The effect of rural training experiences during residency on the selection of primary care careers: a retrospective cohort study from a single large internal medicine residency program

Expanding Primary Care Experiences With Novel Rotations for Residents at a VA Medical Center

BACKGROUND

The number of graduating primary care physicians will not meet the demands of the growing and aging US population. In 2011, the Veterans Affairs (VA) Office of Academic Affiliations established 5 Centers of Excellence in Primary Care Education (CoEPCE) to transform primary care training.

OBJECTIVE

We created an innovative training model with immersive primary care experiences to foster careers in primary care for residents.

METHODS

As a CoEPCE, the Seattle VA partnered with the University of Washington internal medicine residency program to form a Center of Excellence (CoE) pathway with increased outpatient training time. The CoEPCE created a longitudinal curriculum of continuity clinic immersion and new thematically based rotations (eg, Homeless Health) for CoE residents. These rotations expanded primary care experiences and allowed for in-depth opportunities to care for the unique needs of veterans. Resident feedback was solicited through program evaluations, and career choices were tracked.

RESULTS

Eighty-five of 102 (83%) possible rotation evaluations from 2014 to 2017 were reviewed. Residents reported that CoEPCE rotations had a positive effect on their care of patients and career choice, and provided opportunities to interface with faculty role models. Seventy-five percent of Seattle VA CoE residents selected primary care careers compared to 36% of historical controls.

CONCLUSIONS

The CoEPCE rotation curriculum offers in-depth primary care training and may contribute to trainees maintaining interest in primary care careers.

Preparing Physicians for Rural Practice: Availability of Rural Training in Rural-Centric Residency Programs

BACKGROUND

Exposing residents to rural training encourages future rural practice, but unified accreditation of allopathic and osteopathic graduate medical education under one system by 2020 has uncertain implications for rural residency programs.

OBJECTIVE

We describe training locations and rural-specific content of rural-centric residency programs (requiring at least 8 weeks of rurally located training) before this transition.

METHODS

In 2015, we surveyed residency programs that were rurally located or had rural tracks in 7 specialties and classified training locations as rural or urban using Rural-Urban Commuting Area (RUCA) codes.

RESULTS

Of 1849 residencies in anesthesiology, emergency medicine, general surgery, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry, 119 (6%) were rurally located or offered a rural track. Ninety-seven programs (82%) responded to the survey. Thirty-six programs required at least 8 weeks of rural training for some or all residents, and 69% of these rural-centric residencies were urban-based and 53% were osteopathic. Locations were rural for 26% of hospital rotations and 28% of continuity clinics. Many rural-centric programs (35%) reported only urban ZIP codes for required rural block rotations; 54% reported only urban ZIP codes for required rural clinic sessions, and 31% listed only urban ZIP codes in reporting rural full-time training locations. Programs varied widely in coverage of rural-specific training in 6 core competencies.

CONCLUSIONS

In multiple specialties important for rural health care systems, little rurally located residency training and rural-specific content was available. Substantial proportions of training locations reported to be rural were actually urban according to a common rural definition.

A National Survey of Internal Medicine Primary Care Residency Program Directors

BACKGROUND

The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes.

OBJECTIVE

We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers.

DESIGN

Cross-sectional study PARTICIPANTS: Seventy out of 100 (70%) IM primary care program directors completed the survey.

MAIN MEASURES

Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences.

KEY RESULTS

Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs.

CONCLUSIONS

IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.

Characteristics and Distribution of Graduate Medical Education Training Sites: Are We Missing Opportunities to Meet U.S. Health Workforce Needs?

PURPOSE

Shortages of generalist physicians in primary care and surgery have been projected. Residency programs that expose trainees to community-based health clinics and rural settings have a greater likelihood of producing physicians who later practice in these environments. The objective of this study was to characterize the distribution of residency training sites in different settings for three high-need specialties-family medicine, internal medicine, and general surgery.

METHOD

The authors merged 2012 data from the Accreditation Council for Graduate Medical Education Accreditation Data System and 2010 data from the Centers for Medicare and Medicaid Services hospital cost report to match training sites with descriptive data about those locations. They used chi-square tests to compare the characteristics and distribution of residency programs and training sites in family medicine, internal medicine, and general surgery.

RESULTS

The authors identified 1,095 residency programs and 3,373 training sites. The majority of training occurred in private, not-for-profit hospitals. Only 48 (of 1,390; 4%) family medicine training sites and 43 (of 936; 5%) internal medicine training sites were community-based health clinics. Seventy-eight (6%) family medicine sites, 8 (1%) internal medicine sites, and 16 (2%) general surgery sites were located in rural settings. One hundred thirty (14%) internal medicine sites were Department of Veterans Affairs medical facilities compared with 78 (6%) family medicine sites and 94 (9%) general surgery sites (P < .001).

CONCLUSIONS

Relatively little training occurs in rural or community-based settings. Expanding training opportunities in these low-access areas could improve physician supply there.

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine?

PURPOSE

Professional and governmental organizations recommend an ideal US physician workforce composed of at least 40 % primary care physicians. They also support primary care residencies to promote careers in primary care. Our study examines the relationship between graduation from a primary care or categorical internal medicine residency program and subsequent career choice.

METHODS

We conducted a cross-sectional electronic survey of a cohort of internal medicine residency alumni who graduated between 2001 and 2010 from a large academic center. Our primary predictor was graduation from a primary care versus a categorical internal medicine program and our primary outcome is current career role. We performed chi-square analysis comparing responses of primary care and categorical residents.

RESULTS

We contacted 481 out of 513 alumni, of whom 322 responded (67 %). We compared 106 responses from primary care alumni to 169 responses from categorical alumni. Fifty-four percent of primary care alumni agreed that the majority of their current clinical work is in outpatient primary care vs. 20 % of categorical alumni (p < 0.001). While 92.5 % of primary-care alumni were interested in a primary care career prior to residency, only 63 % remained interested after residency. Thirty of the 34 primary care alumni (88 %) who lost interest in a primary care career during residency agreed that their ambulatory experience during residency influenced their subsequent career choice.

CONCLUSIONS

A higher percentage of primary care alumni practice outpatient primary care as compared to categorical alumni. Some alumni lost interest in primary care during residency. The outpatient clinic experience may impact interest in primary care.