The Affordable Care Act has expanded health coverage to upward of 16.4 million uninsured people. Although this has brought needed health care services to millions, it also brought new access challenges to the US health care system. In addition, emerging accountable care health programs create expectations for more convenient access to care. These new contracts often specify same-day access for primary care to reduce preventable visits to emergency departments (EDs). Although the goals of providing the right care to the right patient at the right place and time are important goals, they pose new challenges for primary care. These problems have been compounded by the limited number of new providers choosing careers in primary care. Given these challenges and constraints, what strategies exist for improving patient access to primary care while supporting the goals of continuity and coordination of care? This article outlines strategies being implemented by University of Washington (UW) Medicine and the UW Neighborhood Clinics (UWNC).

BACKGROUND AND OBJECTIVES:The Medicare Primary Care Exception (PCE) allows residents to see and bill for less-complex patients independently in the primary care setting, requiring attending physicians only to see patients for higher-level visits and complete physical exams in order to bill for them as such. Primary care residencies apply the PCE in various ways. We investigated the impact of the PCE on resident coding practices.METHODS:Family medicine residency directors in a five-state region completed a survey regarding interpretation and application of the PCE, including the number of established patient evaluation and management codes entered by residents and attending faculty at their institution. The percentage of high-level codes was compared between residencies using chi-square tests.RESULTS:We analyzed coding data for 125,016 visits from 337 residents and 172 faculty physicians in 15 of 18 eligible family medicine residencies. Among programs applying the PCE criteria to all patients, residents billed 86.7% low-mid complexity and 13.3% high-complexity visits. In programs that only applied the PCE to Medicare patients, residents billed 74.9% low-mid complexity visits and 25.2% high-complexity visits. Attending physicians coded more high-complexity visits at both types of programs. The estimated revenue loss over the 1,650 RRC-required outpatient visits was $2,558.66 per resident and $57,569.85 per year for the average residency in our sample.CONCLUSIONS:Residents at family medicine programs that apply the PCE to all patients bill significantly fewer high-complexity visits. This finding leads to compliance and regulatory concerns and suggests significant revenue loss. Further study is required to determine whether this discrepancy also reflects inaccuracy in coding.

Introduction: The need for global health training for early-career family medicine physicians is greater than the supply. This paper details the formation of a one-year, self-funded global health fellowship for early-career family medicine physicians. Methods: In August of 2012, the University of Washington Department of Family Medicine established a self-funded, non-ACGME (Accreditation Council for Graduate Medical Education)-accredited fellowship in global health. The fellowship is targeted at early-career family medicine physicians. During the one-year fellowship, the global health fellow rotates through a variety of clinics in the greater Seattle area, including HIV, TB, STD, and other infectious disease clinics. Other activities include selected global health courses at the University of Washington, practice in a continuity clinic seeing both family medicine and pre- and post-travel patients, and a variety of teaching, speaking, and publishing opportunities. The fellow may spent up to two months overseas engaged in clinical practice and/or research; one option for fellows is to work and teach at the district hospital in Naivasha, Kenya, at which the University of Washington has established an ongoing teaching and practice program. The majority of the fellow’s salary and benefits is funded by the fellow’s clinical activities. This funding mechanism allowed the fellowship to be launched with minimal of institutional financial support. Results: Of the first three graduating fellows, two now practice primarily in the US and one works in Malawi with Seed Global Health. The fifth fellow will begin in August 2016. The robust and increasing number of applications suggest that this fellowship is meeting an ongoing need. Conclusion: This fellowship demonstrates that the need for global health training of early-career, family medicine physicians can at least be met in part by self-funded fellowships of this nature.

