The Workforce Needed to Address Population Health.

Policy Points Although a single definition of the population health workforce does not yet exist, this workforce needs to have the skills and competencies to address the social determinants of health, to understand intersectionality, and to coordinate and work in concert with an array of skilled providers in social and health care to address multiple health drivers. On-the-job training programs and employer support are needed for the current health workforce to gain skills and competencies to address population health. Funding and leadership combined are critical for developing the population health workforce with the goal of supporting a broad set of workers beyond health and social care to include, for example, those in urban planning, law enforcement, or transportation professions to address population health.

Competencies, Training Needs, and Turnover Among Rural Compared With Urban Local Public Health Practitioners: 2021 Public Health Workforce Interests and Needs Survey.

Objectives. To compare rural versus urban local public health workforce competencies and training needs, COVID-19 impact, and turnover risk. Methods. Using the 2021 Public Health Workforce Interest and Needs Survey, we examined the association between local public health agency rural versus urban location in the United States (n = 29 751) and individual local public health staff reports of skill proficiencies, training needs, turnover risk, experiences of bullying due to work as a public health professional, and posttraumatic stress disorder symptoms attributable to COVID-19. Results. Rural staff had higher odds than urban staff of reporting proficiencies in community engagement, cross-sectoral partnerships, and systems and strategic thinking as well as training needs in data-based decision-making and in diversity, equity, and inclusion. Rural staff were also more likely than urban staff to report leaving because of stress, experiences of bullying, and avoiding situations that made them think about COVID-19. Conclusions. Our findings demonstrate that rural staff have unique competencies and training needs but also experience significant stress. Public Health Implications. Our findings provide the opportunity to accurately target rural workforce development trainings and illustrate the need to address reported stress and experiences of bullying. (Am J Public Health. 2023;113(6):689-699. https://doi.org/10.2105/AJPH.2023.307273).

Building Rural Primary Care Research by Connecting Rural Programs.

Both research and medical education make substantial contributions to rural primary care and health. An inaugural Scholarly Intensive for Rural Programs was conducted in January 2022 to connect rural programs within a community of practice focused on promoting scholarly activity and research in rural primary health care, education, and training. Participant evaluations confirmed that key learning objectives were met, including stimulating scholarly activity in rural health professions education programs, providing a forum for faculty and student professional development, and growing a community of practice that supports education and training in rural communities. This novel strategy brings enduring scholarly resources to rural programs and the communities they serve, teaches skills to health profession trainees and rurally located faculty, empowers clinical practices and educational programs, and supports the discovery of evidence that can improve the health of rural people.

The Current State of Antiracism Curricula in Undergraduate and Graduate Medical Education: A Qualitative Study of US Academic Health Centers.

PURPOSE: We undertook a study to evaluate the current state of pedagogy on antiracism, including barriers to implementation and strengths of existing curricula, in undergraduate medical education (UME) and graduate medical education (GME) programs in US academic health centers. METHODS: We conducted a cross-sectional study with an exploratory qualitative approach using semistructured interviews. Participants were leaders of UME and GME programs at 5 institutions participating in the Academic Units for Primary Care Training and Enhancement program and 6 affiliated sites from November 2021 to April 2022. RESULTS: A total of 29 program leaders from the 11 academic health centers participated in this study. Three participants from 2 institutions reported the implementation of robust, intentional, and longitudinal antiracism curricula. Nine participants from 7 institutions described race and antiracism-related topics integrated into health equity curricula. Only 9 participants reported having "adequately trained" faculty. Participants mentioned individual, systemic, and structural barriers to implementing antiracism-related training in medical education such as institutional inertia and insufficient resources. Fear related to introducing an antiracism curriculum and undervaluing of this curriculum relative to other content were identified. Through learners and faculty feedback, antiracism content was evaluated and included in UME and GME curricula. Most participants identified learners as a stronger voice for transformation than faculty; antiracism content was mainly included in health equity curricula. CONCLUSIONS: Inclusion of antiracism in medical education requires intentional training, focused institutional policies, enhanced foundational awareness of the impact of racism on patients and communities, and changes at the level of institutions and accreditation bodies.

