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.

Improved Utilization of Preventive Services Among Patients Following Team-Based Annual Wellness Visits.

BACKGROUND The Annual Wellness Visit was designed to enhance preventive services utilization among Medicare beneficiaries; Annual Wellness Visits are underutilized with sparse documented effectiveness. Patients of 3 community-based and 2 retirement community outpatient clinics in western North Carolina had team-based Annual Wellness Visits over a 20-month program, with the goal of improving the uptake and delivery of the Annual Wellness Visit. A clinical pharmacist saw high-complexity patients (≥5 medications) and a licensed practical nurse saw low-complexity patients. We examined the effectiveness of team-based Annual Wellness Visits on patients' use of preventive services.METHOD We conducted a retrospective chart review on a random sample of 500 patients for 12 months post-Annual Wellness Visit. Change over time in use of preventive services was assessed using McNemar's test. Adjusted relative risks of use within 6 months were calculated using generalized linear models with the Poisson loglinear function.RESULTS Overall, utilization of Annual Wellness Visit increased from 14% at baseline to 44% after the 20-month program. The percentage of patients up-to-date with all recommended services increased from 17.4% at the Annual Wellness Visit to 42% within 6 months. Age-appropriate preventive screens and vaccines demonstrated the most improvement (55.8% to 75.4% and 36% to 52.2%, respectively). Community-based patients were less likely to obtain recommended services (RR = 0.618; 95% confidence interval [CI], 0.442-0.865), while patients with supplemental insurance (RR = 1.484; 95% CI, 1.023-2.153), patients seen in subsequent Annual Wellness Visits (RR = 1.405; 95% CI, 1.062-1.858), and patients who were men (RR = 1.422; 95% CI, 1.053-2.041) were more likely to obtain recommended services.LIMITATIONS Generalization is limited by the pre-/post design of one organizational model.CONCLUSION Team-based Annual Wellness Visits with a clinical pharmacist or an LPN, who were supervised by physicians, were associated with significantly improved utilization of preventive services. Use will likely continue to improve as more patients access team-based Annual Wellness Visits yearly.

Graduates' Perceptions of Learning Affordances in Longitudinal Integrated Clerkships: A Dual-Institution, Mixed-Methods Study.

PURPOSE: The authors explored affordances that contribute to participants' successful learning in longitudinal integrated clerkships (LICs). METHOD: This dual-institutional, mixed-methods study included electronic surveys and semistructured interviews of LIC graduates who completed their core clinical (third) year of medical school. These LIC graduates took part in LICs at Harvard Medical School from 2004 to 2013 and the University of North Carolina School of Medicine-Asheville campus from 2009 to 2013. The survey questions asked LIC graduates to rate components of LICs that they perceived as contributing to successful learning. A research assistant interviewed a subset of study participants about their learning experiences. The authors analyzed aggregate data quantitatively and performed a qualitative content analysis on interview data. RESULTS: The graduates reported multiple affordances that they perceive contributed to successful learning in their LIC. The most reported components included continuity and relationships with preceptors, patients, place, and peers, along with integration of and flexibility within the curriculum. CONCLUSIONS: As LIC models grow in size and number, and their structures and processes evolve, learners' perceptions of affordances may guide curriculum planning. Further research is needed to investigate to what degree and by what means these affordances support learning in LICs and other models of clinical education.

Evaluation of a Team-Based, Transition-of-Care Management Service on 30-Day Readmission Rates.

BACKGROUND: Transitions of care from the hospital to the outpatient setting often fail to meet the Triple Aim of improving quality, improving the health of populations, and decreasing the cost of care. A major push to improve the quality of transitions and reduce hospital readmissions is under way. METHODS: We implemented a team-based, transition-of-care model and assessed the impact on 30-day readmission rates. The 3 components of the intervention were contact with a nurse care manager, medication reconciliation, and follow-up with a physician. We compared 30-day readmission rates for the period before versus after implementation of this intervention. RESULTS: The 30-day readmission rate decreased from 14.2% in the usual care group to 5.3% in the intervention group (P = .011). Almost 90% of patients in the intervention group received all 3 components of the intervention. LIMITATIONS: Generalizability is limited to practices with embedded team members. Not all patients received all 3 components of the intervention. CONCLUSIONS: Development of a team-based intervention was associated with a significant reduction in hospital readmissions. This method could be implemented in other primary care offices with team-based care.

Gender Bias in Nurse Evaluations of Residents in Obstetrics and Gynecology.

PURPOSE: We examined the evaluations given by nurses to obstetrics and gynecology residents to estimate whether gender bias was evident. BACKGROUND: Women receive more negative feedback and evaluations than men-from both sexes. Some suggest that, to be successful in traditionally male roles such as surgeon, women must manifest a warmth-related (communal) rather than competence-related (agentic) demeanor. Compared with male residents, female residents experience more interpersonal difficulties and less help from female nurses. We examined feedback provided to residents by female nurses. METHODS: We examined Professional Associate Questionnaires (2006-2014) using a mixed-methods design. We compared scores per training year by gender using Mann-Whitney and linear regression adjusting for resident and nurse cohorts. Using grounded theory analysis, we developed a coding system for blinded comments based on principles of effective feedback, medical learners' evaluation, and impression management. χ examined the proportions of negative and positive and communal and agentic comments between genders. RESULTS: We examined 2,202 evaluations: 397 (18%) for 10 men and 1,805 (82%) for 34 women. Twenty-three compliments (eg, "Great resident!") were excluded. Evaluations per training year varied: men n=77-134; women n=384-482. Postgraduate year (PGY)-1, PGY-2, and PGY-4 women had lower mean ratings (P<.035); when adjusted, the difference remained significant in PGY-2 (MWomen=1.5±0.6 compared with MMen=1.7±0.5; P=.001). Postgraduate year-1 women received disproportionately fewer positive and more negative agentic comments than PGY-1 men (positive=17.3% compared with 40%, negative=17.3% compared with 3.3%, respectively; P=.041). CONCLUSION: Evidence of gender bias in evaluations emerged; albeit subtle, women received harsher feedback as lower-level residents than men. Training in effective evaluation and gender bias management is warranted.

Prenatal care, pregnancy outcomes, and postpartum birth control plans among pregnant women with opiate addictions.

OBJECTIVES: To describe how effectively we provided adequate prenatal care and postpartum contraception to prevent repeat, unintended pregnancies to women using opiates or medication maintenance therapy (MMT) during pregnancy. METHODS: We conducted a retrospective chart review of 94 women using opiates or MMT during 96 pregnancies while receiving prenatal care in the regional high-risk maternity care clinic between July 2010 and June 2012. We examined prenatal care usage, birth outcomes, and postpartum contraception using χ(2), Kruskal-Wallis, and binary logistic regression modeling. RESULTS: Patients were predominately white (93.6%), multiparous (75.5%), and in their 20s; 71 (74%) used MMT and 25 (26%) used prescribed or illicit opiates. Fewer than half (44% [46.2%]) received any documented prenatal counseling about postpartum contraception. Sixteen (17%) babies were premature. Sixty-four (66.7%) infants were diagnosed as having neonatal abstinence syndrome (NAS). Only 42 (43.8%) women attended their postpartum visits. Overall, 60 (62.5%) women received postpartum contraception. The only significant predictors of postpartum contraception use were preterm birth and postpartum appointment attendance. CONCLUSIONS: Alternative strategies for providing postpartum care should be explored because women using opiates or MMT during pregnancy are significantly more likely to use postpartum contraception if they attend their postpartum appointments.