Introducao: Shortages of rural physicians are worsening worldwide. Rural longitudinal integrated clerkships (LIC‘s) based in primary care practices represent a new way to train medical students in rural and underserved locales. These programs place medical students in rural/underserved settings for 5-12 months of their first year of clinical education, the third year of medical school in the U.S. model. Objetivos: Evaluate impact of the 3 oldest US rural LIC‘s on choice of specialty and practice site. Hypotheses: Students who participate in primary care rural LIC‘s during their 3rd year of medical school are more likely to chose primary care specialties and to practice in rural and underserved settings. Metodologia ou Descricao da Experiencia: The medical schools at the Universities of Minnesota, South Dakota, and Washington sponsor the 3 oldest rural LIC‘s in the US. Utilizing program data we studied the likelihood of participants graduating and entering primary care specialties and rural practice sites. An 8 yr. period from 2000-2007, when all programs were fully operational and allowing time for graduation, residency match/training, and practice site selection was utilized as the period of analysis. Choices made by participants of the programs were compared to choices made by other U.S. medical students who graduated in the same time period. Comparison data were statistically analyzed to determine significant differences. Resultados: The students who participated in one of the three rural LIC programs were far more likely to enter a primary care medical specialty than students who did not participate in the programs. This finding was especially true for Family Medicine. Additionally, students who participated in one of the three rural LIC programs were much more likely to enter rural practice on completion of their training than students who did not participate. Conclusao ou Hipoteses: Longitudinal integrated clerkships are an emerging approach to medical education worldwide. This study suggests that rurally located primary care based LIC‘s may be effective in encouraging medical students to chose primary care specialties and to practice in rural underserved locations upon completion of their training. This approach could be part of the solution to rural healthcare workforce shortages.

Objective:We aimed to develop a telehealth network to deliver postdiagnosis cancer care clinical services and education to American Indian and Alaska Native patients, their families, and their healthcare providers. We also sought to identify the challenges and opportunities of implementing such a telehealth-based application for this rural and underserved population.Materials and Methods:We followed a participatory formative evaluation approach to engage all stakeholders in the telehealth network design and implementation. This approach allowed us to identify and address technical and infrastructure barriers, lack of previous experience with telehealth, and political, legal, and historical challenges.Results:Between September 2006 and August 2009, nine tribal clinics in Washington and 26 clinical sites in Alaska had participated in the telehealth network activities. Network programming included cancer education presentations, case conferences, and cancer survivor support groups. Twenty-seven cancer education presentations were held, with a total provider attendance of 369. Forty-four case conferences were held, with a total of 129 cases discussed. In total, 513 patient encounters took place. Keys to success included gaining provider and community acceptance, working closely with respected tribal members, understanding tribal sovereignty and governance, and working in partnership with cultural liaisons.Conclusion:The telehealth network exceeded expectations in terms of the number of participating sites and the number of patients served. Following a participatory formative evaluation approach contributed to the success of this telehealth network and demonstrated the importance of community involvement in all stages of telehealth system design and implementation.

Curriculum Management and Governance Structure ♦ The Curriculum Oversight Committee is the standing committee responsible for the overall curriculum. ♦ Four other curriculum committees (First Year, Second Year, Required Clerkship, Elective Clerkship), composed of course directors, clerkship directors, administrators, and students, provide year-specific discussion and advice on the curriculum (Figure 1).FIGURE 1:: Management of the Curriculum Office of Education ♦ The Curriculum Office within Academic Affairs has primary responsibility for overseeing and managing the curriculum. ♦ The Division of Medical Education and Evaluation within the Department of Medical Education and Biomedical Informatics (MEBI) supports the medical education program in a number of ways. MEBI was founded in 1967 as a division to help medical school faculty improve the teaching and learning process. The division achieved departmental status in 1989. ♦ The department's Division of Medical Education and Evaluation employs nine full-time faculty