area where I am in training right now, but I am not being offered anything. I feel very sad. P4 . Maybe you have a chance to stay, but we can’t offer you a very big contract… they don’t give you much hope either, and you have to organise your life. I have to pay the rent and not wait to see if something falls into my lap. P3 .

For some, a medium- or long-term contract would enhance retention.

I need stability and to know that I am going to have a medium- or long-term contract that will allow me to sort out my life, not to be waiting. P3 .

The nurses perceived a dichotomy between initial expectations and job offers after completion of the residency. They experienced this as a loss of talent and demotivation .

They are doing it wrong because we are all leaving. They should act in your favour because they have already taught you and they have trained you. That’s worth money and, in the end, no, they don’t take you into account as they should. P1 .

Another issue was a loss of economic resources and a lack of expert appraisal.

I don’t understand it because you have already been trained. You have more knowledge. And they don’t value it; they give you a contract just like that person without a specialty. It’s a waste of talent and money. P1 .

Additionally, the time lag between the job offers and having to make a decision limited retention and decreased the offer.

Maybe people will leave anyway, but I think that a percentage would stay if they had that time, let’s say, to make a decision, because it’s not like buying a t-shirt in one colour or another. I mean, it’s choosing your future career and where you are going to live. P3 .

Additionally, some doctors stated that not being able to stay in the unit where they had been trained reduced their chances of retention.

Our management does not offer for us to stay in our health centre but in any centre in the region, and this is a limiting factor. I think that if they offer you your own centre and your familiar environment it would be much better, but to go to a health centre that you don’t know, it means you go to your own city and start there again. P10 .

A negative aspect for nurses was the lack of specialty assessment and not having a specific pool of specialists to fill positions.

We do not have a specific pool, but it is true that I believe that this assessment, this plus, should be given. I think that should be considered when it comes to actually offering something at the end. P3 .

This experience led the nurses to opt for other autonomous communities where the specialty was valued within the labour pool or where there was a specific pool of specialists.

Many of the resident nurses end up returning to their place of origin or to other autonomous communities in Spain where the specialty is valued both economically and when it comes to opting for a position or a longer contract. P3 . They come back also because there are communities where nursing salaries are much higher. So, if they do have a community where they also have a specific pool, they will hire you earlier and with a better salary, and you will also be close to home. P2 .

This study explored the factors related to the recruitment and retention of family and community medicine residents in a rural area of Catalonia (Spain). In addition, the study aimed to determine whether the experiences of the specialty training programme had a relationship with subsequent loyalty to the area where the residents were trained.

The decision of the residents to train in this rural area of Catalonia was, for most of the participants, a consequence of the scores obtained on the internal medicine and nursing residency exams. Most internal medicine resident positions in family and community medicine and internal nursing resident positions in family and community nursing are chosen by the applicants with the lowest internal medical residency exam scores [ 5 , 37 ]. The positions offered in this geographic area are the last positions chosen in Spain. 53% chose the specialty of family and community medicine as their first choice compared to 46% who had other preferences. These data coincide with other studies showing that training in family medicine is not among the best positioned preferences of students [ 1 , 40 ].

The results of the study shows that the decision to work in rural areas is influenced by the convergence of various factors: the training programme, characteristics of the family and community specialty, concept of rural life, family and relational factors, economic and resource factors, and recruitment and job opportunities. These aspects identified by the participants should be considered as a whole set of intertwining factors and not in isolation since they provide a comprehensive view of the complex process involved in the decisions of future professionals.

