Insights from outstanding rural internal medicine residency rotations at the University of Washington.

PURPOSE: Despite being well suited to provide the breadth of care needed in rural areas, few general internists become rural physicians. Little formal rural residency training is available and no formal curricula exist. For over 25 years the University of Washington School of Medicine has provided elective WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) rural residency rotations to expose residents to the rewards and challenges of rural practice. This study identified the characteristics of outstanding rural residency rotations. METHOD: The key preceptors at three outstanding rural residency sites were interviewed about their experiences, teaching strategies, and opinions about curriculum. Their responses were categorized. Seven university-based residents and eight training at WWAMI sites recorded and rated the value of over 1,500 learning encounters. RESULTS: The preceptors agreed that outstanding rotations were led by enthusiastic preceptors who served as role models for excellence. These preceptors provided residents with meaningful responsibilities and emphasized independent decision making based on the history and physical examination. They stressed supervised independence and self-directed learning with frequent structured feedback for residents. The residents rated the learning value of patient encounters in rural locations significantly higher than that of those in university clinics. CONCLUSIONS: Exceptional rural residency experiences involve excellent role models who provide meaningful responsibility and emphasize core skills using a learner-centered approach. Rural training experiences should be supported, and the suggestions of outstanding preceptors should be used to develop and disseminate a curriculum that will better prepare residents for rural practice.     

Preparing and retaining rural physicians through medical education.

PURPOSE: To identify educational approaches that best prepare physicians for rural work and small-town living, and that promote longer rural practice retention. METHOD: In two mail surveys (1991 and 1996-97), the authors collected data from primary care physicians who had moved to rural practices nationwide from 1987 through 1990. A total of 456 eligible physicians responded to both surveys (response rate of 69.0%). The authors identified those features of the physicians' training that correlated with their self-reported preparedness for rural practice and small-town living, and with how long they stayed in their rural practices. Analyses controlled for six features of the physicians and their communities. RESULTS: The physicians' sense of preparedness for small-town living predicted their retention duration (hazard ratio, 0.74, p < .0001), whereas their preparedness for rural medical practice did not predict their retention duration after controlling for preparedness for small-town living (hazard ratio, 0.92; p = .27). For the physicians who had just finished their training, only a few features of their training predicted either rural preparedness or retention. Residency rural rotations predicted greater preparedness for rural practice (p = .004) and small-town living (p = .03) and longer retention (hazard ratio, 0.43, p = .003). Extended medical school rural rotations predicted only greater preparedness for rural practice (p = .03). For the physicians who had prior practice experience, nothing about their medical training was positively associated with preparedness or retention. CONCLUSION: Physicians who are prepared to be rural physicians, particularly those who are prepared for small-town living, stay longer in their rural practices. Residency rotations in rural areas are the best educational experiences both to prepare physicians for rural practice and to lengthen the time they stay there.     

From concept to culture: the WWAMI program at the University of Washington School of Medicine.

Shortages of primary care physicians have historically affected rural areas more severely than urban and suburban areas. In 1970, the University of Washington School of Medicine (UWSOM) administrators and faculty initiated a four-state, community-based program to increase the number of generalist physicians throughout a predominantly rural and underserved region in the U.S. Northwest. The program developed regional medical education for three neighboring states that lacked their own medical schools, and encouraged physicians in training to practice in the region. Now serving five Northwest states (Washington, Wyoming, Alaska, Montana, and Idaho), the WWAMI program has solidified and expanded throughout its 30-year history. Factors important to success include widespread participation in and ownership of the program by the participating physicians, faculty, institutions, legislatures, and associations; partnership among constituents; educational equivalency among training sites; and development of an educational continuum with recruitment and/or training at multiple levels, including K--12, undergraduate, graduate training, residency, and practice. The program's positive influences on the UWSOM have included historically early attention to primary care and community-based clinical training and development of an ethic of closely monitored innovation. The use of new information technologies promises to further expand the ability to organize and offer medical education in the WWAMI region.     

Prior training and recommendations for future training of clinical research faculty members

A survey was conducted of the first authors of half of the research papers published in 18 leading peer-reviewed medical journals over a six-month period in 1986. The first authors of every other article (that is, alternate articles) published during this period were sent a questionnaire that assessed their previous research training and their recommendations for training of clinical research faculty members. Of the 772 physicians sent the questionnaire, 482 responded. Of these, 57% had had some research training in medical school, 52% had received such training during residency, and 87% had received it during their fellowships. Fifty-six percent had taken a formal statistics course, 31.4% had taken some computer training, and 87% had received research supervision in a nonstructured format (that is, no formal course work). Introductory biostatistics was the only formal course in any of the seven subject areas listed in the questionnaire that more than one-third of the respondents had taken, yet at least two-thirds recommended that researchers take formal courses in all of the seven areas listed. The investigators recommend for medical students and postgraduate trainees a graduated experience of research training and exposure that includes formal courses.     