members and two part-time faculty; many clinician–educators have affiliate appointments in the department. MEBI faculty hold many leadership roles in the School of Medicine. These include representatives on every curriculum committee, Year 1 Curriculum Committee chair, School of Medicine Director of Evaluation, Teaching Scholars Program codirectors, OSCE program codirector, Medical Information for Decision Making course chair, and Institute for Simulation and Interprofessional Studies codirector. ♦ The department's mandate has broadened to provide instruction to faculty and students, conduct faculty development workshops, assist with and implement performance-based teaching and evaluation, and train medical education researchers and educators through the Teaching Scholars Program conduct research into teaching and learning in a variety of settings provide professional services for health sciences faculty, including course evaluation and test design and scoring develop innovations in biomedical and health informatics Financial Management of Educational Programs ♦ The diversity in the revenue base of the School of Medicine has helped the School respond to the current global financial crisis. ♦ The School's sources of revenue remain stable. However, the relative proportion of total revenue derived from each source is changing over time: Although state revenues and spending will continue to be constrained and the School of Medicine's state funds were cut in Fiscal Year 2010, the state revenue in support of a recent medical school class expansion will continue to be phased in until fully funded in 2013. The University and the School of Medicine completed a seven-year capital campaign in FY 2008. UW Medicine exceeded its capital campaign goal of $1 billion; the pledges of endowment and gifts supporting faculty, students, and programs will be realized over the next few years. The School is in a good position to continue to realize above-average growth in research programs that are integral to its educational programs. The hiring of faculty who are leaders in biomedical sciences and clinical practice and who are active in biomedical research is an important source of the School's success and high quality. The clinical programs recorded continued growth and positive financial performance in Fiscal Year 2009. Rapid systemwide process improvements to reduce costs, eliminate redundant services, and improve overall efficiency in conjunction with effective strategic planning increased key patient volumes and revenues. Revenues are transferred from the practice plans and hospitals to support the teaching, research, and patient care activities of the School of Medicine. ♦ Both the University and the School of Medicine provided bridge funding to support the academic programs. ♦ UW Medicine, the health system in which the School of Medicine is one of seven entities, is executing a comprehensive strategic plan to improve performance, implement new programs, consolidate programs to reduce costs and increase efficiency, and develop business plans around the larger strategic initiatives. The implementation of the strategic plan will achieve desired growth in the system and inform future decisions around resource allocation in the face of ongoing financial turmoil. Valuing Teaching ♦ The Colleges program, although technically not a teaching academy, has created an effective learning community of medical school teachers: Started in 2001, the Colleges' program consists of 37 faculty educators who function as a cohesive learning community, administrative unit, and cadre of teachers and mentors within the School of Medicine. The Colleges oversee a four-year integrated curriculum of clinical skills and professionalism; teach the Introduction of Clinical Medicine II course throughout the second year through weekly bedside teaching sessions with consistent, small student groups; and provide a consistent faculty mentor for all students throughout their medical school career. Faculty from diverse specialties are selected through a competitive process and devote a minimum of 0.25 FTE to the Colleges; selection criteria include clinical, teaching, and mentoring excellence. Faculty conduct and receive considerable faculty development in addition to direct involvement in curriculum development, teaching, and mentoring activities. ♦ The Teaching Scholars, a nine-month faculty development program, has developed a cadre of faculty educators who continue to work together on educational projects, workshops, and curriculum development after they have completed the formal program. To date, 168 faculty from more than 20 clinical specialties, including nursing, physician assistants, pharmacy, and dentistry, have participated in the program. Many have been promoted and/or gone on to leadership positions at UW and elsewhere. ♦ The UW Medicine Faculty Appointments and Promotions Guide, which augments departmental criteria and the University Faculty Code, states that “to foster innovation and creativity, flexibility is encouraged in how contributions to scholarship, teaching, and service are evaluated