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Abstract
Introduction Family physician anaesthesiologists (FPAs) are essential to providing surgical, critical and obstetrical care in rural communities of Canada. They experience pressing challenges like burnout, isolation and limited opportunities for professional growth. There is a lack of studies synthesising the available evidence on the factors associated with recruitment and retention of FPAs in Canada. We aim to systematically review and describe the nature of the scientific evidence on the facilitators and barriers to the recruitment and retention of FPAs in Canada, and to identify areas to inform potential solutions.
Methods and analysis Our scoping review will search Pubmed, Embase (Ovid), Scopus and grey literature for empirical or theoretical publications in English or French on facilitators and barriers to the recruitment and retention of FPAs in Canada. We will conduct a narrative synthesis of the included publications.
Ethics and dissemination Our results will guide future research and initiatives to enhance the availability of FPAs in Canadian rural and remote settings. The results will be shared through professional networks, presentations at conferences, and publication in a scientific journal. Ethics approval is not required.
- ANAESTHETICS
- GENERAL MEDICINE (see Internal Medicine)
- Health Services Accessibility
- Primary Health Care
- Adult anaesthesia
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- ANAESTHETICS
- GENERAL MEDICINE (see Internal Medicine)
- Health Services Accessibility
- Primary Health Care
- Adult anaesthesia
Strengths and limitations of this study
We will include both published and grey literature exploring the facilitators and barriers to the recruitment and retention of family physician anaesthesiologists in rural Canada.
An experienced health sciences librarian at McMaster University reviewed, adjusted and approved the search strategy.
Our review is limited to Canada, which may affect the generalisability of our results.
Introduction
Canada is the second largest country in the world by total land area, with 25% of its population living in remote, rural and indigenous communities.1 Unfortunately, individuals residing in rural areas often face poorer health outcomes than the broader population,2 3 which is explained by several factors including limited access to healthcare services.3
The country faces a critical shortage of anaesthesia providers, significantly impacting accessibility to surgical, obstetrical and critical care services.4–6 With only around 4300 professionals providing anaesthesia care, the current ratio stands at 11 per 100 000 people, which is considerably lower than that of other high-income countries such as Australia (23 per 100 000), the USA (21 per 100 000) and the UK (18 per 100 000).7 This deficiency is projected to worsen due to an ageing workforce nearing retirement, with 39% of anaesthesia providers aged over 55, and 13% surpassing the age of 65.8
A shortage of anaesthesia providers directly hinders healthcare access, especially for vulnerable groups like obstetric patients and Indigenous communities.5 For example, the absence of accessible anaesthesia services stands as a critical determinant in the cessation of maternity services in rural Canada, constraining the ability to perform caesarean deliveries and exacerbating the trend toward urbanisation in maternity care.9 In Nova Scotia, the deficit of anaesthesiologists has led to a decrease in elective surgeries and has required pregnant women from smaller communities to travel to Halifax for childbirth.10
Family physician anaesthesiologists (FPAs) in Canada
In Canada, anaesthesia care is primarily delivered by three groups of physicians: Canadian-trained anaesthesiologists certified by the Royal College of Physicians and Surgeons of Canada, internationally trained anaesthesiologists certified by provincial/territorial colleges and FPAs. FPAs, who are family physicians with additional certification in anaesthesia, fulfil a vital role in addressing healthcare gaps in rural communities.11 Beyond their primary care responsibilities, FPAs are indispensable for delivering essential surgical, obstetric and critical care services in remote areas, where access to specialised care is limited.6 12
The Canadian Family Practice Anaesthesia Programme is a comprehensive 12-month residency programme designed to equip family physicians with the necessary skills and confidence to administer safe anaesthesia in community settings for both elective procedures and emergencies.13 The programme features rotations in community anaesthesia, adult and paediatric anaesthesia and intensive care units. It is also accredited by the College of Family Physicians of Canada (CFPC) and grants a Certificate of Added Competence in Family Practice Anesthesia from the CFPC.14
Approximately 500 FPAs are currently active in Canada.14 Unfortunately, the rural FPA community has historically faced challenges, including burnout, social isolation and limited opportunities for professional growth. For instance, access to continuing medical education for rural FPAs is often hindered by geographical distance, high costs and logistical challenges.12 15 Additionally, the average professional career of FPAs lasts less than a decade, reflecting the difficulties in retaining these professionals in their working environment.16 These challenges underscore the urgent need for targeted interventions and support mechanisms to recruit and retain FPAs, particularly in rural healthcare settings.
Study rationale
People living in remote, rural and Indigenous communities across Canada have limited access to healthcare services. FPAs are crucial to enhancing access to surgical, obstetrical and critical care services, but they experience pressing challenges like burnout, isolation and limited opportunities for professional growth. Despite this, no knowledge synthesis study has synthesised the evidence on the facilitators and barriers to recruitment and retention of FPAs in Canada. This knowledge gap hinders informed decision-making regarding FPA services and policies.
