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.

Impact of Primary Care Exception Expansion on Family Medicine Resident Billing During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: The Medicare Primary Care Exception (PCE) permits indirect supervision of residents performing lower-complexity visits in primary care settings. During the COVID-19 pandemic, Medicare expanded the PCE to all patient visits regardless of complexity. This study investigates how PCE expansion changed resident billing practices at a family medicine residency during calendar year 2020. We hypothesized that residents not constrained by the PCE would bill more high-level visits. METHODS: We queried billing codes from attendings' and residents' established evaluation and management visits associated with the University of Washington Family Medicine Residency (UWFMR) from January to December 2020. We used χ2 tests to compare resident and attending physicians' use of low/moderate and high-level codes by quarter. RESULTS: Resident high-complexity code use increased after PCE expansion in Q4 (odds ratio [OR] 3.50 [2.34-5.23]) compared to Q1. No change was observed among attending physicians (OR 1.05 [0.86-1.28]). Resident and attending billing patterns became more similar following PCE expansion. CONCLUSIONS: With the PCE expansion, senior family medicine resident physicians at UWFMR used higher-complexity billing codes at a rate approximating that of attending physicians. The findings of this study have implications regarding the financial well-being and sustainability of primary care residency training and raise a relevant policy question about whether the PCE expansion should persist. More research is needed to determine whether these findings were replicated in other primary care residency practices, the impact on resident education, and the impact on patient outcomes.

Understanding and Overcoming Barriers to Rural Obstetric Training for Family Physicians.

BACKGROUND AND OBJECTIVES: Family physicians are the most common health professional providing rural obstetric (OB) care, but the number of family physicians practicing OB is declining. To address rural/urban disparities in parental and child health, family medicine must provide robust OB training to prepare family physicians to care for parent-newborn dyads in rural communities. This mixed-methods study aimed to inform policy and practice solutions. METHODS: We surveyed 115 rural family medicine residency programs (program directors, coordinators, or faculty) and conducted semistructured interviews with personnel from 10 rural family medicine residencies. We calculated descriptive statistics and frequencies for survey responses. Two authors conducted a directed content analysis of qualitative survey and interview responses. RESULTS: The survey yielded 59 responses (51.3%); responders and nonresponders were not significantly different by geography or program type. Most programs (85.5%) trained residents to provide comprehensive prenatal and postpartum care. Continuity clinic sites were predominantly rural across all years and OB training was largely rural in postgraduate year 2 (PGY2) and PGY3. Almost half of programs listed "competition with other OB providers" (49.1%) and "shortage of family medicine faculty providing OB care" (47.3%) as major challenges. Individual programs tended to report either few challenges or multiple challenges. In qualitative responses, common themes included the importance of faculty interest and skill, community and hospital support, volume, and relationships. CONCLUSIONS: To improve rural OB training, our findings support prioritizing relationships between family medicine and other OB clinicians, sustaining family medicine OB faculty, and developing creative solutions to interrupt cascading and interrelated challenges.

A Match Made in Rural: Interpreting Match Rates and Exploring Best Practices.

BACKGROUND AND OBJECTIVES: Although rural family medicine residency programs are effective in placing trainees into rural practice, many struggle to recruit students. Lacking other public measures, students may use residency match rates as a proxy for program quality and value. This study documents match rate trends and explores the relationship between match rates and program characteristics, including quality measures and recruitment strategies. METHODS: Using a published listing of rural programs, 25 years of National Resident Matching Program data, and 11 years of American Osteopathic Association match data, this study (1) documents patterns in initial match rates for rural versus urban residency programs, (2) compares rural residency match rates with program characteristics for match years 2009-2013, (3) examines the association of match rates with program outcomes for graduates in years 2013-2015, and (4) explores recruitment strategies using residency coordinator interviews. RESULTS: Despite increases in positions offered over 25 years, the fill rates for rural programs have improved relative to urban programs. Small rural programs had lower match rates relative to urban programs, but no other program or community characteristics were predictors of match rate. Match rates were not indicative of any of five measures of program quality nor of any single recruiting strategy. CONCLUSIONS: Understanding the intricacies of rural residency inputs and outcomes is key to addressing rural workforce gaps. Match rates likely reflect challenges of rural workforce recruitment generally and should not be conflated with program quality.

