Geographic Benefit from Decentralized Medical Education: Student and Preceptor Practice Patterns

The performance of area health education center (AHEC)-stimulated programs and decentralized education for medicine is not well understood. The Statewide Education Activities for Rural Colorado's Health (SEARCH)/AHEC project at the University of Colorado School of Medicine was examined to determine if the program had an effect on the practice location of its graduates. Practice location and specialty of graduates of the University of Colorado School of Medicine (UCSOM) classes 1980-1985 were compared for students who had participated in decentralized SEARCH/AHEC experiences versus students who had not. The majority of the graduates were practicing out of state in 1990. Non-Colorado doctors were more often practicing in rural (non-metropolitan statistical area [MSA]) counties and in towns of fewer than 2,500, 5,000 and 10,000 residents, respectively. In addition, of the 251 active patient care physicians practicing in Colorado communities of fewer than 10,000 in non-MSA counties in 1986, those who precepted UCSOM students on SEARCH rotations were more likely to have remained in their same practice location in 1992 (77.8% versus 62.1% for those who had not precepted students). This analysis of both student and preceptor practice patterns documents the value of decentralized medical education in addressing the geographic and specialty maldistribution of physicians. These results have important policy implications for funding medical education programs.     

A Comparison of Metropolitan and Rural Medical Schools in China: Which Schools Provide Rural Physicians?

ABSTRACT: To compare the role of metropolitan and rural medical schools in the provision of rural physicians, a survey was conducted in 12 metropolitan and 10 rural medical schools. Rural medical schools enrolled fewer students (P = 0.019), and produced fewer graduates (P = 0.023) than metropolitan medical schools. Students in rural medical schools were mainly from surrounding regional cities and counties, whereas those in metropolitan schools were from cities nationwide (P < 0.001). All rural medical schools produced rural physicians; one rural school reported that of its 256 graduates, 88 (34.4%) entered rural practice. Ten of the 12 metropolitan medical schools did not produce any rural physicians, whereas the remaining two metropolitan schools registered a total of 73 graduates who selected a rural practice location. These results indicate that rural medical schools may play a key role in overcoming the shortage of physicians in rural communities in China.     

Use of resident physicians: an evaluation of the effects of a significant increase

Medical school graduates have become increasingly dependent on former community hospitals for residency programs because charitable institutions attached to medical schools are disappearing. It is not known what impact residencies have on hospitals that were community hospitals. We interviewed private practice physicians, residents, nurses, patients, and other groups in a large former community hospital. Overall, the interviews indicated good support for the hospital's new teaching function. Furthermore, the residents were viewed in very favorable terms by all groups. There were two problem areas. One, some residents seem less sensitive to human relations than private practice physicians and other hospital groups. Two, many private practice physicians are concerned over the number of hospital-salaried physicians and the outpatient care offered by residents supervised by hospital-salaried physicians. This research suggested several recommendations that, if followed, would serve to increase the value of the residency in meeting patient needs in the most effective manner.     

Attracting physicians to underserved communities: the role of health networks

As health networks battle for additional market share and encourage additional Medicaid HMO subscribers to use their physicians and hospitals, more health executives are analyzing proposals of how to attract qualified doctors to practice in poor rural or inner-city communities. Supplying more physicians to those areas by increasing the number of medical schools, expanding the National Health Service Corps (NHSC) program, and allowing more international medical graduates (IMGs) to pursue residency training in the United States have been relatively unsuccessful strategies to improve America's geographic maldistribution of medical manpower. This article focuses on several approaches that health networks might use to increase market penetration and at the same time deliver enhanced health services to the underserved. Health networks may provide eminent leadership in the overall design and governance of soundly conceived Medicaid HMOs; strengthen existing or develop additional community health/primary care centers; interface more effectively with local schools to foster Medicaid HMOs for children of low-income families; and reimburse at "premium rates" primary care physicians who practice in underserved communities. The reluctance of physicians to practice in these areas and of middle-income and upper-income taxpayers, and therefore elected officials, to support increased spending or redirection of funds continue to be major barriers for health alliances to demonstrate willingness to invest additional resources in poor inner-city and rural environments.     

Two Decades of Experience in the University of Washington Family Medicine Residency Network: Practice Differences Between Graduates in Rural and Urban Locations

This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27-item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits. The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates' broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory care. Rural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part-time positions, to facilitate recruitment and retention of physicians, especially women.     

