The Decline In Rural Medical Students: A Growing Gap In Geographic Diversity Threatens The Rural Physician Workforce.

Growing up in a rural setting is a strong predictor of future rural practice for physicians. This study reports on the fifteen-year decline in the number of rural medical students, culminating in rural students' representing less than 5 percent of all incoming medical students in 2017. Furthermore, students from underrepresented racial/ethnic minority groups in medicine (URM) with rural backgrounds made up less than 0.5 percent of new medical students in 2017. Both URM and non-URM students with rural backgrounds are substantially and increasingly underrepresented in medical school. If the number of rural students entering medical school were to become proportional to the share of rural residents in the US population, the number would have to quadruple. To date, medical schools' efforts to recognize and value a rural background have been insufficient to stem the decline in the number of rural medical students. Policy makers and other stakeholders should recognize the exacerbated risk to rural access created by this trend. Efforts to reinforce the rural pipeline into medicine warrant further investment and ongoing evaluation.

The role of medical school culture in primary care career choice.

PURPOSE: To examine individual-level and medical-school-level factors, including the school's primary care culture, that are associated with medical students' likelihood of practicing primary care. METHOD: In spring 2010, the Association of American Medical Colleges Center for Workforce Studies invited all fourth-year medical students at a stratified random sample of 20 U.S. MD-granting medical schools to participate in an online survey examining factors in specialty choice decisions. Schools were stratified according to the historical percentage of their graduates who became practicing primary care physicians. Multilevel logistic regression modeling was used to determine which individual- and school-level characteristics significantly predicted students' likelihood of practicing primary care. RESULTS: Of the 2,604 students invited, 1,661 (64%) responded. Of the 1,554 students with complete data on variables of interest, 207 (13%) planned to enter a primary care residency and stated they were "very likely" to become a primary care physician on completion of training. Students who attended schools with high reported levels of "badmouthing" primary care were less likely to practice primary care (OR, 0.6; 95% CI, 0.4-0.9). Attending a school where students had greater than the median number of positive experiences in primary care clerkships increased the likelihood of practicing primary care (OR, 1.6; 95% CI, 1.1-2.3). Overall, 8% of the total variation in a student's likelihood of practicing primary care was attributable to school-level factors. CONCLUSIONS: Although individual students' characteristics and preferences drive specialty choice decisions, the prevailing primary care culture at a school also plays a role.

Exploring the workforce implications of a decade of medical school expansion: variations in medical school growth and changes in student characteristics and career plans.

PURPOSE: To explore whether medical school enrollment growth may help address workforce priorities, including diversity, primary care, care for underserved populations, and academic faculty. METHOD: The authors compared U.S. MD-granting medical schools, applicants, and matriculants immediately before expansion (1999-2001) and 10 years later (2009-2011). Using data from the American Medical Association Physician Masterfile and the Association of American Medical Colleges, they examined medical schools' past production of physicians and changes in matriculant characteristics and practice intentions. RESULTS: Among the 124 schools existing in 1999-2001, growth varied substantially. Additionally, 11 new schools enrolled students by 2009-2011. Aggregate enrollment increased by 16.6%. Increases in applicants led to a lower likelihood of matriculation for all but those with rural backgrounds, racial/ethnic minorities, applicants >24 years old, and those with Medical College Admission Test scores > 33. The existing schools that expanded most had a history of producing the highest percentages of physicians practicing in primary care and in underserved and rural areas; those that expanded least had produced the greatest percentage of faculty. Compared with existing schools, new schools enrolled higher percentages of racial/ethnic minorities and of students with limited parental education or lower income. Matriculants' interest in primary care careers showed no decline; interest in practicing with underserved populations increased, while interest in rural practice declined. CONCLUSIONS: Despite expansion, the characteristics of matriculating medical students changed little, except at new schools. Further expansion may benefit from targeted consideration of workforce needs.

A quality improvement framework for equity in cardiovascular care: results of a national collaborative.

Disparities in the quality of cardiovascular care provided to minorities have been well documented, but less is known about the use of quality improvement methods to eliminate these disparities. Measurement is also often impeded by a lack of reliable patient demographic data. The objective of this study was to assess the ability of hospitals with large minority populations to measure and improve the care rendered to Black and Hispanic patients. The Expecting Success: Excellence in Cardiac Care project utilized the standardized collection of self-reported patient race, ethnicity, and language data to generate stratified performance measures for cardiac care coupled with evidence-based practice tools in a national competitively selected sample of 10 hospitals with high cardiac volumes and largely minority patient populations. Main outcomes included changes in nationally recognized measures of acute myocardial infarction and heart failure quality of care and 2 composite measures, stratified by patient demographic characteristics. Quality improved significantly at 7 of the 10 hospitals as gauged by composite measures (p < .05), and improvements exceeded those observed nationally for all hospitals. Three of 10 hospitals found racial or ethnic disparities which were eliminated in the course of the project. Clinicians and institutions were able to join the standardized collection of self-reported patient demographic data to evidence-based measures and quality improvement tools to improve the care of minorities and eliminate disparities in care. This framework may be replicable to ensure equity in other clinical areas.

