From a Family Physician's Perspective

Robert C. Bowman, M.D.

Dr. Bowman is the Director of Rural Health Education and Research for the Department of Family Practice. He trained at Baylor College of Medicine, was a solo rural physician in Nowata, Oklahoma, and was director of rural programs at East Tennessee State University. Dr. Bowman is a member of the Health Policy Board of the National Rural Health Association. .

Rural communities, rural physicians, state lawmakers, educators, and government officials have many questions regarding the status of primary care in the state. Current concerns include changes in the health workforce, the survival of rural hospitals, funding complexities during an era of federal and state fiscal challenge, and the ever increasing need for information exchange about existing methods, resources, systems, and opportunities. The health care situation in Nebraska and other rural states is complex. The solutions will not be simple.

This need is even more critical in the counties with less than 10,000 people which represent 67 of the 93 counties in the state. These counties have less tax base, fewer workers, smaller numbers of health providers, gaps in basic services, more working poor, and often the challenge of greater distance. Nineteen counties had no doctor. Of the counties with physicians there were 183 total doctors or an average of 3.5 doctors in each of these most rural counties in 1993.

This paper will examine the current and proposed changes in state and federal legislation that will impact on the counties with less than 10,000. Although these counties only have a total population of 320,000, rural populations include an additional 502,000 people for a total of 52 % of the people in the state. Rural and urban cannot be fully separated as many urban people have jobs involving rural health in areas such as education, insurance, and government.

Each year more and more rural physicians retire, die, or leave practice. Family practice residencies have expanded to meet this need, but few medical students choose FP. Even though FPs are the most likely allopaths to choose rural, few do so. Osteopathic physicians are increasingly choosing the specialized pathways that have also attracted more and more nurse practitioners and physicians assistants. Primary care is, however, far more than numbers and distribution of providers.

Rural communities are still adjusting to the monthly bandaid regulations patching our health system. The eighties brought major changes such as DRGs, the OBRAs, and declining rural economies. The nineties birthed reimbursement changes and may yield a new health care system. Such major changes are likely to both help and hurt rural communities.

It is truly the best of times for some and the worst of times for others. The focus on state and national health policy is an example. The national debates regarding health systems hold promise for many who are currently punished, yet the focus at these levels distracts and overwhelms those who are currently out there doing the work. Rural hospitals, physicians, and communities often miss opportunities and lose precious resources by taking a wait and see attitude. No matter what plan is chosen, there is much to do now.

The most effective work can be done at the local level. Studies have shown that rural communities can do more to support and keep their doctors and hospitals by establishing local programs to keep their own citizens as patients, than they can by working to improve the flow of federal or state dollars into town (Amundson WAMI Rural Research Center).

Those wishing to impact on the production of rural physicians need to have a broad perspective that encompasses multiple levels and multiple locations. A useful reference point is the educational model. This is a chronological approach consisting of four components:

Pre-Professional Education most commonly includes efforts directed at the high school and college levels. Teachers, community people, parents, youth groups, and local providers are key resources for such training. Youth organizations can play a key role in health professions experiences. The commitment of the state to general education is important as schools need career counselors and school health nurses. At the college level, pre-medical programs and faculty prepare students for admission. Health education to all students is critical to both promote health careers and give future citizens a chance to promote their health and prevent disease.

Professional training for primary care physicians includes four years of medical school and three years of family practice, internal medicine, or pediatrics training. An important consideration in this component is the mission of the institution, representation of primary care by the leadership, support of primary care faculty, and commitment to an environment that enthusiastically supports primary care. In such an environment, students are more likely to give primary care a chance.

Post-training factors include recruitment and retention efforts, the current status of local health care, the status of local economy and education and leadership. Communities who take the time to plan their health care and inform (and involve) their citizens and the state about these efforts are in the best position to recruit and retain health care providers and services.

Primary care support at the state and national level is a must for successful production of rural physicians. Trainees at all levels examine what the big picture is for those who graduate. Reimbursement, lifestyle, availability of loans, practice opportunities, and other factors all can act as a magnet attracting some or repelling others. The state must have central coordination and planning. It must have the resources to do so. The national leadership must improve conditions for rural practitioners.

The transitions between the above stages may be the most critical times. Trainees must move physically and mentally from their homes into the training locations and then to rural areas. The path to rural practice is disjointed. There is no overlap between the segments. Communication is essential as changes in any facet can change the entire picture. The final transition from training to practice is critical as this is the key outcome yardstick. Lack of communication in this area can destroy years of effort at the other levels.

