Why Few Young People in Rural America?

Young professionals are the key to new arrivals, new jobs, retaining old jobs, quality of life, services in rural communities, and leadership. Centralization Policies in Rural Public Health and in State Educational Resources illustrate the problem that has grown over the past decades. 

Programs have been able to reverse this centralization and do help to restore the distribution of resources and services to rural areas. Medical education has a role in programs such as the Rural Health Opportunities Program, where selective admissions does help return physicians and other young professionals where they are most needed. These programs illustrate the Community Driven Approach where academic and rural communities meet head on and decide to cooperate fully to resolve problems with underserved populations and peoples. Other similar efforts are listed at Best Models Admissions or Complete Rural School      

The area that could have the most impact at graduating more and better rural physicians for the state is indeed admissions.

The Classic Response Of Medical Leadership to complaints that they are not meeting the needs of society:

"It's the poor rural economy, lifestyle, etc., as illustrated by the President, Jordan J. Cohen, Association of American Medical Colleges, Washington, DC  Academic Medicine, December 1998   Why Doctors Don't Always Go Where They're Needed

Dr. Cohen has modified his admissions views (Cohen Encourages Admissions to Look Beyond MCAT), but he and others need to understand that rural is different, not worse or better. He needs to visit and understand the complex problems of underserved communities, as well as there strengths and true needs. Frankly the same attitudes toward rural living have been present for nearly a hundred years, as seen in this past New York State Medical Journal item from some 80 years ago. Time for a change in attitude please! Medical organizations need to help solve problems, not help create them. Students are getting bad information and losing interest.  See Student Dreams of Rural Practice

See a critique of the Cohen editorial at Why Doctors Don't Go.     

Better approaches at Physicians Can and Will Choose Rural Practice

By denying a key source of physicians who will go rural, medical school leaders are actually contributing to the problem. Each rural physician is a major component of the economic impact in a rural community.

Accreditation is also a problem for those who would work to resolve problems with the underserved, including LCME and Florida State Medical School. Rural training tracks and accelerated programs also face obstacles at the graduate level. Other links to Approaches to Underserved Populations

Rural family medicine is indeed a higher calling to service and lifelong education Osler and Rural Practice. Students often see the challenging areas, but not the rewards. Rural Student Interest Groups can help students to understand the challenges and the rewards.

Dr. Cohen is also right in another area, simply increasing primary care numbers will not address the problem. Family medicine does have the broadest distribution of physicians, but increases in the number of residents over the past 30 years have not resulted in greater numbers graduating into rural practice each year. Also those choosing urban underserved have fallen off a bit after initial gains.

Family medicine and other efforts such as Title VII have been helpful, but are temporary measures while the rest of the nation (and world) discovers the Community Driven Approach. This approach will work, but it may take some time, particularly if the underserved area lacks jobs, professionals, education systems, and leaders. Germany and Japan recovered quickly after WWII because they had these in place. Native reservations, Appalachian communities, and impoverished nations take far more time. The only hope of restoring balance of resources and services and population is to work in multiple areas over time. Targeting students who are likely to become young professionals and most importantly, are likely to desire to return to their communities,  is the best approach.

I have the greatest respect for the work of the admissions committee. It is a long and difficult task. I have discussed some of these studies with admissions members in the past, but I sympathize with them. The forces that push for better board scores and lower rates of academic failure are difficult to resist. The demands upon faculty time only increase as does the information available and the need to choose better candidates. The best suggestion is to choose based on Service Orientation

Overview

1. The Role of Medical Education: Quality research has demonstrated that rural medical education programs can graduate more rural doctors, better rural doctors, and there is growing indication that we can train doctors that stay in rural locations.
2. What is needed is to believe the following: Our medical school can apply the principles noted in these studies and replicate programs successful in other parts of the nation. OUR MEDICAL SCHOOL can graduate more rural doctors, improve rural health care, and greatly enhance rural economic development. By doing so OUR MEDICAL SCHOOL can assure itself a leadership position in the state for decades to come.

A Letter from an Underserved Community

Dr. Bowman,

I am concerned that we are loosing many young people from our part of the state. We would like you to help us explore the reasons why we cannot attract young professionals and others important to our towns. We would also like your help in understanding why so many of our young people are not getting involved with the community. I fear that our failure to attract young people and work with them will lead to more serious problems for our rural communities. 

