Rural Medical Education
The primary concern of rural medical education is addressing the health care
needs of rural peoples in the United States.
Geography, Physician Distribution, and Rural Health Challenges
From the geographic perspective:
• Urban areas include 20 % of the land area, 75 - 80% of the population, and
about 89 - 91% of physicians depending upon the mapping method. Urban born
students are similarly 90% of medical students.
• Rural areas are 80% of the land area of the nation and contain 20 – 25% of the
population and 9 - 11% of the physicians. Rural students have declined to 10% of
allopathic medical students. Rural cities train less than 4% of medical students
and residents. Less than 2% of the physicians associated with medical school zip
codes are listed at rural locations.
The nation sends over 98% of graduate medical education funding and over 99% of
the 16 billion in National Institutes of Health funding to urban areas. Only 3%
of the major medical center physicians in the nation, those located in zip codes
with over 75 physicians, are in rural areas. Rural physicians, rural hospitals,
and the family physicians that are more and more likely to be found as levels of
physicians, population, and health resources decrease, are paid at the lowest
levels.
Rural areas have all of the health care needs of urban areas but have fewer
health care providers and fewer specialized services. Few physicians are trained
outside of major medical centers, fewer are trained in rural areas, and even
fewer are trained to meet the specific needs of rural people and communities.
Rural areas share the health, income, and education problems of inner city areas
and then add some more complicated wrinkles.
• Geographic distances and barriers
• Primary care physician shortages and few specialists
• Rural peoples are older and sicker and have the most hazardous occupations.
• Rural peoples have lower health care coverage and the poorest mental health
and dental health in the nation.
• Not uncommonly state and federal programs involving health care, mental
health, or public health programs are nonexistent or accessed poorly in rural
areas.
• State and federal programs provide less than adequate workforce solutions such
as temporary physicians. Physicians are often not a good match to people or
communities in the most need of care. The increased turnover of temporary
physicians is costly in terms of replacement, poor use of local services, and
loss of local market share from rural systems. The smallest systems must have
coordination and cooperation of all providers, administrators, and facilities
and demands personnel that are committed to the long term.
The two major employers in rural areas are health care and education and the
major determinant of funding for these areas is government. Rural areas return
the favor by some of the most efficient health care and education systems in the
nation. Rural areas tend to be areas where increased expenditures mean improved
outcomes. Across state levels and urban areas, more health care spending is
associated with lower quality. (State correlations)
The nation finds it easy to ignore areas with fewer people, lower income people,
and populations with fewer people. Where all three are found together the people
have the greatest challenges in health, education, economics, and other areas.
This includes the 3 million people in predominantly Hispanic counties on the
border, the 3 million people in the predominantly Black counties in the South,
and the 500,000 in counties where Native peoples are a major group. The
situation is also not improving for the remaining 60 million in Rural America
where 90% are white. The different combinations of peoples, income levels,
health resources, economics, cultures, and education levels present daunting
challenges.
One Size Does Not Fit All: Understanding Physician Distribution
Perhaps the greatest obstacle is a one size fits all mentality for health care,
education, and medical education policy. Those that have done the most to
address health care needs for rural or underserved peoples have been the ones
that have adapted to rural needs. Community Driven Medical Education is a term
that refers to efforts to focus on rural community needs. Adaptations include
improvements in rural education, efforts involving rural colleges, broader
medical school admissions, specific training, and health policy improving health
care coverage.
The one size that the United States favors most is XXXL. About 90% of the
physicians in the United States are stacked in urban areas and 71% of physicians
share major medical center locations with 75 or more physicians at a single zip
code.
Understanding physician distribution involves understanding why physicians fail
to distribute. The physicians most likely to stay in urban and major medical
center areas were born, raised, educated, and trained in such locations in this
nation or in others. The major medical center magnetic attractions of family,
peers, colleagues, urban opportunities, and urban lifestyle are significant.