It is impossible to assess the many programs and years that make up the pipeline to rural practice. Suffice it to say that a single program cannot produce a rural physician. Each level builds on the next. However, a lack of effort at any level can dam the flow of rural physicians for many years.

It is imperative that programs be developed that interact at all levels. There needs to be some central coordination and all should participate in the planning. Each component should interact with the other to assure that physicians stay in the state.

The following are examples relating to the medical education model. Doctors are a major focus in the state. Recruitment and retention of rural physicians means improved health access, increased economic impact, and survival of the existing health system. Primary care doctors are not the only primary care providers. Nurses, nurse practitioners, physicians assistants, and some specialist physicians deliver primary care in Nebraska. Most communities focus on recruiting family physicians and the pipeline to rural practice that is discussed here is relevant to the production of FPs.

The following illustrate the current and potential programs at each level:

RECOMMENDATION - Studies needed to examine the current priority of science education as the major component of preparation for medical school.

The American Medical Association has noted that the development of physicians begins as early as the 4th grade. Science education is a crucial component in the development of today's physicians, but will science be as critical in the future? What about the need for social skills in primary care physicians? Should we continue to prioritize science on the MCAT and GPA scores. Should we approach current or future social workers, psychologists, counselors, and others to interest them in medicine as a career? Does a focus on science develop technologists and others likely to subspecialize? Clearly science is needed, but just as clearly we will need to re-examine our definition of a physician and who is likely to choose the primary care, geriatrics, preventive medicine, and psychiatric residencies that go unfilled at present. Now that the debates turn to who will provide primary care, the science question haunts us. Can we retrain specialists to be generalists, or are they too focused to be able to provide effective primary care?

RECOMMENDATION - Efforts are needed to reverse the decline of college and health career interest in rural high school students.

Career orientation is important in middle school and high school. This can come from presentations or school activities, but often these are extracurricular such as volunteering at hospitals or doctor's offices, medical explorers, or home extension activities. When examining the decreases in the numbers of rural physicians in the state, the declines in rural education in many states, the lack of health career orientation, and declines in health-related extracurricular activities have cut rural background applications to medical schools as much as 50%. Partnerships between medical organizations, local providers, local schools, medical schools, and educators at all levels would help to define and address this decline.

RECOMMENDATION - The RHEN program should be a top priority for UNMC. Those influencing trainees during premed should meet with those working with the students in medical school. The RHEN network is the connection between UNMC and the rural communities.

As students transit from home to professional education, the academic centers need to work closely with high schools and colleges to coordinate the preparation as well as maintain rural contact. Effective programs provide a seamless transition between the various levels rather than bumping them off track.

Existing connections within the Rural Health Education Network have just begun to impact on students in rural areas, informing them and their schools of health career options, and facilitating their admission to health professions training through RHOP, admissions committee activities, and contacts with rural physicians. The RHEN program has communities thinking about pre-professional training. Meetings in communities throughout the state have improved the program. Seminars in March will train communities in pre-professional preparation. Much of this will revolve around support of college premed programs, institution of an example Rural High School Career Days, and educating teachers and counselors about health careers. UNMC works with rural health providers to assist in the career education of these students. Some efforts are made to facilitate health professions admissions for these students, utilizing the community colleges, the rural schools, and rural providers, but more should be done in this area.

RECOMMENDATION - Nebraska should develop an AHEC with state and federal dollars.

AHECs are bridges between academic centers and rural communities. UNMC is already doing most of the AHEC functions. AHEC would supplement the RHEN network of faculty and volunteers. AHEC would add funding for trained facilitators who can best advise communities, the medical center, and the trainees. The AHEC should operate out of the chancellor's office, work with all Hub sites of the RHEN network, and employ a hub coordinator for each of the RHEN hub sites. These coordinators should work with the state manpower committee to help track all those interested in becoming primary care providers from high school into practice, maintaining a file on each one.

RECOMMENDATION - Continue the RHOP program, consider adding five rural students from other state colleges across the state, fund the RHOP loan repayment program, engage the RHOP students coming to UNMC in special programs to maintain their rural interests.

The Rural Health Opportunities Program at Nebraska ties pre-professional and professional education together, offering admission to the university's medical school for students from Chadron and Wayne State Colleges. Twenty students from the most rural communities in the state will enter the class of 120.

