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PubMed1997

A comparison of specialty choices, residency training, and practice locations of early-decision and regular-admission graduates.

PURPOSE: Early-decision (ED) medical school applicants express a clear preference for attending a particular medical school. The present study assessed whether ED graduates would demonstrate similar geographic preferences in their choices of undergraduate institutions and selections of in-state residency sites and practice locations. METHOD: The study was conducted at the University of Kentucky College of Medicine. Uniform academic and nonacademic criteria were used to evaluate the applications of ED and regular-admission students who matriculated from 1974-75 to 1984-85. The student variables assessed were class year, gender, age, county of residence, and undergraduate college, as well as undergraduate science and cumulative grade-point averages (GPAs) and Medical College Admission Test (MCAT) scores. Specialty choice and locations of residency programs were obtained from the medical school's commencement programs. Specialty types and practice locations were obtained from practicing physician records maintained by the alumni office. RESULTS: Of the 1,243 matriculants, 193 (15.5%) gained admission to the school through the ED plan. The ED graduates were significantly more likely to have completed their undergraduate studies at the University of Kentucky than at other public or private schools, in state or out of state, and had significantly higher GPAs and MCAT scores. As a group, the ED graduates were somewhat (though not significantly) more likely than the regular-admission graduates to remain in state for their residencies and practice in state. CONCLUSION: The authors suggest that medical schools should work closely with their undergraduate admission offices to attract academically outstanding high school students. Such students are likely to stay in state for the eight-year span of their undergraduate and medical educations and may have a greater tendency to practice in state.

Academic Medical Centers↗
PubMed2003

Breast cancer screening beliefs by practice location.

BACKGROUND: This study examines variations in breast cancer screening among primary care clinicians by geographic location of clinical practice. METHODS: A cross-sectional survey design was used to examine approaches to breast cancer screening among physicians, nurse practitioners, and physician assistants involved in primary care practice. A summary index of beliefs about breast cancer screening was created by summing the total number of responses in agreement with each of four survey items; values for this summary variable ranged between zero and four. Respondents were classified into urban, rural and suburban categories based upon practise location. RESULTS: Among the 428 respondents, agreement with "correct" responses ranged from 50% to 71% for the individual survey items; overall, half agreed with three or more of the four breast cancer screening items. While no significant differences were noted by practice location, variation in responses were evident. Reported use of written breast cancer guidelines was less in both suburban (OR = 0.51) and urban areas (OR = 0.56) when compared to clinicians in rural areas. CONCLUSION: Development of an evidence-based consensus statement regarding breast cancer screening would support a single set of unambiguous guidelines for implementation in all primary care settings, thus decreasing variations in how breast cancer screening is approached across varied clinical settings.

Attitude of Health Personnel↗
PubMed1989

Likelihood of contact with AIDS patients as a factor in medical students' residency selections.

Results from the National Resident Matching Program for the years 1980, 1983, and 1987 were used to examine changes over time in the matches of U.S. medical students to residencies in cities with high concentrations of patients with acquired immunodeficiency syndrome (AIDS) and to specialties in which the care of AIDS patients was most concentrated. Medical students seeking postgraduate training in categorical surgery residency programs were less likely to be matched with programs located in areas where the numbers of reported AIDS cases were high in 1987 as compared with the "pre-AIDS" years of 1980 or 1983. This trend was more pronounced for students from medical schools located in cities with high numbers of AIDS cases. There was a decline in matches to residencies in categorical internal medicine nationally, regardless of location; this decline was also greater among the students coming from medical schools in cities with high numbers of AIDS cases. The authors discuss the implications for medical educators of declines in matches to specialties in which the care of AIDS patients is most concentrated. The imperfect nature of available measures of students' exposure to AIDS patients makes the data of this study preliminary, and further studies are being undertaken. However, the finding of significant effects in spite of the imprecision of some measures suggests that future work will confirm the results of this study.

Acquired Immunodeficiency Syndrome↗
PubMed2006

Unemployment in an underserviced specialty?: The need for co-ordinated workforce planning in Canadian neurosurgery.

BACKGROUND: A recent report suggested that newly trained Canadian neurosurgeons are experiencing difficulty finding employment in Canada. Such occurrences, in combination with recent certification restrictions imposed in the US, have resulted in increasing concern that we will shortly be seeing a surplus of graduating neurosurgeons in Canada. The purpose of this study was to develop a better understanding of training and employment patterns in the Canadian neurosurgical workforce. METHODS: Using a database provided by the Royal College of Physicians and Surgeons of Canada, the current practice location of recent (1990-2002) neurosurgical certificants and a list of all neurosurgeons practicing in Canada were generated. From these data the number of surgeons per 100,000 patient population, and the number of residents required to maintain this workforce were determined. RESULTS: Practice location could be identified for 183/189 individuals who passed their qualifying examination in neurosurgery during this time. Only 45% of them are currently practicing in Canada. The current service ratio for this specialty is 0.65 per 100,000 population overall. Although 14.6 residents/year are being trained, only 6.5/year are required to maintain the existing neurosurgical workforce. CONCLUSIONS: Our data supports the concern about an imminent employment crisis for young neurosurgeons in Canada with more than twice the required number of residents being trained. However, this shortfall of staff positions is at a time when the specialty may be underservicing the country's population. These results highlight the necessity for more cohesive workforce planning in Canada, and in particular, ensuring the appropriate balance between training and need.

