Purpose: Planning for rural communities, rural practitioners, and those who train them

Nebraska is a unique state. Most of the population is crowded into the easternmost counties. Nebraska has 40 counties each with a population under 10,000 that still have one or more doctors and a hospital. These counties serve at least 280,000 people. Some of these hospitals are relatively isolated with the potential for gaps in health services should some of these 61 hospitals close. The state is transitioning from a rural to an urban state and from a solo and group practice mode to an increasingly corporate model. Across the state, rural physicians are working more and more in groups and networks. Some are now employed by their rural hospital. Others have formed independent practice associations and other relationships to preserve and increase their negotiating ability and improve practice parameters.

The state’s health training programs face a time of declining federal and state dollars in addition to reorganization of health care finance. Demand for clinical services for faculty is increasing, especially for weekend and evening services. Personnel in training programs, administrators, and clinic managers often assist state employees in areas such as recruitment, retention, health planning, and other areas important to rural health.

The state is 49th in per capita expenditure in public health. Basically if Nebraskans cannot do it themselves, it doesn’t get done. This is even more apparent in mental health where the state ranks dead last or 52nd in mental health, behind Guam, Puerto Rico, and Mississippi. On the plus side is education and child safety where Nebraska ranks in the top ten.

Graduates of training programs are insisting on improved lifestyles, higher salaries, and longer guarantees. Graduates receive about $120,000 on average with more for those who plan to do obstetrics or procedures. Female graduates equal or exceed males in almost all primary care training programs. There are some indications that females have more rural interest than males during medical school. After years of decline in rural interest in medical students across the nation, there have been recent increases, although this has not resulted in more residency graduates choosing rural practice. One problem in graduate training is the convenience and high pay of the urgent care centers in Omaha and Lincoln. Residents who used to go regularly to rural hospitals to cover weekend call now can work a lot harder, but get paid much more and not have to travel.

Rural communities sometimes seem to be distracted by external events rather than improving local health planning and services. Some have been slow to adapt to the new graduates, especially those with an expressed need to work less than 50 hours a week. Studies show that females stay as long as males when they choose rural practice, but they need the flexibility to be able to increase or decrease their hours to meet family or other needs (WWAMI).

The supply continues to lag behind the demand. Rural physicians continue to age. A few leave for urban locations. Interestingly just as many came to rural practice from urban areas in a study of primary care graduates over a 12 year period at UNMC. There is some evidence that urban and large rural areas are "filling up", but consumer demand for more services and more convenience continue to increase. This increases the cost of health care, but also allows more family physicians to choose urban areas.

Summary by Robert C. Bowman, M.D.

Outline of potential report (started this 2 years ago, but just didn’t find the time to keep going)

Unique characteristics of state, especially frontier and small rural

Shortage area descriptions and maps - Physician, OB, mental health, general surgery

Communities recruiting practitioners

Workforce projections

Urban

FP (grads, program changes), IM, Ped, Ob, PA (new program), NP, Psych

Sources/Numbers in/Anticipated changes

Losses

Large rural

FP, IM, Ped, Ob, PA, NP, Psych

Sources/Numbers in

Losses

Rural

FP, PA, NP

Sources/Numbers in

Losses

Aging physicians by county

Improving the flow of rural practitioners to the state

Nebraska interested tracking, invitations to recruitment fairs and events

Increasing rural interest and keeping Nebraska trainees in the state

Restore rural mission, don’t allow dilution to all underserved

increasing urban, urban poverty, overall fp demand

Better choices of candidates for training

Screening community service program as part of admissions evaluation

Early exposure to rural

Weekend with rural doc

1st year rural

Rural interest

marriage

international rotations

rural rotations

more females?

Minority interests

hispanic

native american

Keep Nebraska-trained connected to state

Senior send off dinner for primary care residents who leave the state

Return Nebraska background and Nebraska interested trainees for

recruitment fairs

Tracking of those leaving the state and continued attempts to return them

Recruitment Fair at Nebraska Rural Health Association meeting

Recruitment activities of the association

Enhanced recruitment activities at the state level

2 recruiters instead of 1

Increased community training efforts

Special tracks with a rural year in M-3 (by choice) or M-4 year (for those with

special tracks or obligations not taking rural in M-3 yr)

Obligations for scholarships, special tracks, loan repayments

Tuition escrow account

UNMC med school - half of each student’s tuition held in escrow fund

This escrow money and interest would be returned to student if

choice of Nebraska primary care or mental health practice

(year’s escrow/interest for each year service)

If no such choice, escrow funds go to loan repayment funds

If delayed choice, funds revert back to graduate (year for year)

from loan repayment funds

Increasing workforce in underserved areas

9-12 month rural track for minimum of 40% of Med, PA, and NP students or no

state funds

Required rural rotations in fp residencies

2-3 months continuous in 2nd year

1 month in 3rd year (can serve locums for this requirement in 2nd/3rd year)

Support for existing physicians

Practice managment consultation

Enhanced physician cooperation, networking

Locum tenens contracting to keep costs down,

but not promote leaving continuity practices

Administrative/leadership training for practitioners

Integration of public health efforts into a single system of care in rural communities

No need for competing public health system, all must work together

Barriers to address in medical education

Characteristics of FP Programs that produce more rural graduates - research at UNMC

rural mission

rural months

ob months

Needs in Nebraska

Enhanced selections process

Modifications to rural training

Increased Ob training - remove barriers to rural practice consideration and improve

access to primary care practitioner doing OB. Some residency graduates

training entirely in the state have only had 30-50 total deliveries during

their 7 years of training with few if any operative procedures. Previously

used sites outside the states have accepted more residents from other

states, diluting the total experience. Solutions include more deliveries at

hospitals currently not allowing primary care residents to participate or

more longitudinal forms of training (rural training tracks, M-3 or M-4 rural

longitudinal experiences).

Specialist attitudes - JAMA article, incidents at UNMC

Changes to incorporate into training

Changes in ownership

impact on retention?

Growth of physician organizations

Panhandle, Rural Health Partners, SERPA, NIPA, PHOs