An approach to training and retaining primary care physicians in rural Appalachia

Consolidation of the perinatal care system and workload of obstetricians: an ecological study in Japan

Objectives

We examined the relationship between consolidation of delivery and the workload of obstetricians working at perinatal centers.

Methods

We conducted a descriptive analysis using perinatal care areas classified into three types (metropolitan, provincial, and rural). We calculated the Herfindahl-Hirschman Index (HHI) as an index of consolidation and the proportion of the deliveries at clinics as an indicator of the low-risk deliveries and the deliveries per center obstetrician as an indicator of obstetricians' workload. We used >150 deliveries yearly as an excess indicator. The correlation between the HHI and obstetricians' workload and the proportion of deliveries at clinics was examined using the Pearson correlation coefficient.

Results

The proportion of areas with  >150 deliveries yearly was higher in the consolidated areas. In provincial areas, obstetricians' workload was positively correlated with the HHI and was negatively correlated with the proportion of deliveries at clinics.

Conclusions

The obstetricians' workload may be increasing where more consolidation occurs. In provincial areas, the center obstetrician's workload could be reduced not only by consolidation but also by sharing the role of handling low-risk deliveries with clinics and hospitals with obstetric units other than perinatal centers.

Preventive medicine as a first- or second-choice course: a cross-sectional survey into students' motivational differences and implications for information provision

Background

Challenges in recruiting and retaining medical staff in preventive medical specialties have recently been the subject of numerous studies. To improve selection procedures, it is important to understand the career preferences and incentives of students in preventive medicine (PM), who initially marked the program as either their first choice or second choice. 1386 PM students in four Vietnamese medical schools participated in a survey using a structured, written questionnaire. Students were asked about their reasons for entering medical school and studying PM, their perceptions of PM during the academic course, and their expected career path following graduation.

Results

First-choice PM students (group 1) more often had siblings working as a preventive doctor, while second-choice PM students’ siblings (group 2) were more often medical students or clinical doctors. Group 1 had gathered more information about PM by consulting their high-school teachers and the national career guide. They were mainly drawn to the PM program by the newness of the profession, the prospect of a high-income job, its low entry criteria and low study burden compared to general medicine, their desire to uphold their family tradition, and to fulfill their family’s wish of having a doctor in the family. Group 2 chose to study PM because they wanted to pursue their dream of becoming a doctor. Compared to the first group, their perception of PM more frequently changed during the later years of the curriculum and they more frequently envisioned becoming a clinical doctor following graduation.

Conclusions

Interest in and motivation for PM may be cultivated among prospective or current students by improving information provision, diffusing knowledge, and otherwise acquainting students better with the PM specialty before and during the program.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2706-6) contains supplementary material, which is available to authorized users.

A comprehensive medical education program response to rural primary care needs

This article presents the characteristics and results of the Rural Medical Education (RMED) Program which addresses medical workforce needs focused on reducing rural health disparities. The program is comprehensive in implementing a system of recruitment of candidates from rural backgrounds, offering a rural-focused curriculum, and instituting evaluative components to track outcomes. Distinctive program features include a Recruitment and Retention Committee of rural community members; special rural-focused topics and events during the first three years of undergraduate medical education; and a required fourth-year, 16-week rural preceptorship through which students work with primary care physicians and conduct community-oriented primary care projects. Since 1993, 216 students have matriculated. More than three quarters of candidates interviewed received offers into the program (overall acceptance rate of 75%). Comparisons between RMED and all other students on composite MCAT scores and United States Medical Licensing Examination (USMLE) Part 1 scores show a slightly lower MCAT average for RMED students, but USMLE scores are equal to those of non-RMED students. To date, 159 students have graduated, with 76% entering primary care residencies; 103 are currently in practice, with 64.4% in primary care practice in small towns and/or rural communities. RMED Program outcomes compare favorably with those of other rural medical education programs. RMED can serve as a model at many levels, including recruitment, collaboration, curriculum, and retention. Future challenges for program development and disparity reduction include recruiting students from the growing number of rural minority populations, expanding the number of program slots, and integrating the program with other health professions to address the needs of rural populations.

An evaluation of the Rural Medical Education Program of the State University Of New York Upstate Medical University, 1990-2003

PURPOSE

The Rural Medical Education Program (RMED) of the State University of New York (SUNY) Upstate Medical University is a 36-week clinical experience in rural communities for medical students that began in 1989. The authors sought to assess RMED's success in providing a valuable educational experience for students that assists rural communities recruit physicians.

METHOD

In 2004, the authors used the Physician Masterfiles of the American Medical Association to compare practice locations of SUNY Upstate graduates who completed RMED with those who did not; surveyed former RMED students to assess their satisfaction with their practice location and the importance of RMED in helping them choose a location; interviewed hospital administrators in communities that have hosted RMED students to understand the impact of RMED on host communities; and compared United States Medical Licensing Examination Step 2 scores of RMED students with those of non-RMED students to evaluate educational attainment.

