Rural Primary Care Physicians Research Articles

Georgia's harvesting healthy habits: a formative evaluation.

Occupational safety and health researchers seek to conduct effective cancer awareness campaigns to increase agricultural workers' skin cancer prevention and detection behaviors. Georgia undertook such a project using a social cognitive theory (Bandura, 1986) conceptual model, with its objectives focusing on personal determinants of and environmental influences on farmers' behavior. One underused strategy to increase the success of health campaigns, formative evaluation, was undertaken during year one of the demonstration project, with four goals. These included an assessment of: (1) the availability of societal resources to support farmers' practices, (2) the affordability for farmers to follow through with behaviors being promoted, (3) the social support for behaving in ways that reduce farmers' skin cancer risk, and (4) farmers' current knowledge, outcome expectations, and self-efficacy in this regard. Formative evaluation revealed an absence of information, products, services, and social support for farmers' skin cancer prevention and detection. As a result, the Georgia project's plan was refined to include specific activities aimed at increasing the environmental support for health promotion activities relating to farmers' skin cancer prevention and detection. These include a seminar for rural primary care physicians and public health nurses to increase knowledge and skills relating to conducting clinical skin exams; programs for agricultural extension agents, cotton scouts, and 4-H groups to provide opportunities to learn more about and practice sun safety; and a feed and seed store campaign.

An assessment of practice support and continuing medical education needs of rural Pennsylvania family physicians.

Family physicians provide the greatest proportion of care in rural communities. Yet, the number of physicians choosing family practice and rural practice has continued to decline. Undesirable aspects of rural practice, such as professional isolation and a lack of or inadequate resources, are assumed to be associated with this decline. This article reports on the practice support and continuing medical education needs of rural family physicians. A mail survey was conducted in 1993 on a purposive sample of family physicians in 39 of 67 rural-designated or urban Pennsylvania counties with low population densities. The physicians identified needs that included patient education materials and programs, community health promotion, federal regulation updates, technical assistance with computers and business management, database software and a videotape lending library, a drug hotline, and mini-fellowships on clinical skill development. A majority of respondents were willing to participate in clinical educational experiences for students and residents. Some physicians indicated a lack of interest in access to information through telecommunications, e.g., video conference referrals and consultations. Overall, findings revealed that family physicians need and are receptive to a variety of practice support and continuing education programs. A practice support program coupled with policy coordination among public and private organizations is likely to lessen complaints by rural primary care physicians.

Rural human immunodeficiency virus health service provision. Indications of rural-urban travel for care.

We studied the travel of rural individuals positive for human immunodeficiency virus (HIV) to urban areas for HIV diagnosis and for ambulatory and inpatient HIV-related health services. We surveyed all (N = 84) identified HIV-positive adults (aged 18 years or older) residing in rural central and eastern Kentucky. Sixty-three individuals completed the survey, for a response of 75%. Although 60 respondents (95%) were living in a rural area at 18 years of age, 23 (37%) of the survey sample lived in urban areas at the time of their initial HIV diagnosis. Of the respondents, 13 (21%) traveled from rural areas to urban areas for their initial diagnosis of HIV. Forty-seven respondents (74%) traveled outside their county for HIV-related ambulatory care, with 40 respondents (64%) traveling to an urban area. The mean travel time required to obtain care for those who traveled to an urban area was almost 2 hours. Primary reasons for travel for ambulatory care include confidentiality concerns, belief that their physician was not knowledgeable enough about HIV, and referral to an outside physician. Increased training of rural primary care physicians regarding the psychosocial and biomedical aspects of HIV is suggested.

Competition, professional synergism, and the geographic distribution of rural physicians.

This study provides a theoretical and empirical investigation of competition and synergism among physicians in rural areas. The results show that rural primary care physicians cluster together rather than distribute themselves evenly. This suggests that public policy makers and rural communities must take an active role to ensure provider availability in all rural areas. There is less clustering among subspecialists. The results also reveal a disturbing negative relationship between young children and physician availability in rural areas. Finally, the results provide strong evidence that the relationship between rural physicians and hospitals is synergistic.

