Pipeline and training programs throughout medical school also promote rural primary care practice and lifestyle to improve PCP recruitment , retention , and rural patient outcomes . 2 , 3 To move this trajectory forward , academic health centers in WV have integrated into medical school curricula required and elective tracks , rotations , and training in rural and underserved areas to increase student exposure and interest in rural primary care practice . 1 , 2 , 4 , 10 Individual characteristics , including selfidentification with a geographic area , rural background , and medical / professional values , including a person-centered approach to medicine , 2 trust , altruism , and cooperation , are also associated with rural primary care practice choice . 1 Studies indicate that training programs providing and promoting financial incentives that include competitive award amounts and careful consideration of cost-effectiveness and program intent lead to successful recruitment and retention efforts . 3 , 11 , 12 WV has numerous training and financial incentive programs aimed at increasing student interest in primary care practice in rural and underserved areas . 13
WV has more medical students per 100,000 population compared to all other states in the US , with a high percentage of medical students matriculating in their home state ; 88.9 % compared to the national median of 68.2 %. WV ranks amongst the top 10 states for number of residents and fellows on duty per 100,000 population . 14 Data from the American Association of Medical Colleges ( AAMC ) indicate that less than 31 % of WV medical school graduates are retained instate for residency and less than 45 % of physicians remain in-state following completion of residency . 14 Data demonstrate that in-state residency in primary care is more predictive of WV practice than instate medical school attendance . Eightythree percent of 2015 medical school graduates who completed in-state primary care residencies remained in WV to practice upon completion of residency training , whereas only 10 % of those graduates who completed out-of-state residencies returned to practice in WV . 5
This is the second of two articles describing the findings from a statewide survey of physicians currently licensed in WV . The overall goal of the study was to better understand and describe factors that influence the decision to practice medicine in WV . The first article explored the influence of four factors ( financial , quality of life , community attributes , and work environment ) on choice of medical practice in WV . Results showed that quality of life and community attributes were influential factors in deciding to practice medicine in WV across all study respondents ( n = 428 , 45 % identifying as a native of WV , 17 % from rural WV ). Additionally , financial incentives , particularly loan forgiveness / repayment options , were found to be effective physician recruitment tools , and retention was strongly influenced by state social and reimbursement policy , local clinical leadership , and regional lifestyle factors . 15 This article supplements findings in the first article with a focus on pipeline , training , and contextual experiences and factors that influence the decision to practice medicine in WV .
METHODS
Study methods have been described in detail previously 15 and are briefly described here .
STUDY DESIGN AND POPULATION
A cross-sectional study using an online link to an anonymous survey was conducted between November 19 , 2019 , and March 20 , 2020 . The study population included all physicians who were licensed to practice medicine in the state of WV with an email address on file with the WV Board of Medicine or WV Osteopathic Medical Association . This study was acknowledged as exempt by the West Virginia University ( WVU ) Institutional Review Board ( Protocol # 1903504512 ).
PROCEDURES
A REDCap ® electronic survey link 16 , 17 was approved and distributed via email to physicians on the WV Board of Medicine and WV Osteopathic Medical Association listservs at the time of the survey ( N = 9,108 ). The WV Board of Medicine directly emailed this survey request and link to their licensees that included a statement of support for the project from the WV Department of Health and Human Resources Bureau for Public Health . As the WV Board of Osteopathic Medicine does not allow direct email of surveys to their licensees , the WV Osteopathic Medical Association distributed the survey by email to their listserv , which includes more than 95 % of osteopathic physicians licensed to practice in the state .
Practice type was categorized as primary or specialty care . Primary care was defined as family medicine , internal medicine , obstetrics and gynecology , pediatrics , and psychiatry , with all other disciplines categorized as specialty care , in accordance with the RHI definition of primary care . 18 Pipeline programs were defined as programs at all levels of education intended to target , enroll , and support graduation of students interested in health sciences education and included those programs available in WV , including HSTA , STEM programs , WV AHEC , Rural Health Education Partnerships ( RHEP )/ RHI , Interprofessional Training programs ( IPT ), and HOSA , with all other programs coded as others .
Respondents self-reported voluntarily across study measures , which included open text , multiple choice , numerical scale , and Likert with branching logic to opt into follow-up questions . All participants were presented questions in demographics , finance , education , pipeline , and training background sections of the survey and asked to list the zip code ( s ) of practice sites ( four + hours per week ). High school location was used as a proxy for rural background 19 and rural was defined using the Federal Office of Rural Health Policy Rural Health Grants Eligibility Analyzer Tool . 20 Disadvantaged background was defined as having graduated from a high school listed in the Teacher Cancellation Low Income ( TCLI ) Directory , established in 1997 , that lists low-income schools and educational service agencies that are eligible for federal loan forgiveness programs . 21 Following submission of the study survey , all respondents were automatically redirected to a new and separate REDCap ® survey page that thanked participants for their time and invited them to indicate their interest in participating in a follow-up interview or focus group to provide more in-depth understanding of the factors and training experiences assessed within the survey . This separate link was provided to collect the voluntary contact information of respondents with interest in the follow-up study to ensure anonymity of survey responses .
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