2016年乡村全科执业助理医师资格考试(试点)实践技能考试成绩相关因素分析

This study examines rural urban differences in the use of various information technologies (IT) applications by physicians in the ambulatory setting. Findings suggest that no differences exist between rural and urban physicians with respect to the use of a computer (77.4 vs 81.4; p=.144) or with the availability of an Internet connection (95.0 vs 96.5; p=.249) in the office. However, rural physicians were significantly less likely than urban doctors to indicate using e-mail with patients (7.9 vs 17.2%; p<.001) and slightly less likely to use a personal digital assistant (PDA) (32.3 vs 37.9; p=.091). Rural doctors were significantly less likely to indicate routinely using an electronic health records (EHR) system (17.6 vs 24.1; p=.020). EHR differences between rural and urban physicians were not significant (p=.124) in multivariate analyses and were explained away by practice size (p<.001) and practice type (p=.015). Most barriers to EHR did not differ between rural and urban physicians. However, rural physicians more commonly cited barriers associated with temporary disruptions to productivity or disruptions in access to records when computers systems fail. In sum, EHR use and patient e-mailing is less common in rural areas. While much of this variability can be explained by rural practice characteristics, these findings illustrate the need for further efforts to identify and alleviate barriers and encourage health IT adoption in rural areas.

The first trial of the clinical skill test as part of the Korean Medical Licensing Examination was done from September 23 to December 1, 2009, in the clinical skill test center located in the National Health Personnel Licensing Examination Board (NHPLEB) building, Seoul. Korea is the first country to introduce the clinical skill test as part of the medical licensing examination in Asia. It is a report on the introduction and administration of the test. The NHPLEB launched researches on the validity of introducing the clinical skill test and on the best implementation methods in 2000. Since 2006, lists of subjects of test items for the clinical skill test has been developed. The test consisted of two types of evaluation, i.e., a clinical performance examination (CPX) with a standardized patient (SP) and objective structured clinical examination (OSCE). The proctor (medical faculty member) and SP rate the examinees' proficiency for the OSCE and CPX respectively. Out of 3,456 applicants, 3,289 examinees (95.2%) passed the test. Out of 167 examinees who failed the clinical skill test, 142 passed the written test. This means that the clinical skill test showed characteristics independent from the written test. This successful implementation of the clinical skill test is going to improve the medical graduates' performance of clinical skills.

To help increase the supply and retention of rural family physicians, Thomas Jefferson University initiated the Physician Shortage Area Program (PSAP) in 1974. The program selectively admits medical school applicants who both grew up in a rural area and plan to practice in a rural area. During medical school, PSAP students have ongoing mentoring and rural clinical experiences. As the program now approaches the half-century mark, this commentary summarizes several important lessons learned. First, outcomes research is critical, and program leaders have been able to publish 15 papers and a book about the PSAP and its outcomes. Second, these studies have shown that the program has been highly successful, with PSAP graduates 8.5-9.9 times more likely to enter rural family medicine than their peers, and that the PSAP contributed 12% of all rural family physicians in Pennsylvania. Other similar medical school rural programs have had comparable success, with more than half of all graduates combined (including PSAP graduates) practicing rural. Third, long-term retention has a multiplicative impact. Long-term retention of PSAP graduates in rural family medicine was greater than 70% after 20-25 years. Fourth, research has shown that the admissions component accounted for approximately three-quarters of the PSAP's success. Three factors available at the time of matriculation (rural background, plans for rural practice, and plans for family medicine) identified almost 80% of all Jefferson graduates in rural practice 3 decades later. Having a peer group with similar backgrounds, mentoring, and the rural curriculum were also very important. Fifth, wanting to live rural appears key to the rural practice decision. Finally, given that medical school programs like the PSAP produce substantial increases in the supply and retention of rural physicians while requiring modest resources, medical schools can have a critical role in addressing the rural physician shortage.