My response a few years ago: We sent information to the organization on how to recruit better, organize health systems better, etc. At that time I didn’t realize the full extent of the problem. My response was much like our current medical leadership at the national level:

Dr. Cohen's Editorial was not consistent with the opinion of Abraham Flexner, the father of twentieth century medical education:  

Flexner noted in 1910: The small town needs the best and not the worst doctor procurable. For the country doctor has only himself to rely on: he cannot in every pinch hail specialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best trained physician that can be induced to go there. More about Flexner at this site.    Subject: Rural medicine     Contributor: Murray, T. J.    Source: Flexner, Abraham. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, bull. 4. New York: The Carnegie Foundation; 1910, p. 44 [Reprinted in Birmingham, AL: Classics of Medicine Library; 1990, p. 44]. 

Some of Osler's statements were also not far from this mark. Many medical school deans prior to 1950 also made similar statements, back when generalist graduations exceeded specialists. Only recently have we forgotten how to make such efforts to meet the needs of the country.

Mr. Flexner was not a doctor, nor did he understand all he needed about medical schools, but he did know more about rural health than our current medical leaders.

The Response of a Rural Medical Educator:

Only in recent decades has our medical leadership allowed itself to become so distracted by research and clinical pursuits that it has ignored the training of medical students and the needs of the people.I don’t know Dr. Cohen, but I have spent half a lifetime in a variety of positions, examining rural education and rural health and the rural economy. Dr. Cohen is very wrong regarding his statements about rural people. He needs to get in touch with these areas of the nation and what their people are all about. 

1. The rural economy IS health care. As much as 30% of the economic impact in a small rural community is health care. Rural doctors are worth $360,000 a year in local economic impact and 18 jobs (Doeksen, OSU, 1989). Rural hospitals in the smaller communities are often the major employer of the county (Cordes et all). The smaller the town, the more likely that health care is a major contributor to the economy.
2. The rural lifestyle is different, not lacking or inferior. I still cannot believe the statements that he made and has yet to receive criticism for. Had he spoken such discriminatory words to other groups, he would have been fired. I won’t belabor this point because I hope that you understand this. There is no winner when you compare recreational activities such as attending an opera vs being invited to sing at a town gathering at the firehouse on Sunday evening (one approach helps convince graduates to go to an urban site, the other landed one community a rural physician for a lifetime). Ultimate Recruitment Experience It's like comparing apples and oranges. Folks back east or in major urban centers may not understand this, but a more balanced view would hold Dr. Cohen’s statements to be elitist at best. Certain more vocal populations would have him fired for discriminatory statements. Since I do not know him I will reserve judgment as to whether this is part of him or a failure of medical leaders to educate and inform him in this area. Studies have repeatedly shown that those interested in rural practice are interested in service, interpersonal aspects, extracurricular activities, hunting, fishing, and other outdoor activities (AAMC GQ, Utah studies by Harris, recruitment and retention research).
3. One of the primary roles of medical education is to meet the needs of the nation. Now that there are studies that demonstrate success in meeting these needs through admissions and training, these models need to be widely publicized and adopted. End of Story, end of debate, end of whether to studies. Studies show that admissions of minority students can help address urban underserved needs (AAMC data). Rural needs are met by admitting students who will go and stay in rural communities. Studies have shown that the way to pick these doctors is to chose students who are from rural communities and those who are interested in family practice and serving people. (Rabinowitz Physician Shortage Area Program at Jefferson Medical College, Boulger Duluth, Mercer, ETSU, East Carolina, WWAMI, Upper Peninsula). 

Further studies are needed to maximize admissions and assist with retention, but delays in implementation are contraindicated!!!!!

In the past there has been some recognition by AAMC regarding rural medical education. A few AAMC leaders at least accept the concept of the importance of admitting students from rural backgrounds (Kassenbaum DG, Szenas PL. Rural sources of medical students and graduates choice of rural practice. Academic Medicine 1993;68;3:232-6.) Dr. K uses his data to show that more rural graduates are just not possible from the current classes. Dr. Kassenbaum is correct in his data, but the reasons for the decline in rural physicians appear to involve medical students that don’t make it past admissions committees. Additionally, those who do make it into medical school face a socialization process. Selective admissions can result in more minority and rural graduates.  Here is more collected for Academic Leaders Deans Organizations.

The definitive work on rural admissions was done by Howard Rabinowitz at Jefferson Medical College in Philadelphia. His program, the Physician Shortage Area Program (PSAP), has admitted only 1 % of the total medical school graduates of the state of Pennsylvania since 1971 (up to 15 per year). This same program has graduated 12% of the current rural family physicians in the state. This is all the more remarkable because PSAP is located in a private, urban, academic institution. PSAP doctors go and stay in rural areas. What is amazing is that this program continues to go unreplicated!