Sexual behaviors of racial/ethnic minority young men who have sex with men.

We assessed changes in sexual behaviors from baseline to 12-month follow-up among a multisite cohort of HIV-positive racial/ethnic minority young men who have sex with men enrolled in an outreach, linkage, and retention study. In the 3 months prior to their baseline interview, more than three-quarters of participants (78.5%) reported sex with at least one man (mean: 2.3 partners). Among sexually active participants, 44.2% had one partner; 50.5% had 2-9 partners; and 5.3% had 10 or more partners. Over three-quarters (77.5%) reported engaging in sex with at least one steady partner, 43.5% with at least one casual partner, and 29.5% with both casual and steady partners. Exchanging sex for money, drugs, or other needs was reported by 13.2%. Use of condoms during oral and anal sex increased significantly from baseline to 12-month follow-up (oral sex: 29.1-42.5%, p=0.02; anal sex: 67.8-76.2%, p=0.05). While unprotected anal sex significantly decreased among individuals who were new to care (34.8-18.3%, p<0.0001), it significantly increased among individuals who were previously in care (26.7-37.5%, p=0.03). Overall, exchange sex decreased from 13.3% at baseline to 5.0% at 12 months (p=0.001). Despite reductions in unprotected sexual encounters and exchange sex through one year of follow-up, many participants continued to engage in high-risk sexual behaviors. Retention within this study appeared to be associated with decreases in high-risk sexual behaviors, especially among participants who were new to care, although more research is needed. Future studies should investigate sexual network characteristics and the prevalence of behaviors such as serosorting.

Racial and sexual identity-related maltreatment among minority YMSM: prevalence, perceptions, and the association with emotional distress.

Bullying is a form of violence characterized as an aggressive behavior that is unprovoked and intended to cause harm. Prior studies have found that lesbian, gay, bisexual, and transgender (LGBT) youth experience high levels of bullying related to their sexuality and this harassment can lead to engagement in risk behaviors, depression, and suicide. Ethnic/racial minority young men who have sex with men (YMSM) may experience dual levels of stigma and maltreatment due to both their sexuality and their race. The aim of the current study was to assess the prevalence and perceptions of racial and sexual identity-based abuse among a sample of minority YMSM, and whether this maltreatment plays a role in the emotional distress of these youth. We found that overall 36% and 85% of participants experienced racial and sexuality-related bullying, respectively. There was a significant association between experiencing a high level of sexuality-related bullying and depressive symptomatology (p=0.03), having attempted suicide (p=0.03), and reporting parental abuse (p=0.05). We found no association between racial bullying and suicide attempts. In a multivariable logistic regression model, experiencing any racial bullying and high sexuality-related bullying were significant predictors of having a CES-D score ≥16; adjusted odds ratio (OR) 1.83 and 2.29, respectively. These findings contribute to the existing literature regarding the negative experiences and daily stressors facing LGBT youth with regard to both their minority status and LGBT identities. Future interventions for racial/ethnic minority YMSM should provide assistance to achieve a positive view of self that encompasses both their racial and sexual identities.

Effect of vaccination with a recombinant fusion protein encoding an astacinlike metalloprotease (MTP-1) secreted by host-stimulated Ancylostoma caninum third-stage infective larvae.

Laboratory dogs were vaccinated intramuscularly with a recombinant fusion protein (expressed and isolated from Escherichia coli) formulated with the Glaxo SmithKline Adjuvant System 02 (AS02). The fusion protein encoded Ac-MTP-1, a developmentally regulated astacinlike metalloprotease secreted by host-stimulated Ancylostoma caninum third-stage larvae (L3). Control dogs were injected intramuscularly with an equivalent amount of AS02 adjuvant alone. The vaccinated and control dogs were then challenged by s.c. injection of 500 L3 of the canine hookworm A. caninum. The vaccinated dogs developed prechallenge immunoglobulin G2 (IgG2) antibody responses specific to anti-Ac-MTP-1-fusion protein with titers ranging between 1:40,000 and 1:364,000, whereas they developed antigen-specific immunoglobulin E antibody responses with titers ranging between 1:500 and 1:1,500. By immunoblotting, canine sera obtained from the vaccinated dogs recognized a protein of the estimated apparent molecular weight of Ac-MTP-1 in activated L3 secretory products. Spearman rank order correlations between the canine intestinal adult hookworm burden and quantitative egg counts at necropsy and anti-Ac-MTP-1 IgG2 antibody titers revealed a statistically significant inverse association (r = -0.89; P = 0.04), suggesting that this molecule offers promise as a recombinant vaccine.