Where physicians practicing in Appalachia in 1978 to 1990 were trained and how they were distributed in urban and rural Appalachia.

Medical school graduates who graduated from 1978 to 1986 were analyzed to determine the health professions' ability worldwide to educate and place primary care physicians in rural areas of Appalachia. These data indicate that the University System of West Virginia--consisting of the West Virginia School of Osteopathic Medicine, West Virginia University Medical School, and Marshall University Medical School--produced the most primary care physicians who began practicing in rural Appalachia during the 1980s. The West Virginia School of Osteopathic Medicine successfully retained 106 (26%) of its graduates in primary care practices throughout rural Appalachia, with 77 of them in rural West Virginia, making the institution the nation's leading provider of primary care physicians practicing in rural Appalachia and West Virginia during this eight-year study period. With the exception of West Virginia, these and additional data support concerns of medical educators and public health officials that physicians in Appalachia are distributed disproportionately, more to urban than to rural counties.     

Effects of an expanded medical curriculum on the number of graduates practicing in a rural state

In 1973 the University of North Dakota School of Medicine (UNDSM), following the national trend toward four-year medical programs, expanded its previous two-year medical school curriculum to include all four years of medical education. It was hoped that this change, along with a renewed emphasis on primary care-oriented residency training within the state, would encourage medical students to establish practices within the state. In 1985 the UNDSM's Center for Rural Health mailed questionnaires to the 2,230 living graduates of the UNDSM to document a variety of their personal and practice characteristics. Based on the responses to the 924 completed questionnaires, the authors found that (1) the students from rural North Dakota were more likely than were urban students to practice in rural areas of the state, as were the students with primary care specialty training; and (2) the alumni completing residencies in North Dakota following the curriculum expansion (1976-1985) were more than twice as likely to establish practices in North Dakota. It was concluded that recruiting medical students (preferably in-state "natives") from rural areas, training them in primary care specialty areas, and enabling them to remain in North Dakota for the duration of their medical training (including residency training) combined to exert a considerable "retaining" effect on the UNDSM alumni.     

"Industrious, submissive, and free of diseases": 156 years of physicians in Liidlii Kue/Fort Simpson, Northwest Territories

INTRODUCTION: Physician recruitment to rural and remote communities poses a major challenge to health care delivery in Canada. Rather than focusing solely on the politics and policies that contribute to the shortage of family physicians in Canada's North, we argue that more attention should be paid to the reasons that lead, and have led, family physicians to the North, and also to the factors that contribute to physician retention. METHODS: We used archival research and semi- and unstructured interviews to provide a history of medicine in Liidlii Kue/Fort Simpson, NWT, and to describe the features of physicians who have served and continue to serve this Northern community. RESULTS: Results show that medicine in Liidlii Kue/Fort Simpson can be divided into 4 distinct eras: the prehospital era (1848-1916), the early hospital era (1917-1925), the middle era (1926-1972) and the government era (1973-present). Thirty-eight physicians were identified as having worked in Liidlii Kue/Fort Simpson. Of those, 19 were contacted. Nine physicians and the offspring of 1 deceased physician were interviewed. We found physicians fell into 1 of 4 categories: new graduates, those seeking midcareer (or midlife) change, those about to retire and international medical graduates. CONCLUSION: By examining Liidlii Kue/Fort Simpson as a case study, this research fills the dearth of knowledge in the factors that contribute to physician recruitment and retention in Canada's North.     

Rural training tracks in four family practice residencies.

The use of rural training tracks (RTTs) in family practice residencies is a new strategy (beginning in the late 1980s) to increase the number of residents selecting rural careers. The authors describe the four residencies (in Washington, Nebraska, New York, and Kentucky) that have established RTTs. The first residency year is completed in an urban tertiary care center, and the second and third years are completed in a distant rural community wherein the primary faculty are the members of a rural family practice group. Inpatient experience for the residents is provided by community hospitals that offer obstetrics, emergency room care, and first-line critical care. The residents' training is supplemented by specialty faculty practicing in the rural communities. The curricula are highly structured and are evaluated to ensure training experiences of high quality. The RTTs' financial support comes from state initiatives, hospital reimbursement, recruitment budgets, and outpatient care revenues. The authors conclude that the RTT concept has the potential to lessen the shortage of rural physicians.     

