Associations of the Informal Curriculum and Student Perceptions of Research With Family Medicine Career Choice.

BACKGROUND: The United States is facing a primary care physician shortage that is predicted to continue through the next decade. Determining why graduating medical students pursue a career in family medicine may inform efforts to help address this shortage. METHODS: Medical student responses to the Family Medicine Attitudes Questionnaire (FMAQ), a 14-item validated questionnaire developed to assess student attitudes toward family medicine, were collected at 16 US medical schools and compared to each institution's proportion of graduates entering family medicine. We also analyzed subscales of the FMAQ, including attitudes toward family medicine lifestyle, research, importance, and shortages, with respect to student choice of family medicine. We used Pearson coefficients to calculate correlations. RESULTS: Student attitudes toward family medicine careers were strongly correlated with an institution's proportion of graduates entering family medicine. Positive perceptions of family medicine research by students was the factor most strongly correlated with matching into a family medicine residency. CONCLUSION: Strengthening students' exposures and perceptions of family medicine and family medicine research may create viable opportunities for intervention by departments of family medicine and medical schools seeking to increase the number of graduates entering family medicine.

Institutional Characteristics Influencing Medical Student Selection of Primary Care Careers: A Narrative Review and Synthesis.

BACKGROUND AND OBJECTIVES: There is an ongoing shortage of primary care physicians in the United States. Medical schools are under pressure to address this threat to the nation's health by producing more primary care graduates, including family physicians. Our objective was to identify institutional characteristics associated with more medical students choosing primary care. METHODS: We conducted a systematic literature review with narrative synthesis to identify medical school characteristics associated with increased numbers or proportions of primary care graduates. We included peer-reviewed, published research from the United States, Canada, Australia, and New Zealand. The existing literature on characteristics, including institutional geography, funding and governance, mission, and research emphasis, was analyzed and synthesized into summary statements. RESULTS: Ensuring a strong standing of the specialty of family medicine and creating an atmosphere of acceptance of the pursuit of primary care as a career are likely to increase an institution's percentage of medical students entering primary care. Training on regional campuses or providing primary care experiences in rural settings also correlates with a larger percentage of graduates entering primary care. A research-intensive culture is inversely correlated with primary care physician production among private, but not public, institutions. The literature on institutional financial incentives is not of high enough quality to make a firm statement about influence on specialty choice. CONCLUSIONS: To produce more primary care providers, medical schools must create an environment where primary care is supported as a career choice. Medical schools should also consider educational models that incorporate regional campuses or rural educational settings.

How Medical Education Pathways Influence Primary Care Specialty Choice.

BACKGROUND AND OBJECTIVES: Primary care is associated with improved patient health and reductions in health disparities. Consequently, the demand for primary care physicians is increasing. To meet this demand, medical schools have employed strategies to graduate students interested in primary care careers, including medical education pathways-structured, longitudinal experiences that are explicitly separate from the main curricular scope of the undergraduate medical education experience. Our goal was to explore and identify common characteristics of medical education pathways that influence primary care specialty choice. METHODS: Using research articles identified through a scoping review, we performed a qualitative content analysis of studies that evaluated the impact of medical education pathways on medical students' choices of primary care careers. RESULTS: Sixty-three papers described 43 medical education pathways; most studies used quantitative methods to describe outcomes. Program characteristics mapped onto five levels of an emerging socioecological model: state or national, community, institutional, relational, and individual. CONCLUSIONS: Successful medical education pathway programs complement a medical school curriculum that supports a common goal, and demonstrate multiple levels of structural and institutional factors that develop community connectedness, relatedness, and longitudinal community engagement in students. Further work is needed to better understand how each of these levels influence career choice and to reassess how to measure and report medical education outcomes that will more accurately predict the student choice of primary care careers.

The Impact of Family Medicine Interest Groups and Student-Run Free Clinics on Primary Care Career Choice: A Narrative Synthesis.

