Understanding shortages of sufficient health care in rural areas

The following amendments to the 2002 "Ethical Principles of Psychologists and Code of Conduct" (the Ethics Code; American Psychological Association, 2002) were adopted by the APA Council of Representatives at its February 2010 meeting. The changes involve the last two sentences of the final paragraph of the Introduction and Applicability section and Ethical Standards 1.02 and 1.03. The amendments became effective June 1, 2010. A history of these amendments to the Ethics Code is provided in the "Report of the Ethics Committee, 2009" in this issue of the American Psychologist (American Psychological Association, Ethics Committee, 2010). Following are a clean version of the revisions and a version indicating changes from the 2002 language (inserted text is underlined; deleted text is crossed out).

Ethical Principles of Psychologists and Code of Conduct

The number of these RHCs has steadily increased since their inception in 1977 (currently there are approximately 3,300 RHCs) due to decreasing reimbursements from the standard fee-for-service system. Because RHCs receive cost-based reimbursement (as defined and limited by the Medicare and Medicaid Programs), providers continue to turn to the RHC program to enable them to provide service to the rural poor and elderly. As health care providers strive to maintain service to this vulnerable population, RHCs have become an integral part of the rural health care system.

National Rural Health Association.

Rural areas have historically struggled with shortages of healthcare providers; however, advanced communication technologies have transformed rural healthcare, and practice in underserved areas has been recognized as a policy priority. This systematic review aims to assess reasons for current providers’ geographic choices and the success of training programs aimed at increasing rural provider recruitment. This systematic review (PROSPERO: CRD42015025403) searched seven databases for published and gray literature on the current cohort of US rural healthcare practitioners (2005 to March 2017). Two reviewers independently screened citations for inclusion; one reviewer extracted data and assessed risk of bias, with a senior systematic reviewer checking the data; quality of evidence was assessed using the GRADE approach. Of 7276 screened citations, we identified 31 studies exploring reasons for geographic choices and 24 studies documenting the impact of training programs. Growing up in a rural community is a key determinant and is consistently associated with choosing rural practice. Most existing studies assess physicians, and only a few are based on multivariate analyses that take competing and potentially correlated predictors into account. The success rate of placing providers-in-training in rural practice after graduation, on average, is 44% (range 20–84%; N = 31 programs). We did not identify program characteristics that are consistently associated with program success. Data are primarily based on rural tracks for medical residents. The review provides insight into the relative importance of demographic characteristics and motivational factors in determining which providers should be targeted to maximize return on recruitment efforts. Existing programs exposing students to rural practice during their training are promising but require further refining. Public policy must include a specific focus on the trajectory of the healthcare workforce and must consider alternative models of healthcare delivery that promote a more diverse, interdisciplinary combination of providers.

/pdf/recruiting-rural-healthcare-providers-today-a-systematic-2mr61b4pr7.pdf

Recruiting Rural Healthcare Providers Today: a Systematic Review of Training Program Success and Determinants of Geographic Choices.

PurposeTo examine the literature documenting successes in recruiting and retaining rural primary care physicians.MethodThe authors conducted a narrative review of literature on individual, educational, and professional characteristics and experiences that lead to recruitment and retention of rural p

/pdf/the-road-to-rural-primary-care-a-narrative-review-of-factors-18x8erv56m.pdf

The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians.

Context: Small towns across the United States struggle to maintain an adequate primary care workforce. Purpose: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. Methods: A survey mailed in 2004-2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. Findings: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. Conclusions: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.

/pdf/the-primary-care-physician-workforce-in-massachusetts-3e6bpk1z2t.pdf

The primary care physician workforce in Massachusetts: implications for the workforce in rural, small town America

Context: Hospitals in rural communities may seek to increase specialty care access by establishing clinics staffed by visiting specialists. Purpose: To examine the visiting specialist care delivery model in Massachusetts, including reasons specialists develop secondary rural practices and distances they travel, as well as their degree of satisfaction and intention to continue the visiting arrangement. Methods: Visiting specialists at 11 rural hospitals were asked to complete a mailed survey. Findings: Visiting specialists were almost evenly split between the medical (54%) and surgical (46%) specialties, with ophthalmology, nephrology, and obstetrics/gynecology the most common specialties reported. A higher proportion of visiting specialists than specialists statewide were male (P = .001). Supplementing their patient base and income were the most important reasons visiting specialists reported for having initiated an ancillary clinic. There was a signifi cant negative correlation between a hospital ' s number of staffed beds and the total number of visiting specialists it hosted (r =  0.573, P = .032); study hospitals ranged in bed size from 15 to 129. Conclusions: The goal of matching supply of health care services with demand has been elusive. Visiting specialist clinics may represent an element of a market structure that expands access to needed services in rural areas. They should be included in any enumeration of physician availability. 1

