Susan M. Skillman, MS

Deputy Director, WWAMI Rural Health Research Center

Phone: 206.543.3557
Fax: 206.616.4768
E-mail: skillman@u.washington.edu

Department of Family Medicine
University of Washington
Box 354982
Seattle, WA 98195-4982

Current Projects

Factors Associated with Rural-Residing Registered Nurses’ Choices to Work in Urban Locations and Larger Rural Cities
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Mid-level practitioners, Nurses, Workforce
While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI RHRC shows that since 1980, a growing percentage are commuting from rural residences to work within urban and larger rural cities. This study will explore factors that may be associated with RNs’ decisions to commute away from their rural areas of residence to work in less rural areas.

Use of Recommended Radiation Therapy in the Rural U.S.
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Chronic diseases and conditions, Health services
This study will use cancer registry data from 10 U.S. states to examine which rural cancer patients are receiving recommended radiation therapy, and what factors influence receipt of recommended treatment. Identifying gaps in radiation therapy will inform cancer centers, rural program planners, and policy makers in rural cancer service locations and cancer support program development.

WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) Rural Health Workforce Monograph: Guide for State Legislators Regarding Rural Workforce Information and Issues
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Dental health, Nurses, Physicians, Workforce
This project will compile and present state-level information about the rural health workforce in the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region, including data on various health care disciplines. The resulting monograph will illustrate issues such as the shortage of different types of health care providers in various kinds of rural locations.

Completed Projects

Characteristics of Rural RNs in the U.S.: Analysis of the 2000 National Sample Survey of RNs, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Bureau of Health Professions
Topics: Nurses, Workforce
This study used data from HRSA's 2000 National Sample Survey of Registered Nurses (NSSRN) to compare rural and urban RNs' demographic characteristics, educational backgrounds and employment characteristics.

Long Term Trends in Characteristics of the Rural Nurse Workforce: A National Health Workforce Study, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Mid-level practitioners, Nurses, Workforce
This national study characterizes changes in the demographic, education and practice characteristics of registered nurses (RNs) in rural and urban areas from 1980 to 2004. This study provides important information for projecting future trends in rural RN supply.

Retail Pharmacies in Washington: Results of a 2003 Workforce Demand Survey, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Bureau of Health Professions
Topics: Pharmacy and prescription drugs, Workforce
This study surveyed retail pharmacies in Washington to estimate the demand for pharmacists, pharmacy technicians and administrative/clerical staff in rural and urban areas of the state.

The Rural/Urban Practice Location Patterns of Women Medical School Graduates
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Physicians, Women, Workforce
While women are becoming an increasingly large percentage of the graduates of medical schools, they are much less likely to locate their practices in rural towns. This study involved a survey including questions about where the residents preferred to locate and how much they thought they would be practicing in the future.

