Education of Physician Assistants, Nurse Midwives, and Nurse Practitioners for Rural Practice

Physician assistants, nurse midwives, and nurse practitioners have been described as a vital and unique solution to the problem of providing adequate access to high quality health care for many Americans. Each of these classifications of health care providers has been accepted as separate professions with their own standards and identities. Their curricula and educational pathways have developed into clearly distinguishable educational tracks that complement the larger disciplines of nursing and medicine. Physician assistants, nurse midwives, and nurse practitioners have been singled out in federal legislation for their potential contribution to underserved rural communities (e.g., the Rural Health Clinics Services Act of 1977 and its subsequent amendments). This designation is partly due to the fact that certified nurse midwives, nurse practitioners, and physician assistants traditionally chose to practice in rural, underserved areas, and because their skills and practice structures were well matched to the needs and resources of rural areas. That pattern of practice, however, appears to have changed and the distribution of these practitioners has begun to resemble the distribution of physicians and other clinicians with heavy concentrations in urban areas and a growing shortage in rural and underserved areas.     

Rural Health Professions Education at East Tennessee State University: Survey of Graduates From the First Decade of the Community Partnership Program

CONTEXT: To help meet rural Appalachian needs, and with initial support from the W.K. Kellogg Foundation, East Tennessee State University partnered with 2 counties to implement a health curriculum for nursing, public health, and medical students in a rural setting. The Community Partnerships Program 3-year longitudinal curriculum included theoretical, conceptual, and practice elements of the 3 disciplines incorporated into an experiential, inquiry-based, service-learning program. Interdisciplinary learning, problem solving, and reinforcement of career choices in medically underserved rural communities were emphasized. PURPOSE: To compare career choices, attitudes, and practice locations of Community Partnerships Program graduates with traditional graduates. METHODS: Surveys were mailed to Community Partnerships Program and traditional program graduates matriculating from 1992 to 2002 (response rates 58/84 and 72/168, respectively). FINDINGS: Community Partnerships Program graduates indicated a significantly greater interest in rural primary care, care for the underserved and interdisciplinary group collaboration, and were more likely to practice in rural locations than did their traditionally educated peers. Family, personal factors, and the availability of employment were major influences in determining the decision to choose a career in a rural location. Community Partnerships Program graduates indicated they were better prepared to work in interdisciplinary teams and were more likely to work in community-based programs and activities than did the traditional graduates. CONCLUSION: A program that enrolls students interested in rural health care and provides training in rural communities produces graduates who will practice in rural areas.     

The influence of values and background on the location decision of nurse practitioners

The purpose of this study is to examine the influence of the value systems of family nurse practitioners and the background characteristics of family nurse practitioners and their spouses on the decision about location of practice. Information collected from a questionnaire sent to the graduates of the first five classes of the Family Nurse Practitioner Program at the University of Washington revealed that value systems, as measured by the Rokeach Value Survey, did not significantly affect the location decision of the family nurse practitioners, whereas rural background of the family nurse practitioner and spouse did have a major effect. It is concluded that, if we want to encourage family nurse practitioner graduates to practice in rural areas, we need to reevaluate the admissions criteria and training experiences provided by family nurse practitioner programs.Dr. Moscovice is Assistant Professor in the Department of Health Services, University of Washington Seattle, Washington 98195. Ms. Nestegard is a family nurse practitioner; her address is Pine Creek Route, Tonasket, Washington 98855.     

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.     

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.     

The Relationship of Rural Clinical Rotations to Where Registered Nurses Practice

An objective of exposing health profession students to rural clinical experiences was to overcome problems of geographic maldistribution of health personnel. Nevertheless, little can be said about the impact of rural training rotations on the supply of health personnel in rural areas or on students' decisions about where to practice. To assess the relationship between rural clinical rotations and practice locales, surveys were administered to all applicants taking registered nurse exams in Arizona in July 1990, February 1991, and July 1991. The students most likely to be working in rural locations were rural high school graduates with rural clinical experience during nursing school. Students who were urban high school graduates with rural clinical experience were only slightly less likely to locate in rural areas. Rural and urban high school graduates with no rural clinical experience were far less likely to choose rural practice. Rural rotations were associated with rural job selection only if students attended rural educational programs.     

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.     

