Practice locations of graduates of family physician residency and nurse practitioner programs: considerations within the context of institutional culture and curricular innovation through Titles VII and VIII

BACKGROUND

Studies have described the aggregate results of federal funding for health professions education at the national level, but analysis of the long-term impact of institutional participation in these programs has been limited.

PURPOSE

To describe and assess federally supported curricular innovations at East Tennessee State University designed to promote family medicine and nurse practitioner graduate interest in rural and underserved populations.

METHODS

Descriptive analysis of a survey to determine practice locations of nurse practitioner graduates (1992-2002) and graduates of 3 family medicine residencies (1978-2002). Graduates' (N = 656) practice locations were documented using specific federal designations relating to health professions shortages and rurality.

RESULTS

Overall, 83% of family medicine residency and 80% of nurse practitioner graduates selected practice locations in areas with medically underserved or health professions shortage designations; 48% of family physicians and 38% of nurse practitioners were in rural areas.

CONCLUSIONS

Graduates who study in an educational setting with a mission-driven commitment to rural and community health and who participate in curricular activities designed to increase their experience with rural and underserved populations choose, in high numbers, to care for these populations in their professional practice.

Innovation in nursing education: a statewide grant initiative

Meeting the challenges of the nursing shortage appears to be daunting for schools of nursing across the nation as they struggle to meet educational capacity needs with limited resources. A statewide grant program was developed and implemented through legislative initiatives providing opportunities for schools of nursing to respond to the need for innovation in nursing education. This article shares some of the successes and challenges identified through the process of implementing and evaluating this grant program. Insights into the political and regulatory process are provided as a model for other states to consider. Examples of educational strategies that were successful in improving the recruitment and retention of students and faculty are discussed. Nursing and other health care leaders across the nation should look to policy initiatives such as grant programs to infuse innovation into educational programs and to address educational capacity issues compounding the nursing shortage.

New federal guidelines for physician-pharmaceutical industry relations: the politics of policy formation

In October 2002 the federal government issued a draft "Compliance Program Guidance for Pharmaceutical Manufacturers." The draft Guidance questioned the legality of many arrangements heretofore left to the discretion of physicians and drug companies, including industry-funded educational and research grants, consultantcies, and gifts. Medical organizations and drug manufacturers proposed major revisions to the draft, arguing that current practices were in everyone's best interest. To evaluate the impact of their responses, we compare the draft, the changes requested by industry and organized medicine, and the final Guidance document (issued in April 2003). We also explore the implications--some intended, others unanticipated--of the final document.

Educational governance for the regulation of industry sponsored continuing medical education in interventional and device based therapies

The relationship between industry and clinicians in educational programmes needs to be regulated. Industry may be best placed to deliver educational programmes in "craft" related specialties and particularly in areas where device implantation/technology based therapy has a major clinical role. The authors supervise industry sponsored clinical teaching at a purpose built independent teaching facility, and have developed the concept of educational governance to regulate their relationship with their industry sponsor and that concept is presented.

The Bush Administration's record on nursing issues

The article addresses a number of initiatives taken in 2005 by the Bush Administration to address nursing issues. Summaries are provided of the investments in the Nurse Reinvestment Act, Financial Aid, access issues (including expanded community health centers), costs (including medical liability reform), information technology and the revised fair labor standards. Finally, the author concludes with rationale for complete workforce and workplace system redesign and the need for advanced practice nurses to engage in full scope practice without artificially imposed boundaries.

Title VII funding and physician practice in rural or low-income areas

CONTEXT

Whether Title VII funding enhances physician supply in underserved areas has not clearly been established.

PURPOSE

To determine the relation between Title VII funding in medical school, residency, or both, and the number of family physicians practicing in rural or low-income communities.

METHODS

A retrospective cross sectional analysis was carried out using the 2000 American Academy of Family Physicians physician database, Title VII funding records, and 1990 U.S. Census data. Included were 9,107 family physicians practicing in 9 nationally representative states in the year 2000.