Rural Versus Urban Family Medicine Residency Scope of Training and Practice.

BACKGROUND AND OBJECTIVES: Little is known about how rural and urban family medicine residencies compare in preparing physicians for practice. This study compared the perceptions of preparation for practice and actual postgraduation scope of practice (SOP) between rural and urban residency program graduates. METHODS: We analyzed data on 6,483 early-career, board-certified physicians surveyed 2016-2018, 3 years after residency graduation, and 44,325 later-career board-certified physicians surveyed 2014-2018, every 7 to 10 years after initial certification. Bivariate comparisons and multivariate regressions of rural and urban residency graduates examined perceived preparedness and current practice in 30 areas and overall SOP using a validated scale, with separate models for early-career and later-career physicians. RESULTS: In bivariate analyses, rural program graduates were more likely than urban program graduates to report being prepared for hospital-based care, casting, cardiac stress tests, and other skills, but less likely to be prepared in some gynecologic care and pharmacologic HIV/AIDS management. Both early- and later-career rural program graduates reported broader overall SOPs than their urban-program counterparts in bivariate analyses; in adjusted analyses this difference remained significant only for later-career physicians. CONCLUSIONS: Compared with urban program graduates, rural graduates more often rated themselves prepared in several hospital care measures and less often in certain women's health measures. Controlling for multiple characteristics, only rurally trained, later-career physicians reported a broader SOP than their urban program counterparts. This study demonstrates the value of rural training and provides a baseline for research exploring longitudinal benefits of this training to rural communities and population health.

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.

Exploration of Remote Didactics at Rural Family Medicine Training Programs.

BACKGROUND AND OBJECTIVES: Distance learning is a feasible and effective method of delivering education, especially in rural settings. Few studies focus on remote learning in graduate medical education. This study explores remote didactic practices of rural family medicine programs in the United States. METHODS: We conducted an electronic survey of rural family medicine residency site directors across the United States. We completed sample analyses through descriptive statistics with an emphasis on descriptions of current didactic practices, facilitators, and challenges to implementation. RESULTS: The overall response rate was 38% (47/124) for all participants from rural residency programs, representing 28 states. About 24% of rural training track (RTT) participants reported no shared remote didactics between urban and rural sites. More than half of RTT participants (52%) reported remote virtual didactics were either not shared between urban and rural site or were shared less than 50% of the time. Top challenges to implementing remote shared didactics were lack of appropriate technology (31%) and lack of training for faculty and residents in delivery of remote didactics (31%). Top facilitators included having technology for the remote connection (54%), a faculty champion (42%), and designated time to develop the curriculum (38%). CONCLUSIONS: There is potential for improving shared remote didactic sessions between rural and urban sites for family medicine RTTs, which may enhance efficiency of curriculum development across sites and maximize opportunities for bidirectional learning between urban and rural sites.

Gender Differences in Authorship of Family Medicine Publications, 2002-2017.

BACKGROUND AND OBJECTIVES: Representation of women in medicine is increasing, including in academic family medicine. Despite this, women continue to hold a minority of senior faculty and leadership roles. This study examines the trends of women first and senior authorship between 2002 and 2017 in five family medicine journals: Family Medicine, Journal of Family Practice, Journal of the American Board of Family Medicine, Annals of Family Medicine, and American Family Physician. The study also examines gender congruence between first and senior authors and women's membership on editorial boards. METHODS: We collected and analyzed data on a total of 1,671 original articles published in the five family medicine journals in 2002, 2007, 2012, and 2017. We also examined the gender composition of the journals' editorial boards. RESULTS: Overall, women first authorship increased significantly from 32.6% in 2002 to 47.7% in 2017. There was no significant difference in women senior authorship or editorial board representation from 2002 to 2017. Both men and women senior authors partnered with women first authors significantly more over the 15 years. CONCLUSIONS: While there was a statistically significant increase in women first authors between 2002 and 2017, there is still a gap between women's authorship and editorial board representation and their representation within academic family medicine. These gaps could help to explain the continued lack of women represented within senior faculty positions.

