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INTRODUCTION: In this systematic review, the authors review studies of rural colonoscopy to determine specialty types providing rural colonoscopy and the quality of these procedures. METHODS: A systematic MEDLINE search was conducted for articles pertaining to rural colonoscopy. Inclusion criteria were rural location, report of quality outcomes, or report of endoscopy workforce in rural areas. Two investigators independently reviewed and abstracted included articles. The following information was obtained from each study: author identification, citation, study design, source of funding, study duration and follow-up, study population, sample size, study setting, population characteristics, outcomes and results. Standard abstraction forms were used to summarize and assess the quality of evidence. RESULTS: From 121 articles in the MEDLINE search, 11 met inclusion criteria. One additional article found from a reference list was included. Eleven articles from three countries reported on 8703 colonoscopies performed by 25 rural generalists. Reach-the-cecum rates (RCR) ranged from 36% to 96.5% with more recent studies showing higher RCRs. Adenoma detection rates ranged from 16.6% to 46%. The rate of complications was low in all studies. One study of the rural endoscopist workforce reported that general surgeons performed most rural colonoscopies in Canada. CONCLUSIONS: Rural generalist physicians can safely and effectively perform colonoscopies. More research is needed on the rural endoscopist workforce.

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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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The functional IL-5 receptor is a heteromeric complex consisting of an alpha and beta subunit. The cloning, sequencing and expression of guinea-pig IL-5Ralpha and beta subunits is described. The guinea-pig IL-5Ralpha subunit cDNA encodes a protein of M(r)47 kDa, which is 72 and 66% homologous to the human and murine orthologs, respectively. Three guinea-pig IL-5Rbeta subunit cDNA clones were isolated, which differ in the N-terminus and are 56-64% homologous to the human and murine IL-5Rbeta subunits. Expressing human IL-5Ralphabeta and guinea-pig IL-5Ralphabeta(1)in the baculovirus-insect cell system resulted in recombinant receptors which bound hIL-5 with high affinity (K(d)=0.19 and 0.11 nM, respectively). Expressing just gpIL-5Ralpha was not sufficient to demonstrate binding. This contrasts with the human receptor, where hIL-5Ralpha alone can bind hIL-5 with high affinity. gpIL-5Ralphabeta(1)bound both hIL-5 and mIL-5 with comparable affinity (K(i)=0.10 and 0.06 nM), similar to that seen with hIL-5Ralphabeta. Thus, both the heteromeric hIL-5R and gpIL-5Ralphabeta(1)can bind multiple IL-5 orthologs with high affinity whereas the murine IL-5R is selective for the murine ligand.

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Studies have suggested that rural physicians do not use MEDLINE to aid their clinical decision making, and yet rural physicians appear to be a group that would benefit greatly from the use of MEDLINE because of their isolation from libraries and colleagues. This study was undertaken to understand why a population so likely to benefit from the use of MEDLINE is not using it. The study confirmed that rural physicians regard colleagues, reference texts, and journal articles as the most important information sources. However, a surprising number of rural generalist physicians in Washington, 40 percent of respondents, use MEDLINE, and most possess the requisite awareness, resources, and ability to use MEDLINE. Of those who use MEDLINE, 70 percent consider it a valuable clinical tool.

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This study provides the first comprehensive description of Alaska's geographic distribution of generalist physicians relative to population. All 443 generalist care physicians (family, general, general internal medicine, and pediatric) or their office managers were questioned about their specialties, ZIP codes, employers, populations served, and hours spent per week offering direct patient care. The results indicated a 30% overall shortage of generalist physicians for the state, representing roughly 141 full-time-equivalent generalists relative to national practice patterns and trends of health maintenance organizations. Of 17 primary health care areas, including the Anchorage area, 15 showed a need for additional generalist physicians. Most areas had a 20 to 40% shortage. Concerns about transportation and financial barriers to access to care, especially in remote regions, were raised. Other needs emphasized included knowledge of contributions of midlevel health care professionals, Alaska Native versus non-Native care, efforts to train and retain physicians in Alaska, and the need for longitudinal tracking of practice patterns.

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This article describes diagnostic esophagogastroduodenoscopy and its use by primary care physicians. Included in the discussion are reviews of indications and contraindications, patient preparation (including sedation and monitoring), equipment and supplies needed, pertinent normal anatomy, techniques, and applicable common pathologic findings.

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BACKGROUND AND OBJECTIVES: Many strategies have been used by academic institutions to address the shortage of rural family physicians. Fellowship training in rural family medicine represents one approach. METHODS: Tacoma Family Medicine developed a fellowship program of this type. Five years of operations are described, including applicants, educational outcomes, rural outcomes, and adverse outcomes. RESULTS: An adequate applicant pool does exist, composed of both applicants from residency and from practice. A curriculum of advanced obstetrics, electives, and a rural experience has been successful. Unforeseen problems included a strained relationship with family practice residents in the program and competition for community preceptors. CONCLUSIONS: Family practice residencies with a mission of rural training are encouraged to consider the strategy of a rural fellowship.

