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Background To address rural physician workforce shortages, the Health Resources and Services Administration funded multiple Rural Residency Planning and Development (RRPD) awards, beginning in 2019, to develop rural residency programs in needed specialties. Objective To describe early resident recruitment outcomes of the RRPD grants program. Methods A cross-sectional survey of program directors or administrators of these 25 new rural residency training programs across the United States was administered at RRPD award conclusion in 2022. We performed descriptive analyses of applicant and Match data, including applications and interviews per resident position, positions filled in the main Match vs the Supplemental Offer and Acceptance Program (SOAP), and recruitment of residents from the program's state. Results The 25 Cohort 1 RRPD programs ranged from 2 to 8 residents per year. Most programs (16 of 25, 64.0%) were rural expansion tracks of an urban program. Most programs were sufficiently developed to participate in the 2022 (N=17) or 2023 (N=20) Match; we report on 13 of 17 (76.5%) programs for 2022 and 14 of 20 (70.0%) programs for 2023. Programs completed a median of 14.8 interviews per position. Most positions were filled in the Match (43 of 58, 74.1% in 2022; 45 of 58, 77.6% in 2023); most others were filled in the SOAP. On average, 34.4% of enrolled residents were from the same state as the program (range 0-78.6%). Conclusions The early resident recruitment outcomes of the RRPD model for developing new physician training in rural communities had sufficient recruitment success to support program continuation.
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Internado y Residencia , Selección de Personal , Servicios de Salud Rural , Humanos , Estudios Transversales , Estados Unidos , Educación de Postgrado en Medicina , Encuestas y Cuestionarios , United States Health Resources and Services Administration , Población RuralRESUMEN
BACKGROUND AND OBJECTIVES: The widening gap between urban and rural health outcomes is exacerbated by physician shortages that disproportionately affect rural communities. Rural residencies are an effective mechanism to increase physician placement in rural and medically underserved areas yet are limited in number due to funding. Community health center/academic medicine partnerships (CHAMPs) can serve as a collaborative framework for expansion of academic primary care residencies outside of traditional funding models. This report describes 10-year outcomes of a rural training pathway developed as part of a CHAMP collaboration. METHODS: Using data from internal registries and public sources, our retrospective study examined demographic and postgraduation practice characteristics for rural pathway graduates. We identified the rates of postgraduation placement in rural (Federal Office of Rural Health Policy grant-eligible) and federally designated Medically Underserved Areas/Populations (MUA/Ps). We assessed current placement for graduates >3 years from program completion. RESULTS: Over a 10-year period, 25 trainees graduated from the two residency expansion sites. Immediately postgraduation, 84% (21) were in primary care Health Professional Shortage Areas (HPSAs), 80% (20) in MUA/Ps, and 60% (15) in rural locations. Sixteen graduates were >3 years from program completion, including 69% (11) in primary care HPSAs, 69% (11) in MUA/Ps, and 50% (5) in rural locations. CONCLUSIONS: This CHAMP collaboration supported development of a rural pathway that embedded family medicine residents in community health centers and effectively increased placement in rural and MUA/Ps. This report adds to national research on rural workforce development, highlighting the role of academic-community partnerships in expanding rural residency training outside of traditional funding models.
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Internado y Residencia , Servicios de Salud Rural , Humanos , Medicina Familiar y Comunitaria/educación , Población Rural , Estudios Retrospectivos , Área sin Atención Médica , Centros Comunitarios de SaludRESUMEN
BACKGROUND: While evidence supports interprofessional primary care models that include pharmacists, the extent to which pharmacists are working in primary care and the factors associated with colocation is unknown. OBJECTIVES: This study aimed to analyze the physical colocation of pharmacists with primary care providers (PCPs) and examine predictors associated with colocation. RESEARCH DESIGN: This is a retrospective cross-sectional study of pharmacists and PCPs with individual National Provider Identifiers in the National Plan and Provider Enumeration System's database. Pharmacist and PCP practice addresses of the health care professionals were geocoded, and distances less than 0.1 miles were considered physically colocated. SUBJECTS: In all, 502,373 physicians and 221,534 pharmacists were included. RESULTS: When excluding hospital-based pharmacists, 1 in 10 (11%) pharmacists were colocated with a PCP. Pharmacists in urban settings were more likely to be colocated than those in rural areas (OR=1.32, CI: 1.26-1.38). Counties with the highest proportion of licensed pharmacists per 100,000 people in the county had higher colocation (OR=1.38, CI: 1.32-1.45). Colocation was significantly higher in states with an expanded scope of practice (OR 1.37, CI: 1.32-1.42) and those that have expanded Medicaid (OR 1.07, CI: 1.03-1.11). Colocated pharmacists more commonly worked in larger physician practices. CONCLUSION: Although including pharmacists on primary care teams improves clinical outcomes, reduces health care costs, and enhances patient and provider experience, colocation appears to be unevenly dispersed across the United States, with lower rates in rural areas. As the integration of pharmacists in primary care continues to expand, knowing the prevalence and facilitators of growth will be helpful to policymakers, researchers, and clinical administrators.
