6) Miscellaneous Issues

 

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

 

 

     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, Taylor DH Jr, Konrad TR, King TS, Harris T, Henderson TM, Bernstein JD, Tucker T, Crook KD, Spaulding C, Koch GG.

State scholarship, loan forgiveness, and related programs: the unheralded safety net.

JAMA 2000 Oct 25;284(16):2084-92

 

 

 

                       CONTEXT: In the mid-1980s, states expanded their initiatives of scholarships, loan repayment programs, and similar incentives to recruit primary

care practitioners into underserved areas. With no national coordination or mandate to publicize these efforts, little is known about these state programs and their recent growth.                             OBJECTIVES: To identify and describe state programs that provide financial support to physicians and midlevel  practitioners in exchange for a period of service in underserved areas, and to begin to assess the magnitude of the contributions of these programs to the US health care safety net.

                        DESIGN: Cross-sectional, descriptive study of data collected by telephone, mail questionnaires, and through other available documents, (eg, program brochures, Web sites).

                        SETTING AND PARTICIPANTS: All state programs operating in 1996 that provided financial support in exchange for service in defined underserved areas to student, resident, and practicing physicians; nurse practitioners; physician assistants; and nurse midwives. We excluded local community initiatives and programs that received federal support, including that from the National Health Service Corps.

                        MAIN OUTCOME MEASURES: Number and types of state support-for-service programs in 1996; trends in program types and numbers since 1990; distribution of programs across states; numbers of participating physicians and other practitioners in 1996; numbers in state programs relative to federal programs; and basic features of state programs.

                        RESULTS: In 1996, there were 82 eligible programs operating in 41

states, including 29 loan repayment programs, 29 scholarship programs, 11 loan programs, 8 direct financial incentive programs, and 5 resident support programs. Programs more than doubled in number between 1990 (n = 39) and 1996 (n = 82). In 1996, an estimated 1306 physicians and 370 midlevel practitioners were serving obligations to these state programs, a number comparable with those in federal programs. Common features of state programs were a mission to influence the distribution of the health care workforce within their states' borders, an emphasis on primary care, and

reliance on annual state appropriations and other public funding mechanisms.                                            CONCLUSIONS: In 1996, states fielded an obligated primary care

workforce comparable in size to the better-known federal programs. These state programs constitute a major portion of the US health care safety net, and their activities should be monitored, coordinated, and evaluated. State programs should not be omitted from listings of safety-net initiatives or overlooked in future plans to further improve health care access.

JAMA. 2000;284:2084-2092.

 

 

Pathman DE, Williams ES, Konrad TR.Rural physician satisfaction: its sources and relationship to retention

J Rural Health 1996 Fall;12(5):366-77.

 

 

 

                       This study uses survey data to identify areas of satisfaction and dissatisfaction for primary care physicians working in rural areas across the country.

It also identifies the specific areas of satisfaction associated with longer retention within a given rural practice, as well as the characteristics of individuals, practices, jobs, and communities associated with the areas of satisfaction that predict retention. Study subjects comprised a sample 1,600 primary care physicians who moved to nonmetropolitan counties nationwide during the years 1987 through 1990, with oversampling of those who moved to federally designated health professional shortage areas (HPSAs). Physicians serving in the National Health Service Corps (NHSC)

were excluded. Sixty-nine percent of the eligible subjects returned completed mail questionnaires in 1991.

 

                        Analyses for this study were limited to the 620 primary care physicians who worked more than 20 hours per week in towns of fewer than 35,000 population; who were neither in the military nor the NHSC; and who were not in urgent care, emergency room, or full-time teaching positions. Analyses revealed that the areas of rural physicians' greatest satisfaction were their relationships with patients, clinical autonomy, the care they provided to medically needy patients, and life in small communities. Physicians were least satisfied with their access to urban amenities and the amount of time they spent away from their practices. Retention was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals. Retention was also marginally related to physicians' satisfaction with their earnings. Among the areas of satisfaction not related to retention were satisfaction with autonomy, access to medical information and consultants, and the quality of doctor-patient relationships. In a subsequent series of analyses of the factors that predict the three areas of satisfaction that were associated with retention (satisfaction with the community, professional goal attainment, and earnings), a variety of physician, work, and community factors were identified.

 

                        These findings reveal that specific features of rural physicians, their work, and their communities predict each of the various aspects of satisfaction and that only certain aspects of satisfaction predict rural physicians' retention. There are no magic bullets to make rural physicians satisfied in all ways. Nevertheless, there are identified

approaches to elevate the specific aspects of rural physicians' satisfaction important to their retention. Programs to improve the satisfaction of rural physicians should focus on those areas of satisfaction that predict longer retention and other important outcomes.

