Retention of primary care physicians in rural health professional shortage areas

Exploring Current Practices, Needs, and Barriers for Expanding Distributed Medical Education and Scholarship in Psychiatry: Protocol for an Environmental Scan Using a Formal Information Search Approach and Explanatory Design

BACKGROUND

Distributed medical education (DME) offers manifold benefits, such as increased training capacity, enhanced clinical learning, and enhanced rural physician recruitment. Engaged faculty are pivotal to DME's success, necessitating efforts from the academic department to promote integration into scholarly and research activities. Environmental scanning has been used to gather, analyze, and apply information for strategic planning purposes. It helps organizations identify current practices, assess needs and barriers, and respond to emerging risks and opportunities. There are process models and conceptual frameworks developed for environmental scanning in the business and educational sectors. However, the literature lacks methodological direction on how to go about designing and implementing this strategy to guide research and practice in DME, especially in the psychiatry field.

OBJECTIVE

This paper presents a protocol for an environmental scanning that aims to understand current practices and identify needs and barriers that must be addressed to facilitate the integration of psychiatrists from the Dalhousie University Faculty of Medicine's distributed education sites in Nova Scotia and New Brunswick into the Department of Psychiatry, contributing for the expansion of DME in both provinces and informing strategic planning and decision-making within the organization.

METHODS

This protocol adopts an innovative approach combining a formal information search and an explanatory design that includes quantitative and qualitative data. About 120 psychiatrists from 8 administrative health zones of both provinces will be invited to complete an anonymous web-based survey with questions about demographics, participants' experience and interest in undergraduate, postgraduate, and continuing medical education, research and scholarly activities, quality improvement, and knowledge translation. Focus group sessions will be conducted with a purposive sample of psychiatrists to collect qualitative data on their perspectives on the expansion of DME.

RESULTS

Results are expected within 6 months of data collection and will inform policy options for expanding Dalhousie University's psychiatry residency and fellowship programs using the infrastructure and human resources at distributed learning sites, leveraging opportunities regionally, especially in rural areas.

CONCLUSIONS

This paper proposes a comprehensive environmental scan procedure adapted from existing approaches. It does this by collecting important characteristics that affect psychiatrists' desire to be involved with research and scholarly activities, which is crucial for the DME expansion. Furthermore, its concordance with the literature facilitates interpretation and comparison. The protocol's new method also fills DME information gaps, allowing one to identify insights and patterns that may shape psychiatric education. This environmental scan's results will answer essential questions about how training programs could involve therapists outside the academic core and make the most of training experiences in semiurban and rural areas. This could help other psychiatry and medical units outside tertiary care establish residency and fellowship programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46835.

Experiences of primary health care nurses advancing their careers in a remote Western Australian location

OBJECTIVE

The objective of the study was to explore the experiences of primary health care (PHC) nurses advancing their careers in a remote location in Western Australia.

SETTING

The study was conducted in PHC organisations in one remote location in northern Western Australia.

PARTICIPANTS

Six registered nurses working in four PHC organisations participated in the study. All were registered with the Nursing and Midwifery Board of Australia. Participants were all female, and five had child carer responsibilities. They had worked in the region for between 8 months and 10 years.

DESIGN

The design was based on a qualitative, interpretative phenomenological analysis methodology involving in-depth, semi-structured, face-to-face interviews.

RESULTS

Participants faced challenges advancing their careers given the limited employment opportunities and need to balance their professional ambitions with family needs. Participants had limited capacity to support each other's learning and felt poorly supported by employers to undertake professional development not directly related to their role. Participants were not well engaged with professional associations beyond undertaking online professional development activities provided with membership. Accessing professional development was difficult given a lack of time, limited access to local learning activities and a consequent need to travel, which was challenging. Despite the challenges they faced, most nurses remained passionate about their remote nursing roles and enjoyed the lifestyle.

CONCLUSION

Remote PHC nurses face a range of challenges, some of which can be overcome by improved availability of local professional development and better support from employers and professional associations.

Higher hospitalization and mortality rates among SARS-CoV-2-infected persons in rural America

PURPOSE

Rural communities are among the most underserved and resource-scarce populations in the United States. However, there are limited data on COVID-19 outcomes in rural America. This study aims to compare hospitalization rates and inpatient mortality among SARS-CoV-2-infected persons stratified by residential rurality.

METHODS

This retrospective cohort study from the National COVID Cohort Collaborative (N3C) assesses 1,033,229 patients from 44 US hospital systems diagnosed with SARS-CoV-2 infection between January 2020 and June 2021. Primary outcomes were hospitalization and all-cause inpatient mortality. Secondary outcomes were utilization of supplemental oxygen, invasive mechanical ventilation, vasopressor support, extracorporeal membrane oxygenation, and incidence of major adverse cardiovascular events or hospital readmission. The analytic approach estimates 90-day survival in hospitalized patients and associations between rurality, hospitalization, and inpatient adverse events while controlling for major risk factors using Kaplan-Meier survival estimates and mixed-effects logistic regression.

FINDINGS

Of 1,033,229 diagnosed COVID-19 patients included, 186,882 required hospitalization. After adjusting for demographic differences and comorbidities, urban-adjacent and nonurban-adjacent rural dwellers with COVID-19 were more likely to be hospitalized (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI], 1.16-1.21 and aOR 1.29, CI 1.24-1.1.34) and to die or be transferred to hospice (aOR 1.36, CI 1.29-1.43 and 1.37, CI 1.26-1.50), respectively. All secondary outcomes were more likely among rural patients.

CONCLUSIONS

Hospitalization, inpatient mortality, and other adverse outcomes are higher among rural persons with COVID-19, even after adjusting for demographic differences and comorbidities. Further research is needed to understand the factors that drive health disparities in rural populations.

Incentive Programs for Physicians to Practice in Underserved Areas: A Nationwide Snapshot

Access to health care is limited in part by maldistribution of physicians. Physicians agreeing to work in underserved areas can receive a financial incentive or a visa waiver that eases immigration restrictions. However, the overall landscape and scale of incentive programs and providers remains unelucidated. This article aggregates the reported output of state and federal programs and assesses their relative contributions to increasing the physician workforce in underserved areas. The estimates derived suggest that in 2017 the National Health Service Corps supported placement of around 2000 physicians, fully state-funded financial incentive programs about 1000, and visa waiver programs over 3500.

Physician turnover in primary health care services in the East Zone of São Paulo City, Brazil: incidence and associated factors

BACKGROUND

The shortage and high turnover of physicians is a recurrent problem in health care systems; this is especially harmful to the expansion and full operation of primary health care (PHC). The aim of this paper is to analyze incidence and associated factors with physician turnover in primary health care services in the East Zone of São Paulo City.

