Huisartsgeneeskunde: aantrekkingskracht en beroepstrouw ... - Lirias

80 Making General Practice Attractive: Encouraging GP attraction and Retention KCE Reports 90
and to identify with the positive aspects of rural practice. In the USA, programs in this
field are generally linked with medical curricula, as seen above in the "attraction"
50 , 157
section. For example, rural preceptorship is part of RMED programs
(preceptorship means "a period of practical experience and training for a student that is
supervised by a specialist in a particular field", in contrast with residency, which is "a
period of time, after completing an internship, during which a doctor receives special
training in a particular type of medicine"). Original programs were developed to meet
the needs of urban lower economic and minority communities. For example, the Urban
Family Medicine Residency Program of the Ohio State University 85 was established to
improve access of population to health services. The program admits about 2 residents
for training each year. Other programs may be relatively autonomous from medical
schools, such as the Appalachian Preceptorship Program of the East Tennessee State
University, started in 1984 106 . This 4-week summer training served 225 medical US and
foreign students between 1985 and 2004. Rural training tracks (RTT) (in Geyman et al
2000 153 ) are residency programs developed in the 1980s: the first year of residency
occurs in a large urban teaching center and the second and third years occur in small
family practice groups in a distant rural community, implying a major move. It is not sure
if RTT are effective and if they cost less or more as traditional family practice
residencies.
According to Pathman et al 1999 109 , US physicians who are prepared to be rural
physicians, particularly those who are prepared for small-town living, stay longer in their
rural practices. Residency rotations in rural areas are the best educational experiences
both to prepare physicians for rural practice and to lengthen the time they stay there.
Preparedness would therefore be seen as a retention rather than a recruitment policy.
ECONOMIC INCENTIVES
US federal financial incentives
US federal financial incentives were created to address inequities existing in the
availability of GPs between rural and urban areas. The first one targets graduate
students with funded scholarship and obligated service (the National Health Services
Corps - NHSC, 1972). The second one targets medical schools with funding (Title VII
of Public Health Services Act, 1976).
Funded scholarship coupled with obligated service
Funded scholarships are a controversial measure. They address the issue of recruitment
in physician shortage areas with less emphasis on retention: when GPs complete their
obligated service, they are able to move into other areas. Generally, the shift is from
rural to urban areas. The National Health Service Corps (NHSC) is a major US
government initiative aimed to address the shortage of physicians in rural and
underserved areas 162 . Since its introduction in 1972, the NHSC has placed more than
15000 physicians in rural areas at a cost of more than $ 2 billion. The feature of the
NHSC Program is the provision of financial support to health professional students in
exchange for obligated service in selected rural and underserved areas. For each year of
financial assistance received, students incur 1-year obligated service as a NHSC
physician 162 . The hope is that once NHSC assignees will have completed their obligated
service, the experience will encourage them to remain beyond the period of obligation.
Probst et al 2003 163 showed that NHSC alumni (i.e. physicians who once served in the
NHSC) are more likely than non-NHSC to have high Medicaid patients and practice in
areas with health professions shortage and high percentage of minorities and people
living in poverty. It cannot be excluded that students with specific profiles are selfselected
to the program, but no information was found about this.
Some recipients of the scholarship have described the NHSC obligated service as a
"period of servitude". Therefore, the length of time a NHSC physician remains in their
assigned practice, beyond the obligation period, is crucial in the evaluation of the
program.
Nobody casts doubt upon the merits of the NHSC but its effectiveness is questionable
162
.