Lessons Learned as Thomas Jefferson University's Rural Physician Shortage Area Program (PSAP) Approaches the Half-Century Mark.

To help increase the supply and retention of rural family physicians, Thomas Jefferson University initiated the Physician Shortage Area Program (PSAP) in 1974. The program selectively admits medical school applicants who both grew up in a rural area and plan to practice in a rural area. During medical school, PSAP students have ongoing mentoring and rural clinical experiences. As the program now approaches the half-century mark, this commentary summarizes several important lessons learned. First, outcomes research is critical, and program leaders have been able to publish 15 papers and a book about the PSAP and its outcomes. Second, these studies have shown that the program has been highly successful, with PSAP graduates 8.5-9.9 times more likely to enter rural family medicine than their peers, and that the PSAP contributed 12% of all rural family physicians in Pennsylvania. Other similar medical school rural programs have had comparable success, with more than half of all graduates combined (including PSAP graduates) practicing rural. Third, long-term retention has a multiplicative impact. Long-term retention of PSAP graduates in rural family medicine was greater than 70% after 20-25 years. Fourth, research has shown that the admissions component accounted for approximately three-quarters of the PSAP's success. Three factors available at the time of matriculation (rural background, plans for rural practice, and plans for family medicine) identified almost 80% of all Jefferson graduates in rural practice 3 decades later. Having a peer group with similar backgrounds, mentoring, and the rural curriculum were also very important. Fifth, wanting to live rural appears key to the rural practice decision. Finally, given that medical school programs like the PSAP produce substantial increases in the supply and retention of rural physicians while requiring modest resources, medical schools can have a critical role in addressing the rural physician shortage.

Do medical students correctly perceive what patients believe about their own health?

OBJECTIVE: This study set out to estimate the prevalence of any mismatch between medical students' perceptions of patients' health beliefs and those of a normative group of primary care patients. METHODS: A Perception of Health Scale, normed on 314 primary care patients and including four reproducible subscales based on Health Belief Model constructs, was distributed to 500 medical students in Years 3 and 4 at a private US medical school. The students were asked to indicate how a 'typical' patient they had seen with a preceptor or on a rotation might have answered. Responses were scored as matching or not matching the normative data. Group comparisons were made for gender, year of graduation, age and planned specialty. RESULTS: Depending on the subscale, at least 75% of the students' responses did not match those of the normative patient group. There were no consistent group differences. CONCLUSIONS: The findings suggest that medical students do not accurately perceive what patients believe about their own health. Whether this is true for residents and providers in practice remains unknown.

Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication.

PURPOSE: To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication. METHOD: Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed. RESULTS: Ten studies met all inclusion criteria. Outcomes were available for more than 1,600 graduates across three decades from six programs. The weighted average of graduates practicing in rural areas ranged from 53% to 64%, depending on the definition of rural. If 125 medical schools developed similar programs for 10 students per class, this would result in approximately 11,390 rural physicians during the next decade, more than double the current estimation of rural doctors produced during that time frame (5,130). CONCLUSIONS: All identified comprehensive medical school rural programs have produced a multifold increase in the rural physician supply, and widespread replication of these models could have a major impact on access to health care in thousands of rural communities. The current recommendation to expand U.S. medical school class size represents a unique and timely opportunity to replicate these programs.

The home visit experience: a medical student's perspective.

Incorporating home care education into the medical school curriculum is essential for providing a learning experience not duplicated elsewhere. Students rotating through family medicine write a reflection paper on their experiences. The papers about home visits from July 2000 to June 2004 were analyzed by a constant comparison technique developing seven themes: student paradigm shift in their understanding of causes vs. efects of disease, misconceptions about treatment, access to care, a return to the roots of medicine, quality of family caregiving, broader implications of providing care, and controversial issues. The students'papers demonstrate the unique environment of home visits.

Ehlers-Danlos hypermobility type in an adult with chronic pain and fatigue: a case study.

