Family practice training over the first 26 years: a cross-sectional survey of graduates of the University of Washington Family Practice Residency Network.

PURPOSE: To describe the current practice setting, scope of practice, and adequacy of residency training of a large cohort of family practice (FP) residency graduates. METHOD: In February 2000, questionnaires containing 120 demographic, practice, and training items were mailed to 1,498 graduates (1973-1999) of the University of Washington Family Practice Residency Network. RESULTS: A total of 983 (71%) graduates completed the survey. Of the 870 who were currently practicing family physicians, 38% were women, 73% worked full-time, 45% practiced in FP groups, and 97% were board certified in FP. A total of 37% practiced in communities of fewer than 25,000 residents, and 29% practiced in federally designated health provider shortage sites. Most cared for their patients in the hospital: 79% for adult medical patients, 54% for adult ICU/CCU patients, and 71% for children. Most provided maternity care: 63% delivered babies and 58% assisted at cesarean sections (12% as primary surgeon). Even in cities of over 100,000, 58% delivered babies. Large numbers of responders performed colposcopy, flexible sigmoidoscopy, vasectomy, and minor surgery. A higher proportion of the most recent graduates provided maternity care and performed colposcopy. Most graduates reported that residency training prepared them well. CONCLUSIONS: FP residency training is modeled to prepare primary care physicians to meet the needs of all patients in all communities. These data document the success of this model in producing and sustaining family physicians to fulfill these roles in practice.     

The contribution of Memorial University's medical school to rural physician supply

INTRODUCTION: This study identifies the characteristics and predictors of Memorial University of Newfoundland (MUN) medical graduates working in rural Canada and rural Newfoundland and Labrador (NL). METHODS: We linked data from class lists, the alumni and postgraduate databases with the Southam Medical database to determine 2004 practice locations for MUN graduates from 1973 to 1998 (26 yr, inclusive). Multiple logistic regression was used to identify predictors for each outcome. RESULTS: In 2004, 167 (12.6%) MUN graduates worked in rural Canada and 81 (6.1%) MUN graduates worked in rural NL. Those who were more likely to practise in rural Canada (when compared with graduates from urban backgrounds, those who had not done any residency training at MUN or specialists, respectively) were graduates from a rural background (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.38-2.76), those who had done residency training at MUN (OR 1.56, 95% CI 1.06-2.29) and family physicians (FPs)-general practitioners (GPs) (OR 6.64, 95% CI 4.31-10.23). Those who were more likely to practise in rural NL (when compared with graduates from urban backgrounds, those who had not done any residency training at MUN, specialists or non-Newfoundlanders, respectively) were graduates from a rural background (OR 2.54, 95% CI 1.57-4.11), those who had done residency training at MUN (OR 4.12, 95% CI 1.94-8.76), FP-GPs (OR 6.39, 95% CI 3.39-12.05) and Newfoundlanders (OR 7.01, 95% CI 2.16-22.71). CONCLUSION: The MUN medical school has made a substantial contribution to rural physician supply in both NL and Canada. Increasing the number of local rural students as well as providing incentives to graduates to complete postgraduate training in family medicine in the province may increase the number of locally trained rural physicians.     

Long-term retention of graduates from a program to increase the supply of rural family physicians.

PURPOSE: To determine the long-term retention of rural family physicians graduating from the Physician Shortage Area Program (PSAP) of Jefferson Medical College. METHOD: Of the 1,937 Jefferson graduates from the classes of 1978-1986, the authors identified those practicing rural family medicine when their practice location was first determined. The number and percent of PSAP and non-PSAP graduates practicing family medicine in the same rural area in 2002 were then identified, and compared to the number of those graduates practicing rural family medicine when they were first located in practice 11-16 years earlier. RESULTS: After 11-16 years, 68% (26/38) of the PSAP graduates were still practicing family medicine in the same rural area, compared with 46% (25/54) of their non-PSAP peers (p = .03). Survival analysis showed that PSAP graduates practice family medicine in the same rural locality longer than non-PSAP graduates (p = .04). CONCLUSIONS: These results are the first to show long-term rural primary care retention that is longer than the median duration. This outcome combined with previously published outcomes show that the PSAP represents the only program that has resulted in multifold increases in both recruitment (eight-fold) and long-term retention (at least 11-16 years). In light of recent national recommendations to increase the total enrollment in medical schools, allocating some of this growth to developing and expanding programs similar to the PSAP would make a substantial and long lasting impact on the rural physician workforce.     

