1. Family Medicine and Community Health Thirty Years of Family Medicine Residency Training Warren Ferguson, MD Suzanne Cashman, ScD Judy Savageau, MPH Daniel Lasser, MD, MPH Acknowledgments: Linda Cragin and Joanne Dombrowski, MassAHEC Network 2007 STFM Annual Spring Conference Chicago, IL

2. Family Medicine and Community Health Main Questions Do physicians trained in an FQHC go on to practice in an FQHC, or other site, serving the underserved? Do physicians trained in a rural site go on to practice with rural population? Has the UMass residency produced graduates who remain to serve the Commonwealth?

3. Family Medicine and Community Health Literature: Associations With Underserved Practice East Tennessee State FM program: –Designed for rural and underserved practice –80% in HPSA; 48% in rural area (1) NHSC alumni: 52% still in underserved site –Desire, older age, job satisfaction and salary associated (2) Title VII funding matters: –Sample of 9107 FPs –Training in Title VII funded program associated with underserved practice (3)

4. Family Medicine and Community Health Population surveyed Family Medicine Residency graduates, 1976-2005 Three community- based training sites –Family Health Center of Worcester –Barre Health Center –Hahnemann Family Health Center

5. Family Medicine and Community Health Worcester Training Site Locations FHCW HFHC

6. Family Medicine and Community Health Survey Design Survey developed for all graduates of Family Medicine residency training sites Modified survey designed by Pathman et al (4) –Four community dimensions of primary care Demographic data on graduates Demographic data on all key practices since graduation –Types of practice and areas of practice –Characteristics of populations served –Recognized underserved sites

7. Family Medicine and Community Health Survey design: Factors that may influence practice choice Estimate of training in medical school and residency to: –care for underserved populations –be involved in various aspects of community Additional factors influencing practice choice: –Important role models during training –NHSC scholarship commitment

8. Family Medicine and Community Health Methodology Multiple systems used to identify accurate addresses of program graduates Mailed survey with $2.00 incentive Two additional mailings to non- responders Data double-entered into EpiInfo Data analyzed using SPSS

9. Family Medicine and Community Health Definition of Health Professions Shortage Area (HPSA) Self-defined by respondent Practice described as: –Community health center –Indian health service Patient population described as: –Migrant workers –Homeless individuals

10. Family Medicine and Community Health Results 347 packets mailed 262 returned (21 undeliverable) Response rate: 80.4% Mean age: 44.9 years (SD: 8.4) 49% female >70 medical schools

11. Family Medicine and Community Health Types of Patients Included in Most Recent Practice (N=262) Percent of Responders

12. Family Medicine and Community Health Physicians Staying in Same Practice Since Graduation (N=253) Ambulatory training site

13. Family Medicine and Community Health Graduates in HPSA practices (n=262) Practice Population Initial Practice N(%) Current Practice N(%) HPSA54 (20.4)39 (14.9) Not HPSA208 (80.6)223 (84.1) p <.05

14. Family Medicine and Community Health Graduate initial and current practices: HPSA yes/no by ambulatory training site (n=262) Percent Respondents *p <.001 Ambulatory training site

15. Family Medicine and Community Health Factors associated with HPSA practice Variable (Referent group) Odds Ratio (CI) Initial Practice Odds Ratio (CI) Current practice FHCW (vs HFHC) trained 4.37 (2.2-8.8)3.45 (1.6-7.3) NHSC commitment (vs no NHSC) 2.69 (1.2-6.0)NS “Very interested” in underserved 3.24 (1.5-7.2)2.78 (1.2-6.6)

16. Family Medicine and Community Health Respondents’ Initial and Current Practice Sites Graduation Decade HPSA Initial and Current N (%) HPSA Neither Initial nor Current N (%) HPSA Initial; Current Non- HPSA N (%) HPSA Current; Initial Non- HPSA N (%) 1976-85* (n=72) 4 (5.6)57 (79.2)8 (11.1)3 (4.2) 1986-95** (n=80) 8 (10)57 (71.3)11 (13.8)4 (5) 1996-2005** (n=110) 15 (13.6)82 (74.5)8 (7.3)5 (4.5) Total (n=262) 27 (10.3)196 (74.8)27 (10.3)12 (4.6) *p<.01, **p<.001

17. Family Medicine and Community Health Graduate initial and current practices: Rural population (Yes/No) by ambulatory training site (n=262) Percent Respondents *p=.035 **p=.017 Ambulatory training site

18. Family Medicine and Community Health Conclusions Graduates trained in an FQHC significantly more likely to practice initially and currently in a HPSA practice NHSC commitment and interest in underserved at start of residency also associated As move away from graduation decade, proportion of physicians with practice in HPSAs decreases

19. Family Medicine and Community Health Conclusions Graduates trained in a rural setting more likely to practice with a rural population Fifty percent of graduates have stayed in Massachusetts and sixty-four percent in New England Forty-two percent have practiced continuously in the same practice since graduation

20. Family Medicine and Community Health Limitations Results are not generalizable Self-defined designation of underserved practice Lack of depth to questions –“I care for a population that is rural” Addresses reflect mailing address –Uncertain whether home or practice

21. Family Medicine and Community Health Next Steps Periodic short survey with annual report –Add depth to questions –Current practice address Use GIS to identify practices in HPSAs Collaborating with Lawrence Family Practice Residency Collaborate with other programs Get data to policy makers

22. Family Medicine and Community Health References (1) Edwards JB et al. J Rural Health 2006 Winter; 22(1):69-77 (2) Cullen TJ et al. J Am Board Fam Prac 1997 July- Aug;10(4):272-279 (3) Krist AH et al. J Rural Health 2005 Winter;21(1):3- 11 (4) Pathman D et al. J Fam Prac 1998 Apr; 46(4), 293- 303 For more information: Warren Ferguson, MD fergusow@ummhc.org