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PubMed2005

Threats to rural surgery.

BACKGROUND: Rural surgery is a subject that often is discussed but little has been done to address the problems of rural surgery. With a decreased interest in broad-based general surgery, an aging population (especially in rural America), an aging population of general surgeons who are retiring early, surgical care in rural North America is approaching a crisis. METHODS: An internet search was performed to analyze the problems in rural surgery. Also, the experience of a 90-bed rural hospital in south central Kentucky was analyzed. RESULTS: Approximately 17% to 25% of the population in America (55 million) live in a rural environment, depending on the way rural is defined. Rural general surgeons may become an endangered species because of multiple factors, including: lack of broad-based training, increased specialization, lifestyle issues, decreased interest in surgery, increased technology, aging rural surgeons, increased workload for the general surgeon, decreased reimbursement, increased expenses, increased expectations of the general public, and increased malpractice costs. Solutions include programs dedicated to training rural surgeons, networking with university tertiary care hospitals, equal pay for work performed regardless of the location, regionalization of rural surgery centers with multiple surgeons so the lifestyle issues can be addressed. CONCLUSIONS: There is an increasing need for broad-based general surgeons in rural America. Training programs need to address the problem by offering dedicated training programs that should include primary training in general surgery and fellowships for special needs. A new specialty in rural general surgery needs to be created.

Clinical Competence↗
PubMed2002

The association of Title VII funding to departments of family medicine with choice of physician specialty and practice location.

BACKGROUND: Title VII predoctoral and departmental grants for departments of family medicine are intended to increase the number of family and primary care physicians in the United States and increase the number of practices in rural and underserved communities. This study assessed the relationships of Title VII funding with physicians' choices of practice specialty and location. METHODS: Non-federal direct patient care physicians who graduated from US medical schools from 1981-1993 were identified in the 2000 American Medical Association Masterfile. A grant history file was used to annotate Masterfile records with Title VII funding data for the physicians' 4-year medical school enrollment. Characteristics of the county in which they practice were taken from the Area Resource File. Title VII funding variables were then related to practice specialty and location. RESULTS: Predoctoral training and departmental development funding were strongly related to attainment of each of the Title VII program objectives evaluated. CONCLUSIONS: Title VII has been successful in achieving its stated goals and legislative intent and has had an important role in addressing US physician workforce policy issues.

Career Choice↗
PubMedDate not supplied

The influence of practice type, region, and age on treatment recommendations for primary teeth.

The purpose of this study was to investigate dentists' treatment recommendations for interproximal surfaces of primary molars based on the type of practitioner (general dentist or pediatric dentist), geographic location, and age of practitioner. Simulated cases, which included histories and pictures of bite-wing radiographs, were mailed to a random sample of 2000 general dentists and 1000 pediatric dentists. Dentists were asked to select their treatment recommendations for eight cases involving the interproximal surface of a specified primary molar. The return rate was 42% (1245) overall, with 36% (723) from general dentists and 52% (522) from pediatric dentists. An amalgam restoration was recommended most often for these eight cases. Dentists in the age 60+ category and pediatric dentists were more likely to recommend treatment for smaller interproximal lesions. Composite resins were recommended infrequently; however, dentists in the 60+ age category and dentists in the Northeast and Southwest were somewhat more likely to recommend composite resin than younger dentists, or dentists in other geographic locations. Dentists in the 40-49 age range, pediatric dentists, and dentists in the Southwest were the most likely to recommend stainless steel crowns. These simulated cases demonstrate differences and similarities in the treatment recommendations for interproximal lesions on primary molars based on age, practice type, and region.

Adult↗
PubMed1998

Appropriate training for northern physicians.

It remains difficult to find appropriately trained physicians to work in isolated northern areas. Urban-based family medicine programs have not been able to provide appropriate training. The Northern Family Medicine Education (NorFam) Program of Memorial University of Newfoundland was created to fill this need. This paper reviews the NorFam Program and discusses current practice locations and the relevance of the program as reported by its graduates. From 1993 to 1995, the NorFam Program trained 14 residents. The residents participate in a variety of educational and training activities--all chosen to be as relevant to northern practice as possible. When the graduates were surveyed, nine had remained in northern/remote or rural practice and three were doing further medical training. All respondents reported that the NorFam Program gave them more relevant training for northern practice than they would have received in an urban-based family medicine program.

Arctic Regions↗
PubMed1997

Predictors and profiles of rural versus urban family practice.

