Maldistribution Of Physicians Research Articles

Rural Residency Training as a Strategy to Address Rural Health Disparities: Barriers to Expansion and Possible Solutions.

Rural Residency Training as a Strategy to Address Rural Health Disparities: Barriers to Expansion and Possible Solutions.

WORK–LIFE BALANCE OF YOUNG PHYSICIANS IN JAPAN

Background: Geographical and specialty maldistribution of physicians are key
 issues in the Japanese healthcare system. These are strongly related to work–life
 balance issues that physicians face, including long working hours, burnout, and
 discontinuation of female physicians’ careers.
 Objective: To obtain the opinions of young physicians in Japan on policies
 regarding work–life balance and career building.
 Method: A cross-national study was conducted using a questionnaire that was sent
 to physician across Japanese Red Cross Hospitals.
 Results: Young physicians view work–life balance as important in choosing
 specialties and work location. In addition to the motivation to gain training
 experience, they seek adequate rest through shift work, and work efficiency by
 sharing tasks with other medical professionals, using IT, and improving operation
 management.
 Discussion: As an example of work-style reform in progress, we would like to
 introduce the shift-work system at our institution’s Obstetrics and Gynecology
 Department. By clarifying the line between work and life, physicians can balance
 career building and time for self-improvement.
 Conclusion: For young physicians to continue their careers without burning out
 and excel in various fields, we must create a system that allows for efficient
 learning and work–life balance for both mental and physical well-being.

Co-editors' notes

Co-editors' notes

Temporal trends of physician geographical distribution and high and intermediate physician density areas and factors related to physicians’ movement to low physician density areas in Japan: a longitudinal study (1996–2016)

ObjectivesA major issue in Japan’s health policy is the geographical maldistribution of physicians. This study aimed to analyse temporal trends in the geographical distribution of physicians and analyse physicians in...

To Work at Clinics or at Hospitals? Analysis of Family Physician Recruitment Advertising in Taiwan.

Family physicians act as gatekeepers of the healthcare system and have an indispensable role in providing holistic care in the primary care system. While previous studies had focused on the geographic maldistribution of family physicians, the current study investigated the distribution of job opportunities for family physicians by analyzing recruitment advertisements posted in medical association journals, as an indirect way to observe the marketplace demand for physicians. We collected all the recruitment advertisements for family physicians in the twelve issues of the Taiwan Medical Journal, the official organ of the Taiwan Medical Association, in 2018. In contrast to 124 new trainees annually, 739 advertisements for family physicians were posted within the entire year. After eliminating repeated advertisements, there were 302 distinct advertisements, of which hospitals accounted for 18.9% (n = 57). The job opportunities at hospitals were offered mainly by regional hospitals (n = 26) and community hospitals (n = 29), but only two by medical centers. Family physicians in Taiwan were in great demand not only by primary care clinics but also by hospitals. The role of family physicians in hospitals is worth further study.

Survey on Specialty Preference and Work-Life Balance among Residents of Japanese Red Cross Hospitals.

Introduction: The paucity and maldistribution of physicians among various specialties are key issues facing the Japanese health care system. Studies have shown that young physicians place more emphasis on work-life balance while selecting their specialty and that they prefer controllable lifestyle (CL) specialties over noncontrollable lifestyle (NCL) specialties. As this may be a cause of maldistribution, we investigated the relationship between views on work-life balance and specialty selection among young physicians in Japan.Methods: An online questionnaire was sent to 1451 residents (postgraduate years 1-5) at 60 Japanese Red Cross hospitals across Japan. Results: In all, 226 physicians responded (response rate: 15%), with 21% in CL and 74% in NCL specialties. When compared with NCL specialties, CL specialties had less overtime (43% vs. 16%, p = 0.001), considered life to be more important than work (26% vs. 15%, p = 0.018), and were more likely to give precedence to work-life balance over medical interest while choosing their specialty (49% vs. 30%, p < 0.001). Furthermore, physicians were more likely to change their choice of specialty, contrary to their professional interest, because of social reasons (49% vs. 26%, p = 0.007). Conclusions: Our study suggests that young physicians in CL specialties have better working hours and place more emphasis on work-life balance while choosing their specialty compared with those in NCL specialties. The increase in the number of physicians in CL specialties is likely attributable to the growing preference for an optimal work-life balance among young physicians; this seems to have increased the maldistribution of physicians among various specialties. Institutional mechanisms to support the lifestyle of physicians (especially in NCL specialties) are required to provide a balanced medical service in Japan.

