Howard K. Rabinowitz

Recruitment, Retention, and Follow-up of Graduates of a Program to Increase the Number of Family Physicians in Rural and Underserved Areas

BACKGROUND To help address the geographic and specialty maldistribution of physicians, Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974. This unique program, which combines a selective medical school admissions policy with a special educational program, has been shown to be successful in increasing the number of family physicians in rural and underserved areas, but it is not known whether they remain in this type of practice. METHODS Graduates of the PSAP were tracked longitudinally and compared with their non-PSAP classmates. Information was obtained about the retention of family physicians in rural areas and areas with a physician shortage over the previous five years, the geographic and specialty choices of more recent graduates, and the recruitment of applicants into the program. RESULTS Of the 47 PSAP graduates from the classes of 1978 through 1981, reported on earlier, the number who combined a career in family medicine with practice in a rural area or one with a physician shortage remained unchanged, although there was substantial attrition among non-PSAP graduates practicing family medicine in rural (32 percent) and underserved (40 percent) areas. Among the 101 PSAP graduates of the classes of 1982 through 1986, the results were similar to those for the first four classes. Overall, PSAP graduates from the classes of 1978 through 1986 were approximately four times as likely as non-PSAP graduates to practice family medicine (55 percent vs. 13 percent), to practice in a rural area (39 percent vs. 11 percent), and to practice in underserved areas (33 percent vs. 8 percent). They were approximately 10 times more likely to combine a career in family medicine with practice in a rural (26 percent vs. 3 percent) or underserved (23 percent vs. 2 percent) area. Overall, 85 percent of PSAP graduates were either practicing a care specialty or practicing in a rural or small metropolitan area or one with a shortage of physicians. In parallel with national trends, the number of applicants and matriculants to the program decreased during the past decade, so that the percentage of available places filled decreased from 97 percent to 33 percent. However, there has been a recent increase in the number of applicants and matriculants. CONCLUSIONS The results of this study indicate that the PSAP was successful in increasing the number of family physicians in rural and underserved areas as well as in retaining them. This suggests that medical schools can have a substantial influence on the distribution of physicians according to specialty choice and the geographic location of their practices, principally through admission criteria.

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.

Evaluation of a Selective Medical School Admissions Policy to Increase the Number of Family Physicians in Rural and Underserved Areas

Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974; this program preferentially admits medical school applicants from rural backgrounds who intend to practice family medicine in rural and underserved areas. Evaluation of the program has shown that PSAP graduates from the classes of 1978 to 1985 have performed slightly less well than their peers (non-PSAP) during medical school, although there was no difference in attrition between the two groups. Nor did the performance of PSAP and non-PSAP graduates differ during their postgraduate training. PSAP graduates from the classes of 1978 to 1981 were almost five times as likely as non-PSAP graduates to practice family medicine (59.6 vs. 12.6 percent, P less than 0.001), three times as likely to practice in rural areas (37.8 to 42.2 percent vs. 10.0 to 11.8 percent, P less than 0.001), and two four times as likely to practice in areas where there is a physician shortage (26.7 to 40.0 percent vs. 9.2 to 11.2 percent, P less than 0.01). They were 7 to 10 times as likely as their peers to combine a career in family medicine with practice in a rural or underserved area (24.4 to 31.1 percent vs. 3.1 to 3.9 percent, P less than 0.001), thereby fulfilling the goals of the PSAP. This study concludes that the medical school admissions process can have a major influence on the specialty choice and geographic practice location of physicians, and suggests one mechanism for increasing the number of family physicians in rural and underserved areas.

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.

Innovative Approaches To Educating Medical Students for Practice in a Changing Health Care Environment: The National UME-21 Project.

In todays continually changing health care environment, there is serious concern that medical students are not being adequately prepared to provide optimal health care in the system where they will eventually practice. To address this problem, the Health Resources and Services Administration (HRSA) developed a

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

7.6 million national demonstration project, Undergraduate Medical Education for the 21st Century (UME-21). This project funded 18 U.S. medical schools, both public and private, for a three-year period (1998-2001) to implement innovative educational strategies. To accomplish their goals, the 18 UME-21 schools worked with more than 50 organizations external to the medical school (e.g., managed care organizations, integrated health systems, Area Health Education Centers, community health centers). The authors describe the major curricular changes that have been implemented through the UME-21 project, discuss the challenges that occurred in carrying out those changes, and outline the strategies for evaluating the project. The participating schools have developed curricular changes that focus on the core primary care clinical clerkships, take place in ambulatory settings, include learning objectives and competencies identified as important to providing care in the future health care system, and have faculty development and internal evaluation components. Curricular changes implemented at the 18 schools include having students work directly with managed care organizations, as well as special demonstration projects to teach students the knowledge, skills, and attitudes necessary for successfully managing care. It is already clear that the UME-21 project has catalyzed important curricular changes within 12.5% of U.S. medical schools. The ongoing national evaluation of this project, which will be completed in 2002, will provide further information about the projects impact and effectiveness.

Admission, recruitment, and retention

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.

Factors influencing primary care physicians' choice to practice in medically underserved areas.

As the country strives to produce larger numbers of generalist physicians, considerable controversy has arisen over whether or not generalist applicants can be identified, recruited, and influenced to keep a generalist-oriented commitment throughout medical training. The authors present new and existing data to show that: 1) preadmission (BA/MD or post-baccalaureate) programs can help to identify generalist-oriented students; 2) characteristics determinedat admission to medical school are predictive of future generalist career choice; 3) current inpatient-oriented training programs strongly push students away from a primary care career; 4) women are more likely than men to choose generalist careers, primarily because of those careers’ interpersonal orientation; and 5) residency training programs are able to select applicants likely to become generalists. Therefore, to produce more generalists, attempts should be made to encourage generalist-oriented students to enter medical schools and to revise curricula to focus on outpatient settings in which students can establish effective and satisfying relationships with patients. These strategies are most likely to be successful if enacted within the context of governmental and medical school-based changes that allow for more reimbursement and respect for the generalist disciplines.

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

No abstract available.

Recruitment and retention of rural physicians: how much progress have we made?

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.