Internal medicine-pediatrics residency training: current program trends and outcomes.

PURPOSE: Combined internal medicine-pediatrics (med-peds) residency programs have existed since 1967. Due to the rapid growth in the number and size of programs during the 1990s, most current med-peds physicians completed their residency in the last ten years, making older studies of med-peds programs obsolete. The authors sought to determine completion rates of med-peds residency programs and describe the initial career plans for five cohorts of graduating residents from combined med-peds training programs. METHOD: Program directors of all U.S. med-peds residency programs were asked to complete a Web-based survey and base their responses on the records of cohorts of residents completing their programs from 1998 through 2002. To allow sufficient time to complete both the American Board of Pediatrics (ABP) and American Board of Internal Medicine (ABIM) certification examinations, certification status was requested only for the cohort completing training in 1998. RESULTS: Responses were obtained from 92% (83/90) of the programs, reflecting 1,595 residents entering med-peds programs. Of these residents, 91% graduated from a med-peds program. Among the graduates, 82% were seeing both adults and children, 22% went on to subspecialty residencies, 21% began practice in rural or underserved areas, and 25% entered an academic position. ABIM and ABP pass rates for the 1998 cohort were 97% and 96%, respectively. Overall, 79% of the 1998 graduates are board certified in both specialties. CONCLUSIONS: Compared with previous studies, a greater proportion of residents who recently entered med-peds programs completed their dual training, and a larger percentage of graduates are seeing both adults and children. The proportion of residents entering subspecialty residencies has increased significantly, but the proportion of graduates in academic careers has remained stable.     

The geographic relationships between physicians' residency sites and the locations of their first practices

The uneven geographic distribution of physicians has been identified as a significant problem for the delivery of health care services. The present study examined one of the factors that contribute to the distribution of physicians; how far they move from their residency sites to establish their first practices. In 1989, the authors selected a random sample of 701 U.S. residency programs in the ten specialties with the most practitioners, and measured the distance each of these physicians moved to his or her first practice location. Of the 701 programs, 58.5% provided usable information about 2,612 physicians. Of these physicians, over 40% had moved less than 10 miles from their residencies, and over 50% had moved less than 75 miles. Comparisons among the physicians from the various specialties showed that the primary care physicians moved significantly shorter distances than did those from the other specialties. In the last two decades, many efforts have been made to increase the geographic distribution of physicians. The evidence from this study suggests that so far as the distances that physicians move from their practice sites are concerned, little has changed. Recent graduates of residency programs show no more tendency to move far from their residency sites than did their counterparts 30 years ago, as reported in the literature.     

Major changes in medical careers following medical school graduation: when, how often, and why

Knowledge of the timing of, reasons for, and frequency of major medical-career changes of medical school graduates is useful in considering physician manpower needs. This study reports aspects of the medical-career changes made by a cohort of Alberta medical school graduates who graduated from 1973-1985. Of the 603 (81%) who participated, 160 (27%) reported major medical career changes. Significantly more specialists (35%) than family physicians (18%) made major changes. Forty-two percent made changes during the first year of residency, 21% later in residency, and 29% after entering practice. Reasons cited included general dissatisfaction (47%), lifestyle compatibility (24%), and training and practice experiences (19%). This study indicates that while personal needs and preferences influence changes during residency, practice experience is also important to career choices.     

The general practitioner: How much psychiatric education?