and weighted.” The guide describes the scholarship of teaching as an important type of scholarship; teaching contributions listed as scholarship include curriculum development, materials for in-house use, educational software or video, educational information on the Internet, and new methods to evaluate the success of educational programs and the progress of trainees. ♦ Virtually all promotion packets now include a teaching portfolio that documents and highlights the faculty member's educational contributions. ♦ Evaluation of the scholarship of teaching is elicited through solicited evaluations from outside reviews at the time of promotion, including users of the information (faculty, trainees, students, and so on) and/or publication in peer-reviewed journals and presentation at scientific meetings. Curriculum Renewal Process ♦ The UW School of Medicine launched a comprehensive review of the medical school curriculum in 1998. The review was completed in 2001 and implementation of the resulting plan began in 2001-02. ♦ The guiding principles of the charge by the Dean specified that the review should include a balanced, thorough examination of course content examine teaching methods employed, emphasizing the introduction and use of contemporary information technology assure continuity and internal integrity within the curriculum, with strong themes introduced in first year and followed throughout the four years develop clear lines of responsibility and authority for the administration and management of the curriculum and its component parts develop a new approach to teach core clinical skills and professionalism ♦ The curriculum review process was organized into three phases: Phase I assessed the current curriculum, identifying strengths, weaknesses, and opportunities for enhancement; Phase II developed recommended changes to address areas of concern in Phase I; and Phase III developed specific implementation plans for the recommendations. Changes to the first and second years as a result of the curriculum review included addition of an evidence-based medicine and critical thinking first-year course that has evolved into Medical Information for Decision Making greater emphasis on small-group versus lecture-based teaching addition of the Colleges program, in which a cohort of dedicated clinical faculty teach bedside clinical skills to small groups of assigned students throughout the second year and continue to mentor those students throughout their medical school education Major additions to the third and fourth clinical years included: a required 4-week Neurology Clerkship, a required four-week surgical selective, and expansion of the Chronic Care/Rehabilitation Medicine Clerkship from two to four weeks, with focus on chronic care, rehabilitation medicine, geriatrics, pain management, and palliative care. The medical student research requirement was restructured into an Independent Investigative Inquiry, with expanded options for completing the requirement, including data gathering/hypothesis-driven inquiry; critical review of literature; experience-driven inquiry; and a special simulation-based experience. The curriculum management system was restructured to implement year-specific curriculum committees and a curriculum oversight committee. Learning Outcomes/Competencies ♦ The University of Washington School of Medicine learning objectives are available at: http://uwmedicine.washington.edu/Education/MD-Program/Current-Students/Curriculum/Pages/default.aspx. New Topics in the Curriculum Since 2000 ♦ Patient safety is included in the following courses: Medical Information for Decision-Making (first year), Capstone I-Transition to Clerkships (second year), Medicine Health and Society (second year), courses in the Institute for Simulation and Interprofessional Studies (ISIS) (courses available in all years) ♦ Quality improvement is included in the following courses: Medical Information for Decision Making (first year), Medicine, Health and Society (second year), Introduction to Clinical Medicine II (second year), ISIS (all years) ♦ Team-based learning is included in the following courses: Capstone I-Transition to Clerkships (second year), Problem-based Learning (second year), Chronic Care Clerkship (fourth year), Emergency Medicine Clerkship (fourth year), ISIS (all years) ♦ Simulations/training in new surgical techniques are included in the following: Capstone I-Transition to Clerkships (second year), Capstone II-Transition to Residency (fourth year). Started in 2005, ISIS was founded to improve the cost, patient safety, and quality of medicine by improving the education system for health professionals. ISIS trains students, residents, and fellows in psychomotor skills, interprofessional and communication, crisis management, and team building. Currently, ISIS is one of the few simulation centers nationally with a focus on collaborative research and is the nation's only simulation center that has begun to quantify utilization. Future plans focus on integrating education and research to deliver patient safety and quality outcomes and further integrating simulation