Rural Physician Satisfaction: Its Sources and Relationship to Retention

This study uses survey data to identify areas of satisfaction and dissatisfaction for primary care physicians working in rural areas across the country. It also identifies the specific areas of satisfaction associated with longer retention within a given rural practice, as well as the characteristics of individuals, practices, jobs, and communities associated with the areas of satisfaction that predict retention. Study subjects comprised a sample of 1,600 primary care physicians who moved to nonmetropolitan counties nationwide during the years 1987 through 1990, with oversampling of those who moved to federally designated health professional shortage areas (HPSAs). Physicians serving in the National Health Service Corps (NHSC) were excluded. Sixty-nine percent of the eligible subjects returned completed mail questionnaires in 1991. Analyses for this study were limited to the 620 primary care physicians who worked more than 20 hours per week in towns of fewer than 35,000 population; who were neither in the military nor the NHSC; and who were not in urgent care, emergency room, or full-time teaching positions. Analyses revealed that the areas of rural physicians' greatest satisfaction were their relationships with patients, clinical autonomy, the care they provided to medically needy patients, and life in small communities. Physicians were least satisfied with their access to urban amenities and the amount of time they spent away from their practices. Retention was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals. Retention was also marginally related to physicians' satisfaction with their earnings. Among the areas of satisfaction not related to retention were satisfaction with autonomy, access to medical information and consultants, and the quality of doctor-patient relationships. In a subsequent series of analyses of the factors that predict the three areas of satisfaction that were associated with retention (satisfaction with the community, professional goal attainment, and earnings), a variety of physician, work, and community factors were identified. These findings reveal that specific features of rural physicians, their work, and their communities predict each of the various aspects of satisfaction and that only certain aspects of satisfaction predict rural physicians' retention. There are no magic bullets to make rural physicians satisfied in all ways. Nevertheless, there are identified approaches to elevate the specific aspects of rural physicians' satisfaction important to their retention. Programs to improve the satisfaction of rural physicians should focus on those areas of satisfaction that predict longer retention and other important outcomes.     

National Health Service Corp: A survey of Alabama's scholarship recipients

In April 1979, 41 Alabama medical students who had received scholarships from the National Health Service Corps (NHSC) were surveyed. The students were predominantly single urban individuals who received their initial NHSC scholarship in the first or second year of medical school. The majority who planned primary care careers were undecided about remaining in the NHSC after their commitment. The students were concerned about the logistics of the NHSC and practice in rural areas. Based on their response, it is suggested that medical schools, The American Medical Student Association, and the NHSC develop a series of activities designed to facilitate the NHSC scholarship recipients subsequent activities in the NHSC. These suggestions include elective credit for NHSC/AMSA (American Medical Student Association) preceptorships, curriculum offering that facilitate the physician's practice in underserved communities, and activities that facilitate the medical school faculties' understanding of the NHSC.     

Admission factors predicting family medicine specialty choice: a literature review and exploratory study among students in the Rural Medical Scholars Program

Purpose: The Rural Medical Scholars Program (RMSP) was created to increase production of rural family physicians in Alabama. Literature review reveals reasons medical students choose careers in family medicine, and these reasons can be categorized into domains that medical schools can address through admission, curriculum, and structural interventions. We examine whether admission factors can predict family medicine specialty choice among students recruited from rural Alabama. Methods: We developed a questionnaire to study the ability of admission factors to predict family medicine specialty choice among Rural Medical Scholars (RMS). Eighty RMS graduates were surveyed by mail and 64 (80%) responded. Findings: Student characteristics of humanitarian outlook with commitment to rural or underserved populations, family medicine decision or intention made before or at medical school admission, and community influence were positive associations with RMS choosing family medicine residencies; shadowing in an urban hospital was a negative association. Conclusions: Statements of interest, intentions, plans, and decisions regarding family medicine should be elicited at the time of RMSP admission interview. Strong attachment to home community and commitment to serving and living in a rural area are also important. Students whose introduction to medicine was informed through shadowing or observing in urban hospitals should be considered less likely to become family physicians. Larger sample size studies are needed to assess the role of gender, race, marital status, size of rural town, and MCAT score of candidates in affecting residency choices of students selected for this rural medical education track.     

Colorado family practice graduates' preparation for and practice of emergency medicine

BACKGROUND: Family physicians provide care in emergency departments, especially in rural areas; however, no published data describe how they perceive their preparation for emergency practice. We surveyed graduates of Colorado family practice residencies concerning their emergency medicine practice, their comfort working in emergency departments, and their perceived preparation for practicing emergency medicine. METHODS: Seventy recent graduates of Colorado residencies were surveyed regarding their location, work in emergency departments, contact with emergency medical services (EMS) personnel, and perceptions about their emergency medical training. RESULTS: Forty-five percent of respondents practiced in rural settings, 33% worked in emergency departments (56% rural, 14% urban), 60% reported contact with EMS personnel (91% rural, 32% urban), 54% believed their training adequately prepared them for working in emergency departments (82% rural vs 32% urban), 63% of rural and 22% of urban respondents indicated they wanted more major trauma experience during training, 70% reported discomfort with managing trauma, and 44% were interested in a 6-month emergency medicine fellowship. CONCLUSIONS: Most respondents believed their training in emergency medicine was adequate; however, most also reported discomfort with trauma management. Improved training for family physicians who provide emergency care could include expanded trauma care opportunities, increased work with EMS personnel, and postresidency training.     

