Lessons Learned as Thomas Jefferson University's Rural Physician Shortage Area Program (PSAP) Approaches the Half-Century Mark.

To help increase the supply and retention of rural family physicians, Thomas Jefferson University initiated the Physician Shortage Area Program (PSAP) in 1974. The program selectively admits medical school applicants who both grew up in a rural area and plan to practice in a rural area. During medical school, PSAP students have ongoing mentoring and rural clinical experiences. As the program now approaches the half-century mark, this commentary summarizes several important lessons learned. First, outcomes research is critical, and program leaders have been able to publish 15 papers and a book about the PSAP and its outcomes. Second, these studies have shown that the program has been highly successful, with PSAP graduates 8.5-9.9 times more likely to enter rural family medicine than their peers, and that the PSAP contributed 12% of all rural family physicians in Pennsylvania. Other similar medical school rural programs have had comparable success, with more than half of all graduates combined (including PSAP graduates) practicing rural. Third, long-term retention has a multiplicative impact. Long-term retention of PSAP graduates in rural family medicine was greater than 70% after 20-25 years. Fourth, research has shown that the admissions component accounted for approximately three-quarters of the PSAP's success. Three factors available at the time of matriculation (rural background, plans for rural practice, and plans for family medicine) identified almost 80% of all Jefferson graduates in rural practice 3 decades later. Having a peer group with similar backgrounds, mentoring, and the rural curriculum were also very important. Fifth, wanting to live rural appears key to the rural practice decision. Finally, given that medical school programs like the PSAP produce substantial increases in the supply and retention of rural physicians while requiring modest resources, medical schools can have a critical role in addressing the rural physician shortage.

Retention of rural family physicians after 20-25 years: outcomes of a comprehensive medical school rural program.

BACKGROUND: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) is one of a small number of comprehensive medical school rural programs that has been successful in increasing the supply of family physicians practicing in rural areas. Although retention is a critical component of the rural physician supply, published long-term outcomes are limited. METHODS: Of the 1937 JMC graduates from the classes of 1978 to 1986, we identified those who were practicing family medicine in a rural county when they were first located in practice (in 1986 for 1978-1981 graduates and in 1991 for 1982-1986 graduates). Using the Jefferson Longitudinal Study, we then compared the numbers of PSAP and non-PSAP graduates who were still practicing family medicine in the same area in 2011. RESULTS: Of the 92 JMC graduates initially practicing rural family medicine, 90 were alive in 2011, and specialty and location data were available for 89 (98.9%). Of the 37 PSAP graduates who originally practiced rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 compared with 24 of 52 non-PSAP graduates (46.2%; P = .02). CONCLUSION: This study provides additional support for the substantial impact of medical school rural programs, suggesting that graduates of rural programs are not only likely to enter rural family medicine but to remain in rural practice for decades.

The relationship between matriculating medical students' planned specialties and eventual rural practice outcomes.

PURPOSE: To analyze the previously unknown relationships between the specialty plans of entering medical students and their eventual rural practice outcomes. METHOD: For 5,419 graduates from the 1978-2002 classes of Jefferson Medical College, their self-reported specialty plans at the time of matriculation were obtained from the Jefferson Longitudinal Study, as were their 2007 practice locations. Specialty plans were grouped into 12 categories, and the percentages of graduates initially planning each specialty group who were actually practicing in rural areas were determined. RESULTS: Entering medical students' specialty plans were strongly related to eventual rural practice (P < .001). Those students planning family medicine were "highly likely" to practice in rural areas (29.4%, 238/810). They were 1.5 times as likely to practice rural as a "mid-likely" group (those planning general surgery, psychiatry, emergency medicine, general internal medicine, or one of the medical subspecialties: 19.6% [range 17.9%-21.0%], 229/1,167). Students planning family medicine were also 2.1 times as likely to practice rural as those students planning a "lower-likely" group (those planning general pediatrics, one of the surgical subspecialties, the hospital specialties of radiology, anesthesiology and pathology, and obstetrics-gynecology, or other specialties: 14.0% [range 13.0%-14.3%], 142/1,016). CONCLUSIONS: These findings show that students' specialty plans at medical school matriculation are significantly related to rural outcomes, and they provide new information quantifying the absolute and relative likelihood of those planning various specialties to enter rural practice. This information is particularly important for medical schools that have or plan to develop comprehensive rural programs.

The relationship between entering medical students' backgrounds and career plans and their rural practice outcomes three decades later.