The impact on rural New Mexico of a family medicine residency.

PURPOSE: To determine the impact on rural New Mexico of the large, decentralized University of New Mexico (UNM) family medicine residency. METHOD: A cross-sectional study was conducted of all 317 residency's graduates from 1974 to 2004. Location of current practice was correlated with the residents' gender, ethnicity, medical school of origin, and whether most training took place in the urban program or one of three rural programs. The residency's impact on rural communities was assessed. RESULTS: There was no significant gender difference between graduates who went into urban or rural practice. Compared with non-minority graduates, a significantly greater percentage of ethnic minority graduates were in rural and urban New Mexico practices and fewer in out-of-state practices. A greater percentage of graduates who had been medical students in New Mexico practiced in both rural and urban New Mexico areas compared with graduates of out of state medical schools. Finally, a greater percentage of graduates from the three rural family medicine residencies remained in the state and practiced in rural areas compared with graduates from the urban program. The graduates' contributions to the school of medicine and to rural New Mexico are described. CONCLUSIONS: Graduates of UNM's family medicine residency have contributed significantly to the state's rural health workforce. Ethnic minority status, graduation from New Mexico's medical school, and training in one of the three rurally based residencies favored in-state and rural retention, while gender had no significant effect. The rural orientation of the residencies offered rural communities economic benefits.     

A comparison of smoking cessation efforts in African Americans by resident physicians in a traditional and primary care internal medicine residency

Tobacco use causes significant morbidity and mortality among African Americans. Physicians may inconsistently counsel patients against smoking. This retrospective chart review evaluated smoking cessation efforts in African Americans by internal medicine resident physicians in a traditional and a primary care residency program. One hundred twenty-nine African-American patients were evaluated by resident physicians in the traditional internal medicine residency. A tobacco use history was obtained in 84 patients. Twenty-eight patients smoked and two patients were counseled against smoking. Fifty-two African-American patients were evaluated by resident physicians in the primary care residency. A tobacco use history was obtained in 47 patients. Twenty patients smoked and 12 patients were counseled against smoking. There was a statistically significant difference in the rate at which smoking histories were obtained (p = 0.0011) and frequency of counseling against smoking (p < 0.0001). Gender analysis revealed that African-American women were less frequently asked about their smoking history (p = 0.0058) and counseled against smoking (p = 0.0016) by resident physicians in the traditional residency. African-American men received less counseling against smoking (p = 0.055) by resident physicians in the traditional residency. Resident physicians in the primary care residency program demonstrated greater smoking cessation efforts for African American patients. Smoking cessation should be emphasized in all internal medicine residency training programs.     

Long-term retention of graduates from a program to increase the supply of rural family physicians.

PURPOSE: To determine the long-term retention of rural family physicians graduating from the Physician Shortage Area Program (PSAP) of Jefferson Medical College. METHOD: Of the 1,937 Jefferson graduates from the classes of 1978-1986, the authors identified those practicing rural family medicine when their practice location was first determined. The number and percent of PSAP and non-PSAP graduates practicing family medicine in the same rural area in 2002 were then identified, and compared to the number of those graduates practicing rural family medicine when they were first located in practice 11-16 years earlier. RESULTS: After 11-16 years, 68% (26/38) of the PSAP graduates were still practicing family medicine in the same rural area, compared with 46% (25/54) of their non-PSAP peers (p = .03). Survival analysis showed that PSAP graduates practice family medicine in the same rural locality longer than non-PSAP graduates (p = .04). CONCLUSIONS: These results are the first to show long-term rural primary care retention that is longer than the median duration. This outcome combined with previously published outcomes show that the PSAP represents the only program that has resulted in multifold increases in both recruitment (eight-fold) and long-term retention (at least 11-16 years). In light of recent national recommendations to increase the total enrollment in medical schools, allocating some of this growth to developing and expanding programs similar to the PSAP would make a substantial and long lasting impact on the rural physician workforce.     

Obstetrician-gynecologists and primary care: training during obstetrics-gynecology residency and current practice patterns.

