The Decline In Rural Medical Students: A Growing Gap In Geographic Diversity Threatens The Rural Physician Workforce

Financial barriers and inequity in medical education in India: challenges to training a diverse and representative healthcare workforce

India has been historically challenged by an insufficient and heterogeneously clustered distribution of healthcare infrastructure. While resource-limited healthcare settings, such as major parts of India, require multidisciplinary approaches for improvement, one key approach is the recruitment and training of a healthcare workforce representative of its population. This requires overcoming barriers to equity and representation in Indian medical education that are multi-faceted, historical, and rooted in inequality. However, literature is lacking regarding the financial or economic barriers, and their implications on equity and representation in the Indian allopathic physician workforce, which this review sought to describe. Keyword-based searches were carried out in PubMed, Google Scholar, and Scopus in order to identify relevant literature published till November 2023. This state-of-the-art narrative review describes the existing multi-pronged economic barriers, recent and forthcoming changes deepening these barriers, and how these may limit opportunities for having a diverse workforce. Three sets of major economic barriers exist to becoming a specialized medical practitioner in India - resources required to get selected into an Indian medical school, resources required to pursue medical school, and resources required to get a residency position. The resources in this endeavor have historically included substantial efforts, finances, and privilege, but rising barriers in the medical education system have worsened the state of inequity. Preparation costs for medical school and residency entrance tests have risen steadily, which may be further exacerbated by recent major policy changes regarding licensing and residency selection. Additionally, considerable increases in direct and indirect costs of medical education have recently occurred. Urgent action in these areas may help the Indian population get access to a diverse and representative healthcare workforce and also help alleviate the shortage of primary care physicians in the country. Discussed are the reasons for rural healthcare disparities in India and potential solutions related to medical education.

Geographic and demographic trends with the initiation of virtual interviews in general surgery: A 7-program evaluation

BACKGROUND

Although most general surgery residency interviews remain virtual, the effect of this format remains understudied. Single-institution data have shown an increase in the number of applications received and interviews conducted with virtual interviewing but no change in the geographic backgrounds of interviewed or matched applicants. This study sought to compare national trends in geographic characteristics of general surgery applicants, interviewed applicants, and matched applicants between in-person and virtual application cycles.

STUDY DESIGN

A retrospective review of 7 general surgery residency programs from application years 2016-2019 (in-person) and 2020-2021 (virtual) was conducted. Data collected included birth year, sex, race, medical school state, and contact location at the time of application. Data were analyzed using generalized mixed effects linear models.

RESULTS

A total of 52,742 applicants, 4,550 interviewed applicants, and 329 matched applicants were included. During virtual application cycles, there were no increases in the average number of applicants (P = .25), interviewed applicants (P = .36), or matched (P = .84) applicants per year. Virtual cycles were associated with a larger proportion of interviews conducted with applicants from out-of-state medical schools (P < .01) and listing out-of-state contact locations (P < .01) compared with in-person application cycles. There were no significant geographic differences in matched applicants between virtual and in-person application cycles.

CONCLUSION

Virtual application cycles had greater geographic diversity among interviewed applicants. However, similar differences were not seen in the geographic diversity of matched applicants. Additional efforts should focus on why no changes in the geographic diversity of matched applicants were identified.

An Undergraduate Health Care Experience Course Increases Confidence and Improves Student Understanding of Health Care Careers

Increasing the health care work force is critical to underserved communities. Unfortunately, students in these areas lack accessibility to the clinical experiences needed to get an introductory understanding of careers in health care. Therefore, a health care experience (HCE) course was created for undergraduate students that included didactic training, active learning exercises, and coordinated shadowing experiences. To evaluate the effect of the HCE on student interest in science, health care, and rural health a study was performed on HCE participants. This study assessed student background, interest in health care, and plans for future careers in underserved settings. Students who enrolled in the HCE demonstrated high interest in science, health care, and rural health. Evaluation of student reflections indicated students attained novel learning, gained insights, and recognized the importance of communication. The HCE course students exhibited amplified confidence in HCEs and had a significant increase in understanding of health care compared with a control group of students who had not completed the HCE. Undergraduate institutions can include courses like the HCE into curricula to increase accessibility to career experiences for students interested in health care careers.

Characteristics of Hospitals by Graduate Medical Education Expense Category: Implications for Rural Residency Program Expansion

PURPOSE

To describe how the characteristics of the hospitals and communities they serve vary across the 4 hospital graduate medical education (GME) expense categories (according to Section 131 of the Consolidated Appropriations Act of 2021) and identify the rurally located never claimer hospitals that are most similar to teaching hospitals, signaling that they might be good candidates for new rural GME programs.

METHOD

Hospital categories and characteristics were gathered from the March 2022 Medicare Cost Reports; 2022 County Health Rankings & Roadmaps data were used for community characteristics. Each acute hospital was classified into 1 of the following 4 mutually exclusive hospital categories: category A, category B, established teaching hospital (ETH), and never claimer. Multinomial logistic regressions were conducted to estimate the adjusted associations of hospital characteristics with hospital categories and to identify the never claimer hospitals in rural locations that have characteristics similar to teaching hospitals (category A, category B, and ETHs).

RESULTS

Out of 3,590 hospitals, 2,075 (57.8%) were never claimer hospitals. After adjusting for multiple characteristics, rural hospitals had a similar probability of being in each hospital category to that of urban hospitals. Never claimer hospitals served an older population and were located in communities with more uninsured adults and children and less availability of primary care physicians, dentists, and mental health professionals.

CONCLUSIONS

This study demonstrated that most hospitals in every category, but especially teaching hospitals (i.e., category A hospitals, category B hospitals, and ETHs), were concentrated in urban areas. Larger hospitals (measured by net patient revenue) were more likely to report GME expenses (i.e., be a category A hospital, a category B hospital, or an ETH). The study suggests that there are roughly 145 rural never claimer hospitals that might be strong candidates for initiating new residency programs.

Growing a rural family physician workforce: The contributions of rural background and rural place of residency training

OBJECTIVE

To determine the distinct influences of rural background and rural residency training on rural practice choice among family physicians.

DATA SOURCES AND STUDY SETTING

We used a subset of The RTT Collaborative rural residency list and longitudinal data on family physicians from the American Board of Family Medicine National Graduate Survey (NGS; three cohorts, 2016-2018) and American Medical College Application Service (AMCAS).