METHODS

This is a retrospective cohort study of 1378 physicians over a 15 years' time period based on physicians' administrative records from two distinct secondary databases. Physicians' individual characteristics were analyzed including graduation and specialization. Survival analysis techniques such Kaplan-Meier and Cox Regression were used to analyze the termination of contract.

RESULTS

One thousand three hundred seventy-eight physicians were included in the study of which 130 [9.4%(CI95 8.0-11.1%)] remained in the PHC services. The mean and median time until the occurrence of the physician leaving the service was 2.14 years (CI95% 1.98-2.29 years) and 1.17 years [(CI95% 1.05-1.28 years)]. The probability of contract interruption was 45% in the first year and 68% in the second year. Independent factors associated with TEC were identified: workload of 40 h/week HR = 1.71 [(CI95% 1.4-2.09), p < 0.001]; initial salary ≤1052 BGI HR = 1.87 [(CI95 1.64-2.15), p < 0.001]; time since graduation ≤2 years HR =1.36 [(CI95 1.18-1.56), p < 0.001]; and the conclusion of residency in up to 3 years after leaving the service HR = 1.69 [(CI95 1.40-2.04), p < 0.001].

CONCLUSIONS

The time of employment of the physician in PHC was relatively short, with a high probability of TEC in the first year. Modifiable factors such as working hours, starting salary, time since graduation from medical school and need to enter in a residency program were associated with TEC. In pointing out that modifiable factors are responsible for long term employment or the end of contract of physicians in PHC services of the Unified Health System in the periphery of a metropolitan area, the study provides support for the planning, implementation and management of policies and strategies aimed at attracting and retaining physicians in suburban, priority or underserved regions.

Location Effects on Spoken Language and Literacy for Children who are DHH

The purpose of this study was to consider how living in an area that qualifies for a rural health grant interacts with a child's hearing status to affect early language and literacy development. Four-year-old children with hearing aids (n = 45), cochlear implants (n = 47), and with typical hearing (n = 66) completed measures of spoken language knowledge and of emergent literacy skills as part of a larger longitudinal investigation. A significant interaction effect between location (rural or urban/suburban) and amplification group was detected for letter knowledge: children with hearing aids exhibit a performance that is particularly affected by rural location. Overall, children with cochlear implants performed lower across all measures than children with typical hearing, and children with hearing aids performed lower than children with typical hearing on measures of phonological awareness, vocabulary, omnibus language knowledge and articulation.

A Geodemographic Service Coverage Analysis of Travel Time to Glaucoma Specialists in Florida

PRECIS

Approximately 1 in 9 Florida residents over the age of 65 years (438,642 people) live more than an hour away from a glaucoma specialist, which represents a significant barrier to care.

PURPOSE

To describe access to glaucoma care for Florida's elderly population using travel time to American Glaucoma Society (AGS) member offices.

METHODS

For this cross-sectional service coverage analysis, a list of AGS member locations was extracted from the AGS website, and addresses were geocoded using ArcGIS Online. Driving time regions were created using the service area tool in ArcGIS Pro 2.4 and overlaid with 2010 United States Census and 2016 American Community Survey data for all Florida residents age 65 or older.

RESULTS

Fifty-eight AGS member providers with 65 locations were identified and geocoded. There were 3,797,625 individuals aged over 65 years in Florida, of which 1,153,320 (30.4%) lived within 15 minutes of driving time from an AGS provider's office, 2,586,825 (68.1%) within 30 minutes, 3,358,983 (88.4%) within 60 minutes, and 3,491,815 (91.9%) within 120 minutes. The areas with the lowest access include rural areas near Lake Okeechobee and the Florida Panhandle. The population living beyond a 60-minute drive was more likely to be White, non-Hispanic and older, but less likely to be living below the federal poverty level or receiving public assistance than the population living within a 60-minute drive.

CONCLUSIONS

There is a significant travel burden for the elderly community of Florida to reach AGS providers. Additional studies could help identify other social barriers to accessing glaucoma providers in Florida and beyond in an effort to improve patient compliance and, ultimately, vision outcomes.

Determining factors in the retention of physicians in rural and underdeveloped areas: a systematic review

Background

Imbalance in distribution of Health Care Workers (HCWs) in a country is a global challenge. Almost all of the rural and underdeveloped areas are struggling with the shortage of HCWs, especially physicians. Therefore, this study aimed to identify factors governing the retention of physicians in rural and underdeveloped areas.

Methods

International databases including Scopus, PubMed, Web of Science, Proquest, and Embase were searched using Mesh terms in order to find peer-reviewed journal articles addressing physicians’ retention factors in rural and underdeveloped areas. The records were screened, and any duplicate results were removed. The quality of the studies was assessed according to the Critical Appraisal Skills Program developed for different types of studies. Then, through content analysis, the related factors were identified from finally selected papers, coded, and categorized.

Results

The initial search resulted in 2312 relevant articles. On the basis of specific selection criteria, 35 full-text articles were finally reviewed.. The major affecting factors in physicians’ retention in rural and underdeveloped regions were classified into the following six categories: 1) financial; 2) career and professional; 3) working conditions; 4) personal; 5) cultural; and 6) living conditions factors.

Conclusion

There is a complex interplay of factors governing physicians’ retention in rural and underdeveloped areas. If health organizations are concerned with physicians’ retention in deprived areas, they should take into account these main factors. Moreover, they should develop policies and strategies to attract and retain physicians in rural and underdeveloped areas.

The Relationship between the COVID-19 Pandemic and Nursing Students' Sense of Belonging: The Experiences and Nursing Education Management of Pre-Service Nursing Professionals

The COVID-19 pandemic has changed the orders and structures of societies, particularly in the fields of medical and nursing professions. The researcher aims to understand the experiences, sense of belonging, and decision-making processes about Japanese pre-service nursing students and how the COVID-19 pandemic, social distancing, and lockdown has influenced their understanding as pre-service nursing professionals in Japan. As this study focuses on the issues of pre-service nursing students, the researcher invited forty-nine pre-service nursing students for a virtual interview due to the recommendation of social distancing. To increase the coverage of the population, the researcher employed snowball sampling to recruit participants from all over Japan. Although the COVID-19 pandemic influenced the overall performance of the medical and nursing professions, all participants showed a sense of belonging as Japanese citizens and nursing professionals due to the natural disaster of their country. More importantly, all expressed their desires and missions to upgrade and improve the overall performance of the public health system due to the influence of the COVID-19 pandemic. The results discovered that many Japanese nursing students advocated that Japan's national development, the benefits and advantages of their country, were of a greater importance than their own personal development and goals.

