Impact of educational policies on access to health care in Brazil: A cross-sectional study.

INTRODUCTION: Various initiatives to improve access to health care have been implemented internationally. In Brazil, this has included policies intended to expand access to higher education for underrepresented socio-economic groups. These measures have reduced inequalities in access to medical education, but it is not known whether they influence career choices. We examine the effect of these educational policies on physician practice patterns in primary care and/or in medically underserved areas. METHODS: This is a cross-sectional study that analysed the association between affirmative educational policies and the career choices of physicians who graduated between 2010 and 2015. Multivariate binary regression analysis was used to evaluate the impact of affirmative educational policies on physician career choices, including primary care practice, practice in cities with ≤20 000 inhabitants, and practice in less developed municipalities 4 years after graduation. RESULTS: We identified the practice patterns of 65 304 (82.8%) physicians 4 years after their graduation. Most physicians included in our analysis were female (54.5%), aged ≤27 years (72.4%), born in developed cities and studied in private medical schools. Physicians admitted to medical school based on racial or social access policies were more likely to practice in municipalities with fewer than 20 000 inhabitants (odds ratio [OR]: 1.64; 1.36-1.98) and in primary care (OR: 1.55; 1.35-1.53). Physicians who benefited from scholarships for under-represented socio-economic groups were more likely to practice in small cities (OR: 1.24; 1.07-1.43) and primary care (OR: 1.23; 1.11-1.37). The provision of financial aid also improved the likelihood of practice in primary care and underserved areas. Graduation from medical schools located in smaller cities was associated with practice in municipalities ≤20 000 inhabitants and primary care. CONCLUSIONS: Our results demonstrated that educational policies implemented in the Brazilian context are effective in reducing inequities in physician distribution and led to an increase in the number of physicians practicing in primary care.

International Medical Graduate Resident Wellness: Examining Qualitative Data From J-1 Visa Physician Recipients.

PURPOSE: International medical graduates (IMGs), approximately 25% of the U.S. physician workforce, have unique needs as they enter residency programs. This study identified wellness barriers and challenges that IMGs encounter as they transition to the United States. METHOD: The authors analyzed results from 3 open-ended questions in a 21-item survey. This survey was administered in December 2019 to 11,504 IMG resident physicians sponsored by the Educational Commission for Foreign Medical Graduates' J-1 visa program. These questions asked respondents to describe challenges to their wellness, how they maintain wellness, and resources that would have aided their transition. Data were analyzed using a mixed-methods approach, including both qualitative descriptions and category frequencies. RESULTS: Of the surveys administered, 7,817 responses (68% response rate) were received. Respondents identified challenges navigating cultural differences (1,314, 17%), health care system (1,108, 14%), distance from family and friends (890, 11%), bureaucratic barriers (724, 9%), and language/communication and finances (575, 7%; 565, 7%, respectively). They also specified that friendships/relationships (2,800, 36%) followed by exercise (2,318, 30%), family (1,822, 23%), socialization (1,001, 13%), and healthy eating (775, 10%) were factors important to their wellness. Respondents requested more information about socialization (741, 9%), bureaucratic support (456, 6%), IMG support networks (427, 5%), financial support (404, 5%), and greater online resources (240, 3%). CONCLUSIONS: IMGs have needs and concerns specific to their demographic group. Participants' responses suggested that they wanted additional support in the workplace and their personal lives. Answers also indicated that IMGs experienced a unique set of stressors such as fluctuating immigration laws that U.S. medical graduates do not face. Finally, this study supports a body of research that connects social and physical wellness. By identifying and describing these challenges, the authors seek to inform the development of specific programs and resources to improve IMG resident wellness.

Global accreditation practices for accelerated medically trained clinicians: a view of five countries.

BACKGROUND: Shortages and maldistribution of healthcare workers persist despite efforts to increase the number of practitioners. Evidence to support policy planning and decisions is essential. The World Health Organization has proposed National Health Workforce Accounts (NHWA) to facilitate human resource information systems for effective health workforce planning and monitoring. In this study, we report on the accreditation practices for accelerated medically trained clinicians in five countries: Ethiopia, Ghana, Kenya, Malaysia, and Mongolia. METHOD: Using open-ended survey responses and document review, information about accreditation practices was classified using NHWA indicators. We examined practices using this framework and further examined the extent to which the indicators were appropriate for this cadre of healthcare providers. We developed a data extraction tool and noted any indicators that were difficult to interpret in the local context. RESULTS: Accreditation practices in the five countries are generally aligned with the WHO indicators with some exceptions. All countries had standards for pre-service and in-service training. It was difficult to determine the extent to which social accountability and social determinants of health were explicitly part of accreditation practices as this cadre of practitioners evolved out of community health needs. Other areas of discrepancy were interprofessional education and continuing professional development. DISCUSSION: While it is possible to use NHWA module 3 indicators there are disadvantages as well, at least for accelerated medically trained clinicians. There are aspects of accreditation practices that are not readily coded in the standard definitions used for the indicators. While the indicators provide detailed definitions, some invite social desirability bias and others are not as easily understood by practitioners whose roles continue to evolve and adapt to their health systems. CONCLUSION: Regular review and revision of indicators are essential to facilitate uptake of the NHWA for planning and monitoring healthcare providers.