STUDY DESIGN

We conducted a logistic regression, computing predictive marginals to assess associations of background and residency location with physician practice location 3 years post-residency.

DATA COLLECTION/EXTRACTION METHODS

We merged NGS data with residency type-rural or urban-and practice location with AMCAS data on rural background.

PRINCIPAL FINDINGS

Family physicians from a rural background were more likely to choose rural practice (39.2%, 95% CI = 35.8, 42.5) than those from an urban background (13.8%, 95% CI = 12.5, 15.0); 50.9% (95% CI = 43.0, 58.8) of trainees in rural residencies chose rural practice, compared with 18.0% (95% CI = 16.8, 19.2) of urban trainees.

CONCLUSIONS

Increasing rural programs for training residents from both rural and urban backgrounds, as well as recruiting more rural students to medical education, could increase the number of rural family physicians.

The impending hepatology workforce shortage: Ethical considerations for closing the gap

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A State Profile of Disparities in Telehealth Utilization Among Medicare Beneficiaries: An Intersection Between Race/Ethnicity, Rurality, and Chronic Conditions-Arkansas, 2019

Introduction: The COVID-19 pandemic brought about renewed interest and investment in telehealth, while also highlighting persistent health disparities in the Southern states. Little is known about the characteristics of those utilizing telehealth services in Arkansas, a rural Southern state. We sought to compare the characteristics of telehealth utilizers and nonutilizers among Medicare beneficiaries in Arkansas before the COVID-19 public health emergency to provide a baseline for future research investigating disparities in telehealth utilization. Methods: We used Arkansas Medicare beneficiary data (2018-2019) to model telehealth use. We included interactions to assess how the association between the number of chronic conditions and telehealth was moderated by race/ethnicity and rurality, adjusted for covariates. Results: Overall telehealth utilization in 2019 was low (n = 4,463; 1.1%). The adjusted odds of utilizing telehealth was higher for non-Hispanic Black/African Americans (vs. white, adjusted odds ratio [aOR] = 1.34, 95% confidence interval [CI] = 1.17-1.52), rural beneficiaries (aOR = 1.99, 95% CI = 1.79-2.21), and those with more chronic conditions (aOR = 1.23, 95% CI = 1.21-1.25). Race/ethnicity and rurality were significant moderators, such that the association between the number of chronic conditions and telehealth was strongest among white and among rural beneficiaries. Discussion: Among the 2019 Arkansas Medicare beneficiaries, having more chronic conditions was most strongly associated with telehealth use among white and rural individuals, while the effect was not as pronounced for Black/African American and urban individuals. Our findings suggest that advances in telehealth are not benefiting all Americans equally, with aging minoritized communities continuing to engage with more strained and underresourced health systems. Future research should investigate how upstream factors such as structural racism perpetuate poor health outcomes.

A Qualitative Study of Participant Perceptions of a Cancer Research Education Program

Kentucky ranks first in the nation in cancer incidence and mortality rates, with the greatest burden of disease being in the Appalachian region. The cancer disparities in the Appalachian region of the state are tied to high poverty rates, low education attainment, low health care access, and high rates of poor health behaviors, such as tobacco use. The University of Kentucky (UK) Markey Cancer Center (MCC) developed the Appalachian Career Training in Oncology (ACTION) program to address the cancer and education disparities in the region. ACTION is a two-year program that focuses on cancer education and training for high school and undergraduate students from Appalachian Kentucky and features a variety of cancer-focused training activities, including faculty-mentored cancer research, clinical shadowing opportunities, cancer education activities, career development support, and community outreach projects. ACTION has been funded by the National Cancer Institute as a Youth Enjoy Science R25 research education program since 2018. The qualitative study herein used a semi-structured interview approach to identify participants' perceptions of the program including the influential aspects that have helped students pursue their desired academic career paths. Ten ACTION alumni were chosen to participate in the study, including students currently in medical school, graduate school, physician assistant school, and pharmacy school. Thematic analysis generated five themes: motivation for participation, career development, mentorship and future opportunities, knowledge gained, and program improvements. Overall, this study demonstrates that the ACTION program is having a significant impact on students' career preparation.

Implementation of a pediatric asthma management program in rural primary care clinics

OBJECTIVE

Rural communities experience a significant asthma burden. We pilot tested the implementation of Easy Breathing, a decision support program for improving primary care provider adherence to asthma guidelines in a rural community, and characterized asthma risk factors for enrollees.

METHODS

We implemented Easy Breathing in two rural primary care practices for two years. Patient demographics, exposure histories, asthma severity, asthma medications, and treatment plans were collected. Providers' adherence to guidelines included the frequency of children with persistent asthma who were prescribed guidelines-based therapy and the frequency of children with a written asthma treatment plan on file. Clinicians provided feedback on the feasibility and acceptability of Easy Breathing using a validated survey tool and through semi-structured interviews.

RESULTS

Two providers implemented the program. Enrollment included 518 children, of whom 135 (26%) had physician-confirmed asthma. After enrollment into Easy Breathing, 75% of children with asthma received a written asthma treatment plan All children with persistent asthma were prescribed an anti-inflammatory drug as part of their treatment plan. Providers (n = 2) rated Easy breathing as highly acceptable (M = 4.5), feasible (M = 4.5), and appropriate (M = 4.5). Qualitative feedback was positive, with suggestions to integrate the paper-based program into the electronic health record system for broader uptake. Enrollees with asthma were more likely to have a family history of asthma and endorse exposure to tobacco smoke and cockroaches.

CONCLUSIONS

Easy Breathing shows promise as a decision support system that can be implemented in rural, medically underserved communities via primary care.