BACKGROUND AND OBJECTIVES: Student-directed activities such as family medicine interest groups (FMIG) and student-run free clinics (SRFC) have been examined to discover their impact on entry into family medicine and primary care. The objective of this review was to synthesize study results to better incorporate and optimize these activities to support family medicine and primary care choice. METHODS: We conducted a comprehensive literature search using PubMed, Scopus, and CINAHL to identify all English-language research articles on FMIG and SRFC. We examined how participation relates to entry into family medicine and primary care specialties. Exclusion criteria were nonresearch articles, review articles, and research conducted outside the United States, Canada, Australia, and New Zealand. We used a 16-point quality rubric to evaluate 18 (11 FMIG, seven SRFC) articles that met our criteria. RESULTS: Of the nine articles that examined whether FMIG participation impacted entry into family medicine, five papers noted a positive relationship, one paper noted unclear correlation, and three papers noted that FMIG did not impact entry into family medicine. Of the seven articles about SRFC, only one showed a positive relationship between SRFC activity and entry into primary care. CONCLUSIONS: Larger-scale and higher quality studies are necessary to determine the impact of FMIG and SRFC on entry into family medicine and primary care. However, available evidence supports that FMIG participation is positively associated with family medicine career choice. In contrast, SRFC participation is not clearly associated with primary care career choice.

Influences of Medical School Admissions Practices on Primary Care Career Choice.

BACKGROUND AND OBJECTIVES: Medical schools should understand how to matriculate students who are more likely to enter primary care specialties and put admissions processes into place that achieve this result. However, there are no existing reviews that have systematically evaluated medical school admission practices and primary care specialty choice. METHODS: We conducted a narrative synthesis utilizing a systematic literature search to evaluate the effectiveness of medical school admission strategies designed to increase the percentage of graduates entering primary care specialties. RESULTS: We included 34 articles in the narrative review. Multiple prematriculation programs that appear to produce students with a high likelihood of entering primary care have been described in the literature. However, all of these studies are from single institutions, were observational, and limited by selection bias. Applicants who self-identify an interest in primary care, grew up with a rural background, and are older at matriculation are more likely to enter primary care, with stated interest in primary care being most predictive. Gender and race have been associated with primary care specialty choice in some studies, but not all. Insufficient literature on admissions policies and procedures exists to draw conclusions about best practices. CONCLUSIONS: Medical schools that want to increase the percentage of graduates entering primary care should consider developing a prematriculation program that attracts and prepares motivated and talented students with primary care interest. Admissions committees should understand which demographic criteria are associated with increased likelihood of entering primary care. The most important identifiable trait is an applicant's stated interest in primary care.

Medical School Characteristics, Policies, and Practices That Support Primary Care Specialty Choice: A Scoping Review of 5 Decades of Research.

BACKGROUND AND OBJECTIVES: The United States, like many other nations, faces a chronic shortage of primary care physicians. The purpose of this scoping review was to synthesize literature describing evidence-based institutional practices and interventions that support medical students' choices of primary care specialties, published in the United States, Canada, Australia, and New Zealand. METHODS: We surveyed peer-reviewed, published research. An experienced medical librarian conducted searches of multiple databases. Articles were selected for inclusion based on explicit criteria. We charted articles by topic, methodology, year of publication, journal, country of origin, and presence or absence of funding. We then scored included articles for quality. Finally, we defined and described six common stages of development of institutional interventions. RESULTS: We reviewed 8,083 articles and identified 199 articles meeting inclusion criteria and 41 related articles. As a group, studies were of low quality, but improved over time. Most were quantitative studies conducted in the United States. Many studies utilized one of four common methodologic approaches: retrospective surveys, studies of programs or curricula, large-scale multi-institution comparisons, and single-institution exemplars. Most studies developed groundwork or examined effectiveness or impact, with few studies of planning or piloting. Few studies examined state or regional workforce outcomes. CONCLUSIONS: Research examining medical school interventions and institutional practices to support primary care specialty choice would benefit from stronger theoretical grounding, greater investment in planning and piloting, consistent use of language, more qualitative methods, and innovative approaches. Robust funding mechanisms are needed to advance these goals.

