Implementation，Outcome，and Evaluation of Rural Primary Care Physicians Training Programs in Foreign Countries：a Systematic Review

doi:10.12114/j.issn.1007-9572.2021.00.196

Abstract

Abstract: Background　The rural-oriented tuition-waived medical education（RTME） program has been launched in China since 2010，aiming to provide rural areas with more primary care physicians with medical undergraduate education to address the shortage of rural physicians. We systematically reviewed the implementation，outcome and assessment of similar medical education programs among foreign countries，offering theoretical insights into the evaluation and improvement of RTME programs in China. Objective　To understand the implementation，outcome，and assessment of rural physician training programs in foreign countries. Methods　The databases of Ovid MEDLINE，PubMed，Cochrane Library and Google Scholar were electronically searched from February to July 2015 for English language articles published between 2000-01-01 and 2019-01-01 regarding the implementation，outcome and assessment of medical training programs for rural primary care physicians and residents in foreign countries. The search terms used were as follows："as Googlescholar " "medical education+medical undergraduate student" "medical college education" "medical student" "standardized residency programs" "medical specialty+human resource" "rural area" "rural primary healthcare service" "physician practice location" "rural primary care physician" "rural primary care physician training" "rural medical internship"，and "rural clinical clerkship". Results　This study eventually included 53 articles coming from six countries comprising the US，Canada，Australia，Japan，Thailand and South Africa，with 20 medical college programs and 6 residency programs described. Key components consisting of specific enrollment strategies，clinical curriculum highlighting both rural medicine and general practice，mentorship of family physicians practicing in rural areas，and rural clinical practice bases were shared amid the 26 programs. Compared to graduates of non-rural training programs，graduates of rural training programs exhibited significantly higher rates of choosing family medicine as practice specialty，practicing in rural areas，and retaining in rural areas for a long time. No prominent differences were detected between both types of graduates regarding mean scores as well as passing rate of the national medical licensing examination. Long-term rural clinical clerkship，specific enrollment strategies favoring rural background，and mentorship by family physicians practicing in rural areas were key factors associated with ultimate outcomes of those programs. Conclusion　Medical education is an effective solution to address the shortage of rural primary care physicians. Enrollment strategies，clinical curriculum development，mentorship，as well as assessments from these foreign rural primary care physician training programs may provide helpful suggestions for RTME programs in China.

Key words: Rural health；General practitioners；Rural-oriented free tuition medical education；Education, medical；Implementation；Outcome assessment；Systematic review

摘要： 背景　2010年我国农村订单定向医学生免费培养工作启动，旨在为农村地区培养具备本科学历的全科医生，缓解农村地区基层医师匮乏的现状。本研究通过系统综述了解国外类似项目的实施现状、成效及评价，为我国农村订单定向医学生培养工作评价和改善提供理论参考。目的　了解国外农村基层医师医学培养项目实施现状、成效及评价指标方法等。方法　2019年2—7月，采用系统综述的方法，以“医学教育”“医学教育+医学本科生”“医学院校教育”“医学生”“住院医师规范化培训”“医学专业+人力资源”“农村地区”“农村基层医疗服务”“医师执业地点”“农村基层医师”“农村基层医师培养”“农村医学实习”“农村临床见习”为检索词，检索Ovid MEDLINE、PubMed、Cochrane及Google Scholar主要英文数据库，获取2000-01-01至2019-01-01发表的关于全球农村基层医师院校教育及住院医师培训等项目的实施现状、成效及评价的英文文献。结果　最终纳入53篇文献，分别来自美国、加拿大、澳大利亚、日本、泰国及南非6个国家，包括20个院校教育项目和6个住院医师培训项目。文献显示各国农村基层医师培养项目均具有指向性招生策略、面向农村卫生和全科医学的临床课程体系、以农村执业的家庭医生为临床导师及农村地区临床实践基地等要素；培养项目学生选择家庭医学为执业专业、农村地区执业率和长期农村保留率均明显高于非培养项目学生，两者国家医疗执照考试成绩和通过率无明显差异。长期农村地区临床实践培训、招生策略倾斜农村成长背景学生及农村执业的家庭医生导师是影响项目最终效果的关键因素。结论　医学教育是解决农村基层医师匮乏的有效途径。国外农村基层医师培养项目的招生策略、临床课程体系设置、导师指导及评价可为我国农村订单定向医学生培养工作提供有益参考。

