Rural Family Physicians Research Articles

Rural Idaho Family Physicians’ Scope of Practice

Scope of practice is an important factor in both training and recruiting rural family physicians. To assess rural Idaho family physicians' scope of practice and to examine variations in scope of practice across variables such as gender, age and employment status. A survey instrument was developed based on a literature review and was validated by physician educators, practicing family physicians and executives at the state hospital association. This survey was mailed to rural family physicians practicing in Idaho counties with populations of less than 50,000. Descriptive, bivariate and multivariate analyses were employed to describe and compare scope of practice patterns. Responses were obtained from 92 of 248 physicians (37.1% response rate). Idaho rural family physicians reported providing obstetrical services in the areas of prenatal care (57.6%), vaginal delivery (52.2%) and C-sections (37.0%); other operating room services (43.5%); esophagogastroduodenoscopy (EGD) or colonoscopy services (22.5%); emergency room coverage (48.9%); inpatient admissions (88.9%); mental health services (90.1%); nursing home services (88.0%); and supervision to midlevel care providers (72.5%). Bivariate analyses showed differences in scope of practice patterns across gender, age group and employment status. Binomial logistic regression models indicated that younger physicians were roughly 3 times more likely to provide prenatal care and perform vaginal deliveries than older physicians in rural areas. Idaho practicing rural family physicians report a broad scope of practice. Younger, employed and female rural family medicine physicians are important subgroups for further study.

Validation of a Case Definition to Define Hypertension Using Administrative Data

We validated the accuracy of case definitions for hypertension derived from administrative data across time periods (year 2001 versus 2004) and geographic regions using physician charts. Physician charts were randomly selected in rural and urban areas from Alberta and British Columbia, Canada, during years 2001 and 2004. Physician charts were linked with administrative data through unique personal health number. We reviewed charts of approximately 50 randomly selected patients >35 years of age from each clinic within 48 urban and 16 rural family physician clinics to identify physician diagnoses of hypertension during the years 2001 and 2004. The validity indices were estimated for diagnosed hypertension using 3 years of administrative data for the 8 case-definition combinations. Of the 3,362 patient charts reviewed, the prevalence of hypertension ranged from 18.8% to 33.3%, depending on the year and region studied. The administrative data hypertension definition of "2 claims within 2 years or 1 hospitalization" had the highest validity relative to the other definitions evaluated (sensitivity 75%, specificity 94%, positive predictive value 81%, negative predictive value 92%, and kappa 0.71). After adjustment for age, sex, and comorbid conditions, the sensitivities between regions, years, and provinces were not significantly different, but the positive predictive value varied slightly across geographic regions. These results provide evidence that administrative data can be used as a relatively valid source of data to define cases of hypertension for surveillance and research purposes.

The challenges and rewards of rural family practice in New Brunswick, Canada: lessons for retention

This study examined the work environment of rural family physicians in New Brunswick, a province in eastern Canada. The purpose of the research was to explore the job satisfaction of rural family physicians based on gender, age, years in practice, and language and location of practice. We used a qualitative, collective case study approach (24 cases of two individuals each: 48 interviews). Cases were selected based on gender, location (urban/rural), language (French/English) and number of years since medical school graduation (<10 years, 10-20 years, >20 years). The data reported is based on 21 interviews with rural physicians. Participants were recruited using the College of Physicians and Surgeons of New Brunswick website information. The research team traveled to physicians' offices throughout the province of New Brunswick to conduct interviews in the language of preference of the physician (French or English). Male researchers interviewed male participants and female researchers interviewed female participants. Interviews were transcribed verbatim and analyzed for themes related to the benefits and challenges of rural practice. Consensus on themes was reached among the entire research team. Many rural practitioners face a host of challenges ranging from professional isolation, complex patient profiles and maintaining professional boundaries. In this study, the most important challenge rural family physicians faced was the non-clinical issue of boundary maintenance. When rural family physicians had difficulties maintaining boundaries they were more likely to consider leaving their rural practice. Overall, few differences, based on gender, age, years in practice and language of practice were found. A few rural family physicians felt that the benefits of rural practice outweighed the challenges. This study demonstrates that rural family physicians in the province of New Brunswick, Canada face numerous challenges while practicing in rural areas. The most important challenges are not medical or technical in nature, but the 'soft' issue of maintaining professional and private boundaries. Rural physicians, when off duty, want privacy. Rural family physicians have to become more assertive about their needs, while at the same time, patients have to realize that off-duty physicians are private citizens.