The Relationship Between Medical School Clerkships and Primary Care Specialty Choice: A Narrative Review.

BACKGROUND AND OBJECTIVES: There is a persistent shortage of primary care physicians in the United States. Medical schools can help meet societal primary care health needs by graduating more students who select family medicine and other primary care careers. The objective of this narrative review was to evaluate the relationship between clerkships and primary care specialty choice. METHODS: We conducted a systematic literature search and narrative review of research articles examining the association between clerkships and primary care specialty choice. We evaluated the quality of included articles using a validated scale, assessed for methodology and outcomes, and synthesized using a narrative approach. RESULTS: We identified 59 articles meeting our research criteria. A required primary care clerkship in the core clerkship year was associated with increased primary care specialty choice. This finding was strongest for family medicine clerkships and family medicine specialty choice. Clerkships that were longer, were of higher quality, exposed students to a wider scope of primary care practice, and occurred within an institutional climate supportive of primary care were also correlated with more students choosing a primary care specialty. While student self-reported interest in primary care often increased following a primary care clerkship, this interest was not always sustained or consistently associated with a primary care residency match or primary care career. CONCLUSIONS: Required family medicine and primary care clerkships were correlated with primary care specialty choice. More high-quality research is needed to better understand how to maximize the impact of clerkships on primary care specialty choice.

The Influence of Role Modeling and Mentorship on Primary Care Career Choice: What Can Be Gleaned From 30 Years of Research?

BACKGROUND AND OBJECTIVES: Role modeling and mentoring are key aspects of identity formation in medical school and likely influence student specialty choice. No reviews have examined the ways that mentorship relationships impact primary care career choice. METHODS: We conducted a systematic literature search to identify articles describing the influence of role models and mentorship on primary care interest, intention, or choice. A content analysis of the included articles determined which articles focused on mentorship versus role modeling and the definitions of each. We coded articles as groundwork, effectiveness, or impact depending on the methodology and outcomes of each study. RESULTS: Searches yielded 362 articles, of which 30 met inclusion criteria. Three offered definitions of role modeling, and one compared and contrasted definitions of mentoring; 17 articles laid groundwork that indicated that role modeling and mentorship are important factors in career choice and specifically in primary care. Thirteen articles reported the effectiveness and impact of role modeling and mentoring in influencing intent to enter primary care or actual career choice. Primary care and non-primary care physicians influenced student interest, intent, and choice of primary care careers; this influence could be positive or negative. CONCLUSIONS: Role modeling and mentorship influence primary care career choice. Very few articles defined the studied relationships. More work on the impact of mentorship and role modeling on career choice is needed.

Impact of Curricula and Electives on Primary Care Specialty Choice: A Narrative Synthesis.

BACKGROUND AND OBJECTIVES: Educational components and electives that may influence medical student choice of primary care careers have been studied individually, but not reviewed or synthesized. Examining educational components and electives in a comprehensive manner may inform evidence-based approaches to raise the number of primary care physicians in the United States and help optimize use of finite resources. We sought to determine evidence-based educational components and electives associated with increased medical student choice of primary care careers. METHODS: We searched PubMed, Scopus, and CINAHL for undergraduate medical education articles in English describing an educational component or elective and outcome relevant to primary care specialty choice. We assessed titles, then abstracts, and finally full texts for inclusion in a narrative synthesis. RESULTS: The searches returned 11,211 articles and we found 42 that met the inclusion criteria. The most described components were outpatient clinical rotations, preclinical courses, and preceptorships. The most common electives were international health, summer preceptorships, and rural medicine. While most articles described curricula that appeared to have a positive correlation with primary care specialty choice, six articles found limited benefit. In sum, results were mixed. CONCLUSIONS: The current literature is limited, and many contemporary electives have not been studied with respect to primary care choice. Increased attention and funding to studying the impact of electives and other educational components on primary care specialty choice is warranted.