into education. ISIS currently has 16 courses in which medical students can participate, including basics of airway management, emergency medicine procedures and resuscitation, thoracentesis, suturing and wound management for medical students, fundamentals of laparoscopic surgery, and others. Areas of Increased Emphasis Since 2002 ♦ Cultural competency (incorporated into many courses and programs, including Introduction to Clinical Medicine I and II, Healthcare for the Underserved, and through longitudinal pathway programs that students may undertake: Hispanic Health Pathway, Indian Health Pathway, Global Health Pathway, and Underserved Pathway). ♦ Evidence-based medicine (including the required first-year course Medical Information for Decision-Making). ♦ Bedside clinical-skills teaching, especially through the Colleges program in Introduction to Clinical Medicine II. ♦ Professionalism and ethics (incorporated into multiple courses, including Introduction to Clinical Medicine I and II; Cases in Clinical Ethics; and others). ♦ Medical humanities (incorporated into a number of courses, including Mind, Body and Pen: Writing and the Art of Becoming a Physician; Thinking Visually: How to Observe in Depth). ♦ Global health (incorporated into courses offered through the Department of Global Health, including Introduction to Global Health, Multidisciplinary Perspectives in Global Health, Global Health Challenges, and others). ♦ Successful transitions between training stages (incorporated into Capstone I-Transition to Clerkships and Capstone II-Transition to Residency). ♦ Chronic care, including increased attention to end-of-life care (incorporated into the expanded Chronic Care Clerkship that offers rehabilitation medicine, palliative care, pain management, and geriatrics core options; Respectful Death: Exploring Interdisciplinary End-of-Life Care; and other courses). Changes in Pedagogy ♦ Increased emphasis on small-group learning; success is measured through student course evaluations and faculty course evaluations. ♦ New emphasis on alternative learning technologies—Podcasts, Mediasite, common learning resources across regional sites; success is measured through student and faculty course evaluations. ♦ Increased emphasis on bedside teaching of basic skills; success is measured through annual surveys, exit interviews, student performance, attitude surveys, and other methods. ♦ Provision of transitional instruction between classroom and clerkships and medical school and residency; success is measured by surveys at the completion of transition experiences/courses. ♦ Increased emphasis on vertical integration of medical skills; success is measured by regular discussions between College Faculty with clerkship directors. ♦ Increased emphasis on professionalism; success is measured by end-of-year student surveys, student course evaluations, and exit interviews. ♦ Increased emphasis on mentoring and incorporating mentoring into the educational process through the Colleges; success is measured by student surveys and exit interviews. ♦ Increased emphasis on student and faculty learning communities through the Colleges program; success is measured by student surveys, exit interviews, and faculty surveys. ♦ Increased focus on interprofessional collaboration and teamwork; success is measured through multiple ISIS evaluation mechanisms. Changes in Assessment ♦ Clarification of and emphasis on evaluation of professionalism/professional behavior in education and practice. ♦ Limited utilization of web-based testing in basic science and clinical courses. ♦ Use of NBME subject examinations in clerkships. ♦ Increased centralization and standardization of student evaluation of courses and clerkships across all teaching sites. Clinical Experiences ♦ As the regional allopathic medical school for more than one quarter of the land mass of the United States, the UW School of Medicine relies on approximately 200 clinical training sites throughout the five-state WWAMI region (Washington, Wyoming, Alaska, Montana, and Idaho) for ensuring that the students have exposure to an appropriate mix of clinical teaching settings. ♦ The main teaching hospitals and clinics in Seattle are the University of Washington Medical Center, Harborview Medical Center, UW Physicians Neighborhood Clinics, Seattle Children's Hospital, and the VA Puget Sound Health Care System; Northwest Hospital and Regional Medical Center joined UW Medicine in 2010. ♦ These sites are supplemented in the WWAMI region with major, well-established hospital teaching sites in Boise, Idaho, Anchorage, Alaska, Billings and Missoula, Montana, and Spokane, Washington, and smaller hospitals and clinics in towns and cities across the WWAMI region. ♦ The clinical instruction is rated very highly by medical students and is regarded as the greatest strength of the curriculum; the individual clerkships receive exceptional overall ratings, in particular for teaching and patient care interactions. ♦ Because students complete their clerkships across five states with multiple clinical instructors, collecting and providing grades and feedback