Emergency Department Coverage by Primary Care Physicians in a Rural Practice-Based Research Network: Incentives, Confidence, and Training

ABSTRACT:  Context: In rural areas of the United States, emergency departments (EDs) are often staffed by primary care physicians, as contrasted to urban and suburban hospitals where ED coverage is usually provided by physicians who are residency-trained in emergency medicine. Purpose: This study examines the reasons and incentives for rural Oregon primary care physicians to cover the ED and their reported measures of confidence and priorities for additional training. Methods: We conducted a cross-sectional survey of primary care physicians in rural Oregon who are members of the Oregon Rural Practice-Based Research Network (ORPRN). The survey was sent to 70 primary care physicians in 27 rural Oregon practices. Findings: Fifty-two of 70 (74%) ORPRN physicians representing 24 practices returned the questionnaire. Nineteen of the 52 responding physicians reported covering the ED. The majority (75%) of physicians covering the ED did so as a requirement for practice employment and/or hospital privileges. Physicians covering the ED reported low confidence in pediatric emergencies and expressed the need for additional training in pediatric emergencies as their top priority. Conclusions: Almost two fifths of surveyed primary care physicians in a rural practice-based research network provide ED coverage. Based on these physicians' low levels of confidence and desire for additional training in pediatric emergencies, effective education models are needed for physicians covering the ED at their rural hospitals.     

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.     

Colposcopy practice and training in family practice residency programs.

BACKGROUND: The potential growth of colposcopy as a family medicine procedural skill is directly related to the training currently offered to family practice residents. To define whether these skills are being adequately offered to physicians who want to perform this procedure for their patients, a study was designed to investigate the current status of colposcopy practice and training in family practice residency programs. METHODS: A 16-item survey sent to 356 family practice residency directors in the United States included items concerning colposcopy practice, training, educational programs and strategies, colposcopy coordinator educational background, and colposcopic resource materials and equipment. RESULTS: Surveys were returned from 204 (57 percent) family practice residencies. Colposcopy was performed at 45 percent of the residencies that responded. Ninety-six percent of the respondents who did not perform colposcopy believed colposcopy is a procedure that should be performed by family physicians. Clinical teaching and supervision was the most common method of resident training (74 percent). Colposcopy training coordinators were usually family physicians (72 percent), primarily trained by gynecologists. Assistance with implementing a colposcopy training program was requested by 85 percent of those programs presently not performing colposcopy. CONCLUSIONS: This study indicates that there are opportunities for further development of colposcopy practice and training in family practice residencies.     

Length and content of family practice residency training

BACKGROUND: Family practice residency programs are based largely on a model implemented more than 30 years ago. Substantial changes in medical practice, technology, and knowledge necessitate reassessment of how family physicians are prepared for practice. METHODS: We simultaneously surveyed samples of family practice residency directors, first-year residents, and family physicians due for their first board recertification examination to determine, using both quantitative and qualitative methods, their opinions about the length and content of family practice residencies in the United States. RESULTS: Twenty-seven percent of residency directors, 32% of residents, and 28% of family physicians favored extending family practice residency to 4 years; very few favored 2- or 5-year programs. There was dispersion of opinions about possible changes within each group and among the three groups. Most in all three groups would be willing to extend residency for more training in office-based procedures and sports medicine, but many were unwilling to extend residency for more training in surgery or hospital-based care. Residents expressed more willingness than program directors or family physicians to change training. Barriers to change included disagreement about the need to change; program financing and opportunity costs, such as loss of income and delay in debt repayment; and potential negative impact on student recruitment. CONCLUSION: Most respondents support the current 3-year model of training. There is considerable interest in changing both the length and content of family practice training. Lack of consensus suggests that a period of elective experimentation might be needed to assure family physicians are prepared to meet the needs and expectations of their patients.     

Family Medicine Spokane Rural Training Track: 24 years of rural-based graduate medical education

Twenty percent of the US population lives in rural communities, but only about 9% of the nation's physicians practice in those communities. There is little doubt that the more highly specialized physicians are, the less likely they are to practice or settle in rural areas. There is clearly a population threshold below which it is not feasible for specialist (in contrast to generalist) physicians to pursue the specialty in which they have trained. Much of rural America falls below that threshold. This leaves large geographic areas of America to the primary care physician. The proportional supply of family physicians to specialists increases as urbanization decreases. Family physicians are the largest single source of physicians in rural areas. Family medicine residency programs based in rural locations provide a critical mechanism for addressing rural primary care needs. Graduates from rural residency programs are three times more likely to practice in rural areas than urban residency program graduates. There are two primary goals of training residents in rural areas: producing more physicians who will practice in rural areas and producing physicians who are better prepared for the personal and professional demands of rural practice. Rural Training Tracks, where the first year of residency is completed in an urban setting and the second and third years at a rural site (1-2 model), initially proposed by Family Medicine Spokane in 1985, have been highly successful in placing and maintaining more than 70% of their graduates in rural communities. Similar and modifications of the "Spokane RTT model" have been established around the country. Now, more than 24 years of educational experience has been accumulated and can be applied to further development of these successful family medicine residency programs.     

