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80 Making General Practice Attractive: Encouraging GP attraction and Retention KCE Reports 90 and to identify with the positive aspects of rural practice. In the USA, programs in this field are generally linked with medical curricula, as seen above in the "attraction" 50 , 157 section. For example, rural preceptorship is part of RMED programs (preceptorship means "a period of practical experience and training for a student that is supervised by a specialist in a particular field", in contrast with residency, which is "a period of time, after completing an internship, during which a doctor receives special training in a particular type of medicine"). Original programs were developed to meet the needs of urban lower economic and minority communities. For example, the Urban Family Medicine Residency Program of the Ohio State University 85 was established to improve access of population to health services. The program admits about 2 residents for training each year. Other programs may be relatively autonomous from medical schools, such as the Appalachian Preceptorship Program of the East Tennessee State University, started in 1984 106 . This 4-week summer training served 225 medical US and foreign students between 1985 and 2004. Rural training tracks (RTT) (in Geyman et al 2000 153 ) are residency programs developed in the 1980s: the first year of residency occurs in a large urban teaching center and the second and third years occur in small family practice groups in a distant rural community, implying a major move. It is not sure if RTT are effective and if they cost less or more as traditional family practice residencies. According to Pathman et al 1999 109 , US physicians who are prepared to be rural physicians, particularly those who are prepared for small-town living, stay longer in their rural practices. Residency rotations in rural areas are the best educational experiences both to prepare physicians for rural practice and to lengthen the time they stay there. Preparedness would therefore be seen as a retention rather than a recruitment policy. ECONOMIC INCENTIVES US federal financial incentives US federal financial incentives were created to address inequities existing in the availability of GPs between rural and urban areas. The first one targets graduate students with funded scholarship and obligated service (the National Health Services Corps - NHSC, 1972). The second one targets medical schools with funding (Title VII of Public Health Services Act, 1976). Funded scholarship coupled with obligated service Funded scholarships are a controversial measure. They address the issue of recruitment in physician shortage areas with less emphasis on retention: when GPs complete their obligated service, they are able to move into other areas. Generally, the shift is from rural to urban areas. The National Health Service Corps (NHSC) is a major US government initiative aimed to address the shortage of physicians in rural and underserved areas 162 . Since its introduction in 1972, the NHSC has placed more than 15000 physicians in rural areas at a cost of more than $ 2 billion. The feature of the NHSC Program is the provision of financial support to health professional students in exchange for obligated service in selected rural and underserved areas. For each year of financial assistance received, students incur 1-year obligated service as a NHSC physician 162 . The hope is that once NHSC assignees will have completed their obligated service, the experience will encourage them to remain beyond the period of obligation. Probst et al 2003 163 showed that NHSC alumni (i.e. physicians who once served in the NHSC) are more likely than non-NHSC to have high Medicaid patients and practice in areas with health professions shortage and high percentage of minorities and people living in poverty. It cannot be excluded that students with specific profiles are selfselected to the program, but no information was found about this. Some recipients of the scholarship have described the NHSC obligated service as a "period of servitude". Therefore, the length of time a NHSC physician remains in their assigned practice, beyond the obligation period, is crucial in the evaluation of the program. Nobody casts doubt upon the merits of the NHSC but its effectiveness is questionable 162 .
KCE Reports 90 Making General Practice Attractive: Encouraging GP attraction and Retention 81 Title VII of the Public Health Service Act The other US federal financial incentive, Title VII of the Public Health Service Act (1976), authorizes a myriad of programs for students and institutions to improve the geographic distribution, quality, and racial and ethnic diversity of the health care workforce. Title VII funding of departments of family medicine at U.S. medical schools is significantly associated with expansion of the primary care physician workforce and increased accessibility to physicians for the population of rural and underserved areas 164 1372 , 165 . Between 1978 and 1993, 2268 Title VII grants were awarded to 120 U.S. medical schools for family practice predoctoral programs, departmental support, and faculty development. Grants to departments of family medicine in these three programs totaled $290 million over this 16-year period, with an average annual grant amount per institution of $127500. In a comprehensive analysis of Title VII funding between 1978 and 1993, approximately 180 000 medical school graduates were followed to evaluate their practice specialty and practice location in the year 2000. Students who attended schools that received no family medicine Title VII funding during their four-year tenure chose family practice at a rate of 10.2 percent. On the opposite, students who attended schools that received that funding for one or more years of their enrolment chose family practice at a rate of 15.8 percent. Additionally, Title VII funding was associated with higher rates of practice in whole county primary care health personnel shortage areas (1.2 versus 1.5 percent) and practice in a rural area (9.5 versus 12.7 percent). A causal relationship is difficult to ascertain: it is unclear whether some characteristics of medical schools (e.g. location, students’ population) are associated with receiving Title VII funds. In their cross-sectional study on GP location in year 2000, Krist et al (2005) 149 show that Title VII funding of medical students as well as medical schools is associated with an increase in the family physician workforce in rural and low-income communities, and is temporally related to initiation of funding. Krist et al. 2005 149 observed increases by 2% of the number of GPs in underserved communities, which is, according to the authors, "a substantial increase as regards access to healthcare". US state programs offering financial incentives Many US state programs 166 furthermore provide financial support to physicians and midlevel practitioners in exchange for a period of service in underserved areas. These programs may contribute to the US health care "safety net". Pathman et al (2000) 166 identified 82 eligible programs operating in 41 states, including 29 loan repayment programs (funds to repay educational loans of graduates and practitioners in exchange for service), 29 scholarship programs (funds to students for tuition, fees and living expenses, with expected service after training), 11 loan programs (loans to students for tuition, fees and living expenses, with reimbursement or with exchange for service after training), 8 direct financial incentive programs (funds for residents and practitioners in exchange for service), and 5 resident support programs (funds for residents with expected service after training). The three common features of state programs are a mission to influence the distribution of the health care workforce within the state, an emphasis on primary care and the reliance on annual state appropriations and other public funding mechanisms. In 1996, an estimated 1306 physicians and 370 midlevel practitioners were serving obligations to these state programs, a number comparable with those in federal programs. The authors conclude that these state programs constitute a major portion of the US health care safety net. Pathman et al 2000 166 observed than among physicians who train as GPs, the high costs of medical education in the USA appear to promote among future GPs national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for GPs should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging poor students from medical careers. Obviously, this is a context-dependent conclusion.
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