Fred W. Markham

Medical School Programs to Increase the Rural Physician Supply: A Systematic Review and Projected Impact of Widespread Replication

Purpose To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication. Method Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed. Results Ten studies met all inclusion criteria. Outcomes were available for more than 1,600 graduates across three decades from six programs. The weighted average of graduates practicing in rural areas ranged from 53% to 64%, depending on the definition of rural. If 125 medical schools developed similar programs for 10 students per class, this would result in approximately 11,390 rural physicians during the next decade, more than double the current estimation of rural doctors produced during that time frame (5,130). Conclusions All identified comprehensive medical school rural programs have produced a multifold increase in the rural physician supply, and widespread replication of these models could have a major impact on access to health care in thousands of rural communities. The current recommendation to expand U.S. medical school class size represents a unique and timely opportunity to replicate these programs.

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.

Patient perceptions of physician empathy, satisfaction with physician, interpersonal trust, and compliance.

Objectives This study was designed to investigate psychometric properties of the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE), and to examine correlations between its scores and measures of overall satisfaction with physicians, personal trust, and indicators of patient compliance. Methods: Research participants included 535 out-patients (between 18-75 years old, 66% female). A survey was mailed to participants which included the JSPPPE (5-item), a scale for measuring overall satisfaction with the primary care physician (10-item), and demographic questions. Patients were also asked about compliance with their physician’s recommendation for preventive tests (colonoscopy, mammogram, and PSA for age and gender appropriate patients). Results: Factor analysis of the JSPPPE resulted in one prominent component. Corrected item-total score correlations ranged from .88 to .94. Correlation between scores of the JSPPPE and scores on the patient satisfaction scale was 0.93. Scores of the JSPPPE were highly correlated with measures of physician-patient trust (r >.73). Higher scores of the JSPPPE were significantly associated with physicians’ recommendations for preventive tests (colonoscopy, mammogram, and PSA) and with compliance rates which were > .80). Cronbach’s coefficient alpha for the JSPPPE ranged from .97 to .99 for the total sample and for patients in different gender and age groups. Conclusions: Empirical evidence supported the psychometrics of the JSPPPE, and confirmed significant links with patients’ satisfaction with their physicians, interpersonal trust, and compliance with physicians’ recommendations. Availability of this psychometrically sound instrument will facilitate empirical research on empathy in patient care in different countries.

Increasing the Supply of Rural Family Physicians: Recent Outcomes From Jefferson Medical College's Physician Shortage Area Program (psap)

Purpose The shortage of primary care physicians in rural areas is an enduring problem with serious implications for access to care. Although studies have previously shown that medical school rural programs—such as Jefferson Medical Colleges Physician Shortage Area Program (PSAP)—significantly increase the rural workforce, determining whether these programs continue to be successful is important. Method The authors obtained, from the Jefferson Longitudinal Study, the 2007 practice location and specialty for the 2,394 PSAP and non-PSAP graduates of 11 previously unreported Jefferson graduating classes (1992–2002). They determined the relative likelihood both of PSAP versus non-PSAP graduates practicing rural family medicine and of all PSAP versus non-PSAP graduates practicing in Pennsylvanias rural counties. Results PSAP graduates were much more likely both to practice rural family medicine than their non-PSAP peers (32.0% [31/97] versus 3.2% [65/2,004]; relative risk [RR] = 9.9, confidence interval [CI] 6.8–14.4, P < .001) and to practice any specialty in rural Pennsylvania (PSAP 24.7% [24/97] versus non-PSAP 2.0% [40/2,004]; RR = 12.4, CI 7.8–19.7, P < .001). Conclusions Despite major changes in health care in recent decades, Jeffersons PSAP continues to represent a successful model for substantially increasing the supply and distribution of rural family physicians. Especially with the forthcoming expansion in health insurance, access to care for rural residents will require an increased supply of providers. These results may also be important for medical schools planning to develop similar rural programs, given the new Rural Physician Training Grants program.

The use of conjoint analysis to study patient satisfaction.

Previous research has identified aspects of the outpatient interactions between patients and physicians that are important for patient satisfaction. In this study, conjoint analysis was used to determine the relative importance of these factors to patients. This study found the perceived skill of the physician to be the most important factor and waiting time in the office the least important. The use of conjoint analysis should help both patients and physicians to maximize patient satisfaction while minimizing costs as much as possible.

Medical school rural programs: A comparison with international medical graduates in addressing state-level rural family physician and primary care supply

Purpose Comprehensive medical school rural programs (RPs) have made demonstrable contributions to the rural physician workforce, but their relative impact is uncertain. This study compares rural primary care practice outcomes for RP graduates within relevant states with those of international medical graduates (IMGs), also seen as ameliorating rural physician shortages. Method Using data from the 2010 American Medical Association Physician Masterfile, the authors identified all 1,757 graduates from three RPs (Jefferson Medical Colleges Physician Shortage Area Program; University of Minnesota Medical School Duluth; University of Illinois College of Medicine at Rockfords Rural Medical Education Program) practicing in their respective states, and all 6,474 IMGs practicing in the same states and graduating the same years. The relative likelihoods of RP graduates versus IMGs practicing rural family medicine and rural primary care were compared. Results RP graduates were 10 times more likely to practice rural family medicine than IMGs (relative risk [RR] = 10.0, confidence interval [CI] 8.7–11.6, P < .001) and almost 4 times as likely to practice any rural primary care specialty (RR 3.8, CI 3.5–4.2, P < .001). Overall, RPs produced more rural family physicians than the IMG cohort (376 versus 254). Conclusions Despite their relatively small size, RPs had a significant impact on rural family physician and primary care supply compared with the much larger cohort of IMGs. Wider adoption of the RP model would substantially increase access to care in rural areas compared with increasing reliance on IMGs or unfocused expansion of traditional medical schools.