Impact of a Targeted Rural and Underserved Track on Medical Student Match Into Family Medicine and Other Needed Workforce Specialties.

BACKGROUND AND OBJECTIVES: There is a shortage of physicians in rural communities in the United States. More than other types of primary care physicians, family physicians are the foundation for care in rural areas.1 There are also critical shortages of other specialties such as general surgery, pediatrics, internal medicine, and psychiatry in rural America.2-7 This study assessed student participation in the University of Washington School of Medicine's (UWSOM) Targeted Rural Underserved Track (TRUST) program as a predictor for family medicine (FM) and needed workforce specialty residency match. METHODS: The study group was 156 medical students from 2009-2014; 102 were accepted to the TRUST program compared to a control group of 54 who were not accepted into the TRUST program but did matriculate to UWSOM. Student characteristics for the two groups were compared using t tests. Logistic regression analysis determined whether acceptance in TRUST predicted the outcomes measures of FM residency match or residency match into a needed rural physician workforce specialty; t tests compared match rates to family medicine for TRUST applicants and graduates, UWSOM graduates, and US allopathic seniors. RESULTS: TRUST program graduates had the same FM residency match rate and match rate in needed workforce specialties as the control group. The FM match rate for TRUST graduates was 29.1% compared to UWSOM at 16.9% and US seniors at 8.7% (P<.001). CONCLUSIONS: Although match rates in FM and needed workforce specialties were not different in accepted versus not accepted groups, all TRUST applicants had an FM match rate that approaches 30%, which is higher than the general UWSOM class and the United States. In order to help reach the goal of 25% of medical students matching into FM by 2030, medical schools should consider having a rural program and using rural-focused admissions widely.

Pipelines to Pathways: Medical School Commitment to Producing a Rural Workforce.

PURPOSE: Despite the efforts of numerous medical schools to produce rural physicians, many rural communities in the United States still experience physician shortages. This study describes the current landscape of rural efforts in US undergraduate medical education and catalogs medical school characteristics and activities that evidence has suggested, and that many experts in rural medical education believe, may result in more graduates choosing rural practice. METHODS: This is a descriptive study of publicly available and rurally relevant characteristics of all 182 allopathic and osteopathic medical schools operating in the 50 states and the District of Columbia in 2016, with rural program information for these schools updated in 2019. The authors constructed a "rural program" definition in order to systematically catalog coordinated and strategic medical school efforts to produce a rural physician workforce. FINDINGS: Few (8.2%) medical schools expressed an explicit commitment to producing rural physicians in public mission statements. However, most (64.8%) provided rural clinical experiences and many demonstrated their commitment in other ways. Only 39 (21.4%) did so through a formal rural program. CONCLUSIONS: In establishing an explicit rural program definition and documenting other markers of rural commitment, this paper provides a baseline for future studies of rural workforce production and medical school investment in these programs, activities, and personnel. Demonstrating the effectiveness of schools' rural physician education efforts will require collaboration across institutions and more intensive evaluations of programs involving students who, though relatively few in number, have great potential for contributing to the health of rural communities across the nation.

Targeted Medical School Admissions: A Strategic Process for Meeting Our Social Mission.

