Learning on the country: Motivating dental students to attend a rural placement.

PURPOSE/OBJECTIVES: This research aimed to identify factors that affect dental students' attitudes toward participation in rural clinical outplacements (RCOP) in Australia, and to suggest strategies that will increase students' desire to attend RCOP in the future. METHODS: Dental students from the nine dental schools in Australia were invited to an online survey on their willingness to participate in an RCOP and the factors that influence this willingness. These factors were grouped into themes of education, personal and health, social, financial, and information-related. RESULTS: The study had an estimated response rate of 10% with 202 responses. More than two-thirds (68%) of students were willing to participate in an RCOP. Students who grew up in a rural area were significantly more likely to be willing to attend an RCOP, compared to those from urban settings. Attitudes toward the anticipated educational experience of RCOP were positive, while factors related to finances and pre-existing information were of concern to students. Educational, personal/health-related, and social factors had significant impacts on participants' willingness to attend RCOP. CONCLUSION: Overall, despite students holding negative opinions on certain social and financial factors, their positive attitudes toward other factors outweighed these. Universities should aim to further promote the educational benefits of RCOP to improve students' attitudes prior to attending RCOP. In-depth qualitative analysis is required to explore students' concerns regarding RCOP and longitudinal research is warranted to monitor students' attitudes toward RCOP and rural work over time.

Growing a rural family physician workforce: The contributions of rural background and rural place of residency training.

OBJECTIVE: To determine the distinct influences of rural background and rural residency training on rural practice choice among family physicians. DATA SOURCES AND STUDY SETTING: We used a subset of The RTT Collaborative rural residency list and longitudinal data on family physicians from the American Board of Family Medicine National Graduate Survey (NGS; three cohorts, 2016-2018) and American Medical College Application Service (AMCAS). STUDY DESIGN: We conducted a logistic regression, computing predictive marginals to assess associations of background and residency location with physician practice location 3 years post-residency. DATA COLLECTION/EXTRACTION METHODS: We merged NGS data with residency type-rural or urban-and practice location with AMCAS data on rural background. PRINCIPAL FINDINGS: Family physicians from a rural background were more likely to choose rural practice (39.2%, 95% CI = 35.8, 42.5) than those from an urban background (13.8%, 95% CI = 12.5, 15.0); 50.9% (95% CI = 43.0, 58.8) of trainees in rural residencies chose rural practice, compared with 18.0% (95% CI = 16.8, 19.2) of urban trainees. CONCLUSIONS: Increasing rural programs for training residents from both rural and urban backgrounds, as well as recruiting more rural students to medical education, could increase the number of rural family physicians.

Factors influencing nursing and allied health recent graduates' rural versus urban preferred principal place of practice: A cross-sectional data linkage study.

INTRODUCTION: Disparities between metropolitan and non-metropolitan health workforce must be addressed to reduce inequities in health care access. Understanding factors affecting early career practitioners' choice of practice location can inform workforce planning. OBJECTIVE: To investigate influences on rural practice location preferences of recent graduates. DESIGN: Cross-sectional analysis linked university enrolment, Graduate Outcomes Survey (GOS) and Australian Health Professional Regulation Agency (Ahpra) principal place of practice (PPP) for 2018 and 2019 nursing and allied health graduates from two Australian universities. Chi-squared tests and logistic regression compared rural versus urban PPP and locational preference. FINDINGS: Of 2979 graduates, 1295 (43.5%) completed the GOS, with 63.7% (n = 825) working in their profession and 84.0% of those (n = 693) in their preferred location. Ahpra PPP data were extracted for 669 (81.1%) of those working in their profession. Most reported influences were 'proximity to family/friends' (48.5%), 'lifestyle of the area' (41.7%) and 'opportunity for career advancement' (40.7%). Factors most influential for rural PPP were 'cost of accommodation/housing' (OR = 2.26, 95% CI = 1.23-4.17) and 'being approached by an employer' (OR = 2.10, 95% CI = 1.12-3.92). Having an urban PPP was most influenced by 'spouse/partners employment/career' (OR = 0.53, 95% CI = 0.30-0.93) and 'proximity to family/friends' (OR = 0.41, 95% CI = 0.24-0.72). DISCUSSION: While the findings add strength to the understanding that graduates who originated from a rural area are most likely to take up rural practice in their preferred location, varied social and professional factors are influential on decision-making. CONCLUSIONS: It is imperative to recruit students from non-metropolitan regions into health professional degrees, as well as addressing other influences on choice of practice location.

