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Letters to the Editor

“Recruiting for Setting?”: Proceed With Caution

Fyfe, Molly Virginia PhD; Douglass, Christine PhD

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doi: 10.1097/ACM.0000000000003106
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To the Editor:

Raffoul and colleagues propose “recruiting for setting” or “recruiting students from the communities where they will return to work”1 as a selection strategy to address workforce shortages in underserved settings. In our view, recruitment for setting has the potential to exacerbate inequities, and we must proceed with caution in introducing this approach to selection.

A goal of medical education should be to diversify health systems, promote social mobility, ensure equitable access to educational opportunities, and produce a workforce motivated to respond to the priority health and social needs of the population. To this end, we must absolutely recruit from underserved settings. However, in recruiting for setting, we must consider the consequences of an expectation, either implicit or explicit, that students from underserved backgrounds should return to these settings. Underserved and rural careers are rated as less satisfying,2 may offer less professional support and fewer opportunities for professional development, and can be less desirable for family life.3 Prioritizing sending some students back into underserved communities may therefore place an unequal burden upon these students, and at its most extreme, could result in tiered, stratified systems of medical education.

Students from underserved backgrounds do express a greater intention of working with underserved communities in the future.4 However, factors shaping their intentions—and whether intention reflects expectation—remain unknown. We must therefore proceed with caution to ensure that in recruiting for setting we do not achieve progress in addressing workforce shortages while exacerbating inequity. To achieve a truly diverse and equitable workforce selection, all students should have the same possibilities for social mobility, the same opportunities for career satisfaction, and the same expectation of service.

Molly Virginia Fyfe, PhD
Senior teaching fellow, Medical Education Research and Innovation Centre, Department of Primary Care and Public Health, Imperial College London, London, United Kingdom;
Christine Douglass, PhD
Senior teaching fellow, Department of Primary Care and Public Health, Imperial College London, London, United Kingdom.


1. Raffoul M, Bartlett-Esquilant G, Phillips RL Jr.. Recruiting and training a health professions workforce to meet the needs of tomorrow’s health care system. Acad Med. 2019;94:651–655.
2. Vick B. Analyzing rural versus urban differences in career dissatisfaction and plans to leave among Pennsylvanian physicians. J Rural Health. 2016;32:164–175.
3. Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention. BMC Health Serv Res. 2008;8:19.
4. Larkins S, Michielsen K, Iputo J, et al. Impact of selection strategies on representation of underserved populations and intention to practise: International findings. Med Educ. 2015;49:60–72.
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