One hundred nine general physicians practicing in small rural communities completed questionnaires regarding the number of patients they saw with psychiatric problems. Respondents were also asked to give details of their psychiatric and medical training, to indicate where they obtained new information about psychiatric topics, and to rate the importance of 36 items in daily medical practice. Over one half felt their medical school training in psychiatry was not on par with that received in internal medicine, OB-GYN, surgery, and pediatrics. We suggest the 36 items they ranked be used as a guide in developing a core curriculum for family practice residency training programs as well as for the design of continuing medical education for general physicians.     

A follow-up survey of family physicians' interest in and knowledge of nutrition

Forty-two practicing family physicians completed a questionnaire about 33 nutrition topic areas. They were among 71 physicians who, over an eight-year period (1980-1988), completed an identical questionnaire upon entry to their first postgraduate year in the family practice residency program at Brown University/Memorial Hospital of Rhode Island. Specific topic areas were grouped into five scales. Perceived knowledge of these topics significantly increased (p less than .0001) in all areas except nutritional biochemistry. There was significantly less (p less than .0001) interest in learning more about nutrition. One major exception was that the physicians wanted to learn more about nutrition counseling. Another exception was that nutrition in the life cycle remained an area about which they wanted to learn more. The physicians rated nutritional skills as less relevant on the second questionnaire than on the first. The authors conclude that more emphasis on nutrition counseling skills and nutrition in the life cycle may be appropriate in medical education.     

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.     

Medical students trained abroad and medical manpower. Recent trends and predictions

Physicians trained in foreign medical schools, including U.S. citizens, are once again playing a larger part in the provision of medical are in this country. After a decrease in the numbers of such physicians from 1977 through 1980, the number of foreign nationals entering the National Resident Matching Program increased by 312 per cent, and the number of U.S. citizens from foreign schools increased by 273 per cent. U.S. graduates of foreign medical schools participating in Fifth Pathway programs appear to benefit from their extra year of clinical training by being more successful in the National Resident Matching Program and having a higher pass rate on state licensing examinations. These increases in physicians trained in foreign medical schools, together with an increasing number of students graduating from U.S. medical schools, have resulted in an insufficient total number of first-year postgraduate positions, regardless of the specialty, to accommodate all physicians seeking a first-year residency. Since the number of residency positions will probably not expand to meet applicant demand, an increase in the pool of physicians with neither residency training nor licenses to practice medicine is likely. Alien foreign medical-school graduates and U.S. students who go abroad to study medicine can no longer take for granted residency training and practice in the United Stages.     

Women physicians in dual-physician relationships compared with those in other dual-career relationships.

This study compared the career and domestic responsibilities of women physicians whose domestic partners were physicians (WP-Ps) with those of women physicians whose domestic partners were not physicians (WP-NPs). In 1988 the authors surveyed 602 women physicians in a large midwestern city regarding their career and domestic roles; 390 were physicians in training (students and residents), and 212 were physicians in practice (academic medicine and private practice). Overall, 382 (63%) responded; of the 382, 247 (65%) had domestic partners; of these 247, 91 (37%) were WP-Ps and 156 (63%) were WP-NPs. The WP-Ps were found to be twice as likely as the WP-NPs to interrupt their careers to accommodate their partners' careers. The WP-Ps also assumed significantly more domestic responsibilities and worked fewer hours practicing medicine than did the WP-NPs. The 163 women physicians in training (44-48%-of the WP-Ps and 119-76%-of the WP-NPs) demonstrated a more egalitarian division of labor overall, with no significant differences between the WP-Ps and the WP-NPs. The authors recommend that longitudinal studies be undertaken to determine whether women physicians in training continue this trend as they enter the practice of medicine.     

Internal medicine-pediatrics physicians: their care of children versus care of adults.

