4) Undergraduate Medical Education

 

 

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

 

 

 

Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. 

Which medical schools produce rural physicians? 

JAMA 1992 Sep 23-30;268(12):1559-65.

 

 

OBJECTIVE--To examine the hypothesis that medical schools vary systematically and

predictably in the proportion of their graduates who enter rural practice.

 

DESIGN--The December 1991 version of the American Medical Association Physician Masterfile was used to examine the rural and urban practice locations of physicians who graduated from American medical schools between 1976 and 1985. Selected characteristics of the medical schools--including location, ownership, and

funding--were linked to the Physician Masterfile.

 

MAIN OUTCOME MEASURES--The percentage of the graduates from each medical school who were practicing in rural areas in December 1991, disaggregated by physician specialty.

 

RESULTS--Of the practicing graduates from our study, 12.6% were located in rural counties; family physicians were much more likely than members of other specialties to select rural practice, particularly in the smallest and most isolated rural counties. Women were much less likely than men to enter rural practice. Medical schools varied greatly in the percentage of their graduates who entered rural practice, ranging from 41.2% to 2.3% of the graduating classes studied. Twelve medical schools accounted for over one quarter of the physicians entering rural practice in this time period. Four variables were strongly associated with a tendency to produce rural graduates: location in a rural state, public ownership, production of family physicians, and smaller amounts of funding from the National Institutes of Health.

 

DISCUSSION--The organization, location, and mission of medical schools is closely related to the propensity of their graduates to select rural practice. Increasing policy coordination among medical schools and state and federal governmental entities would most effectively address residual problems of rural physician shortages.

 

 PubMed Identifier 1308662

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­

Stearns JA. Stearns MA. Glasser M. Londo RA. 

Illinois RMED: a comprehensive program to improve the supply of rural family physicians.  Family Medicine. 32(1):17-21, 2000 Jan.

 

Abstract

BACKGROUND: Rural areas of the United States are perennially medically underserved, and the state of Illinois is no exception. A recent survey showed that 75 of

Illinois' 84 rural counties are primary care physician shortage areas. In response to this chronic physician shortage, the Illinois Rural Medical Education (RMED)

Program was developed by the University of Illinois College of Medicine at Rockford. The RMED program is a comprehensive, multifaceted program that combines

recruitment, admissions, curriculum, support, and evaluation components and is longitudinal across all 4 years of the medical school experience. The admissions process

seeks to select students who possess traits indicative of success in eventual rural family practice. These traits are fostered and developed by the 4-year rural curriculum,

which emphasizes family medicine, community-oriented primary care, the physician functioning in the context of community, relevant aspects of the "hidden" curriculum,

and service learning. After 6 years, RMED has graduated 39 physicians; 69% have gone into family practice, and a total of 82% have selected primary care residencies.

 

Kindig DA. 

Policy priorities for rural physician supply. 

Academic Medicine. 65(12 Suppl):S15-7, 1990 Dec.

 

Abstract

A number of efforts can be attempted in rural medical education initiatives in recruitment, socialization, curricular reform, and community technical assistance. Further

work is needed in identifying strategies that are most appropriate and cost effective in different states and regions that may have different situations and needs. Careful

consideration needs to be given to reasons why such ideas have not moved beyond the demonstration stage over the past 20 years; it is suggested that without substantial

reform of payment systems favoring rural and primary care, educational reform will have marginal effectiveness and remain at the demonstration level.

 

 

Pathman DE, Konrad TR, King TS, Spaulding C, Taylor DH. 

Medical training debt and service commitments: the rural consequences.

J Rural Health 2000 Summer;16(3):264-72

 

 

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.

 

 

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.

 

Boulger JG.

Minnesota bound. Stability of practice location among UMD family physicians in Minnesota.