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Farmacéuticos , Médicos de Atención Primaria , Humanos , Estados Unidos , Estudios Transversales , Estudios Retrospectivos , Atención Primaria de SaludRESUMEN
OBJECTIVE: The primary objective was to evaluate if the percentage of patients with missing or inaccurate code status documentation at a Trauma Level 1 hospital could be reduced through daily updates. The secondary objective was to examine if patient preferences for DNR changed during the COVID-19 pandemic. METHODS: This retrospective study, spanning March 2019 to December 2022, compared the code status in ICU and ED patients drawn from two data sets. The first was based on historical electronic medical records (EHR), and the second involved daily updates of code status following patient admission. RESULTS: Implementing daily updates upon admission was more effective in ICUs than in the ED in reducing missing code status documentation. Around 20% of patients without a specific code status chose DNR under the new system. During COVID-19, a decrease in ICU patients choosing DNR and an increase in full code (FC) choices were observed. CONCLUSION: This study highlights the importance of regular updates and discussions regarding code status to enhance patient care and resource allocation in ICU and ED settings. The COVID-19 pandemic's influence on shifting patient preferences towards full code status underscores the need for adaptable documentation practices. Emphasizing patient education about DNR implications and benefits is key to supporting informed decisions that reflect individual health contexts and values. This approach will help balance the considerations for DNR and full code choices, especially during health care crises.
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Evidence indicates an increasing shortage of dentists in communities across the United States with potentially significant implications for oral health, as well as overall health and well-being. One strategy to increase access to dental care in rural and underserved communities is community-based postgraduate dental training. However, developing new dental programs requires navigating complex accreditation, financial and community governance, among other, barriers. The Roadmap for Teaching Health Center Dental Program Development presents a framework that guides institutions through the successive steps of developing new postgraduate training programs from identification of need to ultimate maintenance and sustainability. The tool assists programs in anticipating and understanding requirements, reducing time, expense, and uncertainty. While the framework was developed for community-based programs, the steps are applicable to postgraduate programs sponsored by academic institutions as well.
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Atención Odontológica , Educación en Odontología , Humanos , Estados Unidos , Desarrollo de ProgramaRESUMEN
PURPOSE: The purpose of this study is to describe the characteristics of Rural Residency Planning and Development (RRPD) Programs, compare the characteristics of counties with and without RRPD programs, and identify rural places where future RRPD programs could be developed. METHODS: The study sample comprised 67 rural sites training residents in 40 counties in 24 US states. Descriptive statistics were used to describe RRPD programs and logistic regression to predict the probability of a county being an RRPD site as a function of population, primary care physicians (PCP) per 10,000 population, and the social vulnerability index (SVI) compared to a control sample of nonmetro counties without RRPD sites. FINDINGS: Most RRPD grantees (78%) were family medicine programs affiliated with medical schools (97%). RRPD counties were more populous (P<.01), had a higher population density (P<.05), and a higher percent of the non-White or Hispanic population (P = .05) compared to non-RRPD counties. Both higher population (P<.001) and PCP ratio (P = .046) were strong predictors, while SVI (P = .07) was a weak predictor of being an RRPD county. CONCLUSIONS: RRPD sites appear to represent a "sweet spot" of rural counties that have the population and physician supply to support a training program but also are relatively more socially vulnerable with high-need populations. Additional counties fitting this "sweet spot" could be targeted for funding to address health disparities and health workforce maldistribution.
