501519
research-article2013
JPCXXX10.1177/2150131913501519Journal of Primary Care & Community HealthCole et al
Research Letter
Rewards and Challenges of Community Health Center Practice
Journal of Primary Care & Community Health 2014, Vol. 5(2) 148–151 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131913501519 jpc.sagepub.com
Allison M. Cole1, Frederick M. Chen1, Paul A. Ford1, William R. Phillips1, and Nancy G. Stevens1
Abstract Background: More than 1100 community health centers (CHCs) in the United States provide primary care to 20 million underserved patients annually. CHCs have struggled to recruit and retain qualified physicians. Objective: To understand physicians’ work experiences in CHCs and identify major sources of satisfaction and dissatisfaction. Methods: Using purposeful sampling, we conducted semistructured interviews with 12 family physicians practicing in CHCs. Interview questions assessed physicians’ experiences in CHCs and sources of satisfaction and dissatisfaction. Interview notes were coded and analyzed by 2 investigators using a grounded theory approach to identify key themes. Results: Though family physicians feel tremendous satisfaction from care of underserved patients, they are frustrated with the overwhelming workload they experience. Family physicians also report poor administrative management while working in CHCs. Conclusions: Implementation of the Affordable Care Act, which relies on expansion of CHC services, may be adversely affected by family physicians’ frustrations with CHC practice. Further research to explore and potentially improve the CHC work environment may be needed. Keywords community health centers, job satisfaction, qualitative, physicians, primary health care
Introduction
Methods
There are more than 1100 community health centers (CHCs) in the United States that provide primary care to more than 20 million underserved patients annually. Demand for CHC services is expected to increase with implementation of the Affordable Care Act. CHCs have struggled to recruit and retain qualified physicians.1 In a recent survey in Massachusetts, 16% of CHC physicians planned to leave their current practice within 5 years, and 52% planned to leave their current practice within 10 years.2 A nationwide study of actual turnover in CHCs demonstrated that the median duration of practice for new CHC physicians is only 3 years, with almost two thirds of physicians having left their CHC practices by 5 years.3 Family physicians comprise more than 50% of the CHC physician workforce.1 Thus, promoting family physician retention is an important strategy to ensure adequate access to primary care. Understanding of sources of satisfaction for family physicians in CHCs may guide development of focused recruitment strategies. Understanding sources of dissatisfaction may be helpful in developing innovative approaches to improve family physician retention in CHCs.
The primary investigator (AMC) conducted interviews with 12 family physicians practicing in health centers. This project was reviewed and approved by the institutional review board at the University of Washington. We identified eligible physicians from respondents to the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) Family Medicine Residency Network Graduate Follow Up Survey. This survey4 is conducted every 3 years to assess current practice and residency training. Physicians reporting practice in a CHC, migrant health center, or federally qualified health center were eligible to participate. We purposefully selected a sample of 50 physicians that maximized variation in gender, years in practice, and geographic location of practice. Eighteen physicians agreed to participate and 12 completed interviews The principal investigator (AMC) drafted an 1
University of Washington School of Medicine, Seattle, WA, USA
Corresponding Author: Allison M. Cole, Department of Family Medicine, University of Washington, 4311 11th Avenue NE, Suite 210, Seattle, WA 98195-4982, USA. Email: [email protected]
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Cole et al interview guide consisting of 12 open-ended questions with prompts for follow-up when needed. The interview guide included topics such as choice of current job, what is best/ worst about current job, how information is communicated, how decisions are made, and future career plans. Verbal consent was obtained prior to interview. Interviews lasted 30 to 60 minutes. The principal investigator conducted all interviews by telephone (n = 10) or in person (n = 2) at a time and location that was convenient for the subject. The interviewer took detailed notes during the interview and revised all notes for accuracy and detail immediately following the interview. Interview notes were analyzed using a grounded theory approach.5 Two authors (AMC, FMC) independently read and coded 2 transcripts using an iterative process to develop an open coding scheme. The authors independently coded the remaining interviews. A third author (PMF) independently reviewed the coding scheme and all coded notes to ensure that codes had been applied consistently and the selection of codes was complete. We continued to conduct interviews and code interview notes until thematic saturation had been reached.