on clinical performance can take long periods of time; new electronic resources are strongly mitigating this time lag. ♦ The logistics of travel to and housing and services at clinical sites throughout the five-state region can be challenging, especially for students with families; the school and individual clerkships attempt to reduce this challenge as much as possible by providing housing at distant sites. ♦ Residents do not teach students in all regional clinical sites; this introduces both challenges and opportunities. Residents are a good source of constant teaching for students and introduce different levels and types of instruction; where residents are not available for teaching, students have a unique opportunity to work directly and closely with attending physicians, particularly in small rural sites. Regional Campuses ♦ The University of Washington School of Medicine's WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) program utilizes six regional campuses, in addition to the main campus in Seattle, for the first year of medical school: Montana State University—Bozeman, Montana University of Alaska at Anchorage—Anchorage, Alaska University of Idaho—Moscow, Idaho University of Wyoming—Laramie, Wyoming Washington State University—Pullman, Washington Washington State University Riverpoint Campus—Spokane, Washington (started in 2008, adding 20 medical students per class to the School of Medicine) Highlights of the Program/School The Colleges program provides students with a combination of strong, standardized bedside clinical-skills training in the second year in small-group settings, sustained mentoring from a College faculty member throughout students' education, and community and connectedness in the context of a large medical school. As the medical school for the five WWAMI states, the UW School of Medicine's regional program is truly unique; the strong partnership that has developed among universities across these states, including legislatures, academic and community physicians, and health care professionals, is a model of collaboration, resource sharing, and cost efficiency. The School of Medicine focuses on and has relative success in addressing the need for primary care and health care for underserved regions while maintaining a strong research program. In its efforts to increase and enhance primary care and health care for the underserved, the School has developed unique programs, such as the Targeted Rural Underserved Track (TRUST), the WWAMI Rural Integrated Training Experience (WRITE), and the Rural/Underserved Opportunities Program (R/UOP) programs, in which students spend from weeks and months to entire years in rural and underserved communities learning medicine. The Department of Global Health, founded in 2007 as a joint department within the schools of Medicine and Public Health, builds and expands on long-standing strengths in infectious diseases. Students have multiple options for courses and international experiences. Additional educational opportunities are provided through the Institute for Health Metrics and Evaluation, established in 2007. It is a research center that measures the world's pressing health issues and provides scientific evaluations of health system and program performance for guiding health policy and accelerating global health progress.

PURPOSE:Integrated clinical clerkships represent a relatively new and innovative approach to medical education that uses continuity as an organizing principle, thus increasing patient-centeredness and learner-centeredness. Medical schools are offering longitudinal integrated clinical clerkships in increasing numbers. This report collates the experiences of medical schools that use longitudinal integrated clerkships for medical student education in order to establish a clearer characterization of these experiences and summarize outcome data, when possible.METHOD:The authors sent an e-mail survey with open text responses to 17 medical schools with known longitudinal integrated clerkships.RESULTS:Sixteen schools in four countries on three continents responded to the survey. Fifteen institutions have active longitudinal integrated clerkships in place. Two programs began before 1995, but the others are newer. More than 2,700 students completed longitudinal integrated clerkships in these schools. The median clerkship length is 40 weeks, and in 15 of the schools, the core clinical content was in medicine, surgery, pediatrics, and obstetrics-gynecology. Eleven schools reported supportive student responses to the programs. No differences were noted in nationally normed exam scores between program participants and those in the traditional clerkships. Limited outcomes data suggest that students who participate in these programs are more likely to enter primary care careers.CONCLUSIONS:This study documents the increasing use of longitudinal integrated clerkships and provides initial insights for institutions that may wish to develop similar clinical programs. Further study will be needed to assess the long-term impact of these programs on medical education and workforce initiatives.

