5) Graduate Medical Education including RTTs

5) Graduate Medical Education including RTTs and Fellowships

Geyman JP, Hart LG, Norris TE, Coombs JB, Lishner DM.

Educating generalist physicians for rural practice: how are we doing?

J Rural Health 2000 Winter;16(1):56-80

Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to "small rural" communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.

PMID: 10916315

Pathman DE, Steiner BD, Jones BD, Konrad TR.

Preparing and retaining rural physicians through medical education.

Acad Med 1999 Jul;74(7):810-20

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 D .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.

The Effect of Accredited Rural Training Tracks on Physician Placement

http://www.aafppolicy.org/onepagers/19991109.html

Accredited family practice rural training tracks place their graduates in rural settings at very high rates: 76% overall and 88% among programs implemented in the last ten years. Favorable, immediate results could be expected from their continuation and expansion, permitted by adjustments in the Balanc Budget Act of 1997.

In the early 1960s, concern mounted that a physician shortage was developing. Five comprehensive commission reports published from 1959-1970 recommended that the supply of physicians be expanded. Assisted by public funding, 40 additional medical schools were begun and enrollment more than doubled nationally over a period of just 20 years. Now, after years of steadily increasing this country’s supply of doctors, there is growing consensus that it exceeds need.

Even with this possible surplus of physicians, their maldistribution with respect to both practice specialty and location continues to hinder access to primary medical care for millions of Americans. There is broad agreement that geographically, rural (non-MSA) regions are the most disadvantaged. In 1997, 787 of the 859 counties that were Federally classified health personnel shortage areas (HPSAs) were nonmetropolitan. Another 641 rural counties had been partially designated HPSAs. Historically, the residents of remote, sparsely settled communities have relied on family physicians for their health care. In many rural settings family practice is the only generalist specialty that practice is economically viable.

A variety of programs have been implemented to address this inequity in access to care. Previous research suggests that residents whose training occurs in rural areas and emphasizes services necessary for rural practice, are likely to establish practice in rural communities. Among the 474 family medicine residency programs in this country, 29 have established separately accredited rural training tracks. Information about the practice location of graduates from these rural tracks was collected in September of 1999, by questionnaire. Data were not attained for 7 programs (1 closed, 4 new and yet to graduate residents, and 2 non-responses to the questionnaire). Remarkably, every graduate (all 40) of half (11 of 22) of the reporting programs had established practice in a non-MSA county. Overall, 76.0% (136 of 179) of the graduated residents were serving rural communities. Benefit usually accrued to the state in which the training occurred; of the 136 rural practice sites, 95 were located in the state of residency training.

The effect of the substantial success of the separately accredited rural training track components of family medicine residency programs has been limited by several variables. First, they are small. The largest graduates just 6 to 8 residents annually. Most are new; only 3 had graduated more than 5 classes. The tracks are few in number. This is of particular concern since 1 has closed and another will terminate at the end of this year. However, new starts demonstrated immediate effectiveness; among programs implemented within the past 10 years, 88% (94 of 107) of graduates provided care in a non-MSA county.

This performance for rural placement should be viewed in the context of what has otherwise occurred. Nationally, among all non-Federal allopathic family physicians actively providing patient care in 1997, 21.0% practiced in non-MSA counties. For the other 2 primary care specialties; general internal medicine and pediatrics, the proportions were 8.0% and 7.4% in rural practice respectively.

11131773

Stearns JA. Stearns MA.

Graduate medical education for rural physicians: curriculum and retention.

Journal of Rural Health. 16(3):273-7, 2000 Summer.

Abstract

The chronic shortage of rural physicians prompts further consideration of the educational interventions that have been developed to address this issue. Despite rural admission strategies and a variety of undergraduate, graduate and postgraduate curricular innovations, the recruitment and retention of family physicians into many rural areas has not kept pace with the retirement of older general practice physicians.

This paper reviews the 1994 American Academy of Family Physicians' rural training recommendations in the light of several recent educational needs assessments. These studies affirm the need for rural residency rotations and the need to maintain and better implement the established rural clinical training guidelines. However, although preparation for rural medical practice has been addressed and is being adequately accomplished in the clinical knowledge and procedural skills areas, instruction and experiences relating to the "realities of rural living" need to be enhanced to increase the retention duration of rural physicians. This can be accomplished with more curricular emphasis on developing community health competencies, including

community-oriented primary care (COPC). Physicians who know how to collaborate with community members on health improvement projects have skills that can also facilitate integration and, hence, retention.

Rosenthal TC.

Outcomes of rural training tracks: a review.

Journal of Rural Health. 16(3):213-6, 2000 Summer.

Abstract

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

Norris TE, Felmar E, Tolleson G.

Which procedures should be taught in family practice residency programs?

Fam Med 1997 Feb;29(2):99-104

BACKGROUND: Family practice residencies lack clear guidelines defining which procedures should be included in their curricula. The American Academy of Family Physicians (AAFP) Task Force on Procedures developed a recommendation (approved by the AAFP Board of Directors) that can be used to create a set of procedures that should be taught in residencies. The task force recommendation is based on procedures taught in most family practice residencies and performed by most practicing family physicians.