Minn Med 2000 Feb;83(2):48-50

 

 

 

                       Previous studies indicate that physicians often move from one practice setting to another, particularly early in their career. However, data on practice relocation for a group of University of Minnesota, Duluth School of Medicine graduates show a different trend. Minnesota family physicians from the UMD School of Medicine have been remarkably stable in their practices over the past 20 years. More than 80% of these physicians have continued to practice in the same community that they selected after their training. In addition, physicians in this group who are practicing in smaller communities have not relocated to urban practices. These findings suggest that the UMD School of Medicine's emphasis on family medicine and rural practice may have influenced the practice retention rate for these physicians.

 

 

Boulger JG.

Family medicine education and rural health: a response to present and future needs.

J Rural Health 1991 Spring;7(2):105-15

 

 

 

                       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.

 

Boulger JG.

Family practice in the predoctoral curriculum: a model for success.

J Fam Pract 1980 Mar;10(3):453-8

                      

 

 

                       Fifty-five percent of students who began their medical education at the University of Minnesota, Duluth, School of Medicine have elected family practice residencies. A coordinated and concentrated approach to admissions and curriculum, emphasizing family practice as an institutional goal, is described and discussed. As the national average for graduating seniors seems to have stabilized at approximately 13 percent, this approach may serve as a model for other institutions which wish to increase the number of family physicians. Family physicians are heavily involved in all aspects of

the teaching program. Institutional parameters which are necessary for success are briefly discussed.

 

                       PMID: 7354291 [PubMed - indexed for MEDLINE]

 

Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP.

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

JAMA 2001 Sep 5;286(9):1041-8

 

 

 

                       CONTEXT: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (Philadelphia, Pa) is one of a small number of medical school programs that addresses the shortage of rural primary care physicians. However, little is known regarding why these programs work.

                       OBJECTIVES: To identify factors independently predictive of rural primary care supply and retention and to determine which components of the PSAP lead to its outcomes. DESIGN: Retrospective cohort study.

                        SETTING AND PARTICIPANTS: A total of 3414 Jefferson Medical College graduates from the classes of 1978-1993, including 220 PSAP graduates. MAIN                                   OUTCOME MEASURES: Rural primary care practice and retention in 1999 as predicted by 19 previously collected variables. Twelve variables were available for all classes; 7 variables were collected only for 1978-1982 graduates. RESULTS: Freshman-year plan for family practice, being in the PSAP, having a National Health Service Corps scholarship, male sex, and taking an elective senior family practice rural preceptorship (the only factor not available at entrance to medical school) were independently predictive of physicians practicing rural primary care. For 1978-1982 graduates, growing up in a rural area was the only additionally collected independent predictor of rural primary care (odds ratio [OR], 4.0; 95% CI, 2.1-7.6; P<.001). Participation in the PSAP was the only independent predictive factor of retention for all classes (OR, 4.7; 95% CI, 2.0-11.2; P<.001). Among PSAP graduates, taking a senior rural preceptorship was independently predictive of rural primary care (OR, 2.5; 95% CI, 1.3-4.7; P =.004). However, non-PSAP graduates with 2 key selection characteristics of PSAP students (having grown up in a rural area and freshman-year plans for family practice) were 78% as likely as PSAP graduates to be rural primary care physicians, and 75% as likely to remain, suggesting that the admissions component of the PSAP is the most important reason for its success. In fact, few graduates without either of these factors were rural primary care physicians (1.8%).

                        CONCLUSIONS:  Medical educators and policy makers can have the greatest impact on the supply and retention of rural primary care physicians by developing programs to increase the number of medical school matriculants with background and career plans that make them most likely to pursue these career goals. Curricular experiences and other factors can further increase these outcomes, especially by supporting those already likely to become rural primary care physicians.

 

 

Rabinowitz HK, Paynter NP.

The role of the medical school in rural graduate medical education: pipeline or control valve?

