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Background: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) is one of a small number of comprehensive medical school rural programs that has been successful in increasing the supply of family physicians practicing in rural areas. Although retention is a critical component of the rural physician supply, published long-term outcomes are limited., Methods: Of the 1937 JMC graduates from the classes of 1978 to 1986, we identified those who were practicing family medicine in a rural county when they were first located in practice (in 1986 for 1978-1981 graduates and in 1991 for 1982-1986 graduates). Using the Jefferson Longitudinal Study, we then compared the numbers of PSAP and non-PSAP graduates who were still practicing family medicine in the same area in 2011., Results: Of the 92 JMC graduates initially practicing rural family medicine, 90 were alive in 2011, and specialty and location data were available for 89 (98.9%). Of the 37 PSAP graduates who originally practiced rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 compared with 24 of 52 non-PSAP graduates (46.2%; P = .02)., Conclusion: This study provides additional support for the substantial impact of medical school rural programs, suggesting that graduates of rural programs are not only likely to enter rural family medicine but to remain in rural practice for decades.

Purpose: To analyze the previously unknown relationships between the specialty plans of entering medical students and their eventual rural practice outcomes., Method: For 5,419 graduates from the 1978-2002 classes of Jefferson Medical College, their self-reported specialty plans at the time of matriculation were obtained from the Jefferson Longitudinal Study, as were their 2007 practice locations. Specialty plans were grouped into 12 categories, and the percentages of graduates initially planning each specialty group who were actually practicing in rural areas were determined., Results: Entering medical students' specialty plans were strongly related to eventual rural practice (P < .001). Those students planning family medicine were "highly likely" to practice in rural areas (29.4%, 238/810). They were 1.5 times as likely to practice rural as a "mid-likely" group (those planning general surgery, psychiatry, emergency medicine, general internal medicine, or one of the medical subspecialties: 19.6% [range 17.9%-21.0%], 229/1,167). Students planning family medicine were also 2.1 times as likely to practice rural as those students planning a "lower-likely" group (those planning general pediatrics, one of the surgical subspecialties, the hospital specialties of radiology, anesthesiology and pathology, and obstetrics-gynecology, or other specialties: 14.0% [range 13.0%-14.3%], 142/1,016)., Conclusions: These findings show that students' specialty plans at medical school matriculation are significantly related to rural outcomes, and they provide new information quantifying the absolute and relative likelihood of those planning various specialties to enter rural practice. This information is particularly important for medical schools that have or plan to develop comprehensive rural programs.

Purpose: Although many studies have investigated predictors of physician practice in rural areas, few have accounted for the importance of physicians' backgrounds. This study analyzed the relationship between the backgrounds and future career plans of entering medical students and their rural practice outcomes., Method: For 1,111 graduates from Jefferson Medical College (JMC, classes of 1978-1982), three factors self-reported at matriculation and previously related to rural practice were obtained from the Jefferson Longitudinal Study of Medical Education: growing up rural, planning rural practice, and planning family medicine. Their 2007 practice location was determined to be in a rural versus nonrural area. Analyses of graduates with various numbers of predictive factors (0-3) and rural practice were performed., Results: Of the 762 JMC graduates (69%) with complete data, 172 (23%) were practicing in rural areas. Of graduates with all three predictors, 45% (45/99) practiced in rural areas compared with 33% (48/145) of those with two predictors, 21% (42/198) with one predictor, and 12% (37/320) of those with none. Of physicians practicing in rural areas in 2007, only 22% had no predictors., Conclusions: Three factors known at the time of medical school matriculation have a powerful relationship with rural practice three decades later. Relatively few students without predictors practice in rural areas, which is particularly significant given subsequent factors known to be related to rural practice--for instance, rural curriculum, residency location, or spouse. These results have major implications for the role of the medical school admissions process in producing rural physicians.