Publications

• Accounting for Graduate Medical Education Funding in Family Practice Training
  Author(s): Frederick M Chen, RL Phillips Jr, R Schneeweiss, C Holly A Andrilla, L Gary Hart, GE Fryer Jr, S Casey, Roger A Rosenblatt
  Research center: WWAMI Rural Health Research Center
  Topics: Medicare, Physicians, Workforce
  Citation: Fam Med 2002;34(9):663-8
  Date: 10 / 2002
  Background and Objectives: Medicare provides the majority of funding to support graduate medical education (GME). Following the flow of these funds from hospitals to training programs is an important step in accounting for GME funding.
  Methods: Using a national survey of 453 family practice residency programs and Medicare hospital cost reports, we assessed residency programs’ knowledge of their federal GME funding and compared their responses with the actual amounts paid to the sponsoring hospitals by Medicare. Results: A total of 328 (72%) programs responded; 168 programs (51%) reported that they did not know how much federal GME funding they received. Programs that were the only residency in the hospital (61% versus 36%) and those that were community hospital-based programs (53% versus 22%) were more likely to know their GME allocation. Programs in hospitals with other residencies received less of their designated direct medical education payment than programs that were the only residency in the sponsoring hospital (-45% versus +19%).
  Conclusions: More than half of family practice training programs do not know how much GME they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education.
• Assessing Physicians' Continuing Medical Education (CME) Needs in the U.S.-Associated Pacific Jurisdictions
  Author(s): Michael J Thompson, Sue M Skillman, Karin Johnson, Schneeweiss R, Kathleen Ellsbury,L Gary Hart; Pacific Islands Continuing Clinical Education Program Study Team
  Research center: WWAMI Rural Health Research Center
  Topic: Physicians
  Citation: Pacific Health Dialog, 9(1):11-6
  Date: 03 / 2002
  OBJECTIVE: To assess the self-perceived continuing medical education (CME) needs of physicians in American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau. METHODS: Questionnaire-based survey of all physicians. RESULTS: Responses obtained from a total of 143 physicians in the region provided information on training backgrounds, previous experiences with CME, local access to regular CME sessions, perceived priority educational needs and preferred methods of CME delivery. CONCLUSIONS: Overall 64% of respondents had attended a formal CME event in 1999 or 2000, and 71% had access to local weekly or biweekly CME. However the perceived usefulness of these events varied by region. Priority learning needs were identified by physicians including non-communicable diseases such as diabetes, hypertension, cardiac disease; communicable diseases such as tuberculosis, HIV/AIDS and tropical diseases; as well as skills such as EKG and X-ray interpretation, trauma management and cardiac life support. Information on the most pressing educational needs and desired methods of delivery will be crucial in planning CME in this region.
• Availability of Anesthesia Personnel in Rural Washington and Montana
  Author(s): Peter J Dunbar, Jonathan D Mayer, Meredith Fordyce, Denise M Lishner, Amy Hagopian, Ken Spanton, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Mid-level practitioners, Workforce
  Citation: The Journal of the American Society of Anesthesiologists 88(3):800-808
  Date: 03 / 1998
  Anesthesia has historically been an undersupplied specialty. Health personnel issues used to be dominated by the findings of the 1980 Graduate Medical Education National Advisory Committee study, which suggested that anesthesia would be a balanced specialty for the rest of the century. Recent studies, however, have demonstrated that there is an oversupply of all specialists, including anesthesiology. These studies take a "top down" view of health personnel through analysis of national statistics and exploration of subsets of the data by hospital size and rurality. This approach assumes that the databases of the American Hospital Association and the American Medical Association are accurate and do not take into account the presence of certified registered nurse anesthetists (CRNAs), who are the predominant providers of anesthesia care in the smallest and most remote hospitals in the United States. We compared the 1994 master file of the American Medical Association with our local knowledge of the practitioners in the rural areas of Washington state and found numerous small errors. These errors of one or two practitioners made no difference to the analysis of practitioner groups with more than approximately five people, but in the most rural communities the erroneous presence or absence of a single practitioner made a significant difference.
• Changes in the Rural Registered Nurse Workforce from 1980 to 2004 (Final Report)
  Author(s): Skillman SM, Palazzo L, Hart LG, Butterfield P
  Research center: WWAMI Rural Health Research Center
  Topics: Nurses, Workforce
  Report Number: Final Report 115
  Date: 10 / 2007
  There are shortages of registered nurses (RNs) in most parts of the country. Rural strategies to address these shortages may differ from urban strategies, and knowledge of how the rural nurse workforce has changed over time is important for rural health policy and planning. With data from 1980-2004 National Sample Surveys of Registered Nurses, and using Rural-Urban Commuting Area definitions, this study describes changes in rural and urban RN demographics, education, and employment characteristics over time.
• Changes in the Rural Registered Nurse Workforce from 1980 to 2004 (Project Summary)
  Author(s): Skillman SM, Palazzo L, Hart LG, Butterfield P
  Research center: WWAMI Rural Health Research Center
  Topics: Nurses, Workforce
  Report Number: Final Report 115
  Date: 10 / 2007
  Current and projected nationwide shortages of registered nurses (RNs) threaten access to and quality of care in most parts of the country. In rural areas health care is frequently challenged by uneven distribution of health care providers, including nurses. This report shows changes in the rural registered nurse workforce from 1980 to 2004.
• Characteristics of Registered Nurses in Rural Versus Urban Areas: Implications for Strategies to Alleviate Nursing Shortages in the United States
  Author(s): Susan M. Skillman, Lorella Palazzo, David Keepnews, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Nurses, Workforce
  Citation: Journal of Rural Health, 22(2), 151-157
  Date: 2006
  Provides results of a study comparing characteristics of rural and urban registered nurses (RNs) in the United States using data from the 2000 National Sample Survey of Registered Nurses. RNs in 3 types of rural areas are examined using the rural-urban commuting area taxonomy.
• Dimensions of Retention: A National Study of the Locational Histories of Physician Assistants
  Author(s): Eric H Larson, Gary L Hart, Goodwin MK, John Geller, C Holly Andrilla
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Citation: Journal of Rural Health, 15(4), 391-402
  Date: 1999
