Kara Odom Walker

Recruiting and Retaining Primary Care Physicians in Urban Underserved Communities: The Importance of Having a Mission to Serve

OBJECTIVES We examined factors influencing physician practice decisions that may increase primary care supply in underserved areas. METHODS We conducted in-depth interviews with 42 primary care physicians from Los Angeles County, California, stratified by race/ethnicity (African American, Latino, and non-Latino White) and practice location (underserved vs nonunderserved area). We reviewed transcriptions and coded them into themes by using standard qualitative methods. RESULTS Three major themes emerged in relation to selecting geographic- and population-based practice decisions: (1) personal motivators, (2) career motivators, and (3) clinic support. We found that subthemes describing personal motivators (e.g., personal mission and self-identity) for choosing a practice were more common in responses among physicians who worked in underserved areas than among those who did not. By contrast, physicians in nonunderserved areas were more likely to cite work hours and lifestyle as reasons for selecting their current practice location or for leaving an underserved area. CONCLUSIONS Medical schools and shortage-area clinical practices may enhance strategies for recruiting primary care physicians to underserved areas by identifying key personal motivators and may promote long-term retention through work-life balance.

The Association Among Specialty, Race, Ethnicity, and Practice Location Among California Physicians in Diverse Specialties

BACKGROUND Minority physicians are more likely than their counterparts to work in underserved communities and care for minority, poor, and uninsured patients, but much of this research has examined primary care physicians alone. Few have investigated whether non-primary care specialists of minority backgrounds are more likely to serve the underserved than nonminority specialists. OBJECTIVE We examined whether underrepresented minority (URM) physicians from a wide variety of specialties are more likely than non-URM physicians to practice in underserved communities. METHODS Using California Medical Board Physician Licensure Survey (2007) data for 48388 physicians, we geo-coded practice zip codes to medically underserved areas (MUAs) and primary care health professional shortage areas (HPSAs). Logistic regression models adjusting for age, gender, specialty, and other characteristics were used to explore associations with race, ethnicity, specialty, and designated underserved areas. RESULTS We found that African American, Latino, and Pacific Islanders were more likely to work in MUAs and HPSAs than were white physicians (adjusted odds ratio, 1.22-2.25; p < .05). Similar patterns of practice in MUAs and HPSAs by physician race and ethnicity were found when performing the analyses separately among primary care physicians and physicians in non-primary care specialties. CONCLUSION In summary, our study underscores the importance of underrepresented minority physicians in all specialties for the physician workforce needs of disadvantaged communities. To improve health care for underserved communities, continued efforts to increase physician diversity are essential.

The Vulnerability of Middle‐Aged and Older Adults in a Multiethnic, Low‐Income Area: Contributions of Age, Ethnicity, and Health Insurance

This community‐partnered study was developed and fielded in partnership with key community stakeholders and describes age‐ and race‐related variation in delays in care and preventive service utilization between middle‐aged and older adults living in South Los Angeles. The survey sample included adults aged 50 and older who self‐identified as African American or Latino and lived in ZIP codes of South Los Angeles (N=708). Dependent variables were self‐reported delays in care and use of preventive services. Insured participants aged 50 to 64 were more likely to report any delay in care (adjusted predicted percentage (APP)=18%, 95% confidence interval (CI)=14–23) and problems obtaining needed medical care (APP=15%, 95% CI=12–20) than those aged 65 and older. Uninsured participants aged 50 to 64 reported even greater delays in care (APP=45%, 95% CI=33–56) and problems obtaining needed medical (APP=33%, 95% CI=22–45) and specialty care (APP=26%, 95% CI=16–39) than those aged 65 and older. Participants aged 50 to 64 were generally less likely to receive preventive services, including influenza and pneumococcal vaccines and colonoscopy than older participants, but women were more likely to receive mammograms. Participants aged 50 to 64 had more problems obtaining recommended preventive care and faced more delays in care than those aged 65 and older, particularly if they were uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.

Effect of Closure of a Local Safety-Net Hospital on Primary Care Physicians’ Perceptions of Their Role in Patient Care

PURPOSE We examined how the closure of a large safety-net hospital in Los Angeles County, California, affected local primary care physicians. METHODS We conducted semistructured interviews with 42 primary care physicians who practiced in both underserved and nonunderserved settings in Los Angeles County. Two investigators independently reviewed and coded transcripts. Three investigators used pile-sorting to sort the codes into themes. RESULTS Overall, 28 of 42 physicians (67%) described some effect of the hospital closure on their practices. Three major themes emerged regarding the impact of the closure on the affected physicians: (1) reduced local access to specialist consultations, direct hospital admissions, and timely emergency department evaluation; (2) more patient delays in care and worse health outcomes because of poor patient understanding of the health care system changes; and (3) loss of colleagues and opportunities to teach residents and medical students. CONCLUSIONS Physicians in close proximity to the closed hospital—even those practicing in nonunderserved settings—reported difficulty getting their patients needed care that extended beyond the anticipated loss of inpatient services. There is a need for greater recognition of and support for the role primary care physicians play in coordinating care; promoting continuity of care; and informing patients, clinic administrators and policy makers about system changes during such transitions.