RECOMMENDATION - Admissions committees should focus on a screening process to assure readiness for the curriculum, and then pick the 100 most likely to choose careers that would best meet the needs of the state and nation.

The current admissions process involves much time and effort. West Virginia (Robert Walker) estimated in a report to the governor that they trained 30-40 medical students for every shortage area physician produced. Clearly we need many more primary care shortage physicians and far fewer subspecialists. It is impossible to predict specialty choice years in advance. Even doubling those initially interested in rural practice may produce only 3 or 4 more rural doctors at the end of the pipeline. The admissions process is not the only area for changes, but it is a critical area.

In today's medical schools, one of the toughest jobs for faculty is the admissions committee. These members meet weekly for months, spend long hours interviewing candidates, and then take the heat when certain applicants are not selected. For many reasons, they choose the best and brightest. This is good in that these are the most likely to graduate and the least likely to need special help. But this may be bad in that the best and brightest may not be the ones that will do well in rural primary care. One study demonstrated that those who had the highest academic performance were the most likely to feel isolated when in rural areas. Another study asserted that those with the highest MCAT scores were least likely to choose primary care. Most would agree that the area has not had enough study.

The current admissions process utilizes calculations of grade points, letters of recommendation regarding character and experiences, science education background, admissions test scores, and an interview. Most schools have only one or two interviews and few if any check references. The academic area is but one facet of a candidate. Neither the candidate or the school gets a chance for a fair exchange of information.

Admissions committees could have more past, present, and future rural physicians as members. They would help the committee look more closely at students professing interest in primary care. The rural-interested students in particular could have an interesting perspective as they are the ones selecting future colleagues to join them in rural practice.

Admissions committees are working to focus on those who can best meet the needs of the state, but they need more information and support in this effort. Once students are chosen, however, the job has just begun.

Professional training at the medical school level

The goal of rural training is a continuous series of rural and primary care experiences. This includes orientation, an integrated clinical experience emphasizing primary care, six weeks of rural clinical practice at the end of the first year, active family practice and primary care student groups, and a required two months in a rural practice in the third year.

Students have much at stake in the turmoil that is health care in the 1990's. Recent graduates saw many of the negatives of primary care during the national debate of RBRVS. These highlighted the benefits of being a procedural doctor rather than a lower paid cognitive or primary care doctor. During this time period the senior medical student interest in rural practice dropped from over 25% to 13% (AAMC survey).

Primary care is by far the most complex. Primary care providers need a broad education, lots of practice experience, maturity, judgment, and a willingness to sacrifice self and sometimes family. Primary care providers must interact at the tissue, person, family, and community level. They are also expected to prevent disease, counsel patients, and do social work. They are sometime the only friend an elderly patient has. They can face patients with unknown diseases where time can be an ally or critically injured or diseased patients where seconds count. Obviously primary care is the most difficult to present in the few months of curricula allotted to it in most medical schools.

RECOMMENDATION - UNMC should continue to improve its primary care training.

Adoption of the Integrated Clinical Experience curricula has added improved exposure to primary care physicians and patients. Students receive hands on training and history and physical exam skills and a three week rural experience in the first year.

Special programs can improve primary care education. Students at the Rural Physician Associate Program at Minnesota do their usual two years of basic sciences and medicine and obstetrics before they spend 9 - 12 months in a rural practice. After the first 3 months they are overwhelmed by primary care. At 9 months they do not want to leave it. They have had a total primary care environment. Only 50 of 1600 students a year receive this type of primary care training at three medical schools out of over 16,000 nationwide.

RECOMMENDATION - Rural programs need to receive priority funding to impact on admissions, curriculum, rural site development.

Family practice departments are the major primary care influence in medical schools. FP Departments ask for or receive "opportunities" to impact on admissions, curriculum, or the development of rural sites, but are not given the faculty or staff resources to implement them. Family practice departments can not produce as much income for patient care as subspecialty departments. As a result, supplemental teaching resources and faculty salaries are relatively low. This forces department chairmen into continual battles with the institution to insure the resources to maintain student programs, student education, residency education, and research. Often the only improvements come when the institution is hiring a new chairman who hopefully has the sense to negotiate the resources needed to do an adequate job in these areas. Low faculty salaries also fail to attract the practicing physicians that family practice needs to demonstrate true primary care.

RECOMMENDATION - Revise the third year family practice rural clerkship to develop the local curricula.

