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Attracting qualified physicians to underserved areas. Part 1: Why has the U.S. experienced such difficulty?

With health networks searching for additional market share and with a projected 30.2 million to be enrolled in Medicaid HMOs by 2000, more health executives will be weighing various strategies of how to attract qualified physicians to practice in poor inner-city and rural areas. Most frequently cited as solutions are: supplying more physicians, encouraging more medical school graduates to pursue primary care residencies, and modifying the number of international medical graduates entering U.S. residency programs. Part 1 of this article reviews the efficacy of these approaches, while the second part, which will appear in the January/February 1999 issue, explores a more pragmatic option: to simply improve the working conditions and just pay substantially more to physicians who practice in "less desirable" locations.

Education, Medical, Graduate↗

The essence of 'community' within community nursing: a district nursing perspective.

Over the past decade or so, there has been a marked shift in the location and nature of nursing care from the hospital setting to primary and community care. The past decade has also witnessed the development of a number of policy initiatives which indicate that the drive towards the community as a key location of nursing care is set to continue. Although notions of community have been explored extensively within the literature from a number of perspectives, there is an absence of a clear definition, and more particularly for the purposes of the present study, one from a nursing perspective. This lack of conceptual clarity is further compounded when notions of community and the place of nursing within the community are considered contemporaneously. The present pilot study, which was based on semi-structured interviews with district nurses, seeks to address this deficit and explore how district nurses define the nature of their role, both in terms of providing nursing care within the community and also in terms of defining community within the context of their work. The study illuminates the principal position of the home in defining the essence of community within community nursing and notions surrounding the nature of relationships which exist within this setting. This is highlighted through the identification of emerging themes: the maintenance of personal-professional boundaries, notions of holistic care and professional definitions of community. These observations raise important questions regarding the extent to which the location of care and the taken-for-granted assumptions surrounding community-based nursing care have been translated into practice to date. This also raises key issues regarding the tensions which exist for nurses trying to balance notions of community and community-based care within the parameters of organisational and professional boundaries.

Attitude of Health Personnel↗

Initial practice locations of international medical graduates.

OBJECTIVE: To examine the influence of place of graduate medical education (GME), state licensure requirements, presence of established international medical graduates (IMGs), and ethnic communities on the initial practice location choices of new IMGs. DATA SOURCES: The annual Graduate Medical Education (GME) Survey of the American Medical Association (AMA) and the AMA Physician Masterfile. STUDY DESIGN: We identified 19,940 IMGs who completed GME in the United States between 1989 and 1994 and who were in patient care practice 4.5 years later. We used conditional logit regression analysis to assess the effect of market area characteristics on the choice of practice location. The key explanatory variables in the regression models were whether the market area was in the state of GME, the years of GME required for state licensure, the proportion of IMGs among established physicians, and the ethnic composition of the market area. PRINCIPAL FINDINGS: The IMGs tended to locate in the same state as their GME training. Foreign-born IMGs were less likely to locate in markets with more stringent licensure requirements, and were more likely to locate in markets with higher proportions of established IMG physicians. The IMGs born in Hispanic or Asian countries were more likely to locate in markets with higher proportions of the corresponding ethnic group. CONCLUSIONS: Policymakers may influence the flow of new IMGs into states by changing the availability of GME positions. IMGs tend to favor the same markets over time, suggesting that networks among established IMGs play a role in attracting new IMGs. Further, IMGs choose their practice locations based on ethnic matching.

Adult↗

Career differences between primary care and traditional trainees in internal medicine and pediatrics.

OBJECTIVE: To assess the relation of Primary Care Residency Training to career choice, board certification, and practice location of internists and pediatricians. DESIGN: Cohort study with up to 8 years of follow-up. SETTING: The United States. PARTICIPANTS: The 17,933 residents trained in all internal medicine (13,750) and pediatrics (4,183) residency programs between 1977 and 1982 were studied using information from the National Resident Matching Program, the AMA Physician Masterfile, the Area Resource File, and a telephone survey. MEASUREMENTS: Career choice, board certification, and practice location were studied in relation to five explanatory variables: type of residency (primary care or traditional track), gender, year of medical school graduation, educational orientation of the teaching hospital, and medical school prestige. MAIN RESULTS: Graduates of primary care residency training programs chose careers in generalist primary care significantly more often than did graduates of traditional tracks in both internal medicine (72% compared with 54%) and pediatrics (88% and 81%, respectively; P less than 0.001 for both values). Board certification rates in internal medicine were statistically higher for graduates of primary care training programs (80%) than for graduates of traditional programs (76%, P = 0.002) but were not statistically significant for both groups of pediatric graduates. Graduates of primary care programs in pediatrics and internal medicine practiced in medically less served communities more often than did graduates of traditional programs. CONCLUSION: Graduates of primary care residency training programs in internal medicine and pediatrics differ from graduates of traditional residency programs in career choices, board certification rates, and practice locations.

Career Choice↗

'Common sense and a thick hide'. Physicians providing care to their own family members.

