TITLE: Physician Re-Entry: Scoping Review Protocol
AUTHORS: Arshan Goudarzi, Charles S. Dorris MLIS, Anjali Gupta MD

[DESCRIPTION]
Objective: The objective of this scoping review is to assess the extent of literature on re-entry to understand how re-entry is defined, the main reasons for career breaks and re-entry, challenges and barriers to re-entry, as well as solutions developed to assist re-entry for physicians. 
Introduction: Physicians are taking breaks for a variety of reasons. 40% of women physicians reduce to part-time or exit medicine within six years of residency training. Additionally, nearly half of all inactive physicians are primary care physicians. Understanding both barriers and interventions to support re-entry for physicians is essential in the context of upcoming physician shortages.
Inclusion criteria: Physicians who have taken a break or leave from their career and then re-entered the workforce will be included. This does not include medical students. Physician re-entry models, interventions including accessibility and utilization across differing reasons for breaks/leaves, outcomes will be examined. Re-entry for physicians around the world will be studied without limitations on country or setting. Race, ethnicity, and gender of physicians will be extracted from studies. 
Methods: Following PRISMA and JBI reporting guidelines, we plan to search MEDLINE, Embase, Web of Science, and relevant medical associations for English language, peer-reviewed studies. We will include all year-ranges that are indexed within each database. Eligibility screening (title/abstract and full-text) and data extraction will be completed by at least two independent reviewers and conflicts will be resolved as a team. Bibliographic information and key study characteristics from included studies will be collected using a tool that will be developed through an iterative process.

[STEPS]
SECTION: Introduction
1. Physicians are taking breaks for a variety of reasons. 40% of women physicians reduce hours or exit within six years of residency training (Frank et al., 2019). Additionally, nearly half of all inactive physicians are primary care physicians (Jewett et al., 2011). Reasons for taking time off, the amount of time physicians remain out of practice, and reasons for re-entering practice can be variable. The motivation for leaving medicine may inform how to attract physicians to return as well as rates of re-entry; therefore, it is critical to understand this process. Analyzing the demographics of physicians taking breaks may be helpful in supporting the needs of physicians both for retention as well as for re-entry. Flexible hours and part-time schedules may be ways to support physicians with re-entry. 
With an expected physician shortage in the coming decade, especially in primary care, the need for accessible pathways to re-enter the profession is growing larger (Petterson et al., 2012). It is imperative to better understand why physicians leave, the barriers that make re-entering difficult, the options available to help ease the transition back into practice, and what support is necessary to facilitate re-entry.

When physicians decide to re-enter the field, the pathways to do so are often unclear. Re-entry training requirements differ state to state, and programs that support the re-entry process are not always available or accessible. State and national policies by licensing boards can vary depending on location of practice, specialty, and time away from medicine. Exploring the impact on confidence and skills with career breaks could assist in creating better paths to re-entry. 

A systematic review in BMJ Open looked at the personal, social and organizational needs for physicians when returning to clinical work (Attoe et al., 2022). Building upon this research, there may be other areas beyond clinical work that physicians return to upon re-entry into medicine. Analyzing reintegration programs for physicians returning back into the workforce is essential to understanding both the support and unmet needs for re-entry into the healthcare workforce.