The reason for the success is selection. PSAP chooses for rural background and family practice interest. Rabinowitz has learned that you need to work with small colleges across the state where you are more likely to find students than have rural spouses. Other states have similar admissions programs. The importance of rural background is not lost on future rural physicians. Our own medical student rural interest group, SARH, realizes this and is working with rural high school students on career days and through local presentations. They are working to recruit future colleagues and physicians to take over their practices.

The desperate rural leaders who keep coming to the medical center for assistance are right. We can help in several ways. One of the best ways that we can do so is through our educational leadership.

AAMC Data on Rural-Interested Seniors from 1995 GQ Survey

OUR MEDICAL SCHOOL is at a crossroads. Certainly it wants to move up to the level of other higher institutions across the nation. Research and academic excellence are important. We must ask ourselves, however, how can we emphasize such efforts and risk deficits in other areas. We would ignore the very people in the parts of the state that need us most. 

There is a way to have our cake and eat it too, however. Many institutions of higher learning have taken a different route to becoming a dominant academic force. Some reach out to the local community to make an impact. Illustrations of Community Driven Approach

Our state has stumbled on to some of these aspects, but could lose this vision. The upcoming AHEC grant and funds can help, but not if this effort fails to impact the rest of the institution. Here are some ways that OUR MEDICAL SCHOOL has taken a leadership role with little effort or cost, and it could do even more in this area:

Review Important Advances in Rural Medical Education and choose the ones most relevant.

In many studies, such as my own study, this is a key characteristic favoring a return to rural areas. Admissions policies clearly shape the applicant pool, secondary education, and college curricula. Consider the following:

1. What if, instead of requiring Genetics for admission, we decided to require a more concerted effort in a language such as Spanish. What if Texas medical schools in 1985 had implemented a requirement that all medical students speak Spanish? What about medical schools in most of the nation today?
2. What if we required a service project prior to admission and included a detailed evaluation of the candidates project, communication skills, and service motivation? Would this help admission committees choose more with service motivation rather than the usual crop of intellectuals?
3. What if we did away with much of the basic science years before entrance to medical school, allowing some of the students more time to complete these studies before starting clinical efforts? Students would also not have such a spoon fed flavor. They would have to discipline themselves to work toward a goal. Medical school and residency can be more than passing the next exam or rotation. Would this broaden the pool and allow more to qualify who were disadvantaged, rural or minority or both?
4. What about a total rural program? One effort starting in Kentucky will keep rural students in college, medical school, and residency at a rural location entirely. Such a program has virtually no risk of losing anyone to an urban spouse. Keeping rural-interested students away from urban areas is a good thing.

I appreciate your attention. Your advice and critique would be most helpful. I hope that we can work toward these efforts over the next few years.

Other Areas to Address

 Rural Communities (and minorities communities) also have a responsibility   Communities must educate better, expose to careers better, enhance the educated of the right gifted kids who are likely to return, track candidates that do come for rotations, recruit early and often (checklist)  and always, work constantly on retention and building of the practices of current physicians. 

Rural Communities also need a change of attitude. Many think that students who return to their own rural town are somehow failures. Most would take it as a high complement that someone tried out other locations and came home to raise a family. This is often not so. One small town store owner had an effective intervention for this kind of thinking:

Initially from a large town, Maurine married into the furniture store family. Over the years she saw some of the difficulties that kids in town faced when they graduated. Her son was graduating soon and several of the kids in the town hung over at their home after hours. She recognized one friend of her son, Bill, in a great deal of distress. She asked Bill about the reason and finally he stated that the graduation edition of the paper was soon to come out and he had nothing to put in. He didn't have a chance to do athletics or school groups because he helped his dad on the farm and worked weekends helping out at local stores. Bill's grades were not great, but he had done well. He had done some volunteer work with the local EMS system. She encouraged him to put down what he could for the paper and made arrangements for her own graduation dinner.

She invited several of Bill's friends to the dinner, including a Regent's Scholarship winner. When all had arrived, she put Bill at the head of the table. Eventually the question was raised, why Bill in this place of honor? She seized the opportunity to explain that many or most of the high octane folks would leave the town and return rarely if at all. Bill would be serving the town for years or for life with his jobs, his volunteer work at the EMS, and his community efforts. In her view, he was the most valuable of all the graduates.

National and State Objectives for More and Better Rural Physicians