Purpose To determine how practicing physicians who graduated from internal medicine-pediatrics residency programs allocate their practice time and professional activities between adult and child patients, and to investigate whether there are predictors of the extent to which a particular physician's practice is more or less focused on one or the other of these patient groups. Method In 2003, the authors mailed a questionnaire to the 1,300 generalists and 472 subspecialists who, as of 2003, had completed internal medicine-pediatrics training since the inception of the program in 1980. Results The response rate was 73% for the generalists and 65% for the subspecialists. The vast majority of the generalist physicians stated that they provide care to all ages of patients. However, the proportion of care they provided to different age groups was not uniformly distributed, with more care provided to adults than children. Both generalist and subspecialist respondents were more likely to feel better prepared by their residency training to care for adults than for children. Those who felt less well-prepared to care for children were less likely to do so in their practices (odds ratio, 0.68; 95% confidence interval, 0.48-0.96). Fifty-four percent of the subspecialists pursued subspecialty training in internal medicine only, while 38% completed a combined internal medicine-pediatrics subspecialty program. These respondents, like the generalist respondents, also were more likely to focus clinical efforts on adults than children. Fewer than half (43%) provided any care to children zero to one year of age, while 54% provided at least some care to children aged two to 11 years. Conclusions Internal medicine-pediatrics physicians are more likely to spend a majority of their clinical care focused on adults and to perceive that they stay more current in the care of adults than of children. Potential reasons for this disparity may include training issues, greater reimbursement for the care of adults, perceptions of the impact on the medical market of the demographic shifts to older adults, and employment opportunities following training. These results also demonstrate the need for a more detailed and comprehensive assessment of the adequacy of pediatrics training in these programs.     

Effect of nutrition education on nutrition counseling practices of family physicians

The effects of completing a comprehensive nutrition curriculum on the nutrition counseling practices of family physicians trained at the University of Manitoba were investigated by sending a questionnaire to a group of these physicians who had completed the nutrition curriculum and a group that had not. The 48 responding family practice residency-trained physicians who had completed the nutrition curriculum, and the 41 responding hospital-trained physicians who had not, reported counseling practices that were not significantly different (p greater than .05). Implications and recommendations for future teaching of nutrition counseling skills to physicians during residency training are presented.     

The long-term effect of an innovative family physician curricular pathway on the specialty and location of graduates of the University of Washington.

PURPOSE: To report the specialty and rural/urban distribution a mean of 19 years after graduation for a cohort of students from a family physician curricular pathway. METHOD: Specialty and location information for medical students who had entered the University of Washington between 1968 and 1973 was obtained from the 1994 Physician Masterfile of the American Medical Association. RESULTS: Of the 239 family physician pathway graduates, 173 (72%) had intended family practice at graduation, and 136 (57%) were family physicians two decades later. The proportions of all graduates in family practice and of graduates serving rural Washington as family physicians had increased over that of a cohort of students who had entered the University of Washington prior to the introduction of the pathway curriculum. These proportions surpassed the goals set at the time the new curriculum was introduced. CONCLUSION: With early identification and support of students interested in family practice, an increased number entered the specialty and were still family physicians in mid-career.     

Evaluation of a selective medical school admissions policy to increase the number of family physicians in rural and underserved areas

Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974; this program preferentially admits medical school applicants from rural backgrounds who intend to practice family medicine in rural and underserved areas. Evaluation of the program has shown that PSAP graduates from the classes of 1978 to 1985 have performed slightly less well than their peers (non-PSAP) during medical school, although there was no difference in attrition between the two groups. Nor did the performance of PSAP and non-PSAP graduates differ during their postgraduate training. PSAP graduates from the classes of 1978 to 1981 were almost five times as likely as non-PSAP graduates to practice family medicine (59.6 vs. 12.6 percent, P less than 0.001), three times as likely to practice in rural areas (37.8 to 42.2 percent vs. 10.0 to 11.8 percent, P less than 0.001), and two four times as likely to practice in areas where there is a physician shortage (26.7 to 40.0 percent vs. 9.2 to 11.2 percent, P less than 0.01). They were 7 to 10 times as likely as their peers to combine a career in family medicine with practice in a rural or underserved area (24.4 to 31.1 percent vs. 3.1 to 3.9 percent, P less than 0.001), thereby fulfilling the goals of the PSAP. This study concludes that the medical school admissions process can have a major influence on the specialty choice and geographic practice location of physicians, and suggests one mechanism for increasing the number of family physicians in rural and underserved areas.     

