The Issue in Brief

The Primary Care Physician Workforce: Ethical and Policy Implications

Barbara Starfield, MD, MPH , and colleagues

Background Professionals from other countries make up more than a quarter of the medical and nursing workforces in Australia, Canada, the United Kingdom, and the United States. This study examines the characteristics of countries that export doctors to the United States.

What This Study Found Poor countries with high physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates disproportionately help the United States to maintain its primary care workforce. The most impoverished, underdeveloped African nations are a major source of primary care doctors to the United States, further reducing their own abilities to meet the needs of their citizens.

Implications

• The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its supply of primary care doctors.
• The ethical aspects of depending on foreign medical graduates is an important issue, but it is particularly troubling when it deprives disadvantaged countries of their graduates.
• US policy makers need to create more opportunities and incentives for primary care training and practice to make it an appealing career choice for US graduates.

Contact with Primary Care and Specialist Clinicians by Demographics, Insurance, and Health Status

Robert L. Ferrer, MD, MPH

Background This study examines the use of primary care and specialty care among disadvantaged groups and people with chronic illness in the United States.

What This Study Found Primary care clinicians, especially family physicians, are a vital source of care for disadvantaged groups in the United States. In 2004, family physicians saw almost one-half of Americans who sought medical care and were the most commonly seen doctors among adults, senior citizens, and women of child-bearing age. Family physicians were the only clinician group that did not show unequal access to care based on patient income. Adults with low income, minority status, and lack of insurance received care from family physicians 46 percent of the time, whereas adults without disadvantage saw family physicians 31 percent of the time. Visits to family physicians were twice as high for children with disadvantage, compared with children without disadvantage.

Implications

• Primary care clinicians are an important source of equity in health care.
• This study supports a policy of developing and strengthening the primary care workforce and infrastructure in order to reduce disparities in health care.

The Inverse Care Law: Clinical Primary Care Encounters in Deprived and Affluent Areas of Scotland

Stewart W. Mercer, MBChB, PhD , and colleagues

Background The inverse care law states that good medical care is least available where it is most needed. This study aims to learn more about the inverse care law by examining primary care doctor visits in the most and least deprived areas of Scotland.

What This Study Found Patients in most deprived areas had more serious psychological problems, more long-term illness, and a greater number of medical conditions than patients in least deprived areas. Although patients in deprived areas had more problems to discuss, their doctor visits were usually shorter than in less deprived areas. General practitioners working in deprived areas were more stressed than those in the least deprived areas.

Implications

• The increased burden of ill health and multiple medical conditions in poor communities results in high demands on primary care doctor visits.
• If the inverse care law is to be reversed, health care policies must address inequalities in public health by focusing on the primary care setting.

Insurance + Access Healthcare: A Typology of Barriers to Healthcare Access for Low-Income Families

Jennifer E. DeVoe, MD, MPhil , and colleagues

Background Many Americans do not have access to basic medical care. This study identifies barriers faced by low-income parents seeking health care for their children.

What This Study Found Low-income families identify three major barriers to obtaining health care for themselves and their children: lack of insurance coverage, poor access to health care services, and unaffordable costs. Obtaining health insurance is most important to parents. If they obtain insurance, they face issues of access to care. Families that overcome insurance and access barriers struggle with costs such as co-pays for office visits, insurance deductibles, and prescription drug costs.

Implications

• There are three successive barriers to obtaining health care: insurance, access, and cost. Insurance does not guarantee access, and having access to primary care does not guarantee receipt of all necessary care.
• Policy makers must understand the barriers faced by low-income families who are trying to obtain necessary medical care.
• Health insurance is an essential foundation for all families, but it does not solve all problems. Policy reforms need to address insurance, access, and cost.

Mothers' Health and Work-Related Factors at 11 Weeks Postpartum

Pat McGovern, PhD, MPH , and colleagues

Background Many new mothers return to work soon after childbirth. This article examines personal and work-related factors associated with the health of employed women 11 weeks after childbirth.

What This Study Found Interviews of 661 new mothers at 11 weeks after childbirth found that most continue to experience several childbirth-related symptoms, most commonly fatigue. Better health after childbirth is associated with a number of factors including social support from family and friends, lower levels of job stress, a higher sense of control over work and home activities, and more coworker support.