Results Satisfaction From Work Participants were enthusiastic in reporting the aspects of working at a CHC that they found particularly rewarding. For the majority of physicians interviewed the mission of CHCs was very important to them and something with which they strongly identified. In particular, they highlighted the opportunity to care for patients who otherwise would not receive care and sense of gratitude they perceived from the patients. Other physicians cited an opportunity to work with specific populations and communities. This led to an overall sense of family physicians feeling like they were “making a difference.”
Overwhelming Workload When asked about sources of dissatisfaction, family physicians almost uniformly identify overwhelming workload as a significant burden. When describing their current workload, the majority attributed the workload to patient care demands, including the volume of patient visits, the complexity of patient care, and long work hours as factors. This led to several family physicians to question whether their current jobs were sustainable.
Administrative Management Family physicians described frustrations with administrative management at the CHCs where they worked. Findings highlighted hierarchical administrative structures and lack
of opportunity for physician input into practice. Family physicians expressed frustration that there were no clear mechanisms for providing input into administration and operations and physicians were not given opportunities to make changes in their work environment.
Discussion Our study suggests that family physicians working in CHCs report tremendous satisfaction from care for the underserved. However, they also identify overwhelming workload and poor administrative management as major sources of dissatisfaction in their current practices. We found that physicians feel a strong commitment to the mission of CHCs and satisfaction from providing care to underserved patients. This commitment to the mission of CHCs may play an important role in physician recruitment. A survey of physicians practicing in CHCs identified commitment to the mission of CHCs as the most important factor in selecting a CHC job.2 Another qualitative study found that in particular, faith-based CHCs attracted a group of providers with the desire to fulfill a religious calling to ministry through the practice of medicine.6 A study in Australia of physicians who had worked in underserved settings longterm suggested that resiliency was promoted by feeling their work was the “right thing to do” and a deep appreciation and respect for the population they served.7 This is consistent with reports that National Health Service Scholars are less likely to stay in underserved settings long term than physicians who choose to practice in underserved settings without financial incentives.3 A second key finding was that physicians describe feeling overwhelmed by the workload of CHC practice and that poor administration is common. This offers some explanation for a recent finding that CHC physicians were less likely than non-CHC physicians to be highly satisfied with their employers.8 Dissatisfaction with workload among primary care physicians is associated with increased likelihood of leaving current practice.9 Physician perceptions of “low work control” are strongly associated with low physician satisfaction, high stress, burnout, and intent to leave a practice.10 Among CHC medical directors, there is a strong association between satisfaction with administration and overall job satisfaction.11 CHC medical directors who report strong relationships with administrative directors are more likely to stay in their jobs.12 While excessive workload has been identified as a key concern among practicing family physician,13 poor administrative management has not previously been highlighted. Hierarchical organization in community practices is associated with increased physician turnover.14 However, among rural physicians, satisfaction with autonomy is not associated with retention.15 For CHC medical directors, strong
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Journal of Primary Care & Community Health 5(2)
relationships with administrative directors are associated with retention.12 Whether or not the dissatisfaction with CHC administrative management identified by family physicians in our study is associated with retention is an important question worth further research. Though we interviewed a small number of family physicians, we used purposeful sampling based on demographics to maximize the variation in responses. In addition, we only interviewed family physicians for this study. Even though family physicians comprise the largest group of providers at CHCs,1 the findings here may not generalize to other providers working at CHCs such as general internists, general pediatricians, or mid-level providers. Finally, our sample was obtained exclusively from a group of family physicians that graduated from one of the WWAMI Family Medicine Residency programs. All our respondents were practicing in the Northwest region of the United States. It is possible that aspects of training or geographic region influenced their perceptions of their work environment, and thus our conclusions may not apply to physicians who graduated from different programs or practice in different regions. However, our sample included physicians practicing in a variety of settings and those recently graduated as well as more experienced physicians. Further research should evaluate the work environment from the perspectives of CHC staff and administrators to confirm our findings. Our findings present a significant level of detail on the experience of family physicians working in CHCs. Though CHC physicians demonstrate a strong commitment to care for the underserved, we are concerned that frustrations with workload and poor administrative management may affect retention of physicians in this setting. Successful implementation of the Affordable Care Act relies on expansion of CHCs. A stable and growing workforce of family physicians is a critical component of this expansion. Thus, increased work to create sustainable working conditions for family physicians in CHCs is necessary. Authors’ Note Portions of this work were presented at the Society of Teachers of Family Medicine Annual Spring Meeting in April 2012 and North American Primary Care Research Group Annual Meeting in December 2012.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:
University of Washington, Department of Family Medicine, NRSA Primary Care Research Fellowship; University of Washington Family Medicine Residency Network.