  This study describes the locational histories of a representative national sample of physician assistants and considers the implications of observed locational behavior for recruitment and retention of physician assistants in rural practice. Through a survey, physician assistants listed all the places they had practiced since completing their physician assistant training, making it possible to classify the career histories of physician assistants as "all rural," "all urban," "urban to rural" or "rural to urban." The study examined the retention of physician assistants in rural practice at several levels: in the first practice, in rural practice overall and in states. Physician assistants who started their careers in rural locations were more likely to leave them during the first four years of practice than urban physician assistants, and female rural physician assistants were slightly more likely to leave than men. Those starting in rural practice had high attrition to urban areas (41 percent); however, a significant proportion of the physician assistants who started in urban practice settings left for rural settings (10 percent). This kept the total proportion of physician assistants in rural practice at a steady 20 percent. While 21 percent of the earliest graduates of physician assistant training programs have had exclusively rural careers, only 9 percent of physician assistants with four to seven years of experience have worked exclusively in rural settings. At the state level, generalist physician assistants were significantly more likely to leave states with practice environments unfavorable to physician assistant practice in terms of prescriptive authority, reimbursement and insurance.
• Distribution of Rural Female Generalist Physicians in the United States
  Author(s): Mark P Doescher, Kathrine E Ellsbury, Gary L Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Women, Workforce
  Citation: Journal of Rural Health, 16(2), 111-118
  Date: 2000
  Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women in medicine have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States. We examine the geographic distribution of all active U.S. allopathic physicians recorded in the October 1996 update of the American Medical Association Physician Masterfile. Percentages and numbers of female physicians by professional activity, specialty type, and geographic location are reported. Findings reveal there were fewer than 7,000 female allopathic physicians practicing in rural America in 1996. The proportion of generalist female physicians who practice in rural settings was significantly lower than the proportion who practice in urban locations. Although members of the most recent 10-year medical school graduation cohort of female generalist physicians were slightly more likely to practice in rural areas than members of earlier cohorts, female physicians remained significantly underrepresented in rural areas. States varied dramatically in rural female generalist underrepresentation. Should female generalists continue to be underrepresented in rural locations, the rural physician shortage will not be resolved quickly. Effective strategies to improve rural female physician placement and retention need to be identified and implemented to improve rural access to physician care.
• Educating Generalist Physicians for Rural Practice: How Are We Doing?
  Author(s): John P Geyman, Gary L Hart, Tom E Norris, John B Coombs, Denise Lishner
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Citation: Journal of Rural Health, 16(1), 56-80
  Date: 2000
  Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to "small rural" communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.
• Effects of the 1997 Balanced Budget Act on Family Practice Residency Training Programs
  Author(s): Ronald Schneeweiss, Roger A. Rosenblatt, Susan Dovey, L. Gary Hart, Frederick M. Chen, Susan Casey, George E. Fryer Jr
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Physicians, Workforce
  Citation: Fam Med 2003;35(2):93-9
  Date: 2003
  Background and Objectives: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training programs in the United States.
  Methods: We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis.
  Results: A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents, and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 per year between 1988–1997 to 4.8 per year in the 4 years following passage of the BBA.
  Conclusions: The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.
• Emergency Department Use by the Rural Elderly
  Author(s): Denise M Lishner,Roger A Rosenblatt, Laura-Mae Baldwin, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Aging, Emergency medical services (EMS), Hospitals and clinics
  Citation: Journal of Emergency Medicine, 18(3), 289-297
  Date: 2000
  This study uses Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The U.S. Health Care Financing Administration’s National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. The rural elderly living in remote areas are 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly do not vary meaningfully by location. Most ED visits by this group are for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, rural EDs must be capable of dealing with the same range of emergency conditions as urban EDs.
• Family Medicine Training in Rural Areas
  Author(s): Roger A. Rosenblatt, Ronald Schneeweiss, L. Gary Hart, Susan Casey, C. Holly A. Andrilla, Frederick M. Chen
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Citation: JAMA. 2002;288:1063-1064
  Date: 09 / 2002
  Letter to the Editor: The discipline of family medicine was created in the 1970s, in part, as a way to address the chronic shortage of US rural physicians. It was predicted that the new discipline would augment the supply of rural clinicians because family physicians are much more likely than other physicians to settle in rural areas.
  There is also empirical evidence that training family physicians in rural areas increases the likelihood that residency graduates will choose to settle in rural places. However, the exact proportion of family medicine residency programs located in truly rural parts of the United States remains unknown, as does the extent to which training rural physicians is a priority of existing family medicine residency programs.
• Flight of Physicians From West Africa: Views of African Physicians and Implications for Policy
  Author(s): Amy Hagopian, Anthony Ofosub, Adesegun Fatusic, Richard Biritwumd, Ama Essele, L. Gary Hart, Carolyn Watts
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Physicians
  Citation: Social Science and Medicine, 61, 1750-1760
  Date: 2005
  West African-trained physicians have been migrating from the sub-continent to rich countries, primarily the US and the UK, since medical education began in Nigeria and Ghana in the 1960s. In 2003, we visited six medical schools in West Africa to investigate the magnitude, causes and consequences of the migration. We conducted interviews and focus groups with faculty, administrators (deans and provosts), students and post-graduate residents in six medical schools in Ghana and Nigeria. In addition to the migration push and pull factors documented in previous literature, we learned that there is now a well-developed culture of medical migration. This culture is firmly rooted, and does not simply fail to discourage medical migration but actually encourages it. Medical school faculty are role models for the benefits of migration (and subsequent return), and they are proud of their students who successfully emigrate.
• Gender-Related Factors in the Recruitment of Generalist Physicians to the Rural Northwest
  Author(s): Ellsbury KE, Baldwin LM, Johnson KE, Runyan SJ, Hart LG