Policy Recommendations for Improving Rural Cancer Services in the United States

Compared with urban residents, rural Americans have seen slower declines in cancer deaths, have lower incidence but higher death rates from cancers that can be prevented through screening, have lower screening rates, are more likely to present with later-stage cancers, and have poorer cancer outcomes and lower survival. Rural health provider shortages and lack of cancer services may explain some disparities. The literature was reviewed to identify factors contributing to rural health care capacity shortages and propose policy recommendations for improving rural cancer care. Uncompensated care, unfavorable payer mix, and low patient volume impede rural physician recruitment and retainment. Students from rural areas are more likely to practice there but are less likely to attend medical school because of lower graduation rates, grades, and Medical College Admission Test (MCAT) scores versus urban students. The cancer care infrastructure is costly and financially challenging in rural areas with high proportions of uninsured and publicly insured patients. A lack of data on oncology providers and equipment impedes coordinated efforts to address rural shortages. Graduate Medical Education funding greatly favors large, urban, tertiary care teaching hospitals over residency training in rural, critical access and community-based hospitals and clinics. Policies have the potential to transform rural health care. This includes increasing advanced practice provider postgraduate oncology training opportunities and expanding the scope of practice; improving health workforce and services data collection and aggregation; transforming graduate medical education subsidies to support rural student recruitment and rural training opportunities; and expanding federal and state financial incentives and payments to support the rural cancer infrastructure.

Flexible, short-duration outreach sessions in the human anatomy laboratory provide authentic, humanistic experiences

Anatomy laboratories can provide rich opportunities for outreach to K-12 and college students interested in pursuing careers in health, medicine, or science. At the University of Missouri, the Department of Pathology and Anatomical Sciences has designed flexible, one-hour interactive sessions that typically cover basic anatomical concepts using whole-body donors. In order to evaluate whether short-duration programs were impactful in increasing enthusiasm for anatomy and the health professions sciences, we used mixed methods to study participant experience covering three topics: (1) enthusiasm for anatomy, (2) interest in pursuing a career in healthcare professions, and (3) perception of the importance of whole-body donation. The same questions were asked pre- and post-session, and the post-session survey had additional questions related to student satisfaction. Quantitative analyses showed an increased interest in anatomy and appreciation for whole-body donation following the session. Students also perceived that they had a better understanding of the body and what it would be like to attend a health professions school. Thematic analysis revealed an appreciation for contextualizing the size, position, and hands-on feel of anatomical structures, and emphasized that students felt that they understood the body better after having seen a donor's anatomy. This work shows that short-duration, flexible outreach sessions involving whole-body donors can provide students with a rare opportunity to confirm their contextual understanding of anatomy, and provide students with an authentic, and humanistic experience.

Positive yet problematic: Lived experiences of racial and ethnic minority medical students during rural and urban underserved clinical rotations

PURPOSE OF STUDY

Medical students who identify as Black, Indigenous, and People of Color (BIPOC) regularly experience mistreatment and discrimination. This study sought to understand these student experiences during rotations in rural and urban underserved community teaching sites.

METHODS

Self-identified BIPOC medical students who completed the University of Washington School of Medicine's Rural Underserved Opportunities Program from 2019 through 2021 were invited to participate in a 60- to 90-minute focus group discussion via Zoom. From August to September 2021, 4 focus groups and 1 individual interview were conducted with a total of 12 participants. A current BIPOC medical student facilitated the sessions utilizing questions developed by the research team. Four study team members coded transcripts for key themes related to experiences of microaggressions.

FINDINGS

All participants reported having an overall positive experience, but everyone also witnessed and/or experienced at least 1 microaggression. Unlike those in urban placements, participants placed in rural sites expressed anxiety about being in predominantly White communities and experienced feelings of racial and/or ethnic isolation during the rotation. Participants recommended that rural preceptors identify themselves as trusted advocates and the program should prioritize placing BIPOC students at diverse clinical sites.

CONCLUSIONS

Medical schools must take action to address the mistreatment of BIPOC medical students in the clinical environment. Schools and rural training sites need to consider how to best support students to create an equitable learning environment and recruit more BIPOC physicians to rural practice.

Performance on the American Board of Physical Medicine and Rehabilitation certifying examinations: Rural and urban physicians

BACKGROUND

Over 60 million people in the United States live in a rural community making up approximately 20% of the population. Data are minimal about the physiatrists who serve this rural population, their performance on certification examinations and how the American Board of Physical Medicine and Rehabilitation (ABPM&R) serves their ongoing educational, assessment, and practice needs.

OBJECTIVE

To compare the performance of rural and urban physicians on the Part I, Part II, and maintenance of certification (MOC) examinations along with subspecialty preference and continuance of primary certification.

DESIGN

Retrospective cross-sectional study.

SETTING

Board-eligible PM&R physicians and certified diplomates of the ABPM&R.

PARTICIPANTS

Physicians who participated in an initial certification or maintenance of certification examination with the ABPM&R between 2010 and 2019.

METHODS

Comparisons of physician pass rates, mean scaled scores (aggregates), and program pass rates on ABPM&R certifying examinations were completed. Cross-reference to national database and ABPM&R practice site zip codes provided sociogeographic linkage.

INTERVENTIONS

Not applicable MAIN OUTCOME MEASURES: Physician mean scaled scores, pass rates, subspecialty preferences, and primary certification status.

RESULTS

There were no meaningful differences in performance on the ABPM&R Part I, II, and MOC examinations between rural and urban physiatrists. Most common subspecialty is the pain medicine certification whose diplomates most frequently drop their primary certification. Pediatric rehabilitation medicine certification is rare in rural localities and a health care disparity.

CONCLUSION

The study found no meaningful differences in the performance of rural and urban physicians on the ABPM&R certifying examinations.

Diversity in Academic Ophthalmology: Disparities and Opportunities from Medical School to Practice

INTRODUCTION

Compared to the United States population as a whole, physicians are more likely to identify as men, identify as Asian or non-hispanic White, and be raised in wealthier households. Racial, ethnic, gender, and socioeconomic representation in ophthalmology is often blamed on the pipeline of matriculants.

METHODS

This review collects recent data from the US census, AAMC, and primary literature on gender, racial, ethnic, and socioeconomic diversity from medical school to ophthalmology practice.

RESULTS

Data from the medical and ophthalmology literature shows that medical students are less diverse than medical school applicants, ophthalmology residencies are less diverse than graduating medical students, and ophthalmology departments are less diverse than those of most other specialties.

DISCUSSION

At each level, there are limitations in representation beyond the pipeline of medical school applicants or medical students applying to ophthalmology. There are many practical steps the field can take at each level of training to move the specialty toward more equitable representation.

