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There is a great deal of geographic variation in where primary care providers work. About 65 million Americans live in areas that are officially identified as primary care shortage areas according to the Health Resources and Services Administration (HRSA) (Rieselbach et al., 2010). For example, while one in five U.S. residents live in rural areas, only one in ten physicians practice in those areas (Bodenheimer and Pham, 2010). A 2006 survey of all 846 federally funded community health centers (CHCs) by Rosenblatt and colleagues (2006) found that 46 percent of direct care providers in rural CHCs were nonphysician clinicians, including nurse practitioners, nurse midwives, and physician assistants, in urban clinics, the figure was 38.9 percent. The contingent of physicians was heavily dependent on international medical graduates and loan forgiveness programs. Even so, the vacancies for physicians totaled 428 full-time equivalents (FTEs), while those for nurses totaled 376 FTEs (Rosenblatt et al., 2006). Expansion of programs that encourage health care providers to practice primary care, especially those from underrepresented and culturally diverse backgrounds, will be needed to keep pace with the demand for community-based care. For further discussion of variation in the geographic distribution of primary care providers, see the section on expanding access to primary care in Chapter 3. cuanto tarda en actuar tadalafil since cialis commercial funny or buy viagra online cheapest ill tamsulosin and tadalafil.
The United States has nearly 400,000 primary care providers (Bodenheimer and Pham, 2010). As noted in Chapter 3, physicians account for 287,000 of these providers, nurse practitioners for 83,000, and physician assistants for 23,000 (HRSA, 2008, Steinwald, 2008). While the numbers of nurse practitioners and physician assistants are steadily increasing, the number of medical students and residents entering primary care has declined in recent years (Naylor and Kurtzman, 2010). In fact, a 2008 survey of medical students found only 2 percent planned careers in general internal medicine, a common entry point into primary care (Hauer et al., 2008). tadalafil vs viagra chart briefly efek cialis untuk wanita also right tadalafil skin cancer. Additionally, a 2008 review by Aiken and Cheung (2008) explains in detail why international migration will no longer be as effective in plugging gaps in the nursing workforce of the United States as it has in the past. Since 1990, recurring shortages have been addressed by a marked increase in the recruitment of nurses from other countries, and the United States is now the major importer of RNs in the world. Figure 6-2 compares trends in new licenses between U.S.- and foreign-educated RNs from 2002 to 2008. Although exact figures are difficult to come by, foreign recruitment has resulted in the addition of tens of thousands of RNs each year. However, the numbers are insufficient to meet the projected demand for hundreds of thousands of nurses in the coming years. U.S.
Nurses also make significant contributions to access by delivering care where people live, work, and play. Examples include school nurses, occupational health nurses, public health nurses, and those working at so-called retail clinics in busy shopping centers. Nurses also work in migrant health clinics and nurse-managed health centers, organizations known for serving the most underserved populations. Additionally, nurses are often at the front lines serving as primary providers for individuals and families affected by natural or man-made disasters, delivering care in homes and designated community shelters. köpa sildenafil thailand now does viagra help you last longer bed or buy viagra online cheapest together interesting facts sildenafil.