Toward a common framework for rural background.

BACKGROUND AND OBJECTIVES: To develop a standardized framework to discuss rural background, a review of the literature to identify studies regarding the association of rural background with primary care and/or rural health practice was conducted. The various definitions of rural background were collated and from this data a framework for the conceptualization of rural background is proposed. METHODS: The Medline database from 1966-2009 was searched to find citations that included a rural background definition as a variable for rural intent to practice, rural career choice, or rural practice. Studies that included medical school admission outcomes of US medical schools were included if there was (1) a definition of rural background noted, (2) a research-based question, and (3) a defined outcome of rural practice intent or practice in rural area. RESULTS: A full text review was completed for all 45 articles identified. After applying the inclusion and exclusion criteria to the full length articles, there were 15 articles included in the review. The five most common definitions of rural background were (1) a positive answer to the question "Did you grow up in a rural area"? (2) a rural county of birth, (3) grew up in a town of less than 10,000 persons, (4) graduation from a high school located in a town of less than 10,000 persons, and (5) self-declared rural county of residence. CONCLUSIONS: There are multiple terms used in research to elucidate the conceptualization of rural background. Based on a definition of rural as the "anchor," we propose the use of the five most common definitions of rural background as "rural connectors" that can be used to buttress the definition of rural background. The framework of rural connectors can then be used to more closely define rural background.

What words should we use when discussing excess weight?

BACKGROUND: There is limited research on how patients prefer physicians to communicate about the topic of obesity, and there is even less understanding of which terms physicians most commonly use. METHODS: In this cross-sectional, nonrandom sampling study, patients who were seeking treatment for weight loss rated the desirability of 12 terms to describe excess weight, and physicians rated the likelihood with which they would use those terms during clinical encounters. Participants rated terms on a 5-point scale, with -2 representing "very undesirable" or "definitely would not use" and +2 representing "very desirable" or "definitely would use." RESULTS: Patients (n = 143; mean age, 46.8 years; mean body mass index, 36.9 kg/m(2)) rated "weight" (mean +/- SD) as the most desirable term (1.13 +/- 1.10), although it did not significantly differ from 5 other terms provided. They rated "fatness" (-1.30 +/- 1.22) as the most undesirable term, although this rating did not differ significantly from 4 other terms. Physicians affiliated with a community-based medical school (n = 108; mean age, 48.8 years; 79.6% primary care specialty) were most likely to use "weight" (1.42 +/- 0.89), which was significantly different from ratings for all other terms. They were least likely to use "fatness" (-1.74 +/- 0.59), although this rating did not differ significantly from 3 other terms. CONCLUSION: Physicians generally reported that they use terminology that patients had rated more favorably, and they tend to avoid terms that patients may find undesirable. Understanding the preferences and terminology used by patients and physicians is an important initial step to ensure that communications related to obesity and weight loss are efficient and effective.

Comparison of physician weight loss goals for obese male and female patients.

OBJECTIVE: The aim of this study was to compare physicians' weight loss goals for obese male and female patients. METHOD: This study was conducted in 2008-2009 in Florida, USA. Physicians (N=108; 79.6% primary care specialty) reviewed two hypothetical clinical scenarios that were identical with respect to health status and obesity (BMI=33 kg/m(2)) but differed in the gender of the patient. Physicians then completed a survey about the need for weight loss, intentions to provide weight loss counseling, and weight loss goals (i.e., ideal, successful, and acceptable goal weights) for each hypothetical patient. RESULTS: Physicians strongly agreed that both patients should lose weight and physician counseling and/or treatment referrals would be appropriate; however, physician weight loss goals for male and female patients differed. BMI values calculated from the suggested ideal, successful, and acceptable weight goals were significantly lower for female patients than male patients, 22.0 vs. 25. 2 kg/m(2); 25.4 vs. 27. 8 kg/m(2); and 27.0 vs. 29. 2 kg/m(2), respectively, P values <.001. CONCLUSIONS: Physicians endorsed significantly more stringent weight loss goals for obese female patients than obese male patients. Regardless of patient gender, physician goals exceeded the 5-10% losses currently recommended. Additional research is needed to better understand this gender discrepancy in physician expectations for obese patients.

