Understanding the burden of colorectal cancer in a three-county rural region of Michigan: an ecological analysis of incidence, mortality, and risk factors.

PURPOSE: Our aim was to identify whether known colorectal cancer (CRC) risk factors contribute to the high CRC burden in Michigan's Thumb region, a 3-county agricultural rural area in eastern Michigan. METHODS: We examined county-level invasive CRC incidence and mortality rates (2000-2017) from the Michigan Cancer Surveillance Program and county-level data on CRC risk factors from publicly available datasets. Prevalence of CRC risk factors in the Thumb region were compared to Michigan's other rural and urban regions using ANOVA (Analysis of Variance) tests. Multivariable linear regression models with stepwise selection were used to assess whether living in the Thumb region was associated with increased CRC incidence, mortality, and late-stage diagnoses after accounting for other risk factors. RESULTS: Living in the Thumb region (ß = 10.4, p = 0.0003), obesity (ß = 36.9, p = 0.04), and an unhealthy food environment (ß = - 2.7, p = 0.003) were associated with higher CRC incidence. Smoking (ß = 67.3, p < 0.0001), being uninsured (ß = - 29.9%, p = 0.03), living in the Thumb region (ß = 2.47, p = 0.03), lower colonoscopy screening (ß = - 0.14, p = 0.01), and older age (ß = 0.11, p = 0.006) were associated with higher CRC mortality. The percent of late-staged CRC diagnoses was significantly lower in the Thumb region than other rural and urban areas of the state (52.9%, 58.3%, and 54.6%, respectively, p = 0.03). CONCLUSION: Findings suggest that living in Michigan's Thumb region is associated with higher CRC incidence and mortality compared to Michigan's other rural and urban regions, even after controlling for known risk factors. More studies on individual-level demographic, environmental, tumor, and treatment characteristics (e.g., treatment differences, water quality, pesticide use) are needed to further characterize these findings.

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.

Predictors of Primary Care Practice Among Medical Students at the Michigan State University College of Human Medicine.

INTRODUCTION: This study examines the evolution of student and physician interest in primary care from medical school matriculation to practice, focusing on student factors that potentiate primary care (PC) practice. METHODS: We compiled a dataset of 2,047 Michigan State University College of Human Medicine graduates from 1991 to 2010. PC interest was assessed using the Association of American Medical Colleges (AAMC) matriculating student (MSQ) and graduation (GQ) questionnaires. PC practice was determined using AMA physician Masterfile data. C2 analyses and logistic regression were used to examine factors that predict PC practice. RESULTS: PC interest at matriculation and at graduation were the factors most likely to predict PC practice. After controlling for URM status, gender, and rural origin, the odds of practicing PC among those with a sustained interest in PC (on both the MSQ and GQ) were 100 times higher than those with no interest in PC, on either survey (P < .01). Among those students who developed an interest in PC by graduation, the odds of practicing PC were 60 times higher than noninterested students (P < .01). Finally, among students who were interested in PC at matriculation, but not graduation, the odds of eventually practicing PC were 3.8 times higher than noninterested students (P < .01). CONCLUSIONS: Our study suggests that cultivating PC interest at any point during medical school may predict PC practice. Early and sustained interest in primary care was the most substantial predictor of PC practice in our study, highlighting the need for primary care education even before medical school matriculation.

Family Medicine's Gender Pay Gap.

Female physicians earn less than their male counterparts, and many explanatory factors have been offered to account for these differences. An analysis of the 2019 American Board of Family Medicine New Graduate Survey Data demonstrates that women make 16% less than men, regardless of experience or hours worked.

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.

Access to maternity and prenatal care services in rural Michigan.

BACKGROUND: The United States physician shortages affect rural health care access, including maternity care. Project aims were to identify and characterize prenatal and delivery care in Michigan's rural counties and to explore access to trial of labor after cesarean (TOLAC) services for women in rural Michigan. METHODS: Descriptive, cross-sectional design used 2015 Medicaid claims data and public health plan information to identify maternity care services provided within Michigan's rural counties. Publicly available health plan information was used to identify rural maternity hospitals and prenatal care practitioners; findings were verified by Internet searches and telephone interviews. Medicaid claims data were used to determine services provided. High-risk geographic areas were defined as those where women needed to travel >30 miles for maternity-related care. Expected TOLAC rate was determined based on published national birth data; rural hospitals were stratified based on whether they met the expected TOLAC rate, delivered 20%-60% of expected rate, or billed ≤1 TOLAC birth to Medicaid in 2015. RESULTS: In Michigan's 57 rural counties, only 29 hospitals provide maternity care. Geographic high-risk areas were identified in the Upper Peninsula and northeast Lower Peninsula of Michigan. Only two rural hospitals billed for the expected rate of TOLAC births; six delivered at a lower rate, and the remaining 21 hospitals provided no TOLAC services, resulting in large areas of the state where women were not offered this option locally. CONCLUSIONS: Maternity care services are limited for many rural Michigan women. Findings can be used to target specific strategies to improve access to care for these women. Similar analyses, exploring patterns of maternity care delivery in other rural regions worldwide, may uncover similar or additional inequities.

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.

Brain Health: Attitudes towards Technology Adoption in Older Adults.

(1) Background: There is increasing scholarly support for the notion that properly implemented and used, technology can be of substantial benefit for older adults. Use of technology has been associated with improved self-rating of health and fewer chronic conditions. Use of technology such as handheld devices by older adults has the potential to improve engagement and promote cognitive and physical health. However, although, literature suggests some willingness by older adults to use technology, simultaneously there are reports of a more cautious attitude to its adoption. Our objective was to determine the opinions towards information technologies, with special reference to brain health, in healthy older adults either fully retired or still working in some capacity including older adult workers and retired adults living in an independent elderly living community. We were especially interested in further our understanding of factors that may play a role in technology adoption and its relevance to addressing health related issues in this population; (2) Methods: Two focus groups were conducted in an inner-city community. Participants were older adults with an interest in their general health and prevention of cognitive decline. They were asked to discuss their perceptions of and preferences for the use of technology. Transcripts were coded for thematic analysis; (3) Results: Seven common themes emerged from the focus group interviews: physical health, cognitive health, social engagement, organizing information, desire to learn new technology, advancing technology, and privacy/security; and (4) Conclusions: This study suggests that in order to promote the use of technology in older adults, one needs to consider wider contextual issues, not only device design per se, but the older adult's rationale for using technology and their socio-ecological context.

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.