FMAQ-S: Development of a Short Form of the Family Medicine Attitudes Questionnaire.

INTRODUCTION: Identifying and training students who choose family medicine careers is essential to meeting primary care workforce needs in the United States. Medical students' positive attitudes toward family medicine are associated with students' choice of family medicine as a specialty. This study sought to refine a previously tested questionnaire assessing US medical students' attitudes toward family medicine by shortening the questionnaire to make it more useful in educational practice and research settings. METHODS: We refined our existing 14-item questionnaire by item analysis and validation. We conducted item analysis using a graded response model approach after identifying the unidimensionality of the original scale. We selected items based on their item discrimination parameters and item information levels, and calculated the correlation between specialty choice and family medicine attitudes score to evaluate criterion validity. RESULTS: Exploratory factor analyses indicated the questionnaire is unidimensional. Among the original 14 items, 10 items had high item discrimination parameters and low standard error of measurement. These 10 items contribute the most to distinguishing individuals' differences in family medicine attitudes and were selected for inclusion in the short-form questionnaire (FMAQ-S). The point-biserial correlation between the short-form scale and students' choice of family medicine was 0.378, which provides supporting evidence for criterion validity. CONCLUSION: The FMAQ-S is a concise and validated measure for assessing medical student attitudes toward family medicine. This abbreviated questionnaire can be used by medical educators to identify students for specific programming or interventions intended to support family medicine specialty choice.

Examining Access to Psychiatric Care in Michigan's Upper Peninsula.

INTRODUCTION: There is a shortage of mental health services in rural America, and little research is focused on rural underserved communities. Our aim was to identify and map clinical mental health services located in the Upper Peninsula of Michigan (UP) and explore primary care physician (PCP) mental health service provision and barriers to access experienced by this population. METHODS: We mapped clinically active psychiatrists and inpatient psychiatric units in the UP, and identified high-risk regions based on >30 mile distance to ambulatory services or low inpatient bed to population ratio. We surveyed PCPs in identified high-risk areas regarding provision of mental health services, comfort with providing services, and perceived barriers to care. RESULTS: Half of UP counties had no psychiatrists, and only two counties had inpatient psychiatric beds. PCPs are attempting to fill gaps in care, and report comfort with treating depression and anxiety, but less comfort with treating with bipolar disorder and substance use. Nearly all PCPs report barriers to accessing mental health resources; 70% report no psychiatrists to whom they can readily refer. CONCLUSION: Michigan's UP has a shortage of mental health resources. Proposed strategies to confront this shortage include additional training of PCPs for substance use and bipolar disorder, bolstering the mental health workforce, and improving access to consultative services.

Education and Attitudes on Medical Cannabis in Family Medicine Residency Programs.

BACKGROUND AND OBJECTIVES: Medical cannabis has become increasingly prevalent in the United States, however the extent of family medicine resident education on this topic remains unknown. The objective of this study was to ascertain the current state of medical cannabis education across this population and identify patterns in education based on state legality and program director (PD) practices. METHODS: Survey questions were part of the Council of Academic Family Medicine Educational Research Alliance (CERA) omnibus survey from May 2019 to July 2019. PDs from all Accreditation Council for Graduate Medical Education (ACGME)-accredited US family medicine residency programs received survey invitations by email. RESULTS: A total of 251 (40.7%) PDs responded, with 209 (83.6% [209/250]) reporting at least 1 hour of didactic curriculum regarding cannabis. The most common context was substance misuse (mean 3.0±4.1 hours per 3 years), followed by pain management (2.7±3.4 hours), and management of other conditions (2.1±2.7 hours). Thirty-eight programs (15.2% [38/250]) offered clinical experiences related to medical cannabis, and PDs who had previously prescribed or recommended medical cannabis were more likely to offer this experience (P<.0001). Experiences peaked after 3 to 5 years of medical cannabis legality. PD confidence in resident counseling skills was low overall, but did increase among programs with clinical experiences (P=.0033). CONCLUSIONS: The current trajectory of medical cannabis use in the United States makes it likely that residents will care for patients interested in medical cannabis, therefore it is important residents be prepared to address this reality. Opportunities exist for improving medical cannabis education in family medicine residency programs.