PURPOSE: Although many studies have investigated predictors of physician practice in rural areas, few have accounted for the importance of physicians' backgrounds. This study analyzed the relationship between the backgrounds and future career plans of entering medical students and their rural practice outcomes. METHOD: For 1,111 graduates from Jefferson Medical College (JMC, classes of 1978-1982), three factors self-reported at matriculation and previously related to rural practice were obtained from the Jefferson Longitudinal Study of Medical Education: growing up rural, planning rural practice, and planning family medicine. Their 2007 practice location was determined to be in a rural versus nonrural area. Analyses of graduates with various numbers of predictive factors (0-3) and rural practice were performed. RESULTS: Of the 762 JMC graduates (69%) with complete data, 172 (23%) were practicing in rural areas. Of graduates with all three predictors, 45% (45/99) practiced in rural areas compared with 33% (48/145) of those with two predictors, 21% (42/198) with one predictor, and 12% (37/320) of those with none. Of physicians practicing in rural areas in 2007, only 22% had no predictors. CONCLUSIONS: Three factors known at the time of medical school matriculation have a powerful relationship with rural practice three decades later. Relatively few students without predictors practice in rural areas, which is particularly significant given subsequent factors known to be related to rural practice--for instance, rural curriculum, residency location, or spouse. These results have major implications for the role of the medical school admissions process in producing rural physicians.

Medical school rural programs: a comparison with international medical graduates in addressing state-level rural family physician and primary care supply.

PURPOSE: Comprehensive medical school rural programs (RPs) have made demonstrable contributions to the rural physician workforce, but their relative impact is uncertain. This study compares rural primary care practice outcomes for RP graduates within relevant states with those of international medical graduates (IMGs), also seen as ameliorating rural physician shortages. METHOD: Using data from the 2010 American Medical Association Physician Masterfile, the authors identified all 1,757 graduates from three RPs (Jefferson Medical College's Physician Shortage Area Program; University of Minnesota Medical School Duluth; University of Illinois College of Medicine at Rockford's Rural Medical Education Program) practicing in their respective states, and all 6,474 IMGs practicing in the same states and graduating the same years. The relative likelihoods of RP graduates versus IMGs practicing rural family medicine and rural primary care were compared. RESULTS: RP graduates were 10 times more likely to practice rural family medicine than IMGs (relative risk [RR] = 10.0, confidence interval [CI] 8.7-11.6, P < .001) and almost 4 times as likely to practice any rural primary care specialty (RR 3.8, CI 3.5-4.2, P < .001). Overall, RPs produced more rural family physicians than the IMG cohort (376 versus 254). CONCLUSIONS: Despite their relatively small size, RPs had a significant impact on rural family physician and primary care supply compared with the much larger cohort of IMGs. Wider adoption of the RP model would substantially increase access to care in rural areas compared with increasing reliance on IMGs or unfocused expansion of traditional medical schools.

Increasing the supply of women physicians in rural areas: outcomes of a medical school rural program.

BACKGROUND: Women physicians are less likely then men to practice in rural areas. With women representing an increasing proportion of physicians, there is concern that this could exacerbate the rural physician shortage. The Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) is one of a small number of medical school rural programs shown to be successful in addressing the rural physician shortage; however, little is known about their specific impact on women. METHODS: For 2394 physicians from the 1992 to 2002 JMC graduating classes, the 2007 practice location and specialty for PSAP and non-PSAP graduates were obtained from the Jefferson Longitudinal Study. The relative likelihood of PSAP versus non-PSAP graduates practicing in rural areas was determined for women and men and compared. RESULTS: Women PSAP graduates were more than twice as likely as non-PSAP women to practice in rural areas (31.7% vs 12.3%; relative risk, 2.6; 95% CI, 1.6-4.2). This was similar to the PSAP outcomes for men (51.8% vs 17.7%; relative risk, 2.9, 95% CI, 2.2-3.9; relative risk ratio, 0.9, 95% CI, 0.5-1.5). PSAP outcomes were also similar for women and men practicing rural family medicine and rural primary care. CONCLUSION: These results provide support that medical school rural programs have the potential to help address the serious shortage of women physicians in rural areas, thereby increasing access to care for those living there.

Increasing the supply of rural family physicians: recent outcomes from Jefferson Medical College's Physician Shortage Area Program (PSAP).

PURPOSE: The shortage of primary care physicians in rural areas is an enduring problem with serious implications for access to care. Although studies have previously shown that medical school rural programs-such as Jefferson Medical College's Physician Shortage Area Program (PSAP)-significantly increase the rural workforce, determining whether these programs continue to be successful is important. METHOD: The authors obtained, from the Jefferson Longitudinal Study, the 2007 practice location and specialty for the 2,394 PSAP and non-PSAP graduates of 11 previously unreported Jefferson graduating classes (1992-2002). They determined the relative likelihood both of PSAP versus non-PSAP graduates practicing rural family medicine and of all PSAP versus non-PSAP graduates practicing in Pennsylvania's rural counties. RESULTS: PSAP graduates were much more likely both to practice rural family medicine than their non-PSAP peers (32.0% [31/97] versus 3.2% [65/2,004]; relative risk [RR] = 9.9, confidence interval [CI] 6.8-14.4, P < .001) and to practice any specialty in rural Pennsylvania (PSAP 24.7% [24/97] versus non-PSAP 2.0% [40/2,004]; RR = 12.4, CI 7.8-19.7, P < .001). CONCLUSIONS: Despite major changes in health care in recent decades, Jefferson's PSAP continues to represent a successful model for substantially increasing the supply and distribution of rural family physicians. Especially with the forthcoming expansion in health insurance, access to care for rural residents will require an increased supply of providers. These results may also be important for medical schools planning to develop similar rural programs, given the new Rural Physician Training Grants program.

Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication.

PURPOSE: To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication. METHOD: Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed. RESULTS: Ten studies met all inclusion criteria. Outcomes were available for more than 1,600 graduates across three decades from six programs. The weighted average of graduates practicing in rural areas ranged from 53% to 64%, depending on the definition of rural. If 125 medical schools developed similar programs for 10 students per class, this would result in approximately 11,390 rural physicians during the next decade, more than double the current estimation of rural doctors produced during that time frame (5,130). CONCLUSIONS: All identified comprehensive medical school rural programs have produced a multifold increase in the rural physician supply, and widespread replication of these models could have a major impact on access to health care in thousands of rural communities. The current recommendation to expand U.S. medical school class size represents a unique and timely opportunity to replicate these programs.

NIH funding in family medicine: an analysis of 2003 awards.

PURPOSE: We wanted to analyze National Institutes of Health (NIH) awards to departments of family medicine. METHODS: We obtained the list of NIH awards to departments of family medicine in 2003, and collected additional information from the Internet regarding each principal investigator (PI), including whether he or she worked primarily in a core (central) organizational component within a family medicine department. RESULTS: One hundred forty-nine NIH awards were granted to 45 departments of family medicine, for a total of 60,085,000 dollars. Of 146 awards with a designated PI, approximately two thirds of awards (89, 61%) and awarded dollars (39,850,000 dollars, 70%) went to PIs who were either not full-time family medicine faculty primarily working in family medicine departments, or they were not working in core family medicine organizational components. Few awards to physician PIs in these non-core areas were to family physicians (4 of 37, 11%), whereas most awards to physician PIs in core family medicine areas went to family physicians (40 of 45, 89%). In contrast, most K awards (research career programs) went to PIs in core areas (19 of 23, 83%), and most to family physicians (17 of 23, 74%). Nationally, only 17 R01 awards (research project, traditional) went to family physicians. CONCLUSIONS: Most NIH awards to family medicine departments went to PIs in noncore organizational components, where most physician PIs were not family physicians. Family medicine departments interested in increasing NIH funding may want to consider 4 models that appear to exist: individual faculty in core departmental components, K awards, core faculty also working in university-wide organizational components that provide research infrastructure, and integrating noncore administrative components into the department.

Long-term retention of graduates from a program to increase the supply of rural family physicians.

PURPOSE: To determine the long-term retention of rural family physicians graduating from the Physician Shortage Area Program (PSAP) of Jefferson Medical College. METHOD: Of the 1,937 Jefferson graduates from the classes of 1978-1986, the authors identified those practicing rural family medicine when their practice location was first determined. The number and percent of PSAP and non-PSAP graduates practicing family medicine in the same rural area in 2002 were then identified, and compared to the number of those graduates practicing rural family medicine when they were first located in practice 11-16 years earlier. RESULTS: After 11-16 years, 68% (26/38) of the PSAP graduates were still practicing family medicine in the same rural area, compared with 46% (25/54) of their non-PSAP peers (p = .03). Survival analysis showed that PSAP graduates practice family medicine in the same rural locality longer than non-PSAP graduates (p = .04). CONCLUSIONS: These results are the first to show long-term rural primary care retention that is longer than the median duration. This outcome combined with previously published outcomes show that the PSAP represents the only program that has resulted in multifold increases in both recruitment (eight-fold) and long-term retention (at least 11-16 years). In light of recent national recommendations to increase the total enrollment in medical schools, allocating some of this growth to developing and expanding programs similar to the PSAP would make a substantial and long lasting impact on the rural physician workforce.

Lessons learned-UME-21 project.

The Undergraduate Medical Education for the 21st Century (UME-21) project evolved from two prior projects that were aimed at studying the interface between managed care and undergraduate medical education. The project provided funding for 18 US medical schools to demonstrate how they would produce graduates who eventually could practice in a rapidly changing health care environment. Medical schools were required to provide educational opportunities in nine content areas or outline why such educational opportunities could not be provided in their individual projects. Participating schools were chosen via an involved process after careful evaluation by a panel of experienced medical educators. In a project of this type, many lessons are learned. In the UME-21 project, lessons learned were gleaned from progress reports, participant annual reports, proceedings from annual project meetings and a National Symposium, findings of a National Education Group, and published papers. A lesson must have been reported by a least two involved schools to be included. The lessons learned were divided into six categories as follows: content areas, implementation, collaboration, evaluation, governance, implications- summary. Many lessons emanated from each of these categories; however, only the 10 most important lessons in each category are presented. The implications of the lessons learned are outlined and provide direction for the future of medical education innovation and research.