Medical education and the retention of rural physicians.

OBJECTIVE. This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN. Design is a prospective cohort study. PARTICIPANTS. Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION. In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS. Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS. These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.     

Commentary From the Front Lines: Improving the National Health Service Corps' Use of Medical Providers

Abstract: Migrant and community health centers, funded by the Bureau of Primary Health Care (BPHC), provide a vital service to rural communities by ensuring accessible and affordable medical care. One way the BPHC helps communities staff these centers is through the National Health Service Corps (NHSC). In this program, medical professionals receive scholarships or educational loan repayment in return for practicing in medically underserved regions where migrant and community health centers are located. Nurse practitioners, physician assistants, and nurse midwives (nonphysician providers) are a recent addition to the NHSC, and they offer the advantages of reduced cost and a strong primary care orientation. In this commentary, the authors recount their own experiences as a nonphysician provider NHSC scholarship recipient and spouse, and they identify five underlying problems with the current system, which lead to poor nonphysician provider retention. (1) Too few potential placement sites are made available from the outset. (2) NHSC placement deadlines do not allow enough time for making the best possible placement. (3) Many community health centers are not highly supportive of or invested in the program. (4) NHSC efforts to support the development of local medical providers from within underserved regions are inadequate. (5) NHSC officers working with nonphysician providers do not demonstrate a high degree of commitment to achieving an optimal provider-site match. Changes in the NHSC program based on these five problems are recommended to improve the retention of nonphysician providers in this important program.     

The National Health Service Corps for the 21st century

The National Health Service Corps (NHSC) was created in 1970 to provide primary health care clinicians for the underserved. The article includes a review of the peer-reviewed and intragovernmental literature on the NHSC program from 1971 to 1998 and also presents a current profile of the program. Despite significant increases in NHSC field strength since 1991, the 2,439 clinicians meet only 12% of the need for primary health care providers in underserved areas. While the NHSC has successfully addressed clinician diversity and retention issues, community and site development remain barriers to increasing access. Most communities in need are not ready to recruit and support clinicians. The NHSC of the next millennium must work with the neediest communities to reach the appropriate stage of readiness. Only after completing the necessary "preplacement" activities can the NHSC assist in the recruitment and placement of clinicians to increase access.     

Decreasing the field strength of the National Health Service Corps: will access to care suffer?

To study the effect that the decline in physicians in the National Health Service Corps (NHSC) pipeline will have on access to care for patients at sites to which NHSC physicians are assigned, a survey was sent to all NHSC physicians completing their obligated service in 1989. Seventy-four (74) percent of the respondents believed that the decreased number of NHSC doctors in the pipeline would threaten the existence of their site and 52 percent reported that no doctors or clinic sites would be able to provide free or subsidized care if their NHSC site were forced to close. Of the physicians who stated that their NHSC patients would be able to find an alternative source of care, the most commonly cited (33 percent) alternative was the local hospital emergency room. We conclude that access to care for patients at NHSC sites will be seriously impaired by the decline in physicians in the NHSC pipeline.     

A health professional students' cultural competence and attitudes toward the poor: the influence of a clinical practicum supported by the National Health Service Corps

To provide quality health care today, practitioners must be culturally competent. Funding sources, such as the federal government, recognize the need to prepare culturally competent clinicians. The mission of the National Health Service Corps (NHSC), a federal program, is to increase access to primary care services and reduce health disparities by assisting in the preparation of community-responsive, culturally competent primary care clinicians. This study evaluated an NHSC program that funded, in part, health professional students' educational programs. Following their participation in an NHSC-supported clinical experience, students were assessed on their cultural competence, perceptions of the poor, and intention of serving in an underserved community. Health professional students completed a survey before and after the clinical practicum. Participants included students who were studying to be physicians, physician assistants, social workers, and nurse practitioners. Results of the study found no change in students' cultural competence after their clinical practicum. Although they remained in the "culturally aware" stage, they were not considered either "culturally proficient" or "culturally competent." However, their attitudes toward those in poverty were more positive than in previous studies of health professionals. The greatest impact from the students' clinical experience was their increased intention to practice in an underserved community following their practicum. They found their experience with the underserved to be rewarding, challenging, and humbling. Documenting the influence that government-funded programs have on health professional students is extremely important in studies such as this.     