Context Matters: Findings from a Qualitative Study Exploring Service and Place Factors Influencing the Recruitment and Retention of Allied Health Professionals in Rural Australian Public Health Services

Chronic health workforce shortages significantly contribute to unmet health care needs in rural and remote communities. Of particular and growing concern are shortages of allied health professionals (AHPs). This study explored the contextual factors impacting the recruitment and retention of AHPs in rural Australia. A qualitative approach using a constructivist-interpretivist methodology was taken. Semi-structured interviews (n = 74) with executive staff, allied health (AH) managers and newly recruited AHPs working in two rural public health services in Victoria, Australia were conducted. Data was coded and categorised inductively and analysed thematically. The findings suggest that to support a stable and sustainable AH workforce, rural public sector health services need to be more efficient, strategic and visionary. This means ensuring that policies and procedures are equitable and accessible, processes are effective, and action is taken to develop local programs, opportunities and supports that allow AH staff to thrive and grow in place at all grade levels and life stages. This study reinforces the need for a whole-of-community approach to effectively support individual AH workers and their family members in adjusting to a new place and developing a sense of belonging in place. The recommendations arising from this study are likely to have utility for other high-income countries, particularly in guiding AH recruitment and retention strategies in rural public sector health services. Recommendations relating to community/place will likely benefit broader rural health workforce initiatives.

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.

A parent-led intervention to promote recovery following pediatric injury: study protocol for a randomized controlled trial

BACKGROUND

Injury is one of the most prevalent potentially emotionally traumatic events that children experience and can lead to persistent impaired physical and emotional health. There is a need for interventions that promote full physical and emotional recovery and that can be easily accessed by all injured children. Based on research evidence regarding post-injury recovery, we created the Cellie Coping Kit for Children with Injury intervention to target key mechanisms of action and refined the intervention based on feedback from children, families, and experts in the field. The Cellie Coping Kit intervention is parent-guided and includes a toy (for engagement), coping cards for children, and a book for parents with evidence-based strategies to promote injury recovery. This pilot research trial aims to provide an initial evaluation of the impact of the Cellie Coping Kit for Children with Injury on proximal targets (coping, appraisals) and later child health outcomes (physical recovery, emotional health, health-related quality of life).

METHOD / DESIGN

Eighty children (aged 8-12 years) and their parents will complete a baseline assessment (T1) and then will be randomly assigned to an immediate intervention group or waitlist group. The Cellie Coping Kit for Injury Intervention will be introduced to the immediate intervention group after the T1 assessment and to the waitlist group following the T3 assessment. Follow-up assessments of physical and emotional health will be completed at 6 weeks (T2), 12 weeks (T3), and 18 weeks (T4).

DISCUSSION

This will be one of the first randomized controlled trials to examine an intervention tool intended to promote full recovery after pediatric injury and be primarily implemented by children and parents. Results will provide data on the feasibility of the implementation of the Cellie Coping Intervention for Injury as well as estimations of efficacy. Potential strengths and limitations of this design are discussed.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03153696 . Registered on 15 May 2017.

Overcoming the Maternal Care Crisis: How Can Lessons Learnt in Global Health Informatics Address US Maternal Health Outcomes?

Despite unprecedented spending, US maternal outcomes have worsened drastically over the past decade. In comparison, maternal outcomes of many Low and Middle-Income Countries (LMIC) have improved. Lessons learnt by their success may be applicable to the US. We performed a literature review to identify innovations that had met with success across LMIC, and should be considered for adoption in the US. mHealth and patient facing alerts, Telehealth, patient controlled health records, inclusion of patient relationship data in health information systems and positioning empowered community health workers as catalysts of maternal care delivery were identified as innovations worthy of further evaluation. These innovations were categorized into several themes; knowledge, technology, patient/community empowerment, coordination and process change. Tools that place informed and empowered patients and community members at the center of maternal care has greatly improved maternal outcomes, and are suitable to be considered for the US healthcare system.

The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians

PURPOSE

To examine the literature documenting successes in recruiting and retaining rural primary care physicians.

METHOD

The authors conducted a narrative review of literature on individual, educational, and professional characteristics and experiences that lead to recruitment and retention of rural primary care physicians. In May 2016, they searched MEDLINE, PubMed, CINAHL, ERIC, Web of Science, Google Scholar, the Grey Literature Report, and reference lists of included studies for literature published in or after 1990 in the United States, Canada, or Australia. The authors identified 83 articles meeting inclusion criteria. They synthesized results and developed a theoretical model that proposes how the findings interact and influence rural recruitment and retention.

RESULTS

The authors' proposed theoretical model suggests factors interact across multiple dimensions to facilitate the development of a rural physician identity. Rural upbringing, personal attributes, positive rural exposure, preparation for rural life and medicine, partner receptivity to rural living, financial incentives, integration into rural communities, and good work-life balance influence recruitment and retention. However, attending medical schools and/or residencies with a rural emphasis and participating in rural training may reflect, rather than produce, intention for rural practice.

CONCLUSIONS

Many factors enhance rural physician identity development and influence whether physicians enter, remain in, and thrive in rural practice. To help trainees and young physicians develop the professional identity of a rural physician, multifactorial medical training approaches aimed at encouraging long-term rural practice should focus on rural-specific clinical and nonclinical competencies while providing trainees with positive rural experiences.

The gap in human resources to deliver the guaranteed package of prevention and health promotion services at urban and rural primary care facilities in Mexico

BACKGROUND

The purpose of this study was to estimate the gap between the available and the ideal supply of human resources (physicians, nurses, and health promoters) to deliver the guaranteed package of prevention and health promotion services at urban and rural primary care facilities in Mexico.

METHODS

We conducted a cross-sectional observational study using a convenience sample. We selected 20 primary health facilities in urban and rural areas in 10 states of Mexico. We calculated the available and the ideal supply of human resources in these facilities using estimates of time available, used, and required to deliver health prevention and promotion services. We performed descriptive statistics and bivariate hypothesis testing using Wilcoxon and Friedman tests. Finally, we conducted a sensitivity analysis to test whether the non-normal distribution of our time variables biased estimation of available and ideal supply of human resources.

RESULTS

The comparison between available and ideal supply for urban and rural primary health care facilities reveals a low supply of physicians. On average, primary health care facilities are lacking five physicians when they were estimated with time used and nine if they were estimated with time required (P < 0.05). No difference was observed between available and ideal supply of nurses in either urban or rural primary health care facilities. There is a shortage of health promoters in urban primary health facilities (P < 0.05).

