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PROVIDER SHORTAGES IN RURAL AMERICAMany rural Americans have limited access to health care. This problem stems from 2 characteristics of the health care system: the many Americans without health care insurance and the tendency of health care professionals to locate and practice in relatively affluent urban and suburban areas.The relative shortage of physicians in rural areas of the United States is 1 of the few constants in any description of the US medical care system. About 20% of the US population—more than 50 million people—live in rural areas, but only 9% of the nation's physicians practice in rural communities.1Crude comparisons of the physician-to-population ratio in rural versus urban areas can be extremely misleading and provide almost no information about whether shortages or surpluses exist in either location.2 In 1995—the latest year for which data are available—gaps existed between the supply of active physicians in counties of different size (figure 1). As can be seen in this figure, major differences persist between the aggregate supply in urban and rural areas, with the larger counties having many more physicians per 100,000 population.Figure 1Active physicians per 100,000 population by location, 1995. From AMA from BHPr ARF data, 1997.But this information obscures the fact that the physician supply has grown in rural areas in the past 20 years, although the growth has not been uniform. The supply of rural physicians has increased modestly in the past few decades, with most of the increase in the larger rural communities adjacent to metropolitan areas (figure 2). Rural supply lags far behind the current urban supply of physicians, but the urban supply of physicians is, in the opinion of many, excessive.Figure 2Active physicians per 100,000 population by year and location, 1940 through 1995. From AMA from BHPr ARF data, 1997.Physician supply in rural areas is closely tied to the specialty mix of American physicians. Specialty has a powerful effect on physician location choice for each of the major specialty groups (figure 3). Family physicians distribute themselves in proportion to the population in both rural and urban locations and are the largest single source of physicians in rural areas. All other specialties are much more likely to settle in urban areas.Figure 3Patient care physicians per 100,000 population by location and specialty, 1995. From AMA from BHPr ARF data, 1997.Given the expansion of the rural physician supply, it is important to distinguish between rural areas that have definite shortages of critical health professionals and those that have fewer health professionals relative to oversupplied urban areas. Historically, the government has designated areas as seriously underserved based on the physician-to-population ratio within a specific health service area. Populations with too few physicians have been categorized as health professional shortage areas, thus becoming eligible for a broad array of governmental assistance.Summary pointsThere is a relative shortage of physicians in rural areas of AmericaThe more highly specialized the physician, the less likely he or she will settle in a rural areaThe preference of women for urban practice may pose a problem for the future recruitment of rural physiciansAlthough managed care systems can recruit physicians to rural areas, systems are growing slowly in rural areas and their doctors may be of little use to the working poor who have neither Medicaid nor conventional health insurancePossible solutions to the problem of physician shortages in rural areas include changing the medical education system so that it trains more physicians who choose rural practice, changing the reimbursement strategies of Medicare and Medicaid, and changing the existing federal and state programs
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Culture and Medicine
Physicians and rural America
PROVIDER SHORTAGES IN RURAL AMERICA
Many rural Americans have limited access to health care.
This problem stems from 2 characteristics of the health
care system: the many Americans without health care in-
surance and the tendency of health care professionals to
locate and practice in relatively affluent urban and subur-
ban areas.
The relative shortage of physicians in rural areas of the
United States is 1 of the few constants in any description
of the US medical care system. About 20% of the US
population—more than 50 million people—live in rural
areas, but only 9% of the nation’s physicians practice in
rural communities.
1
Crude comparisons of the physician-to-population ra-
tio in rural versus urban areas can be extremely misleading
and provide almost no information about whether short-
ages or surpluses exist in either location.
2
In 1995—the
latest year for which data are available—gaps existed be-
tween the supply of active physicians in counties of dif-
ferent size (figure 1). As can be seen in this figure, major
differences persist between the aggregate supply in urban
and rural areas, with the larger counties having many more
physicians per 100,000 population.
But this information obscures the fact that the physi-
cian supply has grown in rural areas in the past 20 years,
although the growth has not been uniform. The supply of
rural physicians has increased modestly in the past few
decades, with most of the increase in the larger rural com-
munities adjacent to metropolitan areas (figure 2). Rural
supply lags far behind the current urban supply of physi-
cians, but the urban supply of physicians is, in the opinion
of many, excessive.