Health policy also favors urban and major medical center locations as these are
the locations with higher reimbursements, more resources, and the large
collections of patients required for subspecialists.
The complexity of care involving rural and underserved populations and
especially rural and underserved populations has been grossly underestimated. It
is difficult for those who have been born, raised, educated, trained, and
located in the most urban and highest income medical school locations to
comprehend. Frankly they have encountered very few distributional students and
even fewer family physicians.
For those steeped in this nondistributional perspective, physician distribution
appears to be an impossible task. The scientific findings conflict with this
opinion. Physicians have been distributed by a number of methods that are
documented in the medical literature in multiple programs, medical schools, and
statewide efforts lasting for decades. The successful efforts consistently
involve
1. Admission of rural background students
2. Admission of students interested in family medicine
3. Graduation of more family physicians
Education and health policies that accomplish the above also facilitate the
distribution of physicians to rural areas.
Specific efforts to graduate more family physicians also have resulted in more
rural physicians, as in the distributional medical schools. Those with rural
origins and lower income origins are not only the most likely to choose rural
locations, they are also the most likely to choose family medicine. Middle
income and diverse students also choose family medicine and rural practice at
higher levels. Medical schools that have average MCAT scores or lower scores
also have greater levels of physician distribution.
In fact the only schools that do not distribute physicians and the only students
that do not distribute are those that have the highest scores, the most urban
origins, the youngest ages, and the most elite origins. These include students
from families with the highest levels of income, education, and professional
degree. Even Association of American Medical Colleges leaders such as Michael
Whitcomb has noted that the nation is in danger of having physicians who share
origins with only the very rich. Acad med june 06
Age, origins, socioeconomics, and choice of family medicine also impact
physician distribution. For allopathic graduates of United States medical
schools, family physicians are 30% of all rural physicians, increasing to 58%
for isolated rural or lower income rural counties. Family physicians are 50% of
the physicians in Community Health Centers, increasing to 61% of rural Community
Health Center physicians. (Rosenblatt)
The databases used in this section involve the AMA Masterfile in 2005 locations.
The most recent 40% of the workforce was included, those graduating from
allopathic medical schools in the United States from 1987 – 1999. Each year
about 16,000 allopathic US graduates enter practice out of 22,000 – 23,000
graduates of all medical schools worldwide that end up as US physicians. (MMS
Masterfile reference)
Physician locations are mainly expressed as zip codes in physician databases
such as the American Medical Association Masterfile. Rural Urban Commuting Area
codes were used to categorize rural location. Underserved locations were defined
as zip codes in whole county primary care shortage areas, the lowest 6% of
counties by income level, zip codes shared with Community Health Centers or
National Health Service Corps sites, or zip codes with over 20% of the nearest
population in poverty.
When including a number of years of graduates, the physician careers and
locations represent equilibrium conditions much more than first choices. In
these studies there are losses of general internal medicine and pediatrics
physicians and concentrations of physicians in major medical center locations.
The directions are reversed for family medicine. Family physicians accumulate
away from major medical centers and remain in office based primary care. Family
physicians
• Stay in family medicine at 98%;
• Stay in office based primary care at 90%, 95% for rural family physicians;
• Concentrate in lower income, underserved, shortage, Community Health Center,
and isolated rural areas providing 50 – 75% of total physicians.
Community Driven Approach: Linking Resources with True Needs
Birth Origins and Distribution Tables
Chief contact at CME, really helpful lady!
http://www.unmc.edu/Community/ruralmeded/RMEPost/RuralGME2.pdf
What we worked on
http://www.unmc.edu/Community/ruralmeded/RMEPost/defining_a_rural_residency.htm
Discussion around this
http://www.unmc.edu/Community/ruralmeded/RMEPost/defining_rural_medical_education.htm
Plans that we had and did some and still have
http://www.unmc.edu/Community/ruralmeded/RMEPost/federal_advocacy_report_2002.htm