Purpose: Comprehensive medical school rural programs (RPs) have made demonstrable contributions to the rural physician workforce, but their relative impact is uncertain. This study compares rural primary care practice outcomes for RP graduates within relevant states with those of international medical graduates (IMGs), also seen as ameliorating rural physician shortages., Method: Using data from the 2010 American Medical Association Physician Masterfile, the authors identified all 1,757 graduates from three RPs (Jefferson Medical College's Physician Shortage Area Program; University of Minnesota Medical School Duluth; University of Illinois College of Medicine at Rockford's Rural Medical Education Program) practicing in their respective states, and all 6,474 IMGs practicing in the same states and graduating the same years. The relative likelihoods of RP graduates versus IMGs practicing rural family medicine and rural primary care were compared., Results: RP graduates were 10 times more likely to practice rural family medicine than IMGs (relative risk [RR] = 10.0, confidence interval [CI] 8.7-11.6, P < .001) and almost 4 times as likely to practice any rural primary care specialty (RR 3.8, CI 3.5-4.2, P < .001). Overall, RPs produced more rural family physicians than the IMG cohort (376 versus 254)., Conclusions: Despite their relatively small size, RPs had a significant impact on rural family physician and primary care supply compared with the much larger cohort of IMGs. Wider adoption of the RP model would substantially increase access to care in rural areas compared with increasing reliance on IMGs or unfocused expansion of traditional medical schools.

Purpose: We wanted to analyze National Institutes of Health (NIH) awards to departments of family medicine., Methods: We obtained the list of NIH awards to departments of family medicine in 2003, and collected additional information from the Internet regarding each principal investigator (PI), including whether he or she worked primarily in a core (central) organizational component within a family medicine department., Results: One hundred forty-nine NIH awards were granted to 45 departments of family medicine, for a total of 60,085,000 dollars. Of 146 awards with a designated PI, approximately two thirds of awards (89, 61%) and awarded dollars (39,850,000 dollars, 70%) went to PIs who were either not full-time family medicine faculty primarily working in family medicine departments, or they were not working in core family medicine organizational components. Few awards to physician PIs in these non-core areas were to family physicians (4 of 37, 11%), whereas most awards to physician PIs in core family medicine areas went to family physicians (40 of 45, 89%). In contrast, most K awards (research career programs) went to PIs in core areas (19 of 23, 83%), and most to family physicians (17 of 23, 74%). Nationally, only 17 R01 awards (research project, traditional) went to family physicians., Conclusions: Most NIH awards to family medicine departments went to PIs in noncore organizational components, where most physician PIs were not family physicians. Family medicine departments interested in increasing NIH funding may want to consider 4 models that appear to exist: individual faculty in core departmental components, K awards, core faculty also working in university-wide organizational components that provide research infrastructure, and integrating noncore administrative components into the department.

The Undergraduate Medical Education for the 21st Century (UME-21) project evolved from two prior projects that were aimed at studying the interface between managed care and undergraduate medical education. The project provided funding for 18 US medical schools to demonstrate how they would produce graduates who eventually could practice in a rapidly changing health care environment. Medical schools were required to provide educational opportunities in nine content areas or outline why such educational opportunities could not be provided in their individual projects. Participating schools were chosen via an involved process after careful evaluation by a panel of experienced medical educators. In a project of this type, many lessons are learned. In the UME-21 project, lessons learned were gleaned from progress reports, participant annual reports, proceedings from annual project meetings and a National Symposium, findings of a National Education Group, and published papers. A lesson must have been reported by a least two involved schools to be included. The lessons learned were divided into six categories as follows: content areas, implementation, collaboration, evaluation, governance, implications- summary. Many lessons emanated from each of these categories; however, only the 10 most important lessons in each category are presented. The implications of the lessons learned are outlined and provide direction for the future of medical education innovation and research.