OBJECTIVE: To determine how frequently physicians treat their relatives in 17 categories of care, their reasons for deciding to treat, and their level of comfort with this practice. DESIGN: Mailed survey. SETTING: Rural, suburban, and urban practices in Oregon. SUBJECTS: Two thousand fourteen physicians in the following specialties: general practice, family practice, general internal medicine, general surgery, orthopedic surgery, obstetrics/gynecology, and pediatric medicine. RESULTS: One thousand two hundred ninety-two questionnaires (64%) were returned. Minor prescribing was done most frequently, followed by routine pediatric care, physical examinations, and minor surgery. All other forms of care occurred rarely, and there appears to be a gradient based on the level of complexity, seriousness, and potential for conflict with privacy. In general, older, male, and rural physicians provided more services to family members than their younger, female, and urban counterparts. General and family practitioners performed the most family care; general internists, the least. The most important reasons for providing care were convenience for the patient and request from relatives. Providers were most comfortable providing care to their children and least comfortable providing care to their grandparents. CONCLUSIONS: There is a wide range of practice, depending on the nature of the care and provider characteristics. Physicians report treating their own family members rarely and face significant dilemmas when doing so.

Adult↗

The nonmetropolitan plastic surgeon.

A questionnaire survey was conducted of 54 board-eligible or board-certified plastic surgeons practicing outside urban or suburban areas. Marketplace forces were determined to have been important in the choice of nonmetropolitan practice locations. The practitioners surveyed tended to participate in a broad spectrum of plastic surgical practice. On the whole, the surgeons reported themselves busy professionally and contented personally. A characteristic pattern of problems often accompanied the practice style.

Demography↗

Measuring concentration in primary care.

There is evidence that patient choice and the quality of service delivery in primary care can be influenced by the organisation and structure of provision at the local level. However, the formal measurement of structure in primary care has yet to be undertaken. Using data for Coventry, standard concentration measures are estimated, which show that concentration varies considerably across the city and tends to be higher in areas of lower deprivation. Assuming that patient choice is an important consideration in health care planning, concentration measurement may provide a useful tool for health authorities in making decisions about GP numbers, practice mergers and re-location.

Catchment Area, Health↗

A comparison of metropolitan and rural medical schools in China: which schools provide rural physicians?

To compare the role of metropolitan and rural medical schools in the provision of rural physicians, a survey was conducted in 12 metropolitan and 10 rural medical schools. Rural medical schools enrolled fewer students (P = 0.019), and produced fewer graduates (P = 0.023) than metropolitan medical schools. Students in rural medical schools were mainly from surrounding regional cities and counties, whereas those in metropolitan schools were from cities nationwide (P < 0.001). All rural medical schools produced rural physicians; one rural school reported that of its 256 graduates, 88 (34.4%) entered rural practice. Ten of the 12 metropolitan medical schools did not produce any rural physicians, whereas the remaining two metropolitan schools registered a total of 73 graduates who selected a rural practice location. These results indicate that rural medical schools may play a key role in overcoming the shortage of physicians in rural communities in China.

China↗

Relationship of scholarships and indebtedness to medical students' career plans.

Discriminant functions analyses of data from the 1983 survey of senior medical students by the Association of American Medical Colleges showed that the effects of scholarships must be taken into account when assessing the influence of indebtedness on medical students' career choices. Receipt of a federal scholarship, type of medical school attended (public or private), marital status, sex, and receipt of a nonfederal scholarship were found to be more powerful than indebtedness as predictors of whether the students preferred primary care or nonprimary care specialties. Receipt of a federal scholarship, type of school attended, and sex were found to be more powerful than indebtedness as predictors of whether the students preferred private clinical practice, salaried clinical practice in a hospital or clinic, salaried clinical practice in a public agency, or a nonclinical career. Indebtedness was found not to be a predictor of willingness to locate in a socioeconomically deprived area.

Career Choice↗

The intersection of race, gender, and primary care: results from the Women Physicians' Health Study.

The Women Physicians' Health Study is a nationally distributed mailed questionnaire survey of a random sample of 4501 female physicians. We examined differences in the professional characteristics and personal health habits of minority women physicians compared to other women physicians, with regard to the choice of primary care specialties, type or location of practice site, and career satisfaction. Most women physicians were self-described as non-Hispanic white (77.4%), with 13% Asians, and few blacks (4.3%) or Hispanics (5.2%). Blacks and Hispanics were more likely to choose primary care specialties (61.6% and 57.9%, respectively, vs. 49.3% of whites, p < 0.05). Black and Hispanic physicians were most likely to practice in urban areas (71.8% and 72.2%, respectively, p < 0.001). Minority physicians were most likely to report spending some time each week on clinical work for which they did not expect compensation. Black physicians were least likely to report high levels of work control and were least likely to be satisfied with their careers. While most physicians were compliant with the examined recommendations of the U.S. Preventive Services Task Force, we did find significant differences by ethnicity in compliance with clinical breast exams, mammograms, and pap smears. In conclusion, there continues to be fewer blacks and Hispanics in the U.S. physician workforce than in the general population. Minority women physicians are more likely to provide primary care services in communities that have been traditionally underserved and may also report higher rates of career dissatisfaction.

Adult↗