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.     

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.     

Eliminating Primary Care Health Professional Shortage Areas: The Impact of Title VII Generalist Physician Education

Most policy-makers and researchers agree that although the United States is headed for a significant physician surplus, problems of equity in access to care still remain. To help meet this challenge, Title VII of the Public Health Service Act focuses on producing generalist physicians to serve in medically underserved areas (MUAs). This study estimates the impact Title VII support for generalist training has on reducing and eliminating health professional shortage areas (HPSAs) under multiple scenarios that vary either the Title VII funding level or the percentage of Title VII-funded program graduates who practice in MUAs. For each scenario, the number of Title VII-funded residency graduates who initially practice in MUAs and the time it would take to eliminate HPSAs are estimated. Using 1996 rates, the analysis predicts that 1,214 generalist physicians will enter practice in HPSAs annually, leading to elimination of HPSAs in 24 years. In 1997, Title VII-funded programs increased the rate of graduates entering HPSAs, resulting in 1,357 providers and reducing the time for HPSA elimination to 15 years. Doubling the funding for these programs would increase the number of Title VII-funded generalist physicians entering MUAs and could decrease the time for HPSA elimination to as little as 6 years. The study concludes that eliminating HPSAs requires broader Title VII influence and continuous improvement in rates of production of graduates who practice in MUAs. Without Title VII graduates and continuous improvement of Title VII program, MUA rates, the number of HPSAs and the number of Americans with reduced access to essential health care will continue to expand.     

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 effect of federal grants on medical schools' production of primary care physicians.

OBJECTIVES. Title VII of the Health Professions Educational Assistance Act of 1976 was created to encourage the production of primary care physicians. This study explored recent trends in the proportion of US medical school graduates entering primary care in relationship to Title VII funding. METHODS. The American Medical Association Physician Masterfile was used to determine the specialty choice of all students graduating from American medical schools between 1960 and 1985. RESULTS. The proportion of graduates entering primary care rose from 19.7% in 1967 to 31.1% in 1976 and remained stable for the subsequent decade. The increase occurred before implementation of Title VII. Rural, state-owned medical schools with departments of family medicine tend to produce a greater proportion of primary care physicians than urban private schools without family medicine departments. CONCLUSIONS. The values of American medical schools and the reward structure of American medical practice favor the production of specialists over primary care physicians. Although Title VII helped to encourage and sustain the development of primary care educational programs at both the medical student and graduate levels, an increase in the proportion of primary care physicians will require fundamental changes.     

Physicians Who Treat the Elderly in Rural Florida: Trends Indicating Concerns Regarding Access to Care

CONTEXT: Rural elderly patients are faced with numerous challenges in accessing care. Additional strains to access may be occurring given recent market pressures, which would have significant impact on this vulnerable population. PURPOSE: This study focused on the practice patterns and future plans of rural Florida physicians who routinely see elderly patients. Additionally, we examine those who provide services to a high volume of Medicare (HVM) patients. METHODS: A self-administered mailed survey was sent to rural physicians who identified themselves as practicing family medicine, internal medicine, psychiatry, general surgery, a surgical specialty, or a medical specialty. Questions examined changes in services offered by all rural physicians and among them, the HVM physicians. Impact of the professional liability insurance situation, satisfaction with current practice, and future practice plans on changes in service availability was also examined. RESULTS: Overall, 539 physicians responded for a participation rate of 42.7%. Two hundred eighty eight (54.9%) of all physicians in the study indicated a decrease or elimination of patient services in the last year. HVM physicians, compared to low volume of Medicare providers, were significantly more likely to decrease or eliminate services overall (66% vs 45%, P =.001). Mental health services (47% vs 18%, P =.001), vaccine administration (39% vs 16%, P =.008), and Pap smears (41% vs 13%, P =.008) were more likely to be eliminated among the HVM physicians. HVM physicians were also significantly more likely to be somewhat or very dissatisfied (40% vs 23%, P =.012) with their practice. CONCLUSIONS: Physicians in rural Florida report dissatisfaction with their practice and are decreasing or eliminating services that are important to the elderly. Given the aging population and increasing need for health care services, these trends raise concern about the ability for these patients to receive necessary care.     

Evaluation of a Medical School for Rural Doctors

CONTEXT: Jichi Medical School (JMS) is the first and only medical school in Japan that was founded exclusively to graduate/prepare rural doctors. PURPOSE: To evaluate the long-term effect of JMS on the nationwide distribution of doctors. METHODS: Data from the Japanese population census of 1995 and from the Japanese physician census of 1994 were combined for use in this study. We extracted the JMS graduates from the physician census and compared the distribution of JMS graduates to that of non-JMS graduates. JMS graduates have an obligation to work in rural areas for 9 years after graduation. Therefore, we divided them into those doctors who were either "under rural duty" or "after rural duty."FINDINGS: JMS graduates were more likely than non-JMS physicians to practice in rural municipalities. The percentage of JMS graduates practicing under rural duty in communities meeting at least 1 of 4 possible criteria for being considered rural was 2.7 times greater than the percentage of non-JMS graduates in such communities. The percentage of JMS graduates practicing after rural duty in communities meeting at least 1 rural criterion was 2 times that of non-JMS graduates. The JMS graduates accounted for only 0.7% of all the physicians in Japan. However, they accounted for 4.2%, 1.5%, 1.8%, and 3.0% of the physicians in small population, remote, mountain, and medically underserved municipalities, respectively. CONCLUSIONS: The goal of JMS to produce rural doctors in Japan has made an impact on doctor distribution nationwide.     