Physician supply in rural areas is closely tied to the
specialty mix of American physicians. Specialty has a pow-
erful effect on physician location choice for each of the
major specialty groups (figure 3). Family physicians dis-
tribute themselves in proportion to the population in both
rural and urban locations and are the largest single source
of physicians in rural areas. All other specialties are much
more likely to settle in urban areas.
Given the expansion of the rural physician supply, it is
important to distinguish between rural areas that have
definite shortages of critical health professionals and those
that have fewer health professionals relative to oversup-
plied urban areas. Historically, the government has desig-
nated areas as seriously underserved based on the physi-
cian-to-population ratio within a specific health service
area. Populations with too few physicians have been
categorized as health professional shortage areas, thus
becoming eligible for a broad array of governmental
assistance.
Figure 1 Active physicians per 100,000 population by location, 1995. From AMA from BHPr ARF
data, 1997.
Douglas Diekema
Summary points
There is a relative shortage of physicians in rural areas
of America
The more highly specialized the physician, the less
likely he or she will settle in a rural area
The preference of women for urban practice may pose
a problem for the future recruitment of rural
physicians
Although managed care systems can recruit
physicians to rural areas, systems are growing slowly
in rural areas and their doctors may be of little use to
the working poor who have neither Medicaid nor
conventional health insurance
Possible solutions to the problem of physician
shortages in rural areas include changing the medical
education system so that it trains more physicians
who choose rural practice, changing the
reimbursement strategies of Medicare and Medicaid,
and changing the existing federal and state programs
Roger A Rosenblatt
Department of Family
Medicine
University of
Washington
L Gary Hart
WWAMI Rural Health
Research Center
Box 354696
University of
Washington School of
Medicine
Seattle, WA 98195-4696
Correspondence to:
Dr Hart
gary_hart@fammed.
washington.edu
Competing interests:
None declared
West J Med
2000;173:348-351
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348 wjm Volume 173 November 2000
EFFECT OF SPECIALTY CHOICE AND DISTRIBUTION
Nothing affects the location decision of physicians more
than specialty. The more highly specialized the physician,
the less likely he or she will settle in a rural area. As a
consequence, the growth of specialization is a major con-
tributor to the geographic maldistribution of physicians.
Many of the shortages in communities with fewer than
10,000 residents could have been reduced or eliminated if
even a small fraction of subspecialists produced over the
past 15 years had chosen to become primary care physi-
cians in rural or underserved areas (T R Konrad: Short-
ages of Physicians and Other Health Professionals in Rural
Areas: Background Paper Produced for COGME; Cecil
G Sheps Center for Health Services Research, University
of North Carolina at Chapel Hill, unpublished, 1997).
The recently revived interest in family medicine and
the other generalist disciplines is a major factor in address-
ing rural geographic maldistribution. The decreasing pro-
portion of generalist physicians leveled off in the 1980s
(figure 4).
3
Despite recently increased interest in primary
care, the percentage in generalist disciplines has not yet
shown a substantial increase. An improvement in the bal-
ance of generalists and specialists is a necessary precondi-
tion for eliminating rural physician shortages.
EFFECT OF GENDER ON CHOICE OF
PRACTICE LOCATION
Starting a decade ago, the proportion of women attending
medical school increased rapidly. The number of female
physicians in the United States more than quadrupled
between 1970 and 1991 and has continued to rise.
4
Historically, rural medical care was almost exclusively
provided by male physicians. This was a product of the
paucity of women in medicine and the tendency of the
few female graduates to locate in urban areas. Male gen-
eralist physicians far outnumber their female counterparts
in rural areas across the United States. As the proportion
of women in medical schools has increased, there have
been concerns that the supply of rural physicians might
dwindle if women continue to settle almost exclusively in
urban areas and the largest rural cities.
Recent work suggests that the disparity between male
and female physicians may be growing less acute with
time.