Canada↗
PubMed1992

Factors affecting pharmacists' selection of rural or urban practice sites in Nebraska.

A questionnaire was used to determine why pharmacists in Nebraska chose urban or rural practice sites and to help the University of Nebraska College of Pharmacy encourage students to consider rural practice. Questionnaires were mailed to 1427 Nebraska pharmacists to gather data about their practice, job satisfaction, location of rearing, location of spouse's rearing, and prepharmacy and clerkship training. Usable responses were sorted into those from urban pharmacists (residing in Omaha and Lincoln and their suburban areas) and those from rural pharmacists (all others). Of the 689 usable responses, 315 (45.7%) were from urban pharmacists and 374 (54.3%) were from rural pharmacists. Of the rural pharmacists, 93% [corrected] grew up in communities of fewer than 100,000 people and 60% grew up in communities of fewer than 5,000 people. Respondents cited income potential, desirability of practice site, influence of spouse and family, and quality of children's schools as factors that most influenced their choice of practice site. Based on the survey results, the University of Nebraska College of Pharmacy took actions to recruit students from rural communities and increase students' exposure to rural practice settings. Pharmacists who were reared or trained in rural areas were more likely to practice in rural Nebraska than pharmacists who had only urban experience.

Career Choice↗
PubMed1993

Do physicians locate as spatial competition models predict? Evidence from Alberta.

This article analyses how physicians choose locations of practice in response to spatial competition forces and considers the implications of such choices for public policy to alleviate shortages of practitioners in rural areas. The predicted geographic distribution of physicians, as determined through spatial competition modelling, was compared with the actual distribution of physicians in 1990 among Alberta's 19 census divisions. Physicians were found to respond to spatial competition forces in choosing where to practise, with the qualification that 1 urban patient had a demand weight equal to 2.32 rural patients. A policy to attract more physicians to rural areas by means of income subsidies is technically feasible but expensive. The high cost means that alternative policies such as a bigger and more effective ambulance network to transport patients to medical centres should become the focus of public policies to improve health care in rural areas.

Alberta↗
PubMed2001

John Flynn Scholarship students: case studies of useful contributions to remote health care.

In 1997, the John Flynn Scholarship (JFS) program was launched as an initiative to increase recruitment of doctors to rural areas. These scholarships enable undergraduate medical students to spend 2 weeks each year for 4 years at the same rural location. Given the magnitude of Australia's unmet rural health needs, we asked whether the experience could be enhanced by ensuring the students undertook meaningful work that was useful for the community. This paper describes, using case studies, some of the activities in which four JFS students have been involved and the positive contributions that they have made to rural health. The case studies indicate that pre-clinical students can be valuable members of the rural health workforce. We hope that if JFS students are given the opportunity to work as responsible health professionals they will have a better learning experience and will be more likely to return to the bush as doctors.

Adult↗
PubMed1996

International medical graduates in rural America: the 1987 distribution of physicians who entered the U.S. medical system between 1969 and 1982.

This study examines the differential location on Dec. 31, 1987, in nonmetropolitan U.S. counties of a cohort of international medical graduates (IMGs) (n = 246,754) certified by the Educational Commission for Foreign Medical Graduates between 1969 and 1982, and a matched group of U.S. medical graduates (USMGs). Analysis of counties grouped into categories of population size revealed disparities across certain U.S. census divisions. IMGs were distributed disproportionately in the West North Central and East South Central census divisions. The implications of the IMG presence in numerous rural counties is discussed from the perspective of recent policy proposals to reduce the number of IMGs in the United States.

Chi-Square Distribution↗
PubMed1999

Some factors that endodontists may consider when selecting a practice location.

The distribution of endodontists per population is considered in terms of the ranking of states by the availability of a graduate endodontic training program and selected population demographic characteristics. Statistically significant positive relationships were found for the endodontist to population ratios, and (i) overall health and social conditions, (ii) per capita income, (iii) per capita spending for health care, and (iv) percentage of the population that is Hispanic and Asian-American. Negative relationships were found for (i) increases in the population that is underserved by dentists, (ii) higher levels of out-of-pocket spending for health care, and (iii) increases in the population below the poverty level. Further analysis at the local level (and for individual practitioners) is needed to better understand the decision process in the selection of a practice site.

