OBJECTIVES: To provide an understanding of the decision-making process that rural physicians and their families undergo when they decide to relocate and to draw implications that might be useful for those facing similar relocation decisions.DESIGN: A qualitative study.METHOD: The narrative responses of 121 rural physicians to a survey questionnaire on practice location were analysed using grounded theory to develop a theory for understanding the retention of rural physicians.RESULTS: The findings were organized around 3 major categories: community commitment, medical confidence and compensation. Throughout these categories a theme emerged ? "tipping the decision-making scales" ? which describes the delicate balance of issues that surround the rural physician's decision on practice location. From this theme, important patterns have emerged to explain what tips the balance that leads rural physicians to (1) make a rational decision to leave, (2) wait for the "last straw," (3) experience the "last straw" scenario and (4) make a decision to stay.