Malpractice Burden, Rural Location, and Discontinuation of Obstetric Care: A Study of Obstetric Providers in Michigan

It has long been a concern that professional liability problems disproportionately affect the delivery of obstetrical services to women living in rural areas. Michigan, a state with a large number of rural communities, is considered to be at risk for a medical liability crisis. This study examined whether higher malpractice burden on obstetric providers was associated with an increased likelihood of discontinuing obstetric care and whether there were rural-urban differences in the relationship. Data on 500 obstetrician-gynecologists and family physicians who had provided obstetric care at some point in their career (either currently or previously) were obtained from a statewide survey in Michigan. Statistical tests and multivariate regression analyses were performed to examine the interrelationship among malpractice burden, rural location, and discontinuation of obstetric care. After adjusting for other factors that might influence a physician's decision about whether to stop obstetric care, our results showed no significant impact of malpractice burden on physicians' likelihood to discontinue obstetric care. Rural-urban location of the practice did not modify the nature of this relationship. However, family physicians in rural Michigan had a nearly 4-fold higher likelihood of withdrawing obstetric care when compared with urban family physicians. The higher likelihood of rural family physicians to discontinue obstetric care should be carefully weighed in future interventions to preserve obstetric care supply. More research is needed to better understand the practice environment of rural family physicians and the reasons for their withdrawal from obstetric care.

Competing Norms: Canadian Rural Family Physicians’ Perceptions of Clinical Practice Guidelines and Shared Decisionmaking

Implementation of clinical practice guidelines (CPGs) and shared decision-making are both advocated in primary care. Some authors argue that CPGs can enhance informed decisions by patients and physicians, while others warn that a standardized implementation of CPGs could hinder patients' involvement in decision-making. Our objective was to explore rural family physicians' perception of the interaction between clinical practice guidelines and shared decision-making in medical practice. A qualitative study using a semi-structured focus group interview: with 17 family physicians and residents, in a Canadian rural town. Interviews were audio-taped and transcribed verbatim. Thematic content analysis was performed and validated by the constant comparative method, member checking and group debriefing. Two distinct conceptions of how clinical practice guidelines should assist decision-making emerged. On the one hand, guidelines were seen as helping clinicians to make decisions on behalf of their patient about the best course of action. For interventions with uncertain benefit or that carried significant trade-off for patients, guidelines were seen as a tool that should inform decision-making between physicians and patients, providing them with details about risks, benefits, costs and alternative treatments. The pressure to apply guideline recommendations was perceived as a potential barrier to patient participation in decision-making. In circumstances where physicians judge patient participation in decision-making to be important, physicians perceive a tension between the need to respect patients' preferences and the pressure to apply guidelines. CPGs should include information that supports shared decision-making, besides their current focus on influencing prescription patterns, costs and health outcomes.

Initiatives for establishment of Rural Health in Hungary

There is a strong and well-managed primary health care in Hungary which fulfils quite well its gate-keeper function. But there is no rural health care. The disadvantages of the villagers are considered as a social problem. Hungarian Academic Association of Rural Health (HAARH ) set its main target in 2oo3 to form and elaborate rural health care in Hungary. The association has finished different studies on health and social status of rural population, on the health services in rural areas, on the mental status of rural family physicians, on patient-compliance and on cost-effective medication. The members of HAARH made efforts on implementing Rural Health as an element of Medical Universities' curriculum, to disseminate the knowledge of Rural Health among non medical partners, to make Rural Health accepted as an independent discipline and to be studied in health care universities. The studies are finished, their results are published, and the ongoing new surveys are on alcoholism and on hypertension. The Association has its special conference in every year on different topics in connection with rural and remote health. The summery of them are sent to the chief officers of Health Care in the Ministry, in the Public Health Institute and in the Professional Chamber. HAARH reaches the honour to be accepted as a special group of Professional College of Family Medicine and takes part in the preparation of elaborating professional guide-lines for GP's and represents special interests in preparation of different laws. Rural health is taught in the Medical Universities, and members of HAARH pays active role in the forming of curricula. A functioning and fruitful cooperation is under construction with the Hungarian NGO-s and with the national and international Rural Health Associations.