Retention of Rural Family Physicians After 20–25 Years: Outcomes of a Comprehensive Medical School Rural Program

Background: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) is one of a small number of comprehensive medical school rural programs that has been successful in increasing the supply of family physicians practicing in rural areas. Although retention is a critical component of the rural physician supply, published long-term outcomes are limited. Methods: Of the 1937 JMC graduates from the classes of 1978 to 1986, we identified those who were practicing family medicine in a rural county when they were first located in practice (in 1986 for 1978–1981 graduates and in 1991 for 1982–1986 graduates). Using the Jefferson Longitudinal Study, we then compared the numbers of PSAP and non-PSAP graduates who were still practicing family medicine in the same area in 2011. Results: Of the 92 JMC graduates initially practicing rural family medicine, 90 were alive in 2011, and specialty and location data were available for 89 (98.9%). Of the 37 PSAP graduates who originally practiced rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 compared with 24 of 52 non-PSAP graduates (46.2%; P = .02). Conclusion: This study provides additional support for the substantial impact of medical school rural programs, suggesting that graduates of rural programs are not only likely to enter rural family medicine but to remain in rural practice for decades.

MEDICAL STUDENTS' SPECIALTY CHOICE AND THE NEED FOR PRIMARY CARE Our Future

Recent changes in the health care environment have directed increasing attention to the recognized oversupply of specialists and relative lack of primary care physicians. Despite this imbalance and the need for more primary care physicians, US medical schools are not producing them in adequate numbers. To effect change in the production of primary care physicians, a comprehensive approach that addresses key factors in medical student specialty choice is needed. This article discusses such factors and how they affect medical students during the course of their training. Issues concerning primary care specialty choice and the physician work force are important to the development of the future US health care system.

Increasing the Supply of Women Physicians in Rural Areas: Outcomes of a Medical School Rural Program

Background: Women physicians are less likely then men to practice in rural areas. With women representing an increasing proportion of physicians, there is concern that this could exacerbate the rural physician shortage. The Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) is one of a small number of medical school rural programs shown to be successful in addressing the rural physician shortage; however, little is known about their specific impact on women. Methods: For 2394 physicians from the 1992 to 2002 JMC graduating classes, the 2007 practice location and specialty for PSAP and non-PSAP graduates were obtained from the Jefferson Longitudinal Study. The relative likelihood of PSAP versus non-PSAP graduates practicing in rural areas was determined for women and men and compared. Results: Women PSAP graduates were more than twice as likely as non-PSAP women to practice in rural areas (31.7% vs 12.3%; relative risk, 2.6; 95% CI, 1.6–4.2). This was similar to the PSAP outcomes for men (51.8% vs 17.7%; relative risk, 2.9, 95% CI, 2.2–3.9; relative risk ratio, 0.9, 95% CI, 0.5–1.5). PSAP outcomes were also similar for women and men practicing rural family medicine and rural primary care. Conclusion: These results provide support that medical school rural programs have the potential to help address the serious shortage of women physicians in rural areas, thereby increasing access to care for those living there.

The relationship between matriculating medical students' planned specialties and eventual rural practice outcomes.

Purpose To analyze the previously unknown relationships between the specialty plans of entering medical students and their eventual rural practice outcomes. Method For 5,419 graduates from the 1978–2002 classes of Jefferson Medical College, their self-reported specialty plans at the time of matriculation were obtained from the Jefferson Longitudinal Study, as were their 2007 practice locations. Specialty plans were grouped into 12 categories, and the percentages of graduates initially planning each specialty group who were actually practicing in rural areas were determined. Results Entering medical students’ specialty plans were strongly related to eventual rural practice (P < .001). Those students planning family medicine were “highly likely” to practice in rural areas (29.4%, 238/810). They were 1.5 times as likely to practice rural as a “mid-likely” group (those planning general surgery, psychiatry, emergency medicine, general internal medicine, or one of the medical subspecialties: 19.6% [range 17.9%–21.0%], 229/1,167). Students planning family medicine were also 2.1 times as likely to practice rural as those students planning a “lower-likely” group (those planning general pediatrics, one of the surgical subspecialties, the hospital specialties of radiology, anesthesiology and pathology, and obstetrics–gynecology, or other specialties: 14.0% [range 13.0%–14.3%], 142/1,016). Conclusions These findings show that students’ specialty plans at medical school matriculation are significantly related to rural outcomes, and they provide new information quantifying the absolute and relative likelihood of those planning various specialties to enter rural practice. This information is particularly important for medical schools that have or plan to develop comprehensive rural programs.