J Rural Health 2000 Summer;16(3):249-53

 

 

                       Although rural-based graduate medical education is critically important in the training of competent rural family physicians, the number of physicians selecting these programs is highly dependent on what happens earlier in the pipeline, i.e., during medical school. Using the experience and outcomes research from Jefferson Medical College's Physician Short-age Area Program, as well as from published literature describing six other medical school programs with similar goals, this paper addresses the important role of these programs in substantially increasing the number of physicians interested in rural family practice. Although each of these programs differs in its structure, all contain three core features: a strong institutional mission; the targeted selection of students likely to practice in rural areas, predominantly those with rural backgrounds; and a focus on primary care, especially family practice. Outcomes show that all seven programs have been highly successful. Medical schools, therefore, can have a major impact on the number of rural physicians they produce by acting not only as a pipeline or conduit to residency programs, but also as a control valve, beginning as early as the admissions process. In order to maximize their impact on the supply and training of rural family physicians, rural residency programs should understand, support, collaborate with and help develop medical school programs whose mission is to provide rural physicians.

 

                       PMID: 11131769 [PubMed - indexed for MEDLINE]

 

 

Rabinowitz HK, Diamond JJ, Hojat M, Hazelwood CE.

Demographic, educational and economic factors related to recruitment and retention of physicians in rural Pennsylvania.

J Rural Health 1999 Spring;15(2):212-8

 

 

 

                       While prior studies have identified a number of factors individually related to physician practice in rural areas, little information is available regarding the relative importance of these factors or their relationship to rural retention. Extensive data previously collected from the Jefferson Longitudinal Study were analyzed for 1972 to 1991 graduates of Jefferson Medical College practicing in Pennsylvania in 1996, as were recent self-reported perceptions of Jefferson Medical College graduates in rural practice. Rural background was overwhelmingly the most important independent predictor of rural practice, and freshman plans to enter family practice was the only other independent predictor. No other variable, including curriculum or debt, added significantly to the likelihood of rural practice. None of these variables, however, including rural background, was predictive of retention, which appeared to be more related to practice issues such as income and workload. These results suggest that increasing the number of

physicians who grew up in rural areas is not only the most effective way to increase the number of rural physicians, but any policy that does not include this may be unsuccessful.

 

                       PMID: 10511758 [PubMed - indexed for MEDLINE]

 

 

Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE.

A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.

JAMA 1999 Jan 20;281(3):255-60

 

 

 

                       CONTEXT: The shortage of physicians in rural areas is a longstanding and serious problem, and national and state policymakers and educators continue to face the challenge of finding effective ways to increase the supply of rural physicians.                                                 OBJECTIVE: To determine the direct and long-term impact of the Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) on the rural physician workforce.

                        DESIGN:   Retrospective cohort study.

                        PARTICIPANTS AND SETTING: A total of 206 PSAP graduates from the classes of 1978 to 1991.

                        MAIN OUTCOME MEASURES: The PSAP graduates currently practicing family medicine in rural and underserved areas of Pennsylvania, compared with all allopathic medical school graduates in the state, and with all US and international allopathic graduates. All PSAP graduates were also compared with their non-PSAP peers at JMC regarding their US practice location, medical specialty, and retention for the past 5 to 10 years.

                       RESULTS: The PSAP graduates account for 21% (32/150) of family physicians practicing in rural Pennsylvania who graduated from one of the state's 7 medical schools, even though they represent only 1% (206/14710) of graduates from those schools (relative risk [RR], 19.1). Among all US and international medical school graduates, PSAP graduates represent 12% of all family physicians in rural Pennsylvania. Results were similar for PSAP graduates practicing in underserved areas. Overall, PSAP graduates were much more likely than their non-PSAP classmates at JMC to practice in a rural area of the United States (34% vs 11%; RR, 3.0), to practice in an underserved area (30% vs 9%; RR, 3.2), to practice family medicine (52% vs 13%; RR, 4.0), and to have combined a career in family practice with practice in a rural area (21% vs 2%; RR, 8.5). Of PSAP graduates, 84% were practicing in either a rural or small metropolitan area, or one of the primary care specialties. Program retention has remained high, with the number of PSAP graduates currently practicing rural family medicine equal to 87% of those practicing between 5 and 10 years ago, and the number practicing in underserved areas, 94%.

                        CONCLUSIONS: The PSAP, after more than 22 years, has had a disproportionately large impact on the rural physician workforce, and this effect has persisted over time. Based on these program results, policymakers and medical schools

can have a substantial impact on the shortage of physicians in rural areas.