Moving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encounters

Objective

To understand the communication strategies international medical graduates use in medical interactions to overcome language and cultural barriers.

Methods

In-depth interviews were conducted with 12 international physicians completing their residency training in internal medicine in a large hospital in Midwestern Ohio. The interview explored (a) barriers participants encountered while communicating with their patients regarding language, affect, and culture, and (b) communication convergence strategies used to make the interaction meaningful.

Results

International physicians use multiple convergence strategies when interacting with their patients to account for the intercultural and intergroup differences, including repeating information, changing speaking styles, and using non-verbal communication.

Practice implications

Understanding barriers to communication faced by international physicians and recognizing accommodation strategies they employ in the interaction could help in training of future international doctors who come to the U.S. to practice medicine. Early intervention could reduce the time international physicians spend navigating through the system and trying to learn by experimenting with different strategies which will allow these physicians to devote more time to patient care. We recommend developing a training manual that is instructive of the socio-cultural practices of the region where international physician will start practicing medicine.     

Where physicians practicing in Appalachia in 1978 to 1990 were trained and how they were distributed in urban and rural Appalachia.

Medical school graduates who graduated from 1978 to 1986 were analyzed to determine the health professions' ability worldwide to educate and place primary care physicians in rural areas of Appalachia. These data indicate that the University System of West Virginia--consisting of the West Virginia School of Osteopathic Medicine, West Virginia University Medical School, and Marshall University Medical School--produced the most primary care physicians who began practicing in rural Appalachia during the 1980s. The West Virginia School of Osteopathic Medicine successfully retained 106 (26%) of its graduates in primary care practices throughout rural Appalachia, with 77 of them in rural West Virginia, making the institution the nation's leading provider of primary care physicians practicing in rural Appalachia and West Virginia during this eight-year study period. With the exception of West Virginia, these and additional data support concerns of medical educators and public health officials that physicians in Appalachia are distributed disproportionately, more to urban than to rural counties.     

Declining class size and the decline in graduates choosing family medicine.

In light of the major concern about the marked decline in the numbers of graduates from U.S. medical schools who are entering family medicine, the authors analyzed the effect of declining class size on the numbers of graduates entering family medicine residencies. Data were analyzed from ten years of graduating classes (1981-1990) from the 81 medical schools graduating the most family physicians. The analysis confirmed that declining class size is related to the decline in the production of family physicians. In particular, the 31 schools with the largest declines in the numbers of graduates overall (from the early 1980s compared with the late 1980s and 1990) demonstrated as a group a large fall (nearly 25%) in the production of family physicians. The authors conclude that the large reductions in class size in many medical schools are associated with even larger reductions in the numbers of future family physicians being graduated from U.S. medical schools.     

Allocation of training posts to applicants for postgraduate medical education in austria: survey and analysis.

PURPOSE: To analyze the consequences of the current procedure for allocating training posts to medical graduates in Austria. METHOD: In this cross-sectional study, a questionnaire was sent in two mailings to 8,127 licensed general practitioners and specialists based on the register of the Vienna Medical Chamber in June 2000. The main outcome measures were the percentage of licensed male and female physicians who did not obtain training in their originally preferred medical specialty and the percentage of physicians who were working in a medical specialty other than their originally preferred specialty. RESULTS: A total of 2,736 respondents (34%) completed the questionnaire in the two mailings: 50.3% of physicians--43.2% of male physicians and 58.6% of female physicians--were not practicing in their originally preferred specialty. An average 9% of physicians changed their minds about their preferred specialty during their training. Twenty-one percent of all physicians completed training in an additional specialty. An average of 11 months of additional training was spent at official training posts in specialties other than those finally practiced. CONCLUSIONS: The Austrian allocation procedure is ineffective, uneconomical, and unfair for the applicants. Many medical graduates accept training in a specialty other than the one preferred, not because it is their wish but because Austria's allocation process leaves them no alternative. The authors call the way in which the Austrian training post allocation system governs specialty choice the "musical-chairs effect." This allocation process requires review and the incorporation of recruitment guidelines to ensure equal rights and fair opportunities.