Telemedicine for patient consultation: factors affecting use by rural primary-care physicians in Kansas.

The purpose of our study was to investigate knowledge of, attitudes to, and use of interactive telemedicine for specialist consultation among rural practitioners Kansas. We interviewed 28 rural primary-care practitioners at seven remote health-care facilities in six locations. Content analyses of the interviews showed universal but superficial knowledge of telemedicine, appreciation of the value of the technology, but relatively low usage of the telemedicine service available (32% of subjects). Physicians did not appear to be afraid of change. Telemedicine usage was not related to the professional characteristics of the physicians. Our findings suggest that further growth in the use of telemedicine will depend on efforts directed towards physicians which are aimed at creating a more user-friendly environment and at accommodating the referral practices of potential users.

Interactions with colleagues and their effects on the satisfaction of rural primary care physicians.

Physician work satisfaction is related to several aspects of practice organization, including work group or colleagues, job content, work hours, and future opportunities. Practice location is an important determinant of practice organization and personal life satisfaction. This study compared the professional satisfaction of physicians in rural and urban settings to determine how practice setting, practice type, work hours, and interactions with colleagues influenced satisfaction. Surveys focusing on professional satisfaction were mailed to community-based, primary care physicians in Kentucky. Overall, physicians were satisfied with their practices, with physicians in larger communities being more satisfied than those from smaller communities. Professional satisfaction was associated with practice location, practice type, number of years since graduation from medical school, number of colleagues identified, and the quality of professional interactions with colleagues. The study concluded that collegial support for physicians is important in creating work environments that promote professional satisfaction.

The role of clinical workload and satisfaction with workload in rural primary care physician retention

To examine the relationship between clinical workload and workload satisfaction in rural primary care physician retention. Data from a survey, "Practice Patterns of Young Physicians, 1987: United States," were analyzed. Data on rural primary care (general or family practice, general internal medicine, or pediatrics) physicians working full time (> 35 h/wk) in clinical care were analyzed (n = 373). Self-reported likelihood of leaving the current practice within the next 2 years. Twenty-five percent of the physicians indicated that they were somewhat or very likely to leave the practice within the next 2 years. The modal reason for the likelihood of leaving was working too many hours (21%). Forty-nine percent of the respondents were dissatisfied with their workload. Those who were dissatisfied with their workload reported a greater likelihood of leaving (P = .0005). However, a quantitative measure of workload was not significantly related to the likelihood of leaving. The results of a multiple regression indicated that employees and those dissatisfied with their workload were most likely to leave the practice within the next 2 years. Satisfaction with clinical workload is an important factor in the likelihood of retaining rural primary care physicians.

To stay or not to stay: issues in rural primary care physician retention in eastern Kentucky.

An important aspect of primary care physician availability is the retention of physicians once they have located. While retention has been under-researched compared to recruitment, it is especially important in rural areas where physician shortages already exist. This study reports the results of a retention survey completed by 132 primary care physicians in rural eastern Kentucky. The survey sets up an objective, hypothetical retention scenario and asks physicians to respond to structured questions and to an open-ended question about factors not appearing in the survey. In response to the structured portion of the survey, physicians indicate that relief coverage is the most important factor in rural physician retention. A content analysis of 75 open-ended responses reveals that besides the other factors in the survey, "sociocultural integration" is the pre-eminent retention issue for rural practitioners. This article concludes that the role of the local rural community may be more important in retention than in recruitment. Finally, it is suggested that additional in-depth qualitative research be conducted within the local contexts to enhance the understanding of rural physician retention processes.