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OBJECTIVE: On-line continuing medical education (CME) courses offer at least two potential advantages: They are extremely convenient and relatively inexpensive. Before expanding our department's 2-year-old on-line category 1 accredited CME program, we conducted a survey to assess the need for more courses of this type and to document those topics of most interest to our responders. MATERIALS AND METHODS: An on-line survey form was designed and linked to the home page of our departmental Web server. The 8-month survey asked whether responders were interested in earning category 1 CME hours, how many hours they desired, how much they were willing to pay for each hour, and which topics would interest them most. Responders were also asked to specify their medical practice and medical specialty. All responses were tabulated, and simple descriptive statistics were calculated. RESULTS: Our survey received 317 responses: 188 from physicians, 42 from radiology technologists, 11 from physician assistants and nurse practitioners, and the remainder from 26 other categories of practice. Physician specialties identified included 86 diagnostic radiologists, 24 internists, 18 emergency medicine specialists, 15 family practitioners, and 45 from 14 other specialties. Responses came mainly from the United States; however, 32 responses were received from 15 other countries. The median number of on-line CME hours desired was 15 (range, 1-1324). Physician responders were willing to pay a median amount of $10 per credit hour (range, $0-400). The most commonly suggested topic was general radiology, followed by general reviews of MR imaging, CT, sonography, and various organ-based specialties in radiology such as mammography, neuroradiology, and musculoskeletal radiology. CONCLUSION: Physicians and many other health care workers are interested in on-line CME and are willing to pay for such a service. This information, as well as the suggested topics collected in this survey, may prove helpful in planning future offerings of on-line CME.

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BACKGROUND: Family practice residencies lack clear guidelines defining which procedures should be included in their curricula. The American Academy of Family Physicians (AAFP) Task Force on Procedures developed a recommendation (approved by the AAFP Board of Directors) that can be used to create a set of procedures that should be taught in residencies. The task force recommendation is based on procedures taught in most family practice residencies and performed by most practicing family physicians. METHODS: The AAFP Task Force on Procedures surveyed all family practice residency programs and departments to determine which procedures they were teaching. The task force also surveyed a representative sample of practicing family physicians to find out which procedures they were performing. RESULTS: Residency programs and departments returned 397 surveys (74.1% response), and the sample of 4,400 practicing physicians returned 2,028 surveys (46.1% response). The survey data identified 69 procedures as being taught in most family practice residencies, and 30 of these procedures as being performed by most practicing family physicians. CONCLUSIONS: Many procedures can be identified as being taught in most family practice residencies or performed by most practicing family physicians. Fewer procedures are performed by practicing family physicians than are taught in residencies.

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BACKGROUND: Provision of obstetric care in the United States requires the capacity to perform cesarean sections. It is unknown who actually performs these procedures in rural hospitals and whether nonobstetricians feel comfortable performing cesarean sections. METHODS: We conducted a telephone survey of the 41 rural hospitals in Washington State, asking about the obstetric services offered and the composition and obstetrical practices of physician staff. A supplementary questionnaire was sent to the 112 family physicians providing obstetric services in the subset of hospitals with 50 or fewer beds, asking whether they performed cesarean sections. Eighty-six responded, for a response rate of 75%. RESULTS: Thirty-one (75%) of the rural hospitals provide obstetric services; of the 31 hospitals, 19 (61%) had no obstetricians on staff. In these hospitals the majority of physicians on staff both practice obstetrics and perform cesarean sections. Family physicians performed the majority of cesarean sections in all but the eight largest rural hospitals; even in these large hospitals (mean annual deliveries, 785), family physicians performed 28% of the cesarean sections. Most family physicians who performed cesarean sections felt very comfortable performing these operations. There was a strong association between the number of cesarean sections performed in formal residency training settings and the family physician's comfort level. CONCLUSIONS: Cesarean sections remain an important service in those rural hospitals providing obstetric services. Most Washington State rural hospitals depend on family physicians for this operative intervention. Physicians' comfort in doing cesarean sections appears to be closely related to prior formal training during residency. This relationship suggests that training programs preparing future rural physicians need to ensure adequate training in this area for their residents.

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BACKGROUND: There is a clear national mandate to increase the proportion of generalist physicians within the medical community and to increase their numbers within rural and underserved urban locations. Little is known, however, about the geographic and temporal career patterns of family physicians or about how these patterns differ by sex and graduation cohort. METHODS: Using information from a follow-up survey of the University of Washington Family Practice Residency Network, we analyzed the characteristics of 358 graduate physicians and their 493 practices, including data on geographic practice locations. RESULTS: Two thirds of graduates began their practices in urban locations, and one third initially settled in rural communities. Female graduates were much less likely than their male peers to choose rural practice locations. Few physicians left practices after they had practiced in them for 5 or 6 years. The majority of graduates were still in the practice where they started as long as 18 years earlier. CONCLUSIONS: The most important career decision made by the graduate of a family medicine residency involves practice location. Because women are less likely to practice in rural areas, the increasing proportion of women graduating from family practice residencies might presage shortages of rural physicians in the future.

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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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This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27-item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits. The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates' broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory care. Rural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part-time positions, to facilitate recruitment and retention of physicians, especially women.

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