Context: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (Philadelphia, Pa) is one of a small number of medical school programs that addresses the shortage of rural primary care physicians. However, little is known regarding why these programs work., Objectives: To identify factors independently predictive of rural primary care supply and retention and to determine which components of the PSAP lead to its outcomes., Design: Retrospective cohort study., Setting and Participants: A total of 3414 Jefferson Medical College graduates from the classes of 1978-1993, including 220 PSAP graduates., Main Outcome Measures: Rural primary care practice and retention in 1999 as predicted by 19 previously collected variables. Twelve variables were available for all classes; 7 variables were collected only for 1978-1982 graduates., Results: Freshman-year plan for family practice, being in the PSAP, having a National Health Service Corps scholarship, male sex, and taking an elective senior family practice rural preceptorship (the only factor not available at entrance to medical school) were independently predictive of physicians practicing rural primary care. For 1978-1982 graduates, growing up in a rural area was the only additionally collected independent predictor of rural primary care (odds ratio [OR], 4.0; 95% CI, 2.1-7.6; P<.001). Participation in the PSAP was the only independent predictive factor of retention for all classes (OR, 4.7; 95% CI, 2.0-11.2; P<.001). Among PSAP graduates, taking a senior rural preceptorship was independently predictive of rural primary care (OR, 2.5; 95% CI, 1.3-4.7; P =.004). However, non-PSAP graduates with 2 key selection characteristics of PSAP students (having grown up in a rural area and freshman-year plans for family practice) were 78% as likely as PSAP graduates to be rural primary care physicians, and 75% as likely to remain, suggesting that the admissions component of the PSAP is the most important reason for its success. In fact, few graduates without either of these factors were rural primary care physicians (1.8%)., Conclusions: Medical educators and policy makers can have the greatest impact on the supply and retention of rural primary care physicians by developing programs to increase the number of medical school matriculants with background and career plans that make them most likely to pursue these career goals. Curricular experiences and other factors can further increase these outcomes, especially by supporting those already likely to become rural primary care physicians.

Although rural-based graduate medical education is critically important in the training of competent rural family physicians, the number of physicians selecting these programs is highly dependent on what happens earlier in the pipeline, i.e., during medical school. Using the experience and outcomes research from Jefferson Medical College's Physician Short-age Area Program, as well as from published literature describing six other medical school programs with similar goals, this paper addresses the important role of these programs in substantially increasing the number of physicians interested in rural family practice. Although each of these programs differs in its structure, all contain three core features: a strong institutional mission; the targeted selection of students likely to practice in rural areas, predominantly those with rural backgrounds; and a focus on primary care, especially family practice. Outcomes show that all seven programs have been highly successful. Medical schools, therefore, can have a major impact on the number of rural physicians they produce by acting not only as a pipeline or conduit to residency programs, but also as a control valve, beginning as early as the admissions process. In order to maximize their impact on the supply and training of rural family physicians, rural residency programs should understand, support, collaborate with and help develop medical school programs whose mission is to provide rural physicians.

Accurate data on the number of generalist physicians are needed to monitor the physician workforce and to plan for future requirements in the changing health care system. This study assessed the relationship between two frequently used definitions of a generalist physician: completion of graduate medical education (GME) in only a generalist discipline and physician's self-report of practicing as a generalist. Data for 4,808 physician graduates from six Pennsylvania medical schools from 1986 to 1991 were analyzed using information from the GME tracking census of the Association of American Medical Colleges and the Physician Masterfile of the American Medical Association. Of 1,291 physicians trained in a generalist discipline, 1,205 (93%) reported practicing as generalists. Conversely, of the 3,517 not trained in a generalist discipline, 3,358 (95%) were not practicing as generalists. These results indicate GME training is a valid predictor of self-reported practice and provide baseline data to monitor future changes.

