About the Site and Author Robert C. Bowman, M.D.

Summary of Impacting at Multiple Points - must have a comprehensive approach   

Why family physicians are important - Primary Care Retention and sustained distribution

Quick Review of Approaches That Work:

1. State recruitment efforts such as NC AHEC or Wisconsin Office of Rural Health

2. Small College Approach such as PSAP in Pennsylvania, RHOP in Nebraska - basically get small town people into smaller colleges using small college advisors and rural college locations so they don't marry urban spouses and lifestyles - very low cost approach and documented effectiveness

3. Special Rural Tracks - multiple examples to socialize and protect rural-interested students throughout training, RPAP in Minnesota, Accelerated Rural Training Program in Nebraska

4. Primary Care Only Medical Schools - none in existence - it is about time we had them

During the past century of great change in health care, one thing remains constant - the need for rural doctors. Periodically interest in rural health peaks and a new intervention is added, but rarely is that intervention evaluated or coordinated with other rural programs for maximal effect. This article reviews current data and impressions by experts in the hope that more will adapt a continuous approach to rural medical education beginning and ending successfully in rural communities

The Value of a Rural Family Physician is more than health services and support of facilities. Each physician costs over $300,000 in state tax dollars for some 20 years of education; however, each rural physician is economically worth $380,000 a year and 18 jobs to the local community (Gerald Doeksen OSU 1985). Others estimate 1 million a year By the numbers: Rural Doctors and Rural Economies. Further investment is needed after formal training ends. Corporate medical groups anticipate a $400,000 to 500,000 investment before a primary care doctor becomes "productive". The health business is big business, especially in rural communities where up to 25% of the jobs are health-related. One of the key factors in the success or failure of rural communities is attracting and retaining young professionals and their families. More about the importance of the rural doctor, economically and socially

Methods to Increase Rural Workforce  

A. "Borrow" (steal) providers from other states (or nations)

B. Produce rural doctors in and from the state

C. Support current workforce better

D. Utilize new sources of workforce

Each single method above has consequences that make a single choice ineffective. "Borrowing" from other states leads to increased demand and escalation of the recruiting wars - a war that rural areas with fewer resources cannot win. Producing rural physicians is a specialized effort. States investing solely in producing rural doctors can lose their current rural physicians unless efforts are broadened to keep them in the state. Support of current rural workforce can increase provider satisfaction through organized call sharing, networks, or continued training. The best solution is not A, B, C, or D. The best answer is "E", to integrate all of the above. No one intervention can address rural needs. State, academic, and rural communities must work together. The following guideline is useful for approaching rural workforce.

Also note that other states that fail to graduate students from high school or that fail to invest in higher education or medical education often steal the products of states that do invest in child development, early education, and more. Bright Future Rankings

Integrate - Workforce interventions are interdependent. With a coordinated rural medical education program, a state has the best chance of getting and keeping rural physicians. This means coordination between rural communities, state colleges (particularly the smaller ones), academic centers, training locations, and state government.

Rural is the critical component. Rural communities and physicians are essential for rural medical education. One of the real values of being rural is a willingness to tackle problems with available resources. Rural communities need to be independent, not dependent. Also the doctors that stay the longest come from the most rural communities.

Multiple points - Medical education for rural practice involves four years of medical school and at least three years of residency. The range of programs to address rural needs extends from high school to established practitioners. Each step of education, especially in urban subspecialty environments, can represent a barrier to the choice of rural practice if certain concerns are not addressed. With such a long pipeline of education, even small leaks at multiple points can mean few rural physicians at the other end.

This is a difficult task. Rural medical education in 2001 is about as established as family medicine was in its infancy in the 1970. Rural has never been a top priority for allopathic medical schools and even osteopathic medical schools have demands that compete with their rural and primary care emphasis. Only a handful of medical schools have serious rural programs that address student needs. Only a small percentage of family practice residencies are truly preparing graduates for rural practices. Rare is the allopathic academic institution that prioritizes students who are the most likely to be rural physicians, the combined 1-2 punch of the Duluth and Rural Physician Association Programs (MN) and the Upper Peninsula (MI) program being the notable exceptions. Family practice residents are the key source of future rural physicians, but comparisons of national data on 1986 and 1996 graduates show declines in all rural location categories while inner city underserved locations tripled from 2 to 6 %. Certainly some of above changes are due to changes in gender and the loss of towns from the smallest rural categories, but without intervention the needs of rural towns cannot be met.