CONCLUSION

The available supply of physicians and health promoters is lower than the ideal supply to deliver the guaranteed package of prevention and health promotion services. Policies must address the level and distribution of human resources in primary health facilities.

Rural substance use treatment centers in the United States: an assessment of treatment quality by location

BACKGROUND

While previous research has added to the understanding of rural residents' unique health challenges, much remains to be learned about the provision of substance use disorder (SUD) treatment in rural areas. A key question is difference in structural resources and quality of care between rural and urban treatment centers.

OBJECTIVE

To examine differences in treatment quality in rural and urban centers and to determine if differences in treatment quality are contextualized by centers' structural resources.

METHODS

Utilizing combined data from two representative samples of SUD treatment centers (n = 591), we used a series of multivariate regressions to analyze the association between center rurality and various indicators of structural characteristics and treatment quality. Interaction effects were further examined between structural characteristics and treatment quality indicators.

RESULTS

We found that structural and quality differences between rural and urban treatment centers were present. Rural centers had reduced access to highly educated counselors, were more likely to be non-profit and dependent on public funding, offered fewer wraparound services, and had less diverse specialized treatment options. Our results also indicated that rural centers were less likely to prescribe buprenorphine as part of their treatment but were more likely to employ nursing staff and offer specialized treatment for adolescents. Rural center access to a physician contextualized the association between center rurality and the more limited provision of wraparound services.

CONCLUSION

Our findings suggest that treatment quality differs between urban and rural centers in complex ways that are subject to resource availability.

Regional distribution of physicians: the role of comprehensive private health insurance in Germany

OBJECTIVE

In recent years, the co-existence in Germany of two parallel comprehensive insurance systems-statutory health insurance (SHI) and private health insurance (PHI)-has been posited as a possible cause of a persistent unequal regional distribution of physicians. The present study investigates the effect of the proportion of privately insured patients on the density of SHI-licensed physicians, while controlling for regional variations in the average income from SHI patients.

METHODS

The proportion of residents in a district with private health insurance is estimated using complete administrative data from the SHI system and the German population census. Missing values are estimated using multiple imputation techniques. All models control for the estimated average income ambulatory physicians generate from treating SHI insured patients and a well-defined set of covariates on the level of districts in Germany in 2010.

RESULTS

Our results show that every percentage change in the proportion of residents with private health insurance is associated with increases of 2.1 and 1.3 % in the density of specialists and GPs respectively. Higher SHI income in rural areas does not compensate for this effect.

CONCLUSION

From a financial perspective, it is rational for a physician to locate a new practice in a district with a high proportion of privately insured patients. From the perspective of patients in the SHI system, the incentive effects of PHI presumably contribute to a concentration of health care services in wealthy and urban areas. To date, the needs-based planning mechanism has been unable to address this imbalance.

Determinants of rural Australian primary health care worker retention: A synthesis of key evidence and implications for policymaking

OBJECTIVE

To synthesise key Australian empirical rural retention evidence and outline implications and potential applications for policymaking.

DESIGN

A comprehensive search of Medline, PsychINFO, CINAHL plus, Scopus and EMBASE revealed eight peer-reviewed empirical studies published since 2000 quantifying factors associated with actual retention.

SETTING AND PARTICIPANTS

Rural and remote Australian primary health care workers.

MAIN OUTCOME MEASURES

Hazard ratios (hazard of leaving rural), mean length of stay in current rural position and odds ratios (odds of leaving rural).

RESULTS

A broad range of geographical, professional, financial, educational, regulatory and personal factors are strongly and significantly associated with the rural retention of Australian primary health care workers. Important factors included geographical remoteness and population size, profession, providing hospital services, practising procedural skills, taking annual leave, employment grade, employment and payment structures, restricted access to provider numbers, country of training, vocational training, practitioner age group and cognitive behavioural coaching. These findings suggest that retention strategies should be multifaceted and 'bundled', addressing the combination of modifiable factors most important for specific groups of Australian rural and remote primary health care workers, and compensating health professionals for hardships they face that are linked to less modifiable factors.

CONCLUSIONS

The short retention of many Australian rural and remote Allied Health Professionals and GPs, particularly in small, outer regional and remote communities, requires ongoing policy support. The important retention patterns highlighted in this review provide policymakers with direction about where to best target retention initiatives, as well as an indication of what they can do to improve retention.

How we incorporated service learning into a medical student rural clinical training experience

BACKGROUND

Many medical schools have developed admission policies and clinical training programs designed to address the rural physician workforce shortages in their state.

AIM

To enhance medical student rural clinical training experiences, and assist in preparing students for living and working in rural communities.

METHODS

As part of their Rural Track Clerkship (RTC) Program, the University of Missouri School of Medicine developed the Community Integration Program (CIP). Students, individually or in groups, voluntarily identify a health need and implement a community-based project to meet that need.

RESULTS

From 2007 to 2013, 80 (53%) students participated in the CIP and 86% completed the 11-item post-experience questionnaire. After the experience, participants reported a deeper understanding of the broad impact of a rural physician and the impact of rural culture on physician interactions. Participants reported they felt more integrated into the community, had a greater understanding of community health needs and resources, and were more likely to participate in future community service activities.

CONCLUSIONS

The CIP exposes students to rural culture and helps them understand community health needs. Replication of this program can increase student interest in rural medicine and better prepare students for rural practice.

Analyzing Rural Versus Urban Differences in Career Dissatisfaction and Plans to Leave Among Pennsylvanian Physicians

PURPOSE

This study estimates whether physicians in rural Pennsylvania have higher odds of career dissatisfaction and plans to leave patient care in the next 6 years, compared to their urban counterparts. Rural-urban differences were estimated across specific subgroups of physicians (gender, race, and specialty) and with regard to specific sources of career dissatisfaction.

METHODS

The 2012 Pennsylvania Health Workforce Survey of Physicians allowed for analysis of 17,444 physicians younger than 55 years old actively practicing patient care. Multivariate, logistic regression was performed to estimate the associations with 2 outcome areas: career dissatisfaction and plans to leave patient care in the next 6 years. Controls included rural setting, age, sex, race, work hours, specialty, and practice characteristics.

RESULTS

Over 12% of under-55 physicians are dissatisfied with their careers and over 18% report plans to leave patient care in the next 6 years. Rural physicians in Pennsylvania have 18.6% higher odds of reporting career dissatisfaction and 29.5% higher odds of leaving patient care in the next 6 years (P < .01 for each) versus their urban counterparts.