Purpose: To evaluate an open-ended, computer-scored testing format designed to overcome certain limitations of multiple-choice questions., Method: Test items covering content in family medicine were administered in two different formats to 7,036 resident physicians in 380 training programs, and to 35 experienced, board-certified physicians in conjunction with the In-training Examination of the American Board of Family Practice. Examinees completed a booklet of 40 open-ended, uncued (UnQ) test items by selecting the answer to each item from a list of over 500 responses. Similar items were administered using the standard multiple-choice question (MCQ) format. One year later, another test of 40 UnQ test items dealing with core content in family medicine was administered to 7,138 residents., Results: Examinees completed over 560,000 UnQ responses with high compliance and few errors. Both reliability and validity for the UnQ format were higher than for the MCQ format, and the UnQ items discriminated more accurately among levels of physicians' experience. The UnQ format almost eliminated the possibility that the physicians could answer questions by sight recognition or random guessing, and it was particularly effective in measuring knowledge of core content., Conclusions: This study supports the feasibility of administering open-ended test items to enhance tests of physicians' competence.

Medical education research has identified a number of medical student characteristics that are related to graduates' entering generalist careers. These include initial specialty preference, geographic background, gender, age, ethnicity, economic and lifestyle factors, attitudes and personal values, service orientation, and premedical academic performance. Identifying and giving weight to these factors in the medical school admission process is likely to increase the number of graduates who choose generalist specialties. This paper discusses these medical student characteristics and presents strategies that medical schools could use in the selection process to enhance the matriculation of students who are most likely to become generalists. In this way, medical schools will be able to recruit and select students who are most likely to become excellent physicians, and also produce a more appropriate balance of all specialists to meet the needs of the population.

Background: Given the high occurrence of oral manifestations in patients infected with human immunodeficiency virus (HIV), the relative ease in recognizing these manifestations on physical examination, and their potential impact on the health care and quality of life in these patients, it is critical to provide adequate training for primary care physicians in this area., Methods: Based on a review of the published literature and the consensus of a national panel of primary care physicians and dentists with clinical and research expertise in this area, a core curriculum was developed for primary care physicians regarding oral health care issues in HIV disease., Results and Conclusions: We describe the process of developing the core curriculum of knowledge, skills, and attitudes regarding oral health care issues in HIV disease. The final curriculum is in a format that allows for easy accessibility and is organized in a manner that is clinically relevant for primary care physicians.

As the country strives to produce larger numbers of generalist physicians, considerable controversy has arisen over whether or not generalist applicants can be identified, recruited, and influenced to keep a generalist-oriented commitment throughout medical training. The authors present new and existing data to show that: 1) preadmission (BA/MD or post-baccalaureate) programs can help to identify generalist-oriented students; 2) characteristics determined at admission to medical school are predictive of future generalist career choice; 3) current inpatient-oriented training programs strongly push students away from a primary care career; 4) women are more likely than men to choose generalist careers, primarily because of those careers' interpersonal orientation; and 5) residency training programs are able to select applicants likely to become generalists. Therefore, to produce more generalists, attempts should be made to encourage generalist-oriented students to enter medical schools and to revise curricula to focus on outpatient settings in which students can establish effective and satisfying relationships with patients. These strategies are most likely to be successful if enacted within the context of governmental and medical school-based changes that allow for more reimbursement and respect for the generalist disciplines.

Objective: To assess the specialty plans of current fourth-year medical students and, for those not choosing primary care specialties, to investigate the potential effect that changes in key economic or lifestyle factors could have in attracting such students to primary care., Design and Participants: A survey study was sent to 901 fourth-year medical students in the 1993 graduating classes of six US medical schools., Outcome Measures: Comparisons were made between students choosing and not choosing primary care specialties. For the non-primary care students, we also evaluated whether alteration of income, hours worked, or loan repayment could attract them to primary care careers., Results: Of the 688 responses (76% response rate), primary care specialties were chosen by 27% of the students and non-primary care specialties by 73%. One quarter (25%) of the non-primary care students indicated they would change to primary care for one of the following factors: income (10%), hours worked (11%), or loan repayment (4%). For students whose debt was $50,000 or greater, the loan repayment option became much more important than for students with lesser debt. In all, a total of 45% (n = 313) of the students indicated either they were planning to enter primary care (n = 188) or they would change to a primary care specialty (n = 125) with appropriate adjustments in income, hours worked, or loan repayment., Conclusion: Significant changes in economic and lifestyle factors could have a direct effect on the ability to attract students to primary care. Including such changes as part of health system reform, especially within the context of a supportive medical school environment, could enable the United States to approach a goal of graduating 50% generalist physicians.

