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PubMed2003

Physician use of genetic testing for cancer susceptibility: results of a national survey.

Genetic testing for inherited germ-line mutations associated with cancer susceptibility is an emerging technology in medical practice. Limited information is currently available about physician use of cancer susceptibility tests (CSTs). In 1999-2000, a nationally representative survey was conducted to estimate prevalence of CST use by United States physicians and assess demographic, training, practice setting, and practice patterns associated with use. A stratified random sample of clinicians in eight specialties was selected from a file of all licensed physicians. In total, 1251 physicians, including 820 in primary care and 431 in tertiary care, responded to a 15-min questionnaire by mail, telephone, fax, or Internet (response rate = 71.0%). In the previous 12 months, 31.2% [95% confidence interval (CI), 28.5-33.9] overall, including 30.6% (95% CI, 27.5-33.7) in primary care and 33.4% (95% CI, 27.9-38.9) in tertiary care, had ordered CSTs or referred patients elsewhere for risk assessment or testing. More physicians referred patients elsewhere [26.7% (95% CI, 24.2-29.2)] than directly ordered tests [7.9% (95% CI, 6.3-9.5)]. Factors associated with ordering or referring included practice location in the Northeast [odds ratio (OR), 2.30; 95% CI, 1.46-3.63%], feeling qualified to recommend CSTs (OR, 1.96; 95% CI = 1.41-2.72), receiving CST advertising materials (OR, 1.97; 95% CI, 1.40-2.78%), and most notably, having patients who asked whether they can or should get tested (OR, 5.52; 95% CI, 3.97-7.67%). Lower CST use was associated with not knowing if there were local testing and counseling facilities (OR, 0.39; 95% CI, 0.23-0.66%). These findings underscore the importance of establishing effective clinical approaches to test use and promoting physician education to facilitate communication with patients about cancer genetics.

Adult↗
PubMed1982

New dental graduates: mobility and choice of dental practice arrangement. Bureau of Economic and Behavioral Research.

The key to understanding changes in the distribution of dentists through time is organizing and understanding the location decisions of recent graduates and dentists leaving the armed forces and federal service. New graduates represented approximately 57% of the new practices located between 1976 and 1979, and dentists in institutional service represented 21% of all movers. The migration rate among private practicing dentists who remain in private practice is roughly one-third the rate among all dentists. Further, practitioners who do move do not move very far. The proportion of interstate moves among all private practitioners that moved was only 28%. Apparently, migration among private practicing dentists is a statistically negligible phenomenon, at least in the short run. In contrast, more than 5,000 people have graduated from dental school each year since 1976. Of these, the majority immediately enter private practice, with most of the remainder split between specialty education and some form of institutional practice. Within approximately five years, the transition of the graduation cohort is largely complete. In the three years studied, the number of dentists entering private practice from either dental school or institutional practice is roughly four times the number of private practicing dentists who relocated. Few dentists in private practice do not own or share in the ownership of the practice where they treat patients. Although a higher percentage of the younger, less experienced dentists are in salaried, commissioned, or associate positions compared with all dentists, the majority assumes ownership positions soon after leaving dental school.

Dentists↗
PubMed2004

Do students from rural backgrounds engage in rural family practice more than their urban-raised peers?

INTRODUCTION: In a previous prospective study, students from rural backgrounds were found to be significantly more likely to consider rural practice than their urban-raised peers. The purpose of this study was to determine whether the students with rural backgrounds who participated in the original investigation were more likely than their urban-raised peers to be currently engaged in rural family practice. METHOD: In Canada, family doctors have the greatest opportunity to practise in rural communities. Consequently, rural and urban background students from the original study who entered the discipline of family medicine as a career were identified for practice location follow-up. Participants were categorised as either rural (population less than 10 000) or urban practitioners according to the population of the community in which they practised. The proportion of rural and urban background students engaged in rural or urban practice was analysed using chi-square and relative risk probability. RESULTS: A total of 78 students from the original cohort were found to be practising family medicine; 22 of them had been rurally raised. Seven (32%) of the rural background students were practising in a rural community, compared to 7 (13%) of the 56 urban background students (RR = 2.55; P < 0.05). CONCLUSIONS: Rural background students who went on to complete family medicine residency training were approximately 2.5 times more likely to be engaged in rural practice than their urban-raised peers. Altering medical school admission policy to recruit more rural background applicants should be part of a multi-dimensional approach to increasing the number of rural practitioners.