The necessity of examining patients' social behavior and teaching behavior change theories: curricular innovations induced by the COVID-19 pandemic.

During the COVID-19 pandemic, despite many widespread calls for social distancing, recommendations have not been followed by some people and the high rate of non-compliance has significantly affected lives all around the world. It seems that the rate of non-compliance with the recommendations among medical students has been as high as the rest of the other youth. In the time that students are removed from clinical environments and most physician teachers are strained in providing services to patients, medical students can be trained in interdisciplinary behavior change counseling programs and they can be employed in delivering virtual consultations to the patients referred to medical centers.In this quick review, we provide an argument regarding the importance of integrating the topic of patients' social history into the undergraduate medical curriculum and the necessity of teaching theories of behavior change to medical students. Hypotheses are proposed that focus on the importance of integrating behavioral and social sciences into the medical curriculum and to teach theories or models of behavior change to students. Health professions educators can design and implement interventions to teach hypothesized models of behavioral change to medical students and evaluate the effectiveness of those interventions. The impacts of such educational interventions on increasing people's compliance with recommendations to improve public health can be evaluated as well.

Evaluating medical education regulation changes in Brazil: workforce impact.

BACKGROUND: Shortages and inequitable distribution of physicians is an obstacle to move towards Universal Health Coverage, especially in low-income and middle-income countries. In Brazil, expansion of medical school enrollment, curricula changes and recruitment programs were established to increase the number of physicians in underserved areas. This study seeks to analyze the impact of these measures in reduce inequities in access to medical education and physicians' distribution. METHODS: This is an observational study that analyzes changes in the number of undergraduate medical places and number of physicians per inhabitants in different areas in Brazil between the years 2010 and 2018. Data regarding the number of undergraduate medical places, number and the practice location of physicians were obtained in public databases. Municipalities with less than 20,000 inhabitants were considered underserved areas. Data regarding access to antenatal visits were analyzed as a proxy for impact in access to healthcare. RESULTS: From 2010 to 2018, 19,519 new medical undergraduate places were created which represents an increase of 120.2%. The increase in the number of physicians engaged in the workforce throughout the period was 113,702 physicians, 74,771 of these physicians in the Unified Health System. The greatest increase in the physicians per 1000 inhabitants ratio in the municipalities with the smallest population, the lowest Gross Domestic Product per capita and in those located in the states with the lowest concentration of physicians occurred in the 2013-2015 period. Increase in physician supply improved access to antenatal care. CONCLUSIONS: There was an expansion in the number of undergraduate medical places and medical workforce in all groups of municipalities assessed in Brazil. Medical undergraduate places expansion in the federal public schools was more efficient to reduce regional inequities in access to medical education than private sector expansion. The recruitment component of More Doctors for Brazil Program demonstrated effectiveness to increase the number of physicians in underserved areas. Our results indicate the importance of public policies to face inequities in access to medical education and physician shortages and the necessity of continuous assessment during the period of implementation, especially in the context of political and economic changes.

Medical school expansion policies: educational access and physician distribution.

INTRODUCTION: Many countries are employing strategies intended to reduce maldistribution of health workers and inequities. The purpose of this study was to analyse the impact of expansion policies of medical schools on regional inequalities in the distribution of undergraduate class sizes, and the capacity to attract and retain doctors and to expand health facilities. METHODS: We conducted a descriptive analysis to compare the distribution of undergraduate places in 2007 and 2016 to determine the impact of targeted expansion policies on inequalities in access to medical education in Brazil. A group of municipalities with new medical schools (n = 54) and a control group without medical schools (n = 408) were compared to analyse impacts of expansion in the health sector. We compared the increase in the number of physicians per 1000 inhabitants and health establishments per inhabitants between 2007 and 2016 based on these two groups. We also analysed the relationship between geographic distance from the state capital and capacity to attract physicians. RESULTS: There was a decrease in the regional inequalities of undergraduate places in medical schools; the greatest increase in the places per 1000 inhabitants was in municipalities of between 50 000 and 100 000 inhabitants. Municipalities with new medical schools showed an increase in physicians per 1000 inhabitants and in health establishments per inhabitant ratio, demonstrating the potential to attract and retain doctors, as well as strengthening the health infrastructure. Municipalities more distant from state capitals showed a greater increase in physician : inhabitant ratio. DISCUSSION: Countries with health workforce shortages and inequalities in their distribution might consider public financing and regulation policies for expansion of medical schools as a strategy to attract and retain professionals. Early results in Brazil showed that such strategies could strengthen service networks in deprived areas, supporting implementation of Universal Healthcare Coverage.

A work-centered approach for setting passing scores on performance-based assessments.

Standardized patient examinations are being used for high-stakes decisions (e.g., graduation, licensure, and certification) with growing frequency. Concurrently, research on methods to determine the passing score for these types of performance-based assessments has increased. A wide variety of approaches have been considered in the past several years, many based on traditional techniques developed for use with multiple-choice examinations. More and more, techniques that center on review of examinee work have been employed, often resulting in the establishment of defensible, reproducible standards. The purpose of this article is to describe and evaluate a work-centered approach for determining the passing score for a performance-based assessment of clinical skills. A description of an approach to set passing scores that involves expert review of examinee work is presented. Application and evaluation of the method are illustrated using examination materials obtained from a high-stakes certification assessment.