Into the Unknown: Experiences of Social Newcomers Entering Medical Education

PURPOSE

Amid efforts to diversify the medical profession, research has yet to fully explore the role of early social ties to the field. This study examined diversity through the experiences of students without early ties to medicine through family members working in health care (i.e., "newcomers") in comparison with more-connected peers (i.e., "insiders"), examining how social newcomers to medicine negotiate challenges stemming from their outsider status.

METHOD

The author conducted an exploratory qualitative study from 2018 to 2021 using a constructivist grounded theory approach. Following a voluntary preliminary survey of 2 cohorts of first-year medical students about their social connections in health care, the author conducted interviews over the next 2 years with students who had indicated their willingness to participate. Interviews addressed how social context shaped-and continued to influence-their journeys into medicine. Eighty second- and third-year students participated in 94 interviews, including some follow-up interviews for longitudinal insight into outsider status. Interviews from the second year (58 new, 14 follow-up) provided the foundation of the qualitative results.

RESULTS

Students experienced outsider status primarily on the basis of being newcomers to medicine, often compounded by intersectional characteristics, including first-generation college status, rural or low-income background, race or ethnicity, and nontraditional status. For some, an early shortage of social capital became internalized, continuing to influence confidence and belonging well into training, in line with social reproduction theory. However, newcomers also experienced benefits associated with diverse backgrounds which helped them find a sense of belonging in medicine, as suggested by community cultural wealth and antideficit perspectives.

CONCLUSIONS

Newcomer status proved to be a central cause of outsiderness for students from all backgrounds and warrants greater attention from stakeholders, perhaps mirroring the undergraduate focus on first-generation college-goers. Findings suggest institutions that provide robust networking and community-building opportunities are best positioned to support newcomers.

The Regional Distribution of Psychiatric Residency Positions Funded by the Department of Veterans Affairs and Its Relationship to Rural Veteran Populations

OBJECTIVE

The authors evaluated the distribution of psychiatry residency positions funded by the Department of Veterans Affairs between 2014 and 2020 with respect to geographic location and hospital patient population rurality.

METHODS

The authors collected data on psychiatry residency positions from the Veterans Affairs' Office of Academic Affiliations Support Center and data on hospital-level patient rurality from the Veterans Health Administration Support Service Center. They examined the chronological and geospatial relationships between the number of residency positions deployed and the size of the rural patient populations served.

RESULTS

Between 2014 and 2020, the Department of Veterans Affairs has substantially increased the number of rural hospitals hosting psychiatry residency programs, as well as the number of residency positions at those hospitals. However, several geographic regions serve high numbers of rural veterans with few or no psychiatry resident positions.

CONCLUSIONS

While the VA efforts to increase psychiatry residency positions in rural areas have been partially successful, additional progress can be made increasing support for psychiatry trainees at Veterans Affairs hospitals and community-based outpatient clinics that serve large portions of the rural veteran population.

On the Eve of Integration: Community and Affiliated Residency Programs Pave the Way Towards the Assimilation of Osteopathic Surgery Residents

OBJECTIVE

The 2020 match integrated former osteopathic and allopathic residency programs under single Graduate Medical Education accreditation. We describe the composition of general surgery residency programs prior to the 2020 integration and provide a baseline to monitor future progress.

DESIGN

Retrospective, cross-sectional data provided by the Association of American Medical Colleges for the 2018 academic year were analyzed. Descriptive analyses were used to summarize the characteristics of residents by program type and program location. Logistic regression was used to estimate factors associated with the presence of osteopathic (DO) residents. An alpha of 0.05 defined statistical significance.

SETTING

Data were collected and analyzed at a United States osteopathic medical school.

PARTICIPANTS

All civilian surgery residencies that approved the 2018 Program Survey.

RESULTS

Out of 285 programs, the percentages with at least one DO resident were significantly different among university (44.0%), university-affiliated (62.7%) and community (78.4%) programs (p < 0.001). DO residents made up 41.4% of community residents, 13.3% of university-affiliated residents, and 2.8% of university residents (p < 0.001). A significant regional difference was observed, as DO residents made up 16.9% of residents in the central region, compared to 10.4% in the northeast, 7.0% in the south and 8.9% in the west (p = 0.004). The logistic regression analysis found that the presence of DO residents at a program was significantly related to the type of program (Affiliated vs University OR = 3.1, 95% CI 1.5-6.5; Community vs University OR = 5.2, 95% CI 1.9-14.4) and the presence of DO faculty (OR = 2.7, 95% CI 1.6-4.8) (all p < 0.05).

CONCLUSIONS

We observed significant differences in the presence of DO residents in different program types. As surgical education transitions to single accreditation, this study identifies opportunities for greater integration between osteopathic and allopathic surgery training programs.

Results of Lung Cancer Screening in a Rural Setting: A Retrospective Cohort Study

Background

In this study, we aimed to determine the performance of the lung cancer screening (LCS) program using low-dose computed tomography (LDCT) in a rural community.

Methodology

We conducted a retrospective cohort study of patients who underwent LCS at a rural healthcare institution from September 1, 2016, through December 31, 2019, to determine the utilization of screening, rate of positivity, rate of cancer detection, and patient compliance.

Results

A total of 1,474 patients underwent initial LCS, and 1,776 LCS examinations were performed using LDCT. Of 1,776 tests performed, 375 (21.1%) were categorized as positive (Lung CT Screening Reporting and Data System III or higher), with 215 of the 375 (57.6%) being lost to follow-up. A total of 29 malignancies were identified (in 1.6% of all LCS tests) during the study period, with 23 (82.8%) malignancies being low-stage malignancies (stage I or II), 24 (79.3%) malignancies potentially surgical candidates (stage IIIA or less), and five (17.2%) malignancies being non-surgical candidates based on stage (stage IIIB or IV). A total of 28.7% of all patients eligible for repeat screening had at least one repeat annual test. Overall, 9.9% of all patients eligible for two repeat annual tests had a second repeat annual test.

Conclusions

LCS using LDCT is effective in detecting lung cancer in a rural setting. However, compliance with repeat annual screening and recommendations for further workup is low. This may be exacerbated by healthcare and socioeconomic issues prevalent in rural communities. The use of LCS patient coordinators and dedicated tracking software may improve compliance with repeat annual screening and compliance with recommendations when LCS tests are positive.

