Factors influencing rural versus metropolitan work choices for emergency physicians

Why do doctors work in rural areas in high-income countries? A qualitative systematic review of recruitment and retention

OBJECTIVE

To identify and assess the drivers and barriers to recruiting and retaining doctors in rural communities of high-income countries.

DESIGN

A systematic review and thematic analysis.

SETTING

Publications were sourced from medical and scientific databases online.

PARTICIPANTS

Qualitative, mixed-methods and review studies from peer-reviewed journals published since 2000 that discussed recruitment or retention of doctors to rural areas in high-income countries.

MAIN OUTCOME MEASURES

Identification and assessment of themes in the literature pertaining to recruitment and retention of rural doctors. Recurrent themes were assessed for relevance and applicability to current rural shortages.

RESULTS

A thematic analysis was completed on 41 papers assessed as in scope of the review. Papers were scrutinised for relevance to established rural recruitment and retention strategies. Key themes were rural background, education and training, personal and professional circumstances, and integration with the community.

CONCLUSION

While rural origin has long been promoted as the key factor for recruiting rural doctors, initiatives targeting only these individuals ignore a potentially larger cohort of future rural doctors. Rurally focused medical education and training need to encompass students and doctors from all backgrounds. The major barriers to rural recruitment are family-unit considerations for partners and children, concerns over isolation and a poor perception of rural practice. Attracting doctors to practise rurally is only half the challenge however, and strategies to retain rural doctors need a greater focus on personal and professional support networks and community integration. Additional strategies are needed to retain international and bonded doctors restricted to rural areas.

Impact of pediatric cardiac surgery regionalization on health care utilization and mortality

OBJECTIVE

Regionalization directs patients to high-volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery.

DATA SOURCES/STUDY SETTING

Statewide inpatient data from eleven states between 2000 and 2012.

STUDY DESIGN

Mortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case-volume, categorized into low-, medium-, and high-volume tertiles.

DATA COLLECTION/EXTRACTION METHODS

We used Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) to select pediatric cardiac surgery discharges.

PRINCIPAL FINDINGS

In total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low-, medium-, and high-volume hospitals. Mortality decreased over time, but remained higher in low- and medium-volume hospitals. High-volume hospitals had lower odds of mortality and cost than low-volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high- and medium-volume hospitals, compared to low-volume hospitals (high-volume: RR 1.18, P < 0.01; medium-volume: RR 1.05, P < 0.01).

CONCLUSIONS

Regionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization.

Influence of Japan's 2004 postgraduate training on ophthalmologist location choice, supply and distribution

BACKGROUND

Highly-competent patient care is paramount to medicine. Quality training and patient accessibility to physicians with a wide range of specializations is essential. Yet, poor quality of life for physicians cannot be ignored, being detrimental to patient care and leading to personnel leaving the medical profession. In 2004, the Japanese government reformed postgraduate training for medical graduates, adding a 2-year, hands-on rotation through different specialties before the specialization residency was begun. Residents could now choose practice location, but it sparked concerns that physician distribution disparities had been created. Japanese media reported that residents were choosing specialties deemed to offer a higher quality of life, like Ophthalmology or Dermatology, over underserved areas like Obstetrics or Cardiology. To explore the consequences of Japan's policy efforts, through the residency reform in 2004, to improve physician training, analyzing ophthalmologist supply and distribution in the context of providing the best possible patient care and access while maintaining physician quality of life.

METHODS

Using secondary data, we analyzed changes in ophthalmologist supply at the secondary tier of medical care (STM). We applied ordinary least-squares regression models to ophthalmologist density to reflect community factors such as residential quality and access to further professional development, to serve as predictors of ophthalmologist supply. Coefficient equality tests examined predictor differences before and after 2004. Similar analyses were conducted for all physicians excluding ophthalmologists (other physicians). Ophthalmologist coverage in top and bottom 10% of STMs revealed supply inequalities.

RESULTS

Change in ophthalmologist supply was inversely associated with baseline ophthalmologist density before (P < .01) and after (P = .01) 2004. Changes in other physician supply were not associated with baseline other physician density before 2004 (P = 0.5), but positively associated after 2004 (P < .01). Inequalities between top and bottom 10% of ophthalmologist supply in STMs were large, with best-served areas maintaining roughly five times greater coverage than least-served areas. However, inequalities gradually declined between 1998 and 2012.

CONCLUSIONS

Ophthalmologist supply increased both before and after the 2004 reform, yet contrary to media reports, proceeded at a lesser rate than supply increases for other physicians. After 2004, geographical disparities decreased for ophthalmologists, while increasing for other physicians.

Factors related to doctors' choice of rural pathway in general practice specialty training

OBJECTIVE

To investigate the factors eligible applicants consider in electing for a rural pathway into specialty training.

DESIGN

Cohort study.

SETTING

Australia.

PARTICIPANTS

Applicants to the Australian General Practice Training program.

MAIN OUTCOME MEASURES

Applicants' initial preference of either a general or rural pathway to undertake specialty training.