The Visiting Specialist Model of Rural Health Care Delivery: A Survey in Massachusetts

Integrated primary care is particularly valuable to rural communities. Behavioral health care is often in short supply, and small or close-knit communities can intensify the stigma of seeking specialty mental health in rural settings. These and other barriers result in reduced access to needed behavioral health care. Nonetheless, rural practice of integrated primary care presents unique challenges to practitioners of multiple disciplines, including issues of competence, confidentiality, and dual relationships. This article provides an illustrative vignette to describe ethical issues in the rural practice of integrated primary care. It will review discipline-specific guidance in approaching these challenges and will offer recommendations for addressing disparities in the approaches of various disciplines engaged in the practice of integrated primary care.

/pdf/ethical-matters-in-rural-integrated-primary-care-settings-24ki1tunsu.pdf

Ethical matters in rural integrated primary care settings.

As guest editors for the forum on community-oriented primary care (COPC) and as authors of an article that traces the conceptual roots of COPC and its proposed future role as an “important conceptual framework” for practice, Mullan and Epstein note the existence of various movements in health care that provide natural allies for COPC.1 We would like to suggest an additional ally—the Healthy Communities movement.

Formulated almost 2 decades ago, the principles of Healthy Communities (HC)2 emphasize a democratic approach to addressing community problems that focuses on strengths.3,4 In merging the COPC and HC approaches to engaging community members, we have discovered a positive synergy. While both approaches spring from a common framework of health broadly defined, the language of HC is more lay friendly and broadly participatory. It begins with members of the lay and professional communities imagining what their neighborhoods and communities can become. This step of creating a shared vision, explicit in HC but only implicit in COPC, is an important element of the process. It develops a common bond and identifies areas of shared concerns.5

Mullan and Epstein note, “The idea of community is the core element [of COPC] and the point of departure for the COPC process.”1 Despite the renewed emphasis on community engagement that has appeared in the COPC literature,6,7 however, few articles do more than encourage clinicians to work with community members. Indeed, the emphasis has been placed on the epidemiological skills needed to describe a community and identify its health problems and risks; the skills needed to play a collaborative leadership role in this process are seldom described adequately. One of the contributions of the HC literature is discussion about building effective partnerships among the many players, not simply the health care facility and community members, and the acknowledgement that relationship building and democratic decisionmaking take time. This literature specifically addresses the importance of attention to community-building processes, another area that the COPC literature often finesses. Initiatives that grow from an explicit HC framework recognize the importance of learning to live with—indeed, to value—the tension inherent in balancing process and outcomes simultaneously.8

One example of the allied COPC–HC approach is occurring in central Massachusetts, where a family medicine practice hosted a monthly 8-part discussion series on the principles and precepts of COPC. At the series’ conclusion, organizers made a purposeful, subtle shift from using the COPC paradigm exclusively to incorporating the principles and practice of HC as a way to engage additional citizens. The result has been a community–professional partnership called the East Quabbin Alliance (EQUAL), which has realized remarkable successes in the areas of adolescent and environmental health. The group regularly engages additional citizens and remains closely identified with the family medicine practice.

The notion that other movements can be natural allies of COPC is an important one that practitioners who seek to amalgamate primary care and public health should recognize. As Mullan and Epstein note, while COPC appeals on the basis of practicality and principle, it has not become the prevalent mode of practice in health systems.1 All of us who work in COPC would be wise to seek allies that can help strengthen our efforts. We have found one in Healthy Communities.9

Joseph Stenger

Papers

The primary care physician workforce in Massachusetts: implications for the workforce in rural, small town America

The Visiting Specialist Model of Rural Health Care Delivery: A Survey in Massachusetts

Ethical matters in rural integrated primary care settings.

Healthy communities: a natural ally for community-oriented primary care.