BACKGROUND AND OBJECTIVES: Much of rural Colorado has been designated a shortage area for primary care health personnel. The state's only medical school and its family practice residency programs are expected to address this long-standing problem. This study identified predictors of rural practice location and contrasted the service profiles of rural versus urban family physicians and general practitioners. METHODS: The Colorado Board of Medical Examiners mailed a questionnaire to all licensed Colorado physicians. Logistic regression analyses were conducted using variables determined to be significantly related to practice location (rural versus urban) by univariate statistical tests. Information from the 986 family physician and general practitioner respondents identified personal and educational variables strongly associated with choice of rural practice location and differentiated between practice tendencies of rural versus urban physicians. RESULTS: Having been raised in rural Colorado was the most powerful predictor of rural practice location in the state. Family physicians and general practitioners serving rural populations spent much more time weekly providing direct patient care and more often cared for Medicaid patients. CONCLUSIONS: Personal characteristics and background may be useful considerations in selecting among applicants for medical schools and family practice residency programs committed to reducing the severe shortage of health care service in rural areas.

Adult↗
PubMed2000

General practitioners' attitudes toward complementary therapies.

Attitudes toward complementary therapies were elicited from a postal survey of all identified general practitioners in the state of Tasmania, Australia. Regression analysis of the data indicated that demographic features associated with favourable attitudes were younger age and location in small or single practices. Personal experiences of such therapies or patient endorsement of them were also associated with favourable attitudes. Those who saw the holistic orientation of complementary medicine as an advantage were likely to hold favourable attitudes. Those who saw the cure rate of complementary therapies as problematic and/or had personal knowledge of the harmful effects of such therapies were less likely to have favourable attitudes.

Adult↗
PubMed1985

Effects of affirmative action in medical schools. A study of the class of 1975.

In the early 1970s, affirmative-action programs were introduced to accomplish a number of social goals, including increasing the supply of minority physicians and improving the health care of the poor. To assess the success of such programs, we analyzed data on people who graduated from U.S. medical schools in 1975 to determine how specialty choice, practice locations, patient populations served, and board-certification rates differ between minority and nonminority graduates. A larger proportion of minority graduates (55 per cent vs. 41 per cent, P less than 0.001) chose the primary-care specialties of family practice, general internal medicine, general pediatrics, and obstetrics-gynecology. Significantly more minority physicians (12 per cent vs. 6 per cent, P less than 0.01) practiced in locations designated as health-manpower shortage areas by the federal government and had more Medicaid recipients in their patient populations (31 per cent for blacks, 24 per cent for Hispanics, 14 per cent for whites; P less than 0.001). Physicians from each racial or ethnic group served disproportionately more patients of their own racial or ethnic group (P less than 0.001), but minority physicians did not serve significantly more persons from other racial or ethnic minority groups than did nonminority physicians. Many minority physicians served patient populations much like those of their nonminority colleagues, which indicates that substantial integration of the medical marketplace has taken place. Significantly fewer minority graduates had become board-certified by 1984 (48 per cent vs. 80 per cent, P less than 0.001), and most of this disparity was associated with differences in premedical-school characteristics and in the patient populations they served. Our analysis shows that minority graduates of the medical school class of 1975 are fulfilling many of the objectives of affirmative-action programs.

Certification↗
PubMedDate not supplied

Fighting hand to hand over physician workforce policy.

A vexing problem in health policy is getting the right number of physicians in the right specialties in the right locations at the right time. I examine market and public planning approaches to getting the number "right." After discussing the basic premises of the invisible hand of the market and the heavy hand of government regulation, I apply these concepts to a review of the past century of U.S. physician supply and workforce policy. I conclude by examining recent health system trends that make clear the need for a firm regulatory grasp on physician workforce policy.

Health Care Sector↗
PubMed2000

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

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.

Family Practice↗
PubMed1997

Effective managed care marketing strategies for evolving markets.

In a world of increased competition and changing consumer expectations, one of the keys to a fiscally sound health plan is having a dynamic marketing strategy that takes into account the shifting attitudes of consumers as managed care markets mature. The primary goal of any health plan marketing strategy should be the acquisition and retention of members. Providing cost-efficient and convenient service for enrollees, offering low or no deductibles, having convenient office locations, and minimizing paper-work are important elements of such a marketing strategy. Factors such as brand awareness and the perceived image of a health plan also are important considerations in acquiring and retaining market share. The relative importance of these consumer satisfaction criteria change as a managed care market evolves and matures. Financial and marketing managers, thus, should ascertain their market's stage of development and respond with appropriate marketing strategies.

