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.     

Changes and Challenges in Rural Graduate Medical Education: The Family Medicine Spokane Rural Training Track Experience in Colville, Wash.

Rural community-based graduate medical education programs in family practice are considered wise investments in America's future because they generate highly trained physicians who typically settle and practice in rural communities. In recent years, however, federal funding cutbacks and revised accreditation requirements have threatened the viability of these programs. In Colville, Wash., Mount Carmel Hospital has responded by agreeing to continue its collaboration with the Northeast Washington Medical Group to fully fund the cost of the Family Medicine Spokane Rural Training Track family practice residency program.     

Geriatric medicine training for family practice residents in the 21st century: a report from the Residency Assistance Program/Harfford Geriatrics Initiative

Increasing the quality and quantity of geriatric medicine training for family practice residents is a particular challenge for community-based programs. With support from the John A. Hartford Foundation of New York City, the American Academy of Family Physicians (AAFP) implemented in 1995 a multi-part project to improve the amount and quality of geriatric medicine education received by family practice residents. This report summarizes the initial results of the regional geriatric medicine curriculum retreats for residency directors. The goals of the retreats were to build recognition among the residency directors of the skills that future family physicians will require to be successful providers of primary care to older adults and to allow the residency directors to identify and develop solutions to barriers to improving geriatric medicine training for residents. Forty-six program directors participated in the three retreats between February 2000 and February 2001. The participants represented 52 programs and rural tracks in all geographic regions, small and large programs, and urban and rural settings. The program directors developed a consensus on the geriatric medicine knowledge, skills, and attitudes that should be expected of all family practice residency graduates; developed a list of basic, required educational resources for each family practice residency program; and proposed solutions to common obstacles to successful curriculum development.     

The Rural Physician Workforce in Florida: A Survey of US- and Foreign-Born Primary Care Physicians

CONTEXT: To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed. PURPOSE: This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida. METHODS: Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians. FINDINGS: Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians. CONCLUSIONS: Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.     

A Strategy to Increase the Number of Urban Family Practice Resident Physicians Who Enter Rural Practice

Physician geographic maldistribution is a problem in the United States health care system. Innovative strategies are needed to entice resident family physicians training in the larger, more numerous suburban and urban training programs to practice in rural areas upon completing their training. This paper describes a strategy used at St. Elizabeth Medical Center Family Practice Residency Program, Dayton, OH, to encourage rural practice. In the St. Elizabeth plan, the interested family practice resident moonlights in a rural practice provided by the local county hospital. The county medical staff covers the resident physician's practice during the frequent absences. The residency program faculty provide on-site supervision, telephone back-up coverage, and practice consultation. The county hospital provides billing services; the resident physician retains 100 percent of collections. The resident physician gains exposure to the knowledge, skills, and attitudes needed in rural practice. Upon completion of residency training, the physician remains in practice and is not required to pay back any expenses incurred by the hospital. Two resident physicians participate currently; three others have expressed interest in practicing in the community. A similar plan might work in parts of the United States where, like Ohio, training programs and rural communities are not far apart.     

The University of Missouri Rural Obstetric Network: creating rural obstetric training sites for a university-based residency program

This paper describes a rural obstetric experience that was developed for a university-based family practice residency program and designed to increase the number of deliveries per resident, the number of graduates practicing in rural areas, and the number of graduates doing obstetrics. Rural hospitals can be a source of deliveries for residency training programs. This rural obstetric experience also offers more training months in a rural setting and more months training with family physicians.     

Community medicine in the training of family physicians.

Family practice residency programs are encouraged to include community medicine training in their curriculum, but there is little agreement as to what community medicine is or what would constitute appropriate training. Community medicine is most commonly defined as a discipline concerned with the identification and solution of health care problems of communities or other defined populations. The inclusion of training experiences in the identification and solution of health care problems of communities has two basic advantages for family practice residency programs: it fosters a contextual approach in the care of individual patients and it builds knowledge and skills for those who will work with communities in future practices. An example of curricular content is included. A survey was conducted in order to determine what residency programs teach in the field of community medicine. The results show that few of the responding programs include the areas which most clearly relate to community medicine. It is hoped that the report of these results, the rationale presented for including community medicine in the training of family physicians, and the suggested outline of curricular content will further encourage and assist family practice residency programs to incorporate such training in their curricula.     

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.     