The Effect of Rural Underserved Opportunities Program Participation on Medical Graduates' Decision to Work in Rural Areas.

PURPOSE: There is a persistent rural physician shortage in the United States. Policies to scale up the health workforce in response to this shortage must include measures to draw and maintain existing and newly trained health care workers to rural regions. Prior studies have found that experience in community medicine in rural practice settings increases the likelihood of medical graduates practicing in those regions but have not accounted for selection bias. This study examined the impact of a community-based clinical immersion program on medical graduates' decision to work in rural regions, adjusting for covariates to control for selection bias. METHOD: Data on sociodemographic characteristics and career interests and preferences for all 1,172 University of Washington School of Medicine graduates between 2009 and 2014 were collected. A logistic model (model 1) was used to evaluate the impact of Rural Underserved Opportunities Program (RUOP) participation on the probability of physicians working in a rural region. Another model (model 2) included the propensity score as a covariate in the regression to control for possible confounding based on differences among those who did and did not participate in the RUOP. RESULTS: Of the 994 students included in the analysis, 570 (57.3%) participated in RUOP training, and 111 (11.2%) were currently working in rural communities after their training. Regression analysis results showed that the odds of working in a rural region were 1.83 times higher for graduates who participated in RUOP in model 1 ( P = .03) and 1.77 times higher in model 2 ( P = .04). CONCLUSIONS: The findings of this study emphasize that educational programs and policies are crucial public health interventions that can promote health equity through proper distribution of health care workers across rural regions of the United States.

A disciplina psicologia do esporte nos cursos de psicologia e educação física / Sports psychology in psychology and physical education courses / La materia psicología del deporte en los cursos de psicología y educación física

Este discute a representatividade da disciplina Psicologia do Esporte nos cursos de Psicologia e Educação Física em instituições de ensino superior reconhecidas pelo MEC e situadas na região Sul do país. Foi realizado um estudo documental, com base nos currículos das Instituições. Os resultados revelaram que no Sul do Brasil 21,02% dos cursos de Psicologia, 41,96% dos cursos de bacharelado em Educação Física e apenas 14,83% dos cursos de licenciatura em Educação Física apresentam a disciplina Psicologia do Esporte em sua grade curricular. Observou-se que a disciplina é ofertada mais frequentemente em regime obrigatório nos cursos de bacharelado em Educação Física. Nos cursos de Psicologia, quando ofertada, costuma ser optativa. Os resultados evidenciam uma maior oferta da disciplina para os estudantes de Educação Física, em relação aos de Psicologia, o que pode estar relacionado ao próprio contexto de surgimento da disciplina e sua popularização no meio acadêmico. Para que esse panorama possa mudar e se possa oferecer uma formação adequada no curso de Psicologia para fomentar essa opção de carreira, há necessidade de se repensar o currículo e o próprio perfil do egresso, de forma a dar mais oportunidade aos estudantes para que conheçam as bases teóricas e os campos de aplicação da Psicologia do Esporte. Tal lacuna pode acarretar a fragilização da disseminação desse conhecimento aos estudantes de graduação e a consequente ocupação do mercado de trabalho.(AU)

This study discusses the representativeness of Sports Psychology in Psychology and Physical Education courses at higher education institutions from Southern Brazil. A documentary study was conducted based on the institutions' curricula. Results show that 21.02% of the Psychology major, 41.96% of the bachelor's in Physical Education, and only 14.83% of the license in Physical Education offer Sports Psychology in their curricula. Sports Psychology is most often offered as a compulsory subject in the bachelor's program in Physical Education, whereas Psychology courses offer it mainly as an elective. Physical Education students have greater contact with the discipline when compared with Psychology students, which may be explained by its context of development and popularization in the academic environment. To change this scenario and offer adequate education in the Psychology programs to foster this career option, institutions must rethink their curriculum and the graduate profile itself. This would give students better opportunity to get to know its theoretical bases and fields of application. Such a gap can hinder the dissemination of this knowledge to undergraduate students and the consequent labor market occupation.(AU)