Implications

• Levels of fatigue at 11 weeks after childbirth indicate a need for ongoing rest and recovery.
• New mothers should be evaluated by their doctors to determine fatigue levels and mental and physical symptoms.
• Clinicians should counsel new mothers on ways to decrease job stress, increase social support at work and home, and the occasional use of family and medical leave to help manage their symptoms.

Children With Hearing Loss and Increased Risk of Injury

Joshua R. Mann, MD, MPH , and colleagues

Background Injury is the leading cause of death in children in the United States. It has been suggested that children with sensory disabilities (blindness or deafness) may be at increased risk of injuries, but there has been little research in this area. Based on South Carolina Medicaid data, this study examines rates of emergency department and hospital treatment for injury in children with hearing loss.

What This Study Found Children with hearing loss receive emergency department and/or hospital treatment for injuries at a significantly higher rate than do children without a disability. Rates of injury in children with hearing loss are more than twice as high as those without a disability. This may be due to reduced ability to recognize danger clues or to hear a parent?s warning.

Implications

• Prevention strategies for children with hearing loss and their families should be developed if additional research supports the finding that these children are at higher risk of injury.
• Clinicians should consider discussing injury prevention strategies with parents of children with hearing loss.

Reduction and Management of No-Shows by Family Medicine Residency Practice Exemplars

Bradley J. Johnson, MD , and colleagues

Background Patients' failure to keep scheduled appointments ("no-shows") is a significant problem in family medicine residency practices. This study looks at methods used by family medicine residency practices that have low no-show rates or who manage no-shows well when they occur.

What This Study Found It is possible to reduce no-show rates in residency practices to below 10% by using combinations of well-established methods when they are used consistently and effectively. These methods include patient education, patient reminders, patient sanctions, and open-access scheduling. Reducing the impact of no-shows once they occur is best accomplished by increasing the numbers of walk-ins and work-ins.

Implications

• This study contributes to the existing literature on no-shows in primary care residency program practices and may be helpful to those who are struggling with this important challenge.

Development and Internal Validation of the Male Osteoporosis Risk Estimation Score

Angela J. Shepherd, MD , and colleagues

Background In 2002, men accounted for about 2 million cases of osteoporosis. The purpose of this study is to develop a method to identify men at increased risk for osteoporosis and subsequent fractures who would benefit from bone density testing.

What This Study Found The Male Osteoporosis Risk Estimation (MORES) appears to perform better than currently available osteoporosis risk assessment guidelines for men. Compared with other tests, it is simpler to calculate, addresses more risk factors, and does not require extra cost.

Implications

• In men 60 years of age and older, the MORES is a simple approach to identify those at risk for osteoporosis and refer them for a bone density scan to confirm the results.

Obesity and Diabetes in Vulnerable Populations: Reflection on Proximal and Distal Causes

Lucy M. Candib, MD

Background Rates of obesity and diabetes are climbing to epidemic proportions around the world and across a variety of communities. Explanations that are limited to lifestyle factors, such as diet and exercise, are inadequate. This article looks at the many complex factors that contribute to obesity and diabetes.

What This Study Found Factors that contribute to the obesity/diabetes epidemic range from the genetic, cellular, biologic, and psychosocial levels to the social, historical, economic, and political. A broader view of obesity and diabetes that takes these multiple factors into account could lead to public health efforts that draw on the energy of a variety of forces.

Implications

• To prevent and treat obesity and diabetes in vulnerable populations, clinicians and researchers need to work at multiple levels, including community collaborations.

Promoting Participatory Research by Family Physicians

Ann C. Macaulay, CM, MD, FCFP

What This Study Found In participatory research, researchers partner with people who are affected by the topic being studied. It is increasingly recognized as an effective way to add relevance and value to primary care research. Family physicians are well-suited to this type of research because of their clinical partnerships with patients and communities, training in patient centered care, ability to work with uncertainty, pragmatism, interest in questions from patients, and ability to respond to community requests. The main challenges in conducting participatory research are lack of funding, expertise, and time. These factors might improve as support for this approach grows.