Medical education for African American communities in the rural South: A focus group approach to identify fundamental considerations

PURPOSE

We sought to understand concerns fundamental to planning medical education specific to rural southern African Americans who are virtually nonexistent in American medical schools.

METHODS

A diverse multidisciplinary research team conducted this qualitative study with 3 focus groups, including 17 rural medical educators recruited nationwide, 10 African American alumni of a rural medical education pipeline in Alabama, and 5 community and institutional associates of this pipeline. Analysis of recorded transcripts generated themes fitting an ecological model suggesting concerns and intervention foci at individual, community, and institutional levels.

FINDINGS

Three major themes operating at all ecological levels were: (1) How "rural minority student" is defined, with "rural" often supplanting race to indicate minority status; (2) Multiple factors relate to rural racial minority student recruitment and success, including personal relationships with peers, mentors, and role models and supportive institutional policies and culturally competent faculty; and (3) Challenges to recruitment and retention of rural minority students, especially financial concerns and preparation for medical education.

CONCLUSIONS

Our findings suggest that individuals, communities, and institutions provide intervention points for planning medical education specific to southern rural African Americans. These spheres of influence project a need for partnership among communities and rural medical educators to affect broad programmatic and policy changes that address the dire shortage of rural African American health professionals to help ameliorate health inequities experienced in their home communities. It is likely that linear thinking and programming will be replaced by integrated, intertwined conceptualizations to reach this goal.

Characteristics of family nurse practitioners and their preparation for practice in rural vs urban employment settings

BACKGROUND

Policymakers are increasingly interested in using nurse practitioners to provide health care to rural populations, yet little is known about their characteristics and preparation for independent practice.

METHODS

We obtained data from the 2018 National Sample Survey of Registered Nurses and compared characteristics of family nurse practitioners (FNPs) employed in rural areas versus those employed in non-rural areas. Regression analysis was used to determine the relationship between the outcome variable of interest, preparation for practice and other covariates.

FINDINGS

FNPs practicing in a rural setting felt less prepared for independent practice than their counterparts in non-rural settings except for those prepared with a doctoral degree.

DISCUSSION

The majority of FNPs working in rural areas believed they were not as well prepared for independent practice. Because rural FNPs often practice autonomously and without medical back up, nursing educators need to educate FNPs with the skills and knowledge necessary to practice effectively in rural settings.

Advancing Social Mission Research: A Call to Action

Social mission efforts in health professions education are designed to advance health equity and address the health disparities of the society in which they exist. While there is growing evidence that social mission-related interventions are associated with intended outcomes such as practice in underserved communities, student diversity, and students graduating with skills and knowledge that prepare them to address societal needs, critical evidence gaps remain that limit the possibility of generalizing findings and using social mission strategically to advance health equity. At a time when COVID-19 has been laying bare health disparities related to systemic racism and maldistribution of resources, understanding how health professions training can produce the workforce needed to advance health equity becomes even more imperative. Yet, data and methods limitations are hindering progress in this critical research. The authors present an overview of the social mission research landscape; their review of the research led them to conclude that more rigorous research and data collection are needed to determine the link between social mission activities in health professions education and advances in health equity. To accelerate understanding of how health professions education and training can advance health equity, the authors propose a social mission research road map that includes (1) creating a social mission research community by consolidating stakeholders, (2) building a solid foundation for the research through development of a consensus-driven logic framework and research agenda, and (3) laying out the data and methodological needs that are imperative to strengthening the social mission evidence base and identifying opportunities to address these needs. Core to achieving these milestones is leadership from an organizing body that can serve as a hub for social mission research and engage stakeholder groups in building the evidence base for social mission strategies that will ultimately advance health equity.

Association of professional pre-qualifications, study success in medical school and the eligibility for becoming a physician: A scoping review

BACKGROUND

Literature, individual experiences and common considerations suggest that prior professional qualification can be an advantage for later career development. For instance, in Germany, professional pre-qualification has been honored by medical faculties in selection procedures for several years. However, a systematic evaluation of this relationship lacks. This scoping review summarizes existing literature and addresses the role of prior professional pre-qualifications on objective or subjective study success and the choice of a specialization.

METHODS

The scoping review was performed oriented on the PRISMA guidelines. PsycINFO and PubMed databases were searched for relevant studies that included data of medical students with and without professional pre-qualifications. To answer the underlying research questions, this scoping review also includes studies that examine professional pre-qualifications in association with non-cognitive "soft" criteria.

RESULTS AND FURTHER DIRECTIONS

1055 items were identified and reviewed by two independent reviewers with final 11 studies were included for this scoping review. The results of identified studies that report possible effects of prior pre-professional qualifications are inconclusive but suggest that prior professional qualifications tend not to have rather an advantage on study success. Medical school success for students with prior professional qualifications tended to be below average in the preclinical setting, and there were no differences in the clinical setting compared with students without prior professional qualifications. The influence of professional pre-qualifications has not yet been adequately studied without the moderator variable "waiting time" and "A-levels grade". The scoping review indicates insufficient number of articles stating a co-relation of prior pre-qualifications and subjective data. Again, the results found are not sufficient to state a clear relationship between professional pre-qualifications and the choice of a specific speciality preference. However, professional pre-qualifications, both in medicine and as "practical experience in rural areas", tend to be beneficial for the choice of becoming a rural physician. Large-scale cross-sectional and longitudinal studies are needed to investigate the influence of professional pre-qualifications on different study trajectory parameters.

Rural health disparities in chronic heart disease

Rural communities suffer from significant disparities in cardiovascular health. The reasons for worse cardiovascular health and outcomes is due to a number of factors including economic, educational, and healthcare access. This commentary draws attention to these challenges and highlights how telemedicine may reduce a portion of this gap. In particular, an opportunity to modify cardiac rehabilitation programs to include a remotely-administered model using telemedicine is a novel method that holds promise.

Efforts to Recruit Medical Students From Rural Counties: A Model to Evaluate Recruitment Efforts

Background

Over the past 40 years, the physician supply of North Carolina (NC) grew faster than the total population. However, the distribution of physicians between urban and rural areas increased, with many more physicians in urban areas. In rural counties, access to care and health disparities remain concerning. As a result, the medical school implemented pipeline programs to recruit more rural students. This study investigates the results of these recruitment efforts.