Time changes in the geographical distribution of physicians and factors associated with starting rural practice in Japan.

The geographical maldistribution of physicians is an important issue for health policy. This study aimed to evaluate recent trends in Japan and identify the factors associated with starting a rural practice. A longitudinal study was conducted using secondary analysis of national census data. The number of physicians in each region was described in 1996, 2006, and 2016 and, for two cohorts, 1996 to 2006 and 2006 to 2016; a logistic regression analysis was used to identify factors related to starting a rural practice after 10 years. Between 1996 and 2016, the number of physicians in rural areas increased by 4%. Results of the logistic regression analysis showed that, in both cohorts, the factor with the highest odds ratio for starting a rural practice after 10 years was initial academic hospital experience. Other factors showing positive correlations were additional hospital practice and being qualified and over 30 years old, whereas female sex and aged at least 40 years had negative correlations. From 1996 to 2016, despite the increase in the total number of physicians, geographical maldistribution increased. Some findings support the policy that some physicians should work in rural areas in return for scholarships.

Geographical distribution of family physicians in Japan: a nationwide cross-sectional study

BackgroundGeographical maldistribution of physicians, and their subsequent shortage in rural areas, has been a serious problem in Japan and in other countries. Family Medicine, a new board-certified specialty started 10 years ago in Japan by Japan Primary Care Association (JPCA), may be a solution to this problem.MethodsWe obtained the workplace information of 527 (78.4%) of the 672 JPCA-certified family physicians from an online database. From the national census data, we also obtained the workplace information of board-certified general internists, surgeons, obstetricians/gynaecologists and paediatricians and of all physicians as the same-generation comparison group (ages 30 to 49). Chi-squared test and residual analysis were conducted to compare the distribution between family physicians and other specialists.ResultsFive hundred nineteen JPCA-certified family physicians and 137,587 same-generation physicians were analysed. The distribution of family physicians was skewed to municipalities with a lower population density, which shows a sharp contrast to the urban-biased distribution of other specialists. The proportion of family physicians in non-metropolitan municipalities was significantly higher than that expected based on the distribution of all same-generation physicians (p < 0.001).ConclusionsFamily physicians distributed in favour of rural areas much more than any other specialists in Japan. The better balance of family physician distribution reported from countries with a strong primary care orientation seems to hold even in a country where primary care orientation is weak, physician distribution is not regulated, and patients have free access to healthcare. Family physicians comprise only 0.2% of all Japanese physicians. However, if their population grows, they can potentially rectify the imbalance of physician distribution. Government support is mandatory to promote family medicine in Japan.

Geographic variation in spatial accessibility of U.S. healthcare providers.

BackgroundGrowing physician maldistribution and population demographic shifts have contributed to large geographic variation in healthcare access and the emergence of advanced practice providers as contributors to the healthcare workforce. Current estimates of geographic accessibility of physicians and advanced practice providers rely on outdated “provider per capita” estimates that have shortcomings.PurposeTo apply state of the art methods to estimate spatial accessibility of physician and non-physician clinician groups and to examine factors associated with higher accessibility.MethodsWe used a combination of provider location, medical claims, and U.S. Census data to perform a national study of health provider accessibility. The National Plan and Provider Enumeration System was used along with Medicare claims to identify providers actively caring for patients in 2014 including: primary care physicians (i.e., internal medicine and family medicine), specialists, nurse practitioners, and chiropractors. For each U.S. ZIP code tabulation area, we estimated provider accessibility using the Variable-distance Enhanced 2 step Floating Catchment Area method and performed a Getis-Ord Gi* analysis for each provider group. Generalized linear models were used to examine associations between population characteristics and provider accessibility.ResultsNational spatial patterns of the provider groups differed considerably. Accessibility of internal medicine most resembled specialists with high accessibility in urban locales, whereas relative higher accessibility of family medicine physicians was concentrated in the upper Midwest. In our adjusted analyses independent factors associated with higher accessibility were very similar between internal medicine physicians and specialists–presence of a medical school in the county was associated with approximately 70% higher accessibility and higher accessibility was associated with urban locales. Nurse practitioners were similar to family medicine physicians with both having higher accessibility in rural locales.ConclusionsThe Variable-distance Enhanced 2 step Floating Catchment Area method is a viable approach to measure spatial accessibility at the national scale.

