Academic medicine: a key partner in strengthening the primary care infrastructure via teaching health centers.

In the United States, a worsening shortage of primary care physicians, along with structural deficiencies in their training, threaten the primary care system that is essential to ensuring access to high-quality, cost-effective health care. Community health centers (CHCs) are an underused resource that could facilitate rapid expansion of the primary care workforce and simultaneously prepare trainees for 21st-century practice. The Teaching Health Center Graduate Medical Education (THCGME) program, currently funded by the Affordable Care Act, uses CHCs as training sites for primary-care-focused graduate medical education (GME).The authors propose that the goals of the THCGME program could be amplified by fostering partnerships between CHCs and teaching hospitals (academic medical centers [AMCs]). AMCs would encourage their primary care residency programs to expand by establishing teaching health center (THC) tracks. Modifications to the current THCGME model, facilitated by formal CHC and academic medicine partnerships (CHAMPs), would address the primary care physician shortage, produce physicians prepared for 21st-century practice, expose trainees to interprofessional education in a multidisciplinary environment, and facilitate the rapid expansion of CHC capacity.To succeed, CHAMP THCs require a comprehensive consortium agreement designed to ensure equity between the community and academic partners; conforming with this agreement will provide the high-quality GME necessary to ensure residency accreditation. CHAMP THCs also require a federal mechanism to ensure stable, long-term funding. CHAMP THCs would develop in select CHCs that desire a partnership with AMCs and have capacity for providing a community-based setting for both GME and health services research.

Teaching primary care in community health centers: addressing the workforce crisis for the underserved.

Universal coverage and multiple initiatives to improve health care delivery are crucial components of health care reform. However, the missing link has been a plan to rapidly address the primary care workforce crisis for the underserved. The authors propose a link between primary care graduate medical education and care for the underserved in community health centers, where expansion will be necessary for the anticipated increase in Medicaid and insured patients. This can be achieved by establishing primary care teaching health centers in expanded community health centers, which have established a patient-centered medical home practice environment. Residents would receive their final year of training in these centers, and then have the incentive of National Health Service Corps debt repayment if they subsequently practice in an underserved area. Primary care residents being trained in this setting would immediately increase the clinical capacity of community health centers and ultimately expand the primary care physician workforce. This proposal addresses the primary care physician workforce crisis and the associated key problems of limited access for the underserved and suboptimal primary care graduate medical education.

Perspectives of female physicians practicing in rural Wisconsin.

BACKGROUND: While approximately 30% of the Wisconsin population lives in rural areas, only 11% of physicians practice in these areas. More women are entering medicine today and some studies have raised concerns that women are less likely to practice in rural areas. The intent of this study was to identify which factors influenced female physicians to enter rural practice and to look at the issues they are confronting. METHODS: Ten female physicians practicing in rural Wisconsin towns agreed to participate in 30- to 60-minute semi-structured interviews. Transcripts of the interviews were analyzed to identify common themes in answers to the questions. RESULTS: The physicians had been in practice between 2-26 years, with an average of 13 years. Seven of the 10 had rural backgrounds, which influenced their decisions to practice in rural areas. The physicians cited other factors, such as professional satisfaction, the ability to be engaged with and serve one's community, and having a good place to raise one's family, that made practicing and living in a rural community attractive. However, these physicians also found some drawbacks to rural practice, including too few providers, too much call, and finding a balance between professional and family life. Despite this, all plan to stay in their current practices indefinitely and recommend rural practice to female medical students and residents. CONCLUSIONS: These female physicians find the value of being in rural practice overcome the challenges. The participants provided insight into motivating women to enter rural practice, finding a balance between the challenges and benefits of rural medicine, and promoting the future of rural health care.

LOCUS: immunizing medical students against the loss of professional values.

INTRODUCTION: The Leadership Opportunities with Communities, the Underserved, and Special populations (LOCUS) program at the University of Wisconsin School of Medicine and Public Health is a longitudinal, extracurricular experience for medical students who wish to develop leadership skills and expand their involvement in community health activities during medical school. The program consists of a core curriculum delivered through retreats, workshops, and seminars; a mentor relationship with a physician who is engaged in community health services; and a community service project. METHODS: On-line surveys and interviews with current and past participants as well as direct observations were used to evaluate the effects of the program on participants. RESULTS: Participants indicated that the program was worthwhile, relevant, and effective in building a community of like-minded peers and physician role models. Participants also reported that the program sustained their interest in and commitment to community service and allowed them to cultivate new skills during medical school. CONCLUSIONS: The curriculum and structure of the LOCUS program offers a successful method for helping medical students learn important leadership skills and maintain an altruistic commitment to service.

