Undergraduate Rural Medical Education Program Development: Focus Group Consultation With the NRHA Rural Medical Educators Group

Context: Over a decade ago, leaders in rural medical education established the Rural Medical Educators (RME) Group, an interest group within the National Rural Health Association, to support faculty in rural medical education programs. This group has convened an annual RME conclave since 2006. In 2008, this conclave convened 15 national leaders in rural medical education at The University of Alabama. Methods: In preparation for the conclave, potential participants were e‐mailed a set of questions regarding their respective medical education program's initiating motivation, support, resistance, resources, accomplishments, and continuation plans. Analysis of participants’ responses resulted in a question guide that was used at a focus group conducted at the conclave. Purpose: The purpose of the focus group was to explore the experiences of established rural medical educators related to program development and maintenance. The focus group was recorded and transcribed, and then analyzed using the constant comparative method. Findings: Five essential elements for rural medical education programs emerged from the analysis. The elements were: admit the right student, include curricular elements that occur and are required in rural training sites, establish a cadre of rural physicians who are dedicated to education of their successors, secure financial and relational support for the program, and evaluate program progress. Discussion and Conclusions: Discussion about these 5 elements can provide program guidance to neophyte rural medical education programs. Five recommendations are presented in an effort to continue discussion about the essential elements and identify actions that rural medical educators can take to further assist developing programs.     

上海市社区就诊病人自报家庭医生签约现状与人口学特征分析

目的 了解上海市家庭医生签约现状,探讨社区就诊居民人口学特征与签约的关系.方法 采用自行编制的调查问卷,选取5个社区卫生服务中心拦截式调查社区就诊居民,共计调查1 021人,回收有效的959份,回收有效率为93.9％.结果 调查居民平均年龄（59.91±14.30）岁,其中50岁以上占81.2％,男性348人（36.3％）,女性611人（63.7％）,居民自报家庭医生签约率为30.2％,多因素非条件Logistic回归分析发现女性（OR=1.44,95％CI （1.04～2.00））、年龄大于70岁（OR=2.17,95％CI（1.13～4.14））以及长期服药（OR=2.66,95％CI（1.56～4.54））的人群更倾向于签约家庭医生.结论 病人自报家庭医生签约率尚低,在推广家庭医生签约制时,应在扩大宣传、完善基本配套政策措施上,重点从女性、70岁以上人群及长期服药人群入手,提高居民签约率,以带动其他居民.     

White Nights

“How can you sleep at night after you ruined my life?” Arthur, a veteran patient of mine, implored after receiving his test results. This essay recounts my experience as a physician in coping with an extremely anxious patient, its influence on me, and some of my reflections on the ensuing white nights.     

格林模式在家庭医生签约实践过程中的效果研究

目的探讨运用格林模式在家庭医生签约实践过程中的效果。方法选择天津市区某街道某一小区内380户居民作为研究对象进行家庭医生签约实践,以家庭为单位将居民随机分为试验组(190户)和对照组(190户)。试验组运用格林模式进行宣教,对照组采用传统宣教模式,比较两组居民家庭医生签约率和居民满意度。结果试验组居民家庭医生签约率为49.4%,对照组为30.5%,试验组居民家庭医生签约率明显高于对照组(P<0.001)。已签约居民中,对家庭医生服务了解程度、对签约责任人满意度,试验组明显高于对照组(P<0.01);对签约内容满意度两组比较无显著差异(P>0.05)。结论格林模式在家庭医生签约实践过程中能明显提高居民签约率及居民满意度。     

Family physician consultation patterns indicate high risk for early-onset anorexia nervosa

OBJECTIVE: There is often a delay in the recognition of early-onset anorexia nervosa. The current study aimed to determine whether there are specific patterns in the frequency and content of family physician consultations that might predict its onset. METHOD: Lifetime number and type of family physician consultations were recorded for three groups: (a) an index group comprising 19 girls with anorexia nervosa, onset under 14; (b) a clinical control group comprising 19 girls with an emotional disorder; and (c) a nonclinical group comprising 19 girls with no history of mental health problems. RESULTS: Both clinical groups had an elevated number of consultations, particularly in the 5 years before diagnosis. The index group had a significantly higher number of eating, weight, and shape consultations (especially in the year before diagnosis), whereas the clinical control group had a greater number of psychological consultations. CONCLUSION: A single consultation about eating behaviour or weight and shape concerns is a strong predictor of the subsequent emergence of anorexia nervosa.     