5
The gap between male and female family physi-
cians has narrowed dramatically for more recent graduates
(figure 5). Still, even women in the most recent graduate
cohort are much less likely than their male counterparts to
locate in rural areas, and the disparity is greatest for the
smaller and more remote communities. The continuing
preference of women for urban practiceeven though less
pronounced than in earlier yearsmay still pose a prob-
lem for the future recruitment of rural physicians.
INFLUENCE OF MANAGED CARE
Managed care is a major emerging influence on the delivery
of rural health care. Although it has become dominant in
many urban areas, its effect in rural areas is just beginning to
be felt. More than 80% of all rural counties were in the
service area of at least 1 health maintenance organization
(HMO) by the end of 1995, although the percentage of the
rural population enrolled in HMOs is estimated to be less
than 8%.
6
Managed care is not only a creature of the
private sector; nationally, about a tenth of rural Medicaid
Figure 2 Active physicians per 100,000 population by year and location, 1940 through 1995. From
AMA from BHPr ARF data, 1997.
Figure 3 Patient care physicians per 100,000 population by location and specialty, 1995. From
AMA from BHPr ARF data, 1997.
Douglas Diekema
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Culture and Medicine
Volume 173 November 2000 wjm 349
recipients are enrolled in Medicaid HMOs and prepaid
plans, and the number is increasing rapidly.
Managed care is a 2-edged sword, both with regard to
geographic maldistribution and rural medical underser-
vice. Managed care networks have the potential to provide
organizational vehicles for hiring and deploying physicians
in areas that could not support independent physicians on
their own.
But there are 2 potentially adverse effects of managed
care systems on rural health: the loss of local control of
health care systems and the reluctance of private managed
care systems to provide care to the uninsured. Most man-
aged care systems are sponsored by large metropolitan
organizations, and these entities may have little under-
standing of or empathy for isolated rural areas. The pres-
ence of physicians hired through vertically integrated sys-
tems may mean that the community has health
professionals, but they may be of little use to the working
poor who have neither Medicaid nor conventional health
insurance. The managed care industry is in rapid flux, and
the extent to which managed care will ultimately domi-
nate rural areas as it has dominated some urban ones is
difficult to predict.
POSSIBLE SOLUTIONS TO THE PROBLEM OF
INEQUITIES IN RURAL HEALTH
Educational initiatives
One of the most powerful ways to remedy problems of
rural geographic maldistribution is to change the medical
education system so that it selects, trains, and deploys
more health care workers who choose to practice in rural
areas. Much of the federal support incorporated within the
Title VII programsthe major federal vehicle for gener-
alist trainingis based on the premise that this is an
achievable goal. Talley has discussed the 4 basic truths
about rural health
3
:
Students with rural origins are more likely to train in
primary care and return to rural areas,
Residents trained in rural areas are more likely to
choose to practice in rural areas,
Family medicine is the key discipline of rural health
care, and
Residents practice close to where they train.
To the extent that these relationships are accurateand
evidence supports associations between these characteris-
tics and the decision to practice in rural areas
modifications of the training milieu to incorporate these
factors make sense.
The advantage of this approach is that it takes opti-
mum advantage of free-market solutions to the problem of
geographic physician maldistribution. Rather than requir-
ing the establishment of federal or state delivery systems
that may be controversial, complex, and expensive, gradu-
ating residents gravitate to underserved areas to fill their
personal desires.
Although this type of intervention does not lend itself
to controlled experiments, ample evidence exists that such
an approach works. Publicly owned medical schools in
rural states, particularly those that see their mission as
training future family physicians, have high proportions of
their graduating classes ultimately practicing in rural areas.
By contrast, research-intensive private schools in metro-
politan areas with no commitment to family medicine
have virtually no rural graduates.
4
Changes in reimbursement strategies of
Medicare and Medicaid
A powerful mechanism to improve the flow of health
professionals to rural areas is the use of targeted incentives.
Central to this approach is the belief that physicians and
others act as rational economic beings. If some form of
economic inducement enhances the reimbursement for
rural services, then physicians are more likely to locate in
these areas. This approach has been used with some
success in Britain, Canada, and Australia, where a vari-
ety of bonuses increase reimbursement for selected rural
practitioners.