An integrated, rural-based approach to rural medical education levels can serve to produce more rural physicians while supporting existing ones. The following programs represent partnerships between community and academic communities that are arranged by rural faculty. Each can increase the production of workforce, support existing physicians, and add needed support for rural physicians and communities.

For a summary of programs that work

Getting rural doctors to the smallest towns

In 1971 the Minnesota legislature created the Rural Physician Associate Program. About 30-40 RPAP students spend most of their third year in a rural location. The third is the first full time clinical year and the time when most students make their residency selection decisions. The third year usually involves two to three month rotations through medicine, surgery, and other basic clinical rotations. Shorter rotations are of little service help to hospitals, clinics, or rural physicians. By the time a student arrives and learns the system, they have to go. Students who choose RPAP spend 9-12 months in a rural location. The preceptor trains a student-assistant that can see many patients at the office and screen patients at the ER. RPAP students can produce an extra $40,000 to $70,000 a year of income for their preceptor. RPAP-trained physicians are leaders at local, state, and national levels in service, research, and education (John Verby). The improved access to physicians, the better education, the support of the rural doctor and health system, and the economic impact of the rural physicians after graduation are worth the million dollar yearly state investment in RPAP. RPAP physicians since 1971 have added about a billion dollars to the economy in Greater Minnesota. Other impacts include assistance with retention efforts and improved recruitment into the smaller towns. The initial critique of RPAP is that it was not as educational. Extensive studies prove that it is equivalent or better than the usual third of medical school in knowledge, attitude, procedural, and behavioral categories. Despite this documentation, the RPAP program remains mostly a model with only a handful of fairly recent imitators.

About 50% of family practice residencies require a rural experience of some type. Program directors in Nebraska got together in the 1970s and created the Nebraska Combined Outstate Residency Education (CORE) program. All Family Practice residents serve two consecutive months at one of four rural sites. The program limits sites to ensure a continuous stream of residents each 2 month period for up to 3 years. Only sites that have three to five physicians and are in need of 1-2 providers are selected, assuring a definite rural experiences and a continuing patient population for each successive resident. Sites are far enough from residency programs to ensure that residents live there. Residents basically become physicians in the community, sharing call and patients. Residents benefit because they leave as trainees and return as true physicians, more confident and efficient. The local providers get better call and the stimulation of educating a resident. The connection to the residency does much to educate the site as to the needs of new physicians. Over the past ten years of CORE with well over 30 sites, only two sites have not recruited a new physician during its term as a CORE site (for good reasons). Sites pay resident travel and $2000 per month stipend, but the work of the residents goes to support local physicians as well as stabilizing the health system. An additional cost is faculty and staff time to visit the sites and coordinate schedules. The program, like many rural programs, has had no formal evaluation, but the benefits are obvious to residents, the residency, the rural communities, and rural physicians. The state benefits by maintaining health services in needy rural communities. An added benefit is the maintenance of market share during a shortage of physicians and expansion of local market share, making it easier for a new physician to come in and take over.

Location, Location, Location. The location of a residency is the biggest factor in getting family physicians into the area. Research shows that the smaller the training location, the more likely that the residency will graduate rural physicians. Some of the larger rural towns can support the educational needs of residents for the entire three years of training. Others (Rural Training Tracks) can take FP residents for the last two years. RTT programs graduate 75+% of residents into rural practice vs an average of 22% nationally. Currently Nebraska has Rural Training Tracks across the state at Scottsbluff, North Platte, Kearney, Grand Island, and, in the next few years, Norfolk. These residents used to do 3 years of training in Omaha, but now they are in more rural locations and they are graduating into rural practices. They are also helping to meet local service needs in these towns.