 

                       PMID: 9918481 [PubMed - indexed for MEDLINE]

 

 

Rosenthal MP, Rabinowitz HK, Diamond JJ, Markham FW Jr.

Medical students' specialty choice and the need for primary care. Our future.

Prim Care 1996 Mar;23(1):155-67

                       

 

 

                       Recent changes in the health care environment have directed increasing attention to the recognized oversupply of specialists and relative lack of primary care physicians. Despite this imbalance and the need for more primary care physicians, US medical schools are not producing them in adequate numbers. To effect change in the production of primary care physicians, a comprehensive approach that addresses key factors in medical student specialty choice is needed. This article discusses such factors and how they affect medical students during the course of their training. Issues concerning primary care specialty choice and the physician work force are important to the development of the future US health care system.

 

                       PMID: 8900513 [PubMed - indexed for MEDLINE]

 

 

Brazeau NK, Potts MJ, Hickner JM.

The Upper Peninsula Program: a successful model for increasing primary care physicians in rural areas.

Fam Med1990;22:350-5.

     

 

 

Verby JE, Newell JP, Andresen SA, Swentko WM.

Changing the medical school curriculum to improve patient access to primary care.

JAMA 1991 Jul 3;266(1):110-3

                      

 

 

                       The problems of access to health care by the underinsured demand a systematic response. One of the critical components of that response is medical curriculum reform, with the intent to graduate adequate numbers of physicians to do primary care, to work with the underinsured and the uninsured, and to practice in rural areas. One state, Minnesota, has developed a unique response to these needs, demonstrating problem solving very much in keeping with many of the recommendations in the literature. Highlighted in this article is the University of Minnesota's Rural Physician Associate Program, a predoctoral curriculum innovation functioning for 20 years to help resolve the issue of physician maldistribution in the state. The Rural Physician Associate Program provides students with many of the skills needed to provide primary care, it is cost-effective, and it has brought  number of benefits to the participating communities.

 

                       PMID: 1904505 [PubMed - indexed for MEDLINE]

 

 

Verby JE.

The Minnesota Rural Physician Associate Program for medical students.

J Med Educ 1988 Jun;63(6):427-37

 

 

 

                       The Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School is a clinical education experience for third-year students that lasts nine to 12 months. In 1970 the Minnesota legislature required the medical school faculty to find an educational method to redistribute physicians into the medically underserved rural areas of Minnesota or lose state funds for the medical school. After 16 years of the program, all 87 counties in Minnesota have an acceptable ratio of general physicians for the first time in the state's history. RPAP students work directly with and are supervised by general physicians practicing in rural areas; these preceptors have an average age of 40 years, are board-certified, and have 12 years of clinical experience. They give their teaching services and a $2,500 stipend to the student; the state provides

$7,000 to the student with no obligation that the student practice in rural Minnesota after training. The preceptors, RPAP staff members, and visiting university faculty members provide 50, 30, and 20 percent, respectively, of a student's grades for the program; the student receives six months of credit for the program. As of 1986, 57 percent of the former RPAP students in practice were practicing in rural communities, with a majority in Minnesota and a majority in towns with populations less than 10,000.

 

                       PMID: 3373497 [PubMed - indexed for MEDLINE]

 

Verby JE.

The Minnesota Rural Physician Redistribution Plan, 1971 to 1976.

JAMA 1977 Aug 29;238(9):960-4

                       

 

                       The Rural Physician Associate Program was developed by the University of Minnesota Medical School faculty in an attempt to meet the demands of the citizens of Minnesota to improve the distribution of primary physicians to rural areas. The program is offered to students who have completed 2 2/3 academic years of medical school. There were no regulations requiring the students' return to rural areas after completion of training. Thus far, 163 students have completed the program. Forty-three have continued in medical school and another 27 are in residency-training programs. Primary care residencies have been chosen by 68; another 31 have completed their medical education and are in rural practice. Of the 22 practicing in Minnesota, 21 have returned to rural communities.

 

                       PMID: 577990 [PubMed - indexed for MEDLINE]