Figure 4 Percentage of primary care and non-primary care physicians for selected years, 1931
through 1996. From AMA from BHPr ARF data, 1997.
Figure 5 Male to female family or general physicians by graduation cohort, 1997. From Ellsbury
KE, Doescher MP, Hart LG. US medical schools and the rural family physician gender gap. Fam
Med 2000;32:331-337.
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Culture and Medicine
350 wjm Volume 173 November 2000
Changes in existing direct federal and
state programs
When educational interventions and economic incentives
fail to remedy geographic maldistribution, the major re-
course is the creation of programs that provide direct ser-
vices to underserved areas. There are numerous examples
of such programs, the largest of which are the community
health centers and the National Health Service Corps
(NHSC). There is no question that these 2 federal pro-
grams remain the preeminent safety net programs for rural
America. Studies by the Rural Health Research Centers in
Chapel Hill, NC, and Seattle demonstrate that about 1 in
4 of every new primary care physician entering a health
professional shortage area in the late 1980s was placed
there under NHSC auspices
7
and that 1 in 5 physicians
practicing independently in many of the smallest rural
communities was initially brought to those areas through
their service in the NHSC.
8
Given the realities of the current system, future efforts
should concentrate on improving the fit between need and
services, enhanced coordinationand reduced duplica-
tionof services provided, better identification of stu-
dents to ultimately serve in the NHSC and state pro-
grams, and improved effectiveness and efficiency of
governmentally sponsored health care services, including
those of rural health clinics.
9
The wide variety of programs
availableand the natural variability in the way they are
organized and administeredleads to enormous com-
plexity in the provision of services. It is certainly worth the
effort to simplify programs and their administration and
to ensure that governmental resources follow human need,
not the administrative prowess of officials who excel at the
bureaucratic skills that can obtain these services for their
communities.
New technologies: possible effect
of telemedicine
Telemedicine is an emerging technology with enormous
potential for mitigating the effects of the geographic mal-
distribution of health professionals. Although telemedicine
has a legitimate, important, and growing role in rural
medicine,
10
the path to the future is uncertain. As pointed
out in the 2nd Invitational Consensus Conference on
Telemedicine and the National Information Infrastruc-
ture, multiple and significant obstacles exist that make the
current efforts uncoordinated, expensive, inaccessible, and
at times even illegal.
11
The current state of telemedicine could be character-
ized as creative but relatively unstructured, with a wide
variety of public and private sector experiments proceed-
ing simultaneously. Some applications, such as reading
electrocardiograms at a distance, have become common-
place. Others, such as dermatology consultations, are be-
ing performed in many different places but without stan-
dard protocols for transmission, interaction, evaluation, or
charging. And others, such as doing an appendectomy at
a distance, remain in the realm of science fiction, if just
barely. From the standpoint of geographic maldistribu-
tion, there are 3 key issues (see box).
CONCLUSIONS
Geographic maldistribution of health providers is 1 of the
most deep-seated characteristics of the American health
care system. Even though the 1990s have been marked by
rapid expansion in the absolute and relative number of
practicing physicians, substantial rural shortages have per-
sisted. Rural areas will continue to have structural barriers
that will require special programs to assist in the training,
deployment, and support of health professionals.
This article is adapted, with permission, from Ricketts III TC: Rural
Health in the United States. New York: Oxford University Press; 1999.
....................................................................................................
References
1 Bureau of Health Professions. Rural Health Professions Facts: Supply and
Distribution of Health Professions in Rural America. Rockville, MD:
Health Resources and Services Administration; 1992.
2 Center for the Evaluative Clinical Sciences, Dartmouth Medical School.
The Dartmouth Atlas of Health Care. Chicago: American Hospital
Publishing; 1996.
3 Talley RC. Graduate medical education and rural health care. Acad
Med 1990;65:522-525.
4 Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG.
Which medical schools produce rural physicians? JAMA
1992;268:1559-1565.
5 Doescher MP, Ellsbury KE, Hart LG. The distribution of rural female
generalist physicians in the United States. J Rural Health
2000;16:111-118.