There is a significant body of research on the impact of residency training on the choice to practice in rural areas [ 41 , 42 ] Since this study was conducted in Spain, the results can contribute to a better understanding of whether there are other important factors that have not been previously studied. Most of the residents defined the training programme as rewarding and having significant learning opportunities. Specifically, they highlighted the facilitating factors that allowed them to learn about the resources of the area, carry out shifts on different hospital equipment, and receive teaching during shifts. This reinforces findings from other studies [ 31 ]. The role of the tutor is fundamental because of the progressive assumption of responsibilities. The study also highlights the advantages of training in the rural environment, such as the opportunity to receive individualised training and to be part of small teams, to know the patients’ environment and thus better understand their health needs and to adapt the health resources offered by the rural environment to these needs. However, rural settings can present disadvantages for health care professionals, including smaller teams that limit diverse perspectives and knowledge exchange. Limited resources in local centres lead to fewer services and restricted access to advanced technology, specialists, and continuing education programmes. This narrow exposure to clinical situations and procedures can impact professional development.

In addition, the participants identified the personal and professional relationships established during the training period as factors to be taken into account when assessing their professional future in the environment where they were trained. This can be both an advantage and a disadvantage depending on the quality and support provided by these relationships. Therefore, it is crucial to consider the nature of these relationships when evaluating the impact on residents’ professional trajectory.

Factors related to the characteristics of the family and community specialty

The results are consistent with other research studies that show similar findings. Previous training in primary care during undergraduate studies has been shown to be a motivating factor for choosing a specialty. In this regard, this training should be introduced into the educational curriculum in faculties where it currently has limited or no presence [43, [ 44 ].

Furthermore, general medicine may suffer from a reputation of being undervalued and less prestigious compared to specialised fields [ 43 ], which may discourage medical professionals from choosing this career path. This lack of recognition and societal appreciation may result in decreased professional satisfaction and motivation among general practitioners. Efforts should be made to promote professional development and recognition within the field to attract and retain talented individuals.

During the residency period, the participants discovered aspects of primary care that they considered to be positive for the good professional development of the specialty and that could be related to the retention and professional practice of primary care. They also commented on the presence of negative aspects, such as excessive bureaucracy in consultations and the lack of time dedicated to each patient. Other studies have also recognised these factors as negative aspects of the specialty [ 31 , 44 , 45 ]. In rural primary care, it is even more crucial to take measures to address the challenges related to bureaucracy, resource distribution, and patient-centred care models. These centres often face additional challenges due to the lack of infrastructure and available resources compared to urban centres.

Residents identified the concept of the rural lifestyle as one of the determinants when deciding on their future, in accordance with other studies [ 46 ]. Cosgrave et al. (2019) analysed the social determinants of retention in rural areas and found that fulfilling life aspirations and interest in rurality favoured retention. Students who have personal interests and values related to the rural lifestyle can overcome the perceived barriers and difficulties of being a rural doctor or nurse. Coming from a rural background is one of the strongest predictors of practising in rural areas. However, the results also suggest that coming from cities does not prevent individuals from finding rural life attractive [ 47 ].

Working on barriers as an inclusive aspect of the family and community-based programme may lead to fewer doctors opting to leave. The results of the study showed that feeling like the doctor or nurse of the town supports retention in rural areas. Establishing a meaningful relationship with patients is valued very highly, but it is not enough to improve retention [ 13 , 47 , 48 ]. The rural lifestyle is a negative aspect when it is seen as a barrier to retention globally [ 18 ], so further research should be conducted on aspects that can make rural life attractive to young people.

The participants mentioned the difficulty of having family support to reconcile their personal and professional life if they stayed in rural areas after completing their residencies. These results were also identified in previous studies [ 14 , 49 ]. Feelings of isolation and a lack of integration are personal factors that were identified in other studies [ 50 ], and the current results point in that direction since friendships or support networks were identified as very important and fundamental for retention. It should be noted that the impact of the COVID-19 pandemic during training influenced the ability to form bonds [ 51 , 52 , 53 ]. The experience of being in closed villages and the difficulty of integrating during training may have been consequences of the social impact of the pandemic. On the other hand, Handoyo et al. [ 54 ] showed that people with greater resilience perform better in rural areas.

Economic and resource factors.