Migration of allied health care personnel in and out of an underserved area: a question of roots

The distribution of health personnel and the resulting shortages of health care to economically depressed, ethnic, rural and inner city areas is a serious problem. Recruiting students from and training them in underserved areas has been suggested as one way to improve retention rates among graduates of allied health programs. A one-year follow-up survey of 1974 graduates of allied health programs sponsored by an Area Health Education Center located in an underserved, one ethnic group predominant rural area was done to test this approach. Results show that of the 122 graduates surveyed in this study, one year after graduation 85% had returned to work in the area of their previous residence. Among professional groups, licensed vocational nurses experienced the least migration. Generally, professions requiring higher levels of education showed higher relocation rates. Sex and ethnicity were related to these findings. The appeal of higher salaries or material benefits alone did not appear to attract graduates to migrate. It appears that communities with shortages of health manpower due to maldistribution may be successful in correcting this problem by recruiting students from their own area. Possible explanations and recommendations related to these findings are discussed.     

Gender Differences in Rural and Urban Practice Location Among Mid-level Health Care Providers

CONTEXT: Mid-level providers comprise an increasing proportion of the health care workforce and play a key role in providing health services in rural and underserved areas. Although women comprise the majority of mid-level providers, they are less likely to work in a rural area than men. Maldistribution of health providers between urban and rural practices is an important issue influencing health care. PURPOSE: To gain further insight into this issue, this study examined how mid-level practice location varied by gender. METHODS: Semistructured interviews were conducted with a purposive sample of 55 nurse practitioners, physician assistants, and nurse anesthetists in New York State and Pennsylvania. FINDINGS: Results suggest that family and community ties played a key role in influencing practice location. Men were particularly drawn to the broad scope of practice and autonomous nature of rural practice. Women in rural areas enjoyed the more personable environment and greater respect from colleagues and patients. Both male and female rural providers preferred their location because there were fewer turf issues, while some women were concerned about being professionally isolated. Meanwhile, both men and women enjoyed the fast pace, specialization, and greater opportunities urban areas had to offer. CONCLUSIONS: Recruitment efforts should focus on candidates from rural areas and not underestimate the impact of family in decisions about work location.     

Effectiveness of educational strategies preparing physician assistants,nurse practitioners,and certified nurse-midwives for underserved areas.

A study of physician assistant, nurse practitioner, and certified nurse midwifery programs was undertaken to identify and assess the effectiveness of recruitment, educational, and deployment strategies that programs use to prepare practitioners for medically underserved areas. The 51 programs studied were those having mission statements or known track records relating to this goal. A total of 170 interviews were conducted with faculty, students, graduates, and employers from 9 programs visited on-site and 42 programs surveyed by telephone. All programs had some recruitment and training activities in underserved sites. Only about half of the programs were able to submit data on their graduates'' practice settings and specialties. These data suggest that older students who have backgrounds in underserved areas and clearly identified practice goals are more likely to practice in underserved areas. Programs that actively promote service to the underserved do so through publicly stated missions and recruitment and educational strategies that complement these missions. Such programs also are more likely to evaluate and document their success than programs that lack strategies.     

Nutrition education in health professions programs: a survey of dental, physician assistant, nurse practitioner, and nurse midwifery programs

OBJECTIVE: This study determined the perceived needs and curriculum recommendations for nutrition education, and expected competencies in nutrition of graduates, of predoctoral dental, physician assistant, nurse practitioner, and midwifery programs. SUBJECTS: Surveys were mailed to all dental schools (n = 54) and physician assistant (n = 95), nurse practitioner (n = 150), and certified nurse midwifery programs (n = 42) in the United States. Surveys were addressed to the program directors of physician assistant, nurse practitioner, and certified nurse midwifery programs and the associate or assistant dean of academic affairs of dental schools. DESIGN: A 4-page survey was designed and pilot-tested. The survey included questions on respondents perceptions of and recommendations for their programs in nutrition education and expected nutrition competence level of their graduates. A reminder postcard was mailed 2 weeks after the initial mailing to nonrespondents; a second survey was mailed to nonrespondents 1 month after the postcard mailing. STATISTICAL ANALYSES: Data were analyzed using JMP-IN software. Frequencies, and chi 2 analyses, Wilcoxon rank sum test, Pearson chi 2 test. RESULTS: The overall response rate was 80.7% (n = 276). Perceived needs for competence in nutrition varied by respondents. Most of the physician assistant nurse midwifery, and nurse practitioner program directors had similar perceptions of graduates' competence in nutrition. Dental school academic administrators differed significantly from the program directors about the perceived need for knowing how to counsel on a modified diet and how and when to refer to a registered dietitian. Time was the most important factor that would enhance provision of nutrition education in the programs. Computer-based programs were the most frequently requested education tool to enhance nutrition education. APPLICATIONS/CONCLUSIONS: The disciplines agreed that graduates of dental schools and physician assistant, nurse practitioner, and nurse midwifery programs need some level of competence in nutrition relative to their discipline. Registered dietitians involved in health professions education can play an active role in developing practice-based, time-sensitive, and flexible strategies for nutrition education of these health professions groups.     