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Internado y Residencia , Médicos , Servicios de Salud Rural , Humanos , Estados Unidos , Recursos Humanos , Fuerza Laboral en Salud , Población RuralRESUMEN
Phenomenon: While part-time clinical work options are popular for physicians, part-time residency training is uncommon. Some residency training programs have offered trainees the option to complete their training on a modified schedule in the past. These part-time tracks often involved extending training in order to complete equivalent hours on a part-time basis. Having experience with trainees in such programs, we sought to explore the impact of completing residency training part-time on the professional and private lives of physicians. Approach: Between 2019 and 2020, we conducted interviews with physicians who completed portions of their residency training part-time between 1995 and 2005 in our institution's pediatrics, combined medicine-pediatrics, and family medicine programs. Findings: Seven female physicians who completed at least some portion of residency part-time were interviewed. To better characterize their experiences, we chose phenomenology as our analytic framework. Members of the research team independently coded each interview and met to resolve conflicts. Codes were then combined and discussed to determine four overarching themes as reasons and benefits of part-time training: The pursuit of extended-time training, logistics, effects on career trajectory, and wellness. These themes highlighted the utility of part-time training and the need for programmatic support to ensure their success. Insights: Based on our findings, adaptability for training and a sense of agency from their part-time experiences persisted throughout interviewees' careers. Each felt empowered to make career choices that fit their personal and professional needs. These findings suggest further investigation into the benefits of offering time-variable training in residency programs.
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Internado y Residencia , Medicina , Médicos , Humanos , Femenino , Niño , Selección de Profesión , EstudiantesRESUMEN
Lack of access to high-quality primary care has been shown to contribute to urban-rural health disparities. We describe a model in which an academic health system made targeted primary care investments to address rural health disparities while building the health workforce to ensure sustainability.
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Servicios de Salud Rural , Población Rural , Humanos , Participación de los Interesados , Recursos Humanos , Atención Primaria de SaludRESUMEN
Evidence shows that those living in rural communities experience consistently worse health outcomes than their urban and suburban counterparts. One proven strategy to address this disparity is to increase the physician supply in rural areas through graduate medical education (GME) training. However, rural hospitals have faced challenges developing training programs in these underserved areas, largely due to inadequate federal funding for rural GME. The Consolidated Appropriations Act of 2021 (CAA) contains multiple provisions that seek to address disparities in Medicare funding for rural GME, including funding for an increase in rural GME positions or "slots" (Section 126), expansion of rural training opportunities (Section 127), and relief for hospitals that have very low resident payments and/or caps (Section 131). In this Invited Commentary, the authors describe historical factors that have impeded the growth of training programs in rural areas, summarize the implications of each CAA provision for rural GME, and provide guidance for institutions seeking to avail themselves of the opportunities presented by the CAA. These policy changes create new opportunities for rural hospitals and partnering urban medical centers to bolster rural GME training, and consequently the physician workforce in underserved communities.
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Internado y Residencia , Anciano , Educación de Postgrado en Medicina , Humanos , Medicare , Salud Rural , Población Rural , Estados UnidosAsunto(s)
Internado y Residencia , Servicios de Salud Rural , Humanos , Salud Rural , Población RuralRESUMEN
BACKGROUND AND OBJECTIVES: Experts in medical education hypothesize that programs with a robust culture of feedback foster learning and growth for learners and educators, yet the literature shows no consensus for what defines a feedback culture in graduate medical education. METHODS: Using a two-round, modified Delphi technique in summer and fall of 2019, the authors asked a panel of experts to identify essential elements to a feedback culture. The research team compiled a list of experts and a list of 29 descriptors of a highly functioning feedback culture. Experts rated the items as an essential, compatible, or not important aspect of a highly functioning culture of feedback. Researchers set a minimum threshold of 80% agreement and used comments from panelists to revise elements that did not meet agreement during round one. Experts then rerated the elements using information on their initial ratings, aggregate panelist ratings, and comments from all panelists. RESULTS: The response rates from our panel of experts were 68% (17/25) for round one and 88% (15/17) for round two. Seventeen elements were rated as essential to a feedback culture. CONCLUSIONS: An expert panel endorsed essential elements that can be used to assess feedback culture in graduate medical education programs.