Telepsychiatric Consultation as a Training and Workforce Development Strategy for Rural Primary Care.

PURPOSE: There is a shortage of rural primary care personnel with expertise in team care for patients with common mental disorders. Building the workforce for this population is a national priority. We investigated the feasibility of regular systematic case reviews through telepsychiatric consultation, within collaborative care for depression, as a continuous training and workforce development strategy in rural clinics. METHODS: We developed and pilot-tested a qualitative interview guide based on a conceptual model of training and learning. We conducted individual semistructured interviews in 2018 with diverse clinical and nonclinical staff at 3 rural primary care sites in Washington state that used ongoing collaborative care and telepsychiatric consultation. Two qualitative researchers independently analyzed transcripts with iterative input from other research team members. RESULTS: A total of 17 clinical, support, and administrative staff completed interviews. Participants' feedback supported the view that telepsychiatric case review-based consultation enhanced skills of diverse clinical team members over time, even those who had not directly participated in case reviews. All interviewees identified specific ways in which the consultations improved their capacity to identify and treat psychiatric disorders. Perceived benefits in implementation and sustainability included fidelity of the care process, team resilience despite member turnover, and enhanced capacity to use quality improvement methods. CONCLUSIONS: Weekly systematic case reviews using telepsychiatric consultation served both as a model for patient care and as a training and workforce development strategy in rural primary care sites delivering collaborative care. These are important benefits to consider in implementing the collaborative care model of behavioral health integration.

Service provision and quality outcomes in home health for rural Medicare beneficiaries at high risk for unplanned care.

Multiple barriers exist to providing home health care in rural areas. This study examined relationships between service provision and quality outcomes among rural, fee-for-service Medicare beneficiaries who received home health care between 2011 and 2013 for conditions associated with high-risk for unplanned care. More skilled nursing visits, visits by more types of providers, more timely care, and shorter lengths of stay were associated with significantly higher odds of hospital readmission and emergency department use and significantly lower odds of community discharge. Results may indicate unmeasured clinical severity and care needs among this population. Additional research regarding the accuracy of current severity measures and adequacy of case-mix adjustment for quality metrics is warranted, especially given the continued focus on value-based payment policies.

The built environment and utilitarian walking in small U.S. towns.

OBJECTIVES: The role of the built environment on walking in rural United States (U.S.) locations is not well characterized. We examined self-reported and measured built environment correlates of walking for utilitarian purposes among adult residents of small rural towns. METHODS: In 2011-12, we collected telephone survey and geographic data from 2152 adults in 9 small towns from three U.S. regions. We performed mixed-effects logistic regression modeling to examine relationships between built environment measures and utilitarian walking ("any" versus "none"; "high" [≥150min per week] versus "low" [<150min per week]) to retail, employment and public transit destinations. RESULTS: Walking levels were lower than those reported for populations living in larger metropolitan areas. Environmental factors significantly (p<0.05) associated with higher odds of utilitarian walking in both models included self-reported presence of crosswalks and pedestrian signals and availability of park/natural recreational areas in the neighborhood, and also objectively measured manufacturing land use. CONCLUSIONS: Environmental factors associated with utilitarian walking in cities and suburbs were important in small rural towns. Moreover, manufacturing land use was associated with utilitarian walking. Modifying the built environment of small towns could lead to increased walking in a sizeable segment of the U.S. population.

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.

EMS medical direction and prehospital practices for acute cardiovascular events.