CONCLUSIONS

Rates of dissatisfaction and potential attrition among younger physicians are not insignificant, with a stronger association with rural practice. Given the large number of rural health shortage areas, better understanding this association is important to health care providers and policy makers. Regression results suggest that higher rural odds are related more to physician work (i.e., stress, practice demands, and lack of autonomy) and family situations and less related to income concerns.

Factors Influencing Neurosurgeons' Decision to Retain in a Work Location: A Qualitative Study

INTRODUCTION

Physician retention is a serious concern to have an effective and efficient health system; the key challenge is how best to encourage and retain health providers in their work location. There have been considerable studies on factors influencing physicians' retention but little research has been conducted in Iran. This study aims to determine the affecting factors from neurosurgeons' viewpoint to support policy makers in proposing a sort of evidence based retention strategies.

METHODS

We conducted semi structured interviews with 17 neurosurgeons working in 9 provinces of Iran between September and November 2014. We included physicians remaining to work in a particular community for at least 3 years and asked them about the factors influenced their decision to retain in a work place. Data were thematically analyzed using "framework approach" for qualitative research.

RESULTS

Satisfaction with monetary incentives, availability of adequate clinical infrastructure in a community and appropriate working condition were most commonly cited factors mentioned by all participants as key reasons for retention. Furthermore elements which contributed to the quality of living condition, personal background and incentives, family convenience were emphasized by majority of them. A small number of participants mentioned opportunity for continuing learning and updating knowledge as well as supportive organizational policies as important motivators in a workplace.

CONCLUSION

Ministry of Health and Medical Education (MOHME) should consider a multifaceted and holistic approach to improve neurosurgeons' retention in their work location. Our findings suggests a combination of financial remuneration, establishment of adequate hospitals and clinical facilities, collaborative working environment with reasonable workload, proper living condition, family support and facilities for professional development to be employed as an effective strategy for promoting physicians' retention.

Factors that influence the turnover intention of Chinese village doctors based on the investigation results of Xiangyang City in Hubei Province

INTRODUCTION

This study analyzes the factors that influence the turnover intention of village doctors by investigating village clinic workers in rural areas, particularly in Xiangyang City, Hubei Province.

METHODS

A total of 1184 village clinics were sampled randomly in Xiangyang City. The research assistants distributed 1930 questionnaires to village doctors. This study had a response rate of 97.88%. A total of 1889 village doctors completed the questionnaires.

RESULTS

The results of the investigation conducted in Xiangyang City indicated that 63.2% of the village doctors did not plan to leave the organization where they were currently employed. However, more than one-third (36.8%) of the village doctors considered leaving their posts voluntarily. Some job satisfaction indexes affect their intention to resign. The results showed that income satisfaction and the way organization policies are put into practice, in addition, my pay and the amount of work I do, the chances for advancement on this job and the work conditions are significant factors that contribute to the turnover intention of village doctors.

CONCLUSIONS

This study may interest heath care management administrator and highlight the influence of job satisfaction on turnover intention of village doctors. Our findings outline some issues that contribute to these problems and suggest an approach for health care policy maker to implement a broader national process and organizational strategies to improve the job satisfaction and stability of the village doctors.

Overcoming the triad of rural health disparities: How local culture, lack of economic opportunity, and geographic location instigate health disparities

OBJECTIVE

To discuss how the effects of culture, economy, and geographical location intersect to form a gestalt triad determining health-related disparities in rural areas.

METHODS

We critically profile each component of the deterministic triad in shaping current health-related disparities in rural areas; evaluate the uniquely composed intersections of these disparities in relation to Human Papillomavirus (HPV)-related cancer prevention in three isolated rural Georgia counties; and develop implications for future leadership in rural healthcare research, policy, and practice.

RESULTS

The deterministic triad of culture, economy, and geographical location is unique to a rural community, and even if two rural communities experience the same health disparity, each community is likely to have a discretely different composition of cultural, economic, and geographic determinants.

CONCLUSION

The deterministic triad presents a challenge for health policymakers, researchers, and practitioners trying to develop health-related interventions that are equitable, efficacious, and practical in low-resource rural communities. The situation is worsened by the limited opportunities for employment, which leads to greater disparities and creates propagating cultural norms that further reduce access to healthcare and opportunities for sustainable health promotion.

How best to measure health workforce turnover and retention: five key metrics

OBJECTIVE

This article identifies, critically appraises and illustrates the use of five key workforce turnover and retention metrics that are well suited for use by Australian rural health workforce planners. These are crude turnover (separation) rates, stability rates, survival probabilities, median survival and Cox proportional hazard ratios. Examples of their calculation are presented using actual data obtained from payroll records in Australian rural and remote health services.

CONCLUSION

The use of this small number of metrics as a 'workforce measurement package' can help overcome many of the limitations evident when a single measure is reported in isolation, by providing a more comprehensive picture of turnover and retention patterns. We suggest that health services themselves can calculate the simplest measures, whereas regional and centralised health authorities with higher levels of expertise undertake survival analysis and comparisons of compiled data.

IMPLICATIONS

These key metrics can be used routinely to measure baseline levels of health worker turnover and retention, to quantify important determinants of turnover and retention, and importantly, to make valid comparisons. This enables areas for improvement to be better targeted using appropriate retention strategies, and changes resulting from retention interventions to be evaluated effectively.

Entrepreneurial Environment and the Prevalence of Diabetes in U.S. Counities

Objective. To examine whether the presence of an entrepreneurial culture in a community is associated with county-level diabetes prevalence in the U.S. after accounting for high level of spatial clustering of prevalence rates observed in prior research. Methods. We perform a county-level spatial regression analysis of CDC diabetes prevalence rates. We measure entrepreneurial culture as the number of businesses with 0 to 4 employees per 1,000 residents. Results. The level of entrepreneurial culture in a community is associated with lower rates of diabetes. Our findings show that the key measure of entrepreneurial culture has expected effects on county diabetes rates. However, we show that failure to control for spatial error dependence in previous research leads to an overestimation of the effects of entrepreneurial culture on diabetes prevalence. Conclusion. Policies aimed at curbing diabetes prevalence should utilize the business community as a key agent of social change. Researchers should also utilize spatial regression techniques when analyzing county-level diabetes prevalence rates, because of high level of spatial clustering of rates.

A qualitative study of factors influencing different generations of Newfoundland and Saskatchewan trained physicians to leave a work location

BACKGROUND

Some studies have suggested that young physicians may have different expectations and practice behaviours than their older generational counterparts, including their reasons for wanting to remain or leave a community. This study examined the factors associated with a physician's decision to leave a work location. We compared different generations of physicians to assess whether these factors have changed over generations.