El objetivo de este estudio es discutir la representatividad de la materia Psicología del Deporte en los cursos de Psicología y Educación Física en instituciones de educación superior de la región Sur de Brasil, reconocidas por el Ministerio de Educación (MEC). Se realizó un estudio documental, basado en los planes de estudio de las instituciones. Los resultados revelaron que, en el Sur de Brasil, el 21,02% de los cursos de Psicología, el 41,96% de los cursos de licenciatura en Educación Física y sólo el 14,83% de los cursos de profesorado en Educación tienen la materia Psicología del Deporte en sus planes de estudio. Se observó que la materia Psicología del Deporte se ofrece con mayor frecuencia como asignatura obligatoria en los cursos de licenciatura en Educación Física. Cuando se ofrece en los cursos de Psicología, es una materia optativa. Los resultados muestran una mayor oferta para los estudiantes de Educación Física en comparación con Psicología, lo que puede estar relacionado con el contexto del surgimiento de la Psicología del Deporte como materia y su popularización en el ámbito académico. Para que este escenario cambie y sea posible ofrecer una formación adecuada en el curso de Psicología con el fin de fomentar esta opción de carrera, es necesario repensar el plan de estudios y el perfil del egresado, así los estudiantes tendrán más oportunidades de conocer sus bases teóricas y sus campos de actuación. Tal brecha puede debilitar la difusión de este conocimiento a los estudiantes de grado y la consecuente ocupación en el mercado laboral.(AU)

Identidade profissional do psicólogo judiciário: um estudo sobre configurações identitárias / Forensic psychologist´s professional identity: a study about identity configurations / Identidad profesional del psicólogo forense: un estudio sobre configuraciones de identidad

Este estudo objetivou descrever a identidade profissional de psicólogos judiciários, partindo do cenário contemporâneo da Psicologia Jurídica brasileira, contexto que envolve crises e conflitos sobre a forma de responder a atribuições e demandas do campo legal. Pela perspectiva da sociologia das identidades profissionais de Claude Dubar, sustenta-se a hipótese de que a identidade profissional do psicólogo judiciário depende de estratégias de compatibilização entre o pertencimento à categoria e as atribuições legais e institucionais. Participaram 95 psicólogos do quadro ativo do Tribunal de Justiça de São Paulo, que responderam a um formulário online sobre a percepção de si e do campo de atuação. Os dados foram submetidos à análise de conteúdo. Os resultados indicam a saliência da avaliação psicológica e da interdisciplinaridade na identidade profissional, e as rupturas identitárias diante de práticas verificatórias. Tais achados apontam a necessidade de participação da categoria na construção de suas atribuições; e dificuldades para o exercício das funções por limitações à autonomia profissional.(AU)

This study aimed to describe the professional identity of forensic psychologists, considering Brazil's Legal Psychology contemporary scenario which relates to a critical issues on how practitioners respond the demands of the legal system. Based on Claude Dubar's sociology of professional identities, we support the hypothesis that forensic psychologists' professional identity depends on strategies of compatibilization between belonging their reference group and the institutional attributions. There were 95 participants, all from the current staff of the Court of Justice of the state of São Paulo, who answered an online form. The data were subjected to content analysis. The results indicate a professional identity with noted salience on psychological assessment and interdisciplinarity, and the identity crises regarding verification practices. Such findings highlight the importance of practitioners taking part on the construction of their own tasks.(AU)

Este estudio tuvo como objetivo describir la identidad profesional de los psicólogos forenses, considerando el escenario de la Psicología Jurídica brasileña, que se relaciona con una crisis sobre si estos profesionales responden a las demandas del sistema legal. Teniendo en cuenta la sociología de las identidades profesionales de Claude Dubar, sostenemos la hipótesis de que la identidad profesional de los psicólogos forenses depende de estrategias de compatibilización entre la pertenencia a su grupo profesional y a instituciones. Participaron 95 psicólogos, quienes actuaban en el Tribunal de Justicia del Estado de São Paulo, a los cuales se aplicó un formulario en línea. Los datos se sometieron a análisis de contenido. Los resultados indican una identidad profesional saliente en cuanto a la evaluación psicológica y la interdisciplinariedad, pero también crisis de identidad en relación con las prácticas de verificación. Tales resultados señalan la importancia de que la categoría participe en la construcción de sus propias atribuciones.(AU)

