The distribution of rural female generalist physicians in the United States.

Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women in medicine have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States. We examine the geographic distribution of all active U.S. allopathic physicians recorded in the October 1996 update of the American Medical Association Physician Masterfile. Percentages and numbers of female physicians by professional activity, specialty type, and geographic location are reported. Findings reveal there were fewer than 7,000 female allopathic physicians practicing in rural America in 1996. The proportion of generalist female physicians who practice in rural settings was significantly lower than the proportion who practice in urban locations. Although members of the most recent 10-year medical school graduation cohort of female generalist physicians were slightly more likely to practice in rural areas than members of earlier cohorts, female physicians remained significantly underrepresented in rural areas. States varied dramatically in rural female generalist underrepresentation. Should female generalists continue to be underrepresented in rural locations, the rural physician shortage will not be resolved quickly. Effective strategies to improve rural female physician placement and retention need to be identified and implemented to improve rural access to physician care.

Perceptions of practice among rural family physicians--is there a gender difference?

BACKGROUND: Women physicians are relatively less likely to practice in rural areas. The purpose of this study was to describe differences in perceptions of rural practice between male and female physicians currently in rural practice. METHODS: A questionnaire was developed from interviews with rural family physicians and mailed to 118 randomly selected board-certified family physicians in rural towns of the northwestern United States. RESULTS: Responses from 63 physicians were analyzed quantitatively and qualitatively. Female family physicians were more likely than their male counterparts to agree they had been attracted by the availability of part-time work and by opportunities for their personal partner. Compared with men, women were more likely to expect to earn less in rural than in urban practice. On open-ended questions analyzed using qualitative methods, women were more likely to report discouragement by professional isolation and by potential lack of privacy in rural areas. CONCLUSIONS: These responses suggest that during recruitment efforts rural communities might be able to attract more female physicians by offering flexible schedules, spouse or partner opportunities, role boundaries, and professional or personal support networks.

US medical schools and the rural family physician gender gap.

BACKGROUND: Women comprise increasing proportions of medical school graduates. They tend to choose primary care but are less likely than men to choose rural practice. METHODS: This study used American Medical Association masterfile data on 1988-1996 medical school graduates to identify the US medical schools most successful at producing rural family physicians and general practitioners of both genders. RESULTS: The number of listed rural female family physician or general practitioner graduates among schools ranged from 0-27 (0% to 4.4% of each school's 1988-1996 graduates). There were approximately twice as many male as female rural family physicians and general practitioners. Publicly funded schools produced more rural female family physicians and general practitioners than their privately funded counterparts. CONCLUSIONS: Our findings suggest that a few schools, most of them public, may serve as models for schools that aim to train women who later enter rural practice.

A study of medical students' specialty-choice pathways: trying on possible selves.

PURPOSE: To describe the decision-making processes reported by graduating medical students in choosing primary care (PC) or non-primary-care (NPC) specialties. METHOD: Members of the University of Washington School of Medicine's graduating class of 1995 were invited to participate in focus groups. Six specialty-choice pathways were defined based on a previously administered survey of recalled preferences at matriculation and stated choice at the time of the National Resident Matching Program. Students were assigned to focus groups based on specialty-choice pathway. Transcribed discussions and summaries were thematically coded and analyzed using grounded theory and quantitative comparisons. RESULTS: Of 157 students, 140 (89%) completed the initial survey, and 133 (85%) provided enough information to be classified by pathway. In all, 47 students participated in the focus group discussions. The PC students cited PC orientation, diversity of patients and activities, role models and mentors, interaction with patients, and overall medical school culture as having influenced their choice. The NPC students cited lifestyle, controllable hours, opportunities to do procedures, therapeutic urgency and effect, active tempo, exciting settings, and intellectual challenge. Role models influenced PC career choice much more than NPC career choice, and often served to refute negative stereotypes. The sense of personal fit between themselves and specialties was important to the students in all groups, but differed in emphasis according to career-choice pathways. Those whose preferences did not change experienced a confirmation of pre-existing beliefs, while those who switched specialty areas developed a sense of fit through the inclusion or elimination of different practice aspects. Those who switched specialty areas reported more negative influences and misunderstanding of their initially preferred specialties. CONCLUSION: The process of specialty choice can be described usefully as a socially constructed process of "trying on possible selves" (i.e., projecting oneself into hypothetical career and personal roles). This may explain role models' exceptional influence in disproving negative stereotypes. Medical students' choices can best be facilitated by recognizing their needs to gain knowledge not only about specialty content, but also about practitioners' lives and the students' own present and possible selves.

