The integration of a telemental health service into rural primary medical care.

Mental health care shortages in rural areas have resulted in the majority of services being offered through primary medical care settings. The authors argue that a paradigm shift must occur so that those in need of mental health care have reasonable, timely access to these services. Changes proposed include integrating mental health services into primary medical care settings, moving away from the traditional view of mental health care services (one therapist, one hour, and one client), and increasing the consultative role of psychologists and other mental health care providers in primary medical care. Characteristics of mental health providers that facilitate effective integration into primary medical care are presented. The results of a needs assessment survey and an example of a telemental health project are described. This project involved brief consultations with patients and their physicians from a shared care model using a broadband internet telecommunications link between a rural clinic and mental health service providers in an urban area.

Minnesota bound. Stability of practice location among UMD family physicians in Minnesota.

Previous studies indicate that physicians often move from one practice setting to another, particularly early in their career. However, data on practice relocation for a group of University of Minnesota, Duluth School of Medicine graduates show a different trend. Minnesota family physicians from the UMD School of Medicine have been remarkably stable in their practices over the past 20 years. More than 80% of these physicians have continued to practice in the same community that they selected after their training. In addition, physicians in this group who are practicing in smaller communities have not relocated to urban practices. These findings suggest that the UMD School of Medicine's emphasis on family medicine and rural practice may have influenced the practice retention rate for these physicians.

Physicians' perceptions of risk adjustment and health policy formation in Minnesota.

A questionnaire was used to assess Minnesota physicians' knowledge of and opinions about risk adjustment, a policy designed to modify payments to health providers based on the relative "sickness" level of the provider's patient population. Additionally, attitudes toward this policy were measured to examine physicians' perceptions of health policy formation in Minnesota. Although familiarity with this policy appears low, respondents support the concept of diagnosis-based risk adjustment. Physicians are divided on whether to further modify risk-adjusted rates with a conversion factor; their written comments suggest a mistrust of the policymaking process. Physicians most often listed the Minnesota Medical Association as a primary source for health policy information, while few respondents reported any communication with state legislators in health policy matters. Respondents perceive an imbalance in the influence wielded by various entities in health policy formation. Only 5% believe individual physicians have significant influence in policymaking. Increased communication between physicians and their legislators may be one way for physicians to gain such influence.

Family medicine education and rural health: a response to present and future needs.

The importance of family medicine in providing rural health services has been established for quite some time. The need to train physicians who select the specialty of family medicine is critical at a time when medical student interest in the primary care specialties appears to be diminishing. Renewed efforts by educational institutions and incentives at the state and federal levels will be necessary to assist in the alleviation of shortages of rural physicians. The educational program at the University of Minnesota, Duluth, School of Medicine has achieved a great deal of success in training rural family physicians. A coordinated program effort, featuring the efforts of more than 200 family physicians during the past 15 years, has led to 52.5 percent of all graduates selecting family practice and more than 41 percent choosing practice sites with a population fewer than 20,000. Elements of the program at Duluth could serve as a model for other schools desiring to increase the number of students entering family medicine and rural practice.

Medical students view family practice.

All students at the University of Minnesota, Duluth, School of Medicine responded to a 65-item questionnaire about their perceptions of changes facing medicine, the future of family practice, and career choices. Three different orientations toward family practice were identified--"stayers," "defectors," and "potential defectors." Students who had abandoned their original preference for family medicine (defectors) were compared with students who had maintained an interest in family medicine (stayers). Defectors anticipated a diminishing clinical role for future family practitioners, expressed doubt about the financial viability of smaller community based family practices, and explicitly linked concerns about their anticipated debt load to their changes in career preferences. This study also identified a subgroup of "potential defector" students (within the stayer cohort) who maintained an interest in family practice but evidenced concerns similar to the defector students. Implications of these findings for the future supply of primary care physicians for rural and traditionally underserved communities are discussed.

A look by medical students at medical practice in the future.

Ninety-six first- and second-year students (97 percent) at the University of Minnesota, Duluth, School of Medicine responded to a questionnaire on their career choices and their perceptions of changes in the organization and financing of medical care. Their responses indicated a great deal of student concern regarding the future of medical practice. Overall, the students were the most concerned about a perceived loss of practice autonomy and inadequate financial rewards. In the face of these perceptions, the students reported changes in career preferences: from smaller to larger communities, from solo or partnership arrangements to group practice settings, and from generalist to specialist practices. A student's anticipated debt level was the most important predictor of whether the student changed career goals.

Family practice in the predoctoral curriculum: a model for success.

Fifty-five percent of students who began their medical education at the University of Minnesota, Duluth, School of Medicine have elected family practice residencies. A coordinated and concentrated approach to admissions and curriculum, emphasizing family practice as an institutional goal, is described and discussed. As the national average for graduating seniors seems to have stabilized at approximately 13 percent, this approach may serve as a model for other institutions which wish to increase the number of family physicians. Family physicians are heavily involved in all aspects of the teaching program. Institutional parameters which are necessary for success are briefly discussed.