Canada↗
PubMed2005

Isolated rural general practice as the focus for teaching core clinical rotations to pre-registration medical students.

BACKGROUND: Earlier studies have successfully demonstrated that medical students can achieve success in core clinical rotations with long term attachments in small groups to rural general / family practices. METHODS: In this study, three students from a class of 226 volunteered for this 1-year pilot program, conducted by the University of Queensland in 2004, for medical students in the 3rd year of a 4-year graduate entry medical course. Each student was based with a private solo general practitioner in a different rural town between 170 and 270 km from the nearest teaching hospital. Each was in a relatively isolated rural setting, rated 5 or 6 on the RRMA scale (Rural, Remote, Metropolitan Classification: capital city = 1, other metropolitan = 2, large regional city = 3, most remote community = 7). The rural towns had populations respectively of 500, 2000 and 10,000. One practice also had a General Practice registrar. Only one of the locations had doctors in the same town but outside the teaching practice, while all had other doctors within the same area. All 3 supervisors had hospital admitting rights to a hospital within their town. The core clinical rotations of medicine, surgery, mental health, general practice and rural health were primarily conducted within these rural communities, with the student based in their own consulting room at the general practitioner (GP) supervisor's surgery. The primary teacher was the GP supervisor, with additional learning opportunities provided by visiting specialists, teleconferences and university websites. At times, especially during medicine and surgery terms, each student would return to the teaching hospital for additional learning opportunities. RESULTS: All students successfully completed the year. There were no statistical differences in marks at summative assessment in each of the five core rotations between the students in this pilot and their peers at the metropolitan or rural hospital based clinical schools. CONCLUSION: The results suggest that isolated rural general practice could provide a more substantial role in medical student education.

Clinical Clerkship↗
PubMed2004

Office systems and their influence on mammography use in rural and urban primary care.

CONTEXT: Breast cancer screening rates are lower in rural communities. Although studies have addressed barriers to mammography for rural residents, physician practice barriers have received less attention. PURPOSE: Controlled clinical trials have shown that the use of office reminder systems in primary care practices is related to increased clinical care rates. Therefore, we compared office systems use in primary care practices located in rural and urban communities and assessed the impact of these systems on rural-urban differences in mammography utilization. METHODS: We identified female Kansas Medicare beneficiaries aged 65 to 79 from Medicare claims data (N = 24,030) and determined which beneficiaries received a mammogram between April 1, 1999, and March 31, 2001. We linked beneficiaries to their primary care providers and obtained surveys from 180 primary care practices on their use of office reminder systems. FINDINGS: Mammography rates ranged from 20% to 92% (mean = 65%) among the 180 practices. Flowsheets with a mammography prompt were used by 33% of the practices, 38% utilized nonphysician staff to identify women due for mammograms, and 15% used computerized reminder systems. Urban practices used flowsheets more often than rural practices (44% versus 16%, P < 0.001). A multivariable regression model demonstrated higher mammography rates in urban practices, group practices, and practices using mammography flowsheets. CONCLUSIONS: Despite success in randomized controlled trials, reminder systems are not used often by primary care providers and are used even less often in rural compared to urban practices. Consistent implementation may be a major barrier to the successful adaptation of flowsheets by primary care offices.

Aged↗
PubMed2000

A comparison of nurse anesthesia practice types.

