Define Rural or Shortage please
There are three major reasons that the nation does not have enough rural physicians:
Target medical leadership for efforts
Cooperative Efforts Are Needed
Rather than another cycle of blame and short term fixes, it is time to take a different approach that will link rural and academic communities. For improvements in physician distribution, all three major components must be addressed simultaneously. The weak link increasingly appears to be medical schools, both directly in their role as producers of physicians and indirectly as leaders in education.
It is important to target medical education. First, it takes many years for the earliest and most effective interventions to deliver results because the "pipeline to rural practice" involves so many years of training. Second, medical schools can focus local efforts and manage a statewide effort with its ability to influence state government. Third, many medical schools already have connections with rural physicians and communities that can be strengthened to provide mutual support and benefit.
The complexity of the task is daunting, but there is reason to believe that progress can be made after decades of failure. Several advances give rise to new hope. These advances involve the areas of workforce preparation, health policy, and the role of medical centers as health system facilitators.
Many rural communities are just not organized well in several areas. In particular many are not as good at recruitment as most others are in a very competitive market. Some have not had to recruit in some years. Others may no longer have the personnel to recruit well. We had a rural recruitment dinner and four communities in need of docs were invited. 19 residents came with their spouses, the best turnout of residents for any fair, noon conference, or other recruitment activity. Yet one community failed to show up. Here sat 90% of the future rural doctors of the state in the next 3 years and they were a no show. Do you want the best or do you just want to settle for anyone?
Small organizations tend to be unstable, all physicians, hospital people, health and community leaders have to get along.
Lack of acceptance of nurse practitioners/physician assistants - Rural physicians are as bad as any in this group.
Other barriers exists in rural communities. Some do not expose students to health careers at all. Others have neglected local education, keeping rural students from competing successfully for advanced professional training.
Health policy reforms addressed gross inequities in reimbursement to rural physicians and rural hospitals. These included rural health clinics, shortage area bonuses, RBRVS reforms, and increased rural hospital payments. Reforms in capitation hold further potential for rural providers who work together with the raising of the AAPCC floor to a minimum of $400 per member per month. Reimbursement for rural health services still lag behind the rest of the nation. Improvements in capitation rates for rural services has the potential to increase health care dollars in rural areas, if these dollars are not diverted to outside health entities.
State governments have also reached out with insurance pool legislation and some have assistanted providers interested in bidding on capitated Medicaid contracts. More could be done in this area and there is a constant danger that these benefits could become eroded over time. States are also not working with rural communities and smaller colleges in rural locations when local education resources are deficient. Small colleges have continually faced declining budgets. They often face difficult decisions and cut, or are forced to cut, courses that pre-professional students need. Without a comprehensive state effort there will be few doctors, teachers, lawyers, and other professionals in rural areas. There is some evidence that the quality of education in science and math can suffer if small colleges lose access to high quality pre-professional students. Unless medical and other professional schools remind states of this responsibility and assist in the effort, the only voices that will be heard are those pushing for more "efficient" education, with less and less resources for small rural colleges, rural communities, and rural students. Too often professional schools are a part of the centralization problem rather than part of the solution.
Economic/support needs, especially for the type of physician. It takes 2500 for and FP, 5000 for a general internist or pediatrician, and more for other types. Equal share of the blame with state government, medical schools, and rural communities.
The introduction and expansion of family medicine was a major step toward more physicians who could become rural physicians. For the first time rural communities could access a broadly-trained specialist that could meet their needs. In its early years, family medicine graduated a fairly high percentage into rural practice (see graph). The success was not limited to the graduate years. Certain rural medical education programs also demonstrated that physicians could be selected and trained not only to choose rural practice, but to stay there many years (Rabinowitz and PSAP). These and other innovative programs impacted on medical students early and at multiple levels, giving them rural experiences and specific preparation for rural practice (Minnesota’s Duluth-RPAP, East Carolina, Mercer, Michigan’s Upper Peninsula.
Medical centers began new roles as health system facilitators by reaching out to assist rural communities with health planning (WAMI) or the development of independent health systems (Nebraska AHCPR grant).
The focus of this article will remain the role of medical schools (and those who influence them) in addressing the nation’s needs either alone or by working with rural communities and providers.