Formação em psicologia escolar: implicações para a prática em equipe multiprofissional / The school psychology formation: implications for the practice in multidisciplinary team / Formación en psicología escolar: implicaciones para la práctica en equipo multiprofesional

O objetivo dessa pesquisa foi levantar o perfil sociodemográfico e formativo de psicólogos escolares, e discutir seu impacto nas práticas junto ao coletivo escolar e no trabalho em equipe. No município onde ocorreu a pesquisa, o psicólogo escolar é membro da equipe de especialistas em Educação. Participaram da pesquisa 62 psicólogos que atuam no Ensino Fundamental I, II, e na Educação de Jovens e Adultos. Os participantes responderam um questionário on-line com perguntas abertas e fechadas sobre dados sociodemográficos, de formação e atuação profissional. Realizou-se uma análise qualitativa a partir dos objetivos e itens do instrumento, quais sejam: caracterização do perfil sociodemográfico dos psicólogos escolares, formação acadêmica, atuação em psicologia escolar, atuação em outros campos/áreas da psicologia, e atuação em equipe de especialistas. A média de idade dos profissionais é de 47,46 anos, e apenas um é do sexo masculino. Possuem tempo de atuação de um a 36 anos, e a maioria não possui estágio supervisionado e pós-graduações no campo da psicologia escolar. Parte das equipes que trabalham nas escolas está incompleta, e há uma variabilidade nos dias e horários de reuniões. Reafirma-se que a formação de psicólogos escolares tem repercussões na atuação junto à equipe multidisciplinar, e a importância de intervenções pautadas na perspectiva crítica e psicossocial em Psicologia Escolar. Ademais, conhecer o perfil sociodemográfico e formativo destes profissionais possibilita obter um quadro atualizado sobre o grupo pesquisado e criar estratégias de intervenção que potencializem a atuação desses profissionais junto à equipe de especialistas e demais setores da escola.(AU)

The aim of this research is to identify the sociodemographic and training profile of school psychologists, and discuss their impact on practices within the school collective and the teamwork. In the city where the research took place, the school psychologist is a member of the council's expert team in Education. The research participants included 62 psychologists that work in elementary and intermediate school, and EJA. They answered an open and multiple choice online survey on sociodemographic, formation, and working data. A qualitative analysis was conducted considering its objectives and items, namely: sociodemographic profile, academic education, professional background on school psychology, other psychology fields/ areas, and participation on expert teams. The professionals are 47 and 46 years old, average, only one of them being male. They work in this position from one up to 36 years, and most of them do not have training experience and postgraduate studies in school psychology. Part of the teams working at schools are incomplete, and there is a variability concerning days and hours to team meetings. It is notable that the training profile of psychologists has repercussions in the performance with the multidisciplinary team, and in the importance of interventions based on critical and psychosocial perspectives in School Psychology. Moreover, knowing the sociodemographic and training profile of these professionals allowed us to have an updated chart about the researched group, as well as to create intervention strategies that enhance these professionals' performance within the expert team and other sectors of the school.(AU)

Esta investigación tuvo por objetivo levantar el perfil sociodemográfico y formativo de psicólogos escolares para discutir su impacto en las prácticas junto al colectivo escolar y al trabajo en equipo. En el municipio donde ocurrió la investigación, este profesional es miembro del equipo municipal de especialistas en Educación. Participaron 62 psicólogos que actúan en la educación primaria, secundaria y en la educación para jóvenes y adultos (EJA), y que respondieron a un cuestionario en línea con preguntas abiertas y de opción múltiple sobre datos sociodemográficos, de formación y de actuación profesional. Se realizó un análisis cualitativo según sus objetivos e ítems, o sea: perfil sociodemográfico, formación académica, actuación en Psicología Escolar, en otros campos/áreas de la Psicología o en equipo de especialistas. La edad mediana de los profesionales es de 46-47 años, y solo uno es del sexo masculino. El tiempo de actuación en el área varía entre 1 y 36 años, y la mayoría de los encuestados no tiene formación inicial y posgrado en el campo de la Psicología Escolar. Parte de los equipos que trabajan en las escuelas está incompleta, y existe una variabilidad en los días y horarios de reuniones. Se observó que la formación de los psicólogos escolares tiene repercusiones en la actuación con el equipo multidisciplinario y en la importancia de intervenciones basadas en la perspectiva crítica y psicosocial en Psicología Escolar. Además, conocer su perfil sociodemográfico y formativo posibilita obtener un cuadro actualizado sobre el grupo investigado, además de crear estrategias de intervención que potencialicen la actuación junto al equipo de especialistas y a los demás sectores de la escuela.(AU)

