Critical factors for designing programs to increase the supply and retention of rural primary care physicians

Context  The Physician Shortage Area Program (PSAP) of Jefferson Medical College (Philadelphia, Pa) is one of a small number of medical school programs that addresses the shortage of rural primary care physicians. However, little is known regarding why these programs work. Objectives  To identify factors independently predictive of rural primary care supply and retention and to determine which components of the PSAP lead to its outcomes. Design  Retrospective cohort study. Setting and Participants  A total of 3414 Jefferson Medical College graduates from the classes of 1978-1993, including 220 PSAP graduates. Main Outcome Measures  Rural primary care practice and retention in 1999 as predicted by 19 previously collected variables. Twelve variables were available for all classes; 7 variables were collected only for 1978-1982 graduates. Results  Freshman-year plan for family practice, being in the PSAP, having a National Health Service Corps scholarship, male sex, and taking an elective senior family practice rural preceptorship (the only factor not available at entrance to medical school) were independently predictive of physicians practicing rural primary care. For 1978-1982 graduates, growing up in a rural area was the only additionally collected independent predictor of rural primary care (odds ratio [OR], 4.0; 95% CI, 2.1-7.6; P<.001). Participation in the PSAP was the only independent predictive factor of retention for all classes (OR, 4.7; 95% CI, 2.0-11.2; P<.001). Among PSAP graduates, taking a senior rural preceptorship was independently predictive of rural primary care (OR, 2.5; 95% CI, 1.3-4.7; P = .004). However, non-PSAP graduates with 2 key selection characteristics of PSAP students (having grown up in a rural area and freshman-year plans for family practice) were 78% as likely as PSAP graduates to be rural primary care physicians, and 75% as likely to remain, suggesting that the admissions component of the PSAP is the most important reason for its success. In fact, few graduates without either of these factors were rural primary care physicians (1.8%). Conclusions  Medical educators and policy makers can have the greatest impact on the supply and retention of rural primary care physicians by developing programs to increase the number of medical school matriculants with background and career plans that make them most likely to pursue these career goals. Curricular experiences and other factors can further increase these outcomes, especially by supporting those already likely to become rural primary care physicians.      

Attitudes of primary care physicians toward corporal punishment.

OBJECTIVE--The purpose of this study was to determine whether or not family physicians and pediatricians support the use of corporal punishment. The frequency with which these physicians offer anticipatory guidance on discipline was also studied. DESIGN--Self-report survey, mailed to study participants. PARTICIPANTS--The sample for this study was 800 family physicians and 400 pediatricians, randomly selected from the Ohio State Medical Board's roster of family physicians and pediatricians. Physicians with a subspecialty were excluded. Participants who did not return their surveys received a second, and if necessary, a third mailing of the survey. After three mailings, a total of 619 physicians (61%) completed a survey. MAIN OUTCOME MEASURE--Participants were considered to support corporal punishment if they would tell a parent in their medical practice that spanking would be an appropriate response to any one of a series of childhood misbehaviors presented in the survey. RESULTS--Of family physicians, 70% (95% confidence interval [CI], 66% to 75%) support use of corporal punishment. Of pediatricians, 59% (95% CI, 52% to 66%) support corporal punishment. Of pediatricians, 90% (95% CI, 86% to 94%) indicated that they include discipline issues either always or most of the time when providing anticipatory guidance to parents. Significantly fewer family physicians (52%; 95% CI, 47% to 57%) indicated that they discuss discipline either always or most of the time when providing anticipatory guidance (P less than .01). CONCLUSIONS--Most family physicians and pediatricians support the use of corporal punishment in spite of evidence that it is neither effective nor necessary, and can be harmful. Pediatricians offer anticipatory guidance on discipline more often than family physicians.     

Early detection of depression by primary care physicians.

The overall prevalence of depression is from 3.5% to 27%. The burden of suffering is high and includes death through suicide. In most cases treatment is effective, but important episodes of depression are being missed. To determine whether a brief, systematic assessment for the early detection of depression should be part of the periodic health examination we searched MEDLINE and the Science Citation Index for randomized controlled trials that evaluated the effectiveness of early detection of depression with a questionnaire. Seven instruments met our quality criteria; the Beck Depression Inventory, the Center for Epidemiologic Studies Depression Scale, the Zung Self-Assessment Depression Scale, the General Health Questionnaire, the Hopkins Symptom Checklist, the Mental Health Inventory and the Hospital Anxiety and Depression Scale. The four randomized controlled trials failed to provide adequate evidence of the benefit of routine screening. Early detection is difficult because of depression's natural history, the role of symptoms, the cultural diversity of Canada and how detection instruments have been developed. Depression deserves careful attention from primary care physicians; however, further research and development is required before the widespread routine use of any detection test can be recommended.     