The residents stressed that receiving economic and financial incentives could help them settle in remote areas [ 17 , 55 ]. On the other hand, the cost of living in the rural area studied was high in comparison with other geographical areas in the rest of Spain. This resulted in many residents deciding to return to their area of origin where the cost of living was lower. This aspect is difficult to combat unless economic and fiscal incentive policies are put in place, such as housing subsidies, free public transport, and tax reductions for settling in rural areas. Similar strategies are currently being implemented by some governments to build pharmacist loyalty in rural areas [ 48 ]. However, for more effective retention, in addition to one-off financial strategies, personal and professional strategies that promote long-term recognition must be addressed [ 56 ].

Factors related to recruitment and job opportunities .

In terms of factors related to recruitment and job opportunities, there are significant differences between medical and nursing residents. While medical residents claim that they are offered the possibility of accessing stable interim contracts, the same is not true for nurses, who complain that they do not have the opportunity to access stable contracts. Nurses are among the health professionals with the lowest proportion of permanent contracts, standing at 25% during the first 4 years of employment in Catalonia [ 57 ]. Spain’s precarious employment of nurses and the emigration of nurses to work in other European countries or around the world during the last decades has been well documented in previous studies [ 58 ]. The situation for doctors is very different, as there is a high shortage of professionals, which leads them to be hired very quickly [ 3 ]. The results, however, show that better planning of the supply would help people stay in the area and would give them the opportunity to stay in the same centre where they were trained. Although the nursing specialty programmes, specifically the family nursing programme, show positive results in terms of professional skills acquired, the nursing residents themselves indicate that they do not feel sufficiently recognised because they do not have a specific score valued for entry into public health service provider companies. This exacerbates their feelings of frustration and dissatisfaction [ 48 ].

Limitations

This study has some limitations. The study design was qualitative; therefore, it was not possible to quantify the results of the training experience and its link to retention. Furthermore, the research examined perceptions and attitudes towards retention and the possible relationship with the training programme. A future study with a mixed methodology could achieve a more detailed analysis of the aspects that could be included in the training programme to promote better acceptance of the rural environment.

The study only included residents’ perspectives. A broader investigation including other people, such as tutors, policy-makers and academics, could be useful to complement the data. Likewise, a longitudinal study could complete our knowledge of the barriers and facilitators found over time regarding professional practice in rural areas.

Rural-trained family and community medicine and nursing residents are satisfied with the specialty programme and with primary care but experience a wide range of uncertainties in deciding on their professional future in terms of living in villages, family support, financial and economic support, and recruitment. They also propose the implementation of more established retention strategies. Overall, this study contributes to the literature by providing a comprehensive analysis of the factors that influence the recruitment and retention of health care professionals in rural areas, as demonstrated in the context of family and community medicine in Spain. The identification of key themes, insights into perceptions and attitudes, and consideration of individual and structural factors offer valuable knowledge to inform strategies aimed at retaining doctors and nurses in rural areas. This study opens the way for the development of interventions in the field of health management and teaching to promote better retention in rural areas where health workers have been trained and introduces ways to address the shortage of health care professionals.

Data Availability

The data that support the findings of this study are available (de-identified) from the corresponding author upon reasonable request.

Change history

02 november 2023.

A Correction to this paper has been published: https://doi.org/10.1186/s12909-023-04814-z

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G.T-N. designed the study. G.T-N, M.F.P, J.D.R and J.V-A. wrote the main manuscript. G.T-N. conducted the qualitative analysis. L.V.A. and A.F.A. prepared tables. J.D.R, L.V.A, A.F.A. and J.V-A. reviewed the manuscript. All authors read and approved the final manuscript.

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Tort-Nasarre, G., Vidal-Alaball, J., Pedrosa, M.F. et al. Factors associated with the attraction and retention of family and community medicine and nursing residents in rural settings: a qualitative study. BMC Med Educ 23 , 662 (2023). https://doi.org/10.1186/s12909-023-04650-1

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