Fifteen-Year Outcomes of a Rural Residency: Aligning Policy With National Needs

Robert Ross MD MScEd

摘要

Rural areas of the United States have a shortage of physicians relative to urban areas.1,2 Despite 30 years of policy initiatives, the number of physicians in rural practice remains virtually unchanged and insufficient.3-5Cascades East Family Medicine Residency Program (CEFMR) administered by Oregon Health & Science University (OHSU), is situated in Klamath Falls, OR (population ~42,000), at a 96-bed, not-for-profit community hospital, Sky Lakes Medical Center (SLMC). CEFMR remains the only Oregon residency program outside the metropolitan Portland area. According to our investigations through the American Academy of Family Physicians (AAFP), Accreditation Council for Graduate Medical Education (ACGME), and other organizations, CEFMR is the most rural and remote 3-year residency training site in the nation, and SLMC is the smallest institution supporting a 3-year residency. The program’s main goal is to produce full scope of practice family physicians to enter rural practice. In both OHSU and SLMC, family physicians have full admitting privileges and perform many procedures (C-sections, endoscopy) that are confined to subspecialists in most other locales.Is this a successful model for rural family medicine training? Where do the graduates of the program practice? How often do they relocate? This study aimed to answer these questions using data gathered from a detailed postgraduate survey instrument mailed to all graduates of the program, with follow-up electronic, written, and phone reminders. All addresses and practice locations were verified with personal or email contact. A search of studies in OVID MEDLINE, CINAHAL, EMBASE, and the Cochrane database shows there are few outcome studies or statistics available for residency programs of any specialty published in the literature. Other databases (eg, the American Medical Association [AMA] physician masterfile) are incomplete and do not have relevant information about practice activity or content.6Many methods have been used to entice physicians into postgraduate training designed to bolster the supply of rural providers, the most numerous being through family medicine programs where residents are assigned to a central teaching hospital for the PGY-1 year and then spend the final two training years in a rural community. These programs, which produce small numbers of graduates, seem to successfully place rural family physicians,7 but the literature reveals limited information on graduate outcomes of these or other residency program designs. A recent article from the Spokane Family Medicine Residency states that 49% of graduates from this program practice in rural communities (defined as populations of less than 25,000 located further than 25 miles from a town larger than 25,000) and goes on to quote a much older article citing that 76% of graduates of 1-2 programs practice in rural areas.7 No methodologies are presented for supporting the reported data.8 In fact, a recent (2009) Cochrane review revealed virtually no evidence about the most effective way of producing practitioners for rural locations.9 In the author’s words, “There are no studies in which bias and confounding are minimized to support any of the interventions that have been implemented to address the inequitable distribution of health care professionals. Well-designed studies are needed to confirm or refute findings of various observational studies.”We have previously demonstrated our success in placing graduates in isolated and underserved areas. Of 63 graduated residents (as of March 2008), 17 (27%) were practicing in Federally Qualified Health Centers (FQHC-330 Grant Based), 39 (62%) in Health Professional Shortage Areas (HPSAs) and three (7%) in Indian Health Service (IHS) sites or tribal clinics. The survey design was altered in 2009 to reflect longitudinal progression of our graduate’s practices over time. The results of our investigations form an initial but incomplete attempt to establish a database that a

机译：美国的农村地区相对于城市地区缺乏医生。1,2尽管采取了30年的政策举措，但农村实践中的医生人数实际上保持不变且不足。3-5级联东部家庭医学住院医生计划（CEFMR）由俄勒冈州健康与科学大学（OHSU）管理的医院位于俄勒冈州克拉马斯福尔斯（人口约42,000），位于拥有96张床位的非营利性社区医院，天湖医疗中心（SLMC）。 CEFMR仍是俄勒冈州大都市地区以外唯一的俄勒冈州居住计划。根据我们通过美国家庭医师学会（AAFP），研究生医学教育认证委员会（ACGME）和其他组织进行的调查，CEFMR是美国最农村和偏远的3年居住培训地点，而SLMC是支持三年居留权的最小的机构。该计划的主要目标是让全科医生家庭医生进入农村实践。在OHSU和SLMC中，家庭医生都具有充分的承认特权并执行许多程序（剖腹产，内窥镜检查），这些程序仅限于其他大多数地区的专科医师。这是农村家庭医学培训的成功模式吗？该课程的毕业生在哪里实习？他们多久搬一次？这项研究旨在使用从详细的研究生调查工具收集的数据来回答这些问题，该工具已邮寄给该计划的所有毕业生，并提供后续的电子，书面和电话提醒。所有地址和练习地点均已通过个人或电子邮件联系方式进行了验证。在OVID MEDLINE，CINAHAL，EMBASE和Cochrane数据库中进行的研究搜索显示，很少有成果研究或统计数据可用于文献中发表的任何专业的住院医师计划。其他数据库（例如，美国医学协会[AMA]医师主文件）不完整，并且没有有关执业活动或内容的相关信息。6许多方法已被用来诱使医师参加研究生培训，旨在加强农村医疗服务提供者的服务。通过家庭医学计划的人数最多，其中将居民分配到PGY-1年的中央教学医院，然后在农村社区度过最后的两个培训年。这些方案产生的毕业生人数很少，似乎已成功地安置了农村家庭医生7，但文献表明，这些方案或其他居住方案设计的毕业生成果信息有限。斯波坎家庭医学居所最近的一篇文章指出，该计划的毕业生中有49％在农村社区（定义为少于25,000的人口位于距25,000以上的城镇超过25英里的地方），并继续引用年龄更大的人文章引用了1-2个项目的毕业生中的76％在农村地区实习。7没有提供支持所报告数据的方法。8实际上，最近（2009年）的Cochrane评论几乎没有证据表明最有效的生产方式9用作者的话说：“没有任何研究能够将偏见和混淆最小化，以支持为解决卫生保健专业人员分布不均而采取的任何干预措施。需要进行精心设计的研究，以确认或驳斥各种观察性研究的结果。“我们先前已经证明了我们成功地将毕业生安置在偏僻且服务不足的地区。在63名毕业的居民中（截至2008年3月），有17名（27％）在联邦合格健康中心（基于FQHC-330补助金）执业，39名（62％）在卫生专业短缺地区（HPSA）执业，三名（7％）在印度卫生服务（IHS）站点或部落诊所。 2009年对调查的设计进行了更改，以反映我们的研究生实践随时间的纵向发展。我们的调查结果构成了建立数据库的初步尝试，但尝试并不完整，

Fifteen-Year Outcomes of a Rural Residency: Aligning Policy With National Needs

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