The present study examined the differences between anesthesia care team (ACT) and non-ACT practice types. Six practice variables were analyzed. We prepared and distributed a 13-item questionnaire to 1,000 practicing Certified Registered Nurse Anesthetists (CRNAs) with a 44.4% response rate. Data analysis revealed that nurse anesthetists in ACT practices had fewer years of experience and were younger than non-ACT nurse anesthetists (alpha = 0.05). Also, a significantly greater percentage of ACT nurse anesthetists were female, held master-level degrees, and practiced in urban and metropolitan locations. This also was true for placement of laryngeal mask airways and arterial lines, and in providing anesthesia for cardiopulmonary bypass, pediatric, intracranial, and trauma cases. However, a significantly greater percentage of non-ACT nurse anesthetists placed epidurals and central lines and were involved in pain management and critical care consultations. Income was significantly greater for non-ACT nurse anesthetists as well, but they worked more hours per week on average. Lastly, evaluation of employment arrangements showed that more than 91% (n = 361) of ACT nurse anesthetists were employees, and only 4% (n = 17) were self-employed. However, only 49% (n = 24) of non-ACT nurse anesthetists were employees, and almost 43% (n = 21) were self-employed. The present study demonstrates that significant differences exist between the 2 nurse anesthesia practice types examined. As nurse anesthesia practice arrangements continue to change and fewer CRNAs are hospital employed, each nurse anesthetist must be aware of current practice trends and understand the alternatives.

Adult↗
PubMedDate not supplied

Employment choices in conditions of physician oversupply: a study of graduates of San Francisco internal medicine programs, 1979-1984.

The authors surveyed 297 internists who completed residency or fellowship training at six San Francisco institutions from 1979 through 1984 to assess how the recent expanded supply of physicians has affected their intensity of practice and their decisions about location of practice. The vast majority of internists (93%) settled in metropolitan areas, with 56% remaining in the San Francisco Bay Area, despite that region's already high concentration of physicians. Mean annual income, in 1984 dollars, was slightly more than figures from national surveys of physicians of similar age ($72,560 vs. $71,900), but reported mean work week was shorter (54.8 hours vs. 60.5). Although subspecialists earned significantly more than generalists, this was because they worked more hours. Those who graduated later were significantly less likely to be in private practice in 1985, mainly because they initially selected salaried institutional work more often than earlier graduates (p less than 0.001). Women worked 85% of the men's work week and subspecialized significantly less often (p less than 0.05). These findings suggest that internists trained in already "over-doctored" areas will continue to settle there or in similar communities.

Adult↗
PubMedDate not supplied

Gender-related factors in the recruitment of physicians to the rural Northwest.

BACKGROUND: This study examines differences in the factors female and male physicians considered influential in their rural practice location choice and describes the practice arrangements that successfully recruited female physicians to rural areas. METHODS: This cross-sectional study was based on a mailed survey of physicians successfully recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest. RESULTS: Responses from 77 men and 37 women (response rate 61%) indicated that women were more likely than men to have been influenced in making their practice choice by issues related to spouse or personal partner, flexible scheduling, family leave, availability of childcare, and the interpersonal aspects of recruitment. Commonly reported themes reflected the respondents' desire for flexibility regarding family issues and the value they placed on honesty during recruitment. CONCLUSIONS: It is very important in recruitment of both men and women to highlight the positive aspects of the community and to involve and assist the physician's spouse or partner. If they want to achieve a gender-balanced physician workforce, rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse-partner, and interpersonal issues in the recruitment process.

Adult↗
PubMed2002

Successful physician-hospital integration in rural areas.

OBJECTIVES: During the 1990s hospitals competed to acquire physician practices. Those competitive bidding wars could have pushed the price of practices beyond the value obtained by gaining influence over physicians. This paper examines how hospital location and competition for physician practices affects the profitability of physician-hospital integration in rural areas. MATERIALS AND METHODS: Eight years of data covering 338 rural hospitals are used to test whether the acquisition of physician practices is more successful in more isolated, uncompetitive rural markets than in competitive rural markets. A hospital without a competitor within a 15-mile radius is deemed to operate in an uncompetitive market. Success is measured by shifts in admissions, lengths of stay, and overall profitability following the acquisition of a physician practice. RESULTS: Hospitals in uncompetitive rural markets that acquired practices showed decreased lengths of stay and increased admissions with no reduction in profitability. Hospitals in more competitive rural markets that acquired practices showed a decrease in profitability. CONCLUSIONS: Integration was a more profitable strategy for isolated rural hospitals than for hospitals with nearby competitors. Although further research is needed to determine if these results are due to the affect of competition on the cost of acquiring and operating practices, isolated rural hospitals should be open to the prospect of acquiring physician practices. Hospitals in competitive markets should be cautious about entering bidding wars for physician practices.