PURPOSE: To assess obstetrician-gynecologists' perceptions of their residency training in primary care, document health issues assessed at annual visits, and identify practice patterns of both generalist and specialist obstetrician-gynecologists. METHOD: Questionnaires were mailed to a random sample of 1,711 American College of Obstetricians and Gynecologists Young Fellows in September 2005. Information was gathered on perceptions about adequacy of residency training, how well training prepared obstetrician-gynecologists for current practice, and typical practice patterns for various medical diagnoses. Data were analyzed using univariate analysis of variance, t tests, and chi-square tests. RESULTS: Of 935 respondents (55% response rate), physicians estimated that 37% of private, nonpregnant patients rely on them for routine primary care. Approximately 22% report that they needed additional primary care training, specifically for metabolism/nutrition and dermatologic, cardiovascular, and psychosexual disorders. A wide range of topics, except for immunizations, were typically discussed at annual visits. Patients with pulmonary diseases, vascular diseases, and nongenital cancers were most often referred to specialists, whereas patients with urinary tract infections, sexually transmitted infections, or who are menopausal are most often managed totally. Self-identification as a generalist or specialist was associated with some practice patterns. Respondents were neutral about the role of primary care in obstetrics-gynecology residency training. CONCLUSIONS: For several primary care issues, obstetrician-gynecologists assumed sole management for obstetric patients but deferred to a primary care physician for gynecological patients. There is a continuing need for primary care training in obstetrics-gynecology residency, although it is unclear whether current training is adequate to meet their needs.     

The residency program in social medicine of Montefiore Medical Center: 37 years of mission-driven, interdisciplinary training in primary care, population health, and social medicine.

Founded in 1970 to train physicians to practice in community health centers and underserved areas, the Residency Program in Social Medicine (RPSM) of Montefiore Medical Center, Bronx, New York, has graduated 562 board-eligible family physicians, general internists, and pediatricians whose careers fulfill this mission. The RPSM was a model for federal funding for primary care residency programs and has received Title VII grants during most of its history. The RPSM has tailored its mission and structured its curriculum to promote a community and population orientation and to provide the requisite knowledge and skills for integrating social medicine into clinical practice. Six unique hallmarks of RPSM training are (1) mission-oriented resident recruitment/selection and self-management, (2) interdisciplinary collaborative training among primary care professionals, (3) community-health-center-based and community-oriented primary care education, (4) biopsychosocial and ecological family systems curriculum, (5) the social medicine core curriculum and projects, and (6) grant support through Title VII. These hallmark curricular, training, and funding elements, in which population health is deeply embedded, have been carefully evaluated, regularly revised, and empirically validated since the program's inception. Practice outcomes for RPSM graduates as leaders in and advocates for population health and the care of underserved communities are described and discussed in this case study.     

The geographic relationships between physicians' residency sites and the locations of their first practices

The uneven geographic distribution of physicians has been identified as a significant problem for the delivery of health care services. The present study examined one of the factors that contribute to the distribution of physicians; how far they move from their residency sites to establish their first practices. In 1989, the authors selected a random sample of 701 U.S. residency programs in the ten specialties with the most practitioners, and measured the distance each of these physicians moved to his or her first practice location. Of the 701 programs, 58.5% provided usable information about 2,612 physicians. Of these physicians, over 40% had moved less than 10 miles from their residencies, and over 50% had moved less than 75 miles. Comparisons among the physicians from the various specialties showed that the primary care physicians moved significantly shorter distances than did those from the other specialties. In the last two decades, many efforts have been made to increase the geographic distribution of physicians. The evidence from this study suggests that so far as the distances that physicians move from their practice sites are concerned, little has changed. Recent graduates of residency programs show no more tendency to move far from their residency sites than did their counterparts 30 years ago, as reported in the literature.     

Comments from the National Medical Association concerning a "white paper" on proposed strategies for fulfilling primary care manpower needs

The NMA has long had the participation and leadership of those in primary care and those who practice in medically underserved or medically indigent areas. We, therefore, are most supportive of the objectives and goals you have presented. We have offered suggestions to strengthen your "White Paper" by emphasizing the vital nature of the current and future role of primary health care delivery; by stating the effects that changes in physician reimbursement, especially utilizing the Relative Value Scale, will have on the expectations of those who are considering primary care; by continuing to offer scholarship assistance and loan forgiveness to those who are willing to commit during their medical education to a primary care career through the NHSC; by making a priority the effort to recruit older physicians by providing well-defined incentives, including liability relief; and by emphasizing the continued recruitment, retention, and encouragement of minority and disadvantaged applicants entering health care careers and stressing the support they must receive to be able to afford to practice in underserved areas. The National Medical Association welcomes the chance to undertake any collaborative efforts which may aid our mutual missions. Therefore, we are willing to assist you in helping to solve the critical need for primary care physicians in medically underserved communities.     

