{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T12:55:32Z","timestamp":1781873732740,"version":"3.54.5"},"update-to":[{"DOI":"10.12688\/f1000research.174754.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T00:00:00Z","timestamp":1781827200000}}],"reference-count":65,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T00:00:00Z","timestamp":1781827200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns5:p>\n                    Background The global shortage of primary care physicians (PCPs) poses a critical threat to healthcare accessibility and system performance in high-income countries. Previous reviews have documented a wide range of recruitment and retention (R&amp;R) strategies, but the evidence base remains fragmented, outdated, and geographically uneven. In light of demographic transitions, the increasing burden of multimorbidity, and evolving models of care accelerated by the COVID-19 pandemic, an updated synthesis is needed to guide sustainable and context-sensitive workforce policies. Methods This systematic review will follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines and is registered with PROSPERO (International Prospective Register of Systematic Reviews) (CRD420251008508). MEDLINE (via PubMed), Embase, and CENTRAL (Cochrane Central Register of Controlled Trials), will be searched for quantitative studies published from February 2015 onward, without language restrictions. Eligible studies will evaluate interventions designed to improve the recruitment and\/or retention of PCPs, medical students, or residents in high-income countries. Primary outcomes will include the number of physicians recruited or retained and the duration of retention. Secondary outcomes will cover career intentions, cost-effectiveness, physician satisfaction and well-being, and workforce stability. Two reviewers will independently conduct study selection, data extraction, and risk of bias assessment using validated NIH (National Institutes of Health) quality assessment tools. Findings will be synthesized narratively, with thematic grouping by intervention type, career stage, and contextual factors (e.g., rurality, health system model). Discussion This review will provide an updated and comprehensive assessment of R&amp;R strategies for PCPs in high-income countries. By examining intervention logic, outcomes, and contextual modifiers, it will identify which approaches are most effective under specific conditions. The results aim to inform policymakers, educators, and workforce planners in designing targeted, scalable, and context-sensitive strategies to strengthen primary care workforce resilience.\n                    <ns5:bold>Systematic Review Registration<\/ns5:bold>\n                    : PROSPERO registration number: CRD420251008508.\n                  <\/ns5:p>","DOI":"10.12688\/f1000research.174754.2","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T12:14:06Z","timestamp":1781871246000},"page":"194","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Physicians shortage in primary care: a protocol for updating a systematic review of recruitment and retention strategies"],"prefix":"10.12688","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-5670-3753","authenticated-orcid":false,"given":"Federico","family":"Contu","sequence":"first","affiliation":[{"name":"Department of Medicine Sciences and Public Health Cagliari Sardinia University of Cagliari"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giulia","family":"Cossu","sequence":"additional","affiliation":[{"name":"Department of Medicine Sciences and Public Health Cagliari Sardinia University of Cagliari"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barbara","family":"Bitti","sequence":"additional","affiliation":[{"name":"Cagliari Italy Independent researcher"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diego","family":"Primavera","sequence":"additional","affiliation":[{"name":"Department of Medicine Sciences and Public Health Cagliari Sardinia University of Cagliari"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Puja","family":"Verma","sequence":"additional","affiliation":[{"name":"London Marylebone Health Centre"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Viviana","family":"Forte","sequence":"additional","affiliation":[{"name":"Department of Medicine Sciences and Public Health Cagliari Sardinia University of Cagliari"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Ford","sequence":"additional","affiliation":[{"name":"Wolfson Institute of Population Health London England Queen Mary University of London"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mauro Giovanni","family":"Carta","sequence":"additional","affiliation":[{"name":"Department of Medicine Sciences and Public Health Cagliari Sardinia University of Cagliari"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2560","published-online":{"date-parts":[[2026,6,19]]},"reference":[{"key":"ref2","article-title":"Addressing the 18 million health worker shortfall \u2013 35 concrete actions and 6 key messages."},{"key":"ref3","doi-asserted-by":"publisher","first-page":"e629","DOI":"10.1016\/S2214-109X(23)00172-9","article-title":"Health-care workers must be trained and retained.","volume":"11","year":"2023","journal-title":"Lancet Glob. 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We have considered each of your suggestions and respond point by point below.  \n<b>Meta-analysis feasibility and heterogeneity thresholds.