This scoping review will be the first knowledge synthesis study summarising the available evidence on the facilitators and barriers to recruitment and retention of FPAs in Canada. Such insights can inform targeted interventions to improve FPA support and well-being, thereby enhancing healthcare delivery in underserved communities.
Study objective
The objective of this study protocol is to systematically review and describe the nature of the scientific evidence on the facilitators and barriers to the recruitment and retention of FPAs in Canada, and to identify areas to inform potential solutions.
Methods
In conducting our scoping review, we will adhere to the methodologies outlined by Arksey and O’Malley17 and Levac et al18 encompassing the following steps: (a) formulation of the research question; (b) identification and retrieval of pertinent studies; (c) organisation and mapping of data and (d) synthesis and presentation of findings.
The review team comprises exclusively of medical learners: a Postgraduate Year 2 (PGY-2) in Family Medicine (JP), two medical students (MA and NC) and a PGY-3 in FPA (PG-R), all of whom are training at McMaster University in Ontario, Canada. The planned start and end dates for the study are June 2025 and June 2026.
Research question
Our review will answer the question: what is the extent and nature of the evidence on the facilitators and barriers to the recruitment and retention of FPAs in Canada? The protocol for our study will be accessible beforehand, registered and made publicly accessible through OSF registries.19
We chose a scoping review because it allows the exploration of broad research questions, mapping of key concepts and identification of gaps in the literature.20 This approach is ideal for summarising diverse evidence in emerging or complex fields like FPA, unlike systematic reviews, which focus on answering specific research questions stemming from interventions.21 It aligns with our aim to provide a comprehensive overview related to our research question.
Identification and retrieval of pertinent studies
Eligibility criteria
The eligibility criteria were determined based on insights gained from the initial searches. Eligible studies will include those that are empirical publications (case reports or series, observational and experimental studies) or theoretical publications, written in English or French and discussing facilitators and barriers for the recruitment and retention of FPAs in Canada. In our study, recruitment was defined as attracting or placing FPAs in positions in rural, remote and Indigenous communities (as defined by each study), while retention was defined as keeping FPAs in these communities.22 Recruitment and retention can be determined by either objective indicators (eg, retention rate) or subjective reports (eg, practice location decision).
Documents must fulfil all the criteria to be eligible for inclusion. Publications outside Canada or publications focused on anaesthesia providers other than family physicians will not be considered for inclusion.
Search strategy
We will search in Pubmed, Embase (Ovid) and Scopus, using Boolean operators, truncators and search terms according to each database. Additionally, using the same search terms, we will include databases such as the Enhanced Surgical Skills Library on the Society of Rural Physicians of Canada website,23 the Rural Surgical & Obstetrics Networks website24 and OpenGrey25 to search for grey literature. An experienced health sciences librarian at McMaster University reviewed, adjusted and approved the search strategy. Table 1 shows our search strategy.
Search strategy of the scoping review
Study selection and data extraction
Two reviewers, working independently, will conduct the initial screening of titles and abstracts using the open-source systematic review tool, Rayyan.26 Any discrepancies will be resolved through discussion and consensus. Following this, they will obtain the full-text versions of the selected documents, eliminate duplicates using Endnote X8.2 and finalise the study selection based on predetermined eligibility criteria.
Organisation and mapping of data
Charting the included studies is a ‘technique for synthesising and interpreting qualitative data by sifting, categorising and sorting material according to key issues and themes’.17 A spreadsheet-based data management tool will be used to develop our data charting form. Through regular meetings, two reviewers will iteratively refine the data charting form, aligning it with the variables essential to address our research question. To ensure its effectiveness, we will pilot the form with a representative of 5% of the identified studies. The finalised data extraction form will be provided as an online supplemental appendix.
Supplemental material
We will extract the following data from eligible studies: authors, province, type of study (case series, observational, experimental, theoretical), aim, sample size, reported facilitators and barriers for the recruitment and retention of FPAs in Canada and conclusions. An inductive thematic analysis approach27 will be employed to identify key themes related to the facilitators and barriers affecting the recruitment and retention of FPAs in Canada.
Synthesis and presentation of findings
We will generate a narrative synthesis of the main results and create tables to display an overview of the included studies. A narrative synthesis involves juxtaposing and integrating findings from the studies included in the review.28 We will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for reporting scoping reviews.29
Ethics and dissemination
We will present the protocol of our scoping review at Canadian conferences related to family medicine and anaesthesiology. Additionally, we will present the results of our study at similar conferences and disseminate our findings to relevant organisations, such as the College of Family Physicians of Canada, the Canadian Anesthesiologists’ Society, the Society of Rural Physicians of Canada and recruitment agencies like Canadian Locum Services. These organisations are deeply involved in workforce planning, rural health, medical education and policy development.
All data will be included with the results of our scoping review and made publicly available (online supplemental file 1). Our scoping review does not require ethical approval.