Educational package on hypertension for primary care physicians.

The usefulness of an educational package on hypertension that provides clinically important, up-to-date medical information and office "aids" to primary care physicians was tested in a randomized controlled trial. Fifty-six physicians completed a pretest multiple-choice questionnaire and were allocated at random either to a group that received the educational package (the "study group") or to a control group. There was a highly significant correlation between the pretest scores and the number of years since graduation (r = -0.55, p less than 0.0001), which indicated that younger physicians are more likely than older physicians to have an up-to-date knowledge of the management of hypertension. The increase in knowledge in the study group (17.5%) was significantly greater than that in the control group (2.7%). Furthermore, although the post-test scores in the control group were still significantly correlated with the number of years since graduation, those in the study group were not. It was concluded that although the older physicians knew less than their younger colleagues about hypertension, the use of the educational package significantly increased knowledge, and the increase was not limited by the physician's age.     

Hepatitis C: a review for primary care physicians

Primary care physicians see many of the estimated 250 000 Canadians chronically infected with the hepatitis C virus (HCV). Of this number, about one-third are unaware they are infected, which constitutes a large hidden epidemic. They continue to spread HCV unknowingly and cannot benefit from advances in antiviral therapy that may clear them of the virus. Many HCV-infected people remain asymptomatic, which means it is important to assess for risk factors and test patients accordingly. The third-generation enzyme immunoassay for HCV antibodies is a sensitive and specific test, although the presence of the virus can be confirmed by polymerase chain reaction testing for HCV RNA in some circumstances. Pegylated interferon-α and ribavirin combination therapy clears the virus in about 45%–80% of patients, depending on viral genotype. Preventive strategies and counselling recommendations are also reviewed.     

Compliance with screening mammography. Survey of primary care physicians

A survey of primary care physicians in the greater Tampa Bay metropolitan area was conducted to determine compliance with screening mammography and associated physician characteristics. Information requested included their age, sex, specialty, and board certification status, and the ages and frequencies that they recommend screening mammography for their patients. A total of 565 physicians responded. Even though 88% indicated they follow American Cancer Society recommendations when advising screening mammography, only 62% were actually in full compliance. A significantly greater percentage of obstetricians/gynecologists were compliant (74%) compared to other specialties (family practice, 57%, p = .006; internal medicine, 56%, p = .007; general practice, 53%, p = .003). Women physicians were more likely to be compliant than men (83% versus 58%, p less than .001), and younger physicians more likely than older physicians (72% versus 49%, p less than .001). There was no significant difference in compliance rates between board certified and noncertified physicians.     

Prayer in medicine: a survey of primary care physicians

Prayer and spirituality have been shown to have a significant impact on several health variables. Additionally, studies have shown that patients think prayer is important to their health. Very little research, however, has been done to determine primary care physicians' opinions regarding prayer and spirituality as it pertains to healthcare. We surveyed primary care physicians in Mississippi to assess their use of prayer in medical practice. Ninety-one percent of respondents considered prayer an important treatment modality, but 50.6% rarely or never discussed prayer with patients. Most who excluded prayer from clinical practice did so to avoid imposing their beliefs upon patients. A majority of primary care physicians in Mississippi recognize prayer as an important psychosocial variable in assessing and treating patients, but many are hesitant to incorporate this variable into the doctor-patient encounter.     

The knowledge and attitudes of the primary care physicians on developmental dysplasia of the hip

OBJECTIVE: For the prevention and early diagnosis of developmental dysplasia of the hip (DDH), a detailed clinical screening of the newborn performed by a primary care (PC) physician is recommended as a standard practice throughout the most western countries. We aimed to determine the knowledge and attitudes of the PC physicians towards DDH, and to develop further educational and training programs, according to the results obtained from the study. METHODS: The study was a pre- and post- test with a cross-sectional design. In winter of 2005, the participants included 102 PC physicians from 20 primary health care centers in Kahramanmaras, Turkey. A structured questionnaire was prepared consisting of 28 statements on medical, practical, and traditional knowledge and attitudes concerning DDH. RESULTS: There was a significant difference between the pre-test (71.47 +/- 9.92) and post-test scores (78.85 +/- 12.86) of participants (p=0.000). Of the participants, 83 (81.4%) before, and 93 (91.2%) after the lecture, thought that DDH is a preventable disease. Prior to the lecture, only 27.5% of the physicians were aware of the wrong traditional attitudes that are considered as risk factors for DDH. CONCLUSION: The knowledge and attitudes of PC physicians on DDH needs to be improved by providing continuous education programmes.