PURPOSE:This case study describes the findings of a physician workforce analysis and how an institution is using these findings to address the decreasing proportion of medical students choosing primary care careers. METHODS:A University of Washington School of Medicine committee commissioned an analysis of the American Medical Association Physician Masterfile. The analysis examined physician-to-population ratios, rural-urban geographic distribution, physician demographics, and physician graduation from the university or one of its affiliated residency programs for graduates of allopathic medical schools and residencies at the county level in the 5 states in the WWAMI partnership (Washington, Wyoming, Alaska, Montana, and Idaho). RESULTS:The analysis found that in 2005, the 5 WWAMI states ranked at the bottom of US states in the number of publicly supported medical school and residency slots per capita. Although physician-to-population ratios were comparable to those in the rest of the country, the 5 WWAMI states imported most of their physicians, including family physicians, approximately 70% of whom came from other medical schools or residency programs. Family physicians were the only specialty distributed across the population gradient from urban to isolated rural areas. The workforce analysis is informing planning for medical school expansion, admissions, support for primary care, curriculum, and research at an institution with a clear mission that includes training the health workforce for its region. CONCLUSIONS:The analysis has wide potential applicability, but it has special relevance for primary care and has been particularly useful in making the case for supporting primary care education in the WWAMI region.

At a time of record prices for oil, it is important to recognise that pipelines do more than carry petroleum – in the case of rural physicians, they carry our future. In October 2004, I had the opportunity to attend the WONCA (World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians) world assembly in Orlando, FL, USA, where I was privileged to present a joint presentation on maintaining the viability of rural practice with Dr David Mildenhall from Albany, Australia. WONCA is the worldwide organisation of general practitioners and family physicians, and their international meetings create a remarkable setting for learning about family or general practice around the world. The WONCA meeting, and my presentation with Dr Mildenhall, reaffirmed my awareness of the global shortage of rural generalists, as well as the universal problems encountered in training and recruiting rural physicians. These events, coupled with my conversations with Dr Mildenhall and rural physicians from around the world, also underlined the critical importance of the educational and recruitment ‘pipeline’ in providing future rural physicians. The concept of an educational pipeline should be universal. Although we have had much experience with this approach with our WWAMI (Washington, Wyoming, Alaska, Montana, Idaho states) program in the USA, it is clear that the same paradigm applies in Australia, and probably in the rest of the world as well. I have used the ‘pipeline’ metaphor to describe our sequence of rurally orientated programs at the University of Washington School of Medicine, but the notion is readily generalisable to rural settings around the world.1 Rural physicians rarely grow up in cities, and our increasingly specialised medical schools do not, as a matter of course, turn out large numbers of rural physicians. Thus, we need effective strategies to ‘grow our own’. The educational and experiential pipeline that leads to becoming a rural physician should start in rural places, very early in the educational process. Bright rural children, as they reach the age of considering a career, should be empowered to see themselves as rural physicians. We need to provide them with both a vision of themselves in the physician's role, and the tools that will allow them to understand and to walk the paths that will get them there. These paths require good schools, with excellent general education and especially good science instruction, in rural communities. They then require organised opportunities that allow rural adolescents to ‘shadow’ and work with rural physicians. Summer ‘exposure’ programs at regional universities can provide encouragement and kindle excitement in these future doctors. These programs can also help rural students, who might not otherwise plan a university education, to comprehend the possibility and the importance of further schooling. Once these students (who grew up in a rural community with a dream of becoming a physician, studied science in their local schools, and are now ready for college) reach the university campus, we need to supply organised ‘pre-med’ activities – chances to learn more about medicine and to associate with like-minded students – we need to keep the ‘spark’ alive. These programs can often be created by groups of practising physicians, who can serve as mentors for the students. Next, as these learners graduate from their university training and enter medical schools, we need to ensure that medical schools do not divert them from the path towards generalism or primary care that is likely to lead back to a small town. This can be performed with a carefully constructed sequence of activities that endeavours to keep the medical student connected with generalists, rural doctors, rural communities and the health care needs of rural places. Finally, upon graduation from medical school, it is very important to help these new physicians connect with high-quality graduate medical education opportunities that will complete the task of preparing them for the broad scope of practice that is demanded from rural physicians. This paradigm of an organised pipeline, from a rural youngster with a dream, through solid science education in secondary school, through university and medical school, with constant attention to the provision of a prearranged sequence of mentors and relevant activities that nurture their rural links, is applicable to rural settings worldwide. The tools are available, and their efficacy is proven. Partnerships between organisations of physicians and medical schools have proven useful in operationalising these programs. If we can increase the use of these sequences, we will positively impact our shortages of rural physicians.