Medical school type and physician income

We wanted to determine whether the type of medical school attended--private US, public US, or foreign medical school--is associated with practice characteristics or incomes of physicians. Therefore, we used survey responses obtained during the 1990s from 10,436 actively practicing white male physicians who worked in one of 13 medical specialties and who graduated from a public US (5,702), private US (3,797), or international (937) medical school. We used linear regression modeling to determine the association between type of medical school attended and physicians' annual incomes after controlling for specialty, work hours, provider characteristics, and practice characteristics. We found that, for most specialties, international medical school graduates worked longer hours, were less likely to be board certified, had practiced medicine for fewer years, and were less likely to work in rural settings than US medical school graduates. After controlling for key variables, international medical school graduates' annual incomes were 2.6 percent higher (95% CI: 0.1%, 4.4%, p = .043) and public US medical school graduates' were 2.2 percent higher (95% CI: -0.9% -6.1%, p = 0.2) than private US medical school graduates' incomes. Because of their lower tuition expenses, international and public US medical school graduates may experience higher returns on educational investment than their counterparts who graduated from private US medical schools.     

Relationship between US medical school admission policy and graduates entering family practice

Rural areas in the United States continue to lack an adequate supply of primary care doctors, particularly family physicians, despite the oversupply of physicians nationally. Previous studies have provided strong evidence that students from rural backgrounds, as well as those who expressed an interest at the time of medical school admission for a career in family medicine, are significantly more likely to eventually practise family medicine in rural areas than their peers. US medical schools were classified into three groups based on their written selection factors for preferentially admitting students into the graduating class of 1982. Of those schools with selection factors for students from both a rural background and an interest in a future career in family medicine, 23.7% of their graduates entered family medicine training programmes. This compares with 14.5% of graduates from schools with a preference for students from a rural background, and 12.4% from all other schools (P less than 0.001). Coupled with previous data which shows that family physicians from rural areas are more likely to eventually practise in rural areas than their peers, preferentially admitting students from rural backgrounds interested in a career in family medicine could help to solve the problem of the shortage of primary care physicians in rural areas in the US.     

Characteristics of and Issues Faced by Rural Female Family Physicians

The purpose of this study was to identify characteristics of and issues faced by female family physicians practicing in rural areas. A 37-item survey was designed to obtain demographic information about the background, community and practice of rural female physicians. An open-ended question regarding the issues and problems faced by female physicians in rural communities was included. Study subjects were identified from the membership of the American Academy of Family Physicians (AAFP). The questionnaire was mailed to all 850 active female AAFP members practicing in communities with less than 50,000 inhabitants during the winter of 1999. Completed and usable surveys were received from 587 (69.9 percent). The average age of respondents was 45. The majority were married (81.1 percent) and had children (80.1 percent). Half of the women had grown up in communities of 25,000 or less population. Twenty-seven percent of the respondents had no rural exposure in medical school; 39 percent had no rural exposure in residency; and 16 percent had no rural exposure in medical school or residency. The majority of respondents (62 percent) practiced in communities of less than 10,000. A large majority (70 percent) of these women planned to stay in the community for 10 years or more, with 58.6 percent responding that they plan to stay indefinitely. Assumptions regarding rural physicians, especially women, must be updated to accurately assist communities in recruiting rural physicians and to assist medical schools and residencies in adequately preparing graduates for rural practice.     

Entry of US medical school graduates into family medicine residencies: 2010-2011 and 3-year summary

This is the 30th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family medicine residency programs. This retrospective analysis based on data reported to the AAFP from medical schools and family medicine residency programs shows approximately 8.0% of the 17,081 graduates of US medical schools between July 2009 and June 2010 were first-year family medicine residents in 2010, compared to 7.5% in 2009 and 8.2% in 2008. Medical school graduates from publicly funded medical schools were more likely to be first-year family medicine residents in October 2010 than were residents from privately funded schools (9.6% versus 5.4%). The Mountain and West North Central regions reported the highest percentage of medical school graduates who were first-year residents in family medicine programs in October 2010 (14.3% and 11.3%, respectively); the New England and Middle Atlantic regions reported the lowest percentages (5.6% and 5.3%, respectively). Approximately four in 10 of the medical school graduates (40.3%) entering a family medicine residency program as first-year residents entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. This article reports the 3-year average percentage from each medical school of graduates entering family medicine residencies and the number and percentage of graduates from colleges of osteopathic medicine who entered Accreditation Council for Graduate Medical Education-accredited family medicine residency programs in 2010.     