Snapshots of Haiti: a physician's relief work in a country in crisis

On January 12, 2010, a 7.0 magnitude earthquake struck Haiti. All told, more than 240,000 perished; another 200,000 were injured; and one-half of the city's 2,000,000 residents were left homeless. In March I volunteered with Medishare to help with the relief effort. Being a family physician, broadly trained in all aspects of medicine, I knew many of my skills would be needed. In the 7 days I was in Haiti, I worked excruciatingly long hours, witnessed the sorrow of death and joy of birth, and was continually confronted with the challenge of giving adequate and meaningful health care in a broken country. I learned that the physical and emotional toll on those who provide care in a crisis like Haiti is immense and unrelenting. But most importantly, I left Haiti with a renewed belief in what humans are able to accomplish when we all work together for a common purpose.     

Recruiting and Retaining Physicians in Very Rural Areas

Context: Recruiting and retaining physicians is a challenge in rural areas. Growing up in a rural area and completing medical training in a rural area have been shown to predict decisions to practice in rural areas. Little is known, though, about factors that contribute to physicians’ decisions to locate in very sparsely populated areas. Purpose: In this study, we investigated whether variables associated with rural background and training predicted physicians’ decisions to practice in very rural areas. We also examined reasons given for plans to leave the study state. Methods: Physicians in the State of Wyoming (N = 693) completed a questionnaire assessing their background, current practice, and future practice plans. Findings: Being raised in a rural area and training in nearby states predicted practicing in very rural areas. High malpractice insurance rates predicted planning to move one's practice out of state rather than within state. Conclusions: Rural backgrounds and training independently predict practice location decisions, but high malpractice rates are the most crucial factor in future plans to leave the state.     

荷兰以人为本整合型卫生服务的实践与启示*

从服务提供、治理机制、组织管理和筹资支付四个维度,分析荷兰实现以人为本的整合型卫生服务的关键要素,包括以全科医生服务团队为核心的网络化医疗卫生服务体系、良性市场竞争机制和广泛的社会参与及多部门合作的治理网络,促进整合的医保支付制度,成熟的全科医生培养体系和互联互通的信息系统,并结合中国实际,提出我国现阶段应将基层医疗卫生服务体系作为建设重点和优先领域,以家庭医生签约服务为抓手,加强医保对服务提供者的激励和约束,破除市场竞争、人才培养和信息共享等方面的体制机制障碍,构建以家庭医生服务团队为核心的网络化服务体系。     

Tobacco smoking habits among a cross-section of rural physicians in China

OBJECTIVE: To investigate the prevalence and distribution of tobacco smoking among rural Chinese physicians. DESIGN: A self-reporting survey adapted from previous international studies. Setting: A teaching hospital in Hebei Province, China. SUBJECTS: A complete cross-section of 361 physicians working in all hospital departments. RESULTS: The overall response rate was 79.2%, among whom 15.7% (95% confidence interval (CI) 12.0-20.4) were current smokers and 1.0% ex-smokers (95% CI 0.4-3.1). There were no female smokers when stratified by sex, although the prevalence rate among male physicians was 31.9% (95% CI 24.8-40.0). The prevalence of smoking varied widely by hospital department, ranging from zero in the obstetrics and gynaecology department, to 32.6% in the surgical unit. Smoking rates also varied by age, with physicians younger than 25 years having the lowest prevalence (6.3%). Although they only accounted for 7.1% of the entire group by number, the highest smoking prevalence was seen among physicians aged 50-54 years (31.6%). CONCLUSIONS: Although our study suggests that smoking is an important health issue for rural Chinese physicians, the distribution of risk is not uniform. Future preventive measures will, therefore, need to consider the individual situation of physicians who smoke, particularly those in the older age groups.     

推行家庭医生签约对社区卫生服务利用的影响

目的 :了解上海市长宁区家庭医生制的实施效果,为完善家庭医生服务内容提供依据和支撑。方法 :使用自行设计的"家庭医生服务利用及效果评价"调查表,采用入户调查的方式收集资料,所有的调查员均由复旦大学统一培训。结果 :共调查社区常住居民736人,其中签约居民412人(56.0%),60岁以上居民占60.1%,38.9%的调查对象有明确诊断的慢性病。既往半年有就诊记录的调查对象中,签约居民对社区卫生服务中心的利用率(77.9%)是非签约居民(31.5%)的2.47倍(P0.01)。家庭居住区域、是否签约家庭医生、家庭人均年收入影响社区居民的就诊行为。签约居民、低学历居民、41~80岁社区居民生病后到社区卫生服务中心的首诊意愿高于非签约居民(OR=1.80,95%CI:1.11~2.92)、高学历居民(其中初中及以下组OR=4.45,95%CI:1.86~10.61;大专组OR=2.29,95%CI:1.06~4.97)、40岁及以下居民(其中41~60岁组OR=2.78,95%CI:1.10~7.00;61~80岁组OR=3.46,95%CI:1.00~11.90;80岁以上组OR=4.55,95%CI:0.97~21.43)。签约居民对家庭医生满意度非常高,总体评分为93.44。结论 :上海市长宁区试行的家庭医生制成效明显,为探索"优化社区卫生资源配置、建立分级诊疗制度"提供了科学依据。     

Starting rural,staying rural: How can we strengthen the pathway from rural upbringing to rural practice?

