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A Washington state survey has provided information on hospital administrators' academic backgrounds and geographic career patterns. Some 93% of urban respondents reported having advanced degrees, compared to 74% of rural respondents. The survey's results provide little evidence that administrators see rural positions as a means of advancing to urban careers., Summary Information on academic and geographic career patterns was obtained through a survey of 93 urban and rural hospital administrators in the State of Washington in 1990 (90 percent response [...]

CEO turnover occurred in 78 out of 148 rural hospitals in four northwestern states during the three-year period between 1987 and 1990. CEO responses to a questionnaire on the conditions under which they left their hospitals are analyzed. The majority who resigned within four years sought better positions elsewhere. More turnover was found in small hospitals than in larger institutions. The need for strategies to attract and retain qualified administrators for rural northwestern hospitals is indicated, and suggestions for this are discussed.

Surplus or Shortage? Unraveling the Physician Supply Conundrum How many physicians does the United States need? The question is simple, but the answer is convoluted and controversial. Despite the plethora [...]

Abstract: Context:The topic of physician‐assisted suicide is difficult and controversial. With recent laws allowing physicians to assist in a terminally ill patient's suicide under certain circumstances, the debate concerning the appropriate and ethical role for physicians has intensified. Purpose:This paper utilizes data from a 1997 survey of family physicians (FPs) in Washington State to test two hypotheses: (1) older respondents will indicate greater opposition to physician‐assisted suicide than their younger colleagues, and (2) male and rural physicians will have more negative attitudes toward physician‐assisted suicide than their female and urban counterparts. Methods:A questionnaire administered to all active FPs obtained a 68% response rate, with 1074 respondents found to be eligible in this study. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas. Findings:One‐fourth of the respondents overall indicated support for physician‐assisted suicide. When asked whether this practice should be legalized, 39% said yes, 44% said no, and 18% indicated that they did not know. Fifty‐eight percent of the study sample reported that they would not include physician‐assisted suicide in their practices even if it were legal. Responses disaggregated by age‐groups closely paralleled the group overall. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents. Even among those reporting support for physician‐assisted suicide, many expressed reluctance about including it in their practices. Conclusions:These findings highlight the systematic differences in FP attitudes toward one aspect of health care by gender, rural‐urban practice location, and other factors.

One of the most recalcitrant problems of the rural health landscape is the uneven distribution and relative shortage of medical care providers. Despite considerable efforts by federal and state governments over the past three decades to address these problems, rural provider distribution and shortage issues have persisted. The purpose of this article is to identify the challenges for rural health research and policy regarding health provider supply in the first decade of the 21st century. While the emphasis in this article is on physicians, workforce concerns pertaining to nurses, nurse practitioners, and physician assistants are briefly described. Physician supply, geographic and specialty distribution, age, gender, quality of care, recruitment and retention, training, productivity and income, reimbursement aid managed care, federal and state ameliorative programs, safety net, and telehealth are discussed. Also highlighted are issues concerning rural health care workforce research, methods, and data as well as a series of policy‐relevant questions. Solutions to rural health personnel problems can only be successfully addressed through multifaceted approaches. No vision of the future of rural health can come to fruition if it does not promote stable, rewarding, and fulfilling professional and personal lives for rural health care providers.

Abstract: Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to “small rural” communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.

Abstract: Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994

Rural health care facilities commonly employ community health care surveys as marketing research instruments to assess consumer utilization of and satisfaction with local services. However, there is little information on the use of survey findings as a way to design interventions to enhance consumer satisfaction and hospital viability. A community survey was administered in six Northwest rural communities as part of the Rural Hospital Project (RHP) to identify weaknesses in local health care services, guide remedial activities, act as a catalyst for change, and assess changes in community perceptions following project interventions. Descriptive findings revealed problems typically observed in small rural communities, including relatively low hospital and physician market share, outmigration for certain types of health care not available locally, and dissatisfaction with some aspects of hospital and physician services. Satisfaction with various aspects of care tended to be lower among males, the uninsured, and younger respondents. Comparisons of survey responses before (1985) and after (1989) the RHP generally demonstrated stability in hospital and physician market share, with project hospitals performing well in 1989 in comparison to other rural hospitals of similar size. The percentage of respondents who rated overall quality of local hospital and physician care positively generally increased or remained stable over the study period. Substantial decreases in satisfaction levels were found for access to care. Importantly, gains were made in those areas and services which received particular emphasis in the project.

A major goal of the Rural Hospital Project (RHP) was to assist communities in defining an optimal scope of hospital and community health services. It was hypothesized that a rational basis for service planning would result in an expansion of locally provided health services, increased local hospital and physician market share, improved hospital workload performance, and higher levels of consumer satisfaction with community‐based services. However, given the recent decline in performance of many small rural hospitals in general and in RHP hospitals in particular, at a minimum, stabilization of these troubled facilities could be considered a successful outcome. Data were collected from the six rural communities participating in the RHP both before and after the intervention (1985 and 1989) to assess changes in community scope of health services and utilization patterns. Comparative data were also compiled from peer group hospitals when available. Results generally demonstrated stabilization or expansion in: (1) the range of community and hospital services, (2) the availability of community physicians and visiting specialties, and (3) physician and hospital market share. While findings were mixed for patient days, average daily census, and number of births, substantial increases were documented for the number of surgical procedures, emergency room visits, and x‐rays over the study period. RHP hospitals generally outperformed peer group hospitals on market share measures.

Abstract: State action immunity from antitrust liability has been proposed as an important tool for preserving and strengthening fragile rural health care delivery systems. Washington is a leader in the use of state action immunity, having passed a statute and having approved several applications for immunity. This paper summarizes the current status of state action immunity, both in general and in Washington, including a review of the literature and an explication of issues of particular relevance to rural areas. Additionally, a summary is presented of inter‐views with key informants in nine rural Washington communities, including an organization that had received a grant of immunity, one rural community just across a state border, and one other organization with rural operations that was given a grant of immunity. The interviews suggest that antitrust immunity, given the current interpretations of laws and guidelines by the courts, the Federal Trade Commission, and the Department of Justice, is not playing a significant role in the plans and decisions of health care providers in rural Washington. In larger rural areas, it was thought that activities could be structured to avoid antitrust liability without needing to apply for immunity; in smaller areas, there was little knowledge of antitrust issues, few resources to obtain knowledgeable advice, and little activity for which immunity might be useful. Overall, the authors did not find a large role for state action antitrust immunity in health care in rural Washington under current conditions.