RESULTS

Of the 2,221 applicants, 45% were Australian Medical Graduates (AMGs), 27% Foreign Graduates of Accredited Medical Schools (FGAMS) and 29% International Medical Graduates (IMGs). Through government regulation, two thirds (70%) were eligible to train on both general and rural pathways and a third (30%) were required to train rurally. For applicants eligible for general pathway (n = 1552), those with rural background [Odds Ratio (OR) = 3.7, 95% CI 2.7-5.2] and rural clinical school experience (OR = 2.0, 95% CI 1.5-2.8) were more likely to choose the rural pathway. In addition, FGAMS who were eligible for the general pathway were less likely to choose a rural pathway when compared with IMGs (OR = 0.33, 95%CI 0.1 = 0.7). In applicants who changed their training pathway from their initial to revised preference, lower Multiple-Mini-Interview (OR = 0.54, 95% CI 0.43-0.66) and Situational Judgement Test z-scores (OR = 0.68, 95% CI 0.56-0.83) were associated with a higher probability of changing from a general to rural pathway preference.

CONCLUSION

For those eligible for a general or rural pathway, rural background and rural clinical school experience are associated with the decision to elect for rural training. Targeted support for international and foreign graduates of Australia/New Zealand schools may influence them to train rurally.

Correlation between pediatrician supply and public health in Japan as evidenced by vaccination coverage in 2010: secondary data analysis

Background

In industrialized countries, assessment of the causal effect of physician supply on population health has yielded mixed results. Since the scope of child vaccination is an indicator of preventive health service utilization, this study investigates the correlation between vaccination coverage and pediatrician supply as a reflection of overall pediatric health during a time of increasing pediatrician numbers in Japan.

Methods

Cross-sectional data were collected from publicly available sources for 2010. Dependent variables were vaccination coverage for measles and diphtheria, pertussis, and tetanus (DPT) by region. The primary predictor of interest was number of pediatricians per 10 000-child population (pediatrician density) at the municipality level. Multivariate logistic regression models were used to estimate associations of interest, conditional on a large range of demographic and infrastructure-related factors as covariates, including non-pediatric physician density, total population, per capita income, occupation, unemployment rate, prevalence of single motherhood, number of hospital beds per capita, length of roads, crime rate, accident rate, and metropolitan area code as urban/rural status. The percentage of the population who completed college-level education or higher in 2010 was included in the model as a proxy for education level.

Results

Pediatrician density was positively and significantly associated with vaccination coverage for both vaccine series. On average, each unit of pediatrician density increased odds by 1.012 for measles (95% confidence interval, 1.010–1.015) and 1.019 for DPT (95% confidence interval, 1.016–1.022).

Conclusions

Policies increasing pediatrician supply contribute to improved preventive healthcare services utilization, such as immunizations, and presumably improved child health status in Japan.

Evaluating the effect of Japan's 2004 postgraduate training programme on the spatial distribution of physicians

BACKGROUND

In 2004, the Japanese government permitted medical graduates for the first time to choose their training location directly through a national matching system. While the reform has had a major impact on physicians' placement, research on the impact of the new system on physician distribution in Japan has been limited. In this study, we sought to examine the determinants of physicians' practice location choice, as well as factors influencing their geographic distribution before and after the launch of Japan's 2004 postgraduate medical training programme.

METHODS

We analyzed secondary data. The dependent variable was the change in physician supply at the secondary tier of medical care in Japan, a level which is roughly comparable to a Hospital Service Area in the US. Physicians were categorized into two groups according to the institutions where they practiced; specifically, hospitals and clinics. We considered the following predictors of physician supply: ratio of physicians per 1,000 population (physician density), age-adjusted mortality, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004.

RESULTS

Baseline physician density showed a positive association with the change in physician supply after the launch of the 2004 programme (P-value < .001), whereas no such effect was found before 2004. Urban locations were inversely associated with the change in physician supply before 2004 (P-value = .026), whereas a positive association was found after 2004 (P-value < .001). Urban location and area-level socioeconomic status were positively correlated with the change in hospital physician supply after 2004 (P-values < .001 for urban centre, and .025 for area-level socioeconomic status), even though in the period prior to the 2004 training scheme, urban location was inversely associated with the change in physician supply (P-value = .015) and area-level socioeconomic status was not correlated.

CONCLUSION

Following the introduction of the 2004 postgraduate training programme, physicians in Japan were more likely to move to areas with already high physician density and urban locations. These changes worsened regional inequality in physician supply, particularly hospital doctors.

Pediatricians' practice location choice-Evaluating the effect of Japan's 2004 postgraduate training program on the spatial distribution of pediatricians

OBJECTIVES

To explore determinants of change in pediatrician supply in Japan, and examine impacts of a 2004 reform of postgraduate medical education on pediatricians' practice location choice.

METHODS

Data were compiled from secondary data sources. The dependent variable was the change in the number of pediatricians at the municipality ("secondary tier of medical care" [STM]) level. To analyze the determinants of pediatrician location choices, we considered the following predictors: initial ratio of pediatricians per 1000 children under five years of age (pediatrician density) and under-5 mortality as measures of local area need, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004. Basic comparisons of pediatrician coverage in the top and bottom 10% of STMs were conducted to assess inequality in pediatrician supply.

RESULTS

Increased supply was inversely associated with baseline pediatrician density both in the pre-period and post-period. Estimated impact of pediatrician density declined over time (P = 0.026), while opposite trends were observed for measures of residential quality. More specifically, urban centers and the SES composite index were positively associated with pediatrician supply for the post-period, but no such associations were found for the pre-period. Inequality in pediatrician distribution increased substantially after the reform, with the best-served 10% of communities benefitting from five times the pediatrician coverage compared to the least-served 10%.

CONCLUSIONS

Residential quality increasingly became a function of location preference rather than public health needs after the reform. New placement schemes should be developed to achieve more equity in access to pediatric care.