Students rotating in rural areas need more than clinical skills. They need to see the role of the rural physician in the community. They need to meet the people and understand their ways. They need time to assess themselves and their motivations for medicine. The primary care clinical experiences are helpful, but a good rural experience is much more.

RECOMMENDATION - Increase the opportunities for primary care research for students interested in primary care.

Students interested in primary care have little opportunity for research in primary care. High school and college students need equal opportunity for clinical, basic science, or primary care research. Most medical students do not realize that primary care research exists. Faculty in primary care need to increase the interactions with students as well and research provides this opportunity.

Studies show that most students enter medical school with thoughts of primary care, but they drop out of this interest over the four years. There are individual student factors as well as institutional factors. Medical education currently focuses training physicians to fight disease. The control factors in medical education are financial and promotion and tenure. Cuts in federal and state finance have medical schools at the mercy of the current reimbursement system which warps medical schools into subspecialization. For example family practice faculty grew 13% nationwide over a 5 year period while urologists in academic centers grew by 40% (recent JAMA).

RECOMMENDATION - Teaching and research in primary care should be a priority for promotion and tenure.

More primary care faculty are involved in the teaching areas, yet promotion and tenure are based on research grants and national recognition. Those institutions with the most National Institutes of Health grants produce the least family and primary care physicians.

RECOMMENDATION - Primary care faculty should be given opportunities for leadership in committees and as assistant deans.

Finally there are few primary care candidates for leadership positions as deans or chancellors. Primary care needs faculty at this level as well. Faculty need support to become leaders in national and state organizations. Others are invited to leadership training by foundations or government. UNMC has several primary care faculty who have received this type of experience.

RECOMMENDATION - a change in the medical school environment

UNMC is doing a better job of informing, educating, preparing and advising students about rural primary care. These efforts center on a total environmental change in the medical school. This will consist of the rural interest group activities, expanded bulletin board space, library space for FP and rural, bookstore sections on family medicine, rural newsletters to students, increased marketing of information resources available to rural FPs (MIDAS and SYNAPSE), rural and primary care research with primary care faculty, rural career advising by rural faculty, and most importantly, an ongoing dialog between students and faculty about their needs and concerns regarding primary care.

Another area will be changing the environment for students as much as possible. This includes student travel with faculty when visiting Greater Nebraska as well as a careful examination of rural preceptors, their practices, and their communities. This will allow maximal education and illustration of the positives of rural practice.

RECOMMENDATION - Support for pre-professional and primary care student groups

With rural programs such as RHOP underway, a rural student interest group is essential. This group will have several functions:

a. Inform about rural experiences, rural training programs, loan repayments, scholarships, and the basics of rural practice and lifestyle

b. Assist in the development and selection of students who are likely to return to rural areas through RHEN and the admissions process

c. Support each other in the decision for primary care and rural practice

d. Facilitate student contacts with rural physicians and rural faculty advisors

e. Keep department faculty informed regarding important issues with students that impact on their decision for rural practice and assist faculty with the design of UNMC programs

f. Sponsor a community problem solving competition by high school and college pre-professional groups

g. Combat misinformation about rural practice and primary care often fostered by other students and some faculty

 

 

RECOMMENDATION - UNMC will support students who wish to aincreased visits to Kansas City for family practice interest students to AAFP meetings as well as rural health meetings.

RECOMMENDATION - To improve the environment for primary care, UNMC and the state should establish a system of primary care awards and rewards

a. For primary care students and residents who show community involvement ($500)

b. For primary care students and residents for best research ($500)

c. Awards for primary care faculty (recognition) and rewards to departments or divisions at the state ($20,000)

 

 

Transitions are a difficult time for students. Some are ready for major decisions and some are drifting. Those who know what they want can move to a higher level of training without problems. For adequate training in primary care the seven years of education is needed.

RECOMMENDATION - UNMC should expand the primary care and accelerated tracks.

The primary care track in the fourth year of medical school has demonstrated improved primary care preparation over the past five years. The trainees have also chosen rural locations. The accelerated residency program is just beginning. Students with an interest in rural practice and a primary care and procedural family practice residency can convert their fourth year of medical school into the first year of residency. After four years of residency they will enter rural practice. The fourth year emphasizes the procedures such as obstetrics and endoscopy. Students who demonstrate the readiness for such a program should have a chance to enter these programs.

The state does support primary care training, but this level of support has not changed in ten years. As rural physicians retire, leave, or die, shortages are becoming more critical. Residents help meet these needs by choosing rural practice, by moonlighting, or by doing rotations or training tracks in rural areas.