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Women, Workforce
  Citation: Journal of the American Board of Family Practice, 15(5), 391-400
  Date: 09 / 2002
  Background: This study examines differences in the factors female and male physicians considered influential in their rural practice location choice and describes the practice arrangements that successfully recruited female physicians to rural areas.
  Methods: This cross-sectional study was based on a mailed survey of physicians successfully recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest.
  Results: Responses from 77 men and 37 women (response rate 61%) indicated that women were more likely than men to have been influenced in making their practice choice by issues related to spouse or personal partner, flexible scheduling, family leave, availability of childcare, and the interpersonal aspects of recruitment. Commonly reported themes reflected the respondents' desire for flexibility regarding family issues and the value they placed on honesty during recruitment.
  Conclusions: It is very important in recruitment of both men and women to highlight the positive aspects of the community and to involve and assist the physician's spouse or partner. If they want to achieve a gender-balanced physician workforce, rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse-partner, and interpersonal issues in the recruitment process.
• Growth and Change in the Physician Assistant Workforce in the United States, 1967-2000
  Author(s): Eric H Larson, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Mid-level practitioners, Workforce
  Citation: Journal of Allied Health, Volume 36 Number 3, pp. 121-130
  Date: 2007
  The physician assistant (PA) profession grew rapidly in the 1970s and 1990s. As acceptance of PAs in the health care system increased, roles for PAs in specialty care took shape and the scope of PA practice became more clearly defined. This report describes key elements of change in the demography and distribution of the PA population between 1967 and 2000, as well as the spread of PA training programs. Individual-level data from the American Academy of Physician Assistants, supplemented with county-level aggregate data from the Area Resource File, were used to describe the emergence of the PA profession between 1967 and 2000. Data on 49,641 PAs who had completed training by 2000 were analyzed. More than half (52.4%) of PAs active in 2000 were women. PA participation in the rural workforce remains high, with more than 18% of PAs practicing in rural settings, compared with about 20% in 1980. Primary care participation appears to have stabilized at about 47% among active PAs for whom specialty is known. By 2000, 51.5% of practicing PAs had been trained in the states where they worked. The profession has grown rapidly; 56% of all PAs were trained between 1991 and 2000. In 2000, more than 42% of accredited PA programs offered a master's degree, compared to master's degree programs in 1986. Although many critical issues of scope of practice and patient and physician acceptance of PAs have been resolved, the PA profession remains young and continues to evolve. Whether the historical contribution of PAs to primary care for rural and underserved populations can be sustained in the face of increasing specialization and higher-level academic credentialing is not clear.
• Local Health Districts and the Public Health Workforce: A Case Study of Wyoming and Idaho
  Author(s): Richardson M, Casey S, Rosenblatt RA
  Research center: WWAMI Rural Health Research Center
  Topics: Public health, Workforce
  Citation: Journal of Public Health Management Practice, 7(1):37-48
  Date: 2001
  This study of personnel in local health departments (LHDs) focused on two predominantly rural states: Idaho and Wyoming. Although in the same region of the country, the structure of local public health is different in each state. Idaho's regionalized LHDs are relatively autonomous, whereas Wyoming's are county based, with many public health functions retained at the state level. The majority of professionals are nurses followed by environmental health workers and sanitarians, similar to data reported nationally. With increased emphasis on core public health functions of policy, assurance, and assessment, rural LHDs will be challenged to redirect the functions of their workforce.
• Metropolitan, Urban and Rural Commuting Areas: Toward a Better Depiction of the U.S. Settlement System
  Author(s): Richard Morrill, John Cromartie,L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topic: Rural statistics and demographics
  Citation: Urban Geography, 20(8), 727-748
  Date: 1999
  Discontent with the current definition of metropolitan areas and the lack of differentiation within nonmetropolitan territory provided the incentive for the research presented here. Census tracts rather than counties were used as the building blocks for assignment of tracts, not just to metropolitan areas, but also to larger towns (10,000 to 49,999) and to smaller urban places (2,500 to 9,999). The analysis used 1990 census-defined urbanized areas and tract-to-tract commuter flows. Results include a modest shift of population from metropolitan to nonmetropolitan, as well as a significant reduction in the areal size of metropolitan areas, disaggregation of many areas, and frequent reconfiguration to a more realistic settlement form.
• Migration of Physicians From Sub-Saharan Africa to the United States of America: Measures of the African Brain Drain
  Author(s): Amy Hagopian, Matthew J Thompson, Meredith Fordyce, Karin E Johnson, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Physicians
  Citation: Human Resources for Health, 2(1):17
  Date: 2004
  The objective of this paper is to describe the numbers, characteristics, and trends in the migration to the United States of physicians trained in sub-Saharan Africa.
  Methods: We used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA.
  Results: More than 23% of America's 771 491 physicians received their medical training outside the USA, the majority (64%) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group, a number that represents more than 6% of the physicians practicing in sub-Saharan Africa now. Nearly 86% of these Africans practicing in the USA originate from only three countries: Nigeria, South Africa and Ghana. Furthermore, 79% were trained at only 10 medical schools.
  Conclusions: Physician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain.
• National Estimates of Physician Assistant Productivity
  Author(s): Eric H Larson, L. Gary Hart, Ruth Ballweg
  Research center: WWAMI Rural Health Research Center
  Topics: Mid-level practitioners, Workforce
  Citation: Journal of Allied Health, Volume 30, Number 3, pp. 146-152(7)
  Date: 2001
  Analysis of productivity data from a nationally representative sample of physician assistants (PAs) showed that PAs performed 61.4 outpatient visits per week compared with 74.2 visits performed by physicians, for an overall physician full-time equivalent (FTE) estimate of 0.83. However, productivity of PAs varies strongly across practice specialty and location, with generalist PAs performing more visits than their specialist counterparts. Rural PA productivity is higher than urban productivity because of the concentration of generalist PAs in rural settings. A generalist PA physician FTE estimate of 0.75 appears to be more accurate than the 0.5 currently under consideration in proposed modifications to Health Personnel Shortage Area designation regulations.
