When 1+2≠3 for Hard-working Rural Physicians

UNDERSTANDING THE challenges and rewards of rural medical practice has long seemed to be the key to designing effective programs to increase the number of rural physicians. We believe that if we could only figure out what negative aspects of rural medicine prompt physicians to leave rural communities, we could solve the attrition half of the perennial rural physician shortage problem. When we also understand what is needed to attract more physicians into rural areas, the shortage can be eliminated completely

Changes in rates and content of primary care visits within an evolving health care system

It is no secret to patients and clinicians that the past decade has brought many changes to the organization, operations, and financing of health care in the United States. The Patient Protection and Affordable Care Act of 2010 (ACA) expanded the number of insured and otherwise reduced costs as a barrier to care, bolstered federal safety net programs, and promoted coverage of preventive services and wellness programs. The advent of the patient-centered medical home and primary care practice redesign has broadened services provided both during and between office visits through care teams that can include health coaches, panel managers, patient navigators, and care coordinators. Electronic medical records (EMRs) have become central to patient care, supporting chronic disease and preventive care management, promoting quality of care for set metrics, and providing new ways for patients, staff, and physicians to communicate. Institutional reorganization and new financing models now have most physicians working in practices that have contracted with accountable care organizations (ACOs) and other value-based payment arrangements, becoming responsible for the health and care of a growing 10% of the US population. Care previously received from standalone outpatient practices and siloed hospitals is now often received through regional integrated health care systems, with their centralized management, standardized protocols, and growing incentives for patients and clinicians. For the first time, fewer than one-half of physicians work in practices they own

Are Bias, Harassment, and Discrimination by Physician-Peers a Reason Why Some Physicians Leave Rural Communities?

The challenges of recruiting and, separately, retaining primary care physicians in rural and underserved settings are long-standing, but many of the fundamental factors, forces, and remedies are understood. Primary care physicians are generally drawn (recruited) to rural communities for the lifestyle, the beauty of the countryside and its outdoor activities, and the closeness of the people, in addition to the style of practice and professional challenges there. Many grew up in rural communities, but just as many simply prefer what these communities offer. Many have a personal drive to work in communities with a clear medical need and where the impact of their life’s work can be readily felt. The community, its people, the general feel of the place, and the intimate size of a rural practice and a rural medical community are principal draws

When access-to-care indicators meet. Designated shortage areas and avoidable hospitalizations.

PARCHMAN AND Culler, in this issue of the ARCHIVES, explore the difficult terrain of primary health care system assessment. Their work integrates 2 important measures of the primary care delivery system: the health professional shortage area (HPSA) classification of primary care access and the ambulatory care–sensitive (ACS) admission count, an emerging outcome measure of the adequacy and effectiveness of primary care services. In controlled analyses, they found that among elderly patients in fair or poor health, those who lived in HPSAs had a greater likelihood of experiencing an ACS admission than similar individuals in nonshortage counties

Satisfaction of the primary care, mental health, and dental health clinicians of the national health service corps loan repayment program

The National Health Service Corps (NHSC) aims to foster a positive service experience for its clinicians to promote long- term retention. We assess the satisfaction of primary care, dental, and mental health clinicians in the NHSC’s Loan Repayment Program (LRP). Survey data are from 1,193 clinicians (72.4% response) who completed NHSC LRP contracts in 16 states from July 2015 through December 2016. Eighty-one percent reported overall satisfaction with their work and practice, without differences across disciplines. Nearly 95% were satisfied with the mission and patients of their practices. Fewer clinicians were satisfied with compensation (51%) and time demands of work (36%). Ninety- four percent reported the NHSC experience met or exceeded their expectations, and 94% recommend the NHSC LRP to others. In summary, the NHSC LRP experience is generally positive for clinicians of all disciplines. Clinicians’ issues with their incomes and with the time demands of their work deserve attention from the NHSC

Students with global experiences during medical school are more likely to work in settings that focus on the underserved: an observational study from a public U.S. institution