Scope of Practice and Location of 3- Versus 4-Year Family Medicine Residency Graduates.

BACKGROUND AND OBJECTIVES: The John Peter Smith (JPS) Family Medicine Residency Program participated in two national experiments: Preparing the Personal Physician for Practice (P4, 2007-2012) and the Length of Training Pilot, which began in 2013. In these experiments, JPS created optional integrated 4-year areas of emphasis (AOE). The objective of this study was to examine the career outcomes of JPS graduates differentiated by those who completed a 4-year AOE, versus traditional fourth-year fellowship, vs 3-year only. METHODS: We surveyed each graduate who started residency from 2007-2016 on their scope of practice. We also searched each graduate via Google to identify each of their practice sites and ascertain their status as a Health Professional Shortage Area (HPSA) or Medically Underserved Area for primary care (MUA-P). RESULTS: Of the 220 residents who entered the program as interns, 70 completed an integrated AOE (31.8%), 54 completed 3 years of training with a traditional fourth-year fellowship (24.5%, 40 at JPS, 14 at another location), and 93 completed only 3 years of training (42.3%). The overall percentage of JPS graduates who work in the United States (n=201) in HPSAs or MUA-Ps is similar to national numbers (45.3% vs 43.5% for HPSAs, 35.3% vs 33.3% for MUA-Ps). Graduates of a JPS integrated AOE track were more likely to work in a HPSA or MUA-P than other graduates (81.4% vs 38.5% traditional fellowship vs 45.6% 3-year only, P<.001; US practice sites only). Graduates of sports medicine fellowships were particularly less likely to work in HPSAs/MUA-Ps than other graduates (26.1%). Graduates of integrated AOEs provided much broader scopes of cognitive and procedural services than fellowship or 3-year graduates. CONCLUSIONS: In JPS graduates, 4 years of training with an integrated AOE had a large association with serving vulnerable populations, and providing broader cognitive and procedural services.

Geographic differences in community oncology provider and practice location characteristics in the central United States.

PURPOSE: How care delivery influences urban-rural disparities in cancer outcomes is unclear. We sought to understand community oncologists' practice settings to inform cancer care delivery interventions. METHODS: We conducted secondary analysis of a national dataset of providers billing Medicare from June 1, 2019 to May 31, 2020 in 13 states in the central United States. We used Kruskal-Wallis rank and Fisher's exact tests to compare physician characteristics and practice settings among rural and urban community oncologists. FINDINGS: We identified 1,963 oncologists practicing in 1,492 community locations; 67.5% practiced in exclusively urban locations, 11.3% in exclusively rural locations, and 21.1% in both rural and urban locations. Rural-only, urban-only, and urban-rural spanning oncologists practice in an average of 1.6, 2.4, and 5.1 different locations, respectively. A higher proportion of rural community sites were solo practices (11.7% vs 4.0%, P<.001) or single specialty practices (16.4% vs 9.4%, P<.001); and had less diversity in training environments (86.5% vs 67.8% with <2 medical schools represented, P<.001) than urban community sites. Rural multispecialty group sites were less likely to include other cancer specialists. CONCLUSIONS: We identified 2 potentially distinct styles of care delivery in rural communities, which may require distinct interventions: (1) innovation-isolated rural oncologists, who are more likely to be solo providers, provide care at few locations, and practice with doctors with similar training experiences; and (2) urban-rural spanning oncologists who provide care at a high number of locations and have potential to spread innovation, but may face high complexity and limited opportunity for care standardization.

