The impact of family physicians in rural maternity care.

BACKGROUND: Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. METHODS: We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. RESULTS: The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round-trip to access care if those FPs were to stop delivering. CONCLUSIONS: Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families.

Teaching the Evaluation of Female Pelvic Pain: A Hands-On Simulation to Reinforce Exam Skills and Introduce Transvaginal Ultrasound.

Introduction: Reproductive-age female patients commonly seek evaluation for pelvic pain in a variety of health care settings. Thus, teaching medical students how to effectively evaluate female pelvic pain is a necessary part of medical education. There are limited opportunities, however, to reinforce the needed skills for this common but sensitive presentation that can be anxiety-producing for preclinical students. Methods: The case involved a 23-year-old female presenting with lower abdominal/pelvic pain. Students performed the necessary history, physical examination, cervical sampling, and transvaginal ultrasound evaluation to make the diagnosis of pelvic inflammatory disease (PID) complicated by a tubo-ovarian abscess. The 30-minute simulated patient encounter was followed by a 30-40 minute faculty-led debrief. Results: This simulation case has been sustained in the curriculum since 2011 for 65 students per year. Through use of a faculty critical action checklist, debrief discussion, examination performance, and student evaluation feedback, this simulation has demonstrated effectiveness. Of students, 93 of 193 students (48%) who participated in the simulation case from 2018-2020 completed a survey in which they rated the degree of agreement with statements about the simulation based on a 5-point Likert Scale (1 = strongly disagree, 5 = strongly agree). All questions had a mean response of 4.5-4.8 in 2018-2020, demonstrating the consistent agreement by students of the clarity, fidelity, and knowledge-enhancing value of the simulation. Discussion: This simulation provided a useful opportunity and a safe environment for preclinical medical students to acquire knowledge and skills necessary to evaluate a female patient with pelvic pain and PID.

Obstetrical Care in Rural Minnesota: Family Physician Perspectives on Factors Affecting the Ability to Provide Prenatal, Labor, and Delivery Care.

PURPOSE: With decreasing access to rural obstetrical care, this study aimed to identify factors that contribute to the ability of Minnesota's rural communities to continue to offer obstetrical services locally. The study also sought to characterize attributes that differentiate rural communities that continue to offer obstetrical care from those that do not. METHODS: Family medicine physicians practicing in communities of fewer than 20,000 people were interviewed through a phone survey that included multiple choice and open-ended questions. Quantitative and qualitative analyses were performed on data collected from the responses. FINDINGS: Within the Minnesota communities represented (N = 25), prenatal care was provided broadly, regardless of whether labor and delivery services were available. For the communities providing local labor and delivery (N = 17), several factors seemed to be key to sustaining these services: having a sufficient cohort of delivering providers, having surgical backup, having accessible confident nurses and nurse anesthetists, sustaining a sufficient annual birth volume at the hospital, and having organizational and administrative support. In addition, supporting anesthesia and analgesic services, access to specialist consultation, having resources for managing and referring both newborn and maternal complications, and sustaining proper equipment were also requisite. CONCLUSIONS: Rural Minnesota family medicine physicians practicing in communities providing local labor and delivery care emphasized several essential components for sustainable provision of these services. With awareness of these essential components, rural health care providers, administrators, and policy makers can focus resources and initiatives on efforts that are most likely to support a sustainable and coordinated rural labor and delivery program.

Transforming Rural Family Medicine Curriculum From Experiential to Virtual: A Response to COVID-19 Limitations.

Cessation of all classroom and clinical activities in the spring of 2020 for first- and second-year medical students at the University of Minnesota Medical School Duluth campus both forced and enabled revision of rural medicine instruction and experiences. Creatively utilizing rural family physicians and third-year rural physician associate medical students to interact with first-year students virtually in a number of areas and using electronic connectivity enabled the institution to continue to emphasize rural medical health issues with the students.

Contributions of US Medical Schools to Primary Care (2003-2014): Determining and Predicting Who Really Goes Into Primary Care.

BACKGROUND AND OBJECTIVES: Schools of medicine in the United States may overstate the placement of their graduates in primary care. The purpose of this project was to determine the magnitude by which primary care output is overestimated by commonly used metrics and identify a more accurate method for predicting actual primary care output. METHODS: We used a retrospective cohort study with a convenience sample of graduates from US medical schools granting the MD degree. We determined the actual practicing specialty of those graduates considered primary care based on the Residency Match Method by using a variety of online sources. Analyses compared the percentage of graduates actually practicing primary care between the Residency Match Method and the Intent to Practice Primary Care Method. RESULTS: The final study population included 17,509 graduates from 20 campuses across 14 university systems widely distributed across the United States and widely varying in published ranking for producing primary care graduates. The commonly used Residency Match Method predicted a 41.2% primary care output rate. The actual primary care output rate was 22.3%. The proposed new method, the Intent to Practice Primary Care Method, predicted a 17.1% primary care output rate, which was closer to the actual primary care rate. CONCLUSIONS: A valid, reliable method of predicting primary care output is essential for workforce training and planning. Medical schools, administrators, policy makers, and popular press should adopt this new, more reliable primary care reporting method.

First year allopathic medical student attitudes about vaccination and vaccine hesitancy.