Catchment Area, Health↗
PubMed1996

Gender differences in characteristics, infection control practices, knowledge and attitudes related to HIV among Ontario dentists.

We surveyed 5,997 dentists in Ontario to investigate gender differences in the characteristics, infection control practices, knowledge and attitudes regarding the treatment of HIV-infected patients. The response rate was 70.3%. Reports indicated that female dentists are younger and more likely to work in larger urban centres (P < 0.00001), and in general practice (P < 0.0001) than their male counterparts. Multiple logistic regression analyses indicated that many significant gender differences in the univariate analyses could be explained by the confounding influence of age, practice location, and specialty; however, some differences remain significant: Women were more likely than men to report attending continuing education dealing with HIV/AIDS in the past two years (P < 0.001), and to use masks and eye protection (P < 0.00001). Men reported more economic concerns than women: they were more concerned about the financial burden of infection control costs (P < 0.00001), and losing patients from their practice if it is known that they treat patients with HIV (P < 0.05). However, there were no significant differences in willingness to provide treatment for patients with HIV. We conclude that there is little evidence to show that access to oral care for patients with HIV is affected by gender differences.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Deviation from the carrying capacity for physicians and growth rate of physician supply: the Taiwan case.

This study applies the theory of carrying capacity to examine the effects of market forces on the location pattern of physicians in Taiwan between 1974 and 1982. The data for the analysis were collected from governmental publications. The township was selected as the geographic unit of analysis. By using a regression model of physician supply, this study developed a proxy for physician carrying capacity and a deviation indicator to classify townships as attractive or unattractive. The results of this study indicate that: (1) within attractive townships, the greater the deviation from physician carrying capacity, the faster the growth rate of the physician-population ratio; (2) the overall pattern of the growth rate is quite similar across different sizes of townships; and (3) due to a loss of population, unattractive townships do not necessarily have the lowest growth rates of the physician-population, unattractive they gain few physicians. This study thus concludes that market forces are powerful in determining the physician distribution.

Economic Competition↗
PubMed1998

Variation in periodontal referral by general dental practitioners.

This study investigated the extent of and reasons for variation in the periodontal referral patterns of general dental practitioners in Northern Ireland. A questionnaire was circulated to all general dental practitioners in Northern Ireland. This questionnaire investigated the management of periodontal disease in the general dental service and referral for specialist periodontal advice and treatment. A usable return was made by 355 (68%) of those surveyed. The mean number of periodontal referrals by each respondent in the past year was 6.5 (SD 7.7), range 0 to 80. Backward stepwise logistic regression analysis indicated that independent predictors of high referral rate were practice location close to the referral centre (p<0.0001); dissatisfaction with ability to treat periodontal disease under the National Health Service (p=0.001); that previous refusals of referral had not dissuaded a dentist from continuing to offer referral (p=0.002); not offering root planing as a treatment (p=0.005); and perceived inadequate postgraduate education in periodontology (p=0.03). It is concluded that considerable variation exists between general dental practitioners working in Northern Ireland in relation to the referral of patients for specialist periodontal advice and treatment. It is further concluded that in many cases non-disease factors, such as the accessibility of the specialist service, have powerful effects on the decisions made by dentists and patients in relation to periodontal referral.

Adult↗
PubMed1994

Medical education and the retention of rural physicians.

OBJECTIVE: This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN: Design is a prospective cohort study. PARTICIPANTS: Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION: In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS: Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS: These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.

Adult↗
PubMed2005

Rural medical school applicants: do their academic credentials and admission decisions differ from those of nonrural applicants?