Gender and interest in academic careers among first- and third-year residents.

BACKGROUND: While increasing proportions of medical students and residents are women, the proportion of women in the advanced ranks of medicine remains small. This study describes gender differences among residents concerning interest in academic medicine and related influences. METHOD: A survey instrument was mailed to all 308 first- and third-year residents at the University of Washington School of Medicine in the late summer of 1993. The survey assessed interest in academic careers, values, psychological traits, exposure to mentoring, and perceived role stress. Frequency analysis and chi-square analysis were performed to compare the distribution responses by gender within the entire respondent group and within the first-year and third-year subgroups. RESULTS: A total of 180 (58%) of all first- and third-year residents responded; 99 (55%) were men. Although the level of interest in academic careers was similar among first-year male and female residents, the level of interest was greater among third-year men than among third-year women. Women overall were less likely to consider it personally important to achieve national recognition. Women in the third (but not the first) year of residency were significantly less likely than men to agree that leading others was personally important to them. Women reported feeling less confident, were less likely to have identified a faculty member who had successfully balanced career and personal life, and were significantly more likely to feel under stress and to have interrupted their careers for childbearing. CONCLUSION: The interest in academic careers appeared to be lower among third-year female residents than among third-year male residents, despite the similar interests in academic medicine among male and female first-year residents. Increasing role stress among women in training may explain the reduced interest in leadership and academic careers among women at more advanced levels of training.

Attitudes of Washington State primary care physicians toward capitation-based insurance plans.

Recent years have brought many changes in health care financing, including health care insurance plans based on capitation allowances to physicians. This study describes a survey examining physician attitudes toward such plans. The survey was distributed to a random sample of 30% of the family physicians, general practitioners, general internists, and general pediatricians in the Washington State Medical Association in 1986. Responses from 322 physicians (71%) indicated that most primary care physicians had a negative attitude toward such plans. Participants in capitation-based plans (48% of total respondents) had a nearly neutral attitude, which was significantly different from the attitude of nonparticipants. Respondents identified the main disadvantages of such plans as confusion about benefits, increased administrative demands, liability risks, altered professional relationships, and loss of autonomy. The main advantages perceived were increased physician awareness of cost, increased importance of the primary care role, and reduction of unnecessary health care utilization. Attitudes were significantly more negative among solo practitioners and physicians with more years in practice. Respondents rated selection of consultants, favorable economic arrangements, and benefits information as the features most likely to influence them to participate in capitation-based plans.

Enrollment factors and preexisting medical conditions in a prepaid capitated plan. A comparison of university and nonuniversity clinic enrollees.

Traditional wisdom suggests that academic medical centers attract sicker patients than nonacademic facilities, thereby incurring greater risk when caring for patients enrolled in prepaid health care plans. This study examines the affiliation of an academic medical center with a prepaid capitation-based medical plan in western Washington state and focuses on demographic characteristics, prior existing medical conditions, recent utilization, and factors affecting enrollee choice of health care plan, clinic, and physician. It was hypothesized that university clinic enrollees would differ from nonuniversity clinic enrollees with regard to many of these factors. A questionnaire was sent to a random sample of 400 university clinic enrollees and 759 enrollees in nonuniversity, private practice settings. The response rate was 56.1%. Results showed that, when compared with nonuniversity clinic enrollees in the same plan, university clinic enrollees were significantly younger and had more formal education. University clinic enrollees reported less health care utilization and expressed fewer strong preferences than nonuniversity clinic enrollees in choosing a health care plan, clinic, and physician. Based on this survey, there was no evidence that the academic medical center attracted sicker HMO enrollees than did nonuniversity clinics.