Ehlers-Danlos syndrome hypermobility type (EDS-HT) is an underdiagnosed genetic connective tissue disorder that causes joint hypermobility and widespread pain. We present a patient with the chief complaint of shoulder pain, a long history of widespread joint pain, and associated comorbidities. EDS-HT provided a unifying diagnosis and direction for management.

Long-term retention of graduates from a program to increase the supply of rural family physicians.

PURPOSE: To determine the long-term retention of rural family physicians graduating from the Physician Shortage Area Program (PSAP) of Jefferson Medical College. METHOD: Of the 1,937 Jefferson graduates from the classes of 1978-1986, the authors identified those practicing rural family medicine when their practice location was first determined. The number and percent of PSAP and non-PSAP graduates practicing family medicine in the same rural area in 2002 were then identified, and compared to the number of those graduates practicing rural family medicine when they were first located in practice 11-16 years earlier. RESULTS: After 11-16 years, 68% (26/38) of the PSAP graduates were still practicing family medicine in the same rural area, compared with 46% (25/54) of their non-PSAP peers (p = .03). Survival analysis showed that PSAP graduates practice family medicine in the same rural locality longer than non-PSAP graduates (p = .04). CONCLUSIONS: These results are the first to show long-term rural primary care retention that is longer than the median duration. This outcome combined with previously published outcomes show that the PSAP represents the only program that has resulted in multifold increases in both recruitment (eight-fold) and long-term retention (at least 11-16 years). In light of recent national recommendations to increase the total enrollment in medical schools, allocating some of this growth to developing and expanding programs similar to the PSAP would make a substantial and long lasting impact on the rural physician workforce.

The use of an indirect Ostertagia ostertagi ELISA to predict milk production response after anthelmintic treatment in confined and semi-confined dairy herds.

An indirect Ostertagia ostertagi ELISA was used in late lactation milk samples from cows in confined and semi-confined dairy herds to determine if it could predict milk production response after endectocide treatment at calving. Holstein cows from 9 dairy farms from Prince Edward Island (PEI), 5 from central Nova Scotia and 16 from southern Ontario that were participating in a clinical trial of endectocide treatment around calving were used in this study. The cows were randomly treated with either eprinomectin pour-on endectocide or a placebo solution. Milk samples were obtained from cows late in the lactation before treatment was applied. These samples were tested for antibodies to gastrointestinal nematodes (GIN) using the indirect ELISA with the results expressed as optical density ratios (ODR). Production records were obtained from a computerized database of dairy herd improvement data. Pre-calving ODR showed a seasonal pattern. They were higher in the summer and fall and lower during the winter months. Older animals had higher pre-calving ODR values compared with younger cows. Similarly, cows from semi-confined herds had higher parasite antibody levels compared with cows from confined herds. The endectocide treatment did not affect the milk production response in the overall study population. However, the interaction effect between treatment and pre-calving ODR on milk production response after endectocide treatment was significant (P = 0.02), with some evidence of positive treatment response in cows with an ODR > 0.4. The relationship between pre-calving ODR and production response appeared to be quadratic rather than linear.

Evaluation of the stability of Ostertagia ostertagi ELISA microtitre plates over time using cow milk samples.