RECOMMENDATION - Implement a local curriculum development in the rural rotations for residents.

One of the best rural rotations in the nation is at UNMC. The need for local curricula was discussed in the student section. Residents at UNMC and Lincoln do two months of rural rotations in their second or third year. The current sites are McCook, Albion, Superior, and Chadron.

RECOMMENDATION - Increase the community-based and rural training track programs in the state to forty first year family practice resident positions a year. Fund fellowships for those fourth year primary care residents who choose extra training to prepare for rural practice.

Program location is a key determinant of eventual practice location. Nebraska's community based residencies have filled for years. UNMC's rural training tracks are also filled. The state cannot afford to pass up the opportunity to keep graduates here as well as attract graduates from other states to train here. Fellowships offer a chance to attract more residents to the state to do rural training. Fellows can also do locum tenens and rural practice in the state. Fellows will also moonlight and provide services for rural emergency rooms.

The department has successful rural training tracks up and running in Grand Island and Kearney that have kept Nebraska graduates in the state and are more likely to keep them here. Future RTTs for Norfolk, Scottsbluff, and North Platte are ready for development. This will require much effort from faculty.

RECOMMENDATION - Increase funding for faculty activities in rural health to provide faculty or fellows to do locum tenens for Nebraska rural physicians and to work with rural physicians and communities on the recruitment of residents.

Rural faculty have been busy in this state. There are programs at all levels of training. There is much to be done to insure that the RHEN, RHOP, and rural student interest programs are a success. They are new and need to be taken to a higher level. Faculty are a key source of information on the state of rural health in the state. Other faculty and staff have had to double up in the teaching and administrative duties. All faculty continue to see patients. Despite this extra effort, faculty still find the time to travel out to rural locations to support rural physicians and advise residents on their rural rotation. This keeps faculty in touch with residents and rural physicians and rural communities.

To improve and expand these programs, faculty need support for these activities. No "rural" faculty exist at the medical school. Only a few faculty can spend as much as twenty per cent of their time on rural programs. Rural positions have been created out of the need to meet the needs of the state, but expansions and a lack of resources keeps the programs from full impact. Faculty help support rural physicians. They provide recruitment assistance, help with practice management, faculty development for clinical preceptors, and support in times of need.Without sufficient resources, faculty may be unable to help residents to make the final connection with rural practices in the state. Faculty have a key role in unblocking the jams in the flow of rural physicians to the state. In a time of budget cuts, faculty who are not supported will need to devote increasing time to patient care to develop revenues for their departments. This leaves less time for rural activities.

The final transition from training to practice is critical as this is the key outcome yardstick. Lack of communication in this area can destroy years of effort at the other levels. The transition from residency to practice is the most critical step in the process of recruitment and retention of physicians. All the investment of faculty, programs, and dollars is for naught if it is difficult to find and keep a practice in rural Nebraska. Those working with trainees during residency should meet with those who need physicians on a regular basis to exchange information at meetings, conferences, etc.

UNMC works with the state and individual rural communities to help residents to decide on rural practice. Communities have access to residents at state meetings, during rotations, and during some noon conferences. Interviews and discussions with the residents will assist in these areas. UNMC faculty "jawbone" with practices, hospitals, and physicians to improve recruitment and retention. Faculty are a reliable source of information about candidates and the current offers for physicians. More is needed.

RECOMMENDATION - Adopt a Nebraska First program

Step 1 - Making it easier to go to Nebraska than any other place. Graduates can choose almost any location and benefit package. Many of these same packages exist in Nebraska. Candidates either don't find out about them or find out too late. The state needs to be a state of the art central depository of information. Information from across the state should reach this location. Candidates should be able to call in and learn about rural practice, learn that their needs can be met in certain Nebraska communities, and be assured that their needs will be addressed. This should be a time-efficient exercise for the candidate. This also involves multiple visits and contacts with Nebraska communities. Wisconsin has a model program in this area. Loan repayment program should begin half way through residency and extend for three years after graduation.

Opportunity fairs (Nebraska First) should make sure that the first look by trainees should be at practices in Nebraska.

Communities should participate in training and funding of scholarship/loan repayment programs. Communities must attempt a goal of at least four physicians practicing together for call or group practice.

Scholarship and loan repayment trainees should go only to those communities who demonstrate a commitment to meeting the needs of their citizens and their health providers.