A Cohort Study of Family Practice Residency Graduates in a Predominantly Rural State: Initial Practice Site Selection and Trajectories of Practice Movement

Limited information is available on long-term patterns of practice location choice among family physicians, although these patterns will significantly affect the quantity, quality, and continuity of health care provided in rural areas. From 1992 through 2000, five biennial surveys were administered to graduates of three family practice residency programs. Graduates were asked the location of their current and previous practice site locations, specific practice information, and global satisfaction with family practice. Identifiable practice sites were assigned a U.S. Department of Agriculture rural-urban continuum code based on the county in which the practice was located. The use of rural-urban continuum codes as a measure of rurality was believed to be particularly applicable to the small rural and frontier counties typical of the Great Plains region. For purposes of this study, practice locations were considered rural if they were in rural-urban continuum codes 7, 8, or 9. Of 593 graduates, 514 (87%) returned at least one questionnaire. Overall, about one-third of graduates had chosen their first practice sites in counties with rural-urban continuum codes of 7, 8, or 9. While most graduates remained in their initial practice site, almost half moved at least once. Those who left nonmetropolitan practices tended to move to less rural locations, though a few moved against this gradient. Moves away from the initial practice site occurred after a median of 3 years, and the likelihood of a first move decreased rapidly 5 to 6 years after graduation. Much remains to be learned about decisions to enter or leave practice in rural-urban continuum code 7, 8, and 9 counties.     

A rural service-learning model for health administration education

Service learning for students in the health professions can best be described as an educational methodology based on the collaboration between an academic discipline and a community agency to link student learning with community-based service. This paper describes a service-learning model in rural and medically underserved communities used in a master in health administration program in a rural Southern state. It presents the process, components, outcomes, and challenges. Over the past five years, 56 students completed 116 experiences involving internships, field projects, or special projects in rural and medically underserved communities. A total of 27 percent of our graduates who completed rural and medically underserved experiences accepted job positions in rural health care entities. Strategies utilized by this rural service-learning model include interdisciplinary team training, partnerships among rural and medically underserved community health care entities and academic institutions, faculty-preceptor retreats, and involvement in local community initiatives. These experiences prepare future health administrators to contribute in a meaningful way toward building an effective rural health care delivery system.     

Family Medicine Education and Rural Health: A Response to Present and Future Needs

The importance of family medicine in providing rural health services has been established for quite some time. The need to train physicians who select the specialty of family medicine is critical at a time when medical student interest in the primary care specialties appears to be diminishing. Renewed efforts by educational institutions and incentives at the state and federal levels will be necessary to assist in the alleviation of shortages of rural physicians. The educational program at the University of Minnesota, Duluth, School of Medicine has achieved a great deal of success in training rural family physicians. A coordinated program effort, featuring the efforts of more than 200 family physicians during the past 15 years, has led to 52.5 percent of all graduates selecting family practice and more than 41 percent choosing practice sites with a population fewer than 20,000. Elements of the program at Duluth could serve as a model for other schools desiring to increase the number of students entering family medicine and rural practice.     

Do International Medical Graduates (IMGs) “Fill the Gap” in Rural Primary Care in the United States? A National Study