Attitudes Toward Family Medicine Among Students Choosing Other Primary Care Specialties.

BACKGROUND AND OBJECTIVES: Little is known about how medical students choose between primary care specialties. We compared the attitudes toward family medicine of medical students intending to practice primary care but not family medicine (PCNFM), with students intending to practice family medicine (FM) and those intending nonprimary care (NPC) careers. METHODS: The Family Medicine Attitudes Questionnaire (FMAQ) was distributed to 2,644 fourth-year medical students at 16 medical schools in spring 2017. Respondents were stratified by career intention. In this secondary data analysis, we used descriptive statistics to characterize responses to each questionnaire item and FMAQ total score, and analysis of variance with Bonferroni post hoc analyses to compare category and item mean responses. RESULTS: Of 2,644 fourth-year medical students who received the FMAQ, 1,188 (41.8%) submitted usable responses. The 14-item FMAQ has a maximum score of 70. Mean total scores differed by category: 59.05 for FM, 52.88 for NPC, and 54.83 for PCNFM (F=108.96, P<.01); the differences between each possible pairing were significant (P<.05). Comparing the responses of students intending PCNFM careers with those of students intending NPC careers, there were no differences in mean responses for 8 of 14 FMAQ items. Responses of students intending PCNFM careers were similar to students intending FM for only 4 of 14 items (P<.05). CONCLUSIONS: Fourth-year students intending to match into PCNFM have attitudes toward FM that more closely approximate the attitudes of NPC students than the attitudes of FM students. Future research should explore implications for curricular development, student mentorship, and career advising.

Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities.

Telehealth programs have long held promise for addressing rural health disparities perpetuated by inadequate healthcare access. The COVID-19 (coronavirus disease 2019) pandemic and accompanying social distancing measures have hastened the implementation of telehealth programs in hospital systems around the globe. Here, we provide specific examples of telehealth efforts that have been implemented in a large rural healthcare system in response to the pandemic, and further describe how the massive shift to telehealth and reliance on virtual connections in these times of social isolation may impact rural health disparities for those without access to necessary broadband to deploy digital technologies. Finally, we provide recommendations for researchers and policymakers to ensure that telehealth initiatives do not amplify existing health disparities experienced by those living in rural communities.

Trends in Subspecialization: A Comparative Analysis of Rural and Urban Clinical Education.

BACKGROUND AND OBJECTIVES: Medical students who train in rural communities are often exposed to physicians practicing a broad scope of care, regardless of discipline. We examined how rural education is associated with practice specialization rates for students who match in primary care or general core specialties. METHODS: We linked practice and specialty data (2016 AMA Masterfile dataset), demographics (American Medical College Application Service data), and internal college data for 1974-2011 Michigan State University College of Human Medicine graduates who received clinical education on either the Upper Peninsula (rural) or Grand Rapids (urban) campuses. Current practice was verified using internet searches. We compared specialty and practice data by rural or urban campus, controlling for multiple variables. RESULTS: More rurally-trained graduates entered primary care (PC) residencies (128/208, 61.5%) than urban-trained graduates (457/891, 51.3%; P<.01), with rurally-trained graduates being twice as likely to enter family medicine (FM) residencies. Most FM residents remained PC physicians (205/219, 93.6%). Internal medicine residents were least likely to remain in primary care (91/189, 48.1%). Of the general core disciplines, general surgeons were least likely to remain in general surgical practice (45/134, 33.6%). Within each PC or general core discipline, the proportion of graduates who specialized did not differ by type of campus. CONCLUSIONS: Rurally-trained graduates are more likely to practice primary care, chiefly due to increased likelihood of choosing a FM residency. Graduates entering PC or general core residencies subspecialize at similar rates regardless of rural or urban education. FM residency match rate may be the best predictor of long-lasting impact on the primary care workforce.