Exposure of Early Pediatric Trainees to Blood and Marrow Transplantation Leads to Higher Recruitment to the Field

The National Marrow Donor Program (NMDP) projects the need for allogeneic unrelated blood and marrow transplantation (BMT) in the United States as 10,000 per year. Although the NMDP is preparing to facilitate that number by the year 2015, there are several barriers to meeting this goal, including the need to recruit more health care personnel, including BMT physicians. To learn how best to recruit BMT physicians, we examined why practicing BMT physicians chose to enter the field and why others did not. We conducted a Web-based survey among pediatric hematology/oncology (PHO) and BMT physician providers and trainees to identify the factors influencing their decision to choose or not choose a career in BMT. Out of 259 respondents (48% male, 74% of Caucasian origin), 94 self-identified as BMT physicians, 112 as PHO physicians, and 53 as PHO trainees. The PHO and BMT providers spent an average of 53% of their time in clinical activities. More than two-thirds of PHO providers reported providing BMT services at their institutions, most commonly for inpatient coverage (73%). The proportion of providers exposed to BMT early in training was significantly higher among BMT providers compared with PHO providers (51% versus 18% in medical school [P < .0001]; 70% versus 50% during residency [P < .005]). Exposure during fellowship (94%) did not differ between the 2 groups. The decision to pursue a career in BMT was made before fellowship (medical school or residency) by 50% of the respondents. A lower proportion of BMT providers than PHO providers reported current involvement in the education of medical students and residents (76% versus 98%; P < .0001). Of the 53 trainees who responded, 64% reported not contemplating a career in BMT. Of these, 68% identified inadequate exposure to BMT before PHO fellowship as the reason behind this decision. Only 26% reported receiving exposure to the BMT field while in medical school, and 43% reported exposure during residency. The 2 most common reasons cited for choosing a career as a BMT physician were the degree of intellectual and scientific challenge (89%) and the influence of role models/mentors in the field (67%). The results of this survey suggest that early exposure to BMT during medical school and residency is associated with increased interest in pursuing a career in BMT. BMT physicians and training program directors can foster interest in the field by promoting BMT-focused education and clinical inpatient and outpatient rotations during medical school and residency. This early exposure to BMT may aid recruitment of future transplantation providers.     

Evaluating whether a combined internal medicine-pediatrics practice was successful

Will primary care practices set up by physicians trained in combined internal medicine-pediatrics residencies be successful? To address this question, the recruitment of patients to the medicine-pediatrics office established in May 1985 by a northeastern medical center and the patients' understanding of and satisfaction with the combined practice were studied via the billing system and a questionnaire mailed to 1,001 households of patients in November 1988. Although equally divided between children and adults, the patient population had two large bulges, infants less than 2 years old and young adults aged 18-39 years. Most of the 833 patients (from 406 households) who returned the questionnaires were well educated and professional. They indicated they were aware of the nature of the practice; had been looking for a specialist, not a "doctor for the family"; and were highly satisfied. Therefore, the medicine-pediatrics residency program studied appears to have been very successful in preparing primary care physicians. These physicians had a particular appeal to young upper-middle-class families.     

The contribution of Memorial University's medical school to rural physician supply

INTRODUCTION: This study identifies the characteristics and predictors of Memorial University of Newfoundland (MUN) medical graduates working in rural Canada and rural Newfoundland and Labrador (NL). METHODS: We linked data from class lists, the alumni and postgraduate databases with the Southam Medical database to determine 2004 practice locations for MUN graduates from 1973 to 1998 (26 yr, inclusive). Multiple logistic regression was used to identify predictors for each outcome. RESULTS: In 2004, 167 (12.6%) MUN graduates worked in rural Canada and 81 (6.1%) MUN graduates worked in rural NL. Those who were more likely to practise in rural Canada (when compared with graduates from urban backgrounds, those who had not done any residency training at MUN or specialists, respectively) were graduates from a rural background (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.38-2.76), those who had done residency training at MUN (OR 1.56, 95% CI 1.06-2.29) and family physicians (FPs)-general practitioners (GPs) (OR 6.64, 95% CI 4.31-10.23). Those who were more likely to practise in rural NL (when compared with graduates from urban backgrounds, those who had not done any residency training at MUN, specialists or non-Newfoundlanders, respectively) were graduates from a rural background (OR 2.54, 95% CI 1.57-4.11), those who had done residency training at MUN (OR 4.12, 95% CI 1.94-8.76), FP-GPs (OR 6.39, 95% CI 3.39-12.05) and Newfoundlanders (OR 7.01, 95% CI 2.16-22.71). CONCLUSION: The MUN medical school has made a substantial contribution to rural physician supply in both NL and Canada. Increasing the number of local rural students as well as providing incentives to graduates to complete postgraduate training in family medicine in the province may increase the number of locally trained rural physicians.