Family Medicine Care Research Articles

Recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas.

To help address the geographic and specialty maldistribution of physicians, Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974. This unique program, which combines a selective medical school admissions policy with a special educational program, has been shown to be successful in increasing the number of family physicians in rural and underserved areas, but it is not known whether they remain in this type of practice. Graduates of the PSAP were tracked longitudinally and compared with their non-PSAP classmates. Information was obtained about the retention of family physicians in rural areas and areas with a physician shortage over the previous five years, the geographic and specialty choices of more recent graduates, and the recruitment of applicants into the program. Of the 47 PSAP graduates from the classes of 1978 through 1981, reported on earlier, the number who combined a career in family medicine with practice in a rural area or one with a physician shortage remained unchanged, although there was substantial attrition among non-PSAP graduates practicing family medicine in rural (32 percent) and underserved (40 percent) areas. Among the 101 PSAP graduates of the classes of 1982 through 1986, the results were similar to those for the first four classes. Overall, PSAP graduates from the classes of 1978 through 1986 were approximately four times as likely as non-PSAP graduates to practice family medicine (55 percent vs. 13 percent), to practice in a rural area (39 percent vs. 11 percent), and to practice in underserved areas (33 percent vs. 8 percent). They were approximately 10 times more likely to combine a career in family medicine with practice in a rural (26 percent vs. 3 percent) or underserved (23 percent vs. 2 percent) area. Overall, 85 percent of PSAP graduates were either practicing a care specialty or practicing in a rural or small metropolitan area or one with a shortage of physicians. In parallel with national trends, the number of applicants and matriculants to the program decreased during the past decade, so that the percentage of available places filled decreased from 97 percent to 33 percent. However, there has been a recent increase in the number of applicants and matriculants. The results of this study indicate that the PSAP was successful in increasing the number of family physicians in rural and underserved areas as well as in retaining them. This suggests that medical schools can have a substantial influence on the distribution of physicians according to specialty choice and the geographic location of their practices, principally through admission criteria.

Caring for the Uninsured and Underinsured

To the Editor. —As a public hospital physician overwhelmed by the growing number of indigent and uninsured patients, I want to thank you for devoting the May 15 JAMA issue to health care reform. The articles were most informative; Dr Lundberg's editorial 1 was inspirational. Although several viewpoints regarding reform were presented, all overlooked a major component in the quest to build a more just health care system. While I concur that the discussions of different possibilities of payer mixes and administrative structures are, in fact, central to any basic reform, provider mix, perhaps the most important element in a rational delivery system, was not discussed. There is a consensus that at least 50% of the providers must be in primary care—family medicine, general internal medicine, or general pediatrics—if our goal to develop a cost-effective system with universal access to basic services for all is to be achieved. I note

Studentsʼ evolving attitudes toward family medicine and specialty choices at one medical school

Seventy members of the class that entered Dartmouth Medical School in 1984 responded in 1984 and again in 1988 to statements regarding their attitudes towards family medicine, their general criteria for choosing a specialty, and their concerns about lifestyle; also, the students were asked in 1984 to indicate their interest in a career in family medicine and in 1988 to indicate their long-term specialty choices. The students' attitudes towards family medicine were generally positive on entry and became even more positive by their fourth year. Of the 25 students who indicated an initial interest in family medicine, six chose residencies in this field. Because most of the students studied showed strengthening agreement with both (1) the belief that family practitioners are particularly capable of providing comprehensive care and (2) the desire to concentrate on a specialty that would enable them to feel very competent and sure of their work, the authors hypothesize that the students may have feared that their desire for competence and certainty was incompatible with the comprehensiveness of family medicine.

The New Mexico experiment: educational innovation and institutional change.