Characteristics of and Issues Faced by Rural Female Family Physicians

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

Graded exercise stress test training in family practice and internal medicine residencies

A mail survey of upper Midwest family practice and internal medicine residency program directors was performed to determine the prevalence and characteristics of exercise stress test training. Two mailings provided a 68% response rate for the 184 programs surveyed. Internal medicine programs were significantly more likely to offer exercise stress test training than family practice programs (57% vs 34%). Overall, an estimated 31% of family practice and internal medicine residency graduates are performing exercise stress tests in their practice. Programs provided an average of 7.3 hours of didactic instruction and 32.7 stress tests per resident. A minority (43%) had an established minimum number of exercise stress tests recommended for competency. Programs with and without exercise stress test training did not differ significantly with respect to age, size of program, or size of community. There were some interstate differences in the extent of exercise stress test training provided by family practice residency programs. Internal medicine programs were more likely to require a minimum number of treadmill tests. Otherwise there were few differences between family practice and internal medicine program instruction in exercise stress test training. Family practice program directors were more likely to believe that their residents should be taught this procedure and to include family physicians in their panel of instructors. Specific guidelines should be created to assure adequate stress test training for interested residents.     

Family care in a family practice group.

A fundamental claim of family medicine is that the family physician treats the "whole" family--an ideological principle that guides undergraduate and residency education. Using archival data obtained from a random sample of 500 patients in one group of family physicians, this study analyzed the extent to which this principle is carried out in practice. Physicians trained in family practice residency programs were compared with their colleagues. Family types and marital stability were also examined. Results indicate that in only 28 percent of families (excluding single person households) were all family members seen by the same family physician. This occurred despite the high preponderance and stability of traditional nuclear families in the practice. There was no significant difference in this rate between graduates and nongraduates of approved family practice residency programs.     

Outcomes of Rural Training Tracks: A Review

Rural training tracks (RTTs) have developed as a strategy to encourage family medicine resident entrance into rural practice. Because most programs are small (two to four residents), data must be aggregated to determine RTT impact on practice preparation and location. Several studies over the last decade reveal that 76 percent of RTT graduates are practicing in rural America and that graduates describe themselves as prepared for rural practice. Sixty-five percent are providing obstetrical services, and half are performing cesarean sections. From 1989 to 1999, there were a total of 107 graduates of rural training programs, making it unlikely that, without significant investment, this model could supply an adequate quantity of family physicians for rural America.     

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

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

Attracting physicians to underserved communities: the role of health networks

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

Postgraduate Medical Education for Rural Family Practice in Canada

Canada is a large country with a diverse and spread-out rural population. Compared to their urban counterparts, rural Canadians have fewer family doctors and dramatically fewer specialists, and they face other significant geographic barriers to accessing health care. This paper describes the milieu of the rural physician in Canada and reports on efforts to develop a postgraduate medical education model for rural family practice that will produce more physicians with the knowledge, skills and interest to practice in small and mid-sized communities. Key recommendations of the College of Family Physicians of Canada include: providing earlier and more extensive rural medicine experience for all undergraduate medical students, developing rural postgraduate training programs, providing third-year optional special and advanced rural family medicine skills training and making advanced family medicine skills training competency-based and nationally accredited.     

Location patterns of recent physician settlers in rural America

The location patterns of young physicians who settled in the most rural communities of America between 1973 and 1976 are analyzed. The majority of these recent rural settlers were primary care practitioners. They tended to be the alumni of state university medical schools in states with large rural populations. Foreign medical graduates were heavily represented. The principal finding—a tendency toward further concentration of rural physicians within existing medical communities—suggests that those rural communities with the greatest needs may remain underserved without the assistance of organized external programs.     

House call practices among young family physicians

Once a major part of medical practice, physician house calls have declined in frequency over the years. Recently, it has been suggested that house calls are increasing. This study examined the current self-reported house call practices among recent graduates of family practice residency programs in the United States. A questionnaire was mailed to a cross-sectional, random national sample of 301 family physicians who are members of the American Academy of Family Physicians and who completed a residency between 1981 and 1986. There was a 66% response rate to three mailings, with 197 questionnaires analyzed. Sixty-two percent of the physicians reported they were making house calls. The majority (53%) made less than one house call per month. Fewer than 15% made house calls on a weekly basis. There was a downward trend by residency year in the percentage of physicians making house calls when comparing graduates from 1981 to 1986. House calls do not appear to be a significant part of the practice of young family physicians.     

Long-term outcomes of primary care residency choice by graduating medical students in one medical school

The ratio of primary care physicians to subspecialists is of major importance to the future of American medicine. This study examined the output of primary care physicians by a state-supported medical school that has a goal of placing 50% of its graduates in primary care. Data were obtained from alumni office questionnaires and published board-certification listings for 1102 graduates of the University of Kentucky College of Medicine from 1973 through 1983. Fifty percent of these graduates chose residency training in primary care. Of all 1102 graduates, 37% are categorized as practicing primary care physicians; 29% of the total are board certified in a primary care discipline. Attrition from primary care as an initial career choice at entry into residency was 26%. With declining medical student interest in primary care and a shortage of primary care physicians, new initiatives in medical education and in the practice of medicine are necessary to balance the specialty distribution of physicians more favorably toward primary care.