Despite continued federal and state efforts to increase the number of physicians in rural areas, disparities between the supply of rural and urban physicians persist. The authors examined the training of the rural physician workforce in the United States. Using a national cross-sectional analysis of the 2005 American Medical Association and American Osteopathic Association Masterfile physician data, the authors examined a 10-year cohort of clinically active MD and DO physicians who graduated from medical school between 1988 and 1997. Eleven percent (20,037) of the physician cohort were currently practicing in a rural location in 2005. Eighteen percent (2,045) of osteopathic medical school graduates were currently practicing in a rural location. Twenty-three percent (6,282) of family physician graduates practiced in rural areas. Women continue to be less likely than men to practice in rural areas, although the gap is narrowing. Rural residency trainees were over three times more likely to practice in rural areas (RR = 3.4, P < .001). The proportion and number of physicians entering rural practice has remained stable compared with earlier analyses. However, recent trends such as declining primary care interest are not yet reflected in these data and may portend worsening shortages of rural physicians.

Several studies highlight the role of physicians in determining cervical and breast cancer screening rates, and some urban studies report higher screening rates by female physicians. Rural women in North America remain underscreened for breast and cervical cancers. This survey was conducted to determine if there were significant gender differences in practices and perceptions of barriers to breast and cervical cancer screening among rural family physicians in Ontario, Canada. One hundred ninety-one family physicians (response rate 53.1%) who practiced in rural areas, small towns, or small cities completed a mail questionnaire. The physicians' mean age was 44.4 years (SD 9.9), and mean number of years in practice was 16.6 years (SD 10.3). Over 90% of physicians reported that they were very likely to conduct a Pap test and clinical breast examination (CBE) during a periodic health examination, and they had high levels of confidence and comfort in performing these procedures. Male (68%) and female (32%) physicians were similar in their likelihood to conduct screening, levels of confidence and comfort, and knowledge of breast and cervical cancer screening guidelines. However, the self-reported screening rates for Pap tests and CBE performed during last year were higher for female than male physicians (p < 0.01). Male physicians reported they were asked more frequently by patients for a referral to another physician to perform Pap tests and CBE (p < 0.001). Also, male physicians perceived patients' embarrassment as a stronger barrier to performing Pap tests (p < 0.05) and CBE (p < 0.01) than female physicians. No gender differences were observed in screening rates or related barriers to mammography referrals. These findings suggest that physicians' gender plays a role in sex-sensitive examination, such as Pap tests and CBE. There is a need to facilitate physician-patient interactions for sex-sensitive cancer screening examinations by health education initiatives targeting male physicians and women themselves. The feasibility of providing sex-sensitive cancer screening examinations by a same-sex health provider should also be explored.

