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Shortages of primary care physicians have historically affected rural areas more severely than urban and suburban areas. In 1970, the University of Washington School of Medicine (UWSOM) administrators and faculty initiated a four-state, community-based program to increase the number of generalist physicians throughout a predominantly rural and underserved region in the U.S. Northwest. The program developed regional medical education for three neighboring states that lacked their own medical schools, and encouraged physicians in training to practice in the region. Now serving five Northwest states (Washington, Wyoming, Alaska, Montana, and Idaho), the WWAMI program has solidified and expanded throughout its 30-year history. Factors important to success include widespread participation in and ownership of the program by the participating physicians, faculty, institutions, legislatures, and associations; partnership among constituents; educational equivalency among training sites; and development of an educational continuum with recruitment and/or training at multiple levels, including K--12, undergraduate, graduate training, residency, and practice. The program's positive influences on the UWSOM have included historically early attention to primary care and community-based clinical training and development of an ethic of closely monitored innovation. The use of new information technologies promises to further expand the ability to organize and offer medical education in the WWAMI region.

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Academic medical centers are under increasing pressure to find alternatives to residents for the provision of patient care and to expand and improve the educational opportunities for residents. To address these concerns, the authors performed a study of the medical wards at Harborview Medical Center, a county-owned medical center managed by the University of Washington School of Medicine. Admitting diagnoses, provider names, and billings were obtained from professional practice plan billing records. Based on the distribution of admitting diagnoses, a subset of patients was identified that could be removed from routine care by residents and could instead be cared for by non-physician providers (i.e., physician assistants and nurse practitioners) using clinical pathways. The cohort was large enough to reduce the number of patients per resident to within national accreditation guidelines, and to provide faculty with more time available for teaching. The authors summarize the approach used to identify the new model for care delivery indicated above and the plans made to implement that model and to analyze its impact on the quality of patient care, hospital costs, residents' education, and the process of implementing change. The authors conclude that solutions to the problems of workload and education that they confronted will vary by department and hospital setting. Yet a systematic approach to discovering solutions, such as they present, can be adapted to any setting.

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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.

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OBJECTIVE: To describe variation in the clinical management of minor head trauma in children among primary care and emergency physicians. DESIGN: A survey of pediatricians, family physicians, and emergency physicians drawn from a random sample of members of the American Academy of Pediatrics, the American Academy of Family Physicians, and the appropriate American Medical Association specialty listings, respectively. Physicians were given clinical vignettes describing children presenting with normal physical examination results after minor head trauma. Different clinical scenarios (brief loss of consciousness or seizures) were also presented. Information was gathered on initial and subsequent management steps most commonly used by the physician. RESULTS: Surveys were returned by 765 (51%) of 1500 physicians. Of these, 303 (40%) were pediatricians, 269 (35%) family practitioners, and 193 (25%) emergency physicians. For minor head trauma without complications, observation at home was the most common initial physician management choice (n = 547, 72%). Observation in office or hospital was chosen by 81 physicians (11%). Head computed tomographic (CT) scan was chosen by 7 physicians (1%) and skull x-ray by 24 physicians (3%) as the first management option. Most physicians (n = 445, 80%) who initially chose observation at home would obtain a CT scan if the patient showed clinical deterioration. In the original scenario, if the patient had also sustained a loss of consciousness, 383 physicians (58%) altered management. Of these, 120 (18%) chose CT, 13 (2%) chose skull x-ray, 1 (1%) chose magnetic resonance imaging, 141 (21%) chose inpatient observation, and 125 (19%) chose a combination of CT scanning and observation. With seizures, 595 (90%) altered management, with 176 physicians (27%) choosing CT scan, 5 (1%) skull x-ray, 60 (9%) inpatient observation, and 299 (45%) a combination of radiological evaluation and observation. CONCLUSIONS: Most physicians surveyed chose clinic or home observation for initial management of minor pediatric head trauma. Clinical management was more varied when patients had sustained either loss of consciousness or seizures. Further study of the appropriate management of minor head trauma in children is needed to guide physicians in their care.

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BACKGROUND: A shortage of family physicians persists in rural and medically underserved areas of the United States. We explore the hypothesis that a definable set of educational needs should be addressed for rural family physicians, both during their formal education and as part of continuing education while in practice. METHODS: An educational needs assessment questionnaire was sent to 1096 family physicians who had finished residency and entered rural practice within the last 3 years. Six hundred twenty-seven (57.2 percent) of the questionnaires were returned. The demographic characteristics of the respondent physicians and their assessment of the appropriateness and adequacy of their educational process in preparing them for rural practice were analyzed by looking at individual items and groups of items or subject areas. RESULTS: We were able to define successfully a group of items that were important components of rural practice but were not adequately addressed in training programs. Theses groups included counseling, pediatrics, obstetrics and gynecology, geriatrics, surgery and trauma, medical specialties, surgical specialties, community medicine and management, and a mixed factor that included rehabilitation, behavioral sciences, learning disabilities (in children), chronic childhood problems, and human growth. CONCLUSIONS: It is possible to define a group of educational areas not covered adequately by standard family practice curriculum that should be included in preparation for rural practice. If these areas were included in the education of rurally oriented family practice medical students and residents, these physicians would be more adequately prepared to meet the demands of rural practice. If preparation for rural practice is improved, rural communities might be more successful in recruiting and retaining well-trained family physicians.

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The purpose of this study was to prospectively study inpatients admitted for failure to thrive during their first year of life. Twelve infants with failure to thrive were studied and compared with 17 healthy controls. Mothers and infants with nonorganic failure to thrive scored lower on the Nursing Child Assessment Feeding Scale, reported more change in their lives, and less social support. The need for further research is discussed and suggestions for beginning level interventions are made.

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Of 400 Washington State family practitioners surveyed in 1986, 46% of those who give routine immunizations reported that they require written parental consent before administering vaccine. In all, 57% of respondents said they discuss diphtheria-tetanus-pertussis, measles-mumps-rubella, and oral polio vaccine with their patients. Nearly half provide written information on these immunizations, except for inactivated polio vaccine, for which fewer than 20% of the physicians surveyed provide verbal or written information.

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This article summarizes the practice content and continuity for 35 senior residents in six family medicine residency model teaching units utilizing a computerized information management system. Comparisons are drawn with the content of family practices in the National Ambulatory Medical Care Survey (NAMCS), showing that family medicine third-year residents provide a large proportion of pregnancy care and general medical examinations and treat a smaller number of chronic illness patients compared with family physicians in practice. Third-year residents performed few surgical procedures in the model teaching units. Continuity of care, though espoused by family medicine residencies in principle, was deficient in the model teaching units studied. Intensive training to compensate for these deficiencies is recommended.

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Abdominal B-scan ultrasound imaging was performed on 35 infants who presented with vomiting. A thick hypoechoic ring was visualized in 21 of the 23 patients found at surgery to have hypertrophic pyloric stenosis. The ring was shown to represent the hypertrophied circular muscle of the pylorus. Each side of the ring measured 4 mm or more in thickness in the positive studies. None of the patients without hypertrophic pyloric stenosis showed this finding, although thinner hypoechoic rings were often seen, representing parasagittal sections of distal antral muscle.

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