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.     

Obstetric care in family practice residencies: a 5-year follow-up survey

BACKGROUND: The percentage of family physicians delivering babies decreased from 46% in 1978 to 32% in 1992. Some family practice leaders predicted that, by the turn of the century, training for family practice obstetrics would focus primarily on those planning to work in remote or rural settings. A 1993 study found three primary factors associated with an increased incidence of future maternity care. In 1997 the Residency Review Commission (RRC) stipulated that all family practice residencies have at least 1 family physician serve as an intrapartum attending physician for family practice resident deliveries. METHODS: Using an instrument similar to that used in 1993, we surveyed the directors of 462 family practice residencies in the United States. Sixty-four percent (295) of the program directors responded to one of two mailings. RESULTS: Compared with the survey published in 1993, program directors estimated a 16% increase in the number of residents who included obstetrics in their first practice after residency. Factors associated with increased obstetric participation included having only family physician faculty supervise uncomplicated deliveries and having family physician faculty who could perform other perinatal procedures. Programs that had 4 or more family physician faculty doing obstetrics and those that had more than 10 deliveries per month also produced more physicians who provided maternity care. Fifty-three percent of residencies that did not have family physician faculty attending deliveries before 1997 now meet this RRC requirement. CONCLUSIONS: This study shows that, according to their program directors' estimates, more family practice residents are including obstetrics in their first practice after residency compared with 5 years ago. The new RRC regulation was associated with more than 50% of previously noncompliant programs adding or retraining faculty who could attend resident deliveries within 12 months of the inception of the new policy.     

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.     

Childhood immunization practices of primary care physicians.

OBJECTIVE: To assess if immunization utilization practices differ between rural and urban primary care physicians in Kentucky. DESIGN: Survey of 200 primary care physicians. PARTICIPANTS: Pediatricians, family physicians, and general practitioners in Kentucky. SELECTION PROCEDURES: Participants completed a 20-item questionnaire that surveyed selected demographics with regard to the physician and practice, immunizations offered to children, and reasons why the responding physicians did not offer immunizations and where they referred patients for this service. RESULTS: Physicians practicing in rural counties offered immunizations to their patients less frequently than did urban physicians (54% vs 77%). Rural and urban physicians cited immunization costs to patients as the chief reason that immunizations were not used more often and referred patients primarily to county health departments. CONCLUSIONS: Rising costs have limited physician use of immunizations in rural areas to a greater extent than that seen in urban areas. This may make access to immunizations more difficult for children living in rural areas.     

Acceptance and self-reported use of national occupational medicine practice guidelines

The authors conducted a survey to ascertain post-training attitudes and self-reported use of the American College of Occupational and Environmental Medicine occupational medicine practice guidelines. Trainees were surveyed 3 to 4 months after completing a case-based practice ACOEM occupational practice guidelines seminar. Of 96 physician respondents, 95% reported that the guidelines improved their practice in some manner. Fifty-two percent of physicians thought that guideline use decreased medical costs. Seventy-one percent reported that their care complied with the guidelines in 70% or more of their cases; however, "actually considering the guidelines in particular cases" was reported by only 47%. Discussion of cases was frequent (92%) and involved physicians, patients, and other health care providers. We concluded that physicians' attitudes toward the guidelines are positive and that reported compliance is high. Guidelines are discussed frequently.     

Obstetric care among family physicians in Pennsylvania. Trends, association with residency training, and policy implications

A study was designed to investigate the status of obstetric practice by Pennsylvania family physicians and its relationship to family practice residency training. A 50% probability sample of all family and general physicians and of all graduates of Pennsylvania family practice residency programs was surveyed by mail. Ten percent of Pennsylvania family physicians and general practitioners reported currently practicing obstetrics, 44% of whom said they planned to stop within 3 years. Telephone survey information from nonresponders suggests that even fewer (5%) of the state's family physicians may actually be practicing obstetrics. Family practice residency training, postresidency obstetric training, and small community size were the best predictors of current obstetric practice. Family physicians in the smallest communities, however, were also those most likely to be planning to stop, and graduates of residency programs were increasingly choosing not to practice obstetrics. Cost of liability insurance and fear of lawsuits were primary reasons cited for stopping obstetrics. Family physicians have been major providers of obstetric care in the nation's rural areas. Now, increasingly firm evidence that fewer family physicians are practicing obstetrics signals increasing shortages in obstetric care for women in rural communities. Changes in the practice climate and obstetric training programs for family physicians seem essential to help reverse these trends.     