The objective of this study was to assess the stability of ELISA plates prepared with one of three blocking agents and used with one of two conjugates at various time intervals after preparation of the plates. Two of the blocking agents used were commercially available: one termed stabilgaurd (stab) and one manufactured by SVANOVA Biotek AB Inc. (svan). The third blocking agent used was bovine serum albumin (bsa). A polyclonal rabbit anti-bovine IgG (poly) and an anti-bovine IgG monoclonal (mono) conjugate were used. Eighteen composite individual cow milk samples collected late in lactation (200-400 days in milk) were used in this study. An indirect microtitre plate ELISA that used the Ostertagia ostertagi antigen was used to quantify antibodies against the parasite, present in the milk samples. Each of six blocking agent/conjugate combinations (called systems) were used to test 18 milk sub-samples at 1, 4 and 24 weeks after blocking the plates. Plates blocked with stab and svan were kept at room temperature and an additional set were incubated at 37 degrees C so as to mimic long term storage (about 1 year) and tested only once at 4 weeks. Those blocked with bsa were frozen at -20 degrees C. Concordance correlation coefficients (CCC) and reproducibility were used to assess the agreement between test results conducted on the same milk sample at the various test-times using a particular system. Generally, there was good agreement between tests conducted at different times for all systems. However, the svan-mono and bsa-poly systems had the best agreement with overall CCC values of 96% and 93%, respectively. The svan-poly system had the lowest CCC of 75%. The CCC and reproducibility ranked the systems in a similar way. The high CCC between tests done using plates kept at room temperature and ones incubated at 37 degrees C, suggested that plates would be stable up to a year after blocking. The storage of plates blocked with svan and stab agents under room temperature, makes them more convenient to use and transport relative to bsa-blocked plates that have to be frozen.

Applying a kinetic method to an indirect ELISA measuring Ostertagia ostertagi antibodies in milk.

Indirect enzyme-linked immunosorbent assays (ELISAs) are frequently run as endpoint ELISAs (e-ELISAs). However, kinetic ELISAs (k-ELISAs) have certain advantages over e-ELISAs. The objective of this study was to understand the relationship between e-ELISA and k-ELISA results. Specifically, to determine whether it was possible to run both k-ELISA and e-ELISA on the same plate and establish an appropriate time interval for k-ELISA measurements. A normalization method for k-ELISA slopes (slope ratio) is proposed. Using an indirect e-ELISA test measuring antibodies against Ostertagia ostertagi in milk from dairy cattle, we found that running a k-ELISA had no effect on optical density ratio results of an e-ELISA on the same plate, and that agreement was very strong at 10, 15, and 28 min, allowing for a reduction in the total processing time for ELISA tests.

Les épreuves immunoenzymatiques indirectes (ELISA) sont fréquemment effectuées comme ELISA avec un point limite (e-ELISA). Toutefois, une épreuve ELISA cinétique (k-ELISA) a certains avantages par rapport à une e-ELISA. L'objectif de la présente étude était de comprendre la relation entre les résultats d'une e-ELISA et ceux d'une k-ELISA. Spécifiquement, déterminer s'il est possible de réaliser simultanément sur la même plaque une épreuve k-ELISA et une épreuve e-ELISA et d'établir un intervalle de temps approprié pour les mesures de k-ELISA. Une normalisation de la méthode pour les pentes des k-ELISA (rapport de pente) est proposée. En utilisant une épreuve e-ELISA indirecte pour mesurer les anticorps dirigés contre Ostertagia ostertagi dans le lait de bovins laitiers, nous avons trouvé que d'effectuer une k-ELISA n'avait aucun effet sur les résultats des ratios de densité optique d'une e-ELISA effectuée sur la même plaque, et que l'accord était très élevé à 10, 15, et 28 min, permettant ainsi une réduction du temps de traitement total pour les épreuves ELISA.(Traduit par Docteur Serge Messier).

Milk antibodies against Ostertagia ostertagi: relationships with milk IgG and production parameters in lactating dairy cattle.

The present study was carried out to evaluate the relationship between milk optical density ratios (ODRs) from an indirect Ostertagia ostertagi ELISA, total milk IgG levels and milk production and then establish a correction factor to adjust ODR. Five hundred and sixty composite milk samples collected from 358 cows on four dairy herds in June and August 2002 were used in this analysis. The average ODR was 0.34. A positive correlation was found between ODR and IgG values in milk, days in milk, age and log transformed somatic cell counts (SCC). However, ODR was negatively correlated with milk production. The IgG levels and ODR values were constant from 30 to 200 days in milk. However, ODRs increased from 200 days until the end of the lactation. After controlling for age, season, herd and SCC, an increase in milk production of 13 kg/day was associated with a reduction in ODR values of 0.052. The results of the present study suggest that ODR values are not greatly influenced by production factors. ODR follow the same pattern as the IgG variation across lactation and could be adjusted in order to compare ODR values obtained from high producing cows with those obtained from low producing animals.