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Educación de Postgrado en Medicina , Consenso , Técnica Delphi , Retroalimentación , HumanosRESUMEN
OBJECTIVES: Almost 15% of all US births occur in rural hospitals, yet rural hospitals are closing at an alarming rate because of shortages of delivering clinicians, nurses, and anesthesia support. We describe maternity staffing patterns in successful rural hospitals across North Carolina. METHODS: All of the hospitals in the state with ≤200 beds and active maternity units were surveyed. Hospitals were categorized into three sizes: critical access hospitals (CAHs) had ≤25 acute staffed hospital beds, small rural hospitals had ≤100 beds without being defined as CAHs, and intermediate rural hospitals had 101 to 200 beds. Qualitative data were collected at a selection of study hospitals during site visits. Eighteen hospitals were surveyed. Site visits were completed at 8 of the surveyed hospitals. RESULTS: Nurses in CAHs were more likely to float to other units when Labor and Delivery did not have patients and nursing management was more likely to assist on Labor and Delivery when patient census was high. Anesthesia staffing patterns varied but certified nurse anesthetists were highly used. CAHs were almost twice as likely to accept patients choosing a trial of labor after cesarean section (CS) than larger hospitals, but CS rates were similar across all hospital types. Hospitals with only obstetricians as delivering providers had the highest CS rate (32%). The types of hospitals with the lowest CS rates were the hospitals with only family physicians (24%) or high proportions of certified nurse midwives (22%). CONCLUSIONS: Innovative staffing models, including family physicians, nurse midwives, and nurse anesthetists, are critical for the survival of rural hospitals that provide vital maternity services in underserved areas.
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Salas de Parto/organización & administración , Hospitales Rurales/organización & administración , Servicios de Salud Materna/provisión & distribución , Servicios de Salud Rural/provisión & distribución , Recursos Humanos/organización & administración , Femenino , Encuestas de Atención de la Salud , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Área sin Atención Médica , North Carolina , Enfermeras Anestesistas/provisión & distribución , Enfermeras Obstetrices/provisión & distribución , Médicos de Familia/provisión & distribución , Embarazo , Investigación CualitativaRESUMEN
PROBLEM: The U.S. primary care workforce remains inadequate to meet the health needs of the U.S. population. Effective programs are needed to provide workforce development for rural and other underserved areas. APPROACH: At the University of North Carolina (UNC) School of Medicine (SOM), between November 2014 and July 2015, the authors developed and implemented the Fully Integrated Readiness for Service Training (FIRST) Program, an accelerated curriculum focused on rural and underserved care that links 3 years of medical school with a conditional acceptance into UNC's 3-year family medicine residency, followed by 3 years of practice support post-graduation. Students are recruited to the FIRST Program during the fall of their first year of medical school. The FIRST Program promotes close faculty mentorship and familiarity with the health care system, includes a longitudinal quality improvement project with an assigned patient panel, includes early integration into the clinic, and fosters a close cohort of fellow students. OUTCOMES: As of March 2020, the FIRST Program had successfully recruited 5 classes of medical students, and 3 of those classes had matched into residency. In total, as of March 2020, 18 students had participated in the FIRST Program. NEXT STEPS: The FIRST Program will be expanded to additional clinical sites across North Carolina and to specialties beyond family medicine, including pediatrics, general surgery, and psychiatry.
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Educación de Pregrado en Medicina/organización & administración , Área sin Atención Médica , Médicos de Atención Primaria/educación , Médicos de Atención Primaria/provisión & distribución , Desarrollo de Programa , Población Rural , Curriculum , Educación de Postgrado en Medicina/organización & administración , Educación de Postgrado en Medicina/normas , Educación de Pregrado en Medicina/normas , Fuerza Laboral en Salud , Humanos , Internado y Residencia/organización & administración , Internado y Residencia/normas , Tutoría , North Carolina , Mejoramiento de la CalidadRESUMEN
Characterizing the asymptomatic spread of SARS-CoV-2 is important for understanding the COVID-19 pandemic. This study was aimed at determining asymptomatic spread of SARS-CoV-2 in a suburban, Southern U.S. population during a period of state restrictions and physical distancing mandates. This is one of the first published seroprevalence studies from North Carolina and included multicenter, primary care, and emergency care facilities serving a low-density, suburban and rural population since description of the North Carolina state index case introducing the SARS-CoV-2 respiratory pathogen to this population. To estimate point seroprevalence of SARS-CoV-2 among asymptomatic individuals over time, two cohort studies were examined. The first cohort study, named ScreenNC, was comprised of outpatient clinics, and the second cohort study, named ScreenNC2, was comprised of inpatients unrelated to COVID-19. Asymptomatic infection by SARS-CoV-2 (with no clinical symptoms) was examined using an Emergency Use Authorization (EUA)-approved antibody test (Abbott) for the presence of SARS-CoV-2 IgG. This assay as performed under CLIA had a reported specificity/sensitivity of 100%/99.6%. ScreenNC identified 24 out of 2,973 (0.8%) positive individuals among asymptomatic participants accessing health care during 28 April to 19 June 2020, which was increasing over time. A separate cohort, ScreenNC2, sampled from 3 March to 4 June 2020, identified 10 out of 1,449 (0.7%) positive participants.IMPORTANCE This study suggests limited but accelerating asymptomatic spread of SARS-CoV-2. Asymptomatic infections, like symptomatic infections, disproportionately affected vulnerable communities in this population, and seroprevalence was higher in African American participants than in White participants. The low, overall prevalence may reflect the success of shelter-in-place mandates at the time this study was performed and of maintaining effective physical distancing practices among suburban populations. Under these public health measures and aggressive case finding, outbreak clusters did not spread into the general population.