FINDINGS

Physicians exposed to Title VII funding through medical school and residency were more likely to have their current practice in low-income communities (11.9% vs 9.9%, P< or =.02) and rural areas (24.5% vs 21.8%, P< or =.02). Physicians were more likely to practice in rural communities if they attended medical schools (24.2% vs 21.4%; P =.009) and residencies (24.0% vs 20.3%; P =.011) after the school or program had at least 5 years of Title VII funding vs before. Similar increases were not observed for practice in low-income communities. In a multivariate analysis, exposure to funding and attending an institution with more years of funding independently increased the odds of practicing in rural or low-income communities.

CONCLUSIONS

Title VII funding is associated with an increase in the family physician workforce in rural and low-income communities. This effect is temporally related to initiation of funding and independently associated with effect in a multivariate analysis, suggesting a potential causal relationship. Whereas the absolute 2% increase in family physicians in these underserved communities may seem modest, it can represent a substantial increase in access to health care for community members.

The Nurse Reinvestment Act: the impact of governmental and nongovernmental administrative tools

The Nurse Reinvestment Act has ushered in a new wave of federal involvement intended to address the issue of the critical nursing shortage. To implement this act, administrators will rely on a series of governance tools often called upon to address issues related to the social welfare of the country. Included among these tools are grants and loans through which the intent of the legislation will be formalized. The purpose of this analysis is to provide an overview of the characteristics associated with these tools, specifically as they relate to nursing education. Consideration will be given to the political environment through which funding, and thus the ability to implement the Nurse Reinvestment Act, will be realized, and the potential obstacles when executing federal programs in a market-driven economy.

Outcomes of States’ Scholarship, Loan Repayment, and Related Programs for Physicians

CONTEXT

Many states attempt to entice young generalist physicians into rural and medically underserved areas with financial support-for-service programs-scholarships, service-option loans, loan repayment, direct financial incentives, and resident support programs-with little documentation of their effectiveness.

OBJECTIVE

The objective of this study was to assess outcomes of states' support-for-service programs as a group and to compare outcomes of the 5 program types.

DESIGN

We conducted a cross-sectional, primarily descriptive study.

PARTICIPANTS

We studied all 69 state programs operating in 1996 that provided financial support to medical students, residents, and practicing physicians in exchange for a period of service in underserved areas; federally funded initiatives were excluded. We also surveyed 434 generalist physicians who served in 29 of these state programs and a matched comparison group of 723 nonobligated young generalist physicians.

DATA COLLECTION

Information on eligible programs was collected by telephone, mail questionnaires, and from secondary sources. Obligated and nonobligated physicians were surveyed, with 80.3% and 72.8% response rates, respectively.

MAIN OUTCOME MEASURES

Levels of socioeconomic need of communities and patients served by physicians, programs' participant service completion and retention rates, and physicians' satisfaction levels.

RESULTS

Compared with young nonobligated generalists, physicians serving obligations to state programs practiced in demonstrably needier areas and cared for more patients insured under Medicaid and uninsured (48.5% vs. 28.5%, P <0.001). Service completion rates were uniformly high for loan repayment, direct incentive, and resident-support programs (93% combined) but lower for student-targeting service-option loan (mean, 44.7%) and scholarship (mean, 66.5%) programs. State-obligated physicians were more satisfied than nonobligated physicians, and 9 of 10 indicated that they would enroll in their programs again. Obligated physicians also remained longer in their practices than nonobligated physicians (P = 0.03), with respective group retention rates of 71% versus 61% at 4 years and 55% versus 52% at 8 years. Retention rates were highest for loan repayment, direct incentive, and loan programs.

CONCLUSIONS

States' support-for-service programs bring physicians to needy communities where a strong majority work happily and with at-risk patient populations; half stay over 8 years. Loan repayment and direct financial incentive programs demonstrate the broadest successes.