A longitudinal study of gastrointestinal parasites in Canadian dairy farms. The value of an indirect Ostertagia ostertagi ELISA as a monitoring tool.

The general objective of this study was to evaluate a crude Ostertagia ostertagi antigen enzyme-linked immunosorbent assay (ELISA) for monitoring gastrointestinal parasites in lactating dairy cattle. A longitudinal study of gastrointestinal parasites in lactating dairy cows was carried out in 38 herds in four provinces of Canada (Prince Edward Island, Quebec, Ontario and Saskatchewan) from September 1999 to October 2000. Bulk tank milk, cow milk, serum and fecal samples were collected monthly or quarterly from all these farms. Information on herd management factors was collected by a standard questionnaire and individual cow production data were obtained from an electronic database. The overall mean optical density ratio (ODR) was 0.30 and ranged from -0.05 to 1.55. Although a clear seasonal pattern was not observed, the ODR values tended to decrease during the housing period and start increasing in the spring before the cows went out to pasture. The second and third or greater lactation cows had significantly higher ODR values compared with first lactation animals. The individual cow ODR had a very low correlation with individual squared root fecal egg counts but showed a reasonably high correlation when herd averages values were computed (r=0.73). A moderate correlation (r approximately 0.50) between the bulk tank and herd average ODR was observed. Milk yield was negatively associated with individual cow milk ODR and a quadratic effect on ODR was observed for days in milk. Twenty-eight of the herds participated in a clinical trial of eprinomectin (Ivomec Eprinex) treatment at calving. The cow level ODR values determined late in the previous lactation had a marginally significant effect (P=0.07) on treatment response, suggesting that high OD cows responded better to the anthelmintic treatment. However, because of the small sample size available in this model, more research is needed to better understand this relationship. In conclusion, the indirect ELISA using an O. ostertagi crude antigen appears useful as a technique for monitoring gastrointestinal parasite burdens in adult dairy cows and holds promise as a potential predictor of response to anthelmintic treatment.

Evaluations of medical students' clinical experiences in a family medicine clerkship: differences in patient encounters by disease severity in different clerkship sites.

BACKGROUND AND OBJECTIVES: Evaluation of medical students'clinical encounters is an essential component of optimizing their educational experience. In this study, we collected data on the diagnoses and disease severity in student-patient encounters at different family medicine clerkship sites. METHODS: Participants were 582 third-year medical students who completed a total of 7,515 specially designed patient encounter cards in a 6-week family medicine clerkship atfive training sites over 3 years. RESULTS: Variation was found in the average number of encounters in different clerkship sites. The findings for three frequently encountered diseases (essential hypertension, diabetes mellitus, and upper respiratory infection) showed significant differences in the proportions of patients at different stages of the disease in different clerkship sites. CONCLUSIONS: Students at different clerkship sites experience different numbers of encounters with patients and significant variation in the illness severity of patients seen in those encounters.

Retention of rural family physicians after 20-25 years: outcomes of a comprehensive medical school rural program.

BACKGROUND: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) is one of a small number of comprehensive medical school rural programs that has been successful in increasing the supply of family physicians practicing in rural areas. Although retention is a critical component of the rural physician supply, published long-term outcomes are limited. METHODS: Of the 1937 JMC graduates from the classes of 1978 to 1986, we identified those who were practicing family medicine in a rural county when they were first located in practice (in 1986 for 1978-1981 graduates and in 1991 for 1982-1986 graduates). Using the Jefferson Longitudinal Study, we then compared the numbers of PSAP and non-PSAP graduates who were still practicing family medicine in the same area in 2011. RESULTS: Of the 92 JMC graduates initially practicing rural family medicine, 90 were alive in 2011, and specialty and location data were available for 89 (98.9%). Of the 37 PSAP graduates who originally practiced rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 compared with 24 of 52 non-PSAP graduates (46.2%; P = .02). CONCLUSION: This study provides additional support for the substantial impact of medical school rural programs, suggesting that graduates of rural programs are not only likely to enter rural family medicine but to remain in rural practice for decades.

