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The challenges facing emergency medicine (EM) services in Canada reflect the limitations of the entire healthcare system. The emergency department (ED) is uniquely situated in the healthcare system such that shortcomings in hospital- and community-based services are often first revealed there. This is especially true in rural settings, where there are additional site-specific barriers to the provision of EM care. Existing studies look at the factors that influence rural EM physicians in isolation. This study uses a qualitative approach and generates a theoretical model that describes the complex interplay between major factors that influence the experience of rural EM physicians.Eight focus groups were conducted with 39 physicians from rural British Columbia, Canada. Semi-structured focus group protocols were designed to leverage the diversity of the focus groups, which included rural generalists, full-time EM practitioners, physicians from very small and remote communities, locums, international medical graduates, physicians new to practice, and physicians who no longer practice rural EM. Following the principles of grounded theory, interview probes were adjusted iteratively to reflect emerging findings. Transcripts were analysed to identify codes and major themes, which served as the basis for the theoretical model.The theoretical model reveals how the causal conditions (a lack of medical and human resources, and the isolation of rural communities due to topography, distance, and inclement weather) contribute to physicians&#39; common experience of feeling fearful and under-supported at work. Two core phenomena emerge as important needs: supportive professional relationships, and healthcare system adaptability. Contextual factors such as remuneration and continuing medical education funding, and the intervening conditions of physicians&#39; rural exposure during formative years, also have an effect. Physicians create innovative solutions to address the challenges that arise in the practice of rural EM. Ultimately, the ability to manage the pressures of rural EM leads physicians to either thrive in or leave rural EM practice.The theoretical model provides a more complex view of the realities of rural EM care than has been previously described. It identifies factors that enable and hinder rural EM physicians in their practice, and provides an understanding of the strategies they employ to navigate challenges. Some elements of the theoretical model have been previously identified. For example, existing work has found that many rural physicians experience fear and anxiety in their practice. The challenges posed by the variation in rural practice environments have also been previously identified as an important influence. Other elements of the theoretical model, and the common need for practitioners to creatively respond to barriers arising from the healthcare system&#39;s inability to respond to local needs, have not been previously identified. This work finds these factors to be a common experience for participants, and as such, more widespread recognition of the importance of these factors could lead to system improvements. Future research is needed to test the hypotheses proposed in this study and explore the generalizability of the findings.

Understanding how emergency medicine physicians survive and thrive in rural practice: a theoretical model