High-dose tramadol conversion to buprenorphine-naloxone.

Buprenorphine-naloxone is a combination medication of an opioid partial agonist and opioid antagonist that is proven to be effective in outpatient management of opioid use disorder (OUD). Tramadol is a centrally acting analgesic. This commonly used pain medication inhibits serotonin and noradrenaline reuptake by acting as a selective agonist on opioid µ receptors. Transition and tapering high-dose tramadol to buprenorphine-naloxone is not well described in the literature. We report a case of a patient who was taking 1,000-1,250 mg of tramadol daily upon presentation to the clinic. She was originally prescribed 150 mg daily with escalation in dose and frequency over a 10-year period. The patient was converted to bupren-orphine-naloxone and has been successful in treatment of OUD for 1 year.

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.

Family medicine graduate proximity to their site of training: policy options for improving the distribution of primary care access.

BACKGROUND AND OBJECTIVES: The US Graduate Medical Education (GME) system is failing to produce primary care physicians in sufficient quantity or in locations where they are most needed. Decentralization of GME training has been suggested by several federal advisory boards as a means of reversing primary care maldistribution, but supporting evidence is in need of updating. We assessed the geographic relationship between family medicine GME training sites and graduate practice location. METHODS: Using the 2012 American Medical Association Masterfile and American Academy of Family Physicians membership file, we obtained the percentage of family physicians in direct patient care located within 5, 25, 75, and 100 miles and within the state of their family medicine residency program (FMRP). We also analyzed the effect of time on family physician distance from training site. RESULTS: More than half of family physicians practice within 100 miles of their FMRP (55%) and within the same state (57%). State retention varies from 15% to 75%; the District of Columbia only retains 15% of family physician graduates, while Texas and California retain 75%. A higher percentage of recent graduates stay within 100 miles of their FMRP (63%), but this relationship degrades over time to about 51%. CONCLUSIONS: The majority of practicing family physicians remained proximal to their GME training site and within state. This suggests that decentralized training may be a part of the solution to uneven distribution among primary care physicians. State and federal policy-makers should prioritize funding training in or near areas with poor access to primary care services.