Predicting Rural Practice and Service to Indigent Patients: Survey of Dental Students Before and After Rural Community Rotations

Community-based clinical rotations in rural areas expose dental students to diverse patient populations, practice models, and career opportunities as well as rural culture. The aims of this study at West Virginia University were to determine the best predictors of rural practice, assess the predictive validity of students' intention to practice in a rural area before and after their rural rotations, and evaluate the relationship between students' intention to practice in a rural area and intention to provide care for indigent patients. Online survey data were submitted pre- and post-rural clinical rotation by 432 of 489 dental students over the study period 2001-12, yielding an 88% response rate. In 2013, practice addresses from the West Virginia Board of Dentistry were added to the student database. The results showed that significant predictors of rural practice site were intended rural practice choice, rural hometown, and projected greater practice accessibility for indigent patients. The likelihood of students' predicting they would choose a rural practice increased after completion of their rural rotations. After the rotations, students predicted providing greater accessibility to indigent patients; these changes occurred for those who changed their predictions to rural practice choice after the rotations and those who subsequently entered rural practice. The dental students with a rural background or a greater service orientation were also more likely to expect to enter a rural practice and actually to do so after graduation. These findings suggest that dental school curricula that include rural rotations may increase students' sensitivity to issues of indigent patients and increase students' likelihood of rural practice choice.

Validity of Medical Student Questionnaire Data in Prediction of Rural Practice Choice and Its Association With Service Orientation

PURPOSE

The validity of medical student projection of, and predictors for, rural practice and the association of a measure of service orientation, projected practice accessibility to the indigent, were investigated.

METHODS

West Virginia (WV) medical student online pre- and postrural rotation questionnaire data were collected during the time period 2001-2009. Of the 1,517 respondent students, submissions by 1,271 met the time interval criterion for inclusion in analyses. Subsequent WV licensing data were available for 461 in 2013. These 2 databases were used to assess for validity of projection of rural practice, for predictors of rural practice, and for student projected accessibility of the future practice to indigent patients.

FINDINGS

There were statistically significant associations between both pre- and postrotation projections of rural practice and subsequent rural practice. The most significant independent predictors of rural practice were student rural background, reported primary care intent, prediction of rural practice and projection of greater accessibility of the future practice to indigent patients. For scoring of practice access, there were trends for higher scoring by rural students and rural practitioners, with greater pre-post increases for those with urban hometowns.

CONCLUSIONS

This study demonstrates the utility of medical student questionnaires for projections of numbers of future rural physicians. It suggests that students with a rural background, rural practice intent, or greater service orientation are more likely to enter rural practice. It also suggests that students, particularly those with urban hometowns, are influenced by rural rotation experiences in forecasting greater practice accessibility and in entering rural practice.

The Influence of Payer Mix and Visit Volume on NRMP Match Rates for Community-based Family Medicine Residency Programs

BACKGROUND

With declining U.S. medical student interest in family medicine, it is important to study factors that may predict for individual residency program fill rates. Predictors of family medicine residency program match rates are few, with location by region of the country being the best predictor. Using a limited database, this study evaluated whether community-based residency program match rates are associated with patient visit volume and payer status.

METHODS

An existing database of characteristics of 42 community-based family medicine residency programs was analyzed for associations of match rate with patient visit volume and with insurance payer status.

RESULTS

Nonsignificant correlations were calculated for match rate with the following factors: patient visit volume per provider, percentage of patient visits with no insurance or with Medicaid payment, percentage of visits with Medicare payment, and percentage of visits with private third party payers. A marginal negative association of match rate with percentage of patient visits with Medicare payment was not significant when adjusted for region of the country.

CONCLUSIONS

In this study, neither patient visit volume nor payer status were predictive of match rate for community-based family medicine residency programs. Limitations to this study are acknowledged.

A gender-based study of attitudes and practice characteristics of rural physicians in West Virginia

Physician gender can affect the numbers of future rural health care providers since female physicians are less likely to enter rural practice, but the proportion of female U.S. medical students is increasing. This survey study of rural West Virginia physicians who were trained in the U.S. obtained information on demographics and prior practice intent, working time, practice characteristics, and satisfaction with practice and community for female vs. male physicians. Female physicians were more likely to report pre-existing intent to work in underserved areas and having higher proportions of Medicaid and uninsured patients, but fewer work hours and on-call services and less likelihood of providing hospital services. Initiatives to help address the shortage of rural providers could include residency program and community initiatives to address work flexibility and personal and spouse concerns for female physicians.

Evaluation of a required statewide interdisciplinary Rural Health Education Program: student attitudes, career intents and perceived quality

INTRODUCTION

A shortage of healthcare providers in West Virginia led to creation of a statewide, community-based program with a required three-month rural experience for most state-sponsored health professions students. Project Description: Initiated using funding from the W. K. Kellogg Foundation and expanded using both state funds and Area Health Education Center support, the West Virginia Rural Health Education Partnerships (WVRHEP) program impacts institutions of higher learning, 50 counties, and 332 training sites, and all students in state-funded health professions schools. A longitudinal database has been constructed to study program effects on students' reported attitudes, service orientation, and career intents.

METHODS

Baseline data are collected from medical students, and students in all disciplines provide feedback on rotations and information about career intents, social responsibility, and attitudes towards rural practice.