OBJECTIVE: The purpose of this analysis was to determine whether there is an association between type of emergency medical services (EMS) medical direction and local EMS agency practices and characteristics specifically related to emergency response for acute cardiovascular events. METHODS: We surveyed 1,292 EMS agencies in nine states. For each cardiovascular prehospital procedure or practice, we compared the proportion of agencies that employed paid (full- or part-time) medical directors with the proportion of agencies that employed volunteer medical directors. We also compared the proportion of EMS agencies who reported direct interaction between emergency medical technicians (EMTs) and their medical director within the previous four weeks with the proportion of agencies who reported no direct interaction. Chi-square tests were used to assess statistical differences in proportion of agencies with a specific procedure by medical director employment status and medical director interaction. We repeated these comparisons using t-tests to evaluate mean differences in call volume. RESULTS: The EMS agencies with prehospital cardiovascular response policies were more likely to report employment of a paid medical director and less likely to report employment of a volunteer medical director. Similarly, agencies with prehospital cardiovascular response practices were more likely to report recent medical director interaction and less likely to report absence of recent medical director interaction. Mean call volumes for chest pain, cardiac arrest, and stroke were higher among agencies having paid medical directors (compared with agencies having volunteer medical directors) and agencies having recent medical director interaction (compared with agencies not having recent medical director interaction). CONCLUSIONS: Our study demonstrated that EMS agencies with a paid medical director and agencies with medical director interaction with EMTs in the previous four weeks were more likely to have prehospital cardiovascular procedures in place. Given the strong relationship that both employment status and direct interaction have with the presence of these practices, agencies with limited resources to provide a paid medical director or a medical director that can be actively involved with EMTs should be supported through partnerships and other interventions to ensure that they receive the necessary levels of medical director oversight.

Is being there enough? Postgraduate nurse practitioner residencies in rural primary care.

PURPOSE: Little research has been conducted on the outcomes of postgraduate nurse practitioner (NP) programs (referred to as residencies), particularly those located in rural communities. This study examined the purpose and characteristics of rural NP residencies that aim to promote the successful recruitment, transition, and retention of NPs in rural primary care practice. METHODS: We compiled a list of rural NP residencies and verified the location of each clinic as rural if it met any of several federal definitions of rurality. We interviewed grant and project administrators, residency program directors, clinic personnel, and former and current NP residents using semistructured guides. FINDINGS: Of 20 rural NP residencies identified, we interviewed 12 program directors or managers; 8 NPs; and 4 clinic personnel. All but 1 program was 12 months long. Three-quarters had federal funding. Each slowly increased residents' patient load and included didactic content and specialty rotations. We identified 2 different program models and 3 administrative models. Some NPs' intentionally chose rural practice, while others opted for a rural residency when unable to secure employment in an urban location. Most programs were new and not yet able to report on residents' subsequent employment locations. CONCLUSIONS: It is premature to conclude definitively that rural NP residencies facilitate and promote NP connectedness to, and investment in, rural communities based on our investigation. Nonetheless, these programs are an option to encourage the recruitment and retention of NPs in rural practice, with further study needed to determine their long-term contribution to rural primary care practice.

Positive yet problematic: Lived experiences of racial and ethnic minority medical students during rural and urban underserved clinical rotations.

PURPOSE OF STUDY: Medical students who identify as Black, Indigenous, and People of Color (BIPOC) regularly experience mistreatment and discrimination. This study sought to understand these student experiences during rotations in rural and urban underserved community teaching sites. METHODS: Self-identified BIPOC medical students who completed the University of Washington School of Medicine's Rural Underserved Opportunities Program from 2019 through 2021 were invited to participate in a 60- to 90-minute focus group discussion via Zoom. From August to September 2021, 4 focus groups and 1 individual interview were conducted with a total of 12 participants. A current BIPOC medical student facilitated the sessions utilizing questions developed by the research team. Four study team members coded transcripts for key themes related to experiences of microaggressions. FINDINGS: All participants reported having an overall positive experience, but everyone also witnessed and/or experienced at least 1 microaggression. Unlike those in urban placements, participants placed in rural sites expressed anxiety about being in predominantly White communities and experienced feelings of racial and/or ethnic isolation during the rotation. Participants recommended that rural preceptors identify themselves as trusted advocates and the program should prioritize placing BIPOC students at diverse clinical sites. CONCLUSIONS: Medical schools must take action to address the mistreatment of BIPOC medical students in the clinical environment. Schools and rural training sites need to consider how to best support students to create an equitable learning environment and recruit more BIPOC physicians to rural practice.