Rural physician assistants: a survey of graduates of MEDEX Northwest.

Graduates of MEDEX Northwest, the physician assistant training program at the University of Washington, were surveyed to describe differences between physician assistants practicing in rural settings and those practicing in urban settings. Differences in demography, satisfaction with practice and community, practice history, and practice content were explored. Of the 341 traceable graduates, 295 (86.5 percent) responded to the mail survey. Although rural- and urban-practicing physician assistants are remarkably similar in most respects--income, hours worked, levels of practice satisfaction, for example--those in rural primary care reported performing a much wider range of medical and administrative tasks than those in urban practice. Half of the physician assistants who grew up in small towns were practicing in rural places compared with 18 percent of those from large towns. The broader scope of practice available to primary care physician assistants in rural areas may be of particular interest to those considering rural careers, to people who train physician assistants, and to rural communities trying to recruit and retain physician assistants. Results also suggest that recruitment of students for rural practice should focus on rural residents. Some problems that rural practitioners are more likely to face than urban ones, such as unreasonable night call schedules and lack of acknowledgement and respect for them as professionals, need to be addressed if rural communities are to be able to attract and retain physician assistants.     

Characteristics of medical students with rural origin: implications for selective admission policies

OBJECTIVES: Selective admission policies of medical schools favoring students of rural origin have been implemented in many countries in hope of increasing rural physicians. This study evaluated the characteristics of medical students from rural origins and their choice of future practice location. METHODS: Personal, familial, and academic information of 1929 graduates of Jichi Medical University (JMU), a Japanese medical school with a special mission to produce rural doctors, was collected on admission and graduation between 1972 and 1997, and follow-up information on workplace addresses were collected in 2000, 2004, and 2006. Jichi Medical University has a unique contract system under which all the graduates have the obligation to work in rural areas in exchange for having their tuition fee during their 6 years of undergraduate medical education waived. RESULTS: Subjects with rural origin were more likely to have parents with lower academic background, improve their academic standing throughout undergraduate medical education, and engage in rural practice than those from urban origins. Positive linear relationships between places of upbringing and workplaces were recognized in various geographic/demographic indicators. CONCLUSIONS: The selective admission policy seems to be a reasonable way of increasing the number of rural physicians without placing an undue burden on medical schools.     

Ophthalmology training in US family practice residencies

Training in office ophthalmology is important in family practice residencies, especially because ophthalmology problems are common in family practice and only one quarter of medical students take structured ophthalmology clerkships in US medical schools. A joint committee of the American Academy of Family Physicians (AAFP) and the American Academy of Ophthalmology (AAO) has developed for family practice residents a core curriculum in ophthalmology listing essential cognitive knowledge and psychomotor skills. A national study on the extent and type of training currently available in US family practice residencies was performed. Based on a response rate of 82 percent, structured ophthalmology training experiences are provided on a required basis by 93 percent of the programs. Of these, 63 percent offer block rotations normally of two or four weeks' duration. Although a majority of the cognitive areas and psychomotor skills recommended by the AAFP-AAO joint committee are likely to be covered in existing family practice residencies, gaps identified in both categories call for closer attention to improving the learning experiences of residents in this field.     

Rural Medical School Applicants: Do Their Academic Credentials and Admission Decisions Differ From Those of Nonrural Applicants?

CONTEXT AND PURPOSE: Medical schools located in states with sizable rural areas are concerned about preparing physicians for practice in these areas; this is of particular concern for medical schools that are part of a state-owned university with a responsibility to educate physicians for rural areas. Because individuals from rural areas are most likely to return to practice medicine in rural areas at the conclusion of their training, it is important to recruit these individuals to medical schools to educate them for rural practice. METHODS: This study examines 7 years of admission data for students who applied and were accepted to the University of Missouri-Columbia School of Medicine, which has as a specific mandate to prepare physicians for rural practice. FINDINGS: The study indicates that rural applicants are more likely to be admitted to the medical school, and based on admissions criteria they are at least as academically qualified as nonrural applicants. CONCLUSIONS: The study demonstrates that a medical school can maintain competitive admission criteria while at the same time accepting those students more likely to enter rural practice. This is valuable information that medical schools with a similar mission to prepare physicians for rural practice might consider in their admissions decision-making process.     

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.