References 1. Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. JAMA. 2006;295:1042-1049. 2. Savageau JA, Ferguson WJ, Bohlke JL, Cragin LJ, O’Connell E. Recruitment and retention of primary care physicians at community health centers: a survey of Massachusetts physicians. J Health Care Poor Underserved. 2011;22:817-835. 3. Singer JD, Davidson SM, Graham S, Davidson HS. Physician retention in community and migrant health centers: who stays and for how long? Med Care. 1998;36:1198-1213. 4. Kim S, Phillips WR, Stevens NG. Family practice training over the first 26 years: a cross-sectional survey of graduates of the University of Washington Family Practice Residency Network. Acad Med. 2003;78:918-925. 5. Strauss A, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage; 1990. 6. Curlin FA, Serrano KD, Baker MG, Carricaburu SL, Smucker DR, Chin MH. Following the call: how providers make sense of their decisions to work in faith-based and secular urban community health centers. J Health Care Poor Underserved. 2006;17:944-957. 7. Stevenson AD, Phillips CB, Anderson KJ. Resilience among doctors who work in challenging areas: a qualitative study. Br J Gen Pract. 2011;61:e404-e410. 8. Cole AM, Doescher M, Phillips WR, Ford P, Stevens NG. Satisfaction of family physicians working in community health centers. J Am Board Fam Med. 2012;25:470-476. 9. Mainous AG 3rd, Ramsbottom-Lucier M, Rich EC. The role of clinical workload and satisfaction with workload in rural primary care physician retention. Arch Fam Med. 1994;3:787-792. 10. Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151:28-36, W6-W9. 11. Shi L, Samuels ME, Cochran CR, Glover S, Singh DA. Physician practice characteristics and satisfaction: a ruralurban comparison of medical directors at U.S. Community and Migrant Health Centers. J Rural Health. 1998;14: 346-356. 12. Cochran C, Peltier JW. Retaining medical directors in community health centers. The importance of administrative relationships. J Ambul Care Manage. 2003;26:250-259. 13. Manca DP, Varnhagen S, Brett-MacLean P, et al. Rewards and challenges of family practice: Web-based survey using the Delphi method. Can Fam Physician. 2007;53:278-286. 14. Ruhe M, Gotler RS, Goodwin MA, Stange KC. Physician and staff turnover in community primary care practice. J Ambul Care Manage. 2004;27:242-248. 15. Pathman DE, Williams ES, Konrad TR. Rural physician satisfaction: its sources and relationship to retention. J Rural Health. 1996;12:366-377.
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Cole et al Author Biographies Allison M. Cole, MD, MPH is Assistant Professor in Family Medicine at the University of Washington in Seattle. Frederick M. Chen, MD, MPH is Associate Professor in Family Medicine at the University of Washington and Chief of Family Medicine at Harborview Medical Center.
Paul A. Ford, MA, is Teaching Associate in Family Medicine and the University of Washington Family Medicine Residency Network. Nancy G. Stevens, MD, MPH is Professor in Family Medicine at the University of Washington and Director of the University of Washington Family Medicine Residency Network.