s, including 145 duplicates removed. Full texts of the remaining 110 articles were obtained. A further 70 articles were excluded as they did not meet the criteria pertaining to NP prescribing practices in the specific countries reviewed. Non-English and systematic reviews and other integrative review papers were also not selected, leaving 40 articles selected for the review (Figure 1). Surveys or questionnaires were the most commonly used method (n=20), followed by focus groups/interviews/expert panel review (n=10), retrospective designs (n=5), audits (n=4), and one randomized control trial (n=1). USA Nurse prescribing has been in place in the USA since the 1960s, with the purpose of reducing the workload of physicians and addressing the needs of patients in remote areas. Nurse and midwife prescribing has evolved in the USA out of the establishment of the advanced practice roles such as NP, physician assistants (PAs), and nurse–midwife. NPs were granted prescriptive privileges in 1969, when initially legislation was introduced to allow NPs to prescribe medications under the rules and regulations of the regulatory Boards of Medicine and Nursing and was limited to a dependant/ collaborative arrangement. By 2005, 13 states and the District of Columbia authorized NPs to independently prescribe, including controlled drugs. This involved state-mandated requirements for collaborative practice arrangements, between the NP and medical practitioner. There are now 21 states in America deemed to have full practice authority. This authority includes prescriptive authority without mandated collaborative arrangements. To obtain licensure in the USA as an NP, candidates must hold a master’s degree, a post-master’s certificate, or a doctoral degree in nursing from an accredited program. There is a move toward a full requirement for a doctorate as the entry level qualification. Generally, NPs are licensed by the Board of Nursing for the state in which they will practice; laws differ depending on the state. Depending on each state’s regulations, licenses must be periodically renewed, with some states requiring continuing education in order to renew licenses. Although NPs have had prescriptive authority for some time, surprisingly, there is limited research published regarding patient outcomes of NP prescribing practice in the USA. Hooker and Cipher studied the prescriptive practices of NPs, PAs, and medical practitioners by analyzing data from The National Ambulatory Medical Care Survey and found that NPs wrote significantly more prescriptions in rural areas when compared to PAs and medical practitioners. It was proposed that this may relate to more primary care NPs being located in nonmetropolitan areas compared to the number of physicians in these areas. There is no significant difference found in antibiotic prescribing by NPs compared to medical practitioners in a retrospective study of data from the National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey between 1997 and 2001, which investigated NPs (n=506) and medical practitioners (n=13,692) prescribing for upper respiratory infections. It appears that in the elderly, the most commonly prescribed drugs by NPs in the USA include antihypertensive drugs, analgesics, cardiovascular drugs, and diabetic medications. In the 2004 AANP National Nurse Practitioner Sample Survey, a survey of 16,543 NPs identified that the most commonly prescribed medications were nonsteroidal anti-inflammatory drugs (NSAIDs) and antibiotics followed by antihypertensive medications, diabetic medications, contraceptives, and bronchodilators. This study reported that NPs routinely prescribe in all 50 states and in the District of Columbia, as well as in all practice settings, regardless of specialty. The types of medications prescribed in the USA support the notion that NPs employ pharmacotherapy in the management of acute and complex chronic conditions as well as health maintenance and diseases prevention. Studies that compared NP’s prescribing practices with other clinicians demonstrated the principal finding that there is no difference between NP and medical practitioners prescribing practices. Europe In mainland European countries, some nurses have prescriptive authority, although this varies among specific European countries. Sweden has had prescriptive authority for nurses since 1994, whereas the Netherlands and Spain have explored legislative and procedural amendments to allow prescriptive authority. The Finnish Government has also proposed that nurses working in national public health centers are given a limited right to prescribe medication to patients in their care. Nurse prescriptive authority was primarily implemented in Europe for similar reasons to the USA to improve the patient’s access to medicines, in particular for those in remote areas to both supplement the shortage of physicians and reduce the work load of medical practitioners. In many European countries, NPs have been practicing in the health care system for years, although the level of education can vary between countries and even within the states

BackgroundThe physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management.Study designA descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated.MethodsThe patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system.FindingsIn total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care.ConclusionsNPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

Medical education is increasingly taking place in rural areas as this is known to help physician recruitment to rural areas. A medical school is planned for Prince Edward Island (PEI) that would use community-based learning as a core principle, yet little is known about the specific factors that influence our rural physicians' participation and engagement in medical education. Our objective is to describe these factors. Using mixed-methods, we conducted a survey of all physician-teachers on PEI and conducted semi-structured interviews with self-selected survey respondents. We gathered quantitative and qualitative data, and conducted an analysis of themes. The study is ongoing and will be completed before March 2022. Early survey results suggest that faculty teach because they enjoy it, and due to a sense of \"paying it forward\" and \"duty\". They face major workload challenges but are very interested in improving their teaching skills. They see themselves as clinician-teachers but not as scholars. Locating medical education in rural communities is known to alleviate physician shortages in those areas. Our early findings suggest novel factors such as identity, and traditional factors such as workload and resources, influence teaching engagement for rural physicians. Our findings also suggest that rural physicians' interest in improving their teaching is not being met by current methods. Our research contributes to the study of factors influencing rural physicians' motivation and engagement in teaching. Further research is required to understand how these findings compare with urban settings, and the implications of these differences for supporting rural medical education.