Whole of Community Facilitators: An Exemplar for Supporting Rural Health Workforce Recruitment through Students' Professional Experience Placements.

The Whole of Community Facilitator model provides support for healthcare students' professional experience placements (PEP) in rural regions in Tasmania. In Tasmania, rural PEP is challenged as healthcare facilities are often small and have limited capacity for staff to devote considerable time to supervising students during PEP. Recruitment and retention of the rural health workforce in Tasmania is sometimes difficult because the island State is geographically distant from mainland Australia, and predominantly classified as a regional, rural, or remote area. The University of Tasmania, College of Health and Medicine (the College) explored various initiatives to support rural workforce sustainability, and the project discussed addresses this issue by promoting rural healthcare facilities as potential employment destinations for students upon completion of their course. The model supports the delivery of high-quality supervision to students whilst undertaking rural PEP, to foster positive experiences and potentially influence their future career choices. A successful exemplar was trialled in 2012 and implemented statewide in 2017 using a Whole of Community Facilitation (WOCF) model. The initiative supports host facilities, supervisors, host staff, and students and promotes positive placement experiences. The initiative was designed in consideration of Tasmania's rurality, and uses a flexible and responsive framework.

National variation in the delivery of radiation oncology procedures in the non-facility-based setting.

PURPOSE: Though utilization of medical procedures has been shown to vary considerably across the United States, similar efforts to characterize variation in the delivery of radiation therapy (RT) procedures have not been forthcoming. Our aim was to characterize variation in the delivery of common RT procedures in the Medicare population. We hypothesized that delivery would vary significantly based on provider characteristics. METHODS: The Centers for Medicare and Medicaid Services (CMS) Physician and Other Supplier Public Use File was linked to the CMS Physician Compare (PC) database by physician NPI to identify and sum all treatment delivery charges submitted by individual radiation oncologists in the non-facility-based (NFB) setting in 2016. Multivariable logistic regression analysis was carried out to determine provider characteristics (gender, practice rurality, practice region, and years since graduation) that predicted for the delivery of 3D conformal RT (3DCRT), intensity modulated RT (IMRT), stereotactic body RT (SBRT), stereotactic radiosurgery (SRS), low dose rate (LDR) brachytherapy, and high dose rate (HDR) brachytherapy delivery in the Medicare patient population. The overall significance of categorical variables in the multivariable logistic regression model was assessed by the likelihood ratio test (LRT). RESULTS: In total, 1,802 physicians from the NFB practice setting were analyzed. Male gender predicted for greater LDR brachytherapy delivery (OR 8.19, 95% CI 2.58-26.05, p < 0.001), but not greater delivery of other technologies. Metropolitan practice was the only predictor for greater HDR brachytherapy utilization (OR 12.95, 95% CI 1.81-92.60, p = 0.01). Practice region was predictive of the delivery of 3DCRT, SRS and SBRT (p < 0.01, p < 0.001, and p < 0.001, respectively). With the Northeast as the reference region, 3DCRT was more likely to be delivered by providers in the South (OR 1.33, 95% CI 1.09-1.62, p < 0.01) and the West (OR 1.38, 95% CI 1.11-1.71, p < 0.01). At the same time, SRS use was less likely in the Midwest (OR 0.71, 95% CI 0.55-0.91, p < 0.01), South (OR 0.49, 95% CI 0.40-0.61, p < 0.001), and West (OR 0.43, 95% CI 0.34-0.55, p < 0.001). SBRT, on the other hand, was more commonly utilized in the Midwest (OR 2.63, 95% CI 1.13-6.13, p = 0.03), South (OR 3.44, 95% CI 1.58-7.49, p < 0.01), and West (OR 4.87, 95% CI 2.21-10.72, p < 0.001). HDR brachytherapy use was also more likely in the Midwest (OR 1.97, 95% CI 1.11-3.49, p = 0.02) and West (OR 1.87, 95% CI 1.08-3.24, p = 0.03). While the degree held by the billing physician did not predict for delivery of a given procedure, greater years since graduation was related to decreased likelihood of SBRT use (OR 0.98, 95% CI 0.96-0.99, p < 0.001) and increased likelihood of LDR brachytherapy use (OR 1.02, 95% CI 1.00-1.04, p = 0.02). CONCLUSIONS: Substantial geographic variation in the use of specific RT technologies was identified. The degree to which this variation reflects effective care, preference-sensitive care, or supply-sensitive care warrants further investigation.