The recent decline in the number of medical students choosing careers in the primary care specialties has engendered increasing concern that economic factors are becoming more important in influencing the career choices of medical students. In order to assess the relationship of first-year medical students' income expectations to whether they chose to specialize in family practice, the authors analyzed data from 532 graduates of Jefferson Medical College (classes of 1987-1989), using the Jefferson Longitudinal Study. At entrance to medical school, each student listed his or her initial specialty preference and future expected peak income; the determination of actual specialty choice was based on the first year of postgraduate training. Both expected peak incomes and freshman specialty choices were independent predictors of actual specialty choices. The students who entered family practice residencies had lower initial expected peak incomes than did the students entering other specialties, especially the surgery specialties. In addition, according to logistic regression analysis, the students with relatively lower income expectations and a freshman preference for family practice were predicted to be nine times more likely to enter family practice residencies than were students with higher income expectations and no initial family practice preference (56% versus 6%). This study suggests that a freshman's income expectation is an important predictor of family practice specialty choice, independent of age, sex, degree of indebtedness, and initial specialty preference. The authors discuss their results in light of the decline in the number of medical students choosing family practice and the other primary care specialties.

Jefferson Medical College has developed a program to successfully meet the goal of teaching ambulatory care to all medical students, by providing each of its 223 third-year students with a required six-week clerkship in family medicine. The structured clerkship takes place at one of seven residency-based family practice centers, is supplemented by a formal curriculum, and is based on the active clinical involvement of caring for patients under full-time family medicine faculty supervision. This clerkship has been in existence for 16 years, and has added over 400,000 student-patient encounters to the clinical education of over 3,500 students. Student evaluations of the clerkship have rated it the highest of the six required core clerkships at Jefferson. In addition, over 16% of Jefferson graduates have entered family medicine residency training programs, a rate higher than that of any other school in the northeastern United States, and significantly higher than the average for all U.S. medical schools (12%). Jefferson's experience suggests that ambulatory care can be taught as a core component of the clinical education of all medical students. To be successful, however, strong institutional support, a structured curriculum, an adequate number of patients, a dedicated faculty, a sufficient number of training sites, an appropriate evaluation process, and significant financial support are all necessary.

Over one third of U.S. medical school matriculants from the graduating class of 1983 had an original career interest in family practice, although there was a significant attrition by the time of medical school graduation. Perhaps of greater importance, however, was that students who entered medical school with an interest in family practice were almost three times as likely to choose family practice as a career than matriculants who were interested in other specialties (24.2% versus 8.4%, P less than .001).

The Department of Family Medicine at Jefferson Medical College, Philadelphia has utilized the modified essay question (MEQ) as an evaluative instrument in its required third-year clerkship since 1976. Previous analysis had indicated that students who participated in their clerkship at the university family practice centre (FPC) consistently performed at a higher level on their MEQ examinations than students who participated in clerkship activities at affiliated FPCs. In order to test the hypothesis that university-taught students had higher final examination scores because university teachers developed and graded the examinations, MEQs were developed by affiliate teachers and used for one half of five final examinations during the 1982-83 academic year. Students at the university-trained site continued to perform better than affiliated-trained students, even on MEQs developed by their own teachers. These results, as well as the significant administrative time involved in the project, have caused the Department of Family Medicine to revert to its previous policy of university teachers being responsible for the final examination.