Self-reported influence of monetary grants in the choice of a medical residency in remote or under-served areas

ObjectivesTo evaluate the effect of monetary grants on young physicians’ choice of remote or rural hospital-based practice.BackgroundIn late 2011, The Israeli Ministry of Health attempted to address a severe physician maldistribution, which involved severe shortages in remotely-located institutions (RLI). The policy intervention included offering monetary grants to residents who chose a residency program in a RLI.MethodsA total of 222 residents from various disciplines were recruited; 114 residents from RLI and 108 residents from central-located institutions (CLI), who began their residency during 2012–2014. Participants were surveyed on demographic, academic and professional data, and on considerations in the choice of residency location.ResultsResidents in RLI attributed significantly more importance to the grant in their decision-making process than did residents from CLI. This effect remained significant in a multivariate model (OR 1.65, 95% CI 1.20–2.27, p = 0.002). The only parameter significantly associated with attributing importance to the grant was older age (OR 1.09, 95% CI 1.00–1.19, p = 0.049).ConclusionThe choice of a RLI for residency may be influenced by monetary grants. This is consistent with real-life data showing an increase in medical staffing in these areas during the program’s duration. Further studies are needed to determine causality and physical practicality of such programs.

Negative Aspects of the Regional Quota System in Japan.

Chiikiwaku is a measure to improve the maldistribution and shortage of physicians in rural areas in Japan. Although Chiikiwaku quota seats have been on the rise, a considerable number of young physicians and medical students return their loans and do not fulfill their duty periods for several important reasons, including an obligation term lasting for 9 years. The number of medical students who do not apply for admission to the Chiikiwaku quota has increased, and vacancies have developed in some medical schools. Urgent modification of this program is therefore required to make it suitable for actual situations of both rural medical care and the education of young physicians.

Board certification and urban\u2013rural migration of physicians in Japan

BackgroundThe board certification system serves as a quality assurance system for physicians, and its design and operation are important health policy issues. In Japan, board certification was established and operated independently by academic societies and has not been directly linked to reimbursement systems. The phenomenon of younger physicians seeking specialist careers has raised concerns about acceleration of the tendency of fewer physicians working in rural areas and the maldistribution of physicians. Little is known about the associations between physicians’ geographical migration patterns and board certification status changes or between the continuation of urban/rural practice and the maintenance of board certification. This study aimed to identify these associations and to discuss their policy implications.MethodsWe analyzed 2012 and 2014 data from the Survey of Physicians, Dentists, and Pharmacists, a national census survey. To analyze geographical migration patterns, transitions in practice location (rural, intermediate, and urban) were analyzed by board certification status change (new, lost, consistently certified, and consistently uncertified). Logistic regression analysis was conducted to assess whether the odds of migrating to more urban/rural municipalities were associated with board certification status changes, adjusting for covariates, and whether practicing in a rural area was associated with maintaining board certification.ResultsAmong 18,726 newly board-certified physicians, 94.9% (13,435/14,150) of those working in urban areas before certification remained in urban areas, whereas 64.6% (393/608) of those working in rural areas stayed in rural areas. Those who were newly certified had higher odds of moving to more urban areas, adjusting for covariates. Those who stayed in rural areas showed lower odds of maintaining board certification, adjusting for covariates.ConclusionsNewly board-certified physicians are more likely to migrate to other types of areas, particularly more urban areas, than other physicians. Allocating more training quotas to rural areas could be one option for leveling the distribution of specialists. It also appeared that those practicing in rural areas have difficulty maintaining their certification, so the need to establish a support system for already-certified physicians in rural areas should be emphasized.

Levers of change: a review of contemporary interventions to enhance diversity in medical schools in the USA.

