Politics of rural health care: recruitment and retention of physicians.

The shortage of physicians in underserviced areas has been defined, and the causative recruitment and retention factors have been identified. The CMA report provides a framework for understanding these factors. Many can be modified, but this requires cooperation between physicians, communities, hospitals, medical schools, medical associations and governments. The development of a rural-practice master plan in each province would facilitate this process.     

Is deleting the digital rectal examination a good idea?

Although the supply of physicians in the United States has doubled during the past 20 years, there is still disagreement as to whether we currently have or should expect a significant surplus of physicians. The evidence suggests that despite the rapid expansion in the pool of available physicians, serious physician shortages persist for certain rural populations, ethnic and occupational groups, and other medically disadvantaged segments of the population. Medical students'' declining interest in rural practice and primary care specialties suggests that problems of geographic and specialty maldistribution may worsen despite a rising population of physicians. It is unlikely that a significant physician surplus will develop unless there is a conscious attempt to limit the proportion of national wealth expended on medical care. Pockets of shortage can be reduced by broadening the availability of health insurance, lessening large income disparities between different specialties, changing the way teaching institutions are reimbursed for their training costs, and supporting direct governmental service programs such as the National Health Service Corps.     

Training Physician Assistants for the Pacific Northwest: The MEDEX Northwest Ten-Year Experience

The student characteristics and employment status of physician assistants trained at MEDEX Northwest in Seattle between 1969 and 1979 were surveyed. There were 201 graduates and an attrition rate of 11.1 percent. Of 142 respondents, 88.7 percent were currently employed as physician assistants or nurse practitioners. Most (77.5 percent) were employed by their teaching preceptors following graduation. A majority (55.6 percent) were working in public or nonprofit private sector facilities.In all, 70 percent were practicing in Washington state, 75 percent were in family practice and 62 percent were working in communities of less than 50,000 population. These results compare favorably with rural and primary care practice data for physician assistants and physicians nationally. An effective preceptorship and deployment system is proposed as an important reason for the results.     

The Role of the Practising Physician in Medical Student Recruitment

The role that the practitioner of medicine can play in assisting recruitment to medical schools is examined. Although the total enrolment in universities has increased sharply in the past decade, the group applying to enter medicine has decreased. The output of Canada''s 12 schools of medicine—850 graduates per year-falls significantly short of the number of new physicians required to maintain the present physician:population ratio. With the expanded output of physicians required in future, an active program of recruitment will be necessary. The recruitment program organized by the practising physicians of British Columbia and the Faculty of Medicine at the University of British Columbia is outlined.     

A Marathon session: A town's MDs develop a philosophy to call their own

Last June CMAJ described how Marathon--a remote town in Northern Ontario--had gone from medical rags to riches in just over a year (CMAJ 1997;156:1593-6). Once chronically underserviced in terms of physician services, this community of 5500 people went from a single overworked doctor to a group practice of 7 physicians. The change involved far more than numbers, however. The Marathon solution was built on a philosophy of physician sustainability and long-term retention, not just recruitment. The change was designed to ensure that the town could finally get off the roller-coaster ride that saw more than 75 doctors come--and go--during the previous 10 years. A year after its initial report, CMAJ returned to see if the Marathon experiment was still working.     

Assessment of physician performance in Alberta: the Physician Achievement Review

The College of Physicians and Surgeons of Alberta, in collaboration with the Universities of Calgary and Alberta, has developed a program to routinely assess the performance of physicians, intended primarily for quality improvement in medical practice. The Physician Achievement Review (PAR) provides a multidimensional view of performance through structured feedback to physicians. The program will also provide a new mechanism for identifying physicians for whom more detailed assessment of practice performance or medical competence may be needed. Questionnaires were created to assess an array of performance attributes, and then appropriate assessors were designated--the physician himself or herself (self-evaluation), patients, medical peers, consultants and referring physicians, and non-physician coworkers. A pilot study with 308 physician volunteers was used to evaluate the psychometric and statistical properties of the questionnaires and to develop operating policies. The pilot surveys showed good statistical validity and technical reliability of the PAR questionnaires. For only 28 (9.1%) of the physicians were the PAR results more than one standard deviation from the peer group means for 3 or more of the 5 major domains of assessment (self, patients, peers, consultants and coworkers). In post-survey feedback, two-thirds of the physicians indicated that they were considering or had implemented changes to their medical practice on the basis of their PAR data. The estimated operating cost of the PAR program is approximately $200 per physician. In February 1999, on the basis of the operating experience and the results of the pilot survey, the College of Physicians and Surgeons of Alberta implemented this innovative program, in which all Alberta physicians will be required to participate every 5 years.     