• National Health Service Corps: Rural Physician Service and Retention
  Author(s): Cullen TJ, L Gary Hart, Whitcomb ME, Roger A Rosenblatt
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Citation: Journal of the American Board Family Practice, 10(4):272-9
  Date: 1997
  BACKGROUND: The National Health Service Corps (NHSC) scholarship program is the most ambitious program in the United States designed to supply physicians to medically underserved areas. In addition to providing medical service to underserved populations, the NHSC promotes long-term retention of physicians in the areas to which they were initially assigned. This study uses existing secondary data to explore some of the issues involved in retention in rural areas.
  METHODS: The December 1991 American Medical Association (AMA) Masterfile was used to determine the practice location and specialty of the 2903 NHSC scholarship recipients who graduated from US medical schools from 1975 through 1983 and were initially assigned to nonmetropolitan counties. We used the AMA Masterfile to determine what percentage of the original cohort was still practicing in their initial county of assignment and the relation of original practice specialty and assignment period to long-term retention.
  RESULTS: Twenty percent of the physicians assigned to rural areas were still located in the county of their initial assignment, and an additional 20 percent were in some other rural location in 1991. Retention was highest for family physicians and lowest for scholarship recipients who had not completed residency training when they were first assigned. Retention rates were also higher for those with longer periods of obligated service. Substantial medical care service was provided to rural underserved communities through obligated and postobligation service. Nearly 20 percent of all students graduating from medical schools between 1975 and 1983 who are currently practicing in rural counties with small urbanized populations were initially NHSC assignees.
  CONCLUSIONS: Although most NHSC physicians did not remain in their initial rural practice locations, a substantial minority are still rural practitioners; those remaining account for a considerable proportion of all physicians in the most rural US counties. This study suggests that rural retention can be enhanced by selecting more assignees who were committed to and then completed family medicine residencies before assignment.
• Poor Birth Outcome in the Rural United States: 1985-1987 to 1995-1997 (Final Report)
  Author(s): Larson EH, Murowchick E, Hart LG
  Research center: WWAMI Rural Health Research Center
  Topics: Children, Health disparities, Maternal and child health
  Report Number: Final Report 119
  Date: 02 / 2008
  Rates of low birthweight, poor outcomes, and inadequate prenatal care among urban and rural areas were evaluated and compared from 1985-1997 using data from the Linked Birth-Death Data Set. The study found that while progress was made in closing rural/urban gaps, rural residence and residence in a persistent poverty county remained independent risk factors for inadequate care and some adverse birth outcomes, especially postneonatal mortality.
• Poor Birth Outcome in the Rural United States: 1985-1987 to 1995-1997 (Project Summary)
  Author(s): Larson EH, Murowchick E, Hart LG
  Research center: WWAMI Rural Health Research Center
  Topics: Children, Health disparities, Maternal and child health
  Report Number: Final Report 119
  Date: 02 / 2008
  Rates of low birthweight, poor outcomes, and inadequate prenatal care among urban and rural areas were evaluated and compared from 1985-1997 using data from the Linked Birth-Death Data Set. The study found that while progress was made in closing rural/urban gaps, rural residence and residence in a persistent poverty county remained independent risk factors for inadequate care and some adverse birth outcomes, especially postneonatal mortality.
• Productivity of Washington State’s Obstetrician–Gynecologist Workforce: Does Gender Make a Difference?
  Author(s): Thomas J. Benedetti, Laura-Mae Baldwin, C. Holly A. Andrilla, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Women
  Citation: Obstetrics and Gynecology, 103(3), 499-505
  Date: 2004
  Objective: To compare the practice productivity of female and male obstetrician–gynecologists in Washington State.
  Methods: The primary data collection tool was a practice survey that accompanied each licensed practitioner’s license renewal in 1998–1999. Washington State birth certificate data were linked with the licensure data to obtain objective information regarding obstetric births.
  Results: Of the 541 obstetrician–gynecologists identified, two thirds were men and one third were women. Women were significantly younger than men (mean age 43.3 years versus 51.7 years). Ten practice variables were evaluated: total weeks worked per year, total professional hours per week, direct patient care hours per week, nondirect patient care hours per week, outpatient visits per week, inpatient visits per week, percent practicing obstetrics, number of obstetrical deliveries per year, percentage working less than 32 hours per week, and percentage working 60 or more hours per week. Of these, only 2 variables showed significant differences: inpatient visits per week (women 10.1 per week, men 12.8 per week, P <= .01) and working 60 or more hours per week (women 22.1% versus men 31.5%, P <= .05). After controlling for age, analysis of covariance and multiple logistic regression confirmed these findings and in addition showed that women worked 4.1 fewer hours per week than men (P < .01). When examining the ratio of female-to-male practice productivity in 10-year age increments from the 30–39 through the 50–59 age groups, a pattern emerged suggesting lower productivity in many variables in the women in the 40–49 age group.
  Conclusion: Only small differences in practice productivity between men and women were demonstrated in a survey of nearly all obstetrician–gynecologists in Washington State. Changing demographics and behaviors of the obstetrician–gynecologist workforce will require ongoing longitudinal studies to confirm these findings and determine whether they are generalizable to the rest of the United States.
• Rural and Urban Physicians: Does the Content of Their Medicare Practices Differ?
  Author(s): Laura-Mae Baldwin, Roger A Rosenblatt, Schneeweiss R,Denise M Lishner, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Medicare, Physicians
  Citation: Journal of Rural Health, 15(2), 240-251
  Date: 1999
  Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.
• Rural-Urban Differences in the Public Health Workforce: Findings From Local Health Departments in three Rural Western States
  Author(s): Rosenblatt RA, Casey S, Richardson M
  Research center: WWAMI Rural Health Research Center
  Topics: Public health, Workforce
  Citation: American Journal of Public Health, 92(7):1102-1105
  Date: 07 / 2002
  Most local health departments or districts are small and rural; two thirds of the nation's 2832 local health departments serve populations smaller than 50,000 people. Rural local health departments have small staffs and slender budgets, yet they are expected to provide a wide array of services during a period when the health care system of which they are a part is undergoing change.