Do Physicians with Self-Reported Non-English Fluency Practice in Linguistically Disadvantaged Communities?

BackgroundLanguage concordance between physicians and patients may reduce barriers to care faced by patients with limited English proficiency (LEP). It is unclear whether physicians with fluency in non-English languages practice in areas with high concentrations of people with LEP.ObjectiveTo investigate whether physician non-English language fluency is associated with practicing in areas with high concentrations of people with LEP.DesignCross-sectional cohort study.ParticipantsA total of 61,138 practicing physicians no longer in training who participated in the California Medical Board Physician Licensure Survey from 2001–2007.MeasuresSelf-reported language fluency in Spanish and Asian languages. Physician practice ZIP code corresponding to: (1) high concentration of people with LEP and (2) high concentration of linguistically isolated households.MethodsPractice location ZIP code was geocoded with geographic medical service study designations. We examined the unadjusted relationships between physician self-reported fluency in Spanish and selected Asian languages and practice location, stratified by race-ethnicity. We used staged logistic multiple variable regression models to isolate the effect of self-reported language fluency on practice location controlling for age, gender, race-ethnicity, medical specialty, and international medical graduate status.ResultsPhysicians with self-reported fluency in Spanish or an Asian language were more likely to practice in linguistically designated areas in these respective languages compared to those without fluency. Physician fluency in an Asian language [adjusted odds ratio (AOR) = 1.77; 95% confidence intervals (CI): 1.63–1.92] was independently associated with practicing in areas with a high number of LEP Asian speakers. A similar pattern was found for Spanish language fluency (AOR = 1.77; 95% CI: 1.43–1.82) and areas with high numbers of LEP Spanish-speakers. Latino and Asian race-ethnicity had the strongest effect on corresponding practice location, and this association was attenuated by language fluency.ConclusionsPhysicians who are fluent in Spanish or an Asian language are more likely to practice in geographic areas where their potential patients speak the corresponding language.

The vulnerability of middle-aged and older adults in a multiethnic, low-income area

This community‐partnered study was developed and fielded in partnership with key community stakeholders and describes age‐ and race‐related variation in delays in care and preventive service utilization between middle‐aged and older adults living in South Los Angeles. The survey sample included adults aged 50 and older who self‐identified as African American or Latino and lived in ZIP codes of South Los Angeles (N=708). Dependent variables were self‐reported delays in care and use of preventive services. Insured participants aged 50 to 64 were more likely to report any delay in care (adjusted predicted percentage (APP)=18%, 95% confidence interval (CI)=14–23) and problems obtaining needed medical care (APP=15%, 95% CI=12–20) than those aged 65 and older. Uninsured participants aged 50 to 64 reported even greater delays in care (APP=45%, 95% CI=33–56) and problems obtaining needed medical (APP=33%, 95% CI=22–45) and specialty care (APP=26%, 95% CI=16–39) than those aged 65 and older. Participants aged 50 to 64 were generally less likely to receive preventive services, including influenza and pneumococcal vaccines and colonoscopy than older participants, but women were more likely to receive mammograms. Participants aged 50 to 64 had more problems obtaining recommended preventive care and faced more delays in care than those aged 65 and older, particularly if they were uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.

The Vulnerability of Middle-Aged and Older Adults in a Multiethnic, Low-Income Area: Contributions of Age, Ethnicity, and Health Insurance: VULNERABILITY OF OLDER ADULTS IN SOUTH LOS ANGELES

This community‐partnered study was developed and fielded in partnership with key community stakeholders and describes age‐ and race‐related variation in delays in care and preventive service utilization between middle‐aged and older adults living in South Los Angeles. The survey sample included adults aged 50 and older who self‐identified as African American or Latino and lived in ZIP codes of South Los Angeles (N=708). Dependent variables were self‐reported delays in care and use of preventive services. Insured participants aged 50 to 64 were more likely to report any delay in care (adjusted predicted percentage (APP)=18%, 95% confidence interval (CI)=14–23) and problems obtaining needed medical care (APP=15%, 95% CI=12–20) than those aged 65 and older. Uninsured participants aged 50 to 64 reported even greater delays in care (APP=45%, 95% CI=33–56) and problems obtaining needed medical (APP=33%, 95% CI=22–45) and specialty care (APP=26%, 95% CI=16–39) than those aged 65 and older. Participants aged 50 to 64 were generally less likely to receive preventive services, including influenza and pneumococcal vaccines and colonoscopy than older participants, but women were more likely to receive mammograms. Participants aged 50 to 64 had more problems obtaining recommended preventive care and faced more delays in care than those aged 65 and older, particularly if they were uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.