Downloaded from jpc.sagepub.com at UQ Library on June 15, 2015
research-article2013
JPCXXX10.1177/2150131913501519Journal of Primary Care & Community HealthCole et al
Research Letter
Rewards and Challenges of Community Health Center Practice
Journal of Primary Care & Community Health 2014, Vol. 5(2) 148–151 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131913501519 jpc.sagepub.com
Allison M. Cole1, Frederick M. Chen1, Paul A. Ford1, William R. Phillips1, and Nancy G. Stevens1
Abstract Background: More than 1100 community health centers (CHCs) in the United States provide primary care to 20 million underserved patients annually. CHCs have struggled to recruit and retain qualified physicians. Objective: To understand physicians’ work experiences in CHCs and identify major sources of satisfaction and dissatisfaction. Methods: Using purposeful sampling, we conducted semistructured interviews with 12 family physicians practicing in CHCs. Interview questions assessed physicians’ experiences in CHCs and sources of satisfaction and dissatisfaction. Interview notes were coded and analyzed by 2 investigators using a grounded theory approach to identify key themes. Results: Though family physicians feel tremendous satisfaction from care of underserved patients, they are frustrated with the overwhelming workload they experience. Family physicians also report poor administrative management while working in CHCs. Conclusions: Implementation of the Affordable Care Act, which relies on expansion of CHC services, may be adversely affected by family physicians’ frustrations with CHC practice. Further research to explore and potentially improve the CHC work environment may be needed. Keywords community health centers, job satisfaction, qualitative, physicians, primary health care
Introduction
Methods
There are more than 1100 community health centers (CHCs) in the United States that provide primary care to more than 20 million underserved patients annually. Demand for CHC services is expected to increase with implementation of the Affordable Care Act. CHCs have struggled to recruit and retain qualified physicians.1 In a recent survey in Massachusetts, 16% of CHC physicians planned to leave their current practice within 5 years, and 52% planned to leave their current practice within 10 years.2 A nationwide study of actual turnover in CHCs demonstrated that the median duration of practice for new CHC physicians is only 3 years, with almost two thirds of physicians having left their CHC practices by 5 years.3 Family physicians comprise more than 50% of the CHC physician workforce.1 Thus, promoting family physician retention is an important strategy to ensure adequate access to primary care. Understanding of sources of satisfaction for family physicians in CHCs may guide development of focused recruitment strategies. Understanding sources of dissatisfaction may be helpful in developing innovative approaches to improve family physician retention in CHCs.
The primary investigator (AMC) conducted interviews with 12 family physicians practicing in health centers. This project was reviewed and approved by the institutional review board at the University of Washington. We identified eligible physicians from respondents to the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) Family Medicine Residency Network Graduate Follow Up Survey. This survey4 is conducted every 3 years to assess current practice and residency training. Physicians reporting practice in a CHC, migrant health center, or federally qualified health center were eligible to participate. We purposefully selected a sample of 50 physicians that maximized variation in gender, years in practice, and geographic location of practice. Eighteen physicians agreed to participate and 12 completed interviews The principal investigator (AMC) drafted an 1
University of Washington School of Medicine, Seattle, WA, USA
Corresponding Author: Allison M. Cole, Department of Family Medicine, University of Washington, 4311 11th Avenue NE, Suite 210, Seattle, WA 98195-4982, USA. Email: [email protected]
Downloaded from jpc.sagepub.com at UQ Library on June 15, 2015
149
Cole et al interview guide consisting of 12 open-ended questions with prompts for follow-up when needed. The interview guide included topics such as choice of current job, what is best/ worst about current job, how information is communicated, how decisions are made, and future career plans. Verbal consent was obtained prior to interview. Interviews lasted 30 to 60 minutes. The principal investigator conducted all interviews by telephone (n = 10) or in person (n = 2) at a time and location that was convenient for the subject. The interviewer took detailed notes during the interview and revised all notes for accuracy and detail immediately following the interview. Interview notes were analyzed using a grounded theory approach.5 Two authors (AMC, FMC) independently read and coded 2 transcripts using an iterative process to develop an open coding scheme. The authors independently coded the remaining interviews. A third author (PMF) independently reviewed the coding scheme and all coded notes to ensure that codes had been applied consistently and the selection of codes was complete. We continued to conduct interviews and code interview notes until thematic saturation had been reached.