Community service by North Carolina family physicians

BACKGROUND: Community service is an integral part of American society. Although Family Medicine advocates community service through community medicine, few data exist on family physicians' involvement in voluntary community service activities or roles as community advocates. METHODS: A questionnaire was mailed to 489 North Carolina family physicians, including a 20% random sample of those in community practice and all statewide faculty physicians. The survey assessed types and amount of volunteer activity, attitudes toward volunteer work, and factors that support or inhibit participation in community service. RESULTS: The overall response rate was 54%. Most respondents reported strong interests in community service before medical school and residency, yet few reported any relevant training during medical education. More than 85% of faculty and community practice family physicians reported participating in volunteer service in the previous year (70.8 mean hours for faculty vs 45.5 mean hours for community practice; P = .06). Family physicians also reported a wide variety of lifetime volunteer activities (mean number of different faculty physician activities 20.8 vs mean number of different community practice physician activities 16.7, P = .00). Less than 50% of both physician groups reported that their practice or program publicly supports those performing community service. CONCLUSIONS: The great majority of family physicians in North Carolina regularly participate in one or more volunteer community service activities, frequently without organizational recognition. Data about the scope of service expected by communities and provided by physicians may assist the discipline in clarifying the place of volunteer community service in medical education, promotion guidelines and practice.     

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.     

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.     

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.     

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.     

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.     

Minnesota general surgeons. Where do they come from?

A downward trend in the number of graduates from U.S. allopathic medical schools applying for general surgery residency positions has raised questions about whether there will be sufficient numbers of general surgeons to meet future needs. Of particular concern are rural areas, which some studies have suggested will increasingly feel the effects of physician shortages because of the aging physician work force, increasing overall population, and aging patient population. Where physicians are educated and trained appears to have a significant effect on where they choose to practice. This article reports on a 2004 study of where practicing general surgeons in Minnesota went to medical school and did their residencies. According to the findings, the majority received their medical school and/or residency training in the Upper Midwest, and many have come from Minnesota's own medical schools and general surgery residency programs.     

The National Area Health Education Center Program and Primary Care Residency Training

The Area Health Education Center (AHEC) program was established in 1972 to improve the supply, distribution, retention and quality of primary care and other health practitioners in medically underserved areas. Through academic/community partnerships, regional AHECs offer a broad array of educational programs for students, residents and practicing health professionals. With primary care medical education a core part of AHEC programs, AHECs have been involved in decentralized residency training from the outset, with particular attention to family medicine. This paper provides an overview of the national AHEC program, its core components and its support for primary care residency training. Although AHECs have achieved considerable success in training primary care physicians for their respective states, continued refinements of programs are needed to address the needs of the most rural and underserved communities.     

A Comparative Assessment of West Virginia's Financial Incentive Programs for Rural Physicians

ABSTRACT: Context: Financial incentive programs are increasingly being used as a strategy to recruit physicians to underserved rural areas. Critical evaluation of state supported programs is often lacking but is necessary to determine their efficacy and to improve outcomes. Purpose: The purpose of this study was to assess 4 service-contingent programs in West Virginia, a state with critical physician shortages. Methods: Survey instruments were developed to evaluate the effectiveness of these programs and to document the practice environments and career paths of obligated allopathic and osteopathic physicians compared with a control group of nonobligated rural practitioners. Data were also collected from physicians who were recipients of multiple incentive programs and from obligated physicians who had defaulted. Findings: Responses from more than 60% of surveyed physicians indicated that the typical respondent was a married white male who was a midcareer Family practice physician. Obligated physicians were more likely than nonobligated physicians to have graduated from a West Virginia medical school and residency program, to be influenced by financial factors in their career decisions, to provide care to uninsured patients, and to work in offices that offered sliding fee scales. Both groups of physicians demonstrated similar retention patterns, reported a high degree of job satisfaction, and expressed a need for more practice management training. Conclusions: Although these financial incentive programs were found to be effective in recruiting primary care physicians to medically underserved areas of the state, the financial support of these programs was found to be too modest, and improved marketing of the programs was indicated.     

Importance of nutritional issues among family physicians

Physicians spend three or more years after medical school in residency training. Nutrition education in medical schools is often absent or inadequate, but residency offers an excellent opportunity for appropriate training. A mail survey of all graduates of a family medicine residency was used to ascertain their nutrition interests and practices, obtaining an 86% response rate (142 responses). Almost all of these physicians counseled patients about nutrition and made referrals for patients with nutritional problems. About 63%, primarily those in metropolitan areas, referred patients to registered dietitians in private practice. These physicians believed that most nutrition issues were important in medical practice, especially nutrition in diabetes management, weight control and cardiovascular disease. Life cycle nutrition issues as a group were ranked as being more important than chronic disease or prevention issues. Physicians who were women, younger (40 years of age), or non-white ranked nutritional issues as more important to the practice of medicine. Nutrition education of physicians during residency should be encouraged, especially as it pertains to chronic disease and prevention.     

Medical Training Debt and Service Commitments: The Rural Consequences

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.