National Health Service Corps Staffing and the Growth of the Local Rural Non-NHSC Primary Care Physician Workforce

CONTEXT: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. PURPOSE: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.     

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.     

Native Hawaiian physician location and service to the underserved in Hawai'i

This study examined the influence of demographic characteristics, training location, and "practice values" on geographic practice location and serving a medically underserved area/population (MUAP) among physicians of Native Hawaiian ancestry practicing within the State of Hawai'i. A survey assessing factors influencing practice location was mailed to 104 identified Native Hawaiian physicians in the State of Hawai'i with a response rate of 79% (n = 82). Factor analysis was used to identify underlying "practice value" variables important in physician practice location, resulting in three robust factors: (1) professional opportunity, (2) lifestyle, and (3) service. Data were analyzed using chi square, analyses of variance, and logistic regressions. Seventy-eight percent of the Native Hawaiian physicians sampled specialized in primary care, which is significantly more than in the general physician population in Hawai'i (57.3%) and in the continental United States (33.1%). Despite not being located in a MUAP, over half of the physicians felt that they provided important services to their medically underserved patients. Logistic regression models predicted 42% of the variance in practice location and 52% of the variance in serving a MUAP. In general, professional opportunity may be more important for non-MUAP physicians whereas service value may be more essential for MUAP physicians. Additional implications and further research are discussed.     

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.     

Physician Practice Characteristics and Satisfaction: A Rural-urban Comparison of Medical Directors at US. Community and Migrant Health Centers

For this study, the association between physician practice characteristics and satisfaction of medical directors at rural and urban Community and Migrant Health Centers (C/MHCs) was investigated. Data for this study came from a 1996 cross-sectional survey of C/MHCs' medical directors. A total of 411 centers (68.3 percent) responded to the survey, including 240 rural (67.4 percent) and 171 urban (68.7 percent) C/MHCs. Factor analysis was used to synthesize physician practice characteristics related to overall satisfaction. The resulting factors were entered as new variables in a predictive logistic regression model of overall satisfaction. Growing up in an inner-city community was significantly associated with practicing in an urban center; whereas, growing up in a rural or frontier community was more likely to result in practicing in a rural center. The majority of medical directors (82.3 percent) were either somewhat satisfied or very satisfied with their work. Satisfaction with work was most significantly associated with overall level of satisfaction, followed by satisfaction with administration, peers and patients. Recruitment efforts are more likely to succeed when they target individuals with prior exposure to underserved areas. Improving the working conditions and interactions with administrators would help sustain the high level of satisfaction experienced by medical directors at C/MHCs.     

States’ Experiences With Loan Repayment Programs for Health Care Professionals in a Time of State Budget Cuts and NHSC Expansion

Purpose: The landscape of education loan repayment programs for health care professionals has been turbulent in recent years, with doubling of the funding for the National Health Service Corps (NHSC) and cuts in funding for some states’ programs. We sought to understand how this turbulence is being felt within the state offices involved in recruiting clinicians to rural and urban underserved communities. Methods: We conducted key informant telephone interviews with staff of state offices of rural health, primary care organizations, and/or related organizations within 28 diverse states to answer questions about perceived changes and interplay among solely state‐funded loan repayment programs, joint state‐federal programs, and the NHSC federal program. Interviews were transcribed, formally analyzed, and key issues summarized. Findings: Informants reported that solely state‐funded and joint state‐federal loan repayment programs are greatly valued for their ability to target a state's particular needs and to complement the NHSC federal program. However, budgets for state programs have been threatened, reduced, or eliminated entirely in many cases. All informants positively perceived the NHSC's recent growth and changes, which they feel are helping fill important workforce needs for their states. Nevertheless, the much larger NHSC federal program now competes with some states’ programs for clinicians and service sites; states’ programs are pushed to adjust their operations to maintain a unique “niche.” Conclusions: States’ key recruiters lament reductions in funding for states’ loan repayment programs, and welcome the NHSC's recent growth and changes. Better coordination is needed to minimize competition and maximize complementarity between state and federal programs.     