METHODS: The AAFP Task Force on Procedures surveyed all family practice residency programs and departments to determine which procedures they were teaching. The task force also surveyed a representative sample of practicing family physicians to find out which procedures they were performing.

RESULTS: Residency programs and departments returned 397 surveys (74.1% response), and the sample of 4,400 practicing physicians returned 2,028 surveys (46.1% response). The survey data identified 69 procedures as being taught in most family practice residencies, and 30 of these procedures as being performed by most practicing family physicians. CONCLUSIONS: Many procedures can be identified as being taught in most family practice residencies or performed by most practicing family physicians. Fewer procedures are performed by practicing family physicians than are taught in residencies.

PMID: 9048168

Norris TE, Coombs JB, Carline J.

An educational needs assessment of rural family physicians.

J Am Board Fam Pract 1996 Mar-Apr;9(2):86-93

BACKGROUND: A shortage of family physicians persists in rural and medically underserved areas of the United States. We explore the hypothesis that a definable set of educational needs should be addressed for rural family physicians, both during their formal education and as part of continuing education while in practice.

METHODS: An educational needs assessment questionnaire was sent to 1096 family physicians who had finished residency and entered rural practice within the last 3 years. Six hundred twenty-seven (57.2 percent) of the questionnaires were returned. The demographic characteristics of the respondent physicians and their assessment of the appropriateness and adequacy of their educational process in preparing them for rural practice were analyzed by looking at individual items and groups of items or subject areas.

RESULTS: We were able to define successfully a group of items that were important components of rural practice but were not adequately addressed in training programs. Theses groups included counseling, pediatrics, obstetrics and gynecology, geriatrics, surgery and trauma, medical specialties, surgical specialties, community medicine and management, and a mixed factor that included rehabilitation, behavioral sciences, learning disabilities (in children), chronic childhood problems, and human growth.

CONCLUSIONS: It is possible to define a group of educational areas not covered adequately by standard family practice curriculum that should be included in preparation for rural practice. If these areas were included in the education of rurally oriented family practice medical students and residents, these physicians would be more adequately prepared to meet the demands of rural practice. If preparation for rural practice is improved, rural communities might be more successful in recruiting and retaining well-trained family physicians.

PMID: 8659270

Baldwin LM, Hart LG, West PA, Norris TE, Gore E, Schneeweiss R.

Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban locations.

J Rural Health 1995 Winter;11(1):60-72

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.

PMID: 10141280

Norris TE, Norris SB

The effect of a rural preceptorship during residency on practice site selection and interest in rural practice

J Fam Pract 1988 Nov;27(5):541-4

Rural areas of the United States face serious shortages in health care personnel. This report evaluates the effect of a rural preceptorship during the second or third year of a family practice residency on interest in rural practice and on practice site selection. A majority of participants (n = 123) felt that this experience influenced their choice of a practice site. Furthermore, a large majority felt that it increased their interest in rural practice opportunities. Rural preceptorships during residency are a timely solution to increase the number of family physicians interested in rural practice.

Acosta, DA

Impact of Rural Training on Physician Work Force: The Role of Postresidency Education, J Rural Health 16(3): 254-261, 2000.

PubMed Identifier

11131770

Abstract

Many innovative strategies have been developed over the years to improve the recruitment and retention of physicians in the shortage areas of rural America. These

strategies have met with varying success. Postresidency education, or fellowship training, for family physicians is yet another strategy that has been developed for the same purpose. Most applicants have been interested in obstetrical and rural health fellowship programs as a means for preparing for rural practice. This paper describes

these programs (demographics, funding, applicant pool, curriculum) and reviews their graduate outcomes (practice location after matriculation, clinical privileges).

Twenty-nine obstetrical and nine rural health fellowships are currently operational in the United States. Fellows who complete a rural health fellowship have a higher

tendency to locate in rural settings. Almost all graduates from obstetrical and rural health programs attain general hospital privileges in family practice, including low-risk

obstetrics. A significant number of graduates from both types of programs attain privileges in high-risk and operative obstetrics as well. Fellowship training can play an

integral role in the preparation of family physicians for rural practice.

Norris TE, Acosta DA.

A fellowship in rural family medicine: program development and outcomes.

Fam Med 1997 Jun;29(6):414-20

BACKGROUND AND OBJECTIVES: Many strategies have been used by academic institutions to address the shortage of rural family physicians. Fellowship training in rural family medicine represents one approach.

METHODS: Tacoma Family Medicine developed a fellowship program of this type. Five years of operations are described, including applicants, educational outcomes, rural outcomes, and adverse outcomes.

RESULTS: An adequate applicant pool does exist, composed of both applicants from residency and from practice. A curriculum of advanced obstetrics, electives, and a rural experience has been successful. Unforeseen problems included a strained relationship with family practice residents in the program and competition for community preceptors.

CONCLUSIONS: Family practice residencies with a mission of rural training are encouraged to consider the strategy of a rural fellowship.

PMID: 9193913