6 Casey MM. Rural managed care. In: Ricketts TC III, ed. Rural Health
in the United States. New York: Oxford University Press; 1999:113-118.
7 Konrad TR. The Rural HPSA Physician Retention Study: Final Report for
Grant No. RO HS 06544-0 from Agency for Health Care Policy and
Research. Chapel Hill, NC: Cecil G Sheps Center for Health Services
Research, University of North Carolina; 1994.
8 Cullen TJ, Hart LG, Whitcomb ME, Lishner DM, Rosenblatt RA.
The National Health Service Corps: rural physician service and
retention. J Am Board Fam Pract 1997;10:272-279.
9 Rural Health Clinics: Rising Program Expenditures Not Focused on
Improving Care in Isolated Areas. Washington, DC: General Accounting
Office; 1996. GAO/HEHS-97-24.
10 Balas EA, Jaffrey F, Kuperman GJ, et al. Electronic communication
with patients: evaluation of distance medicine technology. JAMA
1997;278:152-158.
11 Bashshur RL, Puskin D, Silva J. Telemedicine and the national
information infrastructure. Telemed J 1995;1:321-375.
Key factors in improving the delivery of
telemedicine to rural areas
Resolution of the professional licensure regulations,
allowing physicians in metropolitan areas to make
their expertise available to remote rural areas, even
across state lines
Clear protocols for a unified technologic infrastructure
to reduce costs and to allow rural providers to have
the option of communicating with multiple providers
of these distant services without being captives of any
single information provider
Reasonable reimbursement by third-party payers for
providing medical services at a distance
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Culture and Medicine
Volume 173 November 2000 wjm 351
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Purpose: How care delivery influences urban-rural disparities in cancer outcomes is unclear. We sought to understand community oncologists' practice settings to inform cancer care delivery interventions. Methods: We conducted secondary analysis of a national dataset of providers billing Medicare from June 1, 2019 to May 31, 2020 in 13 states in the central United States. We used Kruskal-Wallis rank and Fisher's exact tests to compare physician characteristics and practice settings among rural and urban community oncologists. Findings: We identified 1,963 oncologists practicing in 1,492 community locations; 67.5% practiced in exclusively urban locations, 11.3% in exclusively rural locations, and 21.1% in both rural and urban locations. Rural-only, urban-only, and urban-rural spanning oncologists practice in an average of 1.6, 2.4, and 5.1 different locations, respectively. A higher proportion of rural community sites were solo practices (11.7% vs 4.0%, P<.001) or single specialty practices (16.4% vs 9.4%, P<.001); and had less diversity in training environments (86.5% vs 67.8% with <2 medical schools represented, P<.001) than urban community sites. Rural multispecialty group sites were less likely to include other cancer specialists. Conclusions: We identified 2 potentially distinct styles of care delivery in rural communities, which may require distinct interventions: (1) innovation-isolated rural oncologists, who are more likely to be solo providers, provide care at few locations, and practice with doctors with similar training experiences; and (2) urban-rural spanning oncologists who provide care at a high number of locations and have potential to spread innovation, but may face high complexity and limited opportunity for care standardization.
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Zusammenfassung Ziel der Studie Die neue Approbationsordnung für Ärzte in Deutschland fordert verstärkt Hospitationen Medizinstudierender in allgemeinmedizinischen Lehrpraxen. Diese Studie soll einen Überblick geben, in welchem Ausmaß komplementär- und alternativmedizinischen Verfahren in deutschen Lehrpraxen angeboten werden und ob sie den Kriterien evidenzbasierter Medizin entsprechen. Orientierung an letzteren ist eine notwendige Voraussetzung für die Qualifikation zur Lehrpraxis. Methodik Nach systematischer Suche nach anerkannten Lehrpraxen der Fakultäten wurden deren Diagnostik- und Therapieangebote über die Praxis-Webseiten erfasst und unterschieden zwischen evidenzbasierter Komplementärmedizin und Alternativmedizin ohne oder mit umstrittener Evidenzbasierung. Ergebnisse Über die Hälfte der 4102 erfassten Lehrpraxen bot mindestens ein Verfahren aus dem komplementär- und/oder alternativmedizinischen Bereich an. Darunter waren überwiegend durch die Ärztekammer anerkannte Zusatzbezeichnungen. Alternativmedizinische Verfahren wurden in 18,2% der Praxen angeboten. Schlussfolgerung Sammelbegriffe und strittige Evidenzlagen erschweren eine Einordnung der Verfahren. Das Angebot nicht-evidenzbasierter Therapien in Lehrpraxen wirft die Frage nach einem Widerspruch zwischen der Rekrutierung vieler neuer Lehrpraxen und der Qualität der Lehre auf. Eindeutige Angebote der Alternativmedizin sollten zur Disqualifikation als Lehrpraxis führen. Umstrittene Verfahren könnten zumindest im Rahmen der akademischen Lehre und der Facharztweiterbildung in Bezug auf EbM-Kriterien und Kommunikationskompetenz unterrichtet werden, sodass junge Mediziner und Ärzte auf die Gespräche mit den Patienten vorbereitet sind.