Technological access barriers,telehealth use and health care visits in the early pandemic period

ObjectiveThis study sought to characterize the role of technological barriers in limiting access to telehealth services.MethodsThe study used data obtained from the 2020 Nebraska Annual Social Indicators Survey (NASIS). A total of 2,213 out of 8,000 respondents returned a completed survey. Multivariate models were developed to estimate the relationship between demographic characteristics, technological barriers and overall telehealth utilization. An additional model was used to estimate the relationship between telehealth use and health care visits in the past year, controlling for the available demographic characteristics. Ordinal logistic regression was used.ResultsApproximately 27.9 percent of respondents had ever used telehealth services. Individuals who had used telehealth services were significantly more likely to have seen a health care provider for reproductive health or for a specific health need in the past year. Approximately 7.2 percent of survey respondents reported access to reliable internet as a barrier to telehealth use, 9 percent reported cost of internet services as a barrier and 7.1 percent reported access to electronic devices as a barrier. Respondents over 65 and those with lower education attainment were more likely to experience barriers to accessing technology. Holding technological access constant, telehealth use was significantly lower among males, individuals over 65 and rural residents.ConclusionsFactors other than cost and access to technology may be driving lower rates of telehealth use among these populations. The findings can help policymakers and health systems strategize approaches to increase access to telehealth among underserved populations.Public abstractLimitations in technology access may limit the usefulness of telehealth in connecting underserved patients to care. This study sought to understand the role of technological barriers in limiting access to telehealth services. Using data obtained from the 2020 Nebraska Annual Social Indicators Survey (NASIS), this study summarizes telehealth use among a random sample of individuals in rural and urban Nebraska. The study then assesses whether lower access to technology is associated with reduced use of telehealth services. Approximately 7.2 percent of survey respondents reported access to reliable internet as a barrier to telehealth use, 9 percent reported cost of internet services as a barrier and 7.1 percent reported access to electronic devices as a barrier. Holding technological access constant, telehealth use was lower among males, individuals over 65 and rural residents. Factors other than access to technology may be driving lower rates of telehealth use among these populations.     

High School Census Tract Information Predicts Practice in Rural and Minority Communities

PURPOSE: Identify census-derived characteristics of residency graduates' high school communities that predict practice in rural, medically underserved, and high minority-population settings. METHODS: Cohort study of 214 graduates of the University of California, San Francisco-Fresno Family Practice Residency Program (UCSF-Fresno) from its establishment in 1970 through 2000. Rural-urban commuting area code; education, racial, and ethnic distribution; median income; population; and federal designation as a medically underserved area were collected for census tracts of each graduate's (1) high school address and (2) practice location. FINDINGS: Twenty-one percent of graduates practice in rural areas, 28% practice in areas with high proportions of minority population (high minority areas), and 35% practice in federally designated medically underserved areas. Graduation from high school in a rural census tract was associated with rural practice (P < .01), Of those practicing in a rural site, 32% graduated from a rural high school, as compared with 11% of nonrural practitioners. Graduation from high school in a census tract with a higher proportion of minorities was associated with practice in a proportionally high minority community (P = .01). For those practicing in a high-minority setting, the median minority percentage of the high school census tract was 31%, compared with 16% for people not practicing in a high minority area. No characteristics of the high school census tract were predictive of practice in a medically underserved area. CONCLUSION: Census data from the residency graduate's high school predicted rural practice and practice in a proportionally high minority community, but not in a federally designated medically underserved area.     

Location decisions of National Health Service Corps physicians

Results of a survey of 100 National Health Service Corps (NHSC) physicians in 10 east coast states (94 per cent response rate) indicate that 56 have plans to locate in a rural area after their service obligation is complete and 15 have not yet decided. Those who decide for a rural practice value personal and community factors to a higher degree than professional factors and are more likely to have a primary care practice.     