The Department of Family Medicine at Jefferson Medical College has since 1974 been successful in administering a required third-year family medicine clerkship, providing students with a structured, didactic, and experiential curriculum in six affiliated family practice centers. Prior analysis (1976-1981) had indicated, however, that variation existed in evaluating similar students, depending on the clerkship training site, i.e., three sites graded students in a significantly different fashion than the three other sites. Utilizing these data to focus on the evaluation process, a comprehensive and specific six-point plan was developed to improve consistency in evaluations at the different training sites. This plan consisted of a yearly meeting of affiliate faculty, assigning predoctoral training administrative responsibility to one faculty member at each training site, increased telephone communication, affiliate-faculty attendance at the university site evaluation session, faculty rotation to spend time at other training sites, and financial reimbursement to the affiliate training sites. After intervention, analysis (1981-1983) indicated that five of the six clerkship sites now grade students in a consistent fashion, with only one affiliate using different grading standards. The intervention was therefore judged to be successful for five of the six training sites, allowing for better communication and more critical and consistent evaluation of medical students.

A survey was performed to obtain information regarding various aspects of pediatric training in family medicine residency programs. A questionnaire was sent to the program directors of all 236 family medicine residency programs which had graduated residents by July 1978. Eighty-two percent returned the questionnaire. The mean duration of child health care training in the three-year residency was 9.0 months. This included 3.4 pediatric equivalent months in the ambulatory family practice center and 5.6 months on pediatric rotations in several other areas. Forty-six percent of programs have one or more full-time, board certified pediatricians on the family medicine staff. Respondents believed that family physicians should be competent to provide total care for normal newborns (93 percent), general inpatient care (79 percent), and general ambulatory care (99 percent). Pediatric training in family medicine residency programs, which constitutes 25 percent of curriculum time, is accomplished by utilizing the family practice center as well as pediatric rotations. Significant variations exist among programs, however, and the quality of training needs to be evaluated.

Family practice as a career choice has been related to a number of educational variables, including the presence of a required clinical clerkship. In order to determine whether or not the timing of the required clinical clerkship was also related to family practice residency selection, a study was undertaken to investigate the relationship between the required third-year family practice clerkship and family practice career choice. The results showed that students who attended medical schools with a required third-year clerkship in family practice were significantly more likely to enter family practice residency training (16.8%), than students who attended schools with a required fourth-year clerkship (14.5% P less than 0.05), or who attended a school with no required family practice clerkship (12.1%, P less than 0.001). These results support the recommendations of the STFM Task Force on Predoctoral Education that a required third-year clerkship in family practice is important in medical student career choice.

Clerkships and preceptorships represent the two major clinical experiences in predoctoral family medicine education. Data was collected from 154 of 211 third year students from Jefferson Medical College during their required family medicine clerkship (residency-based), and compared with similar data from 12 of 20 senior Jefferson students on their elective family medicine preceptorships (private office based) (1984-85). Students on clerkships had fewer patient encounters than on preceptorships (127.6 vs. 320.0 per six week rotation). In addition, clerkship students saw more patients with trauma, vaginitis, and hypertension, although preceptorship students saw more patients with health maintenance, arteriosclerotic problems, lower respiratory infections, and dermatologic problems. These results suggest that medical students should be encouraged to participate in both a third year clerkship and a senior preceptorship, because they represent different and complimentary clinical experiences in family medicine.