First year medical students at an allopathic medical school regional campus were asked to complete a 10-question survey at both the beginning and the conclusion of a required course on immunology, hematology and oncology. The survey was designed to solicit student attitudes about vaccination and the students' level of comfort with and exposure to vaccine hesitant patients. Surveys were administered to five consecutive classes from 2013 to 2017. Total response rate for completion of both surveys was 58.0% (178/307). Pre- and post-course surveys were administered to assess whether curricular experiences altered the students' perceptions about vaccinations and their ability to counsel vaccine hesitant patients. Curricular elements were presented in several different formats aimed at increasing student knowledge about vaccinations and student capacity to work with vaccine hesitant patients and families (problem-based learning, didactic lecture and interactive panel discussion). In the pre-survey, the majority of students reported having already encountered people who decline vaccinations (78.8%). Additionally, in the pre-survey the majority of medical students expressed strong support for vaccination (99.6% agreed with the statement that Vaccinations are a great public health accomplishment) and strong disagreement with both of the assertions that childhood vaccines cause autism and vaccine preservatives cause adverse health effects. In response to questions about comfort level while talking with patients about vaccine choices, baseline responses demonstrated a moderately high level of comfort. Post-course surveys revealed a statistically significant increase in student-rated comfort level in talking with patients about vaccine choices (pre-survey 79.2% report comfort versus post 97.8%; p < 0.001). Though this study is limited to student self-reporting, survey responses suggest that targeted curricular elements can improve medical student confidence in counseling patients about vaccinations. Future curricular elements designed to directly observe student performance could provide verification of counseling skill acquisition.

Perceptions and Prevalence of Alcohol and Cigarette Use Among American Indian Adults With Type 2 Diabetes.

IN BRIEF This study examined community perceptions and prevalence of alcohol use and cigarette smoking among American Indian adults with type 2 diabetes. Results revealed normative rates and perceptions of smoking and negative views and low rates of alcohol use. Participants reported high levels of household indoor smoking and comorbid high-risk drinking and smoking. The high smoking rate among the adult American Indians in this study is especially problematic given the increased risk of cardiovascular problems related to both smoking and type 2 diabetes. The results underscore the importance of considering substance use behaviors and beliefs as a component of overall health and well-being for people with diabetes.

Teaching Community Health Needs Assessment to First Year Medical Students: Integrating with Longitudinal Clinical Experience in Rural Communities.

Community health education is especially important for physicians who will practice in rural communities. However, the majority of efforts to teach community and population health in medical school appear in later years and focus on non-rural contexts. This article presents data from a formative evaluation of a newly developed curricular component on population health and community health assessment for first year medical students in a rural longitudinal clinical preceptorship. Curricular elements included: a classroom lecture and review of online community health databases, an individual homework assignment and a classroom debriefing session. In a sample of 210 students, pre- and post-course surveys and exam questions assessed gains in awareness and skills over the course period. Analyses of data aggregated over four academic years (2013-2014 to 2016-2017) showed that first year medical students reported significant increases in familiarity with online resources (29.5% pre vs. 94.8% post, p < .001), understanding the importance of community health assessments (67.5% pre vs. 96.7%, p < .001), knowing how to plan a community health assessment (20.0% pre vs. 90.5%, p < .001), and awareness of Affordable Care Act expectations for community health assessments (12.4% pre vs. 82.4% post, p < .001). Further, students performed well on exam questions and reported that this component fit well with the objectives of the rural longitudinal clinical preceptorship course. Later-year education should reinforce early learnings and future studies involving long-term follow-up of physicians could assess the impact of early exposure to community health education on physician behaviors.

Sulfide Mining and Human Health in Minnesota.

Sulfide mining (specifically copper-nickel sulfide mining) represents a significant departure from Minnesota's iron mining tradition. Sulfide mining can produce acid waste and sulfates that mobilize the release of heavy metals into the environment. These metals include known neurotoxins such as lead and mercury. Mining activities also create airborne fibers and pollutants that can contribute to increased morbidity. The short- and long-term effects of exposure to these substances on human health should be considered in present and future sulfide mining proposals. In addition, Minnesota physicians need to understand the potential adverse mental and physical health effects of sulfide mining on mine workers and residents of communities near mining operations.

Unconscious biases: racial microaggressions in American Indian health care.

PURPOSE: This article reports on the prevalence and correlates of microaggressive experiences in health care settings reported by American Indian (AI) adults with type 2 diabetes mellitus (T2DM). METHODS: This community-based participatory research project includes two AI reservation communities. Data were collected via in-person article-and-pencil survey interviews with 218 AI adults diagnosed with T2DM. RESULTS: Greater than one third of the sample reported experiencing a microaggression in interactions with their health providers. Reports of microaggressions were correlated with self-reported history of heart attack, worse depressive symptoms, and prior-year hospitalization. Depressive symptom ratings seemed to account for some of the association between microaggressions and hospitalization (but not history of heart attack) in multivariate models. CONCLUSIONS: Microaggressive experiences undermine the ideals of patient-centered care and in this study were correlated with worse mental and physical health reports for AIs living with a chronic disease. Providers should be cognizant of these subtle, often unconscious forms of discrimination.