Differential Access to Digital Communication Technology: Association with Health and Health Survey Recruitment within an African-American Underserviced Urban Population

Digital communication technologies (DCT), such as cell phones and the internet, have begun to replace more traditional technologies even in technology-poor communities. We characterized access to DCT in an underserved urban population and whether access is associated with health and study participation. A general probability community sample and a purposive high-turnover housing sample were recruited and re-interviewed after 3 months. Selected characteristics were compared by sample type and retention. Associations between DCT access and self-reported health were examined using multivariable logistic regression. Of 363 eligible individuals, 184 (general community = 119; high-turnover housing = 65) completed the baseline survey. Eighty-four percent of respondents had a cell phone and 62% had ever texted. Ever use of the internet was high (69%) overall, but frequency and years of internet use were higher in the general community sample. Self-reported fair or poor health was more common for residents of cell phone–only households and those with less frequent internet use. Technology use was similar for those retained and not retained. Overall, access to DCT was high in this underserved urban population but varied by sample type. Health varied significantly by DCT use, but study retention did not. These data have implications for incorporating DCT into health-related research in urban populations.     

Assessing the Quality of Data Regarding Use of the Lactational Amenorrhea Method

This study assesses the quality of Demographic and Health Survey (DHS) data regarding self‐reported current use of the lactational amenorrhea method (LAM). LAM is an important modern contraceptive method that, when practiced correctly, has a 98 percent effectiveness rate six‐months postpartum. The objectives of this study are to examine the accuracy of self‐reported LAM use, compared with the constructed correct‐practice variable, and to explore differentials in accuracy measures by characteristics at the individual and survey level by analyzing data from 73 DHSs conducted in 45 countries between 1998 and 2011. Findings reveal that only 26 percent of reported LAM users meet the criteria for correct LAM practice. We discuss the implications for future DHS data collection and for family planning and maternal and child health programming.     

An Evaluation of a Positive Youth Development Program for Adolescents with Chronic Illness

PurposeYouth with chronic illness often struggle transitioning to adulthood and adult medical care. This article examines the outcomes of a group mentoring program called The Adolescent Leadership Council (TALC) that brings together high school participants and college mentors, all with chronic illness. TALC uses a positive youth development (PYD) approach, emphasizing strong relationships between youth and adults in an environment where youth can learn important life skills and take a leadership role.MethodsA pre-/postprogram participant survey was conducted for high school participants using a loneliness scale and a transition readiness survey. An alumni survey was conducted with all high school and college mentor graduates to assess educational-, vocational-, and health care-related outcomes.ResultsProgram records review and the alumni survey indicated that TALC was consistent with the PYD program model. Twenty high school students participated in the pre-/postprogram outcomes evaluation, which demonstrated a decrease in loneliness from 46 to 38.5 (p < .001) and an increase in health care self-advocacy from 3.8 to 4.2 (p < .001). Thirty-four alumni participated in the alumni survey. All high school and college mentor alumni had graduated from high school and college, respectively, and all were either currently in school or working. The majority of alumni were seeing adult providers for medical care.ConclusionsThe TALC program applies the principles of PYD to support positive educational, vocational, and health care outcomes for youth with chronic illness. Program development using the PYD perspective is an important new approach for supporting adult development of youth with chronic illness.     

The National Health Service Corps: rapid growth and uncertain future

From inauspicious origins in laudable, but vague, legislation and diffident--even disorganized--implementation, the NHSC has evolved into a major federal program for delivering health care to underserved areas. Tying together the financing of medical education and the delivery of health services for the first time could enable responsiveness to both qualitative and quantitative changes in medical care. But competing demands, within the program and its administration, and in the communities to be served, have made evaluation of the NHSC effort and impact difficult, but all the more necessary for future planning.     

Model for development of outcome assessment surveys for allied health educational programs

This article describes a model for survey development used by the Department of Physical Therapy at Saint Louis University to assess the extent to which the program prepares students for a career as physical therapists. From a review of departmental documents including mission and philosophy statements and curriculum goals, eight performance outcomes (e.g., competence as a general practitioner, leadership, ethics, attitude for service, etc.) and two program characteristics (curricuum and program atmosphere) were determined. External documents including accreditation criteria for graduate performance were also reviewed and found to be consistent with the identified characteristics. Based on these findings, items for three surveys were developed and assessed. A 1-year alumni survey solicited feedback on the graduates' perceptions of their educational preparedness for clinical practice. The graduates' employers then were surveyed for an assessment of the graduates' job performance. A 3-year alumni survey followed up to reassess the graduates' perceptions of their educational preparedness and to track the alumni's activities since graduation. Other programs in physical therapy and other health care disciplines can use this model to develop valid survey instruments to assess their program's effectiveness.