The Selection Process
Some correctly point out that there are not enough applicants with rural background or rural interest that could meet the needs of rural America (Kaufman). These studies assume that medical school admissions committees prioritize rural applicants. These studies do not note the success of programs in Kentucky and other areas that maintain and increase rural background application rates, even when overall applications have declined (Kentucky - PEPP).
Another problem is that medical education is predominantly urban. This is a location problem in our society. Even the most rural interested student can lose interest when he or she meets an urban spouse, especially one who also has a professional career. With nearly all higher education in urban areas, there are fewer opportunities to meet rural spouses. Decentralized college and medical education can help here.
Admissions committees can select candidates that are likely to choose rural practice, but are afraid to take the academic risk. Studies indicate that those most likely to choose rural practice are chosen last. Other studies have indicated that students with higher scores might be less likely to choose rural practice. Faced with rural or primary care candidates that might be a lot more effort and risk, it has been easier to select candidates that are more likely to do well on boards (Harris, Bauer).
To address the barriers that prevent the graduation of professionals that could choose rural practice, we should work to:
Medical schools have addressed these issues in different ways:
Schools such as WAMI and Kentucky and some of the newer medical schools specifically train admission committee members to do a better job of selecting those likely to choose rural careers or primary care. Kentucky has a pre-professional preparation program (PEPP) that has been able to increase the number of rural applicants coming from the state’s schools and colleges even when applications are declining at other medical schools. Minority pre-professional programs have had similar results.
Admissions, Ambulatory, and Group Effect
When schools establish programs that select well, integrate rural and primary care experiences into the curricula, and train in more rural locations, more students choose primary care and rural careers. Jefferson’s PSAP demonstrated that even the most urban schools could accomplish this goal. Minnesota’s combined Duluth-Rural Physician Associate Program (RPAP) and the Michigan Upper Peninsula program also have the advantage of a more rural location for training for clinical years. Many of the newer medical schools have taken this strategy with significant results in rural and primary care graduation. Despite these successes, there has been no widespread implementation of such training - a significant failure of the leaders in medical education as well as medical associations.
Minnesota’s rural programs deserve special mention for several reasons. Even though the program began with a confrontation between the state and the medical school, it is a primary example of the power of a cooperative effort that works at multiple levels. The Duluth two year program admits rural-interested candidates and integrates ambulatory training. Many of the Duluth students continue on in their first clinical year in the RPAP program, spending nine months in rural practices. This prepares students specifically for rural practice and keeps them out of the major metropolitan areas throughout most of their training. Studies document the educational value of RPAP and program directors avidly seek RPAP graduates for their residencies. Rural communities and physicians with RPAP students also benefit from their services. RPAP also has the honor of being replicated in a few locations with with some early success (Syracuse, West Virginia, East Tennessee and others). There is an additional "added value" of the RPAP program. Faculty development for rural physicians is commonly mentioned, yet most difficult to implement. The faculty development for the RPAP program begins when the rural physicians were RPAP students. The effort begun almost thirty years ago has replicated itself, decreasing the need for faculty development but paradoxically increasing participation in this effort by rural physicians.
States with a continuous series of rural medical education programs graduate more rural physicians that stay in rural practice. This is demonstrated by the Jefferson PSAP programs (Rabinowitz), the Mercer success, and the Duluth-RPAP programs. WWAMI and Kentucky have taken this larger scale approach and are beginning to show increasing success also. The WAMI study of medical schools sums up the failure of medical education in this area.
Kentucky’s schools have a system that basically accept all medical students from rural and underserved areas of the state that have a chance to survive the intense medical curricula. Training of the admissions committee members and emphasis on fulfilling the rural mission of the schools has resulted in a system that can determine the career choices of graduates with 90% specificity and 90% sensitivity (Rick Blondell). Sadly these two Kentucky schools compete against one another and run out of qualified rural matriculants. Reflection on this competition suggests that the major success of Jefferson’s PSAP program in recruitment and retention of rural physicians may rest on the availability of a larger and more devoted rural pool of premedical students. This also suggests that schools could increase their success, even in less rural states, as this Philadelphia-based school does.
Programs must be patient. It takes time to get it all together at so many levels. Rural programs need a generation or so before evaluation, not a quick look at the first (and usually atypical) group to locate in practice.
Despite the best effort, some are just going to marry the wrong person to go rural. Other folks or their spouses have the wrong perception that personal and family needs needs might not be met in rural areas. Medical training can begin in small colleges and stay in small towns to avoid the spouse problem.