The formalized nurse practitioner (NP) role in British Columbia is relatively new with the majority of roles implemented in primary care. The majority of primary care is delivered by physicians using the fee-for-service model. There is a shortage of general practitioners (GP) and difficulties with recruitment and retention, particularly in rural and remote locations. The uptake of the primary care NP role has been slow with challenges in understanding the extent of its contributions. This study was to identify the impacts and outcomes associated with the NP role in collaborative primary care practice. Multiple case studies where NPs were embedded into rural fee-for-service practices were undertaken to determine the outcomes at the practitioner, practice, community, and health services levels. Interviews, documents, and before and after data, were utilized to identify changes in practise, access, and acute care service utilization. The results showed that NPs affected how care was delivered, particularly through the additional time afforded each patient visit, the development of a team approach with interprofessional collaboration, and a change in style of practise from solo to group practise. This resulted in improved physician job satisfaction. Patient access to the practice improved with increased availability of appointments and practice staff experienced improved workplace relationships and satisfaction. At the community level, access to primary care improved for harder to serve populations and new linkages developed between the practice and their community. The acute care services experienced a statistically significant decrease in emergency use and admissions to hospital (p= .000). The presence of the NP improved their physician colleagues desire to remain in their current work environment. This study identified the diversity of needs that can be addressed by the NP role; the importance of time to enhance patient care, and its associated benefits, especially in the fee-for-service model; the value of the NP’s role in the community; the acceptance of the clinical competence of NPs by their physician colleagues; the outcomes generated at the practice level in terms of organizational effectiveness and service provision; and substantiated the impact of the role in improving primary care access and reducing acute care utilization. / Graduate

Abstract not available

This dissertation analyzes one state's efforts to increase the number of its primary care physicians and encourage their retention and distribution to rural underserved areas. This analysis was accomplished through an examination of physicians as they completed training in Texas family medicine, internal medicine, pediatrics, and obstetric/gynecology residency programs. State licensure data provided insights into these primary care specialties by showing which residents remained in the state to practice, and by showing the numbers and specialties of physicians who practice in rural underserved areas. The primary purpose of this study was to increase understanding and document similarities and differences in the primary care residency programs' production of physicians who remained in Texas and who practiced in a whole county HPSA following training. The following analyses were used to evaluate the research questions and hypotheses: frequency distributions, geographic depictions, Chi-Square tests and binary logistic regression. These analyses provided supporting evidence that significant differences exist among resident programs in the four primary care medical specialties. Differences were also found in residents' likelihood to remain in Texas to practice and their likelihood to practice in whole county Health Professional Shortage Areas (HPSAs). This study showed that those residents who trained in Texas largely remained in Texas and actively practiced medicine years after their residency training had been completed. The training and location of primary care physicians in Texas is influenced by what medical specialty programs are available and where. This suggests that increasing the number and type of residency programs in more remote areas may have a positive influence on the physician workforce of those regions. This study confirms the finding of other institutional and single medical specialty studies that physicians tend to remain in the state in which they complete their residency training. However, this study found that there are variations by primary care specialty, gender, ethnicity, and program location. Residency training is an essential piece in supplying the Texas physician workforce and ensuring that its stability and long-term growth will position it to be prepared to care for the population.