METHODS

We conducted semi-structured, qualitative interviews with 48 physicians who graduated from two Canadian medical schools. We asked each physician about the number and nature of work location changes and the factors related to their decisions to leave each location. Interview transcripts and notes were analysed using a thematic analysis approach.

RESULTS

Dissatisfaction with the working environment was the most frequently cited reason for leaving a location for physicians of all generations. Elements which contributed to the quality of the work environment included the collaborative nature of the practice, the relationship with administrators, and access to resources and personnel. For younger physicians, the work environment had to meet their personal expectations for work-life balance. While remuneration level was given by some physicians as the key reason for leaving a location, for others it was the "last straw" if the work environment was poor. A small number of older generation physicians moved in response to political events and/or policies

CONCLUSIONS

We documented generational differences in physicians' reasons for choosing a work location. We found that a poor work environment was universally the most important reason why a physician chose to leave a location. A few physicians who were unsatisfied with their work location identified level of remuneration as an additional reason for leaving. Some older generation physicians cited political climate as a reason for leaving a work location. While economic factors have largely been the focus of recruitment and retention initiatives, our findings highlight the importance of the work environment and organizational culture on the retention of physicians of all generations.

Quand la famille pèse dans la balance…lors de la décision d’aller vivre en milieu rural ou de le quitter

Le vieillissement et la faible croissance démographique dans plusieurs territoires québécois, notamment ruraux, posent un défi de taille à l’État, aux municipalités et aux divers acteurs locaux. Comment attirer et retenir de nouvelles populations, notamment des familles, dans ces milieux moins densément peuplés que les villes et moins pourvus en services? À partir d’une synthèse de mes recherches portant sur le processus d’insertion de diverses populations dans l’espace rural québécois (agriculteurs immigrants, travailleurs agricoles saisonniers, jeunes régionaux d’origine immigrée, médecins omnipraticiens, néo-ruraux), cet article mettra en évidence l’interaction de plusieurs facteurs susceptibles d’influencer la décision d’aller vivre dans ce type de milieu ou de le quitter. Alors que la littérature insiste plus volontiers sur  les facteurs professionnels, financiers ou personnels, je m’attarderai sur les facteurs moins visibles, à savoir les facteurs familiaux liés aux conjoint(e)s et aux enfants ainsi que les facteurs sociocommunautaires et culturels et ceux concernant l’environnement naturel. Pour terminer, quelques pistes de réflexions et d’actions pouvant encourager l’attraction et la rétention de familles dans les territoires ruraux seront proposées.

Segmenting a general practitioner market to improve recruitment outcomes

Recruitment is an ongoing challenge in the health industry with general practitioner (GP) shortages in many areas beyond rural and Indigenous communities. This paper suggests a marketing solution that identifies different segments of the GP market for recruitment strategy development. In February 2008, 96 GPs in Australia responded to a mail questionnaire (of which 85 questionnaires were useable). A total of 350 GPs were sent the questionnaire. Respondents considered small sets of attributes in the decision to accept a new job at a general practice and selected the most and least important attribute from each set. We identified latent class clusters (cohorts) of GPs from the most-least important data. Three cohorts were found in the GP market, distinguishing practitioners who emphasised job, family or practice attributes in their decision to join a practice. Few significant demographic differences exist between the cohorts. A segmented GP market suggests two alternative recruitment strategies. One option is for general practices to target members of a single cohort (family-, job-, or practice-focussed GPs). The other option is for general practices to diversify their recruitment strategies to target all three cohorts (family-, job- and practice-focussed GPs). A single brand (practice) can have multiple advertising strategies with each strategy involving advertising activities targeting a particular consumer segment.

Health promoting schools provide community-based learning opportunities conducive to careers in rural practice

The World Health Organization conceived "health-promoting schools" as a means of providing the information and support systems necessary for the worldwide changes in behavior that are needed to improve health globally and decrease health care costs. We developed and evaluated a model of progressively implementing health-promoting schools with support from university medical school trainees in Canada and Uganda. The model uses oral health as a medium for establishing rapport and success around a topic with little stigma. The evaluation involved questionnaires of the Canadian trainees about practice intentions before and after involvement in the health-promoting schools to determine whether community-based learning in health-promoting schools resulted in more trainees planning to work in rural areas or underserved countries. We found that Canadian medical trainees cited their personal involvement and perceived ability to effect significant and identifiable positive change in both the school children and the community as reasons why they were more willing to practice in rural or under-served areas.

Physician retention in rural Alberta: key community factors

OBJECTIVES

As part of a larger case study exploring physician retention factors and strategies employed by rural communities, the objective of this analysis was to explore the community factors that promoted physician retention.

METHODS

A qualitative, collective case study design was employed to study four rural communities (cases) in Alberta that retained family physicians for four years or longer. Participants included physicians, staff members, spouses and community members (all were patients from the communities studied). Communities were selected through a retention-specific matrix; each quadrant represented a particular community typology. Case data collected from interviews, documents and observations were analyzed, and similarities and differences among cases were assessed.

RESULTS

A range of community factors that could influence physicians' decisions to stay in a particular community were described by participants. Four themes, Appreciation, Connection, Active Support and Physical/Recreational Assets, were positively related to physician retention in the four communities studied. These community factors existed to different degrees but were present in all communities. Reciprocity was a fifth factor that emerged in three of the four communities studied.

CONCLUSION

Physicians, policy-makers, community members and health care professionals are encouraged to consider the community domain when planning and implementing strategies to retain rural physicians and other health care professionals. The four communities studied were able to promote retention of their primary care physicians by showing appreciation to them, building connections with them and their families, actively supporting their physicians and local health facilities, maintaining and improving local physical/recreational amenities, and nurturing reciprocal rapport with physicians.

Rural health career pathways: research themes in recruitment and retention

OBJECTIVE

This paper describes stages in the research literature related to recruitment and retention of health professionals to rural health careers.

DATA SOURCES

Electronic databases accessed included Medline, CINAHL, Social Sciences and Humanities. Key search terms included 'high school', 'career choices', 'rural', 'attachment', 'recruitment' and 'retention'.

DATA SYNTHESIS

We identified four stages: (1) making career choices; (2) being attached to place; (3) taking up rural practice; and (4) remaining in rural practice. This is termed the 'rural pipeline'. However, as some stages of the 'rural pipeline' refer specifically to the medical profession, we propose an extension of the notion of the medical 'rural pipeline' to include other professions such as nursing, midwifery and allied health. CONCLUSIONS. Utilising the 'rural pipeline' as a template for medicine, nursing and allied health would strengthen current approaches to the recruitment and retention of professionals in rural areas and provide a consolidated evidence base that would assist in policy development to improve availability and service provision of the rural health workforce. Future research that utilises a multidisciplinary approach could explore how the role and relationship between place and identity shape needs of career choices and would provide important information to advance the practical aspects supporting rural health career pathways.

Systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy

BACKGROUND

Poor retention of health workers is a significant problem in rural and remote areas, with negative consequences for both health services and patient care.

OBJECTIVE

This review aimed to synthesise the available evidence regarding the effectiveness of retention strategies for health workers in rural and remote areas, with a focus on those studies relevant to Australia.

DESIGN

A systematic review method was adopted. Six program evaluation articles, eight review articles and one grey literature report were identified that met study inclusion/exclusion criteria.

RESULTS

While a wide range of retention strategies have been introduced in various settings to reduce unnecessary staff turnover and increase length of stay, few have been rigorously evaluated. Little evidence demonstrating the effectiveness of any specific strategy is currently available, with the possible exception of health worker obligation. Multiple factors influence length of employment, indicating that a flexible, multifaceted response to improving workforce retention is required.

CONCLUSIONS

This paper proposes a comprehensive rural and remote health workforce retention framework to address factors known to contribute to avoidable turnover. The six components of the framework relate to staffing, infrastructure, remuneration, workplace organisation, professional environment, and social, family and community support. In order to ensure their effectiveness, retention strategies should be rigorously evaluated using appropriate pre- and post-intervention comparisons.

A qualitative study of naturopathy in rural practice: a focus upon naturopaths' experiences and perceptions of rural patients and demands for their services

BACKGROUND

Complementary and alternative medicine (CAM) use--of which naturopathy constitutes a significant proportion--accounts for approximately half of all health consultations and half of out-of-pocket expenditure in Australia. Data also suggest CAM use is highest amongst rural Australians. Unfortunately little is known about the grass-roots reality of naturopathy or other CAM use in rural regions.

METHODS

Semi-structured interviews were conducted with 20 naturopaths practising in the Darling Downs region of South-East Queensland to assess their perceptions and experiences of rural patients and demand for their services.

RESULTS

Naturopaths described strong demand in rural areas for their services and perceived much of this demand as attributable to cultural traits in rural communities that served as pull factors for their naturopathic services. Such perceived traits included a cultural affinity for holistic approaches to health and disease and the preventive philosophy of naturopathy and an appreciation of the core tenet of naturopathic practice to develop closer therapeutic relationships. However, cost and a rural culture of self-reliance were seen as major barriers to naturopathic practice in rural areas.

CONCLUSIONS

Demand for naturopathic services in rural areas may have strong underlying cultural and social drivers. Given the apparent affinity for and increasingly large role played by CAM services, including naturopathic medicine, in rural areas it is imperative that naturopathic medicine and the CAM sector more broadly become a core focus of rural health research.

Retention of J-1 visa waiver program physicians in Washington State's health professional shortage areas

PURPOSE

To determine whether the Conrad Program, which allows states to recruit 30 foreign-trained physicians per year to work in underserved settings, is meeting its goal of increasing the number of physicians in Washington State's underserved areas. Participating physicians have completed their residency training in, and want to continue residing in, the United States.

METHOD

The authors identified all J-1 visa waiver physicians assigned to employers in Washington between 1995 and 2003, tracked them (whenever possible) through public databases to their current locations, and surveyed them about their experiences in, and subsequent to, the program.

RESULTS

The authors tracked 141 of 155 physicians (91%). Of those 141, 77 (55%) responded to the survey. These respondents reported that they remained with their J-1 waiver employers a median of 23 (range: 0-120) months longer than their required commitment periods and that they remained in practices serving primarily underserved populations for, on average, 34 (0-120) consecutive months after fulfilling their commitments. After leaving J-1 waiver employers, 35 of 47 physicians (74%) who served in rural areas moved toward more urban areas, and 57% (80/141) still live in the state. Whereas most expressed satisfaction with the program, 29/77 (38%) felt employers should have shown them more respect.

CONCLUSIONS

In Washington State, the Conrad Program has increased the number of physicians in underserved areas who frequently stay beyond their obligations. The significant movement away from rural areas for postobligation employment, however, highlights the long-term need to continue state efforts to recruit physicians to these areas.

Why doctors choose small towns: a developmental model of rural physician recruitment and retention

Shortages of health care professionals have plagued rural areas of the USA for more than a century. Programs to alleviate them have met with limited success. These programs generally focus on factors that affect recruitment and retention, with the supposition that poor recruitment drives most shortages. The strongest known influence on rural physician recruitment is a "rural upbringing," but little is known about how this childhood experience promotes a return to rural areas, or how non-rural physicians choose rural practice without such an upbringing. Less is known about how rural upbringing affects retention. Through twenty-two in-depth, semi-structured interviews with both rural- and urban-raised physicians in northeastern California and northwestern Nevada, this study investigates practice location choice over the life course, describing a progression of events and experiences important to rural practice choice and retention in both groups. Study results suggest that rural exposure via education, recreation, or upbringing facilitates future rural practice through four major pathways. Desires for familiarity, sense of place, community involvement, and self-actualization were the major motivations for initial and continuing small-town residence choice. A history of strong community or geographic ties, either urban or rural, also encouraged initial rural practice. Finally, prior resilience under adverse circumstances was predictive of continued retention in the face of adversity. Physicians' decisions to stay or leave exhibited a cost-benefit pattern once their basic needs were met. These results support a focus on recruitment of both rural-raised and community-oriented applicants to medical school, residency, and rural practice. Local mentorship and "place-specific education" can support the integration of new rural physicians by promoting self-actualization, community integration, sense of place, and resilience. Health policy efforts to improve the physician workforce must address these complexities in order to support the variety of physicians who choose and remain in rural practice.

Recruitment and retention of rural physicians: outcomes from the rural physician associate program of Minnesota

CONTEXT

Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed.

PURPOSE

To examine RPAP outcomes in recruiting and retaining rural primary care physicians.

METHODS

The RPAP database, including moves and current practice settings, was examined using descriptive statistics.

FINDINGS

On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice.

CONCLUSION

RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting.