Article
This study contributes to the current understanding of what drives physicians to practice in rural areas by analyzing new, comprehensive survey data of practicing physicians in the United States. This research confirmed that rural origin is a powerful and reliable predictor for rural practice and revealed that new and experienced physicians have different priorities regarding location choice. Physicians choosing rural practice locations are more likely to be motivated by compensation, the resemblance of the environment to the one they grew up in, patient needs, and prenegotiated service obligations or visa/immigration status. They are less likely to attribute their location choice to social network proximity. These findings have important implications for salary incentives and policy initiatives aimed at increasing the rural physician workforce. The results of this study will help decrypt the difficulties rural areas face in attracting and retaining medical and other professionals and inform policy development.
Article
To examine the hypothesis that medical schools vary systematically and predictably in the proportion of their graduates who enter rural practice. The December 1991 version of the American Medical Association Physician Masterfile was used to examine the rural and urban practice locations of physicians who graduated from American medical schools between 1976 and 1985. Selected characteristics of the medical schools--including location, ownership, and funding--were linked to the Physician Masterfile. The percentage of the graduates from each medical school who were practicing in rural areas in December 1991, disaggregated by physician specialty. Of the practicing graduates from our study, 12.6% were located in rural counties; family physicians were much more likely than members of other specialties to select rural practice, particularly in the smallest and most isolated rural counties. Women were much less likely than men to enter rural practice. Medical schools varied greatly in the percentage of their graduates who entered rural practice, ranging from 41.2% to 2.3% of the graduating classes studied. Twelve medical schools accounted for over one quarter of the physicians entering rural practice in this time period. Four variables were strongly associated with a tendency to produce rural graduates: location in a rural state, public ownership, production of family physicians, and smaller amounts of funding from the National Institutes of Health. The organization, location, and mission of medical schools is closely related to the propensity of their graduates to select rural practice. Increasing policy coordination among medical schools and state and federal governmental entities would most effectively address residual problems of rural physician shortages.
Article
Currently, residency training is neither detrimental nor helpful to the problems of rural health. Based on four generally accepted "truths" about rural health, medical schools should recruit students from rural areas, have them choose family practice as a career, and train them in rural settings. Given no substantial changes in residency training, the following recommendations are made. Develop a consensus definition of "rural." Educate rural communities to the purpose of residency training. Residency review committees should support rural rotations of at least six months; consider the number of residencies at a site irrelevant for accreditation; judge the quality of the product as the standard of accreditation; and define teaching competency by other than specialty label. All medical school departments should be involved in seeking solutions to the problems of rural health. New opportunities for funding of rural residency training should be sought. If major changes in residency training are possible, internal medicine, family practice, and pediatrics should merge as a single primary care specialty and for residency training. Only this residency should be considered primary care for residency reimbursement purposes, and only its graduates should be reimbursed for primary care services.