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Enfermedades Asintomáticas/epidemiología , Infecciones por Coronavirus/prevención & control , Infecciones por Coronavirus/transmisión , Pandemias/prevención & control , Neumonía Viral/prevención & control , Neumonía Viral/transmisión , Anticuerpos Antivirales/sangre , Betacoronavirus/inmunología , Betacoronavirus/aislamiento & purificación , COVID-19 , Estudios de Cohortes , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/epidemiología , Femenino , Humanos , Masculino , Programas Obligatorios , North Carolina/epidemiología , Neumonía Viral/diagnóstico , Neumonía Viral/epidemiología , SARS-CoV-2 , Estudios SeroepidemiológicosRESUMEN
BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education requires soliciting learner feedback on faculty teaching, although gathering meaningful feedback is challenging in the medical education environment. We developed the Faculty Feedback Facilitator (F3App), a mobile application that allows for real-time capture of narrative feedback by residents. The purpose of our study was to assess efficacy, usability, and acceptability of the F3App in family medicine residency programs. METHODS: Residents, faculty, and program directors (PDs) from eight residency programs participated in a beta test of the F3App from November 2017 to May 2018; participants completed pre- and postimplementation surveys about their evaluation process and the F3App. We interviewed PDs, and analyzed responses using a thematic analysis approach. RESULTS: Survey results showed significant postimplementation increases in faculty agreement that accessing evaluations is easy (42%), evaluations are an effective way to communicate feedback (34%), feedback is actionable and meaningful (24%), and the current system provides meaningful data for promotion (33%). Among residents, agreement that the current system allows meaningful information sharing and is easy to use increased significantly, by 17% each. The proportion of residents agreeing they were comfortable providing constructive criticism increased significantly (22%). PDs generally reported that residents were receptive to using the F3App, found it quick and easy to use, and that feedback provided was meaningful. CONCLUSIONS: Participating programs reviewed the F3App positively as a tool to gather narrative feedback from learners on faculty teaching.
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Educación de Postgrado en Medicina , Internado y Residencia , Acreditación , Docentes Médicos , Retroalimentación , Humanos , Encuestas y Cuestionarios , EnseñanzaRESUMEN
BACKGROUND AND OBJECTIVES: Direct observation is a critical part of assessing learners' achievement of the Accreditation Council for Graduate Medical Education (ACGME) Milestones and subcompetencies. Little research exists identifying the content of peer feedback among residents; this study explored the content of residents' peer assessments as they relate to ACGME Milestone subcompetencies in a family medicine residency program. METHODS: Using content from a mobile app-based observation tool (M3App), we examined resident peer observations recorded between June 2014 and November 2017, tabulating frequency of observation for each ACGME subcompetency and calculating the proportion of observations categorized under each subcompetency, as well as for each postgraduate year (PGY) class. We also coded each observation on three separate dimensions: "positive," "constructive," and "actionable." We used the χ2 test for independence, and estimated odds ratios and 95% confidence intervals for two-by-two comparisons to compare numbers of observations within each category. RESULTS: Our data include 886 peer observations made by 54 individual residents. The most frequently observed competencies were in patient care, communication, and professionalism (56%, 47%, and 38% of observations, respectively). Practice-based learning and improvement was observed least frequently (16% of observations). On average, 97.25% of the observations were positive, 85% were actionable, and 6% were constructive. CONCLUSIONS: When asked to review their peers, residents provide comments that are primarily positive and actionable. In addition, residents tend to provide more feedback on certain subcompetencies compared to others, suggesting that programs may rely on peer feedback for specific subcompetencies. Peers can provide perspective on the behaviors and skills of fellow residents.