Medical ward care has been increasingly reallocated from medical doctors (MDs) to physician assistants (PAs). Insight into their roles and tasks is limited. This study aims to provide insight into different organizational models of medical ward care, focusing on the position, tasks and responsibilities of the involved PAs and MDs. In this cross-sectional descriptive study 34 hospital wards were included. Characteristics of the organizational models were collected from the heads of departments. We documented provider continuity by examination of work schedules. MDs and PAs in charge for medical ward care (n = 179) were asked to complete a questionnaire to measure workload, supervision and tasks performed. We distinguished four different organizational models for ward care: medical specialists in charge of admitted patients (100% MS), medical residents in charge (100% MR), PAs in charge (100% PA), both MRs and PAs in charge (mixed PA/MR). The wards with PAs had the highest provider continuity. PAs spend relatively more time on direct patient care; MDs spend relatively more time on indirect patient care. PAs spend more hours on quality projects (P = 0.000), while MDs spend more time on scientific research (P = 0.030). Across different organizational models for medical ward care, we found variations in time per task, time per bed and provider continuity. Further research should focus on the impact of these differences on outcomes and efficiency of medical ward care.

Physician assistants (PAs) and nurse practitioners (NPs) have licensure to practice in all states and they have prescriptive authority in 47 and 40 states, respectively. However, there have been no published studies from a national standpoint comparing urban and rural settings. The objective of this study was to describe the characteristics of providers, patients, and the type of prescriptions written by PAs and NPs and to compare these activities to those of physicians in metropolitan and nonmetropolitan settings. The National Ambulatory Medical Care Survey was used to analyze a representative sample of 149,202 visits to primary care physician offices over a 6-year period (1997-2002) in which a prescription was written by a PA, NP or physician. A PA or NP was the provider of record for 3% of the primary care visits. The 3 providers wrote prescriptions for 60% to 70% of all visits, and the mean number of prescriptions was 1.3 to 1.5 per visit (range 0-5), depending on the provider. PAs were more likely to prescribe a controlled substance than were physicians or NPs (19.5%, 12.4%, 10.9% respectively). Only in rural areas did differences emerge. In rural areas, NPs wrote significantly more prescriptions than physicians and PAs, and PAs wrote significantly fewer prescriptions than the other providers. Overall, PAs and NPs are prescribing in a manner similar to physicians in the type of medications used in their patient management. In nonmetropolitan areas, prescribing differences among the 3 types of providers bear further exploration.

Analysis to summarize the state of the evidence on efforts to recruit and retain a racially and ethnically diverse health workforce. The findings presented in this brief are based on a search of the peer-review and grey literature from 2010 to 2015. To set the stage for the findings, the UW HWRC compared the current racial and ethnic mix of the health workforce to the mix ten years

BackgroundMedical care for admitted patients in hospitals is increasingly reallocated to physician assistants (PAs). There is limited evidence about the consequences for the quality and safety of care. This study aimed to determine the effects of substitution of inpatient care from medical doctors (MDs) to PAs on patients’ length of stay (LOS), quality and safety of care, and patient experiences with the provided care.MethodsIn a multicenter matched-controlled study, the traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which besides MDs also PAs are employed (PA/MD model). Thirty-four wards were recruited across the Netherlands. Patients were followed from admission till one month after discharge. Primary outcome measure was patients’ LOS. Secondary outcomes concerned eleven indicators for quality and safety of inpatient care and patients’ experiences with the provided care.ResultsData on 2,307 patients from 34 hospital wards was available. The involvement of PAs was not significantly associated with LOS (β 1.20, 95%CI 0.99–1.40, p = .062). None of the indicators for quality and safety of care were different between study arms. However, the involvement of PAs was associated with better experiences of patients (β 0.49, 95% CI 0.22–0.76, p = .001).ConclusionsThis study did not find differences regarding LOS and quality of care between wards on which PAs, in collaboration with MDs, provided medical care for the admitted patients, and wards on which only MDs provided medical care. Employing PAs seems to be safe and seems to lead to better patient experiences.Trial registrationClinicalTrials.gov Identifier: NCT01835444