In the context of a country and a continent that is largely rural, education for rural medical practice in Africa is relatively undocumented and poorly conceptualized. The arena of medical education in South Africa has been largely unchanged by the transition to democracy, despite intentions of reform. The literature reveals a lack of empirical evidence as well as theory in education for rural health, particularly in developing countries. This report presents twelve original papers on a range of key issues that represent the author’s contribution to filling this gap in South Africa. It aims to contribute to the development of a discourse in education for rural medical practice in an African context, and culminates in a theoretical paper regarding pedagogy for rural health. A conceptual framework is utilized that is based on the standard chronological steps in the initial career path of medical doctors in South Africa. Beginning with the literature that is focused around the need to recruit and retain health professionals in rural and underserved areas around the world, the report then addresses the policy context for medical education in South Africa, examining the obstacles to true reform of a transformatory nature. The selection of students of rural origin, and the curricular elements necessary to prepare graduates for rural practice are then investigated, including the actual career choices that medical graduates make in South Africa. Out in the workplace, the educational components of the year of compulsory community service are described, including organizational learning and apprenticeship as novice practitioners, placed under severe pressure in rural hospitals in the South African public health service. A community-oriented type of medical practice is described amongst exemplary individuals, indicating the aspiration towards a different kind of educational outcome. Finally the thesis as such is presented in the final paper regarding a theoretical basis for education for rural health, consisting of the combined notions of placed-based and critical pedagogy. It is argued that while the geographic elements of rural practice require a pedagogy that is situated in a particular rural context, the developmental imperatives of South Africa demand a critical analysis of health and the health care system, and the conceptual basis of this position is explained. / Thesis (Ph.D.) - University of KwaZulu-Natal, Durban, 2010.

Purpose: Resilience, the capacity to endure and overcome hardship, has been suggested as a basic competency for rural medical practice. Unfortunately for physician educators, the medical education literature offers only limited guidance for nurturing this adaptive capacity. We describe the process and subsequent analysis of a daylong curriculum development workshop conducted at the annual meeting of Rural Medical Educators in 2010. Methods: Fifty administrator, faculty and student attendees reflected individually and worked in groups to construct key curricular components and modalities for teaching this competency. Prior to the meeting, participants were asked to submit a personal story about resilience. The 22 narratives received were distributed across 8 groups and provided the grist for the small group discussions, in which each group identified key concepts for teaching and learning about resilience, constructed a concept map, and developed a curriculum that was presented to all session participants. Concept maps, curriculum outlines and notes taken during the presentations were analyzed using content analysis techniques. Findings: Data highlight the importance of (1) embracing hardship as an opportunity for growth, (2) viewing resilience as both an individual and community property, (3) pursuing adaptability more than hardiness, and (4) setting a lifelong pattern of learning this competency in practice. Specific teaching modalities are suggested including individual reflective time and group activities. Conclusions: To our knowledge this represents a first effort to define and develop a medical curriculum for teaching resiliency in rural predoctoral and residency education.

No description available.

Indiana University-Purdue University Indianapolis (IUPUI) / Purpose: This study examines whether Indiana physicians’ choices to practice in medically underserved and rural areas of Indiana are associated with select physician characteristics. Methods: Physician data were gathered from the American Medical Association Physician Masterfile. Analysis was limited to primary care physicians currently practicing, whose birth city and/or state were known (if American born) and whose current practice location could be matched to an Indiana ZIP Code. The underserved and rural areas and physician data were mapped using ArcGIS. Chi square and logistic regression analyses were performed to identify significant associations between the physician characteristics and choice of practice location. Results: In instances where a physician was born in a county that fell below its state’s median income level in the decade of birth, there is a significant likelihood of future choice to practice in underserved and rural areas. Attending a medical school in the Midwest and region of birth (subdivided by state) were proven to have no predictive value. Conclusions: This result, when compared with other studies that have found physician hometown to be a predictive factor, seems to confirm and strengthen the argument that factors in a physician’s past, including social and economic setting of his or her upbringing, influence choice to practice in underserved and/or rural areas.

