November/December Annals of Family Medicine tip sheet

UNITED STATES POACHING PRIMARY CARE PHYSICIANS FROM LOW-INCOME COUNTRIES

To compensate for the United States' inability to design a health care system that attracts medical students to primary care, the country is relying on medical school graduates from the world's poorest and most deprived countries. Analyzing data from the World Health Organization and American Medical Association Physician Masterfile, researchers found that compared with the U.S. physician workforce contribution to primary care practice (31 percent), poor countries with relatively extreme physician shortages, high infant mortality rates, lower life expectancies and lower immunization rates are disproportionately assisting the country in maintaining its primary care workforce. They assert that this policy is draining developing countries of much needed primary care physicians and call for policymakers to increase opportunities and incentives for the training and practice of primary care.

An accompanying editorial examines how to balance the rights of individuals to move about the globe in pursuit of their own happiness with the needs of communities that have equipped them for their mobility. Hagopian asserts that wealthy countries could reduce their magnetic pull on physicians in poor countries by reversing international monetary policies that create disincentives for those governments to invest in health care.

The Primary Care Physician Workforce: Ethical and Policy Implications By Barbara Starfield, M.D., M.P.H. and George E. Fryer, Jr., Ph.D.

Recruiting Primary Care Physicians From Abroad: Is Poaching From Low-Income Countries Morally Defensible? By Amy Hagopian, Ph.D.

FAMILY PHYSICIANS A VITAL SOURCE OF CARE FOR DISADVANTAGED AMERICANS

Family physicians are an important source of equity in health care, delivering a disproportionate share of outpatient care to disadvantaged populations. Analyzing data on more than 34,000 people from the 2004 Medical Expenditure Panel Survey, Ferrer found that family physicians saw almost one-half of Americans and were the only clinician group that did not show disparities in access across patient income levels. Specifically, they found that adults who are disadvantaged by low income, minority status and lack of insurance received care by a family physician 45.6 percent of the time, compared with those without disadvantage who saw family physicians 30.5 percent of the time. For children, the proportion of visits to family physicians roughly doubled from 16.5 percent among those without disadvantage to 30.1 percent among those with greater levels of disadvantage. With the primary care enterprise in jeopardy, the authors assert that these findings support policies that develop and enhance the primary care workforce and infrastructure as a strategy to reduce disparities and ensure the health of our most vulnerable populations.

Pursuing Equity: Contact With Primary Care and Specialist Clinicians by Demographics, Insurance, and Health Status By Robert L. Ferrer, M.D., M.P.H.

OTHER STUDIES IN THIS ISSUE

COMPLEX FORCES ARE BEHIND THE WORLDWIDE OBESITY/DIABETES EPIDEMIC

The enormous worldwide obesity/diabetes epidemic demands a more systemic way of thinking because the problems underlying the condition are the results of complex factors at work at many levels from the cellular to the global. In her essay, Candib describes several determinants of the obesity/diabetes epidemic, ranging from the genetic, cellular, biologic and psychosocial levels to the social, historical, economic and political. She asserts that to address prevention and treatment for these conditions among vulnerable populations, clinicians and researchers must take a multipronged approach.

Obesity and Diabetes in Vulnerable Populations: Reflection on Proximal and Distal Causes By Lucy M. Candib, M.D.

LOW-INCOME FAMILIES FACE MULTIPLE BARRIERS WHEN TRYING TO ACCESS NEEDED MEDICAL CARE

Low-income families identified three major barriers to obtaining health care for themselves and their children: lack of insurance coverage, poor access to services and unaffordable costs. This analysis of 772 survey responses finds that the barriers to care are successive and hierarchical ¨C insurance does not guarantee access, and having access does not guarantee the receipt of all necessary care because of unaffordable costs, such as co-pays and deductibles ¨C and provides evidence that policy reforms need to go beyond health insurance coverage.

Insurance + Access [Does Note Equal] Health Care: Typology of Barriers to Health Care Access for Low-Income Families By Jennifer E. DeVoe, M.D., D. Phil., et al

THOSE WHO NEED CARE THE MOST ARE LEAST LIKELY TO GET IT

An in-depth analysis of primary care encounters in the most and least deprived areas of Scotland reveals an increased burden of ill health and multimorbidity in poor communities, which in turn results in high demands on primary care. In the most deprived areas, researchers found poor access to care, less time spent with the doctor, higher physician stress and lower patient enablement. These findings demonstrate that the inverse care law, which states that those who need medical care most are least likely to get it, continues to operate and confounds efforts to narrow health inequalities.

The Inverse Care Law: Clinical Primary Care Encounters in Deprived and Affluent Areas of Scotland By Stewart W. Mercer,,MBChB, PhD; and Graham C. M. Watt, MBChB, PhD

NEW MOTHERS STILL EXPERIENCING CHILDBIRTH-RELATED SYMPTOMS AT 11 WEEKS POSTPARTUM

Interviews of 661 new mothers at 11 weeks postpartum revealed that most continue to experience several childbirth-related symptoms, most commonly fatigue, indicating a need for on-going rest and recovery. The authors assert that clinicians should counsel new mothers on strategies to decrease job stress, increase social support at work and home and certify their use of intermittent family and medical leave to help them manage their symptoms.

Mothers' Health and Work-Related Factor at 11 Weeks Postpartum By Pat McGovern, Ph.D., M.P.H, et al

A NEW MEASURE FOR EVALUATING THE RISK OF OSTEOPOROSIS IN MEN

Researchers developed and validated a simple clinical prediction rule, which they termed MORES, to identify men at risk for osteoporosis and refer them for confirmatory scans. The algorithm includes three variables ¨C age, weight and history of chronic obstructive pulmonary disease ¨C and shows excellent predictive validity.

Development and Internal Validation of the Male Osteoporosis Risk Estimation Score By Angela J. Shepherd, M.D., et al

CHILDREN WITH HEARING LOSS MAY BE AT INCREASED RISK OF INJURY

Children with hearing loss may be at increased risk of injury according to an analysis of South Carolina Medicaid billing data. Rates of injury in children with hearing loss were more than twice that of those without a disability.

Children With Hearing Loss and Increased Risk of Injury By Joshua R. Mann, M.D., M.P.H., et al

REDUCING NO-SHOWS IN FAMILY MEDICINE RESIDENCY PROGRAMS

An analysis of 22 family medicine residency programs with low no-show rates demonstrates it is possible to reduce no-show rates to below 10 percent by using combinations of well-established methods, including patient education, patient reminders, patient sanctions, open-access scheduling and by encouraging walk-ins and work-ins.

Reduction and Management of No-Shows in Family Medicine Residency Practice Exemplars By Bradley J. Johnson, M.D.

PROMOTING PARTICIPATORY RESEARCH BY FAMILY PHYSICIANS

In her essay, Macaulay discusses how participatory research offers a means of developing evidence relevant to the care of underserved communities. She highlights key principles, processes, complexities and challenges of participatory research and outlines when it is not appropriate. She also reflects on the training and skills of family physicians that make them especially suited to this kind of research.

Promoting Participatory Research by Family Physicians By Ann C. Macaulay, C.M., M.D., F.C.F.P

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