Continuing decline in service delivery for family physicians: is the malpractice crisis playing a role?

PURPOSE: This study was conducted to monitor trends in the reduction and elimination of services offered by family physicians. In addition, we examined whether the malpractice situation may be influencing these trends. METHODS: We surveyed all family physicians in rural Florida and an equal number of randomly selected, urban, family physicians in the state. We examined changes in professional liability insurance (PLI) premiums, and changes in services offered, practice satisfaction, and future practice plans. RESULTS: Overall, 308 (42.1%) family physicians responded. Results suggest that 60.3% of them reduced or eliminated services in the last year. Specifically, almost two thirds of respondents had eliminated hospital-based surgeries (65.2%) and vaginal deliveries (64.5%). Furthermore, endoscopies were decreased or eliminated by 69% of survey participants, and coverage of emergency departments and nursing homes was reduced or eliminated by 64.1% and 56.4% of respondents, respectively. Increases in the PLI averaged 78.2%. Overall increases in the PLI were significantly related to a decrease or elimination of services offered by family physicians. Dissatisfaction with practice was relatively high (36.8%) and was associated with both the reduction of services and an intention to leave practice within 2 years. No major differences in these trends were noted between rural and urban family physicians. CONCLUSIONS: Access to care provided by rural and urban family physicians in Florida is being hampered by the malpractice situation and other factors. Policymakers may need to focus on these factors in an effort to relieve additional barriers to care for vulnerable populations.

The changing face of access to family physician services in rural Florida.

OBJECTIVES: This study's purpose was to determine whether access to services performed by Florida family physicians in rural areas is changing and whether the recent changes in the availability or cost of professional liability insurance may be influencing service provision. METHODS: We conducted a survey of all family physicians in rural Florida, asking about changes in health care services and procedures provided, insurance coverage and premiums, satisfaction with practice, and plans for future practice. RESULTS: Of the 204 respondents, 96 (49.5%) indicated that they have decreased or eliminated some health care services during the last year. Overall, 69.8% decreased or eliminated vaginal deliveries, 66.2% Cesarean sections, 56.6% endoscopies, 50.9% hospital-based surgeries, 50.7% emergency room coverage, 40.8% office-based surgeries, and 33.6% mental health services. Malpractice premiums increased a mean of 98.5%. Difficulty with finding or paying for insurance was listed as an important factor both by those reducing or eliminating services and by those planning to leave the community within the next 2 years. CONCLUSIONS: Access to some services provided by family physicians in rural areas is decreasing and may be influenced by recent changes in professional liability insurance costs and other factors in Florida. Given the number of states currently experiencing similar insurance cost changes, access to health care in rural areas may be affected nationwide.

The role of disease-specific infectivity and number of disease exposures on long-term effectiveness of the latex condom.

BACKGROUND: Condom use is a primary prevention strategy for sexually transmitted infections (STIs). Consistent condom use substantially reduces the risk of HIV infection. Similar levels of effectiveness for reducing the risk of other STIs have not been established. Differences in disease-specific infectivity and the number of exposures to an infected partner may explain differences in condom effectiveness. GOAL: The goal was to examine the impact of differing infectivities and increasing numbers of exposures on theoretical condom effectiveness. STUDY DESIGN: Mathematical modeling using estimated disease-specific infectivities and condom failure rates. RESULTS: Condom effectiveness decreases as disease-specific infectivity and the number of exposures to infection risk increase. CONCLUSIONS: Condom effectiveness for decreasing STI risk is influenced by disease infectivity and the number of exposures. Generalizations from studies of relatively uninfectious STIs to highly infectious STIs or from short-term studies to longer-term situations will overestimate condom effectiveness.