Integrating Immigrant Health Professionals into the U.S. Healthcare Workforce: Barriers and Solutions.

Internationally educated immigrant healthcare workers face skill underutilization working in lower-skilled healthcare jobs or outside healthcare. This study explored barriers to and solutions for integrating immigrant health professionals. Content analysis identifying key themes from semi-structured qualitative interviews with representatives from Welcome Back Centers (WBCs) and partner organizations. 18 participants completed interviews. Barriers facing immigrant health professionals included lack of access to resources, financial constraints, language difficulties, credentialing challenges, prejudice, and investment in current occupations. Barriers facing programs that assist immigrant health professionals included eligibility restrictions, funding challenges, program workforce instability, recruitment difficulties, difficulty maintaining connection, and pandemic challenges. Long-term program success depended on partner networks, advocacy, addressing prejudice, a client-centered approach, diverse resources and services, and conducting research. Initiatives to integrate immigrant health professionals require multi-level responses to diverse needs and collaborations among organizations that support immigrant health professionals, healthcare systems, labor, and other stakeholders.

Academic Achievement and Competency in Rural and Urban Family Medicine Residents.

BACKGROUND AND OBJECTIVES: The quality of training in rural family medicine (FM) residencies has been questioned. Our objective was to assess differences in academic performance between rural and urban FM residencies. METHODS: We used American Board of Family Medicine (ABFM) data from 2016-2018 residency graduates. Medical knowledge was measured by the ABFM in-training examination (ITE) and Family Medicine Certification Examination (FMCE). The milestones included 22 items across six core competencies. We measured whether residents met expectations on each milestone at each assessment. Multilevel regression models determined associations between resident and residency characteristics milestones met at graduation, FMCE score, and failure. RESULTS: Our final sample was 11,790 graduates. First-year ITE scores were similar between rural and urban residents. Rural residents passed their initial FMCE at a lower rate than urban residents (96.2% vs 98.9%) with the gap closing upon later attempts (98.8% vs 99.8%). Being in a rural program was not associated with a difference in FMCE score but was associated with higher odds of failure. Interactions between program type and year were not significant, indicating equal growth in knowledge. The proportions of rural vs urban residents who met all milestones and each of six core competencies were similar early in residency but diverged over time with fewer rural residents meeting all expectations. CONCLUSIONS: We found small, but persistent differences in measures of academic performance between rural- and urban-trained FM residents. The implications of these findings in judging the quality of rural programs are much less clear and warrant further study, including their impact on rural patient outcomes and community health.

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.

Routes to Rural Readiness: Enhancing Clinical Training Experiences for Physician Assistants.

PURPOSE: The purpose of this study was to describe practices and experiences of rurally oriented physician assistant (PA) training programs in providing rural clinical training to PA students. METHODS: A survey of PA program directors (PDs) included questions about program characteristics, student and clinical preceptor (CP) recruitment in rural areas, and barriers to, and facilitators of, rural clinical training. Programs that considered rural training "very important" to their goals were identified. We interviewed PDs from rurally oriented programs about their rural clinical training and rural CPs about their experiences training PA students for rural practice. We identified key themes through content analysis. RESULTS: Of 178 programs surveyed, 113 (63.5%) responded, 61 (54.0%) of which were rurally oriented and more likely than other programs to recruit rural students or those with rural practice interests and to address rural issues in didactic curriculum. The 13 PDs interviewed linked successful rural training to finding and supporting rural preceptors who enjoy teaching and helping students understand rural communities. The 13 rural CPs identified enthusiastic and rurally interested students as key elements to successful rural training. Interviewees identified systemic barriers to rural training, including student housing, decreased productivity, competition for training slots, and administrative burden. CONCLUSIONS: Physician assistant students can be coached to capitalize on their rural clinical experiences. Knowing how to "jump in" to rotations and having genuine interest in the community are particularly important. Student housing, competition for training slots, and lack of financial incentives are major system-level challenges for sustaining and increasing the availability of PA rural clinical training.