RESULTS

Data indicate an association between perceived quality of the rural experience and increased interest in rural health, social responsibility and confidence in becoming part of the community. Medical students may tend to rate social responsibility higher after completion of the first rural rotation. Students who anticipate practice in smaller towns also tend to rate the quality of the rotation higher, to anticipate careers in primary care, and to acknowledge social responsibility.

CONCLUSION

As WVRHEP program graduates who have completed these surveys enter practice, both personal and community-specific program characteristics may be identified which strengthen interest in rural practice. The predictive validity of intermediate outcomes of attitudes and career intents in forecasting the ultimate outcomes of recruitment and retention may be studied.

Techniques for reducing anesthetic injection pain

BACKGROUND

The authors conducted a study that considered family physicians' and dentists' knowledge and application of techniques to reduce the pain associated with anesthetic injections. They also assessed practitioners' discomfort with patients' injection pain and needle anxiety/phobia.

METHODS

The authors designed a questionnaire about awareness and use of 10 techniques for reducing pain of anesthetic injection and mailed it to 2,000 randomly selected family physicians and general dentists. They analyzed the data to examine differences between disciplines regarding awareness and use of techniques, reasons for not using techniques, number of injections given per week, and predictive value of certain demographic variables on reported use of individual techniques and on practitioner reactions to patients' pain and anxiety.

RESULTS

The response rate was 35 percent. The authors used the chi2 test for differences between disciplines' awareness of and use or nonuse of techniques, Wilcoxon testing to assess differences between disciplines' median values of number of weekly injections and logistic regression to study demographic variables' predictive values (P = .01). General dentists give more injections than do family physicians. Differences existed between disciplines' awareness and use of eight of 10 techniques. Disciplines reported cost and time issues as reasons for not using some techniques. Number of years in practice and age were associated with use of six techniques. Dentists reported feeling greater personal effects of patients' pain and needle anxiety/phobia than did family physicians.

CONCLUSIONS

Those not using pain-lessening techniques inaccurately identified time and cost as problems, suggesting that respondents may be less familiar with these techniques than otherwise reported. Further study is recommended.

CLINICAL IMPLICATIONS

Pain reduction techniques for anesthetic injection cost little to implement, are not time liabilities, and can lessen avoidable pain and reduce the incidence of needle phobia.

A comparative assessment of West Virginia's financial incentive programs for rural physicians

CONTEXT

Financial incentive programs are increasingly being used as a strategy to recruit physicians to underserved rural areas. Critical evaluation of state-supported programs is often lacking but is necessary to determine their efficacy and to improve outcomes.

PURPOSE

The purpose of this study was to assess 4 service-contingent programs in West Virginia, a state with critical physician shortages.

METHODS

Survey instruments were developed to evaluate the effectiveness of these programs and to document the practice environments and career paths of obligated allopathic and osteopathic physicians compared with a control group of nonobligated rural practitioners. Data were also collected from physicians who were recipients of multiple incentive programs and from obligated physicians who had defaulted.

FINDINGS

Responses from more than 60% of surveyed physicians indicated that the typical respondent was a married white male who was a midcareer family practice physician. Obligated physicians were more likely than nonobligated physicians to have graduated from a West Virginia medical school and residency program, to be influenced by financial factors in their career decisions, to provide care to uninsured patients, and to work in offices that offered sliding fee scales. Both groups of physicians demonstrated similar retention patterns, reported a high degree of job satisfaction, and expressed a need for more practice management training.

CONCLUSIONS

Although these financial incentive programs were found to be effective in recruiting primary care physicians to medically underserved areas of the state, the financial support of these programs was found to be too modest, and improved marketing of the programs was indicated.

A community development approach to rural recruitment

Programs designed to empower rural communities for health care provider recruitment have usually focused on the health care sector without aggressively addressing broader community development issues. The Recruitable Community Project (RCP) in West Virginia includes community education on recruiting and also assessments of and recommendations to rural communities on broad-based community development, aiming to enhance communities' recruiting potential. The project provides multidisciplinary university-based planning assistance programs for small communities, involving collaborative community visits. The project also uses a project manager as a "community encourager" who participates in community education and in the formulation of sustained community recruiting efforts. From August 1999 through August 2001, 7 underserved rural communities completed the RCP organizational processes and hosted planning assistance teams. Members of community recruitment boards gave high marks to the RCP process, its planning assistance teams, and its usefulness in establishing community ties to state and academic agencies. Since working with the RCP, the 7 communities have recruited 27 providers, success possibly stimulated by their RCP involvement (data current as of September 2002). This model of community training and development to empower rural communities to better recruit health professionals shows early promise. This model could be broadened to include more collaboration of community development and health science disciplines programs for recruitment and retention efforts.

A study of the future practice location intent of family medicine residents in West Virginia

Recruitment of graduating family medicine residents into practice in rural West Virginia has been hampered by many factors. A cross-sectional survey was done to obtain the opinions of family medicine residents in West Virginia in 1996 in order to characterize their perceptions regarding certain aspects of their rural training and the relative importance of various factors influencing their future practice location intent. There was a positive association between cumulative resident experience and intent to practice in West Virginia and in rural areas. Perceived preparation for rural practice varied with educational area. There was significant variation in the relative importance of recruiting factors for likelihood of practice in West Virginia and in rural areas. Some recruiting factors tended to be positive or negative discriminators for intent to practice in West Virginia and in rural areas. Enhanced recruitment may be aided by an active community involvement which addresses the identified relevant factors.