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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. [ABSTRACT FROM AUTHOR]

Context: The shortage of physicians in rural areas is a longstanding and serious problem, and national and state policymakers and educators continue to face the challenge of finding effective ways to increase the supply of rural physicians.Objective: To determine the direct and long-term impact of the Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) on the rural physician workforce.Design: Retrospective cohort study.Participants and Setting: A total of 206 PSAP graduates from the classes of 1978 to 1991.Main Outcome Measures: The PSAP graduates currently practicing family medicine in rural and underserved areas of Pennsylvania, compared with all allopathic medical school graduates in the state, and with all US and international allopathic graduates. All PSAP graduates were also compared with their non-PSAP peers at JMC regarding their US practice location, medical specialty, and retention for the past 5 to 10 years.Results: The PSAP graduates account for 21% (32/150) of family physicians practicing in rural Pennsylvania who graduated from one of the state's 7 medical schools, even though they represent only 1% (206/14710) of graduates from those schools (relative risk [RR], 19.1). Among all US and international medical school graduates, PSAP graduates represent 12% of all family physicians in rural Pennsylvania. Results were similar for PSAP graduates practicing in underserved areas. Overall, PSAP graduates were much more likely than their non-PSAP classmates at JMC to practice in a rural area of the United States (34% vs 11%; RR, 3.0), to practice in an underserved area (30% vs 9%; RR, 3.2), to practice family medicine (52% vs 13%; RR, 4.0), and to have combined a career in family practice with practice in a rural area (21% vs 2%; RR, 8.5). Of PSAP graduates, 84% were practicing in either a rural or small metropolitan area, or one of the primary care specialties. Program retention has remained high, with the number of PSAP graduates currently practicing rural family medicine equal to 87% of those practicing between 5 and 10 years ago, and the number practicing in underserved areas, 94%.Conclusions: The PSAP, after more than 22 years, has had a disproportionately large impact on the rural physician workforce, and this effect has persisted over time. Based on these program results, policymakers and medical schools can have a substantial impact on the shortage of physicians in rural areas. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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.

In today's continually changing health care environment, there is serious concern that medical students are not being adequately prepared to provide optimal health care in the system where they will eventually practice. To address this problem, the Health Resources and Services Administration (HRSA) developed a $7.6 million national demonstration project, Undergraduate Medical Education for the 21st Century (UME-21). This project funded 18 U.S. medical schools, both public and private, for a three-year period (1998-2001) to implement innovative educational strategies. To accomplish their goals, the 18 UME-21 schools worked with more than 50 organizations external to the medical school (e.g., managed care organizations, integrated health systems, Area Health Education Centers, community health centers). The authors describe the major curricular changes that have been implemented through the UME-21 project, discuss the challenges that occurred in carrying out those changes, and outline the strategies for evaluating the project. The participating schools have developed curricular changes that focus on the core primary care clinical clerkships, take place in ambulatory settings, include learning objectives and competencies identified as important to providing care in the future health care system, and have faculty development and internal evaluation components. Curricular changes implemented at the 18 schools include having students work directly with managed care organizations, as well as special demonstration projects to teach students the knowledge, skills, and attitudes necessary for successfully managing care. It is already clear that the UME-21 project has catalyzed important curricular changes within 12.5% of U.S. medical schools. The ongoing national evaluation of this project, which will be completed in 2002, will provide further information about the project's impact and effectiveness.

Objectives: This study examined the relative and incremental importance of multiple predictors of generalist physicians' care of underserved populations., Methods: Survey results from a 1993 national random sample of 2955 allopathic and osteopathic generalist physicians who graduated from medical school in 1983 or 1984 were analyzed., Results: Four independent predictors of providing care to underserved populations were (1) being a member of an underserved ethnic/minority group, (2) having participated in the National Health Service Corps, (3) having a strong interest in practicing in an underserved area prior to attending medical school, and (4) growing up in an underserved area. Eighty-six percent of physicians with all 4 predictors were providing substantial care to underserved populations, compared with 65% with 3 predictors, 49% with 2 predictors, 34% with 1 predictor, and 22% with no predictors. Sex, family income when growing up, and curricular exposure to underserved populations during medical school were not independently related to caring for the underserved., Conclusions: A small number of factors appear to be highly predictive of generalist physicians' care for the underserved, and most of these predictive factors can be identified at the time of admission to medical school.

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.