Background: Global health interest has grown among medical students over the past 20 years, and most medical schools offer global health opportunities. Studies suggest that completing global health electives during medical school may increase the likelihood of working with underserved populations in a clinical or research capacity. This study aimed to assess the association of global electives in medical school on subsequently working in global health and with underserved populations in the United States (U.S.), additionally considering students’ interests and experiences prior to medical school. We also examined whether respondents perceived benefits gained from global electives. Methods: We surveyed medical school graduates (classes of 2011-2015) from a large public medical school in the U.S. to describe current practice settings and previous global health experience. We evaluated work, volunteer, and educational experiences preceding medical school, socioeconomic status, race and ethnicity using American Medical College Application Service (AMCAS) data. We assessed the association between students’ backgrounds, completing global health electives in medical school and current work in global health or with underserved populations in the U.S. Results: In the 5 to 8 years post-graduation, 78% of 161 respondents reported work, research, or teaching with a focus on global or underserved U.S. populations. Completing a global health elective during medical school (p = 0.0002) or during residency (p = 0.06) were positively associated with currently working with underserved populations in the U.S. and pre-medical school experiences were marginally associated (p = 0.1). Adjusting for pre-medical school experiences, completing a global health elective during medical school was associated with a 22% greater prevalence of working with an underserved population. Perceived benefits from global electives included improved cultural awareness, language skills, public health and research skills, and ability to practice in technology-limited settings. Conclusion: Medical school graduates who participated in global electives as students were more likely than their peers to pursue careers with underserved populations, independent of experiences prior to medical school. We hypothesize that by offering global health experiences, medical schools can enhance the interests and skills of graduates that will make them more likely and better prepared to work with underserved populations in the U.S. and abroad

What makes me screen for HIV? Perceived barriers and facilitators to conducting recommended routine HIV testing among primary care physicians in the southeastern United States

The Centers for Disease Control and Prevention have recommended routinely testing patients (aged 13-64) for HIV since 2006. However, many physicians do not routinely test. From January 2011 to March 2012, we conducted 18 in-depth individual interviews and explored primary care physicians' perceptions of barriers and facilitators to implementing routine HIV testing in North Carolina. Physicians' comments were categorized thematically and fell into 5 groups: policy, community, practice, physician, and patient. Lack of universal reimbursement was identified as the major policy barrier. Participants believed endorsement from the United States Preventive Services Tasks Force would facilitate adoption of routine HIV testing policies. Physicians reported HIV/AIDS stigma, socially conservative communities, lack of confidentiality, and rural geography as community barriers. Physicians believed public HIV testing campaigns would legitimize testing and decrease stigma in communities. Physicians cited time constraints and competing clinical priorities as physician barriers that could be overcome by delegating testing to nursing staff. HIV test refusal, low HIV risk perception, and stigma emerged as patient barriers. Physicians recommended adoption of routine HIV testing for all patients to facilitate and destigmatize testing. Physicians continue to experience a variety of barriers when implementing routine HIV testing in primary care settings. Our findings support multilevel approaches to enhance physician routine HIV testing in primary care settings. © The Author(s) 2014

Experiences of Safety-Net Practice Clinicians Participating in the National Health Service Corps During the COVID-19 Pandemic

Objectives: The impact of the COVID-19 pandemic has been particularly harsh for low-income and racial and ethnic minority communities. It is not known how the pandemic has affected clinicians who provide care to these communities through safety-net practices, including clinicians participating in the National Health Service Corps (NHSC). Methods: In late 2020, we surveyed clinicians who were serving in the NHSC as of July 1, 2020, in 20 states. Clinicians reported on work and job changes and their current well-being, among other measures. Analyses adjusted for differences in subgroup response rates and clustering of clinicians within practices. Results: Of 4263 surveyed clinicians, 1890 (44.3%) responded. Work for most NHSC clinicians was affected by the pandemic, including 64.5% whose office visit numbers fell by half and 62.5% for whom most visits occurred virtually. Fewer experienced changes in their jobs; for example, only 14.9% had been furloughed. Three-quarters (76.6%) of these NHSC clinicians scored in at-risk levels for their well-being. Compared with primary care and behavioral health clinicians, dental clinicians much more often had been furloughed and had their practices close temporarily. Conclusions: The pandemic has disrupted the work, jobs, and mental health of NHSC clinicians in ways similar to its reported effects on outpatient clinicians generally. Because clinicians’ mental health worsens after a pandemic, which leads to patient disengagement and job turnover, national programs and policies should help safety-net practices build cultures that support and give greater priority to clinicians’ work, job, and mental health needs now and before the next pandemic