关键词: 农村卫生；全科医生；订单生培养；教育, 医学；实施现状；成效评价；系统综述

SHEN Ying,HUANG Xing,KONG Yan, et al. Implementation，Outcome，and Evaluation of Rural Primary Care Physicians Training Programs in Foreign Countries：a Systematic Review　[J]. Chinese General Practice, 2021, 24(19): 2385-2393. DOI: 10.12114/j.issn.1007-9572.2021.00.196.
申颖,黄星,孔燕等. 国外农村基层医师医学培养项目实施现状、成效及评价的系统综述[J]. 中国全科医学, 2021, 24(19): 2385-2393. DOI: 10.12114/j.issn.1007-9572.2021.00.196.

References

［1］GU D，ZHANG Z，ZENG Y．Access to healthcare services makes a difference in healthy longevity among older Chinese adults［J］．Soc Sci Med，2009，68（2）：210-219．
［2］LONG S．Primary care health professionals in rural China：current status，influential factors，and countermeasures［J］．J Med Theory Pract，2013，7：878-879．
［3］HOU J，XU M，KOLARS J C，et al．Career preferences of graduating medical students in China：a nationwide cross-sectional study［J］．BMC Med Educ，2016，16：136-142．
［4］中国国家统计局．中国统计年鉴2019［M］．北京：中国统计出版社，2019．
［5］国家卫生健康委员会．2019中国卫生健康统计年鉴［M］．北京：中国协和医科大学出版社，2019.
［6］关于印发开展农村订单定向医学生免费培养工作实施意见的通知［EB/OL］．（2010-06-02）［2020-06-02］．http://www.moe.gov.cn/jyb_xxgk/moe_1777/moe_1779/201012/t20101216_112693.html.
［7］关于进一步做好农村订单定向医学生免费培养工作的意见
［EB/OL］．（2015-05-19）［2020-06-02］．http://old.moe.gov.cn/publicfiles/business/htmlfiles/moe/s7955/201505/188004.html.
［8］黄星，左延莉，唐琦，等．广西农村订单定向免费医学生培养项目实施效果调查分析［J］．中国卫生事业管理，2019，36（3）：204-207.
［9］ZINK T，CENTER B，FINSTAD D，et al．Efforts to graduate more primary care physicians and physicians who will practice in rural areas：examining outcomes from the University of Minnesota-Duluth and the rural physician associate program［J］．Acad Med，2010，85（4）：599-604．DOI：10.1097/ACM.0b013e3181d2b537.
［10］MATSUMOTO M，TAKEUCHI K，TANAKA J，et al．Follow-up study of the regional quota system of Japanese medical schools and prefecture scholarship programmes：a study protocol［J］．BMJ Open，2016，6（4）：e011165．
［11］MATSUMOTO M，INOUE K，KAJII E．Long-term effect of the home prefecture recruiting scheme of Jichi Medical University，Japan［J］．Rural Remote Health，2008，8（3）：930-944.
［12］TECHAKEHAKIJ W，ARORA R．Rural retention of new medical graduates from the Collaborative Project to Increase Production of Rural Doctors（CPIRD）：a 12-year retrospective study［J］．Health Policy Plan，2017，32（6）：809-815．DOI：10.1093/heapol/czx026.
［13］PAGAIYA N，KONGKAM L，SRIRATANA S．Rural retention of doctors graduating from the rural medical education project to increase rural doctors in Thailand：a cohort study［J］．Hum Resour Health，2015，13：10-17．DOI：10.1186/s12960-015-0001-y.
［14］RABINOWITZ H K，DIAMOND J J，MARKHAM F W，et al．Increasing the supply of rural family physicians：recent outcomes from Jefferson Medical College's Physician Shortage Area Program（PSAP）［J］．Acad Med，2011，86（2）：264-269．
［15］WHEAT J R，LEEPER J D，MURPHY S，et al．Educating physicians for rural America：validating successes and identifying remaining challenges with the rural medical scholars program［J］．J Rural Health，2018，34（suppl 1）：s65-74．