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.

Factors associated with emergency medical services scope of practice for acute cardiovascular events.

OBJECTIVES: To examine prehospital emergency medical services (EMS) scope of practice for acute cardiovascular events and characteristics that may affect scope of practice; and to describe variations in EMS scope of practice for these events and the characteristics associated with that variability. METHODS: In 2008, we conducted a telephone survey of 1,939 eligible EMS providers in nine states to measure EMS agency characteristics, medical director involvement, and 18 interventions authorized for prehospital care of acute cardiovascular events by three levels of emergency medical technician (EMT) personnel. RESULTS: A total of 1,292 providers responded to the survey, for a response rate of 67%. EMS scope of practice interventions varied by EMT personnel level, with the proportion of authorized interventions increasing as expected from EMT-Basic to EMT-Paramedic. Seven of eight statistically significant associations indicated that EMS agencies in urban settings were less likely to authorize interventions (odds ratios <0.7) for any level of EMS personnel. Based on the subset of six statistically significant associations, fire department-based EMS agencies were two to three times more likely to authorize interventions for EMT-Intermediate personnel. Volunteer EMS agencies were more than twice as likely as nonvolunteer agencies to authorize interventions for EMT-Basic and EMT-Intermediate personnel but were less likely to authorize any one of the 11 interventions for EMT-Paramedics. Greater medical director involvement was associated with greater likelihood of authorization of seven of the 18 interventions for EMT-Basic and EMT-Paramedic personnel but had no association with EMT-Intermediate personnel. CONCLUSIONS: We noted statistically significant variations in scope of practice by rural vs. urban setting, medical director involvement, and type of EMS service (fire department-based/non-fire department-based; volunteer/paid). These variations highlight local differences in the composition and capacity of EMS providers and offer important information for the transition towards the implementation of a national scope of practice model.

Tracking the geographic distribution and growth of clinicians with a DEA waiver to prescribe buprenorphine to treat opioid use disorder.

PURPOSE: Buprenorphine is an effective medication treatment for opioid use disorder (MOUD) but access is difficult for patients, especially in rural locations. To improve access, legislation, including the Comprehensive Addiction and Recovery Act (2016) and the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act (2018), extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat opioid use disorder (OUD) to numerous types of clinicians. This study updates the distribution of waivered clinicians as of July 2020 and notes regional and geographic differences. METHODS: Using the July 2020 Drug Enforcement Administration list of providers with a waiver to prescribe buprenorphine to treat OUD, we assigned waivered clinicians to counties in one of four geographic categories. We calculated the number of counties in each category that did not have a waivered clinician, available treatment slots, and the county provider to population ratios. FINDINGS: The number of DEA-waivered clinicians more than doubled between December 2017 and July 2020 from 37,869 to 98,344. The availability of a clinician with a DEA waiver to provide MOUD has increased across all geographic categories. Nearly two-thirds of all rural counties (63.1%) had at least one clinician with a DEA waiver but more than half of small and remote rural counties lacked one. There were also significant differences in access by the US Census Division. CONCLUSIONS: Overall, MOUD access has improved, but small rural communities still experience treatment disparities and there is significant regional variation.

Can Family Medicine's Counterculture History Help Shape an Anti-Racist Future?

Family medicine prides itself on community engagement and has embraced its counterculture roots. After the racial and social reckoning of 2020, including the COVID-19 pandemic and the Black Lives Matters movement, family medicine, as a specialty, must embrace anti-racism as a core value to meet community needs. This article reflects on the foundational tenets of family medicine's origin. It highlights the current disparities regarding professional representation while offering equitable, intentional, and collaborative approaches to move toward and achieve anti-racism within the specialty, medical education, and the community.