The relationship between matriculating medical students' planned specialties and eventual rural practice outcomes.

PURPOSE: To analyze the previously unknown relationships between the specialty plans of entering medical students and their eventual rural practice outcomes. METHOD: For 5,419 graduates from the 1978-2002 classes of Jefferson Medical College, their self-reported specialty plans at the time of matriculation were obtained from the Jefferson Longitudinal Study, as were their 2007 practice locations. Specialty plans were grouped into 12 categories, and the percentages of graduates initially planning each specialty group who were actually practicing in rural areas were determined. RESULTS: Entering medical students' specialty plans were strongly related to eventual rural practice (P < .001). Those students planning family medicine were "highly likely" to practice in rural areas (29.4%, 238/810). They were 1.5 times as likely to practice rural as a "mid-likely" group (those planning general surgery, psychiatry, emergency medicine, general internal medicine, or one of the medical subspecialties: 19.6% [range 17.9%-21.0%], 229/1,167). Students planning family medicine were also 2.1 times as likely to practice rural as those students planning a "lower-likely" group (those planning general pediatrics, one of the surgical subspecialties, the hospital specialties of radiology, anesthesiology and pathology, and obstetrics-gynecology, or other specialties: 14.0% [range 13.0%-14.3%], 142/1,016). CONCLUSIONS: These findings show that students' specialty plans at medical school matriculation are significantly related to rural outcomes, and they provide new information quantifying the absolute and relative likelihood of those planning various specialties to enter rural practice. This information is particularly important for medical schools that have or plan to develop comprehensive rural programs.

The relationship between entering medical students' backgrounds and career plans and their rural practice outcomes three decades later.

PURPOSE: Although many studies have investigated predictors of physician practice in rural areas, few have accounted for the importance of physicians' backgrounds. This study analyzed the relationship between the backgrounds and future career plans of entering medical students and their rural practice outcomes. METHOD: For 1,111 graduates from Jefferson Medical College (JMC, classes of 1978-1982), three factors self-reported at matriculation and previously related to rural practice were obtained from the Jefferson Longitudinal Study of Medical Education: growing up rural, planning rural practice, and planning family medicine. Their 2007 practice location was determined to be in a rural versus nonrural area. Analyses of graduates with various numbers of predictive factors (0-3) and rural practice were performed. RESULTS: Of the 762 JMC graduates (69%) with complete data, 172 (23%) were practicing in rural areas. Of graduates with all three predictors, 45% (45/99) practiced in rural areas compared with 33% (48/145) of those with two predictors, 21% (42/198) with one predictor, and 12% (37/320) of those with none. Of physicians practicing in rural areas in 2007, only 22% had no predictors. CONCLUSIONS: Three factors known at the time of medical school matriculation have a powerful relationship with rural practice three decades later. Relatively few students without predictors practice in rural areas, which is particularly significant given subsequent factors known to be related to rural practice--for instance, rural curriculum, residency location, or spouse. These results have major implications for the role of the medical school admissions process in producing rural physicians.

Effects of selenium source on measures of selenium status and immune function in horses.

The effects of selenium (Se) supplementation and source on equine immune function have not been extensively studied. This study examined the effects of oral Se supplementation and Se source on aspects of innate and adaptive immunity in horses. Fifteen horses were assigned to 1 of 3 groups (5 horses/group): control, inorganic Se (sodium selenite), organic Se (Se yeast). Immune function tests performed included: lymphocyte proliferation in response to mitogen concanavalin A, neutrophil phagocytosis, antibody production after rabies vaccination, relative cytokine gene expression in stimulated lymphocytes [interferon gamma (IFNγ), interleukin (IL)-2, IL-5, IL-10, tumor necrosis factor alpha (TNFα)], and neutrophils (IL-1, IL-6, IL-8, IL-12, TNFα). Plasma, red blood cell Se, and blood glutathione peroxidase activity were measured. Plasma and red blood cell Se were highest in horses in the organic Se group, compared with that of inorganic Se or control groups. Organic Se supplementation increased the relative lymphocyte expression of IL-5, compared with inorganic Se or no Se. Selenium supplementation increased relative neutrophil expression of IL-1 and IL-8. Other measures of immune function were unaffected. Dietary Se content and source appear to influence immune function in horses, including alterations in lymphocyte expression of IL-5, and neutrophil expression of IL-1 and IL-8.