While prior studies have identified a number of factors individually related to physician practice in rural areas, little information is available regarding the relative importance of these factors or their relationship to rural retention. Extensive data previously collected from the Jefferson Longitudinal Study were analyzed for 1972 to 1991 graduates of Jefferson Medical College practicing in Pennsylvania in 1996, as were recent self-reported perceptions of Jefferson Medical College graduates in rural practice. Rural background was overwhelmingly the most important independent predictor of rural practice, and freshman plans to enter family practice was the only other independent predictor. No other variable, including curriculum or debt, added significantly to the likelihood of rural practice. None of these variables, however, including rural background, was predictive of retention, which appeared to be more related to practice issues such as income and workload. These results suggest that increasing the number of physicians who grew up in rural areas is not only the most effective way to increase the number of rural physicians, but any policy that does not include this may be unsuccessful.

Recent changes in the health care environment have directed increasing attention to the recognized oversupply of specialists and relative lack of primary care physicians. Despite this imbalance and the need for more primary care physicians, US medical schools are not producing them in adequate numbers. To effect change in the production of primary care physicians, a comprehensive approach that addresses key factors in medical student specialty choice is needed. This article discusses such factors and how they affect medical students during the course of their training. Issues concerning primary care specialty choice and the physician work force are important to the development of the future US health care system.

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.

Background and Methods: To help identify additional information regarding why some individuals are more likely to enter certain medical specialties, we undertook a study to evaluate the relationship between a senior medical student's self-reported alternate career choice (ie, if he or she had not entered medicine), and that student's subsequent choice of a medical specialty., Results: Students entering the specialties of pediatrics, family practice, obstetrics and gynecology, and emergency medicine were likely to have chosen alternate careers in the teaching, health care, humanities, arts, and nonprofessional areas. In contrast, students entering the specialties of anesthesiology, radiology, internal medicine, and surgery (general surgery or the surgical subspecialties) were more likely to have chosen alternate careers in engineering, research, science, business, law, and architecture., Conclusions: The alternate career choices of medical students may be related to their subsequent choice of medical specialty.

Background: To help address the geographic and specialty maldistribution of physicians, Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974. This unique program, which combines a selective medical school admissions policy with a special educational program, has been shown to be successful in increasing the number of family physicians in rural and underserved areas, but it is not known whether they remain in this type of practice., Methods: Graduates of the PSAP were tracked longitudinally and compared with their non-PSAP classmates. Information was obtained about the retention of family physicians in rural areas and areas with a physician shortage over the previous five years, the geographic and specialty choices of more recent graduates, and the recruitment of applicants into the program., Results: Of the 47 PSAP graduates from the classes of 1978 through 1981, reported on earlier, the number who combined a career in family medicine with practice in a rural area or one with a physician shortage remained unchanged, although there was substantial attrition among non-PSAP graduates practicing family medicine in rural (32 percent) and underserved (40 percent) areas. Among the 101 PSAP graduates of the classes of 1982 through 1986, the results were similar to those for the first four classes. Overall, PSAP graduates from the classes of 1978 through 1986 were approximately four times as likely as non-PSAP graduates to practice family medicine (55 percent vs. 13 percent), to practice in a rural area (39 percent vs. 11 percent), and to practice in underserved areas (33 percent vs. 8 percent). They were approximately 10 times more likely to combine a career in family medicine with practice in a rural (26 percent vs. 3 percent) or underserved (23 percent vs. 2 percent) area. Overall, 85 percent of PSAP graduates were either practicing a care specialty or practicing in a rural or small metropolitan area or one with a shortage of physicians. In parallel with national trends, the number of applicants and matriculants to the program decreased during the past decade, so that the percentage of available places filled decreased from 97 percent to 33 percent. However, there has been a recent increase in the number of applicants and matriculants., Conclusions: The results of this study indicate that the PSAP was successful in increasing the number of family physicians in rural and underserved areas as well as in retaining them. This suggests that medical schools can have a substantial influence on the distribution of physicians according to specialty choice and the geographic location of their practices, principally through admission criteria.

Upper respiratory tract infections are among the most common acute infections in humans. This review discusses the clinically important aspects of the epidemiology, etiology, clinical presentation, diagnosis, management, complications, and prevention of the common cold, pharyngitis, otitis media, and sinusitis. Most episodes of the common cold and pharyngitis are of viral origin, and curative therapy is not available. Streptococcal pharyngitis, acute otitis media, and sinusitis are secondary to bacterial infections, and antibiotic therapy is important.

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 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.