Effects of the Affordable Care Act Medicaid Expansion on the Distribution of New General Internists Across States.

BACKGROUND: Some states expanded Medicaid under the Affordable Care Act, boosting their low-income residents' demand for health care, while other states opted not to expand. OBJECTIVE: The objective of this study was to determine whether the Medicaid expansion influenced the states selected by physicians just completing graduate medical education for establishing their first practices. RESEARCH DESIGN: Using 2009-2019 data from the American Medical Association Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following implementation of the expansion to where they located during the 5 years preceding implementation. SUBJECTS: The sample consisted of 160,842 physicians in 8 specialty groups. RESULTS: Thirty-three states and the District of Columbia expanded Medicaid by the end of the study period. Compared with preexpansion patterns, we found that physicians in one specialty group-general internal medicine-were increasingly likely to locate in expansion states with time after the expansion. The Medicaid expansion influenced the practice location choices of men and international medical graduates in general internal medicine; women and United States medical graduates did not alter their preexpansion location patterns. Simulations estimated that, between 2014 and 2019, nonexpansion states lost 310 general internists (95% confidence interval, 156-464) to expansion states. CONCLUSIONS: The Medicaid expansion influenced the practice location choices of new general internists. States that opted not to expand Medicaid under the Affordable Care Act lost general internists to expansion states, potentially affecting access to care for all their residents irrespective of insurance coverage.

Comparison of General Surgical Practice Size and Setting in 2017 vs 2013 in the US.

Importance: As health care delivery markets have changed and new payment models have emerged, physicians in many specialties have consolidated their practices, but whether this consolidation has occurred in surgical practices is unknown. Objective: To examine changes in the size of surgical practices, market-level factors associated with this consolidation, and how place of service for surgical care delivery varies by practice size. Design, Setting, and Participants: A cross-sectional study of Medicare Data on Provider Practice and Specialty from January 1 to December 31, 2013, compared with January 1 to December 31, 2017, was conducted on all general surgeon practices caring for patients enrolled in Medicare in the US. Data analysis was performed from November 4, 2019, to January 9, 2020. Exposures: Practice sizes in 2013 and 2017 were compared relative to hospital market concentration measured by the Herfindahl-Hirschman Index in the hospital referral region. Main Outcomes and Measures: The primary outcome was the change in size of surgical practices over the study period. Secondary outcomes included change in surgical practice market concentration and the place of service for provision of surgical care stratified by surgical practice size. Results: From 2013 to 2017, the number of surgical practices in the US decreased from 10 432 to 8451. The proportion of surgeons decreased in practices with 1 (from 26.2% to 17.4%), 2 (from 8.3% to 6.6%), and 3 to 5 (from 18.0% to 16.5%) surgeons, and the proportion of surgeons in practices with 6 or more surgeons increased (from 47.6% to 59.5%). Hospital concentration was associated with an increase in the size of the surgical practice. Each 10% increase in the hospital market concentration was associated with an increase of 0.204 surgeons (95% CI, 0.020-0.388 surgeons; P = .03) per practice from 2013 to 2017. Similarly, a 10% increase in the hospital-level HHI was associated with an increase in the surgical practice HHI of 0.023 (95% CI, 0.013-0.033; P < .001). Large surgical practices increased their share of Medicare services provided from 36.5% in 2013 to 45.6% in 2017. Large practices (31.3% inpatient in 2013 to 33.1% in 2017) were much more likely than small practices (19.0% inpatient in 2013 to 17.7% in 2017) to be based in hospital settings and this gap widened over time. Conclusions and Relevance: Surgeons have increasingly joined larger practices over time, and there has been a significant decrease in solo, small, and midsize surgical practices. The consolidation of surgeons into larger practices appears to be associated with hospital market concentration in the same market. Although overall care appears to be more hospital based for larger practices, the association between the consolidation of surgical practices and patient access and outcomes should be studied.