［16］GLASSER M，HUNSAKER M，SWEET K，et al．A comprehensive medical education program response to rural primary care needs［J］．Acad Med，2008，83（10）：952-961．
［17］SMUCNY J，BEATTY P，GRANT W，et al．An evaluation of the rural medical education program of the State University of New York Upstate Medical University，1990—2003［J］．Acad Med，2005，80（8）：733-738．
［18］QUINN K J，KANE K Y，STEVERMER J J，et al．Influencing residency choice and practice location through a longitudinal rural pipeline program［J］．Acad Med，2011，86（11）：1397-1406．
［19］WENDLING A L，PHILLIPS J，SHORT W，et al．Thirty years training rural physicians：outcomes from the Michigan State University College of Human Medicine Rural Physician Program［J］．Acad Med，2016，91（1）：113-119．
［20］CRUMP W J，FRICKER R S，ZIEGLER C，et al．Rural track training based at a small regional campus：equivalency of training，residency choice，and practice location of graduates［J］．Acad Med，2013，88（8）：1122-1128．
［21］WENGHOFER E F，HOGENBIRK J C，TIMONY P E．Impact of the rural pipeline in medical education：practice locations of recently graduated family physicians in Ontario［J］．Hum Resour Health，2017，15（1）：16-21．DOI：10.1186/s12960-017-0191-6.
［22］MYHRE D L，BAJAJ S，WOLOSCHUK W．Practice locations of longitudinal integrated clerkship graduates：a matched-cohort study［J］．Can J Rural Med，2016，21（1）：13-16.
［23］JAMAR E，NEWBURY J，MILLS D．Early career location of university of Adelaide rural cohort medical students［J］．Rural Remote Health，2014，14：2592-2602.
［24］SEN GUPTA T，WOOLLEY T，MURRAY R，et al．Positive impacts on rural and regional workforce from the first seven cohorts of James Cook University medical graduates［J］．Rural Remote Health，2014，14：2657-2669.
［25］ELEY D S，SYNNOTT R，BAKER P G，et al．A decade of Australian Rural Clinical School graduates：where are they and why［J］．Rural Remote Health，2012，12：1937-1948.
［26］STAGG P，GREENHILL J，WORLEY P S．A new model to understand the career choice and practice location decisions of medical graduates［J］．Rural Remote Health，2009，9 （4）：1245-1254.
［27］PLAYFORD D E，EVANS S F，ATKINSON D N，et al．Impact of the Rural Clinical School of Western Australia on work location of medical graduates［J］．Med J Aust，2014，200（2）：104-107．
［28］ROSS A J．Success of a scholarship scheme for rural students［J］．S Afr Med J，2007，97（11）：1087-1090.
［29］MAUDLIN R K，NEWKIRK G R．Family medicine spokane rural training track：24 years of rural-based graduate medical education［J］．Fam Med，2010，42（10）：723-728.
［30］STAGEMAN J H，BOWMAN R C，HARRISON J D．An accelerated rural training program［J］．J Am Board Fam Pract，2003，16（2）：124-130．DOI：10.3122/jabfm.16.2.124.
［31］ROSS R．Fifteen-year outcomes of a rural residency：aligning policy with national needs［J］．Fam Med，2013，45（2）：122-127.
［32］PETRANY S M，GRESS T．Comparison of academic and practice outcomes of rural and traditional track graduates of a family medicine residency program［J］．Acad Med，2013，88（6）：819-823．