Nebraska has two programs that assist rural-oriented students with their training decisions. The Primary Care Track program takes 4-5 senior medical students into a specialized 4th year of training to become a rural physician. The Accelerated Rural Training Program bridges the gap between medical school and residency by upgrading the senior (4th) year of medical school to the first year of residency. It adds a rural fellowship year to help train these rural-interested FP docs in procedural training so that fewer small town citizens have to travel out of town for services. By bridging the usual gap during the 4th year (the Match) where students often go out of state or look at other specialties, Nebraska keeps some of the best students in the state and gives them a better preparation for rural practice.

Bridging programs also connect Chadron State and Wayne State to UNMC in the form of the Rural Health Opportunities Program. By getting more students from the smallest towns into medical school, the graduates should choose more rural locations and stay in practice longer. The first RHOP class will graduate from residency in two years, but it will take another 6 years to begin to measure the effectiveness of the program. Chadron State has also reached out to rural communities with their own recruitment fair, attracting high school students, teachers, and parents from 4 states.

Barriers must be breached in order to get rural physicians into the pipeline. Many rural students do not know about health careers. Others just don’t think that they will do well enough to get admitted. Rural communities must expose their students to health careers and service opportunities. Kentucky offers special training for those interested in health professions. This includes assistance with college selection, curriculum, test-taking, and special activities to pursue.

Another barrier that must be addressed on the state level is the centralization of professional preparation courses in the major colleges. Small rural colleges are the breeding ground of future professionals for rural communities, teachers, doctors, lawyers, etc. After years of recovery, the state now faces the somber news that the rural economy is slowing and fewer young people are going to rural locations. States that push "educational efficiency" too far may end up having little left in rural areas. Small towns must priorities education and the state must maintain or expand the small college course selection. In 5 years of RHOP, one professor noted that the students went from 2 A’s to 14 A’s. She cites RHOP students and a resultant increase in those interested in professional degrees as the reasons. The result is likely a better education for all and more young professionals to smaller towns in the future. If rural students have to go to the big city for college, they will probably marry and urban spouse or one with a more specialized job. Rural communities also have to reverse attitudes that see local students who return as failures and those who leave as successes. Small towns should be proud if they recruit their own high school graduates back for professional jobs.

Bridging can occur from residency to rural practice through locums programs that get residents into small towns on vacations or weekends to help with patients. Fewer and fewer residents are choosing rural moonlighting. The fewer that take the rural moonlighting step, the fewer will step out to rural practice. Some coordination and funding could encourage this step. Recruitment fairs and dinners are another way to bridge the gap and keep residents on track to small towns.

Minnesota efforts http://www.ruralresource.org/index.shtml

Students can be employed by communities to assist with surveys or interviews to determine community health needs. The academic center can train the students and recruit them for service. Students benefit from the income and the opportunity to understand health care systems. Communities benefit from better information for the planning of health systems. Academic center can learn much about the needs of students and the state. The mutual connection drives other collaborative efforts. For example, the students gravitate toward the needs of teenagers. A statewide intervention on teenage problems such as pregnancy or alcohol consumption is in the planning stages. This is only one example of the power of integrating the enthusiasm of students, the leadership of the community, and the expertise of the academic centers.

Practitioner and graduate databases can help track individuals for recruitment and assess program effectiveness. Iowa has been one of the most effective states in this area with their Office of Community Based Programs directed by Roger Tracy. Recruitment activities such as meetings with communities, retreats for trainees, and fairs can improve the production of rural physicians. Any and all times are good times for such events, the earlier the better. Studies show that residents often choose from among their first five or six opportunities. States would do well to show them the sites where they could contribute the most as soon in their education as possible.

Some academic programs can shift over time from their initial rural focus. Many family practice and nurse practitioner programs have used a rural emphasis to justify funding, but not all have produced rural providers. Ensure that academic institutions and training programs are held accountable. The best rural programs select rural background students, have rural faculty, train students in rural locations (especially where the students have roots or have indicated an interest in locating), and have a track record of producing rural graduates.   More at Community Role

Impacting at Multiple Points in Rural Medical Education - Listed by year of impact

Beware of centralization issues that can defeat rural efforts. See Centralization and Regionalization

Sources of the Current US Physician Workforce - Essential specialty estimates and sources, geriatrics

Physician Workforce Studies

www.ruralmedicaleducation.org