Influence of Obstetric Practice on Workload and Practice Patterns of Family Physicians and Obstetrician-Gynecologists

Obstetric practice among family physicians has declined in recent years. This study compared the practice patterns of family physicians and obstetrician-gynecologists with and without obstetric practices to provide objective information on one potential reason for this decline--the impact of obstetrics on physician lifestyle. In 2004, we surveyed all obstetrician-gynecologists, all rural family physicians, and a random sample of urban family physicians identified from professional association lists (N =2,564) about demographics, practice characteristics, and obstetric practices. A total of 1,197 physicians (46.7%) overall responded to the survey (41.5% of urban family physicians, 54.7% of rural family physicians, and 55.0% of obstetrician-gynecologists). After exclusions, 991 were included in the final data set. Twenty-seven percent of urban family physicians, 46% of rural family physicians, and 79% of obstetrician-gynecologists practiced obstetrics. The mean number of total professional hours worked per week was greater with obstetric practice than without for rural family physicians (55.4 vs 50.2, P=.005) and for obstetrician-gynecologists (58.3 vs 43.5, P = .000), but not for urban family physicians (47.8 vs 49.5, P = .27). For all 3 groups, physicians practicing obstetrics were more likely to provide inpatient care and take call than physicians not practicing obstetrics. Large proportions of family physicians, but not obstetrician-gynecologists, took their own call for obstetrics. Concerns about the litigation environment and personal issues were the most frequent reasons for stopping obstetric practice. Practicing obstetrics is associated with an increased workload for family physicians. Organizing practices to decrease the impact on lifestyle may support family physicians in practicing obstetrics.

Flinders University School of Medicine, Northern Territory, Australia: Achieving Educational Excellence along with a Sustainable Rural Medical Workforce

Introduction Medical schools today are being challenged to educate doctors who are willing and able to practice in areas of poverty and workforce need. In many countries, there is a shortage of doctors practicing in rural and remote communities. There is evidence that locating undergraduate medical education in rural areas increases the likelihood that graduates will choose to practice in underserved areas. Through its Parallel Rural Community Curriculum (PRCC), Flinders University School of Medicine (FUSM) now enables over 25% of its students to undertake an entire clinical year based in small rural communities supervised principally by rural family physicians. Objective The PRCC was conceived to provide a high quality educational intervention that would result in an increased number of students choosing to practice in rural and remote Australia. It was also designed to test the hypothesis that small rural and remote practices were capable of facilitating a full year of medical training at a standard comparable to that provided at a major tertiary hospital. Intervention Starting with eight students in four towns in 1997, the PRCC now places 30 students across 18 towns in rural Australia. The students simultaneously learn the disciplines of medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry, and family medicine. At the end of the year, all Flinders students, regardless of training location, take the same comprehensive exam. Outcomes PRCC students improved their academic performance in comparison to their tertiary trained peers. This improvement has been consistent over the ten years studied. Seventy percent of the PRCC students have chosen to practice in rural locations, compared to 18 percent of tertiary-trained students. Over twelve years, the program has proved to be sustainable in a private practice environment with a workforce shortage. Conclusions Evaluation of the PRCC indicates that a rural community-based clinical education can provide a high quality academic experience for students as well as a sustainable solution to rural medical workforce maldistribution.