Over the past ten years the University of New Mexico School of Medicine has conducted an educational experiment featuring learner-centered, problem-based, community-oriented learning. The experiment was introduced into an established institution by means of an innovative educational track running parallel to the more conventional curriculum. Students in the innovative track, compared with those in the conventional tract, tended to score lower on the National Board of Medical Examiners (NBME) Part I examination (basic sciences) and higher on NBME Part II (clinical sciences), received higher clinical grades on clinical clerkships, and experienced less distress. They were more likely than conventional-track students to retain their initial interest in or switch their preference to careers in family medicine. The parallel-track strategy for introducing curriculum reform succeeded in fostering institutional acceptance of continuing educational innovation. Generic steps in overcoming institutional barriers to change are identified.

Relationship between US medical school admission policy and graduates entering family practice.

Rural areas in the United States continue to lack an adequate supply of primary care doctors, particularly family physicians, despite the oversupply of physicians nationally. Previous studies have provided strong evidence that students from rural backgrounds, as well as those who expressed an interest at the time of medical school admission for a career in family medicine, are significantly more likely to eventually practise family medicine in rural areas than their peers. US medical schools were classified into three groups based on their written selection factors for preferentially admitting students into the graduating class of 1982. Of those schools with selection factors for students from both a rural background and an interest in a future career in family medicine, 23.7% of their graduates entered family medicine training programmes. This compares with 14.5% of graduates from schools with a preference for students from a rural background, and 12.4% from all other schools (P less than 0.001). Coupled with previous data which shows that family physicians from rural areas are more likely to eventually practise in rural areas than their peers, preferentially admitting students from rural backgrounds interested in a career in family medicine could help to solve the problem of the shortage of primary care physicians in rural areas in the US.

Obstetric malpractice fee phobia among medical students in the United States.

Sixty-three consecutive fourth-year medical students applying for a family medicine training programme based in a county hospital questioned about their anticipated practice style and the projected cost of malpractice insurance premiums during their first year of practice. Those who felt committed to providing obstetric services within their family practice estimated a much lower first-year dollar cost for malpractice insurance than those who were not committed to obstetric services. The difference in estimates was greater than $10 000 per year. Both groups far exceeded the actual quoted first year cost by three separate malpractice insurance companies. This study suggests that medical students may be influenced by unrealistic estimates of malpractice insurance costs prior to real world experiences. Furthermore, these estimates may indicate widespread ignorance and/or misinformation among medical students considering a family medicine career. malpractice suits and the fear of them remain, however, an important distraction from the provision of patient care services in the United States.

Three generations of family medicine: A comparison of social identities

Recent studies have shown that students and residents choosing Family Medicine career orientations have attained an academic parity with their counterparts in other specialties which was not demonstrated by their general practitioner predecessors. Similarly, the advent of Family Practice residencies and undergraduate course work has significantly altered the educational experience of today's medical students. This study adds to the literature by comparing a third element, the social character of Family Medicine oriented students, residents and practicing physicians. Three subgroups of Family Medicine oriented individuals; students, residents, and physicians, were surveyed through a mailed questionnaire. A study population of 768 individuals yielded a 73% response rate. The findings show that students and residents share a common pattern of identities and that this pattern is not shared with the physician subgroup. This results in rejection of the cohort replication theory. It also suggests a need for Family Practice training to provide role models from the new and emerging generation of family physicians.

Trends in medical education and health services. Their implications for a career in family medicine.

Abstract The selection of careers from among available specialties partly depends on an assessment of trends in medicine. More obviously than other specialties those providing primary care (e.g., family practice) are "system-defined" — i.e., they are shaped and made real by the needs of the present system of care. Students now selecting careers in family medicine are acting on current assumptions about the medical-care system of the future, although opinion in academic medicine and among medical practitioners remains divided about these issues. This analysis of factors acting to shape the system of medical care indicates a slow, ponderous and steady movement toward emphasis on primary care, family medicine and family practice. That movement may be expected to accelerate during the next two or three years — a time that will be critical in determining whether the function of primary care and family medicine will be fully professionalized and built into the evolving American medical system.