"Take some action,take some risk," conference on rural recruiting told

Physicians attending a recent conference on the retention of physicians in rural areas proposed more than 40 recommendations for dealing with recruitment and retention issues. The conference was organized by Ontario''s residents, who have been feeling the impact of attempts to encourage physicians to move to rural and underserviced areas.     

Forecasting Japan's Physician Shortage in 2035 as the First Full-Fledged Aged Society

Introduction

Japan is rapidly becoming a full-fledged aged society, and physician shortage is a significant concern. The Japanese government has increased the number of medical school enrollments since 2008, but some researchers warn that this increase could lead to physician surplus in the future. It is unknown how many physicians will be required to accommodate future healthcare needs.

Materials and Methods

We simulated changes in age/sex composition of the population, fatalities (the number of fatalities for the consecutive five years), and number of physicians from 2010 to 2035. Two indicators were defined: fatalities per physician and fatalities by physician working hour, based on the data of the working hours of physicians for each tuple of sex and age groups. We estimated the necessary number of physicians in 2035 and the number of new physicians to maintain the indicator levels in 2010.

Results

The number of physicians per 1,000 population is predicted to rise from 2·00 in 2010 to 3·14 in 2035. The number of physicians aged 60 years or older is expected to increase from 55,375 (20% of physicians) to 141,711 (36%). In 2010 and 2035, fatalities per physician were 23·1 and 24·0 for the total population, and 13·9 and 19·2 for 75 years or older, respectively. Fatalities per physician working hour are predicted to rise from 0·128 to 0·138. If working hours are limited to 48 hours per week in 2035, the number of fatalities per physician working hour is expected to be 0·196, and the number of new physicians must be increased by 53% over the current pace.

Discussion

The number of physicians per population continues to rise, but the estimated supply will not fulfill the demand for healthcare in the aging society. Strategies to increase the number of physicians and improve working conditions are urgently needed.     

CHANGING CONCEPTS IN MEDICAL TREATMENT

In a community—even a small one—where physicians established in practice have intensity of purpose, continuing curiosity, healthy skepticism and the spirit of research, the medical atmosphere is one to attract and welcome young physicians who are recently graduated and eager to apply the knowledge gained from the specialists who taught them in medical schools.As the modern laboratory and other facilities and equipment now in use in teaching institutions become available in more and more small communities, general practice remote from the medical centers probably will have increasing allure for neophyte physicians upon whom great influence is being brought to bear to induce them to practice medicine where the need is greatest.Knowledge of the changes in concepts of medical treatment that have taken place in the life-span of the physicians already established in a community will help the young physician fit himself congenially and effectively into the methods of practice of his elder colleagues, with mutual benefit.     

Diversion programs for impaired physicians.

Nine states have legislated impaired physician programs administered by state medical boards (2), by independent agencies (4), or by medical societies through contracts with medical boards (3). All other state programs are administered by medical societies. California''s diversion program has been in effect for more than 10 years. It was the first program for alcohol- and drug-addicted physicians in the country administered by the state agency that also disciplines physicians. Of the physicians who enrolled in this program, 72% have completed it successfully. A total of 618 physicians have been accepted into the program since its inception, with 247 physicians currently participating.     

The Impact of Japan's 2004 Postgraduate Training Program on Intra-Prefectural Distribution of Pediatricians in Japan

Objective

Inequity in physician distribution poses a challenge to many health systems. In Japan, a new postgraduate training program for all new medical graduates was introduced in 2004, and researchers have argued that this program has increased inequalities in physician distribution. We examined the trends in the geographic distribution of pediatricians as well as all physicians from 1996 to 2010 to identify the impact of the launch of the new training program.