Article
To evaluate controlled evidence on the efficacy of distance medicine technologies in clinical practice and health care outcome. Systematic electronic database and manual searches (1966-1996) were conducted to identify clinical trial reports on distance medicine applications. Three eligibility criteria were applied: prospective, contemporaneously controlled clinical trial with random assignment of the intervention; electronic distance technology application in the intervention group and no similar intervention in the control group; and measurement of the intervention effect on process or outcome of care. Data were abstracted by independent reviewers using a standardized abstraction form and the quality of methodology was scored. Distance technology applications were described in 6 categories: computerized communication, telephone follow-up and counseling, telephone reminders, interactive telephone systems, after-hours telephone access, and telephone screening. Of 80 eligible clinical trials, 61 (76%) analyzed provider-initiated communication with patients and 50 (63%) reported positive outcome, improved performance, or significant benefits, including studies of computerized communication (7 of 7), telephone follow-up and counseling (20 of 37), telephone reminders (14 of 23), interactive telephone systems (5 of 6), telephone access (3 of 4), and telephone screening (1 of 3). Significantly improved outcomes were demonstrated in studies of preventive care, management of osteoarthritis, cardiac rehabilitation, and diabetes care. Distance medicine technology enables greater continuity of care by improving access and supporting the coordination of activities by a clinician. The benefits of distance technologies in facilitating communication between clinicians and patients indicate that application of telemedicine should not be limited to physician-to-physician communication.
Article
The National Health Service Corps (NHSC) scholarship program is the most ambitious program in the United States designed to supply physicians to medically underserved areas. In addition to providing medical service to underserved populations, the NHSC promotes long-term retention of physicians in the areas to which they were initially assigned. This study uses existing secondary data to explore some of the issues involved in retention in rural areas. The December 1991 American Medical Association (AMA) Masterfile was used to determine the practice location and specialty of the 2903 NHSC scholarship recipients who graduated from US medical schools from 1975 through 1983 and were initially assigned to nonmetropolitan counties. We used the AMA Masterfile to determine what percentage of the original cohort was still practicing in their initial county of assignment and the relation of original practice specialty and assignment period to long-term retention. Twenty percent of the physicians assigned to rural areas were still located in the county of their initial assignment, and an additional 20 percent were in some other rural location in 1991. Retention was highest for family physicians and lowest for scholarship recipients who had not completed residency training when they were first assigned. Retention rates were also higher for those with longer periods of obligated service. Substantial medical care service was provided to rural underserved communities through obligated and postobligation service. Nearly 20 percent of all students graduating from medical schools between 1975 and 1983 who are currently practicing in rural counties with small urbanized populations were initially NHSC assignees. Although most NHSC physicians did not remain in their initial rural practice locations, a substantial minority are still rural practitioners; those remaining account for a considerable proportion of all physicians in the most rural US counties. This study suggests that rural retention can be enhanced by selecting more assignees who were committed to and then completed family medicine residencies before assignment.
Article
Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women in medicine have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States. We examine the geographic distribution of all active U.S. allopathic physicians recorded in the October 1996 update of the American Medical Association Physician Masterfile. Percentages and numbers of female physicians by professional activity, specialty type, and geographic location are reported. Findings reveal there were fewer than 7,000 female allopathic physicians practicing in rural America in 1996. The proportion of generalist female physicians who practice in rural settings was significantly lower than the proportion who practice in urban locations. Although members of the most recent 10-year medical school graduation cohort of female generalist physicians were slightly more likely to practice in rural areas than members of earlier cohorts, female physicians remained significantly underrepresented in rural areas. States varied dramatically in rural female generalist underrepresentation. Should female generalists continue to be underrepresented in rural locations, the rural physician shortage will not be resolved quickly. Effective strategies to improve rural female physician placement and retention need to be identified and implemented to improve rural access to physician care.
The Rural HPSA Physician Retention Study: Final Report for Grant No. RO HS 06544-0 from Agency for Health Care Policy and Research
  • Tr Konrad
Konrad TR. The Rural HPSA Physician Retention Study: Final Report for Grant No. RO HS 06544-0 from Agency for Health Care Policy and Research. Chapel Hill, NC: Cecil G Sheps Center for Health Services Research, University of North Carolina; 1994.
Rural managed care Rural Health in the United States
  • Mm Casey
Casey MM. Rural managed care. In: Ricketts TC III, ed. Rural Health in the United States. New York: Oxford University Press; 1999:113-118.