  This study provided quantitative, population-based data on the supply and composition of the rural public health workforce in 3 extremely rural states: Alaska, Montana, and Wyoming. The study focused on the relative supply of personnel in the principal public health occupational categories, differences across states in staffing levels, and difficulties experienced in recruiting and retaining personnel.

• U.S. Medical Schools and the Rural Family Physician Gender Gap
  Author(s): Kathleen E. Ellsbury, Mark P. Doescher, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Women, Workforce
  Citation: Fam Med. May 2000;32(5):331-337
  Date: 05 / 2000
  Background: Women comprise increasing proportions of medical school graduates. They tend to choose primary care but are less likely than men to choose rural practice.
  Methods: This study used American Medical Association masterfile data on 1988–1996 medical school graduates to identify the US medical schools most successful at producing rural family physicians and general practitioners of both genders.
  Results: The number of listed rural female family physician or general practitioner graduates among schools ranged from 0–27 (0% to 4.4% of each school’s 1988–1996 graduates). There were approximately twice as many male as female rural family physicians and general practitioners. Publicly funded schools produced more rural female family physicians and general practitioners than their privately funded counterparts.
  Conclusions: Our findings suggest that a few schools, most of them public, may serve as models for schools that aim to train women who later enter rural practice.
• University of Washington Pacific Islands Continuing Education Program (PICCEP): Guam Conference on Structure and Content of Continuing Clinical Education Programs in the U.S.-Associated Jurisdictions
  Author(s): Thompson MJ, Skillman SM, Schneeweiss R, Hart LG, Johnson K; Pacific Islands Continuing Clilnical Education Program Study Team
  Research center: WWAMI Rural Health Research Center
  Citation: Pacific Health Dialogue, 9(1):119-22
  Date: 03 / 2002
  