Five Careers and Eight Airplanes: An Oral History of John Geyman, MD

Each generation has an obligation to remind succeeding ones about the people, ideas, and events that have gotten us to this point. This essay and an accompanying oral history trace the origins of family medicine through the life of someone who helped found it--John P. Geyman, MD. He is one of the most published family physicians in the United States. In addition to being a rural family physician, he was one of the first residency directors in family medicine and the first editor of the discipline's first academic journal. His career weaves 4 themes together in interesting and creative ways: commitment to the work of clinical practice, a sense of responsibility for strengthening clinical education, a belief that clinical care should be based on science and delivered within a rational system of health care, and a love of flying. His story also exemplifies the generation of general practitioners who started family medicine but who retained both a personal understanding of the complex nature of independent practice and a reliance on community.

Professional Liability Issues and Practice Patterns of Obstetric Providers in Washington State

To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician-gynecologists, family physicians, certified nurse midwives, licensed midwives). All obstetrician-gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes. Fewer family physicians provide obstetric services than obstetrician-gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician-gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers' most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician-gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period. Liability insurance premiums rose dramatically from 2002 to 2004 for Washington's obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study's results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics. III.

Continuing Decline in Service Delivery for Family Physicians

This study was conducted to monitor trends in the reduction and elimination of services offered by family physicians. In addition, we examined whether the malpractice situation may be influencing these trends. We surveyed all family physicians in rural Florida and an equal number of randomly selected, urban, family physicians in the state. We examined changes in professional liability insurance (PLI) premiums, and changes in services offered, practice satisfaction, and future practice plans. Overall, 308 (42.1%) family physicians responded. Results suggest that 60.3% of them reduced or eliminated services in the last year. Specifically, almost two thirds of respondents had eliminated hospital-based surgeries (65.2%) and vaginal deliveries (64.5%). Furthermore, endoscopies were decreased or eliminated by 69% of survey participants, and coverage of emergency departments and nursing homes was reduced or eliminated by 64.1% and 56.4% of respondents, respectively. Increases in the PLI averaged 78.2%. Overall increases in the PLI were significantly related to a decrease or elimination of services offered by family physicians. Dissatisfaction with practice was relatively high (36.8%) and was associated with both the reduction of services and an intention to leave practice within 2 years. No major differences in these trends were noted between rural and urban family physicians. Access to care provided by rural and urban family physicians in Florida is being hampered by the malpractice situation and other factors. Policymakers may need to focus on these factors in an effort to relieve additional barriers to care for vulnerable populations.

Long-Term Retention of Graduates from a Program to Increase the Supply of Rural Family Physicians

To determine the long-term retention of rural family physicians graduating from the Physician Shortage Area Program (PSAP) of Jefferson Medical College. Of the 1,937 Jefferson graduates from the classes of 1978-1986, the authors identified those practicing rural family medicine when their practice location was first determined. The number and percent of PSAP and non-PSAP graduates practicing family medicine in the same rural area in 2002 were then identified, and compared to the number of those graduates practicing rural family medicine when they were first located in practice 11-16 years earlier. After 11-16 years, 68% (26/38) of the PSAP graduates were still practicing family medicine in the same rural area, compared with 46% (25/54) of their non-PSAP peers (p = .03). Survival analysis showed that PSAP graduates practice family medicine in the same rural locality longer than non-PSAP graduates (p = .04). These results are the first to show long-term rural primary care retention that is longer than the median duration. This outcome combined with previously published outcomes show that the PSAP represents the only program that has resulted in multifold increases in both recruitment (eight-fold) and long-term retention (at least 11-16 years). In light of recent national recommendations to increase the total enrollment in medical schools, allocating some of this growth to developing and expanding programs similar to the PSAP would make a substantial and long lasting impact on the rural physician workforce.