Community Participation↗
PubMed2005

An evaluation of the Rural Medical Education Program of the State University Of New York Upstate Medical University, 1990-2003.

PURPOSE: The Rural Medical Education Program (RMED) of the State University of New York (SUNY) Upstate Medical University is a 36-week clinical experience in rural communities for medical students that began in 1989. The authors sought to assess RMED's success in providing a valuable educational experience for students that assists rural communities recruit physicians. METHOD: In 2004, the authors used the Physician Masterfiles of the American Medical Association to compare practice locations of SUNY Upstate graduates who completed RMED with those who did not; surveyed former RMED students to assess their satisfaction with their practice location and the importance of RMED in helping them choose a location; interviewed hospital administrators in communities that have hosted RMED students to understand the impact of RMED on host communities; and compared United States Medical Licensing Examination Step 2 scores of RMED students with those of non-RMED students to evaluate educational attainment. RESULTS: A greater percentage of former RMED students practiced in rural locations [22/86 (26%)] than did non-RMED students [95/1,307 (7%)]. Ninety-one percent (69/76) of former RMED students were satisfied with their location, and 84% (64/76) believed that RMED was important in helping them choose a location. Hospital administrators viewed the program highly because it helped them recruit physicians and benefitted their medical staff. RMED students had higher adjusted mean Step 2 scores than did non-RMED students (212.3 versus 199.1). CONCLUSION: The RMED program has successfully met its goals of providing a valuable educational experience for medical students and assisting rural communities recruit physicians.

Attitude of Health Personnel↗
PubMed1988

A model to evaluate whether a community can support a physician.

A major concern to the rural citizens of the United States is the availability of health care in their community. Community leaders and physicians considering locating in rural communities need a method by which they can evaluate a community's potential for supporting a physician. A detailed survey was conducted in 1986 of 25 physicians' practices in rural Oklahoma. Data were collected from the physicians on their number of patient visits and practice costs in 1985. Using this information, the authors designed a model to project the economic feasibility of establishing a physician practice in a specific community. This model can be used to project the number of physician visits a community can generate, the costs to establish and maintain a clinic, and the gross and net income of the practice.

Adolescent↗
PubMed2004

Geographic location of commercial plasma donation clinics in the United States, 1980-1995.

OBJECTIVE: We examined the location of commercial plasma donation centers in the United States over the period 1980 to 1995 relative to the geographic distribution of risk behaviors associated with transfusion-transmissible infections. METHODS: The census tract locations of commercial source plasma clinics were described by measures of neighborhood social disadvantage and the prevalence of illicit drug use and active local drug economies. RESULTS: Depending on the measure of social environment used, commercial plasma clinics were 5 to 8 times more likely to be located in census tracts designated high-risk than would be expected by chance. CONCLUSIONS: Commercial source plasma clinics were overrepresented in neighborhoods with very active local drug economies. These patterns persisted after the links between human immunodeficiency virus and hepatitis C virus infections and plasma products had been established and may present risks to blood system safety.

Ambulatory Care Facilities↗
PubMed2004

Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: systematic review of the literature.

OBJECTIVE: To evaluate the effectiveness of programs that provide financial incentives to physicians in exchange for a rural or underserviced area return-of-service (ROS) commitment. METHODS: Medline and Ovid HealthSTAR databases were searched from 1966 to 2002. STUDY SELECTION: The initial search yielded 516 results. Bibliography review yielded additional references. Articles were excluded if they involved financial incentives to change physician behaviours or enhance profit. Ten publications were selected as the highest level of evidence available. The quality of the evidence was low and of limited applicability (1 retrospective and 1 prospective cohort study, the remainder cross-sectional surveys). Three studies were from Canada, 1 from New Zealand, and the remaining 6 were from the United States. RESULTS: Outcome measures included initial recruitment of physicians, buyout rates and long-term retention. The majority of studies reported effective recruitment despite high buyout rates in some US-based programs. Increasing Canadian tuition and debt among medical students may make these programs attractive. The 1 prospective cohort study on retention showed that physicians who chose voluntarily to go to a rural area were far more likely to stay long term than those who located there as an ROS commitment. Multidimensional programs appeared to be more successful than those relying on financial incentives alone. CONCLUSION: ROS programs to rural and underserviced areas have achieved their primary goal of short-term recruitment but have had less success with long-term retention. Additional research is needed to examine the cost effectiveness of existing ROS programs and the incorporation of other retention strategies, such as medical education initiatives, community and professional support, differential rural fees and alternate funding models.