Methodology

Descriptive analyses were conducted to compare the number and percentage of rural and urban students from NC who applied, interviewed, and were accepted to the University of North Carolina’s School of Medicine (UNC SOM). The likely pool of rural applicants was based on the number of college-educated 18-34-year-olds by county.

Results

Roughly 10.9% of NC’s population of college-educated 18-34-year-olds live in rural counties. Between 2017 and 2019, 9.3% (n = 225) of UNC SOM applicants were from a rural county. An increase of just 14 additional rural applicants annually would bring the proportion of rural UNC SOM applicants in alignment with the potential applicant pool in rural NC counties.

Conclusions

Our model of analysis successfully calculated the impact of recruitment efforts to achieve proportional parity in the medical school class with the rural population of the state. Addressing rural physician workforce needs will require multiple strategies that affect different parts of the medical education and healthcare systems, including boosting college completion rates in rural areas. This model of analysis can also be applied to other pipeline programs to document the success of the recruitment efforts.

Impact of Longitudinal Virtual Primary Care on Diabetes Quality of Care

BACKGROUND

Lack of healthcare access to due to physician shortages is a significant driver of telemedicine expansion in rural areas. Telemedicine is effective for management of chronic conditions such as diabetes but its effectiveness in primary care settings is unknown.

OBJECTIVE

To evaluate differences in diabetes care before and after implementation of a longitudinal virtual primary care program.

DESIGN

Propensity score-matched cohort study utilizing difference-in-differences analysis.

PARTICIPANTS

Patients with diabetes who received care at VA primary care clinics between January 2018 and December 2019 where the Virtual Integrated Multisite Patient Aligned Care Teams (V-IMPACT) program was implemented.

EXPOSURE

Patient participation in at least one V-IMPACT visit while usual care patients did not participate in V-IMPACT.

MAIN MEASURES

The primary outcome was change in hemoglobin A1C (HbA1C) and secondary outcomes included change in the proportion of patients meeting diabetes quality indicators: blood pressure control, statin use, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEi/ARB) use, and annual microalbuminuria testing.

KEY RESULTS

Our propensity-matched cohort included 9010 patients split evenly between those who participated in V-IMPACT and those who remained in usual in-person care. Among individuals with diabetes who participated in V-IMPACT, the change in mean HbA1C was - 0.055% (95% CI - 0.088 to - 0.022%) while those in usual care had a - 0.047% (95% CI - 0.080 to - 0.014%) change before and after program implementation. We observed a 5.1% (95% CI 2.4 to 7.7%) absolute increase in the proportion prescribed statins in the V-IMPACT group, a 5.3% (95% CI 2.5 to 8.2%) increase prescribed ACE/ARBs, and a 4.6% (95% 1.7 to 7.5%) increase in completed yearly microalbuminuria testing. V-IMPACT was not associated with a significant difference in the proportion with controlled blood pressure at < 140/90 or < 130/90 mmHg thresholds.

CONCLUSIONS

Quality of diabetes care delivered by a longitudinal virtual primary care model was similar if not better than traditional in-person care.

Urban-Rural Disparities in Vaccination Service Use Among Low-Income Adolescents

OBJECTIVE

To access urban-rural disparities in vaccination service use among Medicaid-enrolled adolescents and examine its association with residence county characteristics.

STUDY DESIGN

We used the 2016 Medicaid T-MSIS Analytic File to estimate adolescents' use of vaccination services, defined as the proportion of adolescents aged 11-18 years with ≥ 1 vaccination visit in a county. We used linear regression and the Oaxaca-Blinder decomposition method to examine the association between county characteristics and urban-rural disparities in vaccination service use.

RESULTS

The analysis included 2,473 counties located in 38 states. The mean proportion of adolescents making ≥ 1 vaccination visit at the county level was low (36.09%) and was lower in rural than in urban counties (31.99% vs. 36.85%, p < .01). The number of primary care physicians (PCPs) was positively associated with vaccination service use in rural counties; in urban counties, % of households without a vehicle was negatively associated with vaccination service use. The decomposition results showed that 66.78% (3.24 percentage points) of the urban-rural disparities in vaccination service use could be attributed to urban-rural differences in the county characteristics included in the study. Characteristics measuring access to care (number of PCPs), social and economic factors (% adults with at least a bachelor's degree and % children in poverty), quality of care (influenza vaccination rates and preventable hospital stays), and demographics (% non-Hispanic black, % Hispanic, and % females) played a role in urban-rural disparities.

CONCLUSIONS

Differences in county characteristics could partly explain the observed urban-rural disparities in vaccination service use among low-income adolescents.

Relationship between rural hospital closures and the supply of nurse practitioners and certified registered nurse anesthetists

BACKGROUND

Reductions in primary care and specialist physicians follow rural hospital closures. As the supply of physicians declines, rural healthcare systems increasingly rely on nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) to deliver care.

PURPOSE

We sought to examine the extent to which rural hospital closures are associated with changes in the NP and CRNA workforce.

METHOD

Using Area Health Resources Files (AHRF) data from 2010-2017, we used an event-study design to estimate the relationship between rural hospital closures and changes in the supply of NPs and CRNAs.

FINDINGS

Among 1,544 rural counties, we observed 151 hospital closures. After controlling for local market characteristics, we did not find a significant relationship between hospital closure and the supply of NPs and CRNAs.

DISCUSSION

We do not find evidence that NPs and CRNAs respond to rural hospital closures by leaving the healthcare market.

Trends in Medical School Application and Matriculation Rates Across the United States From 2001 to 2015: Implications for Health Disparities

PURPOSE

Socioeconomic and geographic determinants of medical school application and matriculation may help explain the unequal distribution of physicians in the United States. This study describes trends in MD-granting medical school application and matriculation rates and explores the relationship between county median family income, proximity to a medical school, and medical school application and matriculation rates.

METHOD

Data were obtained from the Association of American Medical Colleges, including the age, gender, and Federal Information Processing Standards code for county of legal residence for each applicant and matriculant to U.S. MD-granting medical schools from 2001 through 2015. The application and matriculation rates in each county were calculated using the number of applicants and matriculants per 100,000 residents. Counties were classified into 4 groups according to the county median family income (high-income, middle-income, middle-low-income, low-income). The authors performed chi-square tests to assess trends across the study period and the association of county median family income with application and matriculation rates.

