Interim evaluation of the Rural Health Scholars Program.

BACKGROUND: The imperative to address physician maldistribution has been directed in part at medical schools. DESCRIPTION: The Rural Health Scholars Program (RHSP) is an enrichment initiative that has been implemented at 2 medical schools to increase the number of students likely to practice primary care in rural, underserved areas. It is a longitudinal program that includes a skill-building workshop; a 5-week summer preceptorship with community-based preceptors in rural, underserved areas; and opportunities to return to preceptorship sites during 3rd- and 4th-year rotations. Students also attend community-based and teleconference seminars and workshops, as well as informal social gatherings. EVALUATION: A static-group comparison design was used to compare program participants with nonparticipants regarding residency program types and locations. CONCLUSIONS: The RHSP is meeting some interim objectives conducive to its long-term goal of developing physicians who will practice primary care medicine in rural, underserved areas of North Carolina.

Safety and efficacy of attempted vaginal birth after cesarean beyond the estimated date of delivery.

OBJECTIVE: To provide data regarding safety and efficacy for women attempting a trial of labor following earlier cesarean birth who have reached their due date. STUDY DESIGN: A computerized data base was analyzed to identify women who were at or beyond 40 weeks of gestation between January 1, 1995, and March 31, 1996. Ninety women attempted vaginal birth after cesarean (VBAC) during the study period; 90 controls were matched for age, race and parity. Delivery route and complications were outcome variables identified. RESULTS: The rate of successful VBAC was 65.6% as compared to the 94.4% vaginal delivery rate among women who had not had a prior cesarean (P < .0001). Among women attempting VBAC, 62% of those who had no prior vaginal births successfully delivered vaginally, while 82% of women with one prior vaginal birth delivered vaginally (P < .0001). Women of greater parity were more successful at a trial of labor. Infectious morbidity was more common among women attempting VBAC than among those with no prior cesarean. CONCLUSION: The patient and her family can be reassured that passing her due date does not alter the efficacy or safety of a trial of labor. No change in counseling is warranted simply due to the completion of 40 weeks' gestation.

Preparing and retaining rural physicians through medical education.

PURPOSE: To identify educational approaches that best prepare physicians for rural work and small-town living, and that promote longer rural practice retention. METHOD: In two mail surveys (1991 and 1996-97), the authors collected data from primary care physicians who had moved to rural practices nationwide from 1987 through 1990. A total of 456 eligible physicians responded to both surveys (response rate of 69.0%). The authors identified those features of the physicians' training that correlated with their self-reported preparedness for rural practice and small-town living, and with how long they stayed in their rural practices. Analyses controlled for six features of the physicians and their communities. RESULTS: The physicians' sense of preparedness for small-town living predicted their retention duration (hazard ratio, 0.74, p < .0001), whereas their preparedness for rural medical practice did not predict their retention duration after controlling for preparedness for small-town living (hazard ratio, 0.92; p = .27). For the physicians who had just finished their training, only a few features of their training predicted either rural preparedness or retention. Residency rural rotations predicted greater preparedness for rural practice (p = .004) and small-town living (p = .03) and longer retention (hazard ratio, 0.43, p = .003). Extended medical school rural rotations predicted only greater preparedness for rural practice (p = .03). For the physicians who had prior practice experience, nothing about their medical training was positively associated with preparedness or retention. CONCLUSION: Physicians who are prepared to be rural physicians, particularly those who are prepared for small-town living, stay longer in their rural practices. Residency rotations in rural areas are the best educational experiences both to prepare physicians for rural practice and to lengthen the time they stay there.

Primary care physicians' training and their community involvement.

BACKGROUND AND OBJECTIVES: Physicians who incorporate a community perspective into their clinical practice can provide more effective care, but little is known about the type of training that helps physicians include this perspective. This study examines associations between physicians' current level of involvement in their communities and a range of prior educational experiences. METHODS: We obtained data from 247 recently graduated primary care physicians through a nationwide mail survey. Physicians described their community-related training experiences during medical school and residency. They also described their current involvement in each of 4 domains of community work. Associations between different training experiences and physicians' current community involvement were examined. RESULTS: Subjects generally reported limited community-related training. Physicians who did receive training in content relevant to a given community domain were significantly more involved in that domain as practicing physicians. Rotating in rural locations and having a mentor active in the community also were associated with greater current community involvement. CONCLUSIONS: These data provide evidence that formal training experiences can influence how actively physicians will later interact with their communities. We should provide medical students and residents with educational content in all 4 domains of community work, place them in carefully selected locations, and arrange mentor relationships.