Community-oriented primary care. Implementation of a national rural demonstration

A major objective of community-oriented primary care (COPC) is to focus the clinical practice on the health care problems of the community that the practice serves. The COPC process defines the community of interest, identifies and prioritizes community health problems, and implements and evaluates interventions. Under sponsorship from the W. K. Kellogg Foundation, the COPC National Rural Demonstration Program was established to explore the feasibility of implementing COPC in 13 rural practices. An evaluation of the program found that local communities played critical roles in defining and implementing COPC interventions. These interventions were most often focused on health promotion/illness prevention activities. At most sites, clinical practices were limited in their ability to incorporate COPC activities by staff and physician turnover and the extensive patient demands on the time of rural primary care physicians. While the COPC process proceeded at different rates across the sites, after 2 1/2 years of grant funding, most sites continued to devote the majority of their resources to designing and implementing interventions. Thus, it appears that coordination by dedicated nonphysician staff and more than 2 years of effort are required to implement COPC concepts in rural practices in underserved areas.

Physician management preferences and barriers to care for rural patients with depression

To describe rural primary care physicians' current preferences in treating depression and the barriers they face in providing effective care for this condition. Cross-sectional survey of randomly selected practicing primary care physicians registered in Arkansas. Primary care practices in nonmetropolitan counties. Forty of 50 eligible physicians completed a face-to-face interview; one physician, an interview by telephone; and two physicians, an interview in questionnaire form. Total response rate was 86%. Physician preferences for and barriers to the effective management of depression. An estimated 44% of rural physicians consider medication alone to be the best initial approach to treating depression; 30% prefer to prescribe medication and refer patients to mental health care professionals for counseling; and 26% prefer to prescribe medication and conduct counseling themselves. The greatest barriers to treatment were the physician's lack of time and the patient's failure to recognize depression. Most physicians had recently referred one or more depressed patients to specialty care and had encountered few referral sources, long waiting lists, and inadequate follow-up. The majority of rural primary care physicians prefer to treat depressed patients in their practices themselves. Except for the limited availability of specialty services, most of the barriers to the provision of effective care for depression perceived by rural physicians do not appear to be unique to rural practices.

Alzheimer's disease and dementing disorders: Practices and experiences of rural physicians

This paper presents information on rural primary care physicians' diagnoses, the procedures used, treatment recommendations, as well as reported advantages and disadvantages ofpracticing in a rural setting and managing patients with Alzheimer's disease and dementing disorders. A total of 102 primary care physicians in rural Illinois counties were interviewed (response rate = 72.3 percent). There was considerable variability in physicians' responses to the causes of dementia syndrome and the procedures used in making a diagnosis. When questioned in an open-ended format about possible causes of dementing disorders, physicians mostfrequently mentioned Alzheimer's disease (80 percent), multi-infarct dementia (56percent), and drug toxicity (53 percent). “Non-specific” causes were also mentioned, including arteriosclerosis (36 percent), organic brain syndrome (27 percent), and old age (25 percent). Laboratory tests and CT scans were most often used in the diagnostic process. Less than 10 percent of the physicians used more formal, cognitive screening tests like the Mini-Mental State Exam. Less than one-half of the physicians had previously recommended nursing home placement in the management of their dementia patients. Physician age, practice type (solo/group) and specialty (internal/family medicine) were associated with some of the physicians' responses regarding dementia causes and procedures used in diagnosis. The rural setting was viewed as inadequate with regard to laboratory facilities and supportpersonnel as well as problematic in requiring long distance travel for consultation. On the other hand, the rural community provided an advantage over the urban in opportunities for support and cooperation forfamilies andfriends to assist in managing the care ofdementia disorder patients. Alzheimer's disease and other dementias present the problem of uncertainty at many levels including medical, patient outcome, and family management issues. In the rural setting, the physician often represents the entire health professions community. It is imperative that rural physicians be prepared to both diagnose and, in turn, manage the complex and difficultsituation created by dementia syndrome.

Medical education and the rural health crisis

While there is good evidence that decisions regarding practice site are influenced by experience in medical school and residency, medical education constitutes only one of a complex set of factors that have made it difficult to recruit physicians to rural America. A solution to the rural health crisis will require not only changes in student selection, curriculum, and training location, but also strengthening of the rural economy, improved reimbursement to rural hospitals and primary care physicians, and increased sensitivity by leaders of the medical profession to the needs of rural areas and rural practitioners.