ABSTRACT:  Context: The contribution that international medical graduates (IMGs) make to reducing the rural-urban maldistribution of physicians in the United States is unclear. Quantifying the extent of such "gap filling" has significant implications for planning IMG workforce needs as well as other state and federal initiatives to increase the numbers of rural providers. Purpose: To compare the practice location of IMGs and US medical graduates (USMGs) practicing in primary care specialties. Methods: We used the 2002 AMA physician file to determine the practice location of all 205,063 primary care physicians in the United States. Practice locations were linked to the Rural-Urban Commuting Areas, and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentage of IMGs and percentage of USMGs in each type of geographic area. This was repeated for each Census Division and state. Findings: One quarter (24.8% or 50,804) of primary care physicians in the United States are IMGs. IMGs are significantly more likely to be female (31.9% vs 29.9%, P < .0001), older (mean ages 49.7 and 47.1 year, P < .0001), and less likely to practice family medicine (19.0% vs 38%, P < .0001) than USMGs. We found only two Census Divisions in which IMGs were relatively more likely than USMGs to practice in rural areas (East South Central and West North Central). However, we found 18 states in which IMGs were more likely, and 16 in which they were less likely to practice in rural areas than USMGs. Conclusions: IMGs fill gaps in the primary care workforce in many rural areas, but this varies widely between states. Policies aimed to redress the rural-urban physician maldistribution in the United States should take into account the vital role of IMGs .     

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.     

Proposed Changes to Designations of Medically Underserved Populations and Health Professional Shortage Areas: Effects on Rural Areas

This paper reports an analysis of the proposed rule to combine medically underserved population (MUP) and health professional shortage area (HPSA) designations, as published by the Bureau of Primary Health Care (BPHC) in the Federal Register on Sept. 1, 1998 (Department of Health and Human Services, 1998). The effects of the proposed rule overall and on rural communities were examined, particularly with respect to current whole county HPSA designations and eligibility for federal assistance programs. National, county-level estimates of primary care provider counts and other measures included in the proposed rule were used. Different primary care provider sources were compared; results were highly dependent on the data source and the inclusions of counts of nurse practitioners and physician assistants. The projections of losses from the proposed rule were higher than those of the BPHC, probably due to the use of different sources for provider counts. Overall, the authors projected that more than 50 percent of current whole-county HPSAs would lose designation using the proposed rule. The proportion of rural counties that lost designation was not significantly greater than the proportion of urban counties, but because there are many more rural counties, more de-designations were projected to occur in rural areas. The researchers also predicted that 58 percent of rural whole-county HPSAs with National Health Service Corps providers would lose their designation, but most rural whole-county HPSAs with Community and Migrant Health Centers or Rural Health Clinics retained their MUP designation using the proposed rule. The proposed rule likely has a larger effect on current designations than originally projected by the BPHC.     

Factors in Recruiting and Retaining Health Professionals for Rural Practice

CONTEXT: Rural communities, often with complex health care issues, have difficulty creating and sustaining an adequate health professional workforce. PURPOSE: To identify factors associated with rural recruitment and retention of graduates from a variety of health professional programs in the southwestern United States. METHODS: A survey collecting longitudinal data was mailed to graduates from 12 health professional programs in New Mexico. First rural and any rural employment since graduation were outcomes for univariate analyses. Multivariate analysis that controlled for extraneous variables explored factors important to those who took a first rural position, stayed rural, or changed practice locations. FINDINGS: Of 1,396 surveys delivered, response rate was 59%. Size of childhood town, rural practicum completion, discipline, and age at graduation were associated with rural practice choice (P < .05). Those who first practiced in rural versus urban areas were more likely to view the following factors as important to their practice decision: community need, financial aid, community size, return to hometown, and rural training program participation (P < .05). Those remaining rural versus moving away were more likely to consider community size and return to hometown as important (P < .05). Having enough work available, income potential, professional opportunity, and serving community health needs were important to all groups. CONCLUSION: Rural background and preference for smaller sized communities are associated with both recruitment and retention. Loan forgiveness and rural training programs appear to support recruitment. Retention efforts must focus on financial incentives, professional opportunity, and desirability of rural locations.     

温州农村地区不同人群计划生育知信行现状及其影响因素

目的:探讨农村地区不同人群计划生育知信行的现状及影响因素。方法:采用分层整群随机抽样方法,对浙江省温州市3个县(市)的农村人口共782人进行横断面调查。结果:不同的职务、文化程度、村落位置的知识得分组间差别有统计学意义(P<0.01);不同的职务、职业、年龄、文化程度、生育情况、家庭收入、村落位置以及对计划生育扶助政策的满意度的信念和行为得分组间差别亦有统计学意义(P<0.05或P<0.01);知识得分、信念得分和行为得分之间存在正相关,信念得分和行为得分之间的相关性更明显。结论:加强对农村人群计划生育宣传和完善计划生育扶助政策,尤其要针对低文化、低收入、务农、首胎为女、40岁以上以及地处偏远山区或农村等特定人群进行重点干预。     

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.