Stroke knowledge among urban and frontier first responders and emergency medical technicians in Montana.

PURPOSE: To assess stroke knowledge and practice among frontier and urban emergency medical services (EMS) providers and to evaluate the need for additional prehospital stroke training opportunities in Montana. METHODS: In 2006, a telephone survey of a representative sample of EMS providers was conducted in Montana. Respondents were stratified into 2 groups: those working in urban and frontier counties. FINDINGS: Compared to EMS providers from urban counties, those from frontier counties were significantly more likely to be older (mean age 44.7 vs 40.1 years), have fewer personnel working in their service (mean 17.7 vs 28.6), to be located farther away from a computed tomography scan (CT scan) (mean 41.3 vs 17.6 miles), and to be volunteers (84% vs 49%). They were also less likely to have a stroke protocol (58% vs 66%) and use a stroke screening tool (36% vs 47%) than their urban counterparts. There were no significant differences between frontier and urban EMS respondents' ability to correctly identify 4 or more stroke warning signs (58% vs 61%), 4 or more stroke risk factors (46% vs 43%), or the 3-hour recombinant tissue plasminogen activator (rt-PA) treatment window (56% vs 57%). Approximately two thirds of respondents from urban and frontier counties believed they had adequate stroke knowledge, but 90% indicated they were interested in additional stroke-related training. CONCLUSIONS: Although stroke knowledge did not differ between urban and frontier groups, stroke screens and stroke protocols were less likely to be used in the frontier areas. Training opportunities and the implementation of stroke protocols and screening tools are needed for EMS providers, particularly in frontier counties.     

The future supply of family physicians: implications for rural America

Throughout the past century rural health care has been dependent upon general practitioners (GPs) and their successors, family physicians (FPs). Only FPs and GPs have practiced in rural areas in proportion to the population, then and now. As specialization occurred, numbers of GPs declined and physician shortages developed in rural areas. The creation of family practice residencies in the 1970s halted this decline, but rural shortages persist today. During the 1990s the number of allopathic and osteopathic FP residency graduates rose 54 percent. At the same time, the percentage of women enrolled in these residencies increased to 46 percent, and women have been less likely than men to select rural practice. We project that if current numbers of graduates continue, the nonmetropolitan FP/GP-to-population ratio will increase 17 percent by the year 2020. However, today, medical students' interest in primary care residencies (including family practice) is declining precipitously. If numbers of FP graduates return to 1993 levels, the density of FPs in rural America and in the nation as a whole will decline after 2010.     

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.     

Rural Emergency Department Staffing and Participation in Emergency Certification and Training Programs

ABSTRACT:  Context: The practice of emergency medicine presents many challenges in rural areas. Purpose: We describe how rural hospitals nationally are staffing their Emergency Departments (EDs) and explore the participation of rural ED physicians and other health care professionals in selected certification and training programs that teach skills needed to provide high-quality emergency care. Methods: A national telephone survey of a random sample of rural hospitals with 100 or fewer beds was conducted in June to August 2006. Respondents included ED nurse managers and Directors of Nursing. A total of 408 hospitals responded (96% response rate). Findings: A majority of rural hospitals use more than one type of staffing to cover the ED. The type of staffing varies by time period and ED volume. On weekdays, about onethird of hospitals use physicians on their own medical staff; one third use contracted coverage; 18% use both; and 14% use physician assistants and/or nurse practitioners with a physician on-call. Hospitals are more likely to use a combination of medical staff and contracted coverage on evenings and weekends. Advanced Cardiac Life Support training is common, but Pediatric Advanced Life Support, Advanced Trauma Life Support, and training in working as a team are less common. More registered nurses working in rural EDs have taken the Trauma Nursing Core Course than the Emergency Nursing Pediatric Course. Conclusions: Rural ED staff would benefit from additional continuing education opportunities, particularly in terms of specialized skills to care for pediatric emergency patients and trauma patients and training in working effectively in teams .     

Self-report of delivery of clinical preventive services by U.S. physicians. Comparing specialty, gender, age, setting of practice, and area of practice.