CONTEXT AND PURPOSE: Medical schools located in states with sizable rural areas are concerned about preparing physicians for practice in these areas; this is of particular concern for medical schools that are part of a state-owned university with a responsibility to educate physicians for rural areas. Because individuals from rural areas are most likely to return to practice medicine in rural areas at the conclusion of their training, it is important to recruit these individuals to medical schools to educate them for rural practice. METHODS: This study examines 7 years of admission data for students who applied and were accepted to the University of Missouri-Columbia School of Medicine, which has as a specific mandate to prepare physicians for rural practice. FINDINGS: The study indicates that rural applicants are more likely to be admitted to the medical school, and based on admissions criteria they are at least as academically qualified as nonrural applicants. CONCLUSIONS: The study demonstrates that a medical school can maintain competitive admission criteria while at the same time accepting those students more likely to enter rural practice. This is valuable information that medical schools with a similar mission to prepare physicians for rural practice might consider in their admissions decision-making process.

Adult↗
PubMed1994

Staff demographic influences on personnel preference of health service location.

Health service personnel maldistribution between rural and urban areas remains unresolved in health care organizations. Career preferences of health workers might be contributory to their maldistribution. The health workers preferences could relate to their demographic characteristics. Such characteristics as relevant to their career preferences would be useful for effective health personnel management. The crucial role of nurses and community health workers in the delivery of primary health care services led to their choice as study subjects among the health care team. Rural and urban health services were used as career preferences and the subjects' demographic characteristics were obtained with questionnaires. Analysis of the results showed that nurses and community health workers who preferred rural to urban health service were mainly males, had rural background and had previous rural health service experience. These findings were considered significant for trainee as well as employee recruitment for health services in order to improve the coverage of rural areas with needed manpower for primary health care.

Adolescent↗
PubMedDate not supplied

Colorado family practice graduates' preparation for and practice of emergency medicine.

BACKGROUND: Family physicians provide care in emergency departments, especially in rural areas; however, no published data describe how they perceive their preparation for emergency practice. We surveyed graduates of Colorado family practice residencies concerning their emergency medicine practice, their comfort working in emergency departments, and their perceived preparation for practicing emergency medicine. METHODS: Seventy recent graduates of Colorado residencies were surveyed regarding their location, work in emergency departments, contact with emergency medical services (EMS) personnel, and perceptions about their emergency medical training. RESULTS: Forty-five percent of respondents practiced in rural settings, 33% worked in emergency departments (56% rural, 14% urban), 60% reported contact with EMS personnel (91% rural, 32% urban), 54% believed their training adequately prepared them for working in emergency departments (82% rural vs 32% urban), 63% of rural and 22% of urban respondents indicated they wanted more major trauma experience during training, 70% reported discomfort with managing trauma, and 44% were interested in a 6-month emergency medicine fellowship. CONCLUSIONS: Most respondents believed their training in emergency medicine was adequate; however, most also reported discomfort with trauma management. Improved training for family physicians who provide emergency care could include expanded trauma care opportunities, increased work with EMS personnel, and postresidency training.

Advanced Cardiac Life Support↗
PubMedDate not supplied

Method of payment for children's dental services by practice type and geographic location.

The purpose of this project was to evaluate practice type and geographical differences in methods of payment accepted for children's dental services. A survey was mailed to 2000 general dentists and 1000 pediatric dentists randomly selected to provide representation from the 50 United States. Dentists were asked to specify the type of practice and the state in which they primarily practice. The survey included Medicaid, dental insurance, preferred provider organizations (PPO), and self-payment as payment options. Dentists were asked to indicate whether they never, occasionally, or frequently accepted each option of payment for children's dental services. Responses were received from 1245 (42%) dentists, including 723 general dentists and 522 pediatric dentists. Chi-square statistical analysis revealed significant practice type and regional differences in the acceptance of Medicaid for payment. Pediatric dentists accept Medicaid more frequently than general dentists (P < 0.001). Most dentists accept dental insurance and self-payment, while few indicate involvement with a PPO. The study revealed significant practice type differences only in the acceptance of Medicaid as payment for children's dental services. On a geographic basis, there were significant differences in the acceptance of Medicaid and dental insurance.

Adolescent↗
PubMed1995

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

This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27-item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits. The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates' broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory care. Rural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part-time positions, to facilitate recruitment and retention of physicians, especially women.

Chi-Square Distribution↗