A growing body of research illustrates the importance of aligning efforts across the operational continuum to achieve diversity goals. This alignment begins with the institutional mission and the message it conveys about the priorities of the institution to potential applicants, community, staff, and faculty. The traditional themes of education, research, and service dominate most medical school mission statements. The emerging themes of physician maldistribution, overall primary-care physician shortage, diversity, and cost control are cited less frequently. The importance and salience of having administrative leaders with an explicit commitment to workforce and student diversity is a prominent and pivotal factor in the medical literature on the subject. Organizational leadership shapes the general work climate and expectations concerning diversity, recruitment, and retention. Following the Bakke decision, individual medical schools, supported by the Association of American Medical Colleges, worked to expand the frame of reference for evaluating applicants for medical school. These efforts have come together under the rubric of “holistic review”, permitted by the US Supreme Court in 2003. A large diverse-applicant pool is needed to ensure the appropriate candidates can be chosen for the incoming medical school class. Understanding the optimal rationale and components for a successful recruitment program is important. Benchmarking with other schools regionally and nationally will identify what should be the relative size of a pool. Diversity is of compelling interest to us all, and should pervade all aspects of higher education, including admissions, the curriculum, student services and activities, and our faculties. The aim of medical education is to cultivate a workforce with the perspectives, aptitudes, and skills needed to fuel community-responsive health-care institutions. A commitment toward diversity needs to be made.

Developing Programs That Will Change Health Professions Education and Practice: Principles of Program Evaluation Scholarship

Developing Programs That Will Change Health Professions Education and Practice: Principles of Program Evaluation Scholarship

Funding Instability Reduces the Impact of the Federal Teaching Health Center Graduate Medical Education Program

The Teaching Health Center Graduate Medical Education (THCGME) program is a decentralized residency training component of the Affordable Care Act, created to combat critical shortages and maldistribution of primary care physicians. The Accreditation Council of Graduate Medical Education and federal data reveal that the THCGME program accounted for 33% of the net increase in family medicine residency positions between 2011 and 2015. However, amid concerns about the program's stability, the contribution of the THCGME program to the net increase fell to 7% after 2015.

Preparing Physicians for Rural-Based Primary Care Practice: A Preliminary Evaluation of Rural Training Initiatives at OSU-COM.

The physician shortage in Oklahoma coupled with geographic maldistribution of primary care physicians limits access to care in rural and underserved areas. One of the most effective strategies to recruit and retain physicians in rural areas is to create undergraduate and graduate medical education training sites in these locations. Oklahoma State University Center for Health Sciences College of Osteopathic Medicine has implemented a rural training program that begins with early recruitment of rural high school students, introduces medical students to rural practice options through rural clinical training opportunities, and provides opportunities to remain in rural Oklahoma for residency training through ongoing graduate medical education development. The purpose of this article is to provide a case study of the development of the college's Rural Medical Track. Preliminary findings indicate that rural-based clinical training for third- and fourth-year students strengthens performance on standardized tests.

Challenges and strategies to improve the availability and geographic accessibility of physicians in Portugal

BackgroundShortages of physicians in remote, rural and other underserved areas and lack of general practitioners limit access to health services. The aims of this article are to identify the challenges faced by policy and decision-makers in Portugal to guarantee the availability and geographic accessibility to physicians in the National Health Service and to describe and analyse their causes, the strategies to tackle them and their results. We also raise the issue of whether research evidence was used or not in the process of policy development.MethodsWe analysed policy and technical documents, peer-reviewed papers and newspaper articles from 1995 to 2015 through a structured search of government websites, Portuguese online newspapers and PubMed and Virtual Health Library (Biblioteca Virtual em Saúde (BVS)) databases; key informants were consulted to validate and complement the documentary search.ResultsThe challenges faced by decision-makers to ensure access to physicians were identified as a forecasted shortage of physicians, geographical imbalances and maldistribution of physicians by level of care. To date, no human resources for health policy has been formulated, in spite of most documents reviewed stating that it is needed. On the other hand, various isolated and ad hoc strategies have been adopted, such as incentives to choose family health as a specialty or to work in an underserved region and recruitment of foreign physicians through bilateral agreements.ConclusionsHealth workforce research in Portugal is scarce, and therefore, policy decisions regarding the availability and accessibility of physicians are not based on evidence. The policy interventions described in this paper should be evaluated, which would be a good starting point to inform health workforce policy development.