The four community dimensions of primary care practice.

BACKGROUND: Despite the growing belief that "the community" should play a larger role in the work of physicians, there is no clear understanding of exactly how physicians should participate in their communities. The primary goals of this study were to propose and test an organizing framework that identified four distinct categories of activities whereby physicians can interact with their communities: (1) identifying and intervening in the community's health problems; (2) responding to the particular health issues of local cultural groups when caring for patients; (3) coordinating local community health resources in the care of patients; and (4) assimilating into the community and its organizations. Other goals were to characterize physicians' level of involvement in each of these four types of community activities, and to identify the correlates of greater and lesser involvement. METHODS: A questionnaire was mailed to a random sample of 500 young primary care physicians in the United States. The response rate was 66.6%. Physicians reported how confident they were in performing each of 15 specific community-relevant activities. Confidence ratings were factor-analyzed to test the hypothesis that physician involvement in community activities can be organized into the four proposed categories. Physicians also self-rated their involvement in various community activities within each of these four categories, and predictors of involvement were identified through ordinary least-squares regression models. RESULTS: Using factor analysis, the community activities sorted cleanly into the four postulated community dimensions of medical practice, providing a measure of validation for the distinctiveness of the four dimensions. Physicians reported active involvement in some activities (eg, speaking to community groups and gaining acceptance in their communities) and little involvement in other activities (eg, working with community groups to address local health problems, familiarity with local women's shelters). Contrary to expectations, physicians who worked with minority and poorer patient populations and counties generally reported less community involvement. Physicians caring for more patients covered by HMO or capitated health insurance plans also reported lower participation in their communities. CONCLUSIONS: This study provides support for the hypothesis that the community plays a role in the work of physicians that can be categorized into four types of activities. This framework may help physicians and practices recognize the breadth of ways they can meet the growing demand that they approach their work with a community perspective.

Does training location influence the clinical skills of medical students?

PURPOSE: To examine the benefits of the shift of medical education into ambulatory primary care settings by investigating whether medical students exposed to a common primary care problem (low back pain) in ambulatory care settings develop better clinical skills. METHOD: In 1995, the authors categorized 420 students from all four North-Carolina medical schools into groups that had previously encountered patients with low back pain in ambulatory primary care settings, tertiary care settings, both, or neither. The clinical skills of the groups were determined using data collected during standardized-patient examination in which students took the history of, physically examined, and chose a diagnostic strategy for patients with acute, uncomplicated low back pain. RESULTS: In general, there was no difference between the performances of the student groups associated with the settings of their previous encounters with low back pain. On average, the students failed to ask 35% of the history items and failed to perform 35% of the physical examination items. Many students chose inappropriate diagnostic strategies. CONCLUSION: The lack of difference between the groups' clinical performances indicates a need to more rigorously define and evaluate outcomes of education in ambulatory care settings. The generally poor clinical performance of all groups suggests that the current curriculum inadequately teaches clinical skills needed to assess and manage common problems. Clearer expectations of competencies and assurances that preceptors in ambulatory care settings will help students meet those learning objectives might lead to better outcomes.

Are medical students ready to provide HIV-prevention counseling?