Over the past decade, the Department of Family Medicine at Jefferson Medical College has used a network of seven residency-based family practice centers each year to teach 223 third-year medical students in their required family medicine clerkship. A comparison of these affiliated residency programs with a control group of the other family medicine residency programs in Pennsylvania and Delaware (with minimal third-year teaching responsibilities) from 1976 to 1984 has shown that the affiliated programs had a significantly higher National Residency Matching Program (NRMP) fill rate (92% v. 77%), had a higher percentage of programs with fill rates above the national average (71% v. 41%), and filled their full complement of residents more often (82% v. 52%) than the control programs. This success in residency recruitment was due in part to the fact that the affiliated programs filled one-third of their positions with Jefferson graduates, three times the percentage found in the control programs. For family medicine residency programs, teaching third-year medical students in a required clerkship offers a major opportunity to improve their residency selection results in the NRMP.

In an attempt to address the problem of physician maldistribution, Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974, a special admissions program that preferentially selects applicants who intend to practice family medicine in physician shortage areas in Pennsylvania. Forty-seven students in four classes have been graduated from the program. Evaluation of these students during medical school shows that their academic performance has been similar to their classmates. Follow-up evaluation indicates that PSAP graduates are five times as likely as their peers (non-PSAP) to enter a family medicine residency program during the first postgraduate year (62% v 12%), and almost twice as likely to enter family medicine as a comparable group of non-PSAP students who originally entered Jefferson with plans of becoming a family physician (62% v 33%).

Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974; this program preferentially admits medical school applicants from rural backgrounds who intend to practice family medicine in rural and underserved areas. Evaluation of the program has shown that PSAP graduates from the classes of 1978 to 1985 have performed slightly less well than their peers (non-PSAP) during medical school, although there was no difference in attrition between the two groups. Nor did the performance of PSAP and non-PSAP graduates differ during their postgraduate training. PSAP graduates from the classes of 1978 to 1981 were almost five times as likely as non-PSAP graduates to practice family medicine (59.6 vs. 12.6 percent, P less than 0.001), three times as likely to practice in rural areas (37.8 to 42.2 percent vs. 10.0 to 11.8 percent, P less than 0.001), and two four times as likely to practice in areas where there is a physician shortage (26.7 to 40.0 percent vs. 9.2 to 11.2 percent, P less than 0.01). They were 7 to 10 times as likely as their peers to combine a career in family medicine with practice in a rural or underserved area (24.4 to 31.1 percent vs. 3.1 to 3.9 percent, P less than 0.001), thereby fulfilling the goals of the PSAP. This study concludes that the medical school admissions process can have a major influence on the specialty choice and geographic practice location of physicians, and suggests one mechanism for increasing the number of family physicians in rural and underserved areas.

Rural areas in the United States continue to lack an adequate supply of primary care doctors, particularly family physicians, despite the oversupply of physicians nationally. Previous studies have provided strong evidence that students from rural backgrounds, as well as those who expressed an interest at the time of medical school admission for a career in family medicine, are significantly more likely to eventually practise family medicine in rural areas than their peers. US medical schools were classified into three groups based on their written selection factors for preferentially admitting students into the graduating class of 1982. Of those schools with selection factors for students from both a rural background and an interest in a future career in family medicine, 23.7% of their graduates entered family medicine training programmes. This compares with 14.5% of graduates from schools with a preference for students from a rural background, and 12.4% from all other schools (P less than 0.001). Coupled with previous data which shows that family physicians from rural areas are more likely to eventually practise in rural areas than their peers, preferentially admitting students from rural backgrounds interested in a career in family medicine could help to solve the problem of the shortage of primary care physicians in rural areas in the US.

This paper describes the extensive experience of the Department of Family Medicine at Jefferson Medical College in utilizing the modified essay question (MEQ) as a final examination for its required third-year clerkship in family medicine. The results of a preliminary study are presented, comparing the MEQ as a method of evaluation with the multiple choice question (MCQ) format on similar content material. MCQ performance was found to be a better predictor of National Board Part I and II scores, but neither format was found to be a good predictor of postgraduate performance. The data were statistically significant (P less than 0.05) that MEQ performance was related to postgraduate performance in the area of professional attitude while the MCQ was not; however, the number of students in the analysis was small. Additional studies are planned to test this hypothesis further.