OBJECTIVES: To summarize national survey results for key clinical preventive services provided by primary care physicians, characterize the results by demographic and practice attributes of the respondents, and compare the results to those obtained in other studies. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 3881 clinicians who provided primary care at least 50% of their time, randomly sampled from the professional associations representing family practitioners, pediatricians, internists, and OB-GYNs. MEASURES: The Primary Care Providers Survey instrument of 1992, administered through the Office of Disease Prevention and Health Promotion, designed to assess the provision of clinical preventive services by primary caregivers. MAIN RESULTS: Few of the physicians surveyed reported providing most indicated clinical preventive services more than 80% of the time. For the purposes of this paper, > 80% provision of preventive services is considered adequate. Female physicians reported providing more preventive services involving exercise, diet, alcohol/drugs, seatbelts, sexual activity, family planning, immunizations, and screening procedures. Physicians aged < 50 reported providing more preventive services involving smoking, alcohol/drugs, seatbelts, sexual activity, and family planning. Older physicians generally reported more delivery of vaccines and screening procedures. Practitioners from big metropolitan areas reported more preventive services involving alcohol/drugs and family planning while respondents in rural areas reported less immunizations and screening procedures. When analyzed by specialty, physicians reporting the most preventive care varied by type of preventive care. CONCLUSIONS: Small differences in the self-report of provision of clinical preventive services between specialties and demographic subgroups did exist. At the time of this survey, however, no group of primary care physicians reported providing clinical preventive services to their patients at adequate levels.     

A comparison of practice outcomes of graduates from traditional and non-traditional medical schools in Australia

AIM: The primary aim of the study was to compare the practice outcomes of doctors who graduated from a non-traditional, problem-based medical school (University of Newcastle) with those of graduates from a traditional programme (University of Sydney), matched randomly on the background characteristics of graduation year, age, gender, and rural primary and secondary school education. Our secondary aim was to differentiate admission from curricular influences by comparing the outcomes of Newcastle and Sydney graduates who entered medical school under similar admission criteria ('traditional academic' entry). DESIGN: Nested case-control analysis in a retrospective cohort study. METHODS: A validated mail-out survey was distributed to all Newcastle and Sydney graduates registered to practise in the state of New South Wales, Australia. OUTCOME MEASURES: Current main occupation (clinician or other), clinical career choice (family medicine and psychiatry or other specialties), practice location (urban or rural) and employment sector (public or private). RESULTS: A total of 513 Newcastle respondents (68% of the original, eligible Newcastle sample) were each matched randomly with a Sydney respondent according to the four background characteristics. Medical school background was not related to main occupation; over 90% of all graduates were employed in clinician positions. A greater proportion of Newcastle than Sydney graduates were either training or qualified in family medicine or psychiatry rather than in other specialties. The school of graduation was not related to practice environment; fewer than 20% of all graduates were working in rural locations and around 25% were employed in the public sector. There were no differences in outcome between Newcastle and Sydney graduates who had entered medical school under similar academic criteria. CONCLUSION: Our study suggests that initial selection procedures of medical school candidates with particular background characteristics and attributes may influence practice outcomes. Further research is required to confirm these findings.     

Minnesota bound. Stability of practice location among UMD family physicians in Minnesota

Previous studies indicate that physicians often move from one practice setting to another, particularly early in their career. However, data on practice relocation for a group of University of Minnesota, Duluth School of Medicine graduates show a different trend. Minnesota family physicians from the UMD School of Medicine have been remarkably stable in their practices over the past 20 years. More than 80% of these physicians have continued to practice in the same community that they selected after their training. In addition, physicians in this group who are practicing in smaller communities have not relocated to urban practices. These findings suggest that the UMD School of Medicine's emphasis on family medicine and rural practice may have influenced the practice retention rate for these physicians.     

Perceptions of philosophic and practice differences between US osteopathic physicians and their allopathic counterparts

Data were gathered through a random national mail survey of 3000 US osteopathic physicians. Nine hundred and fifty-five questionnaires were usable for analysis. Through open-ended questions, osteopathic physicians identified philosophic and practice differences that distinguished them from their allopathic counterparts, and whether they believed the use of osteopathic manipulative treatment (OMT), a key identifiable feature of the osteopathic profession, was appropriate in their specialty. Seventy-five percent of the respondents to the question regarding philosophic differences answered positively, and 41 percent of the follow-up responses indicated that holistic medicine was the most distinguishing characteristic of their profession. In response to the question on practice differences, 59 percent of the respondents believed they practiced differently from allopathic physicians, and 72 percent of the follow-up responses indicated that the osteopathic approach to treatment was a primary distinguishing feature, mainly incorporating the application of OMT, a caring doctor-patient relationship, and a hands-on style. More respondents who specialized in osteopathic manipulative medicine and family practice perceived differences between them and their allopathic counterparts than did other practitioners. Almost all respondents believed OMT was an efficacious treatment, but 19 percent of all respondents felt use of OMT was inappropriate in their specialty. Thirty-one percent of the pediatricians and 38 percent of the non-primary care specialists shared this view. Eighty-eight percent of the respondents had a self-identification as osteopathic physicians, but less than half felt their patients identified them as such. When responses are considered in the context of all survey respondents (versus only those who provided open-ended responses) not a single philosophic concept or resultant practice behavior had concurrence from more than a third of the respondents as distinguishing osteopathic from allopathic medicine. Rank and file osteopathic practitioners seem to be struggling for a legitimate professional identification. The outcome of this struggle is bound to have an impact on health care delivery in the US.