Canada↗
PubMed2003

"Where have all the students gone?" Retaining medical school graduates through educational innovations.

CONTEXT: New Mexico is a sparsely populated rural state in the USA, with 20% of New Mexicans living in poverty. There is a need for physicians in the state, especially in primary care. New Mexico's only medical school, the University of New Mexico School of Medicine is state supported. New Mexico and its medical school have a vested interest in its graduates returning to the state to practice. OBJECTIVES: Evaluate the effects of early community preceptorships on graduating physicians' specialty choice and subsequent return to practice in the state where they attended medical school. STRATEGIES: A Primary Care Curriculum (PCC) was introduced into the medical school in 1979. Students expressing interest in this programme were considered. Twenty students per year were assigned to the PCC. The remainder went through the traditional curriculum. The PCC used a problem-based learning model. All PCC students participated in a 16-week, one-on-one community preceptorship (Phase 1B) in a small or rural community during their first year. Graduates from 1983-1996 were analysed for specialty and practice location. MAIN OUTCOMES: Of the 294 students doing Phase 1B, 99 (40%) returned to New Mexico to practice compared to 221 (32%) of traditional students. Fifty-eight (23%) of the Phase 1B students practice primary care compared to 112 (16%) of the traditional students. CONCLUSION: Self-selected students choosing and participating in early community-based clinical experiences coupled with problem-based learning are more likely to return to the state and to practice primary care.

Career Choice↗
PubMed1998

Health maintenance organization penetration and the practice location choices of new physicians: a study of large metropolitan areas in the United States.

OBJECTIVES: The rapid growth of health maintenance organizations is reshaping the practice opportunities available to physicians. The practice location decisions of new physicians provide a sensitive bellwether of these changes. This study assessed the effect of health maintenance organization penetration on practice location for physicians completing graduate medical education (GME). METHODS: Conditional logit regression analysis was used to determine the effect of health maintenance organization penetration on practice location, controlling for other market characteristics. Subjects were physicians who finished GME between 1989 and 1994 and who located in one of the 98 US metropolitan areas with more than 500,000 population. The outcome measure was the particular metropolitan area chosen by each new physician. RESULTS: Early in the study period, new generalists were significantly more likely to locate in metropolitan areas with high health maintenance organization penetration than in low penetration areas, whereas new specialists' practice location choices were not associated with health maintenance organization penetration. The likelihood of choosing a high penetration relative to a low penetration area declined with time, however, for both generalists and specialists. Consequently, by the end of the study period, health maintenance organization penetration had a weak but significant negative effect on practice location for generalists and a strong negative influence on practice location for specialists. CONCLUSIONS: New generalists who completed graduate medical education between 1989 and 1994 were more likely than new specialists to locate in market areas with high health maintenance organization penetration; however, the proportions of both generalists and specialists who chose high penetration areas decreased during the study period. This finding may reflect reduced practice opportunities in high penetration areas relative to low penetration areas as health maintenance organizations' systems for controlling utilization began to yield results. Alternatively, new physicians may have become more hesitant to accept available positions in high penetration areas.

Adult↗
PubMed1994

Survey of postgraduate fellows in otolaryngology-head and neck surgery.

A survey of fellowship-trained otolaryngologists was undertaken. Seven hundred forty-four questionnaires were mailed, and 344 were returned. The survey respondents were asked questions regarding their fellowship training, location of practice, attitudes regarding certification, relevancy of fellowship to practice, and quality of fellowship training, among others. Results of this survey provide some information regarding the ongoing proliferation of fellowships in Otolaryngology--Head and Neck Surgery and the philosophies of those having taken fellowships. Generally, this survey indicates that fellowship-trained specialists feel that there are enough fellowships currently, and suggestions are made to improve the quality of fellowship training. Almost 70% of this survey's respondents prefer a Certificate of Added Qualifications from the American Board of Otolaryngology for credentialing and validation of their fellowship training.

Accreditation↗
PubMed1992

Dentists' attitudes to cross-infection control.

The wearing of gloves by dentists undertaking clinical procedures has been recommended by many authorities as an essential element of dental surgery cross-infection control. This paper reports an investigation into patterns of glove-wearing by practising dentists, and considers the effect of practice location and practising arrangements on this issue and other aspects of cross-infection control. The results show that these factors, including the type of patient treated, may influence the pattern of glove-wearing by dentists in England and Wales. These findings suggest that groups least likely to follow the recommended infection control procedures should be targeted when assessing dental education requirements.

Attitude of Health Personnel↗