BACKGROUND AND OBJECTIVES: Increased medical school class sizes and new medical schools have not addressed the workforce inadequacies in primary care or underserved settings. While there is substantial evidence that student attributes predict practice specialty and location, little is known about how schools use these factors in admissions processes. We sought to describe admissions strategies to recruit students likely to practice in primary care or underserved settings. METHODS: We surveyed admissions personnel at US allopathic and osteopathic medical schools in 2018 about targeted admissions strategies aimed at recruitment and selection of students likely to practice rurally, in urban underserved areas, or in primary care Results: One hundred thirty-three of 185 (71.8%) US medical schools responded. Respondents reported targeted admissions strategies as follows: rural, 69.2%; urban underserved, 67.4%; and primary care, 45.3%. Nearly 90% reported some type of recruitment outreach to 4-year universities, but much less to community colleges. Student characteristics used to identify those likely to practice in targeted areas were largely evidence-based. Strategies to select students varied widely. CONCLUSIONS: Most responding US medical schools reported a targeted process to recruit and select students likely to practice in rural, urban underserved, or primary care settings, indicating widespread awareness of workforce challenges. This study also demonstrates varying approaches to and allocation of resources toward admissions targeting, especially the application and interviewing processes. Understanding how schools identify and admit students likely to practice in these fields is a first step in identifying best practices for selective admissions focused on addressing workforce gaps.

Promoting Health Careers Among Rural K-16 Students: A Mixed-Method Study to Describe Pathway Programs.

Health career pathway programs can promote and prepare rural students in grades kindergarten through college (K-16) for health careers, but little is known about the prevalence and characteristics of these programs in the U.S. This mixed-methods study provides a baseline description of health career pathway programs for rural K-16 students through a scoping review, survey, and semi-structured interviews with program directors. Among 165 programs responding to the survey, motivational or health career awareness (95.1%), health care exposure (92.0%), and mentorship (70.2%) were the most commonly used strategies. About one-third of programs (34.6%) had discontinued at least one strategy in the past three years, often due to loss of funding or a change in priorities. While reported outcomes suggested positive program effects, evaluations lacked rigor to draw definitive conclusions about program success. This study serves to generate hypotheses for further studies examining characteristics of student participants, program strategies and activities, and outcome measurement for health career pathway programs.

Challenges and Best Practices for Implementing Rurally Targeted Admissions in U.S. Medical Schools.

Student attributes can predict future rural practice, but little is known about how medical schools use these factors in admissions. This mixed-methods study examined admissions strategies to recruit and select students likely to practice rurally. Admissions personnel at U.S. allopathic and osteopathic medical schools were surveyed about rurally targeted admissions. Personnel from selected schools were interviewed to understand further targeted admissions practices. Among 185 medical schools, 133 (71.8%) responded. Schools engaged with students from four-year universities through career exploration (89.9%), admissions preparation (57.7%), academic enhancement (47.7%), and articulation agreements (42.9%). Applicant selection practices included preferential scoring in screening (38.2%) and admissions decisions (30.0%), modified MCAT (21.4%) and GPA cutoffs (18.8%), and reserved class slots (20.2%). Personnel from 10 schools identified key themes of motivations, resources, challenges, and recommendations. Understanding how schools identify and admit rurally inclined students is a first step in identifying best practices for addressing rural workforce gaps.

Investigating the Impact of Geographic Location on Colorectal Cancer Stage at Diagnosis: A National Study of the SEER Cancer Registry.

BACKGROUND: Early detection of colorectal cancer (CRC) is associated with decreased mortality and potential avoidance of chemotherapy. CRC screening rates are lower in rural communities and patient outcomes are poorer. This study examines the extent to which United States' rural residents present at a more advanced stage of CRC compared to nonrural residents. METHODS: Using the 2010-2014 Surveillance, Epidemiology and End Results Incidence data, 132,277 patients with CRC were stratified using their county of residence and urban influence codes into 5 categories (metro, adjacent micropolitan, nonadjacent micropolitan, small rural, and remote small rural). Logistic regression was used to investigate the relationship between late stage at diagnosis and county-level characteristics including level of rurality, persistent poverty, low education and low employment, and patient characteristics. RESULTS: In the adjusted analysis the rate of stage 4 CRC at diagnosis differed across geographic classification, with patients living in remote small rural counties having the highest rate of stage 4 disease (range: 19.2% in nonadjacent micropolitan counties to 22.7% in remote small rural counties). Other factors, such as patient characteristics, insurance status, and regional practice variation were also significantly associated with late-stage CRC diagnosis. CONCLUSIONS: Geographic residence is associated with the rate of stage 4 disease at presentation. Additional patient factors are associated with stage 4 CRC disease at diagnosis. Cancer outcomes are worse for rural patients, and late stage at diagnosis may partially account for this disparity. These differences have persisted over time and suggest areas for further research, patient engagement, and education.