Defining Rural: The Predictive Value of Medical School Applicants' Rural Characteristics on Intent to Practice in a Rural Community.

PURPOSE: To understand the predictive value of medical student application characteristics on rural practice intent. METHOD: The authors constructed a linked database of 2012-2017 medical school matriculants from American Medical College Application Service applications and Association of American Medical Colleges Matriculating Student Questionnaire (MSQ, 2012-2017) and Graduation Questionnaire (GQ, 2016-2018). Using logistic regression, they compared application variables (birth, high school, childhood county, and self-declared geographical origin) to students' MSQ and GQ intent to practice rurally. Rural practice intent from matriculation to graduation was compared using the McNemar test for paired nominal data. RESULTS: The number of students meeting inclusion criteria was 115,027. More students self-declared rural origin (18,662; 16.4%) than were identified using geographically coded variables (6,097-8,784; 6.1%-8.1%). Geographically coded rural variables were all strongly and similarly associated with rural practice intent, with rural high school being the most predictive on both MSQ (odds ratio [OR], 6.51; CI, 6.1-7.0) and GQ (OR, 5.4; CI, 4.9-6.0). Self-declared geographical origin was associated with a similar rural practice intent on both MSQ (OR, 6.93; CI, 6.5-7.3) and GQ (OR, 5.69; CI, 5.2-6.2). Rural practice intent declined for all groups from matriculation to graduation. CONCLUSIONS: Considering students who self-declare as rural identifies a larger group of rural medical school applicants than more "objective" geographic variables, without negatively impacting students' predicted interest in eventual rural practice. Further research should track actual practice location and explore strategies to mitigate declining rural career interest.

The Effect of a Community-Based Medical School on the State and Local Physician Workforce.

PURPOSE: To assess the effect of community-based medical education as implemented by Michigan State University College of Human Medicine (MSU-CHM), which has immersed students in diverse communities across Michigan since its founding, on the physician workforce in the six communities in which clinical campuses were initially established. METHOD: The authors used American Medical Association Masterfile data from 2011 to obtain practice locations and specialty data for all MSU-CHM graduates from 1972 through 2006. They classified physicians as either practicing primary care or practicing in a high-need specialty. Using Geographic Information Systems software, the authors geocoded practice locations to the ZIP Code level, evaluated whether the practice was within a Health Professional Shortage Area, and determined rurality, using 2006 Rural-Urban Commuting Area Code data. They visually compared maps of the footprints of each campus to glean insights. RESULTS: The authors analyzed 3,107 of 3,309 graduates (94%). Of these, 635 (20%) practiced within 50 miles of their medical school campus. Saginaw and Flint graduates were more likely to practice in Detroit and its surrounding suburbs, reflecting these communities' urban character. Grand Rapids, the community with the strongest tertiary medical care focus, had the lowest proportions of rural and high-need specialty graduates. CONCLUSIONS: This case study suggests that distributed medical education campuses can have a significant effect on the long-term regional physician workforce. Students' long-term practice choices may also reflect the patient populations and specialty patterns of the communities where they learn.

Preparing Family Physicians to Care for Underserved Populations: A Historical Perspective.

BACKGROUND: Family physicians have been involved in the care of rural and urban underserved populations since the founding of the specialty. In the early 1970s family medicine training programs specifically focused on training residents to work with the underserved were established in both urban and rural settings. Key to the success of these programs has been a specific focus on improving access to care, understanding and eliminating health disparities, cultural competency and behavioral science training that recognizes the challenges often faced by patients and families living in poor rural and urban areas of the country. In keeping with a focus on the underserved, several urban underserved residencies also became national models for the provision of primary care to patients and families affected by HIV/AIDS. Family medicine training programs focused on the underserved have resulted in the development of a cohort of family physicians who care for those most in need in the United States. Despite these achievements, persistent challenges remain in providing adequate access to care for many living in rural and inner city settings. New strategies will need to be developed by family medicine programs and others to better meet these challenges.