BACKGROUND:Telemedicine, based on the use of interactive video consultations, is being used more commonly in rural settings. This development is potentially important to rural patients because there are fewer physicians, particularly specialist physicians, in rural areas. Declining costs of telemedicine equipment and transmission have created increased access to these technologies for rural family physicians and their patients.METHODS:This study considers satisfaction levels of rural family physicians, academic-based specialists, and rural patients in 130 consultations between rural physicians, rural patients, and urban academic specialists. To increase the practicability for rural use, low-cost equipment and low-bandwidth digital telephone transmission lines were utilized. Data were collected using questionnaires that were completed by patients, family physicians, and specialist consultants after each consultation.RESULTS:All categories of participants noted very high levels of satisfaction.CONCLUSION:Telemedicine-based consultations are well accepted by rural patients, rural family physicians, and urban academic specialist consultants. This approach could offer a useful adjunct to rural health care.

The middle-aged family physician (FP) entered the exam room to see Alicia Jones, a 47-year-old female patient. He had provided care for Ms. Jones intermittently for years, so he was not too disturbed when Ms. Jones’s chart could not be located (a situation that occurred several times each day in his practice). Her presenting complaint concerned a cough that produced blood. The history indicated that, within the 2 days prior to the visit, she had a morning cough that produced “several drops” of blood each day. The patient was a nonsmoker. After a physical examination of the lungs that was unremarkable, Ms. Jones was sent to the imaging center for a chest X ray. A short while later, the radiologist called the FP stating, “It looks like widespread lung metastases from the breast cancer we found on the mammogram 2 years ago. We will send the patient back up to your office so that you can talk with her about it.”

An Overview of Primary Care Informatics.- The Electronic Medical Record (EMR).- Importation of Data from Other Programs and Databases - HL7 Interfaces.- Importing of Laboratory Data.- Import of Images.- Evidence-Based Medicine.- Clinical Decision Support.- Knowledge Resources: Finding Answers to Primary Care Questions.- Using Computer-Based Information Systems to Manage Patient Education Resources and Instruction in Your Practice.- Workflow Automation with Electronic Medical Records.- Privacy and Security of Patient Information: the ABC's.- Electronic Billing for the Primary Care Physician.- Reporting & Analysis.- Telecommunications in Primary Care.

Informatics, the study of the science of information and related disciplines, is being increasingly applied to medicine and healthcare. Medical schools are de veloping departments, divisions, and sect

Procedures are an important component of the practice of medicine. Students and residents must be trained to perform procedures safely and well. Simultaneously, we must seek consensus on what procedures should be taught, and we must develop better, safer techniques to teach them. Finally, we must develop objective measures of initial and continuing competency for those who perform procedures. We must try to overcome the “turf” battles in this area and focus on what is best for patients, students, and residents.

more block time on the surgical subspecialties-they are screaming at us to shift paradigms. Residencies have done remarkably wen at teaching residents the content of family medicine. What is needed now is a focus shift to process. The problem this article begs to have solved is how to better teach residents the skills needed to continuously improve their knowledge and competence. It makes sense that residencies are generally located in urban areas. Such a location allows residents a high volume of patient experience, an adequate medicallibrary, and access to generalist and specialist expertise. It is a natural situation in which to learn content. It is a difficult situation, however, in which to teach residents how to continue to learn while living in a rural area. It is difficult to avoid stagnation while living in an information ghetto--I wonder how many rural communities have medical libraries like ours, which consists of stacks of oidJAMAs a retiring physician emptied from his garage. In fact, the survey respondents seem to agree that residency least adequately trained them in this process. Of all the content area groups considered, community medicine and practice management were perceived as the most deficient. This alternative interpretation of the data would create a larger chore for teachers of family medicine, but with a larger payoff for residents heading to rural practices. Steven Wells, MD Colusa Family Health Center Colusa, Calif