농어촌지역 일차의료인력의 양성과 유지에 대한 천성과 양육(nature and nurture)의 역할

농어촌지역 일차의료인력의 양성과 유지에 대한 천성과 양육(nature and nurture)의 역할

The Roles of Nature and Nurture in the Recruitment and Retention of Primary Care Physicians in Rural Areas: A Review of the Literature

Robert G. Brooks, MD, Michael Walsh, Russell E. Mardon, PhD, Marie Lewis, MPH, and Art Clawson, MS

결과 요약

의과대학 전 요소(Pre-medical school factors, 농어촌지역에서 성장, 전공과에 대한 선호도 등)가 농어촌지역으로 의료인력을 모집(recruitment)하는 것에 있어서 가장 강한 상관관계를 가지는 것으로 나타났다. 훈련 요소(Training factor, 레지던트 기간 중 농어촌지역 관련 교육과정 및 로테이션)는 농어촌지역의 의료인력 유지(retention)과 강한 상관관계가 있었다.

Pre-medical school factors such as rural upbringing and specialty preference were most strongly correlated with recruitment of physicians to rural areas. Training factors such as commitment to rural curricula and rotations, particularly during residency, were most strongly correlated with retention in rural areas

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이들 연구결과는 일관되게 농어촌지역에서 성장하는 것이 나중에 농어촌지역에서 진료를 하는 것과 상관관계를 갖는다는 것을 보여준다.

These studies consistently found that rural upbringing was positively associated with physicians’ practicing in rural

communities.

의과대학이 농어촌 주에 위치하고, 공립이며, 가정의학과 전문의를 키워내고, NIH에서 funding이 적은 것이 농어촌지역 의사양성과 강한 상관관계를 갖는 것을 보여줬다.

Rosenblatt and colleagues published the results of a cross-sectional study of U.S. medical school graduates from 1976 to 1985 who had subsequently completed residency, in which they found that a medical school’s location in a rural state, public ownership, production of family physicians, and smaller amounts of funding from the National Institutes of Health (NIH) were each strongly associated with the production of more physicians practicing in rural communities.3

로지스틱 모델에서 학생의 농어촌지역 배경, 전공 선호도에 대한 영향을 배제하자 농어촌지역 교육과정(rural curriculum)은 농어촌지역 진료여부에 대해서 예측하지 못했다.

However, when a logistic model was used to separate out rural background and specialty interest, rural curriculum was not an independent predictor of current rural practice.

많은 연구결과들이 졸업후 레지던트 경험이 농어촌지역 의료인력의 모집과 유지에 중요한 요소임을 보여주고 있다.

Most data support the fact that the postgraduate residency experience is also important to the recruitment and retention of physicians in rural areas (see Table 3).10,17,21,26–28

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농어촌지역 의료를 향상시키기 위한 교육적 파이프라인은 길고도 복잡하다.

As Geyman and colleagues have recently stated, ‘‘the educational pipeline to rural medical practice is long and complex.’’30

어떤 사람들은 그 어떤 교육적 측면보다도 의사 개개인의 특성이 가장 관련이 있다고 믿고 있으며, 농어촌지역에서 성장한 사람을 의사로 만드는 것이 가장 효과적일 뿐만 아니라, 이러한 요소를 고려하지 않는 정책은 그 어떤 것도 성공할 수 없다고 생각한다.

Some of those involved with policy relative to rural physician recruitment and retention believe that the preference among physicians for rural practice ‘‘appears more highly associated with physician characteristics than by any aspect of their medical education,’’ 11 and that ‘‘increasing the number of physicians who grew up in rural areas is not only the most effective way to increase the number of rural physicians, but any policy that does not include this may be unsuccessful.’’9 

반면, 의대입학전 인구학적 특성(pre-medical school demographic data)의 가치를 뒷받침하는 연구결과가 제한적이고, 의과대학과, 특히 레지던트 기간동안의 경험이 후에 농어촌지역에서 진료를 할지 여부와 진료의 지속기간에 영향을 준다는 연구가 되어있다.

On the other hand, most controlled studies suggest that the value of pre–medical school demographic data is limited9,10

and that the experiences students have in medical school and especially residency training have a significant role in

their decisions to practice or remain in rural areas.13,17,27,29

전반적으로 의과대학과 레지던트 훈련 환경이 그 학생이 궁극적으로 어떤 선택을 하는가에 있어서 중요한 부분을 차지한다. 이것을 뒷받침하는 근거로서, 처음부터 가정의학과를 하고자 하는 학생이 가정의학과를 하게 될 가능성이 더 높긴 하지만, 가정의학과 의사의 절반 이상 입학당시에는 가정의학과가 희망 리스트에 없었다는 사실을 눈여겨 볼 필요가 있다.

overall it appears that the training environments in medical school and residency are important in the students’ eventual decisions about specialty and practice community. To support this fact, we think it is important to note that, although students who initially express a desire to go into family practice have a much higher likelihood of doing so, more than half of all students who end up in family practice residencies did not list family practice as their specialty choice when admitted to medical school.31,32

분명히, 가정의학에 더 초점을 맞추는 의과대학에서 가정의학을 전공하는 학생이 더 많다.

Clearly, medical schools that focus on family practice have higher numbers of graduates who go into the family practice specialty.32

농어촌지역의 보건요소를 포함시킴으로써, 가정의학에 초점을 맞춘 레지던트 프로그램을 마친 사람이 더 농어촌지역에서 진료를 할 가능성이 높다는 것을 뒷받침하는 연구가 있다. 농어촌지역에 대한 "mission"을 가지고 있는, 더 농어촌지역 주에 위치한, 농어촌지역 로테이션이 더 긴 프로그램으로부터 더 많은 농어촌지역 의사가 배출될 가능성이 높아 보인다.

Studies do support the finding that residency programs that focus on family medicine with an integrated rural health component have more graduates who go on to practice in rural areas.27 Programs with rural ‘‘missions,’’ located in more rural states, and with longer rural rotations, seem to produce more rural physicians. 

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Acad Med. 2002 Aug;77(8):790-8.

The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a reviewof the literature.

Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A.

Source

health affairs, Florida State University College of Medicine, Tallahassee, FL 32306-4300, USA. Robert.Brooks@med.fsu.edu

Abstract

PURPOSE:

A systematic review of factors associated with recruitment and retention of primary care physicians in rural areas.

METHOD:

Using PubMed and Medline databases, 21 quantitative articles analyzing recruitment and retention of primary care physicians in ruralareas from 1990 to 2000 were found. To assess the methodologic strengths of these articles, a formal evaluation was conducted based on study design, study population, response rate, years studied, data source, and statistical methods (total possible score = 60 points). Studies were grouped by whether the factors assessed were related to pre-medical school, medical school, or residency.

RESULTS:

A total of six studies (score range: 30-52) analyzed pre-medical school factors, 15 (score range: 30-52) considered medical school factors, and six (score range: 20-52) analyzed residency factors related to rural recruitment and retention. Pre-medical school factors such as ruralupbringing and specialty preference were most strongly correlated with recruitment of physicians to rural areas. Training factors such as commitment to rural curricula and rotations, particularly during residency, were most strongly correlated with retention in rural areas.

CONCLUSIONS:

Although important gaps exist, scientific studies available to health educators and policymakers show there are predictable factors that influence recruitment and retention in rural areas. Policies for staffing rural areas with primary care physicians should be aimed at both selecting the right students and giving them during their formal training the curriculum and the experiences that are needed to succeed in primary care in ruralsettings.

Comment in

• Primary care medicine in the United States: where are we headed? [Acad Med. 2002]