The effect of the physician J-1 visa waiver on rural Wisconsin.

CONTEXT: One strategy to increase the number of physicians in rural and other underserved areas grants a waiver to foreign physicians in this country on a J-1 education visa allowing them to stay in the United States if they practice in designated underserved areas. PURPOSE: The goal of this study is to evaluate the retention and acceptance of the J-1 Visa Waiver physicians in rural Wisconsin. METHODS: Sites in Wisconsin at which physicians with a J-1 Visa Waiver practiced between 1996 and 2002 were identified. A 12-item survey that assessed the acceptance and retention of these physicians was sent to leaders of institutions that had participated in this program. Retention of J-1 Visa Waiver physicians was compared to other physicians recruited to rural Wisconsin practices by the Wisconsin Office of Rural Health during the same time period. FINDINGS: While there was a general perception that the communities were well satisfied with the care provided and the physicians worked well with the medical community, there was a lower satisfaction with physician integration into the community-at-large. This was found to correlate with the poor retention rate of physicians with a J-1 Visa Waiver. Physicians participating in a placement program without J-1 Visa Waivers entering practice in rural communities had a significantly higher retention rate. CONCLUSIONS: Physicians with J-1 Visa Waivers appear to provide good care and work well in health care environments while fulfilling the waiver requirements. To keep these physicians practicing in these communities, successful integration into the community is important.

Improving rural cancer patients' outcomes: a group-randomized trial.

CONTEXT: Significant barriers exist in the delivery of state-of-the-art cancer care to rural populations. Rural providers' knowledge and practices, their rural health care delivery systems, and linkages to cancer specialists are not optimal; therefore, rural cancer patient outcomes are less than achievable. PURPOSE: To test the effects of a strategy targeting rural providers and their practice environment on patient travel for care, satisfaction, economic barriers, and health-related quality of life. METHODS: A group-randomized trial was conducted with 18 rural communities in the north-central United States. Twelve of these communities were included and defined as the unit of analysis for the patient outcomes portion of the study. The intervention targeted rural providers and their practice environment. The subjects were patients with breast, colorectal, lung, and prostate cancers from the rural communities. The main outcomes were patients' travel to obtain health care, satisfaction with care, perceptions of economic barriers to care, and health-related quality of life. In total, 881 patients were included. RESULTS: Group randomization was balanced. Travel for health care was significantly reduced in the community group exposed to the intervention during months 13 to 24 following cancer diagnosis. The mean miles traveled per patient were 1,326 (SE = 306) for the experimental group and 2,186 (SE = 347) for the control group (P = 0.03). No significant differences in satisfaction with care, economic barriers to care, or health-related quality of life were found. CONCLUSIONS: The intervention significantly reduced cancer patient travel for health care, which suggests that access to care improved in the experimental group. The results of this study do not allow conclusion that there was no effect on other patient outcomes. The results supported the study's conceptual framework and many of its hypotheses.

Lake Superior Rural Cancer Care Project, Part III: provider practice.

PURPOSE: Effective methods that encourage rural primary-care physicians to adopt state-of-the-art cancer-management practices are needed. The purpose of this study was to evaluate educational and systems strategies to improve rural primary-care physicians' cancer practice behaviors. DESCRIPTION OF STUDY: The Lake Superior Rural Cancer Care Project was a group-randomized, controlled trial conducted with 18 rural communities in the North Central United States over 4 years. Although the unit of analysis was the community, the subjects were 104 primary-care physicians and 2089 rural patients with cancer. The intervention was educational and comprised systems strategies that targeted rural primary-care physicians and their healthcare delivery systems. The outcome measures reported here were physician practice behaviors regarding cancer diagnosis, staging, treatment, clinical trial participation, and post-treatment surveillance. RESULTS: The intervention significantly improved 5 of the 37 cancer practice end points. The overall result of the study did not support the majority of the study hypotheses. Because 16 practice end points were found to be at acceptable performance levels, the possibility of a measurable intervention effect was limited. CLINICAL IMPLICATIONS: Earlier, the authors reported the results of the intervention on providers' cancer management knowledge, which showed significant improvement. The present study findings demonstrated that improving provider knowledge does not necessarily improve practice performance. Changing practice behaviors requires much more effort. Furthermore, interventions found to be effective in other diseases, types of providers, or settings may not work on rural providers for cancer management.