 

Program for loan repayment/opportunity fair/community match/community needs assessment and planning -

Loan repayments should attract and hold graduates in the state. Loans should begin the last half of training (last 18 months of FP residency) and should be 10000 a year with 20000 a year payoff.

Loans should be repaid based on medical shortage of the area, activity of the loan recipient, and retention of the recipient. A candidate going to the highest need area (+ $16,000/yr) who lives in the community (+$2000), and is active in the community (organizations, recruiting +2000) would receive $20,000 in loans repaid per year. After three years of service this would increase by 10% a year until all loans are paid off.

Step 2 - Preparing rural communities - Most communities need help to acquaint themselves with the competition. Nearly all communities need better ongoing recruitment retention committees. When the goal is 4 or 5 doctors for a steady primary care base, and since doctors leave every 4 or 5 years, the committee should never cease functioning. The START program is an excellent example to help communities assess needs and resources as well as plan their health care services and facilities. START communities are in the best position to understand recruitment and retention factors.

Step 3 Retention - Retaining the rural doctors in the state just 6 more months is the equivalent of over a hundred doctor-years. A conservative estimate of this economic impact would be 100 doctors q 5 yrs / 2 half years or ten doctors a year times $400,000 or $4 million a year in economic impact, not to mention the jobs retained and attracted because of the existence of health care or the money saved in education expenses for the state. Communities who do not prepare themselves for recruitment and retention can waste precious resources. Candidates should receive information about these communities, but they should know that these communities do not participate in enhanced recruitment and retention programs. Retained doctors can recruit more doctors and support each other.

The funding for the above programs should be from communities matched with some state and federal funds and grants.

RECOMMENDATION - Adopt a Nebraska Always - retention package

Reimbursement improvements for medicaid, insurance

Bonuses for choosing shortage areas (used for equipment)

State income tax reductions for providers making less than $75000

Retention grant program of 15 awards of up to $10,000 for retaining current shortage area doctors. To be designed to foster cooperation between the doctor and other doctors, the community, and the facilities. Communities can work with their existing rural physicians who have been in needy Nebraska communities for two and a half years on a retention bonus of up to $10,000 a year to be used for equipment, personnel, educational programs, or community activities that would aid in the retention of the physician. Examples include a colposcope, consultation for better office management, a part time social worker or psychologist, a preceptorship program, establishment of a non-profit community organization.

Once in practice, rural physicians need a variety of supports. Educational programs can provide contact. Information services are helpful. State organizations assist them with practice needs. The state needs to carefully consider changes in reimbursement and other areas. It should consider a policy that assures that physicians practicing in shortage areas receive the highest reimbursement. Those who agree to practice in shortage areas should have a loan repayment available. Legislators should be aware that rural physicians have faced federal discrimination for years and are at a crisis point.

RECOMMENDATION - Information support for rural physicians needs to be expanded.

UNMC assists rural physicians through Synapse and Midas and NebSAT for Continuing Medical Education, through on-line info, Medicaid information, technical information, communication support, referral assistance, and practice management training. consultation. Physicians are extremely frustrated with the explosion of information, expecially in the practice management area. A program to retain these physicians and improve the quality of practice needs to address these areas more and more.

RECOMMENDATION - The state needs more group practice opportunities as well as more types of practices designed for rural areas such as rural health clinics and community health centers

Consideration of increased community health centers for the state (only Omaha, Scottsbluff, and Winnebago sites in the state access these federally funded programs)

RECOMMENDATION - UNMC yearly report on primary care education at the community, institution, and state level

RECOMMENDATION - a change in the faculty at UNMC toward responding to rural practitioners.

UNMC faculty have improved their services to Nebraska physicians. Further improvements depend on the new dean and implementation of a program to improve faculty efforts. Lack of access or dependence on residents is a common complaint. Other medical centers have a better reputation. A call by a rural doc will receive an answer by the faculty member within 15 min, or if no response the chair in the next 15 min, and if no response the dean in the next 15 min.

RECOMMENDATION - Continue to develop an ongoing group of special rural health advisors at UNMC regarding rural telecommunications, rural health education programs, rural health planning, rural grants, rural health workforce, and rural community relations.

There is a need for all groups and organizations and institutions to work together in this and other areas so that efforts are not duplicated and counterproductive. This is true even within departments as the rural programs tend to keep faculty and staff busy and traveling.

RECOMMENDATION - Quarterly assessment of health workforce and factors impacting on that workforce.