Results Satisfaction From Work Participants were enthusiastic in reporting the aspects of working at a CHC that they found particularly rewarding. For the majority of physicians interviewed the mission of CHCs was very important to them and something with which they strongly identified. In particular, they highlighted the opportunity to care for patients who otherwise would not receive care and sense of gratitude they perceived from the patients. Other physicians cited an opportunity to work with specific populations and communities. This led to an overall sense of family physicians feeling like they were “making a difference.”
Overwhelming Workload When asked about sources of dissatisfaction, family physicians almost uniformly identify overwhelming workload as a significant burden. When describing their current workload, the majority attributed the workload to patient care demands, including the volume of patient visits, the complexity of patient care, and long work hours as factors. This led to several family physicians to question whether their current jobs were sustainable.
Administrative Management Family physicians described frustrations with administrative management at the CHCs where they worked. Findings highlighted hierarchical administrative structures and lack
of opportunity for physician input into practice. Family physicians expressed frustration that there were no clear mechanisms for providing input into administration and operations and physicians were not given opportunities to make changes in their work environment.
Discussion Our study suggests that family physicians working in CHCs report tremendous satisfaction from care for the underserved. However, they also identify overwhelming workload and poor administrative management as major sources of dissatisfaction in their current practices. We found that physicians feel a strong commitment to the mission of CHCs and satisfaction from providing care to underserved patients. This commitment to the mission of CHCs may play an important role in physician recruitment. A survey of physicians practicing in CHCs identified commitment to the mission of CHCs as the most important factor in selecting a CHC job.2 Another qualitative study found that in particular, faith-based CHCs attracted a group of providers with the desire to fulfill a religious calling to ministry through the practice of medicine.6 A study in Australia of physicians who had worked in underserved settings longterm suggested that resiliency was promoted by feeling their work was the “right thing to do” and a deep appreciation and respect for the population they served.7 This is consistent with reports that National Health Service Scholars are less likely to stay in underserved settings long term than physicians who choose to practice in underserved settings without financial incentives.3 A second key finding was that physicians describe feeling overwhelmed by the workload of CHC practice and that poor administration is common. This offers some explanation for a recent finding that CHC physicians were less likely than non-CHC physicians to be highly satisfied with their employers.8 Dissatisfaction with workload among primary care physicians is associated with increased likelihood of leaving current practice.9 Physician perceptions of “low work control” are strongly associated with low physician satisfaction, high stress, burnout, and intent to leave a practice.10 Among CHC medical directors, there is a strong association between satisfaction with administration and overall job satisfaction.11 CHC medical directors who report strong relationships with administrative directors are more likely to stay in their jobs.12 While excessive workload has been identified as a key concern among practicing family physician,13 poor administrative management has not previously been highlighted. Hierarchical organization in community practices is associated with increased physician turnover.14 However, among rural physicians, satisfaction with autonomy is not associated with retention.15 For CHC medical directors, strong
Downloaded from jpc.sagepub.com at UQ Library on June 15, 2015
150
Journal of Primary Care & Community Health 5(2)
relationships with administrative directors are associated with retention.12 Whether or not the dissatisfaction with CHC administrative management identified by family physicians in our study is associated with retention is an important question worth further research. Though we interviewed a small number of family physicians, we used purposeful sampling based on demographics to maximize the variation in responses. In addition, we only interviewed family physicians for this study. Even though family physicians comprise the largest group of providers at CHCs,1 the findings here may not generalize to other providers working at CHCs such as general internists, general pediatricians, or mid-level providers. Finally, our sample was obtained exclusively from a group of family physicians that graduated from one of the WWAMI Family Medicine Residency programs. All our respondents were practicing in the Northwest region of the United States. It is possible that aspects of training or geographic region influenced their perceptions of their work environment, and thus our conclusions may not apply to physicians who graduated from different programs or practice in different regions. However, our sample included physicians practicing in a variety of settings and those recently graduated as well as more experienced physicians. Further research should evaluate the work environment from the perspectives of CHC staff and administrators to confirm our findings. Our findings present a significant level of detail on the experience of family physicians working in CHCs. Though CHC physicians demonstrate a strong commitment to care for the underserved, we are concerned that frustrations with workload and poor administrative management may affect retention of physicians in this setting. Successful implementation of the Affordable Care Act relies on expansion of CHCs. A stable and growing workforce of family physicians is a critical component of this expansion. Thus, increased work to create sustainable working conditions for family physicians in CHCs is necessary. Authors’ Note Portions of this work were presented at the Society of Teachers of Family Medicine Annual Spring Meeting in April 2012 and North American Primary Care Research Group Annual Meeting in December 2012.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:
University of Washington, Department of Family Medicine, NRSA Primary Care Research Fellowship; University of Washington Family Medicine Residency Network.