Premedical Student Exposure to Pharmaceutical Marketing: Too Much, Too Soon?

BACKGROUND AND OBJECTIVES: Direct pharmaceutical marketing to physicians by pharmaceutical representatives is effective in changing behavior of health care providers, resulting in less evidence-based prescribing. Although much has been written about pharmaceutical marketing exposures among medical students, less is known about direct marketing exposures before students matriculate. This study examined the types of pharmaceutical representative direct marketing exposures for premedical students and where they occurred. METHODS: From June to August of 2017, researchers surveyed students who accepted admission to US public medical schools. These prematriculated students completed our survey just prior to matriculation. The survey inquired about whether the students were exposed to pharmaceutical marketing directly from pharmaceutical salespeople, the types of marketing they observed or received, and where these interactions occurred. RESULTS: Survey participants included 911 prematriculated students from 14 of the 188 medical schools invited to participate. Seventy-one percent (646) of the participants received or observed someone receiving pharmaceutical marketing gifts, small meals or snacks, articles, or samples. The two most common contexts for direct pharmaceutical marketing exposures were during shadowing experiences (54%, 346) and during employment (50%, 323). CONCLUSIONS: The findings suggest that it may be common for medical students to have interacted directly with pharmaceutical salespeople or observed other health professionals in these interactions before they matriculate in medical school. Because many of these interactions occur during clinical experiences required by institutions for admission, medical schools and premedical associations should consider delivering conflict-of-interest education early in medical school education or before students matriculate.

An Update on Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) includes 2 chronic idiopathic inflammatory diseases: ulcerative colitis and Crohn disease. The incidence and prevalence of IBD is increasing worldwide. It can affect people of all ages, including children and geriatric populations, and can impact all aspects of life. In this article, diagnosis and treatment of IBD in adults, pediatric, pregnant, and elderly populations are explored from the perspective of a primary care physician.

Student Perceptions About Benets From an Extracurricular Curriculum: A Qualitative Study of the Underserved Pathway.

INTRODUCTION: Too few medical graduates choose to care for underserved populations. This qualitative study explores medical student perceptions of the benefits of participating in the Underserved Pathway (UP), a 4-year extracurricular program designed to nurture interest in, and develop skills to serve vulnerable populations. METHODS: Fourteen of 28 graduating students in the class of 2013 who completed the UP were interviewed. Using conventional qualitative content analysis, an iterative process was used to code transcriptions until there was high concordance among the assigned codes. The research team analyzed the data for common themes, theme saturation, and unique perspectives. RESULTS: Four major thematic areas emerged: 1) the underserved curriculum scaffold, 2) influence on career choice, 3) influence on residency choice, and 4) capacity to match. Of all participants, 78.6% thought the UP influenced their career choice, 64.3% stated the UP played a role in residency choice and rank, and 85.7% thought participation in the UP would improve match success. No single curricular component of the UP was individually responsible for career or specialty choice, or as being most useful to student understanding of the underserved. CONCLUSIONS: Students noted that participation in the UP provided them with a scaffold to support their interest in underserved careers, and influenced their specialty and residency choice. They also perceived it as making them more competitive as residency applicants. This study provides medical educators with insight into the importance of building robust frameworks, even extracurricular ones, to support student interests in serving vulnerable communities.