Objective: To determine if selecting rural background students into the Monash Bachelor of Medicine and Bachelor of Surgery (MBBS) program affects vocational training location and intended practice location after training. Design: Retrospective cohort mail survey. Setting: Australia. Participants: Rural‐background students at Monash 1992–1994 (n = 24/40) and 1995–1999 (n = 59/120) and urban background students (n = 36/93 and 104/300, respectively). Overall study population: 62% female, average age of 28 years; 79% Australian‐born; and 60% married/partnered. Interventions: Rural or urban background, rural undergraduate exposure. Main outcome measures: Intent towards rural medical practice, vocational training location and subsequent practice location. Results: There was a positive and significant (P ≤ 0.05) association between rural background and rural practice intent when respondents began (10‐times higher than urban graduates) and completed (three times higher) their MBBS course. Rural practice intent increased fourfold in urban background graduates. There was a positive and significant association between rural background and preferred place of practice in 5–10 years in a Rural, Remote and Metropolitan Area (RRMA) 3–7 community (three times higher). There was a positive, but non‐significant association between rural background and RRMA 3–7 community as their current location and first place of practice once vocationally qualified. Conclusions: Interest in rural practice is not fully reflected in location during or after vocational training. The beneficial effects of rural undergraduate exposure might be lost if internship and vocational training programs provide insufficient rural clinical experiences and curriculum content. Continuation of the rural pathway might be needed to maintain rural practice intent.     

Determinants of general practitioners' wages in England

We analyse the determinants of annual net income and wages (net income/hours) of general practitioners (GPs) using data for 2271 GPs in England recorded during Autumn 2008. The average GP had an annual net income of £97 500 and worked 43 h per week. The mean wage was £51 per h. Net income and wages depended on gender, experience, list size, partnership size, whether or not the GP worked in a dispensing practice, whether they were salaried of self‐employed, whether they worked in a practice with a nationally or locally negotiated contract, and the characteristics of the local population (proportion from ethnic minorities, rurality, and income deprivation). The findings have implications for pay discrimination by GP gender and ethnicity, GP preferences for partnership size, incentives for competition for patients, and compensating differentials for local population characteristics. They also shed light on the attractiveness to GPs in England of locally negotiated (personal medical services) versus nationally negotiated (general medical services) contracts. Copyright © 2010 John Wiley & Sons, Ltd.     

自回归移动平均模型评价社区卫生服务连续性

目的对我国城市社区家庭医生签约服务模式的服务连续性进行评价。方法对签约、电子病历与一般就诊人群的门诊就诊人次拟合时间序列自回归移动平均(ARMA)模型并做出预测。结果玉林社区卫生服务中心签约人群的门诊量明显上升。增长速度远高于一般就诊人群。根据签约病人门诊人次时间序列模型预测，签约人群的门诊人次仍将呈现明显的增长态势。人均门诊人次的增长已成为签约人群门诊服务量增长的主要原因。结论城市社区家庭医生签约服务可为签约居民提供个性化的卫生服务，是适合我国社区卫生服务实际情况的一种医疗保健模式。     

“健康中国”视域下社区老年人对家庭医生式服务 认知和需求分析*

目的了解健康中国视域下丽水市老年人对家庭医生式服务的认知现状和需求,为优化家庭医生式服务和建立良好的就医秩序提供参考。方法采用多阶段整群随机抽样法在丽水市莲都区的城区和郊区共抽取5个街道900名老年人采取问卷调查。问卷内容包括老年人基本情况、慢性病患病情况、家庭医生式服务认知和家庭医生式服务需求四个方面。共发放问卷900份,回收有效问卷847份,有效回收率为94.1%。结果调查847名老年人中慢性病患者438例,签约家庭医生式服务者590例。老年人家庭医生式服务知晓率为64.1%,总体需求程度较高,其中,老年人服务包需求程度较高。在各项服务项目中,老年人对体格检查、建立电子健康档案需求较高。职业、家庭月收入、费用承担能力和长期服用药物情况等对老年人家庭医生式服务需求的差异有统计学意义。结论老年人对家庭医生式服务认知层次较浅,需求程度较高,不同特征人群对该服务需求不同,建议加强宣传力度,挖掘个性化服务项目,完善签约制度,从而形成合理就医秩序,建设全面、科学和公平的健康中国。