COVID-19 and doctor emigration: the case of Ireland.

BACKGROUND: Since the 2008 recession, Ireland has experienced large-scale doctor emigration. This paper seeks to ascertain whether (and how) the COVID-19 pandemic might disrupt or reinforce existing patterns of doctor emigration. METHOD: This paper draws on qualitative interviews with 31 hospital doctors in Ireland, undertaken in June-July 2020. As the researchers were subject to a government mandated work-from-home order at that time, they utilised Twitter™ to contact potential respondents (snowball sampling); and conducted interviews via Zoom™ or telephone. FINDINGS: Two cohorts of doctors were identified; COVID Returners (N = 12) and COVID Would-be Emigrants (N = 19). COVID Returners are Irish-trained emigrant doctors who returned to Ireland in March 2020, just as global travel ground to a halt. They returned to be closer to home and in response to a pandemic-related recruitment call issued by the Irish government. COVID Would-be Emigrants are hospital doctors considering emigration. Some had experienced pandemic-related disruptions to their emigration plans as a result of travel restrictions and border closures. However, most of the drivers of emigration mentioned by respondents related to underlying problems in the Irish health system rather than to the pandemic, i.e. a culture of medical emigration, poor working conditions and the limited availability of posts in the Irish health system. DISCUSSION/CONCLUSION: This paper illustrates how the pandemic intensified and reinforced, rather than radically altered, the dynamics of doctor emigration from Ireland. Ireland must begin to prioritise doctor retention and return by developing a coherent policy response to the underlying drivers of doctor emigration.

Factors associated with medical students' interest in remote and very remote practice in Australia: A national study.

OBJECTIVE: To investigate the factors that are associated with medical student interest in remote and very remote practice in Australia. DESIGN: Aggregated data of an annual cross-sectional survey from 2013 to 2017. SETTING: Australia. PARTICIPANTS: Medical students from 17 medical schools, at the point of finishing one year of clinical training in a rural or remote location in Australia. MAIN OUTCOME MEASURES: Intention for working in a remote or very remote location as a doctor. RESULTS: Responses were analysed from 3328 medical students. From this cohort, 37.6%, 54.0% and 7.0% of students reported future career intent in capital or major cities; regional Australia; and remote or very remote Australia respectively. Multivariable analysis indicated students interested in remote and very remote practice compared to those interested in regional practice were more likely to be from a rural background, have prior generalist intentions, felt as though their rural clinical school (RCS) experience increased interest in remote and very remote practice, and had higher rural practice self-efficacy. Odds ratios were larger for these factors when students interested in remote or very remote practice were compared with students interested in practicing in capital or major cities. CONCLUSIONS: Rural background, prior generalist intentions, rural practice self-efficacy and the overall influence of the RCS experience are associated with interest in remote and very remote practice.

"We learnt it, then we lived it": Influencing medical students' intentions toward rural practice and generalist careers via a socially-accountable curriculum.

OBJECTIVE: The James Cook University (JCU) medical school has a mission to produce graduates committed to practising with underserved populations. This study explores the views of final-year students regarding the influence of the JCU medical curriculum on their self-reported commitment to socially-accountable practice, intentions for rural practice, and desired postgraduate training pathway. METHODS: Cross-sectional survey of final year JCU medical students (n = 113; response rate = 65%) to determine whether their future career directions (intentions for future practice rurality and postgraduate specialty training pathway) are driven more by altruism (commitment to socially accountable practice/community service) or by financial reward and/or prestige. RESULTS: Overall, 96% of responding students reported their JCU medical course experiences had cultivated a greater commitment towards 'socially-accountable' practice. A commitment to socially-accountable practice over financial reward and/or prestige was also significantly associated with preferring to practise Medicine in non-metropolitan areas (p = 0.036) and intending to choose a 'generalist' medical discipline (p = 0.003). CONCLUSIONS: The findings suggest the JCU medical curriculum has positively influenced the commitment of its graduating students towards more socially accountable practice. This influence is a likely result of pre-clinical teachings around health inequalities and socially-accountable medical practice in combination with real-world, immersive experiences on rural and international placements.