Outpatient Colonoscopy by Rural Family Physicians

Five percent of family physicians offer colonoscopy services, either in the office or the hospital, often in rural areas that have no gastroenterologist. Two previous large series have shown the quality and safety of colonoscopy performed by family physicians. The purpose of this study was to verify these findings in an outpatient setting, as well as to obtain patient satisfaction data. Data were obtained from 731 colonoscopies performed between 1996 and 2001 in a rural Virginia family practice. These data included patients' age and sex, indications for the procedure, drug dosages for sedation, cecal intubation rates, pathologic findings, complications, and referral correlation findings compared with the original examination. A patient satisfaction survey was done. The adenoma detection rate was 27.2% for men and 21.4% for women older than age 50 years. Six adenocarcinomas and 5 large (>2 cm) villous adenomas were detected, and the patients were referred for definitive surgical resection. A total of 29 patients (4%) were referred: 10 to colorectal surgery and 19 to gastroenterology for resection of large polyps. Correlation of findings at referral with the initial examination was excellent. Cecal intubation rates increased from 89.5% from 1996-1998 to 94.6% from 1999-2001. Minor sedation complications occurred in 5 cases (<1%), and patients responded to supportive care. A high degree of satisfaction was reported by patients, with a mean satisfaction score of 8.8 on a scale from 1 to 10. Colonoscopy can be performed safely and competently by properly trained family physicians in an outpatient setting with a high degree of patient satisfaction.

Medicare and rural kidney medicine

Medicare and rural kidney medicine

Colonoscopy in rural communities: can family physicians perform the procedure with safe and efficacious results?

Colonoscopy is becoming increasingly necessary for many patients in screening, diagnosing, and treating colorectal problems. Because the majority of rural doctors are family physicians, providing colonoscopy for the enlarging group of patients with valid indications in rural areas is difficult, unless rural family physicians perform the procedure. Subspecialists in academic settings have been responsible for most of the previously reported studies regarding colonoscopy. We have studied the safety and efficacy of the procedure when performed by rural family physicians. A total of 200 sequential colonoscopies performed by family physicians in a rural setting were prospectively collected. Outcomes were measured based on current recommendations and benchmarks, including rate of reaching the cecum, time to reach the cecum, time to completion of the study, pathologic lesions found, and complications. The rate of reaching the cecum was 96.5%, and the average time to the cecum was 15.9 minutes. The average time to study completion was 34.4 minutes. The rate of neoplastic polyps and cancer found was 22.5% and 2.5%, respectively. There were no serious complications. Adequately trained family physicians can provide safe and technically competent colonoscopy in a rural setting. Their results compare favorably to the currently reported comparative benchmarks from other endoscopists.

Responses of rural family physicians and their colleague and coworker raters to a multi-source feedback process: a pilot study.

To describe responses of family physicians, their medical colleagues, and coworker raters to a multisource feedback assessment process. Data collection tools included multisource feedback self-assessment and medical colleague, coworker, and patient rating forms; and program evaluation physician and rater questionnaires. The pilot study included 142 physicians and their raters, with 113 (80%) physicians completing evaluations. Positive correlations were found between familiarity scores and medical colleague and coworker mean ratings. Peer medical colleagues were significantly more familiar with physicians than were consultants. Consultants were unable to rate items most frequently. Physicians disagreed with colleague feedback more frequently. Agreement was positively correlated with scores. Familiarity, ability to observe physicians appropriately to rate them, and physicians' responses to feedback are factors to consider when multisource feedback is used.

Medical Education for Agricultural Health and Safety

ABSTRACT Medical education for agricultural health and safety is evolving to intersect primary care, rural community health, and occupational and environmental medicine (OEM). Agricultural hazards are concentrated among the diverse concerns of primary care and community health. Family physicians who respond to this diversity can maintain their rural practices while establishing the credibility necessary for acceptance as partners in programs for agricultural community health. Rural family physicians with expertise in community health and OEM can be the front line of agricultural medicine. Several educational efforts are relevant to producing these physicians: (1) rural medicine, (2) rural public health, (3) family medicine, and (4) OEM (including agricultural medicine). Agromedicine education to prepare physicians to partner with agricultural scientists and cooperative extension agents should also be considered. Each of these efforts requires faculty with special expertise and resources. Few institutions are prepared currently to merge and coordinate these programs into a coherent rural and agricultural medicine program. We recommend that a medical school in each distinctive agricultural region construct a model for developing agricultural medicine physicians and seek partners and resources to operationalize the model. Examples include the Iowa, South Carolina, and Alabama models. A vocal rural and agricultural constituency may be required for success.