PURPOSE: To determine whether medical students were prepared to assess risk and counsel patients about prevention of HIV infection, and whether HIV-related experience produced better knowledge and counseling skills. METHOD: In 1995, students at four North Carolina medical schools interviewed a standardized patient portraying a young woman concerned about HIV infection. The standardized patient recorded whether students asked risk-behavior questions and provided risk-reduction advice. A 21-item questionnaire assessed the students' knowledge of HIV testing and prevention. Students indicated whether they had had experience in educational settings related to HIV or STDs. RESULTS: 415 students completed both the patient interview and the questionnaire. Many failed to ask the patient about several HIV-risk behaviors. Although nearly all (98%) inquired about condom use, fewer than two thirds asked about the patient's history of STDs, number of sexual partners, or specific sexual practices. Most students advised the patient to use condoms. The average score on the knowledge test was 79%; 70% of students confused anonymous with confidential testing, more than half overestimated the risk of HIV transmission from a needle stick, and nearly one in ten did not know how to use a condom. Educational exposures did not produce significantly better risk assessment, counseling information, or knowledge scores. CONCLUSION: A majority of experienced medical students did not assess several important risk factors of a patient concerned about HIV infection, and many would have provided incorrect information related to HIV testing and prevention of infection. Patient contact in traditional clinical settings did not influence prevention knowledge or behavior. More innovative methods are needed to train students in HIV-infection prevention and counseling.

Do adolescents want to hear preventive counseling messages in outpatient settings?

BACKGROUND: In response to the high prevalence of health-risk behaviors among adolescents, policy agencies have urged primary care clinicians to discuss these behaviors with all adolescents. Yet such discussions frequently do not take place. A commonly mentioned barrier is the clinician perception that patients are not interested in, or are embarrassed by, such discussions. The purpose of this study was to assess the accuracy of this perception by conducting a survey of adolescents. METHODS: Self-administered questionnaires were distributed to 305 adolescents, ages 11 to 16 years, waiting to be seen in three community health centers and three private practices. The questionnaire queried adolescents' willingness to talk about eight preventive counseling topics with health care practitioners, and information was collected on variables that might influence willingness. Descriptive frequencies were generated. Chisquare analysis and stratification assessed differences between groups. RESULTS: A majority of adolescents felt that it is a clinician's job to discuss health risk behaviors. On the current visit, however, fewer than 20% wanted to talk about drugs, alcohol, cigarettes, or depression; fewer than 40% about sex; and fewer than 55% about diet or exercise. Adolescents reporting previous conversations on a topic were more likely to want to talk about that issue at the current visit. Willingness to talk did not vary by visit type (well care vs acute care). CONCLUSIONS: This study confirms that adolescents are hesitant to discuss health risk behaviors with clinicians, but the findings also suggest that receptivity increases if clinicians address these topics on repeat occasions.

Developments on the Internet: a practical guide for primary care physicians.

Recent developments have made the Internet a helpful professional resource for primary care practitioners. The introduction of the World Wide Web has overcome many of the barriers that previously made it difficult to access useful information on the Internet. For teachers of primary care, the capability of combining graphic, sound, and video files is particularly exciting. User-friendly search strategies help users find needed information quickly. This article provides practical steps for accessing the Internet, introduces the concept of the World Wide Web, and provides a list of specific resources useful to primary care teachers, clinicians, and researchers.

Associations with high-risk sexual behavior: a survey of young men of color attending urban youth centers.

BACKGROUND: Sexually transmitted diseases and human immunodeficiency virus (HIV) represent growing health care concerns that affect subgroups of the population in disproportionately high numbers. We researched associations with high-risk sexual behavior in young men of color living in an economically depressed area of a mid-size city. Our results are used to discuss the possibility of more effective interventions. METHODS: We analyzed the responses of 95 men (aged 12 to 29 years) to a self-administered questionnaire. We then examined variables hypothesized to be associated with high-risk sexual behavior and used bivariate and multivariate analyses to report associations found for this group. RESULTS: Improved perception of one's general health (odds ratio [OR] 0.95) and believing that peers approved of condoms (OR 0.51) were inversely associated with high-risk sexual behavior, whereas use of illegal drugs (OR 6.0), history of being arrested (OR 3.92), and age older than 18 years (OR 1.4) were directly associated. Knowledge about HIV was not significantly different in men who participated in high-risk sexual behavior and those who did not. Seventy-eight percent of HIV knowledge questions were answered correctly by both groups. CONCLUSIONS: Our findings support the need to develop interventions that focus on more than knowledge dissemination. Interventions using modeling and education by peers have the potential to reach at-risk adolescents and young adults more effectively. Such interventions should address broader societal problems, such as health perceptions, drug abuse, and crime.