RESULTS

A greater percentage of former RMED students practiced in rural locations [22/86 (26%)] than did non-RMED students [95/1,307 (7%)]. Ninety-one percent (69/76) of former RMED students were satisfied with their location, and 84% (64/76) believed that RMED was important in helping them choose a location. Hospital administrators viewed the program highly because it helped them recruit physicians and benefitted their medical staff. RMED students had higher adjusted mean Step 2 scores than did non-RMED students (212.3 versus 199.1).

CONCLUSION

The RMED program has successfully met its goals of providing a valuable educational experience for medical students and assisting rural communities recruit physicians.

Physicians for Rural America: The Role of Institutional Commitment Within Academic Medical Centers

CONTEXT

Prior study suggests that contextual characteristics of medical schools (e.g., state demographics, public vs private, NIH research effort) predict output of rural physicians without also considering the effects of the medical schools' own policies and programs.

PURPOSE

This study examines medical school commitment to rural policies and programs and its relationship to contextual characteristics and rural physician output.

METHODS

A survey of 122 U.S. allopathic medical schools provided data to construct a 32-item Rural Commitment Index for each medical school. Data for other characteristics were linked from published sources. Correlations, t tests, and multiple regression analysis were used to study the association between variables and percentage of medical school graduates (1988-1996) who were in rural primary care practice in 2000.

FINDINGS

Among 90 medical schools (response rate, 73.8%), the Rural Commitment Index correlated with the percentage of the state population that is rural and whether the school is public or private, and it joined percentage state population rural, public vs private, and National Institutes of Health support in correlating with percentage of graduates in rural primary care. In a regression model that explained 48.4% of variation in the percentage of graduates in rural primary care, the Rural Commitment Index explained most variation, followed by percentage state population rural, public vs private, National Institutes of Health support, and the interaction between the Rural Commitment Index and public vs private.

CONCLUSIONS

The findings support the proposition that observable institutional commitment affects rural physician output and provide justification for a definitive study to verify that a change in medical school commitment to rural medicine produces a change in rural physician output.

The role of medical education in the recruitment and retention of rural physicians

In many countries the sustainability of rural healthcare systems is being challenged by a shortage of rural physicians and difficulties in recruiting and retaining physicians in rural practice. There are numerous factors that influence efforts in rural physician recruitment and retention, many of which are beyond the scope of the academic medical centre and medical education. Nevertheless, there are strategies that medical schools can adopt to contribute to efforts to recruit and retain physicians in rural communities. Rural student recruitment, admissions policies, rural-oriented medical curriculum, rural practice learning experiences, faculty values and attitudes, and advanced procedural skills training are areas which the medical school has direct control of and which have been shown to influence the likelihood of medical students entering rural primary care practice. The purpose of this paper is to elaborate on some of the key strategies that have been identified in the literature.

Increasing rural activity and curriculum content in the Adelaide University Medical School

This study aimed to document the level of rural activity and curriculum content in the Adelaide University Medical School. A questionnaire was distributed to all heads of departments within the Medical School and additional information was obtained from reports and discussions with key personnel. There has been an increase in the proportion of students with a rural background enrolled from 9% in 1994 to 22% in 2000. There has also been an increase in the number of weeks available for rural placements from 12 (mostly optional) to 29 weeks (some mandatory), and an increase in the number of departments offering rural placements. There has also been improved academic support to rural practitioners and many departments directly provide services in rural communities. A new combined University Department of Rural Health (UDRH)/Rural Clinical School associated with the Adelaide University Medical School aims to provide at least half of all clinical training to 25% of all medical students of Australian origin.

Medical residencies and increased admissions in rural hospitals with fewer than 200 beds

Medical education programs in general, and rural residency programs in particular, can be beneficial for rural hospitals. This study of 1,792 non-metropolitan statistical area, acute general hospitals with fewer than 200 beds from 1993 to 1996 was designed to help rural hospitals and communities to quantify the likely effects of rural residency programs on hospital admissions. Data came from the hospital Prospective Payment System minimum data set. The results show that additional residents at rural hospitals with fewer than 200 beds generally result in an increase of approximately 100 to 200 admissions per resident--more for smaller hospitals and fewer for larger hospitals. Because increased admissions generally improve the financial health and continued operation of rural hospitals, this study confirms the importance of education-based strategies in ensuring access to care in rural communities.

Graduate medical education for rural physicians: curriculum and retention

The chronic shortage of rural physicians prompts further consideration of the educational interventions that have been developed to address this issue. Despite rural admission strategies and a variety of undergraduate, graduate and postgraduate curricular innovations, the recruitment and retention of family physicians into many rural areas has not kept pace with the retirement of older general practice physicians. This paper reviews the 1994 American Academy of Family Physicians' rural training recommendations in the light of several recent educational needs assessments. These studies affirm the need for rural residency rotations and the need to maintain and better implement the established rural clinical training guidelines. However, although preparation for rural medical practice has been addressed and is being adequately accomplished in the clinical knowledge and procedural skills areas, instruction and experiences relating to the "realities of rural living" need to be enhanced to increase the retention duration of rural physicians. This can be accomplished with more curricular emphasis on developing community health competencies, including community-oriented primary care (COPC). Physicians who know how to collaborate with community members on health improvement projects have skills that can also facilitate integration and, hence, retention.