Measuring inequality in physician distributions using spatially adjusted Gini coefficients.

To measure inequality in physician distributions using Gini coefficient and spatially adjusted Gini coefficients. Measurements were based on the distribution of physician data from the Taiwan National Health Insurance Research Database (NHIRD) and population data from the Ministry of the Interior in Taiwan. The distribution of population and physicians in Taiwan from 2001 to 2010. This study considered 35 000 physicians who are registered in Taiwan. To calculate the Gini coefficient and spatially adjusted Gini coefficients in Taiwan from 2001 to 2010. The Gini coefficient for each year, from 2001 to 2010, ranged from 0.5128 to 0.4692, while the spatially adjusted Gini coefficients based on travel time and travel distance ranged, respectively, from 0.4324 to 0.4066 and from 0.4408 to 0.4178. We found that, in each year, irrespective of the type of spatial adjustment, the spatially adjusted Gini coefficient was smaller than the Gini coefficient itself. Our empirical findings support that the Gini coefficient may overestimate the maldistribution of physicians. Our simulations demonstrate that increasing the number of physicians in medium-sized cities (such as capitals of counties or provinces), and/or improving the transportation time between medium-sized cities and rural areas, could be feasible solutions to mitigate the problem of geographical maldistribution of physicians.

Geographic Maldistribution of Physicians in Japan : Increasing the Number of Generalists is One Solution

Despite massive intervention from Japan's national and local governments, the skewed distribution of physicians remains a serious social problem. This review paper summarizes past literature and proposes a future strategy to deal with this sophisticated issue based on scientific evidence. There are several ways to achieve a more balanced distribution, the most feasible of which is to increase the number of generalists. This increase might be imminent with the establishment of a formal board certification for general practitioners (sougou‐shinryou‐i) and raising the number of rural subquota (chiikiwaku) entrants to medical school. All the stakeholders should co‐operate to take advantage of this great opportunity to increase the number of generalist physicians and solve Japan's distribution problem.

What factors influence the choice of urban or rural location for future practice of Nepalese medical students? A cross-sectional descriptive study.

BackgroundNepal is experiencing a public health issue similar to the rest of the world, i.e., the geographical maldistribution of physicians. Although there is some documentation about the reasons physicians elect to leave Nepal to work abroad, very little is known about the salient factors that influence the choice of an urban versus rural practice setting for those physicians who do not migrate. In recent years, around 1000 medical students became doctors within Nepal, but their distribution in rural locations is not adequate. The purpose of this study was to explore what factors influence the choice of urban or rural location for the future clinical practice of Nepalese medical students in the final year of their programMethodsA cross-sectional descriptive study design was used for this study involving Nepalese medical students in their final year of study and currently doing an internship in a medical college. The sample consisted of 393 medical students from four medical colleges in Nepal that were selected randomly. An anonymous self-administered questionnaire was used for data collection. To determine the association with rural location choice for their future practice setting, a comparison was done that involved demographic, socio-economic, and educational factors. Data were entered in EpiData and analyzed by using SPSS version 16.ResultsAmong the 393 respondents, two thirds were male (66.9%) and more than half were below 25 years of age. Almost all (93%) respondents were single and about two thirds (63.4%) were of Brahmin and Chhetri ethnic origin. About two thirds (64.1%) of the respondents were born in a rural setting, and 58.8% and 53.3% had a place of rearing and permanent address in a rural location, respectively. The predictors of future rural location choice for their clinical practice (based on the bivariate analysis) included:Rural (versus urban) place of birth, place of rearing, and permanent addressSource of family income (service, business, and agriculture)Occupation of father (service, business and agriculture)Wealth ranking (higher, middle, and lower wealth rank)Educational factors: location, type of secondary education, and type of higher secondary educationConclusionFor medical students who were soon to complete their studies, demographic and educational factors were found to be significant predictors for a rural location choice, as opposed to socio-economic factors. Our findings indicate that to ensure the rural retention of physicians, the government of Nepal should attract potential medical students from those who were reared and educated in a rural setting.