Continual assessment of state's primary care needs by catchment area. County by county review of shortage area designations to access benefits for reimbursement and increased recruiting help

A tracking database is needed to evaluate, assess, and aid analysis of the state's programs.

Doctors mean more than health care. More government officials are seeing that each physician represents over $500,000 a year in local economic impact and 18 jobs. The survival of the hospital and local health system is important to recruitment and retention of jobs and business. Some states such as Oklahoma act in partnership with rural communities to share costs and the rewards.

Communities - Rural communities in Nebraska invest much in the training of physicians. Communities and rural physicians give over $100,000 a year to support UNMC medical students who spend two months in rural communities. However many communities realize that the costs of recruiting each new primary care physician can run $40,000 to $100,000 so they are willing to invest $1000 a year in hopes of doing long term recruiting. They also support family practice residents during their two month stay in rural communities.

The current climate of state health policy across the nation is one of recognition of the importance of primary care in delivering cost-effective care. Unfortunately the past century has seen the nation driven far away from primary care. The following is a quick overview of medical education in the past thirty years.

Leadership - Subspecialists dominate almost all medical departments. This has a major impact in internal medicine departments have key roles in teaching and leadership. Historically internists and surgeons have been in charge. It takes time to develop leaders in a specialty. Only recently have pediatricians assumed leadership positions in the Public Health Service some 30 - 40 years after establishing their specialty. Family medicine has great hopes, but within the traditional medical education systems, FPs need another decade to train and place leaders.

State Legislatures - State governments face rising education and health care costs, especially Medicaid. The public demands high quality efforts in both health and education, but is often unwilling to pay for such efforts. Many legislatures feel that they have invested much in health education in the state without realizing much. Physicians in particular seem to be costly at over $500,000 in training costs for the 11 years of state sponsored education (4 of college, 4 of medical school, and 3 of residency training). Communities and legislatures often underestimate the value of rural physicians, however. Each physician is worth over $400,000 a year and 18 jobs in economic impact on the community. Physicians also recruit their peers and replacements, support local hospitals and other health facilities, make health care more accessible, and are a major factor in the recruitment and retention of jobs for the community.

Expectations - During the 60s and 70s much was invested in medical education with the expectation that increased numbers would drive doctors into underserved areas. When this was ineffective, scholarships from the National Health Service Corps (and other sources) and preceptorships became the "fix" to solve the primary care problem. Some states established new "primary care" medical schools. These newer schools produce up to three times as many rural physicians, but the establishment of a medical school is a major expense. These programs did get physicians to rural areas, but to get and keep physicians in rural areas, most now believe that a more comprehensive approach is needed.

Some legislatures have mandated curricula, often without the funding to accomplish the changes. Some of the more successful states in the area have put medical schools on notice, demanded changes to meet the needs of the state, and provided some resources to meet those needs. For example, the Minnesota legislature mandated changes in 1971. Creative medical educators produced the Rural Physician Associate Program and established the Duluth Medical School. The Duluth program produces over 50% family physicians (nationwide average 11%). RPAP has trained over 700 rural physicians (the nationwide pool of rural doctors is probably 16000).

Other legislatures have threatened to cut spending on medical education or even family practice line items. Even reductions across the board can defeat new primary care programs or those which are stretched to make ends meet. Cuts in funding also mean less influence by the state and more influence by the federal system which currently rewards subspecialization, expensive tertiary care, and research grants. Cuts or reductions in primary care medical education or family practice mean less home grown physicians, the ones more likely to stay in the state.

Nebraska has a great opportunity to impact on rural health. The state invested wisely in education reform. Rural student performance is improving. These students were given an opportunity through the RHOP program. This new program now is in the hands of the medical school. These students will need encouragement and support. For them to do well in practice and stay there, the state needs a major investment in current physicians. The state needs a major push in recruitment, further loan repayments for those in state and out of state.

In a time where dollars are limited, we must make some hard choices about the types of programs and support. Some say we should shift funds from one component of our communities to another. A few say we need broad cuts. There is a rule in Monopoly that says that you must build evenly on all properties. Each component depends on the others. Public health needs some major improvements. Shortages in this area have cost us through lost time and disability of citizens who needed preventive services. Lack of Health Department resources fuels the debates over licensure and the complaints of communities who feel that they do not get the physicians that they should. In Tennessee one county made major inroads into health care, leadership, and economic development, but this same county continues to fire school superintendants instead of investing in education. Cuts in education, economic development, or health care can be very damaging.