Influence of a rural primary care clerkship on medical students' intentions to practice in a rural community

The purpose of this study is to examine the relationship of a rural clerkship to medical students' interest in establishing careers in rural communities. The Association of American Medical Colleges Medical School Graduation Questionnaire (GQ) for years 1988 through 1997 was examined to compare the career plans of students graduating from Morehouse School of Medicine (MSM) with those of all students graduating from United States medical schools before the period 1988 through 1992 and after the period 1993 through 1997, after the inception of the rural clerkship at MSM. Select GQ data items examined include student demographics, medical school experiences, and career plans. Statistical analyses were used to compare pre- and post-clerkship responses for MSM students and to compare their responses with the national trends. Results indicate that, following a transition period, MSM students showed an increased preference for a future career in a rural community. A smaller upward trend in the national data was observed. There appears to be an association between the rural clerkship experience at MSM and the stated preferred career choices of the students.

Educating generalist physicians for rural practice: how are we doing?

Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to "small rural" communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.

Interdisciplinary student health teams: combining medical education and service in a rural community-based experience

Several initiatives have been introduced over the years to address the maldistribution of health care professionals and to improve access to care for underserved rural populations. One of these is the sponsorship of community-based, service-oriented teams comprised of students from various health disciplines. This study investigated extramural training as a complement to traditional hospital-based experiences. The specific objective of the study was to determine the extent to which the nation's medical schools combine training with a rural community-based experience in the form of an interdisciplinary student health team program. In the fall of 1994, a 32-item questionnaire was mailed to the chief academic or clinical affairs administrators of the nation's 126 allopathic medical schools. A total of 104 (82.5%) medical schools responded to the survey. Eighty-six of the respondents (82.7%) reported some type of rural training or public service activity; 22 (21.2%) acknowledged the sponsorship of an interdisciplinary student health team program. Small rural communities, those with populations of 5,000 or fewer, were the focus of 76 percent of the reporting programs. Nearly two-thirds of the reporting programs were located in the South, the region with the nation's lowest physician-to-population ratio. The nursing and medical professions were most frequently represented, although a wide range of disciplines were identified as participating on the student health teams. Activities of the teams included both ambulatory care and community outreach services. The majority of the programs used team-building exercises to enhance team effectiveness. Extramural training programs offer students a realistic examination of the social, cultural, economic, and political forces that influence both individual and community health. Rural community-based programs, such as interdisciplinary student health teams, should be valued because they can strengthen the link between the sponsoring institution's educational mission and its public service obligation.

The push toward generalism: a view from surgery

Recent proposals for health care reform center on restructuring the physician workforce in favor of more "generalists." These plans are based on several assumptions that have been neither clearly argued nor proved. Despite this, each of the plans enunciated thus far dictate that primary care physicians comprise at least 50% of the nation's physician workforce. Such a mandate has enormous repercussions for medical education. This paper takes issue with several assumptions underlying these reform initiatives, particularly the assumption that primary care does not include surgery. Because of the primary nature of surgical care, the prevalence of surgical diseases, the projected shortage of physicians entering general surgery, and the fact that surgical care is most effectively and efficiently provided by general surgeons, general surgery should not be handicapped as it would under present reform proposals. We recommend that the assumptions underlying plans to restructure the nation's physician workforce be tested, and that any reform enacted be based on rational criteria linked to the projected prevalence of disease in the nation as well as a determination of which practitioners care for those diseases most effectively and efficiently. We further recommend that medical students' time in surgical activities be increased rather than decreased, that general surgeons increase their activity in medical school curricular development and teaching, and that surgeons become involved more actively in the graduate training of primary care physicians.

Training generalist physicians: structural elements of the curriculum

To train more generalist physicians, structural changes must be made along the continuum of medical education. Future generalists require in-depth exposure to primary care practice, with substantive experience in the longitudinal management of patient panels and the opportunity to work with successful generalist role models. Clinical training and course work must incorporate a wide range of skills and disciplines, including areas now under-emphasized, such as epidemiology, health services, and psychosocial medicine. Recommendations for structural changes to increase the generalist focus of medical education include: 1) the development within institutions of central authorities, involving departments of internal medicine, family medicine, and pediatrics, in joint efforts to foster all aspects of generalist training, including recruitment, curriculum development, community linkages, innovative approaches to training, and recognition and support for successful generalist teachers; 2) commitment of a minimum of 50% of clinical training to ambulatory care settings at both medical school and residency levels; 3) required longitudinal care experiences for all medical students and a 20% or greater time commitment to longitudinal care for internal medicine, pediatrics, and family medicine residents; and 4) increased numbers of generalist faculty and enhanced teaching skills among faculty in the outpatient environment, to guarantee increased exposure of medical students and residents to generalist role models.