Les effets d'un supplément de sélénium (Se) ainsi que sa source sur la fonction immunitaire équine n'ont pas été étudiés à fond. On examina dans la présente étude les effets d'un supplément oral en Se et les sources de Se sur des éléments de l'immunité innée et adaptative de chevaux. Quinze chevaux ont été assignés à un de trois groupes (5 chevaux/groupe); témoin, Se inorganique (sélénite de sodium), et Se organique (Se provenant de levures). Les tests de fonctions immunitaires effectués étaient : prolifération lymphocytaire en réponse au mitogène concanaviline A, phagocytose par les neutrophiles, production d'anticorps après vaccination anti-rabique, expression relative des gènes des cytokines de lymphocytes stimulés [interferon gamma (IFNγ), interleukine (IL)-2, IL-5, IL-10, facteur de nécrose tumorale alpha (TNFα)], et de neutrophiles (IL-1, IL-6, IL-8, IL-12, TNFα). Le Se plasmatique et des globules rouges, ainsi que l'activité de la glutathion peroxydase ont été mesurés. Le Se plasmatique et des globules rouges étaient plus élevés chez les chevaux dans le groupe de Se organique, comparativement au groupe recevant le Se inorganique ou le groupe témoin. Un supplément de Se organique entraîna une augmentation d'expression relative d'IL-5 par les lymphocytes, comparativement au Se inorganique ou aucun Se. Un supplément de Se augmenta l'expression relative d'IL-1 et IL-8 par les neutrophiles. Les autres mesures des fonctions immunitaires n'étaient pas affectées. Le contenu et les sources de Se alimentaire semblent influencer les fonctions immunitaires des chevaux, incluant des altérations dans l'expression d'IL-5 par les lymphocytes, et l'expression d'IL-1 et IL-8 par les neutrophiles.(Traduit par Docteur Serge Messier).

Medical school rural programs: a comparison with international medical graduates in addressing state-level rural family physician and primary care supply.

PURPOSE: Comprehensive medical school rural programs (RPs) have made demonstrable contributions to the rural physician workforce, but their relative impact is uncertain. This study compares rural primary care practice outcomes for RP graduates within relevant states with those of international medical graduates (IMGs), also seen as ameliorating rural physician shortages. METHOD: Using data from the 2010 American Medical Association Physician Masterfile, the authors identified all 1,757 graduates from three RPs (Jefferson Medical College's Physician Shortage Area Program; University of Minnesota Medical School Duluth; University of Illinois College of Medicine at Rockford's Rural Medical Education Program) practicing in their respective states, and all 6,474 IMGs practicing in the same states and graduating the same years. The relative likelihoods of RP graduates versus IMGs practicing rural family medicine and rural primary care were compared. RESULTS: RP graduates were 10 times more likely to practice rural family medicine than IMGs (relative risk [RR] = 10.0, confidence interval [CI] 8.7-11.6, P < .001) and almost 4 times as likely to practice any rural primary care specialty (RR 3.8, CI 3.5-4.2, P < .001). Overall, RPs produced more rural family physicians than the IMG cohort (376 versus 254). CONCLUSIONS: Despite their relatively small size, RPs had a significant impact on rural family physician and primary care supply compared with the much larger cohort of IMGs. Wider adoption of the RP model would substantially increase access to care in rural areas compared with increasing reliance on IMGs or unfocused expansion of traditional medical schools.