Preventive services in a hybrid capitation and fee-for-service setting.

The potential omission of indicated tests for patients enrolled in prepaid health care plans has been raised as a possibility. This study reviewed the charts of 149 adult patients seen for routine physical examinations or checkups in university-based family medicine or internal medicine clinics. Of the patients included, 67 were enrolled in a capitated plan and 82 enrolled in fee-for-service based plans. Results showed that the rates of compliance with preventive services appropriate to patients' age and sex (Papanicolaou smears, breast examination, mammography, and stool examination for occult blood) were not significantly different for capitated and fee-for-service patients.

Physician knowledge and attitudes about health insurance after the introduction of capitated health care plans.

A two-part closed-end survey similar to a survey done in 1980 was given to 25 family physicians at an academic family medical center to assess physician knowledge about five insurance programs covering most of the patients seeking care in the center, and to assess physician attitudes about the capitated insurance plan with which the clinic was affiliated. Results did not differ significantly from those obtained in a similar survey four years earlier at the same center. Physicians correctly identified benefits offered by insurance programs only about one half of the time and many did not ascertain patient insurance coverage at all. Physicians considered the most important advantages of capitated health care to be the patient protection from fees for services obtained, the coverage for health care maintenance, and the potential for controlling health care costs. Physician-perceived disadvantages included difficulties controlling costs generated by other specialists, dealing with after-the-fact authorization requests, controlling access to services, and obtaining information about costs within the capitated system.

Content of the model teaching unit ambulatory care training and continuity of care in six family practice residency programs.

This article summarizes the practice content and continuity for 35 senior residents in six family medicine residency model teaching units utilizing a computerized information management system. Comparisons are drawn with the content of family practices in the National Ambulatory Medical Care Survey (NAMCS), showing that family medicine third-year residents provide a large proportion of pregnancy care and general medical examinations and treat a smaller number of chronic illness patients compared with family physicians in practice. Third-year residents performed few surgical procedures in the model teaching units. Continuity of care, though espoused by family medicine residencies in principle, was deficient in the model teaching units studied. Intensive training to compensate for these deficiencies is recommended.

Gatekeeping--clinical and administrative issues.

Most gatekeeper-based models of health care delivery utilize primary care physicians for authorizing services, screening referrals, managing cases and monitoring costs. Issues in four major areas related to gatekeeping have arisen in such systems: those affecting patients primarily, those affecting physicians primarily, those related to administering the gatekeeping function and, finally, those issues related to the health care system as a whole.

Abdominal pain in pregnancy.

In many respects abdominal pain in pregnancy is managed just as in a nonpregnant patient, but the diagnostic criteria, methods of diagnosis, therapy, and consequences of mismanagement differ. This article discusses appendicitis, cholecystitis, urolithiasis, pancreatitis, and intestinal obstruction--conditions that often manifest a similar clinical picture. The article presents epidemiologic data, distinguishing characteristics, modifications of the workup, and treatment appropriate to pregnancy and perinatal complications of each condition.

Therapeutic alternatives and clinical outcomes in peritonsillitis.

A retrospective study was conducted on 32 patients with the discharge diagnosis of peritonsillar abscess or peritonsillar cellulitis. Three had pre-existing chronic conditions that may have contributed to the peritonsillitis. The average duration of symptoms prior to diagnosis was 7.4 days. Most patients responded to penicillin given parenterally until the patient were able to take medication orally. Pus was obtained in 88 percent of the patients who underwent drainage procedures. Eight patients were treated with parenteral antibiotics without drainage, including three from whom pus was aspirated. All eight recovered without complication. The most common organism cultured was beta-hemolytic streptococcus, group A (seen in 31 percent). There was no association between the dose or type of oral antibiotic used prior to diagnosis of peritonsillar cellulitis. The clinical outcome suggests that some patients with peritonsillitis may respond to parenteral antibiotics without drainage procedures or tonsillectomy.