Over the last seven years the recruitment of overseas trained doctors (OTDs) has formed a significant part of Australia’s policy to address the medical workforce issue of geographic maldistribution to ensure that communities in rural and remote Australia have access to adequate general practice (GP) services. This policy has not been without problems, particularly in the areas of assessment of skills and qualifications, appropriate orientation and integration into Australian communities, and retention of these doctors within rural and remote communities. To date there has been little evidence-based research on the role of OTDs in the medical workforce in Australia. This study explores the service provision and quality of care provided by OTDs using the 5 Year OTD Scheme as the case study. In doing so, it assesses the adequacy of this strategy and discusses the implications for future workforce policies and programs. A mixed method design was used in the study. The quantitative component involved secondary analysis of Medicare Australia data for all OTDs participating in the 5 Year OTD Scheme in 2002 and all Australian trained doctors (ATDs) practising in rural and remote Australia in the same year. A log Poisson regression model was used to assess the interactive effect of the various GP characteristics, such as age, sex, experience and practice location with OTD/ATD status on the rate of a particular service item per patient, adjusted for patient age and sex. The qualitative component involved two focus groups with OTDs which were used to help explain the relationships between variables found in the quantitative component of the study. Template analysis was used to identify themes from the focus group. Significantly different rates per patient between OTDs and ATDS were found across most service items and GP characteristics examined. The greatest variation was found among items relating to in-surgery consultations and non-surgery consultations such as nursing home visits. Fewer differences were found between groups relating to pathology, imaging or procedural services. Analysis of surrogate quality items identified few differences between OTDs and ATDs. The focus group identified a number of other factors that influenced their patterns of service and accounted for some of the differences identified in the quantitative analysis. These factors included knowledge of the health care system in Australia, cultural and communication influences, health conditions of patients, patient and community attitudes, remuneration influences and training influences. These had varying degrees of influence on their patterns of service. The reasons for the differences found between OTDs and ATDs are partially explained by the characteristics of the GPs examined and partially explained by other external influences that relate to the particular circumstances of the OTDs, such as knowledge of the Australian health care system and cultural and communication issues. Understanding the nature of practice is central to ensuring appropriate professional support measures. The study findings highlight the need for a targeted training program for OTDs that address the areas that have the greatest influence on patterns of service to ensure that rural and remote communities receive the same quality of service from OTDs as provided by ATDs. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1320385 / Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

Magister Public Health - MPH / Interprofessional Education (IPE) for the undergraduate health sciences students has been seen as a vehicle that could prepare health professionals for improved collaboration in health care (Reeves, 2000). Early health curricula did not allow interaction among students of different disciplines. As a result students were equipped to only function in their own disciplines for their own professional purposes (Beatty, 1986). The Faculty of Community and Health Sciences (CHS), at the University of the Western Cape (UWC), introduced IPE in 1994 and established an Interdisciplinary Teaching and Learning unit (ITLU) to coordinate the interdisciplinary structured modules for undergraduate community and health sciences students. This research is an additional qualitative inquiry which is part of a bigger IPE study. The main aim of the bigger study, coordinated by the Collaboration for Health Equity in Education and Research (CHEER), is to investigate the impact of Collaborative Interprofessional Education and Practice on the development of socially responsible graduates who are well equipped to practice in rural and disadvantaged areas. This researcher aimed to explore the insights and attitudes of the current third and fourth year undergraduate community and health sciences students who are involved in the IPE programme regarding their appreciation of the other students‟ profession and their attitude to future interprofessional collaboration. Students were asked about their experiences in the IPE programme focusing on their initial experience, interaction in interprofessional groups and insights, and attitudes to being involved in the programme. Based on their experiences, they were also asked to provide recommendations for the programme. An exploratory qualitative study was conducted using focus group discussions and semi-structured interviews. Six focus group discussions were held with 3rd and 4th year students from occupational therapy, psychology, social work, physiotherapy and nursing at UWC to explore in-depth students‟ insights and attitudes towards the IPE programme. Two additional interviews were conducted with students individually. Six semi-structured interviews were conducted to obtain background information from key informants (Unit coordinator, Course convenor, two field coordinators and two lecturers) involved in the IPE programme at the UWC. The data collected were then transcribed and analysed by thematic content analysis. The findings revealed that the UWC IPE programme is very useful and important and can be potentially beneficial in health professional training especially in fostering collaboration. The results show both positive and negative attitudes by students at their initial encounter with the programme and a shift to a positive attitude and greater insight as students became more involved in the programme. The positive attitude is linked to an appreciation of their own and other professions‟ roles; recognition of the importance of a collaborative role in the health care setting and the relevance of the programme (content, practical work) to their work. The negative attitudes emanate from uncertainties and structural challenges within the programme (timing, lecturing process, etc). There are also challenges linked to course organisation which are important to improving the programme and have a potential to influence the attitudes of students.