RESULTS

There were 581,833 applicants and 262,730 (45.2%) matriculants to MD-granting medical schools between 2001 and 2015. The application rates per 100,000 residents during 2001-2005, 2006-2010, and 2011-2015 were 57.2, 62.7, and 69.0, respectively, and the corresponding matriculation rates were 27.5, 28.1, and 29.8. The ratios of the application rate in high-income counties to that in low-income counties during the 3 time periods were 1.9, 2.4, and 2.8, respectively.

CONCLUSIONS

The application and matriculation rates to MD-granting medical schools increased steadily from 2001 to 2015. Yet, applicants and matriculants disproportionately came from high-income counties. The differences in the application and matriculation rates between low-income and high-income counties grew during this period. Exploring these differences can lead to better understanding of the factors that drive geographic differences in physician access and the associated health disparities across the United States.

Factors Associated With Working in Remote Indonesia: A National Cross-Sectional Study of Early-Career Doctors

Background: Doctor shortages in remote areas of Indonesia are amongst challenges to provide equitable healthcare access. Understanding factors associated with doctors' work location is essential to overcome geographic maldistribution. Focused analyses of doctors' early-career years can provide evidence to strengthen home-grown remote workforce development.

Method: This is a cross-sectional study of early-career (post-internship years 1–5) Indonesian doctors, involving an online self-administered survey on demographic characteristics, and; locations of upbringing, medical clerkship (placement during medical school), internship, and current work. Multivariate logistic regression was used to test factors associated with current work in remote districts.

Results: Of 3,176 doctors actively working as clinicians, 8.9% were practicing in remote districts. Compared with their non-remote counterparts, doctors working in remote districts were more likely to be male (OR 1.5,CI 1.1–2.1) or unmarried (OR 1.9,CI 1.3–3.0), have spent more than half of their childhood in a remote district (OR 19.9,CI 12.3–32.3), have completed a remote clerkship (OR 2.2,CI 1.1–4.4) or internship (OR 2.0,CI 1.3–3.0), currently participate in rural incentive programs (OR 18.6,CI 12.8–26.8) or have previously participated in these (OR 2.0,CI 1.3–3.0), be a government employee (OR 3.2,CI 2.1–4.9), or have worked rurally or remotely post-internship but prior to current position (OR 1.9,CI 1.2–3.0).

Conclusion: Our results indicate that building the Indonesian medical workforce in remote regions could be facilitated by investing in strategies to select medical students with a remote background, delivering more remote clerkships during the medical course, deploying more doctors in remote internships and providing financial incentives. Additional considerations include expanding government employment opportunities in rural areas to achieve a more equitable geographic distribution of doctors in Indonesia.

Viewpoints on Healthcare Delivery Science Education Among Practicing Physicians in a Rural State

INTRODUCTION

Healthcare Delivery Science Education (HDSE) covers important aspects of the business of medicine, including, operations management, managerial accounting, entrepreneurship, finance, marketing, negotiations, e-health and policy/advocacy. We need to investigate and understand practicing physicians' viewpoints on HDSE in order to inform interventions capable of preventing the double loss phenomena and improving medical and continuing medical education opportunities in HDSE. This qualitative study aims to provide a rich, contextualized understanding of the HDSE experiences and interests of physicians practicing in a rural state through the intensive study of particular cases.

MATERIALS AND METHODS

We interviewed 18 practicing physicians from a rural, Midwestern state over the telephone about their viewpoints on past experiences obtaining HDSE, interest in HDSE, barriers to pursuing HDSE, and interest in an example HDSE certificate program.

RESULTS

Salient themes in our study were that physicians were interested in HDSE and believed HDSE could lead to improved patient care and practice efficiency. However, many of the respondents had not received longitudinal, diversified, didactic or practical HDSE. Time limited many physicians from pursuing HDSE opportunities. Many physicians in the study were interested in the example HDSE certificate program.

DISCUSSION AND CONCLUSIONS

Physicians in our qualitative study were interested in obtaining HDSE and had not received diversified, didactic HDSE in the past. Our research suggests innovative HDSE programs will likely be utilized and pursued if they are developed.

Rural Workforce Years: Quantifying the Rural Workforce Contribution of Family Medicine Residency Graduates

BACKGROUND

Rural regions of the United States continue to experience a disproportionate shortage of physicians compared to urban regions despite decades of state and federal investments in workforce initiatives. The graduate medical education system effectively controls the size of the physician workforce but lacks effective mechanisms to equitably distribute those physicians.

OBJECTIVE

We created a measurement tool called a "rural workforce year" to better understand the rural primary care workforce. It quantifies the rural workforce contributions of rurally trained family medicine residency program graduates and compares them to contributions of a geographically matched cohort of non-rurally trained graduates.

METHODS

We identified graduates in both cohorts and tracked their practice locations from 2008-2018. We compared the average number of rural workforce years in 3 cross sections: 5, 8, and 10 years in practice after residency graduation.

RESULTS

Rurally trained graduates practicing for contributed a higher number of rural workforce years in total and on average per graduate compared to a matched cohort of non-rural/rural training tack (RTT) graduates in the same practice intervals (P < .001 in all 3 comparison groups). In order to replace the rural workforce years produced by 1 graduate from the rural/RTT cohort, it would take 2.89 graduates from non-rural/RTT programs.

CONCLUSIONS

These findings suggest that rural/RTT-trained physicians devote substantially more service to rural communities than a matched cohort of non-rural/RTT graduates and highlight the importance of rural/RTT programs as a major contributor to the rural primary care workforce in the United States.

Rural Employment of Health Care Workers: A Longitudinal Cohort Study

PURPOSE

Preserving and increasing the health care workforce in rural areas has become imperative due to the shortage of health care workers serving rural populations. However, limited data are available on long-term patterns of employment in rural settings among health care workers.

METHODS

We analyzed the National Longitudinal Survey of Youth, which enrolled a nationally representative sample of adolescents in 1979 and tracked their career outcomes through 2016. Using the US Census Bureau occupation codes, we identified participants who worked in health care occupations, and we classified their employment in rural versus urban areas.