Letters Health AffairsVol. 39, No. 4: Integrating Social Services & Health Addiction Treatment In Rural AreasElizabeth C. Wilkinson and John M. Westfall AffiliationsRobert Graham Center Washington, D.C.PUBLISHED:April 2020Free Accesshttps://doi.org/10.1377/hlthaff.2020.00213AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSAccess to careAddictionWe appreciate Michael Barnett and coauthors’ addressing the need for addiction treatment in rural areas (Dec 2019). We applaud the nurse practitioners (NPs), physician assistants (PAs), and physicians who are increasing patient access by obtaining waivers to prescribe buprenorphine.The authors claim that growth in buprenorphine waivers in rural communities was driven by NPs and PAs. This is a mischaracterization of the data subsequently presented in this study. While there was growth among these groups (they accounted for 56 percent of the increase of 7.2 newly waivered clinicians per 100,000 population in rural counties), this reflects a catching-up process, as there were no waivered NPs or PAs in 2016.The authors’ exhibit 1 shows that the average number of waivered NPs and PAs per 100,000 county population remained below the number of physicians throughout the study period. For example, physicians accounted for 9.7 of the 13.7 waivered clinicians in rural counties in 2019.Exhibit 1 also shows that the average county buprenorphine treatment capacity per 100,000 population for NPs and PAs increased from 0 in 2016 to 174 in 2019 in rural counties, while physician treatment capacity grew from 479 to 734. This increase in patients with new access to care is driven by physicians, who accounted for 59.4 percent of the overall increase (from 479 to 908).Improving buprenorphine access is critical, and solutions must acknowledge the contributions by physicians as well as by NPs and PAs in rural communities. The claim that “lowering barriers for NPs to prescribe buprenorphine could improve access to buprenorphine in ways that expanded physician waivers might not achieve” does not identify an adequate policy response. The policy necessary to improve access is removing the unnecessary requirement for a waiver from the Drug Enforcement Administration to prescribe buprenorphine for all prescribers. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 6 April 2020 Information© 2020 Project HOPE—The People-to-People Health Foundation, Inc.PDF downloadRelated articlesIn Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven By Nurse Practitioners And Physician Assistants03 Dec 2019Health AffairsAddiction Treatment: The Authors Reply06 Apr 2020Health Affairs

The practice of emergency medicine presents many challenges in rural areas. We describe how rural hospitals nationally are staffing their Emergency Departments (EDs) and explore the participation of rural ED physicians and other health care professionals in selected certification and training programs that teach skills needed to provide high-quality emergency care. A national telephone survey of a random sample of rural hospitals with 100 or fewer beds was conducted in June to August 2006. Respondents included ED nurse managers and Directors of Nursing. A total of 408 hospitals responded (96% response rate). A majority of rural hospitals use more than one type of staffing to cover the ED. The type of staffing varies by time period and ED volume. On weekdays, about onethird of hospitals use physicians on their own medical staff; one third use contracted coverage; 18% use both; and 14% use physician assistants and/or nurse practitioners with a physician on-call. Hospitals are more likely to use a combination of medical staff and contracted coverage on evenings and weekends. Advanced Cardiac Life Support training is common, but Pediatric Advanced Life Support, Advanced Trauma Life Support, and training in working as a team are less common. More registered nurses working in rural EDs have taken the Trauma Nursing Core Course than the Emergency Nursing Pediatric Course. Rural ED staff would benefit from additional continuing education opportunities, particularly in terms of specialized skills to care for pediatric emergency patients and trauma patients and training in working effectively in teams.

Women in rural areas are highly dependent on public clinics for family planning services, yet little information has been collected on rural family planning providers, especially on their funding and operation. All 31 family planning clinic sites in rural Washington State were surveyed about their sponsorship, staffing, service provision and population coverage. Clinic sites were located in 25 of the 53 discrete rural health service areas of Washington State. While the three wealthiest areas had clinics, eight of the poorest areas had no clinics. Eight clinics were Planned Parenthood affiliates, eight were private freestanding clinics and 15 were local health department sites. Clinic sites were small (with the equivalent of 2.4 full-time staff members, on average) and offered a mean of 18 of 43 potential reproductive and women's health care services; general primary care services were rarely provided. Only one clinic offered abortions. Family planning clinics in rural Washington State offer an important but limited number of services. Many rural areas have no local family planning clinic. Given these clinics' reliance on federal and state funding, decreased public support might seriously impair family planning provision in rural areas.