• Updating Hospital Reference Resources in the U.S.-Associated Pacific Basin: Efforts of the Pacific Islands Continuing Clinical Education Program (PICCEP)
  Author(s): Karin E Johnson, Sue M Skillman, Kathleen E Ellsbury, Michael J Thompson, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Citation: Journal of the Medical Library Association, 92(4):495-497
  Date: 2004
  This article describes a project by the Pacific Islands Continuing Clinical Education Program (PICCEP) at the University of Washington (UW) to supplement hospital reference materials in six jurisdictions in the US-associated Pacific Islands. It outlines a model for cooperatively developing a suite of clinical reference materials suitable to low-resource settings.
• Washington State Nurse Anesthetist Workforce: A Case Study
  Author(s): Louise Kaplan, Marie-Annette Brown, Holly Andrilla, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Mid-level practitioners, Workforce
  Citation: American Association of Nurse Anesthestists 75:37-42
  Date: 02 / 2007
  The purposes of this study were to describe the Washington State Certified Registered Nurse Anesthetist (CRNA) workforce and analyze selected dimensions of their clinical practice. The authors developed a 31-item CRNA Practice Questionnaire that was mailed to CRNAs licensed in Washington with an address in Washington, Oregon and Idaho. Workforce data may assist CRNAs when negotiating with employers and institutions and in resolving interprofessional conflicts and can have implications for scope of practice, policy and legislative issues.