Rural health leaders pipeline, 1990-2005: case study of a second-generation rural medical education program

A pipeline model has been suggested to increase the rural physician supply. This study is an institutional case report used to describe the context, development, and in-house evaluation of the University of Alabama Rural Health Leaders Pipeline, 1990-2005. This program was developed at a University of Alabama School of Medicine branch campus to target rural students at multiple levels, elementary schools through residency, and includes a minority focus. Requirements to enter the medical program include living 8 years in rural Alabama, meeting admission requirements, and affinity for rural lifestyles. Twenty-six percent of 316 high school participants, all 40 students in the minority-focused college program, and 3% of 90 medical program students were African American. The program includes (1) puppet shows in elementary schools depicting different health professions, (2) Rural Health Scholars Program for 11th-grade students, (3) Minority Rural Health Pipeline Program for college students, (4) Rural Medical Scholars Program, a 5-year track of study in rural community health and medicine, and (5) assured admission to family medicine residency. Outcomes studied in this case report included medical school performance, graduation rate, selection of family medicine specialty, and rural practice location. Medical scholars were anticipated to experience academic difficulty, select family medicine specialty, and locate in rural practice more often than peers. Compared to peers, medical scholars showed lower scores on preclinical courses and USMLE steps 1 and 2, reflective of their lower MCAT and GPA scores, but had (1) similar graduation rates (95% vs peers 84%), (2) higher family medicine selection rate (47% vs Huntsville 27% vs Tuscaloosa 12% vs Birmingham 4% [OR compared to Birmingham 22.7, 95% CI 10.5-49.4]), and (3) higher rural practice rate (67% vs peers 14% vs national group 9%) in the first RMSP classes. Based on these important outcomes being better than or equal to the traditional student cohorts, the institution concluded that the Rural Health Leaders Pipeline demonstrates successful use of the rural pipeline model.

Urban-rural flows of physicians

CONTEXT

Physician supply is anticipated to fall short of national requirements over the next 20 years. Rural areas are likely to lose relatively more physicians. Policy makers must know how to anticipate what changes in distribution are likely to happen to better target policies.

PURPOSE

To determine whether there was a significant flow of physicians from urban to rural areas in recent years when the overall supply of physicians has been considered in balance with needs.

METHODS

Individual records from merged AMA Physician Masterfiles for 1981, 1986, 1991, 1996, 2001, and 2003 were used to track movements from urban to rural and rural to urban counties. Individual physician locations were tracked over 5-year intervals during the period 1981 to 2001, with an additional assessment for movements in 2001-2003.

FINDINGS

Approximately 25% of physicians moved across county boundaries in any given 5-year period but the relative distribution of urban-rural supply remained relatively stable. One third of all physicians remained in the same urban or rural practice location for most of their professional careers. There was a small net movement of physicians from urban to rural areas from 1981 to 2003.

CONCLUSIONS

The data show a net flow from urban to rural places, suggesting a geographic diffusion of physicians in response to economic forces. However, the small gain in rural areas may also be explained by programs that are intended to counter normal market pressures for urban concentrations of professionals. It is likely that in the face of an overall shortage, rural areas will lose physician supply relative to population.

Career intentions of U.S. medical graduates and international medical graduates

OBJECTIVE

This study reports on career intentions of U.S medical graduate (USMG) and international medical graduate (IMG) residents who completed residency training from 2000 to 2003 in California.

METHODS

A retrospective study of 3178 responses to the Survey of Residents Completing Training in California.

RESULTS

USMGs were 86% and 14% were IMGs. IMG holders of temporary visas had the highest obligation to serve in health professional shortage areas (HPSA) and were also the most likely to serve in HPSAs (p = 0.012). Underserved residency program location (OR = 2.7, p = 0.000), HPSA obligation (OR = 5.93, p = 0.001) and postresidency training (OR = 0.561, p = 0.048) were independently predictive of practice in underserved location, HPSA or public hospital. In addition, underrepresented minorities, primary care specialty and income were independently predictive of HPSA practice.

CONCLUSION

In California, HPSA obligation, residency training programs characteristics and underrepresented minorities are important predictors of residents choosing to work in underserved areas.

Primary and community care workforce planning and development

AIM

This article reports a study that provided primary and community care managers with information, allowing them to: (a) evaluate the size and mix of their workforce; and (b) develop knowledgeable and skilled teams to meet the demands of growing and changing services.

BACKGROUND

Primary and community care services are growing in the United Kingdom, but workforce planning and development, despite their wide-ranging cost and quality implications, have not received the same attention. Indeed, most primary and community care workforce planning and development issues are universal. Demand 1-1 side workforce planning is concerned not only with the number, but also with staff mix; but how these autonomous and isolated practitioners spend their time is unique. The other side of the equation, workforce supply, raises many recruitment and retention challenges for managers in many countries. Any country's main workforce planning methods apply equally well to primary care, but each is flawed. A second, main problem is that the methods lead to fragmented services, whereas modern workforce planning methods should be multidisciplinary. Consequently, it has never been more important for managers to have data and algorithms to develop appropriate care teams.

METHOD

A large and versatile workforce database, profiling 304 English primary care trusts using demographic, socio-economic, mortality, morbidity, staffing and performance workforce-related variables, compiled in 2002 and updated yearly, is described. Data were supplemented with a systematic literature review leading to a 340-item annotated bibliography; and qualitative interviews with managers.

RESULTS

Workforce size and mix are historical and irrational at best. Moreover, the number of variables that influence staffing is growing, thereby complicating workforce planning.

CONCLUSION

Evaluating and adjusting the size and mix of teams using empirically determined community demand and performance variables based on the area's socio-economic characteristics is feasible.

Rural residents with disabilities confront substantial barriers to obtaining primary care

OBJECTIVE

To learn about the health care experiences of rural residents with disabilities.

STUDY SETTING

Rural areas in Massachusetts and Virginia.

STUDY DESIGN

Local centers for independent living recruited 35 adults with sensory, physical, or psychiatric disabilities to participate in four focus group interviews.

DATA COLLECTION METHODS

Verbatim transcripts of interviews were reviewed to identify major themes.

PRINCIPAL FINDINGS

Interviewees described the many well-recognized impediments to health care in rural America; disability appears to exacerbate these barriers. Interviewees reported substantial difficulties finding physicians who understand their disabilities and sometimes feel that they must teach their local doctors about their underlying conditions. Interviewees described needing to travel periodically to large medical centers to get necessary specialty care. Many are poor and are either uninsured or have Medicaid coverage, complicating their searches for willing primary care physicians. Because many cannot drive, they face great difficulties getting to their local doctor and especially making long trips to urban centers. Available public transportation often is inaccessible and unreliable. Physicians' offices are sometimes located in old buildings that do not have accessible entrances or equipment. Based on their personal experiences, interviewees perceive that rural areas are generally less sensitive to disability access issues than urban areas.

CONCLUSIONS

Meeting the health care needs of rural residents with disabilities will require interventions beyond health care, involving transportation and access issues more broadly.