Decision Making↗
PubMed2005

Preparedness for rural community leadership and its impact on practice location of family medicine graduates.

OBJECTIVE: To identify non-clinical dimensions of preparedness for rural practice and to determine whether preparedness for rural practice is predictive of rural practice location. DESIGN: Cross-sectional postal survey mailed in 2001. SETTING: Communities across Canada where graduates were practising. SUBJECTS: Graduates (n = 369) of the family medicine residency program at the universities of Alberta (U of A) and Calgary (U of C) between 1996 and 2000, inclusive. INTERVENTIONS: Using a 4-point scale, graduates rated the extent to which the residency program prepared them for eight dimensions of rural practice: clinical demands of rural practice, understanding rural culture, small community living, balancing work and personal life, establishing personal/professional boundaries, becoming a community leader, handling a 'fish bowl' lifestyle, and choosing a suitable community. MAIN OUTCOME MEASURE: Identification of non-clinical dimensions of preparedness for rural practice and whether scores on preparedness scales are predictive of rural practice location. RESULTS: The overall response rate was 76.4%. Factor analysis of the eight preparedness items produced two factors, 'rural culture' and 'rural community leader' which explained 72% of the variance. The alpha coefficient for each factor was 0.87. Odds ratios revealed that family medicine graduates prepared for rural community leadership roles were 1.92 (CI = 1.03-3.61) times more likely to be in rural practice. Rural physicians were also 2.14 (CI = 1.13-4.03) times as likely to have a rural background. CONCLUSIONS: Preparedness to be a rural community leader and having a rural background were predictive of rural practice. Educators should consider this in both family medicine residency admissions policy and practice and when designing and implementing family medicine residency curricula.

Adult↗
PubMedDate not supplied

Rural-urban and gender differences in procedures performed by family practice residency graduates.

OBJECTIVE: We compared the types of procedures performed and obstetrical care provided by family practice residency graduates, by practice location and physician gender METHODS: We conducted a cross-sectional questionnaire survey of 702 graduates who completed family practice residency programs in Alberta, Canada, from 1985 to 1995, inclusive. Graduates were asked to indicate which of 28 procedures and 7 obstetrical care practices they performed. The data were analyzed by gender and current practice location. RESULTS: A total of 442 (63%) of the graduates responded to the survey. The top five procedures performed by family practice graduates were minor office surgery, foreign body removal (eye), joint aspiration, joint injection, and anterior nasal packing. There was a declining trend in the number of procedures performed by family practice graduates from rural, to regional, to metropolitan areas. Relatively more males performed procedures; however, more females did IUD insertion and obstetrical care practice. Except for a few exceptions, a similar proportion of male and female graduates in rural practice performed procedures. CONCLUSIONS: The procedural and obstetrical care pattern of practice differs between family practice graduates in rural and urban areas, as well as between male andfemale graduates. Family practice residency programs should consider additional training in procedural skills for those planning to practice in rural areas, as well as encourage females to become skilled at performing procedures relevant to family practice.

Adult↗
PubMed1998

One-two rural residency tracks in family practice: are they getting the job done?

BACKGROUND: In the 1990s, the Residency Review Committee for Family Practice (RRCFP) and the American Board of Family Practice used the development of rural training programs as a strategy to bridge training experiences across urban referral centers and rural community hospitals. These programs are relatively small and attract trainees who are predisposed to rural practice. Aggregating data from several programs yields insight about their challenges and their ability to produce graduates who enter rural practice. METHODS: This descriptive analysis is based on self-reported data from a 1996 survey mailed to the residency program directors of rural training programs, identified by the RRCFP office as one-two programs. RESULTS: More than half of the rural training programs surveyed were located in health professions shortage areas, most in communities with little urban influence. These programs are equally likely to be sponsored by university- or community-based residency programs. Most (75%) placed two or fewer residents per year in the rural site; minorities accounted for 4% of placements. Thirty percent of programs report unfilled positions. Seventy-five percent use televideo communications and find experiences in surgery and obstetrics relatively easy to arrange but dermatology and critical care difficult. Seventy-six percent of graduates enter rural practice after graduation. CONCLUSIONS: This survey suggests that family practice rural one-two residencies are meeting the goal of providing trainees with a rural immersion experience, in anticipation of selecting rural practice after graduation.

Community Health Services↗
PubMed1997

Attitudes of general practitioners who practice in remote island communities.