FINDINGS

Of the 1,007 respondents (including 109 doctoral health professionals), 70% worked only in urban locations, 13% worked only in rural locations, and 17% worked in both rural and urban locations during their health care career. Rural upbringing, White race, and female gender were associated with rural employment. Among nondoctoral health professionals, lower educational attainment was associated with increased likelihood of working only in rural settings.

CONCLUSION

Our study indicates the rural workforce is split between workers who are only employed in rural settings, and those who are intermittently employed in rural and urban settings. Therefore, retention of health care workers in rural settings and recruitment of workers from urban settings to practice in rural areas are important strategies for addressing the rural health care worker shortage. Rural upbringing, previously described as predictive of physician practice in rural locations, appears the strongest predictor of rural employment for both doctoral health professionals and nondoctoral health professionals.

Pipeline Programs Can Support Reforms in Medical Education: A Cohort Study of Alabama's Rural Health Leaders Pipeline to Engage Community Leaders

Purpose

To demonstrate for county leaders the utility of rural pipelines to gain physicians and produce health professionals.

Methods

This cohort study, 1993‐2018, aggregated 1,051 students in the Rural Health Leaders Pipeline to their home counties (N = 67) to study the relationship between county participation in pipeline programs and outcomes of family physicians gained and health professionals produced. Additional county demographics were included. We conducted descriptive, bivariate, and multivariable linear regression analyses controlling for poverty, race, and rurality.

Findings

All 67 Alabama counties participated with means of 9.6 Rural Health Scholars, 2.7 Rural Minority Health Scholars, 3.4 Rural Medical Scholars, 67% rural population, 29.7% Black population, and 21.5% under poverty. Best regression model for gaining family physicians included Rural Medical Scholars involved (b = 0.24, P < .001) with R² 0.30, indicating a county gained 1 family physician for 4 students. Best model for health professionals included Rural Health Scholars involved (b = 0.20, P < .001) with R² 0.31, indicating production of 1 health professional for 5 students. Best model for any professional included Rural Health Scholars involved (b = 0.23, P < .001) with R² 0.35, indicating 1 professional produced for 4 students.

Conclusions

Rural pipeline programs can be useful tools in medical education reform to benefit counties with the gain of family physicians and production of health professionals. Local public officials could use these findings, eg, 1 family physician gained for every 4 students a county involved in the pipeline, to advocate that health professional education employ such pipelines.

National Trends in the United States Eye Care Workforce from 1995 to 2017

PURPOSE

To describe temporal and geographic trends in the US eye care workforce.

DESIGN

Cross-sectional study.

METHODS

We obtained data from the 2017 Area Health Resources File. The main outcomes were ophthalmologist and optometrist density, as defined as the number of providers per 100,000 individuals, the ratio of ophthalmologists ≥55 years of age to those <55 years of age, and county characteristics associated with the availability of an ophthalmologist.

RESULTS

From 1995 to 2017, the national ophthalmologist density decreased from 6.30 to 5.68 ophthalmologists per 100,000 individuals. Although rural counties experienced a mean annual increase in ophthalmologist density by 2.26%, they still had a lower mean ophthalmologist density (0.58/100,000 individuals) compared with nonmetropolitan (2.19/100,000 individuals) and metropolitan counties (6.29/100,000 individuals) in 2017. The ratio of older to younger ophthalmologists increased from 0.37 in 1995 to 0.82 in 2017, with the greatest ratio increase occurring in rural counties (0.29 to 1.90). The presence of an ophthalmologist was significantly associated with a greater proportion of individuals with a college degree and health insurance, and more developed health care infrastructure. From 1990 to 2017, the density of optometrists increased from 11.06 to 16.16 optometrists per 100,000 individuals.

CONCLUSIONS

Over the last 2 decades, the national density of ophthalmologists has decreased and the workforce has aged. In contrast, the density of optometrists has increased. Rural counties continue to have a disproportionately lower supply of eye care providers, although some growth has occurred. Given the rising ratio of optometrists to ophthalmologists, it is of interest for future work to determine how the optometrist workforce can best complement potential shortages of ophthalmologists.

Status of the Rural Surgical Workforce

Rural hospitals are closing at an increasing rate. From 2010 to 2014, 47 rural hospitals closed, affecting 1.5 million people. The presence of surgeons is critical to keeping these hospitals open; to provide initial trauma care, cancer screening, and care to populations that cannot easily travel; and to provide solid general surgery procedures to almost 60 million Americans. Actions to provide surgeons trained for rural practice include exposure of surgery to students in high school (and earlier), recruitment of rural students into medical school, rural rotations in medical school, rural tracts within surgical residencies, and programs to support and retain rural surgeons.

Movers and Stayers: What Birthplaces Can Teach Us About Rural Practice Choice Among Midwestern General Surgeons

PURPOSE

This study compares practicing rural Midwestern general surgeons born in urban areas to those born in rural areas to describe the association between birthplace and current practice location.

METHODS

The 2017 AMA MasterFile was used to study general surgeons in the Midwest Census Division. Surgeons were assigned to categories based on birthplace and current practice locations: urban-urban stayers, urban-rural movers, rural-rural stayers, and rural-urban movers. Urban and rural classifications corresponded to the metropolitan and nonmetropolitan definitions with Rural-Urban Continuum Codes (urban, RUCCs 1-3; rural, RUCCs 4-9). Bivariate tests and logistic regression were used to determine factors associated with rural practice choice.

FINDINGS

There were 3,070 general surgeons in the study population: 70.6% urban-urban stayers, 13.1% urban-rural movers, 10.7% rural-urban movers, and 5.7% rural-rural stayers. Rural areas netted 74 surgeons (327 rural-urban movers versus 401 urban-rural movers). Logistic regression results found different factors predicted rural practice among urban-born versus rural-born surgeons. Older urban-born surgeons were more likely to practice rurally, as were male surgeons, DOs, and those trained in less-urban residency programs. Among rural-born surgeons, more rural birthplaces and having trained at a less-urban residency were associated with practicing rurally.

CONCLUSIONS

Recruiting urban-born surgeons to rural areas has proven successful in the Midwest; our findings show urban-born surgeons outnumber rural-born surgeons in rural communities. Given the ongoing need for surgeons in rural areas, urban-born surgeons should not be overlooked. Findings suggest educators and community leaders should expand less-urban training opportunities given their potential influence on all general surgeons.