Emergency patient transfers from rural hospitals: a regional study

To clarify case mix, mode of transport and reasons for interfacility transfer from rural emergency departments (EDs) and to make recommendations for improved emergency health care delivery in rural settings. This was a multi-centre descriptive study, based in 5 rural Ontario EDs. Over a 1-year period, all ED patients who required transfer to another hospital were studied. Data collection forms were completed prospectively by the most responsible nurse involved in the transfer. Main measurements included patient age, gender, place of residence, circumstances and reason for transfer, primary diagnosis, mode of transport and receiving hospital. Of 53 796 patients who presented to the 5 participating EDs, 98.4% were managed locally and 836 (1.6%) were transferred to referral centres. Most patients (86%) were transferred because they required treatment beyond the scope of the local hospital. The need for orthopedic care, CT and pediatric care accounted for 23.6%, 14.1% and 8.7% of transfers respectively. These data suggest that rural family physicians may benefit from increased orthopedic and pediatric training and support. The study also identified a need for increased specialist availability in our rural setting. The high number of transfers for CT scans suggests that some rural health regions should consider acquiring a "regional" CT scanner. The development of a regional hospital, with a CT scanner and specialist resources, especially a general surgery on-call system, would reduce the need for transfer outside the region.

Characteristics of and issues faced by rural female family physicians.

The purpose of this study was to identify characteristics of and issues faced by female family physicians practicing in rural areas. A 37-item survey was designed to obtain demographic information about the background, community and practice of rural female physicians. An open-ended question regarding the issues and problems faced by female physicians in rural communities was included. Study subjects were identified from the membership of the American Academy of Family Physicians (AAFP). The questionnaire was mailed to all 850 active female AAFP members practicing in communities with less than 50,000 inhabitants during the winter of 1999. Completed and usable surveys were received from 587 (69.9 percent). The average age of respondents was 45. The majority were married (81.1 percent) and had children (80.1 percent). Half of the women had grown up in communities of 25,000 or less population. Twenty-seven percent of the respondents had no rural exposure in medical school; 39 percent had no rural exposure in residency; and 16 percent had no rural exposure in medical school or residency. The majority of respondents (62 percent) practiced in communities of less than 10,000. A large majority (70 percent) of these women planned to stay in the community for 10 years or more, with 58.6 percent responding that they plan to stay indefinitely. Assumptions regarding rural physicians, especially women, must be updated to accurately assist communities in recruiting rural physicians and to assist medical schools and residencies in adequately preparing graduates for rural practice.

Rural physicians' perspectives on cervical and breast cancer screening: a gender-based analysis.

Several studies highlight the role of physicians in determining cervical and breast cancer screening rates, and some urban studies report higher screening rates by female physicians. Rural women in North America remain underscreened for breast and cervical cancers. This survey was conducted to determine if there were significant gender differences in practices and perceptions of barriers to breast and cervical cancer screening among rural family physicians in Ontario, Canada. One hundred ninety-one family physicians (response rate 53.1%) who practiced in rural areas, small towns, or small cities completed a mail questionnaire. The physicians' mean age was 44.4 years (SD 9.9), and mean number of years in practice was 16.6 years (SD 10.3). Over 90% of physicians reported that they were very likely to conduct a Pap test and clinical breast examination (CBE) during a periodic health examination, and they had high levels of confidence and comfort in performing these procedures. Male (68%) and female (32%) physicians were similar in their likelihood to conduct screening, levels of confidence and comfort, and knowledge of breast and cervical cancer screening guidelines. However, the self-reported screening rates for Pap tests and CBE performed during last year were higher for female than male physicians (p < 0.01). Male physicians reported they were asked more frequently by patients for a referral to another physician to perform Pap tests and CBE (p < 0.001). Also, male physicians perceived patients' embarrassment as a stronger barrier to performing Pap tests (p < 0.05) and CBE (p < 0.01) than female physicians. No gender differences were observed in screening rates or related barriers to mammography referrals. These findings suggest that physicians' gender plays a role in sex-sensitive examination, such as Pap tests and CBE. There is a need to facilitate physician-patient interactions for sex-sensitive cancer screening examinations by health education initiatives targeting male physicians and women themselves. The feasibility of providing sex-sensitive cancer screening examinations by a same-sex health provider should also be explored.