OBJECTIVE: To describe the personal, social and medical attitudes of doctors who practice on the islands off the West coast of Scotland. DESIGN: Questionnaire survey with a single follow-up. SUBJECTS: All 65 general practitioners (GPs) who practice on the 17 islands located off the West coast of Scotland. RESULTS: Fifty-two (80%) responded after a single reminder. The main advantages identified were continuity of care, personal relationships with patients and involvement with the local community. Other important reasons were the opportunity to exercise clinical skills and appreciation of their local environment such as the beauty of the scenery. Disadvantages were associated with isolation, difficulty in obtaining cover, in attending refresher courses and the burden of sole responsibility. CONCLUSION: The GPs who practice in remote island practices believe that the advantages outweigh the disadvantages. They value continuity of care and their relationships with patients and communities. This survey suggests that the difficulties of staffing remote island communities may partly be addressed by allowing undergraduate students and postgraduate colleagues access to these general practitioners.

Adult↗
PubMed1992

Job satisfaction among hospital nurses: facility size and location comparisons.

Despite recent declines in turnover and vacancy rates, maintaining a stable nursing staff continues to be critical to the effective operation of American hospitals. Job satisfaction is a pivotal element in nurse retention, and organizational theory suggests that some of the factors that influence job satisfaction vary by facility size. This is a study of job satisfaction among a sample of 731 nurses providing direct patient care in 22 hospitals. The sample includes approximately equal numbers of nurses employed in very small rural hospitals (1-49 beds), medium sized facilities located in small towns (50-99 beds), and larger metropolitan institutions (> 100 beds). Differences by hospital size were observed in overall job satisfaction and in five sub-dimensions of that concept (i.e., professional status, task requirements, pay, organizational policies, and autonomy). With the exception of pay, the results indicated that nurses employed in the very small rural hospitals were more satisfied with their jobs. Differences by hospital size were also observed in the personal characteristics of the nurses, several specific aspects of their job, and in their perceptions of job mobility. A set of four hierarchically nested ordinary least squares regression models indicated that job-specific characteristics were the most powerful predictors of job satisfaction.

Attitude of Health Personnel↗
PubMed2005

High school census tract information predicts practice in rural and minority communities.

PURPOSE: Identify census-derived characteristics of residency graduates' high school communities that predict practice in rural, medically underserved, and high minority-population settings. METHODS: Cohort study of 214 graduates of the University of California, San Francisco-Fresno Family Practice Residency Program (UCSF-Fresno) from its establishment in 1970 through 2000. Rural-urban commuting area code; education, racial, and ethnic distribution; median income; population; and federal designation as a medically underserved area were collected for census tracts of each graduate's (1) high school address and (2) practice location. FINDINGS: Twenty-one percent of graduates practice in rural areas, 28% practice in areas with high proportions of minority population (high minority areas), and 35% practice in federally designated medically underserved areas. Graduation from high school in a rural census tract was associated with rural practice (P < .01), Of those practicing in a rural site, 32% graduated from a rural high school, as compared with 11% of nonrural practitioners. Graduation from high school in a census tract with a higher proportion of minorities was associated with practice in a proportionally high minority community (P = .01). For those practicing in a high-minority setting, the median minority percentage of the high school census tract was 31%, compared with 16% for people not practicing in a high minority area. No characteristics of the high school census tract were predictive of practice in a medically underserved area. CONCLUSION: Census data from the residency graduate's high school predicted rural practice and practice in a proportionally high minority community, but not in a federally designated medically underserved area.

Adolescent↗
PubMed2005

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.

Area Health Education Centers↗
PubMed1991

Rural populations and rural physicians: estimates of critical mass ratios, by specialty.

As physicians and other providers of health care services see their traditional markets erode, an increasingly important element of any provider location decision is the determination of a population base or "critical mass" that can professionally and financially support a given set of health care services. While the size of a local population is not the sole determinant of success, ultimately an adequate population base to support a given spectrum of services must be defined, and providers increasingly need tools for evaluating opportunities in the new economic market. This is especially true in rural areas. An earlier supply and demand model for estimating the critical mass of population needed to support a physician in any one of 25 specialties and subspecialties in urban and suburban areas is adapted to the rural market. The assumptions inherent in the earlier model are examined and the issue of "critical mass" is examined from a rural health care perspective in this paper.

Catchment Area, Health↗
PubMedDate not supplied

Incorporating patient travel times in decisions about size and location of dialysis facilities.

This report demonstrates the power and usefulness of mathematical optimization as a decision support tool in the medical services industry by presenting an application to dialysis service planning. Models to predict the number of dialysis beds in a given region are usually population-based. Dialysis planners and providers have found a need to accommodate sparsely populated regions by making some allowance for patient travel times. A formal approach to incorporating travel times into dialysis planning, based on the formulation and solution of a mixed-integer programming model, is presented. The development of a method for dialysis planning serves as a platform to demonstrate the use of integer programming to support decision making. Major modeling principles are presented; output interpretation and sensitivity analysis are illustrated by examples; and computational requirements are discussed.

Ambulatory Care Facilities↗