 

Pathman DE, Konrad TR, Ricketts TC 3rd.

The National Health Service Corps experience for rural physicians in the late 1980s

JAMA 1994 Nov 2;272(17):1341-8.

 

 

 

 

                       OBJECTIVE--To learn from physicians in the National Health Service Corps (referred to as NHSC or the Corps) scholarship program about their experiences in rural health professional shortage areas (HPSAs), to contrast their experiences with those of other physicians working in rural HPSAs, and to learn how NHSC physicians' retention is associated with the quality of their experiences. DESIGN--Cohort study.

                       PARTICIPANTS--Two groups of primary care physicians who moved to rural HPSAs nationwide from 1987 through 1990 were surveyed in 1991:

group 1 consisted of all 675 physicians in the NHSC scholarship program, and

group 2 consisted of a stratified random sample of 1000 non-Corps physicians. Response rates were 73.7% and 69.1%, respectively. Analyses used comparable subsets of 417 NHSC and 206 non-NHSC respondents.

                       RESULTS--Among NHSC physicians, 51% initially anticipated working in underserved areas longer than 10 years, although only 14% expected to remain more than 5 years in their assigned practices. Three quarters of the Corps group felt there were few acceptable practice sites available to them, one third likely would have preferred urban sites, and two thirds were matched in states where they had not lived or trained earlier. Corps physicians felt their spouses' and children's needs were less well satisfied in their communities than non-Corps physicians. Corps physicians reported lower satisfaction in their work and personal lives and demonstrated poorer retention. Group differences in satisfaction and retention remained after controlling for various features of physicians and sites where they worked. Among NHSC physicians, retention was dramatically lower for those less well matched to their communities and those less satisfied.

                        CONCLUSIONS--The needs and preferences of NHSC physicians and families are not well accommodated. Low morale and poor retention are endemic among NHSC physicians. The NHSC is challenged by twin goals of meeting the immediate needs of underserved communities and providing personally and professionally satisfying environments where physicians can pursue long-term careers.

 

Hafferty FW, Boulger JG.

Medical students view family practice.

Fam Med 1988 Jul-Aug;20(4):277-81

 

 

                       All students at the University of Minnesota, Duluth, School of Medicine responded to a 65-item questionnaire about their perceptions of changes facing medicine, the future of family practice, and career choices. Three different orientations toward family practice were identified--"stayers," "defectors," and "potential defectors." Students who had abandoned their original preference for family medicine (defectors) were compared with students who had maintained an interest in family medicine (stayers). Defectors anticipated a diminishing clinical role for future family practitioners, expressed doubt about the financial viability of smaller community based family practices, and explicitly linked concerns about their anticipated debt load to their changes in career preferences. This study also identified a subgroup of "potential defector" students (within the stayer cohort) who  maintained an interest in family practice but evidenced concerns similar to the defector students. Implications of these findings for the future supply

of primary care physicians for rural and traditionally underserved communities are discussed.

 

Rosenthal MP, Diamond JJ, Rabinowitz HK, Bauer LC, Jones RL, Kearl GW, Kelly RB, Sheets KJ, Jaffe A, Jonas AP, et al.

Influence of income, hours worked, and loan repayment on medical students' decision to pursue a primary care career.

JAMA 1994 Mar 23-30;271(12):914-7

                      

 

 

                       OBJECTIVE--To assess the specialty plans of current fourth-year medical students and, for those not choosing primary care specialties, to investigate the potential effect that changes in key economic or lifestyle factors could have in attracting such students to primary care.

                        DESIGN AND PARTICIPANTS--A survey study was sent to 901 fourth-year medical students in the 1993 graduating classes of six US medical schools.

                       OUTCOME MEASURES--Comparisons were made between students choosing and not choosing primary care specialties. For the non-primary care students, we also evaluated whether alteration of income, hours worked, or loan repayment could attract them to primary care careers.

                       RESULTS--Of the 688 responses (76% response rate), primary care specialties were chosen by 27% of the students and non-primary care specialties by 73%. One quarter (25%) of the non-primary care students indicated they would change to primary care for one of the following factors: income (10%), hours worked (11%), or loan repayment (4%). For students whose debt was $50,000 or greater, the loan repayment option became much more important than for students with lesser debt. In all, a total of 45% (n = 313) of the students indicated either they were planning to enter primary care (n = 188) or they would change to a primary care specialty (n = 125) with appropriate adjustments in income, hours worked, or loan repayment.

                        CONCLUSION--Significant changes in economic and lifestyle factors could have a direct effect on the ability to attract students to primary care. Including such changes as part of health system reform, especially within the context of a supportive medical school environment, could enable the United States to approach a goal of graduating 50% generalist physicians.

 

                       PMID: 8120959 [PubMed - indexed for MEDLINE]