References 1. Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. JAMA. 2006;295:1042-1049. 2. Savageau JA, Ferguson WJ, Bohlke JL, Cragin LJ, O’Connell E. Recruitment and retention of primary care physicians at community health centers: a survey of Massachusetts physicians. J Health Care Poor Underserved. 2011;22:817-835. 3. Singer JD, Davidson SM, Graham S, Davidson HS. Physician retention in community and migrant health centers: who stays and for how long? Med Care. 1998;36:1198-1213. 4. Kim S, Phillips WR, Stevens NG. Family practice training over the first 26 years: a cross-sectional survey of graduates of the University of Washington Family Practice Residency Network. Acad Med. 2003;78:918-925. 5. Strauss A, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage; 1990. 6. Curlin FA, Serrano KD, Baker MG, Carricaburu SL, Smucker DR, Chin MH. Following the call: how providers make sense of their decisions to work in faith-based and secular urban community health centers. J Health Care Poor Underserved. 2006;17:944-957. 7. Stevenson AD, Phillips CB, Anderson KJ. Resilience among doctors who work in challenging areas: a qualitative study. Br J Gen Pract. 2011;61:e404-e410. 8. Cole AM, Doescher M, Phillips WR, Ford P, Stevens NG. Satisfaction of family physicians working in community health centers. J Am Board Fam Med. 2012;25:470-476. 9. Mainous AG 3rd, Ramsbottom-Lucier M, Rich EC. The role of clinical workload and satisfaction with workload in rural primary care physician retention. Arch Fam Med. 1994;3:787-792. 10. Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151:28-36, W6-W9. 11. Shi L, Samuels ME, Cochran CR, Glover S, Singh DA. Physician practice characteristics and satisfaction: a ruralurban comparison of medical directors at U.S. Community and Migrant Health Centers. J Rural Health. 1998;14: 346-356. 12. Cochran C, Peltier JW. Retaining medical directors in community health centers. The importance of administrative relationships. J Ambul Care Manage. 2003;26:250-259. 13. Manca DP, Varnhagen S, Brett-MacLean P, et al. Rewards and challenges of family practice: Web-based survey using the Delphi method. Can Fam Physician. 2007;53:278-286. 14. Ruhe M, Gotler RS, Goodwin MA, Stange KC. Physician and staff turnover in community primary care practice. J Ambul Care Manage. 2004;27:242-248. 15. Pathman DE, Williams ES, Konrad TR. Rural physician satisfaction: its sources and relationship to retention. J Rural Health. 1996;12:366-377.
Downloaded from jpc.sagepub.com at UQ Library on June 15, 2015
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Cole et al Author Biographies Allison M. Cole, MD, MPH is Assistant Professor in Family Medicine at the University of Washington in Seattle. Frederick M. Chen, MD, MPH is Associate Professor in Family Medicine at the University of Washington and Chief of Family Medicine at Harborview Medical Center.
Paul A. Ford, MA, is Teaching Associate in Family Medicine and the University of Washington Family Medicine Residency Network. Nancy G. Stevens, MD, MPH is Professor in Family Medicine at the University of Washington and Director of the University of Washington Family Medicine Residency Network.
Downloaded from jpc.sagepub.com at UQ Library on June 15, 2015