［33］HOGENBIRK J C，TIMONY P E，FRENCH M G，et al．Milestones on the social accountability journey：family medicine practice locations of Northern Ontario School of Medicine graduates［J］．Can Fam Physician，2016，62（3）：e138-145.
［34］JAMIESON J L，KERNAHAN J，CALAM B，et al．One program，multiple training sites：does site of family medicine training influence professional practice location［J］．Rural Remote Health，2013，13（4）：2496-2507.
［35］PLAYFORD D E，NICHOLSON A，RILEY G J，et al．Longitudinal rural clerkships：increased likelihood of more remote rural medical practice following graduation［J］．BMC Med Educ，2015，15：55-63．DOI：10.1186/s12909-015-0332-3.
［36］MATSUMOTO M，INOUE K，KAJII E．Characteristics of medical students with rural origin：implications for selective admission policies［J］．Health Policy，2008，87（2）：194-202．
［37］STRASSER R P，LANPHEAR J H，MCCREADY W G，et al．Canada's new medical school：the Northern Ontario School of Medicine：social accountability through distributed community engaged learning［J］．Acad Med，2009，84（10）：1459-1464．DOI：10.1097/ACM.0b013e3181b6c5d7.
［38］WOOLLEY T，SEN GUPTA T，BELLEI M．Predictors of remote practice location in the first seven cohorts of James Cook University MBBS graduates［J］．Rural Remote Health，2017，17（1）：3992-4002．DOI：10.22605/rrh3992.
［39］RABINOWITZ H K，DIAMOND J J，MARKHAM F W，et al．A program to increase the number of family physicians in rural and underserved areas：impact after 22 years［J］．JAMA，1999，281（3）：255-260．DOI：10.1001/jama.281.3.255.
［40］RABINOWITZ H K，DIAMOND J J，MARKHAM F W，et al．Long-term retention of graduates from a program to increase the supply of rural family physicians［J］．Acad Med，2005，80（8）：728-732．DOI：10.1097/00001888-200508000-00004.
［41］RABINOWITZ H K，DIAMOND J J，MARKHAM F W，et al．Retention of rural family physicians after 20-25 years：outcomes of a comprehensive medical school rural program［J］．J Am Board Fam Med，2013，26（1）：24-27．
［42］MATSUMOTO M，INOUE K，KAJII E．A contract-based training system for rural physicians：follow-up of Jichi Medical University graduates（1978—2006）［J］．J Rural Health，2008，24（4）：360-368．DOI：10.1111/j.1748-0361.2008.00182.
［43］YI Y，CHONGSUVIVATWONG V，SRIPLUNG H，et al．CPIRD：a successful Thai programme to produce clinically competent medical graduates［J］．F1000 Res，2015，4：158-167．DOI：10.12688/f1000research.6638.1.
［44］KONDALSAMY-CHENNAKESAVAN S，ELEY D S，RANMUTHUGALA G，et al．Determinants of rural practice：positive interaction between rural background and rural undergraduate training［J］．Med J Aust，2015，202（1）：41-45．DOI：10.5694/mja14.00236.
［45］Increasing access to health workers in remote and rural areas through improved retention：global policy recommendations［M］．Geneva：World Health Organization，2010.
［46］李玉华，郝婷，陈立章．我国高校农村订单定向医学本科生培养方案现状研究［J］．中国全科医学，2018，21（16）：1989-1997．DOI：10.3969/j.issn.1007-9572.2018.16.017.　
LI Y H，HAO T，CHEN L Z．Medical science undergraduate free training programs specifically designed for rural practice in China［J］．Chinese General Practice，2018，21（16）：1989-1997．DOI：10.3969/j.issn.1007-9572.2018.16.017.