Nebraskans have made an investment in many areas. It is not time to cut education. It is time to invest more in public health.

Choices at the top - slicing the pie

cut education no, must keep the investment for better health care and economic development, many Nebraskans returning to the state as other states face crunches

cut higher ed Not a good idea as we compete for higher paying jobs If we cannot keep our graduates here, we need to invest more in economic and job development to keep them here, rather than cutting education

cut medicaid - revisions, not cuts, especially care not to hurt rural doctors and prenatal patients

 

 

 

 

 

 

New proposals to consider

RECOMMENDATION - UNMC should establish a trial program to provide improved evaluation of candidates for admission to the medical school. This would be a two month service project working with faculty and/or primary care physicians in the state.

A trial program involving thirty students a year could examine students more closely. Students would work on a community health project. They would gather information, work with health professionals and patients, and work with a primary care physician. They would receive a stipend. All would have entry and exit interviews and surveys regarding certain factors such as teamwork, altruism, respect for authority, orientation to health professions, exposure to primary care and other factors. After they graduate, analysis will be possible regarding these factors. If the process is valuable in predicting those who will choose primary care, then the next step is to apply the criteria to pick incoming medical students. The potential for savings in terms of excess subspecialists (over $400,000 a year a subspecialist) and lost educational dollars ($500,000 per trainee) is tremendous.

RWJ Practice sights Palm leaning toward albion, gordon, sargeant

RECOMMENDATION not training all 120 students in rural practices

Currently all of the class goes out for a rural primary care experience. This involves much effort in coordinating the program. Not all students desire such a primary care experience and this can be frustrating for the rural physician faculty who volunteer their time and efforts. The state does not need to waste scarce resources of loans, scholarships, or primary care faculty on these students. Students at this stage know if they are interested in primary care a lot, some, or not at all. Those who answer not at all do not tend to change their minds. As medical schools become more primary care oriented, the entire class can receive this training.

The Model of Primary Care Training to Produce Rural Physicians

College preparation -

advisement, preparation

serve in clinic or medical mission

service

evaluation for admissions

Admissions - who is most likely to do primary care

academics background service health

baseline personal more likely experiences

parents

spouse

Basic sciences

integrated approach

continual pc activities

early h and p

Yearly paid pc experience

service

research

Third year

six months clinical prep then preceptorship for 12 months

Jan of Fourth year - choice time

1. Qualified pc bound continue seeing office pts and training at site and integrate in specialty training in ambulatory settings as much as possible, paired with other trainees so that the two maintain clinical continuity of patients. This leads to three and a half years of graduate training which should exceed the continuity requirements of the fp rrc. The ambulatory training component is crucial and must be monitored at each site so as to comply.

2. Opt for traditional training, finish out 6 months of electives and take the traditional route

 

 

 

 

What has been done

What impact

What should be done

use of residents 1-2 months rural

state pay residencies $2000 a month per rural month by residents

community pays travel and housing and $1000 to residency

residents paid 1500 per month for rural rotations

travel and housing pd by site

supervisor there

use for search funds

use of consultants

state pays UNMC depts $300 for each day spent in rural outreach

loan repayment

each day of locums in shortage area pays off $100 of loan

Rural Recruitment and retention foundation

state funds

unmc funds

penalty funds

foundation/grant funds

30% of funds for retention

x for maintenance

x for recruitment

Board

unmc

nerha

hosp assoc

state health dept

nafp

nna

pa assoc

Workforce

The lack of production of rural primary care physicians

The recruitment of rural doctors

The retention of rural doctors

Utilization and access for nurse practitioners and PAs

Trends in NPs and PAs

Allied health and nurse training and distribution

Emergency medical systems

Facilities

The challenges to rural hospitals

Ongoing State Health Care Reforms

Proposed revisions in Medicaid

Resources at the State Health Department

Recruitment

Retention

State funded rural programs

Scholarship

Loan Repayment

RHEN

RHOP

Ongoing Federal Health Care Reforms

Rural Health Clinics/FQHC's/CHC

Notification of potential eligibility for shortage area

Instruction in the process of RHC, CHC, and FQHC

DRGs

leveling the playing field

RBRVS

keeping tabs on policies that hurt rural areas

Managed competition

tailoring for rural areas

Reimbursement changes Medicaid, Medicare,under- & un-insured

Communication issues