<\/b>  We agree with this point and have addressed it. We have expanded the Data synthesis section to specify the decision rules for quantitative synthesis: meta-analysis will be considered only where at least two studies report comparable outcomes with effect estimates that can be appropriately pooled, using a random-effects model. We have also clarified that statistical heterogeneity will be assessed using the I&sup2; statistic, interpreted alongside clinical and methodological judgement on comparability, and that where heterogeneity is substantial or pooling is otherwise inappropriate, findings will be synthesized narratively.  \n<b>Operational definitions of &quot;recruitment&quot; and &quot;retention&quot;.<\/b>  We would respectfully note that one of the primary objectives of this review (Objective 2) is precisely to map and compare the definitions and measures of &quot;recruitment&quot; and &quot;retention&quot; used across studies and contexts, and to identify the points of divergence that affect comparability. Pre-specifying operational definitions at the screening stage would risk constraining the very heterogeneity of definitions that the review seeks to capture, potentially excluding relevant studies that conceptualize these outcomes differently. For this reason, we have retained our planned approach of mapping definitions across the included studies. We recognize the value of standardization, and we will draw on the resulting mapping to propose operational definitions and a categorization framework as part of the final systematic review.  \n<b>Conceptual framework, structured GRADE assessment, data extraction form, handling of missing data, and reviewer calibration.<\/b>  As these refinements pertain primarily to the synthesis and reporting of results rather than to the scientific validity of the protocol itself, we will incorporate them at the appropriate stage of the final systematic review \u2014 including a conceptual model linking intervention types, mechanisms, and outcomes; a more structured, GRADE-informed narrative appraisal of certainty per outcome; and fuller documentation of the data extraction form, the handling of missing or unclear data, and the inter-reviewer calibration exercise. We will keep these points in mind throughout the conduct of the review.   We thank you again for your feedback, which has strengthened the protocol.","URL":"https:\/\/f1000research.com\/articles\/15-194\/v2#referee-comment-16431","order":1,"name":"referee-comment-16431","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.192678.r486296, Ferdinando Petrazzuoli, Lund University, Malm\u00f6, 26 May 2026, version 1, indexed","URL":"https:\/\/f1000research.com\/articles\/15-194\/v1#referee-response-486296","order":2,"name":"referee-response-486296","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Federico Contu<\/b>; \n<i>Posted: 15 Jun 2026<\/i>; \n<b>Dear Dr Petrazzuoli,<\/b>  Thank you for your careful and constructive appraisal of the protocol, and for your positive overall assessment. We have considered each of your recommendations, and respond point by point below.  \n<b>Criteria for meta-analysis feasibility.<\/b> We agree and have addressed this point. We have expanded the Data synthesis section to specify that meta-analysis will be undertaken only where at least two studies report comparable outcomes amenable to pooling, using a random-effects model. We have further clarified how heterogeneity, assessed via the I&sup2; statistic and interpreted together with judgements on the clinical and methodological comparability of studies, will inform the decision between quantitative pooling and narrative synthesis.  \n<b>Documentation of protocol amendments.<\/b> We have adopted this recommendation. We have aligned the Amendments section of the protocol with your suggested wording, clarifying that any important amendments \u2014 including changes to eligibility criteria, outcomes, search strategy, or synthesis methods \u2014 will be documented transparently in the PROSPERO record and reported in the final review, with the date and rationale for each change.  \n<b>Operational definitions of &quot;recruitment&quot; and &quot;retention&quot;.<\/b> As one of the primary objectives of the review (Objective 2) is to map and compare the definitions and measures of &quot;recruitment&quot; and &quot;retention&quot; across studies and contexts, pre-specifying operational definitions at the screening stage would risk constraining the diversity of definitions the review aims to capture, and could lead to the exclusion of relevant studies adopting alternative conceptualisations. We have therefore retained our planned mapping approach, and we will build on its findings to propose operational definitions and a categorisation framework within the final systematic review.  \n<b>Conceptual framework, structured certainty-of-evidence assessment, and prioritisation of findings.<\/b> As these refinements relate to the synthesis and interpretation of results rather than to the scientific soundness of the protocol, we will incorporate them at the appropriate stage of the final systematic review \u2014 including a conceptual model linking intervention categories, mechanisms of action, and workforce outcomes; a more structured, GRADE-informed narrative assessment of certainty for each primary outcome; and pre-specified criteria for prioritising findings (for example, greater interpretive weight to primary outcomes, physician-level recruitment and retention outcomes, and higher-quality comparative studies) should the evidence base prove broad or heterogeneous. We will keep these points in mind throughout the conduct of the review.  We thank you again for your comments, which have strengthened the protocol.","URL":"https:\/\/f1000research.com\/articles\/15-194\/v2#referee-comment-16432","order":3,"name":"referee-comment-16432","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The author(s) declared that no grants were involved in supporting this work","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}