Methods

The Gini coefficient was calculated using municipalities as the study unit within each prefecture to assess whether there were significant changes in the intra-prefectural distribution of all physicians and pediatricians before and after the launch of the new training program. The effect of the new program was quantified by estimating the difference in the slope in the time trend of the Gini coefficients before and after 2004 using a linear change-point regression design. We categorized 47 prefectures in Japan into two groups: 1) predominantly urban and 2) others by the definition from OECD to conduct stratified analyses by urban-rural status.

Results

The trends in physician distribution worsened after 2004 for all physicians (p value<.0001) and pediatricians (p value = 0.0057). For all physicians, the trends worsened after 2004 both in predominantly urban prefectures (p value = 0.0012) and others (p value<0.0001), whereas, for pediatricians, the distribution worsened in others (p value = 0.0343), but not in predominantly urban prefectures (p value = 0.0584).

Conclusion

The intra-prefectural distribution of physicians worsened after the launch of the new training program, which may reflect the impact of the new postgraduate program. In pediatrics, changes in the Gini trend differed significantly before and after the launch of the new training program in others, but not in predominantly urban prefectures. Further observation is needed to explore how this difference in trends affects the health status of the child population.     

Deportation proceedings against Canadian MDs may hold lesson for others heading south

Two Alberta physicians who emigrated to a medically underserviced part of Kentucky have learned a harsh lesson about American immigration law. Drs. David Zetter and Sabina Seitz had been settled in western Kentucky for 2 years when the US government launched deportation proceedings against them. American officials allege that they misrepresented themselves when they entered the US on a temporary visa. They may be allowed to stay following a public outcry against their deportation.     

Problems of value in medicine and the humanities, or will the real doctor please stand up?

After a general discussion of the need for physicians to concern themselves with questions of human ethics, this paper considers genetics, the population explosion, abortion, curing patients of psychological problems which are perfectly normal (such as masturbation), and behavior modification. The population explosion is the outgrowth of the understandable desire to reduce disease and death. Now births must be reduced immediately or the world will eliminate starvation among infants only to have starvation among adults. The 2nd problem is preventing births. Contraception is not caught up in moral problems but abortion pits 1 set of ethics against another. Here, again, the physician must have a broad world view. The humanist theory holds that procedures that enhance human freedom are both natural and desirable while procedures that suppress it are unnatural and undesirable. This also applies to medical procedures. An understanding of the humanist point of view is important to the physician in his work.     

The future of family practice training in California.

Although the number of physicians in California has doubled since 1963, the number of family and general practice physicians has declined. The ratio of office-based primary care physicians to population has also decreased. Graduate medical education is funded largely from patient care revenues, but the low rate of reimbursement for ambulatory care makes training in primary care specialties especially dependent on public support. Medicare, the Veterans Administration, and the University of California provide more than $325 million a year in support of graduate medical education in California. Federal and state grant programs provide $5 million a year for family physician training in the state, but appropriations to these programs have been reduced in real terms. California family practice residencies are disproportionately located at county hospitals, where funding shortfalls make them especially vulnerable to cuts in grant programs. Additional resources will be needed if more family physicians are to be trained.     

THE NUMBER AND DISTRIBUTION OF PHYSICIANS IN CALIFORNIA

The ratio of physicians to general population in California has been approximately the same for many years, the influx of physicians having kept pace with the population trend.For many years California has licensed more physicians than any other state.The five medical schools in this state have been increasing the number of candidates admitted to the freshman class. Attempts are being made to increase the number of medical schools in this state to seven in anticipation of the future growth and medical needs of the population.The heaviest concentration of physicians is as always in the thickly populated areas as determined by the population physician ratio.A study of the detailed statistics presented in this paper should be of interest to all California physicians.     

Perinatal care in British Columbia: Diagnosis and management of hemolytic disease of the newborn

We undertook to measure standards of perinatal care in British Columbia by studying the management of hemolytic disease of the newborn as the sample situation.Our data show that many isoimmunized pregnant women are delivered in hospitals that have infrequent experience with this problem, and by physicians who have little experience with this disease.The physician referral pattern, in regard to maternal isoimmunization, indicated that the more severely affected patients were managed by specialists, particularly those attached to teaching hospitals. However, 25% of the infants treated by exchange transfusion were managed by nonspecialists in nonteaching hospitals.Hospital record search, used as a method of medical audit and as a source of data for comparison with physician reports, did not result in dependable or complete information. Rates of disagreement between items from two data sources, physician report and hospital record, were frequently very high. Our experience suggests that comparison of these two data sources is not an ideal method of assessment of quality of care.A smaller caseload of isoimmunized pregnant women will result from the present prevention program. Nevertheless, cases will continue to occur. Our work supports the conclusion that a program of continuing education covering the diagnosis and management of hemolytic disease of the newborn is still necessary.     