This scoping review aims to map the research on re-entry and identify gaps in the research. The objective of this scoping review is to assess the extent of literature to further understand how re-entry is defined, the main reasons for career breaks and re-entry, challenges and barriers to re-entry, as well as solutions developed to ease re-entry for physicians. Better understanding of re-entry is critical in the context of upcoming physician shortages.
SECTION: Methods
4. This scoping review will be reported according to the JBI Methodology for Scoping Reviews (Peters et al., 2020) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018) and follows the framework outlined by Arksey and O'Malley (Arksey et al., 2005) and further refined by Levac and colleagues (Levac et al., 2010).
Search strategy
The search strategy will consist of a combination of keywords and database-specific subject headings. Keywords will be limited to the title, abstract, and author-supplied keywords field and we will adapt subject headings to each database that utilizes them. See the appendix for the initial MEDLINE search strategy. During the screening process, we will also scan reference lists of included articles to help identify additional articles.
Studies published in the English language will be included. There will be no date restrictions in the search strategy and we will be including studies from all years that are covered within each database. We will not be using date restrictions to examine studies published.
The databases to be searched include MEDLINE (Ovid), Embase (Ovid), and Web of Science Core Collection. Sources of unpublished studies / grey literature to be searched include professional medical societies and organizations. 
Study/Source of Evidence selection
All identified citations from the systematic searches will be imported into EndNote 20 (Clarivate Analytics, PA, USA) and the duplicates will be removed. Citations will be uploaded to Rayyan (Ouzzani, 2016) for screening. Following a pilot test, titles and abstracts will then be screened by two independent and blinded reviewers for assessment against the eligibility criteria for the review. All included citations' full text will then be screened by two independent and blinded reviewers to assess for eligibility. Reasons for exclusion of sources of evidence at full text that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with an additional reviewer. The results of the searches and the study inclusion process will be reported in full in the final manuscript and presented in a PRISMA-ScR flow diagram (Tricco et al., 2018).
Data Extraction
Data will be extracted from papers included in the scoping review by two or more independent reviewers using a data extraction tool developed by the reviewers. The data extracted will include information about the article, study, definition of re-entry, participants, leave, challenges/barriers, interventions, and key findings.
Reviewers will use the draft extraction form for initial articles and then revise the form as needed during the process of extracting data from each included evidence source. Modifications will be detailed in the scoping review. Any disagreements that arise between the reviewers will be resolved through discussion or with an additional reviewer. If appropriate, authors of papers will be contacted to request missing or additional data, when required.
Data Analysis and Presentation
The data will be presented in diagrammatic and/or tabular form; a narrative summary will accompany the tabulated results. 
SECTION: Review Question
2. What are the main reasons physicians take career breaks, the challenges and barriers to re-entry after career breaks, and the solutions developed to assist transitioning physicians who re-enter the workforce?
SECTION: Eligibility Criteria
3. Participants
Physicians who have taken a break or leave from their career and then re-entered the workforce will be included. This does not include medical students.
Concept
Physician re-entry models, interventions including accessibility and utilization across fields for breaks/leaves, outcomes
Context
Re-entry for physicians around the world will be studied without limitations on country or setting. Race, ethnicity, and gender of physicians will be extracted from studies. 
Types of Sources
This scoping review will consider both qualitative and quantitative studies as long as the study has gone through a peer-review process. We will be excluding opinion pieces, editorials, and conference abstracts from the search strategy. 

Secondary research will not be excluded from the search so that we can harvest the primary research citations found within the reviews. 
SECTION: Acknowledgements
5. None
SECTION: Funding
6. No source of funding for this review.
SECTION: Conflict of Interest
7. No actual or potential conflicts of interest to declare.
SECTION: Appendix
8. Ovid MEDLINE Search Strategy
1. ((exp Physicians/ OR Education, Professional, Retraining/ OR  "Internship and Residency"/ OR Education, Medical, Graduate/) AND (("re-entry" OR "re-enter*" OR reentry or reenter* OR "return* to work" OR "return* to practic*" OR "back to work" OR "back to practic*" OR reintegrat* OR "family leave" OR "parental leave" OR "maternity leave" OR "paternity leave" OR "adoption leave" OR "leave of absence*" OR "transition back" OR "extended pause*" OR career break*).ti,ab,kf. OR (Return to Work/ OR Family Leave/ OR Parental Leave/)))
2. ((re-entry OR re-enter* OR reentry OR reenter* OR "return* to work" OR "return* to practic*" OR "back to work" OR "back to practic*" OR reintegrat* OR family leave OR leave of absence OR transition back OR extended pause* OR career break*) ADJ2 (clinical practice OR medical practice OR physician* OR doctor* OR trainee* OR resident* OR residenc* OR registrar* OR attending OR consultant*)).ti,ab,kf.
3. (((break OR breaks OR pause*) ADJ2 (career* OR train* OR work OR practic*)) AND (clinical OR medical OR physician* OR doctor* OR trainee* OR resident* OR residenc* OR registrar* OR attending OR consultant*)).ti,ab,kf.
Combo: 1 OR 2 OR 3
Limits: AND NOT (Address OR Comment OR Editorial).pt.