Patient and public involvement
Following the completion of our scoping review, we will conduct an additional qualitative descriptive study involving interviews with a selected group of experienced FPAs who have faced challenges related to recruitment and retention in rural communities. A structured interview protocol, informed by the scoping review results, will guide discussions to ensure consistency in data collection. Participants will be identified through snowball sampling until data saturation is reached. These interviews aim to validate our scoping review findings, uncover additional insights and gather input on potential solutions. We will use ATLAS.ti to conduct an inductive thematic analysis, enabling the identification of key themes from participants’ responses. The findings from these consultations will be compared and integrated with the scoping review results to enhance the relevance and applicability of our recommendations.
Discussion
Recruiting and retaining family physicians in rural and remote settings across Canada remains challenging.3 Yet, rural research activity is limited and largely underfunded, receiving less than 1% of the total funding allocated by the Canadian Institutes of Health Research.6 Although scarce, some studies have explored the recruitment and retention of Canadian FPAs. Buhiire et al12 conducted a cross-sectional survey to explore factors influencing retention of Canadian FPAs and reported factors such as moving to a new community, personal or family reasons, retirement and burdensome/overwhelming job environment. At the international level, some anaesthesiologists have reported a low salary, lack of equipment/medication for safe anaesthesia, isolation and demoralisation as factors affecting job satisfaction and retention.12 Additionally, anaesthesiologists working in pain medicine reported reasons for quitting the field such as feeling pressure to perform unnecessary procedures, dealing with insurance issues, feeling pressure to prescribe opioids, feeling overwhelmed and lack of social service support. Our scoping review represents an opportunity to contrast the aforementioned observations with those reported by Canadian FPAs.30
Though not focused on anaesthesia, Asghari et al conducted a systematic review of reviews that explored factors influencing the recruitment and retention of rural family physicians.31 They identified 14 systematic reviews reporting 158 specific factors that were then summarised into 11 categories. The most important factors included longitudinal rural training or rotations in residency or clerkship, rural background, being raised or attending high school in a small town and preferential admission as factors facilitating the retention of family physicians in rural and remote settings. Ours will be the first knowledge synthesis study related to the recruitment and retention of rural family physicians with a specific focus on FPAs.
In terms of potential solutions, some have suggested ideas to address the lack of anaesthesia providers in rural Canada. For example, Orser and Wilson5 suggested five key points inspired by the Rural Road Map for Action, developed by the College of Family Physicians of Canada and the Society of Rural Physicians of Canada.32 It features: (1) social accountability: medical training should address the needs of local communities including rural and Indigenous; (2) policy interventions: including optimal physician remuneration, coaching and mentorship, return of service and licensing; (3) rural and remote practice models: supportive medical environment and social support from communities; (4) national research agenda: increased research funding to better understand the unique needs of rural workforce and (5) mentorship and continuing professional education: which facilitates refreshing skills and long-term peer support. Although valuable, a rigorous research methodology was not used to define these action areas. Our scoping review will contrast and discuss the pillars proposed by Orser and Wilson, with a final goal of informing initiatives to optimise anaesthesia care recruitment and retention in rural settings.
Our scoping review will benefit both the FPAs and the communities they serve. For example, understanding the facilitators and barriers to recruitment and retention of FPAs can lead to targeted interventions to improve rural healthcare access. The Clinical Coaching for Excellence in British Columbia33 was developed to address the lack of continuing professional development in FPA. Similarly, a mandatory continuing professional development activity was developed to refresh the skills of Australian FPAs.34
Some have called for innovation to strengthen and retain anaesthesia care teams that work in rural and remote regions.6 Our scoping review could potentially inform future innovations to enhance the recruitment and retention of FPAs in rural and remote settings. Additionally, our results will highlight research gaps that need to be addressed to better understand the facilitators and barriers to the recruitment and retention of FPAs in Canada. For example, our review could expand on the role of the relationship between FPAs and specialists in influencing the recruitment and retention of FPAs.
This scoping review is subject to certain limitations. The paucity of published research reporting on FPA activity may limit the conclusions that can be drawn from our investigation. Moreover, the findings from our study will be inherently restricted to Canada due to the geographical limitation of our inclusion criteria. Hence, the impact of this study will remain limited in scope. Nonetheless, we expect this study to reveal important results that could spark future investigations and inform clinical guidelines. Finally, we will not assess the quality of the studies included in our review as this is not a typical objective of scoping reviews.17
FPAs play an important role in increasing access to healthcare in rural, remote and Indigenous communities in Canada. Unfortunately, FPAs face unique challenges affecting their recruitment and retention in these communities. No knowledge synthesis study has summarised the evidence on barriers and facilitators to FPAs recruitment and retention. Our study will address this knowledge gap, thus generating evidence that can inform initiatives which enhance recruitment and retention of FPAs in rural, remote, and Indigenous communities of Canada.
Acknowledgments
Kevin Chi contributed to the construction of the research team. Cassandra Laurie proofread the manuscript, and Librarian Jo-Anne Petropoulos assisted in the development of the database search. The McMaster Department of Family Medicine supported the publication of this article.
References
Footnotes
X @juanppimentel
Contributors JP conceived of the idea and developed the first version of the manuscript. JP is the guarantor. MA, NC and PG-R aided in developing the research question and study methods and contributed meaningfully to the drafting and editing. All authors approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.