Alberta's Rural Physician Action Plan: an integrated approach to education,recruitment and retention

This paper describes the development and characteristics of a comprehensive, integrated and sustained program for the education, recruitment and retention of physicians for rural practice in Alberta--the Rural Physician Action Plan. The participation of key stakeholders (including government, the provincial medical association, the licensing authority, faculties of medicine, practising rural physicians and regional health authorities) and a sustained program budget have been key organizational issues for success. Critical to the effectiveness of this program has been the focus on professional and lifestyle issues targeting 3 distinct groups: physicians in training, physicians in practice, and rural communities and health authorities. Substantial program funding since 1991-92 of up to $3 million per year has increased rural-based activities significantly. For example, 87% of medical students and 91% of residents in family medicine in Alberta now experience 4 weeks or more of rural practice. The authors believe that the historic issues and recent trends militating against recruitment and retention of rural physicians will continue unchecked without comprehensive and sustained approaches such as Alberta''s Rural Physician Action Plan.     

Doing what the patient orders: maintaining integrity in the doctor-patient relationship

No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician....I have also considered the common practice of patient referral from the standpoint of physician integrity, and asked whether a physician who refuses to treat a patient as a matter of conscience can consistently refer the patient to another physician for the same treatment....     

Monitoring Sub-Saharan African Physician Migration and Recruitment Post-Adoption of the WHO Code of Practice: Temporal and Geographic Patterns in the United States

Data monitoring is a key recommendation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, a global framework adopted in May 2010 to address health workforce retention in resource-limited countries and the ethics of international migration. Using data on African-born and African-educated physicians in the 2013 American Medical Association Physician Masterfile (AMA Masterfile), we monitored Sub-Saharan African (SSA) physician recruitment into the physician workforce of the United States (US) post-adoption of the WHO Code of Practice. From the observed data, we projected to 2015 with linear regression, and we mapped migrant physicians’ locations using GPS Visualizer and ArcGIS. The 2013 AMA Masterfile identified 11,787 active SSA-origin physicians, representing barely 1.3% (11,787/940,456) of the 2013 US physician workforce, but exceeding the total number of physicians reported by WHO in 34 SSA countries (N = 11,519). We estimated that 15.7% (1,849/11,787) entered the US physician workforce after the Code of Practice was adopted. Compared to pre-Code estimates from 2002 (N = 7,830) and 2010 (N = 9,938), the annual admission rate of SSA émigrés into the US physician workforce is increasing. This increase is due in large part to the growing number of SSA-born physicians attending medical schools outside SSA, representing a trend towards younger migrants. Projection estimates suggest that there will be 12,846 SSA migrant physicians in the US physician workforce in 2015, and over 2,900 of them will be post-Code recruits. Most SSA migrant physicians are locating to large urban US areas where physician densities are already the highest. The Code of Practice has not slowed the SSA-to-US physician migration. To stem the physician “brain drain”, it is essential to incentivize professional practice in SSA and diminish the appeal of US migration with bolder interventions targeting primarily early-career (age ≤ 35) SSA physicians.     

Learning to deal with drug-dependent patients: one physician's reflections.

Physicians with a contemporary education may not be adequately trained to deal effectively with drug-dependent patients. This paper details the problems that one physician encountered with such individuals in his practice. A retraining program was set up in which he received basic education in drug dependence and became involved in individual counselling with drug abusers and in research studies on alcoholism and drug abuse. Physicians must exercise caution when prescribing medications that are potentially addictive. They must have a responsible attitude in their care of drug-dependent patients. The assessment and treatment of such patients should be carried out only by a multidisciplinary team of health care professionals. These principles are best inculcated by the proper exposure of medical students to substance-abuse problems and by the availability of appropriate courses and studies in this area to practising physicians.