Descriptive and Introductory Works
Barriers to Graduate Medical Education in Rural Areas
Steps to a Rural Graduate Program
Graduate - various files on rural graduate programs
Disclaimers First
Don Pathman is the most knowledgeable person on the planet regarding recruitment and retention issues. It is his feeling, and one I share, that graduate training has more to do with retention (getting folks to stay), rather than recruitment (or getting folks to go rural).
The most important aspect is rural background of candidates. This accounts for half of the rural docs in the US and a higher portion of those in the smaller towns.
Beyond this, there are great unknowns. For example, there is less research on the 50% of rural docs that come from urban backgrounds.
Much of the data supporting proximity or programs comes from family medicine program research, not rural graduate program research, there is a difference
Rural is very different in regions of the country. The procedural items that can drive candidates to choose rural and procedural residencies and practices in the midwest and west may not work for the east with the south in between.
Some states have unique geographies that can inhibit graduate training in rural locations, such as the Houston metro area impacting and isolating medical schools in Houston, Galveston, etc. from rural areas of suitable size, Nebraska and limited numbers of towns with enough size to support residency efforts and meet RRC requirements
The length and location of graduate training in urban areas can inhibit rural location. This was true when FP began 30 yrs ago in Arkansas and Minnesota and likely other locations, and can be true in RTT programs where about 1 in 8 RTT residents refuse to continue into a rural site and move again due to urban connections from 5 years in Omaha, or move to Omaha followed by another move a year later.
Proximity - Studies demonstrate that program location does impact on graduate location:
This one was written from a statewide perspective by the state coordinator in Texas, now at the Southern Regional Education Board - Denton, D.R., Cobb, J.H., and W.A. Webb. "Practice Locations of Texas Family Practice Residency Graduates, 1979-1987: The Inertia Factor." Academic Medicine. 64(7):400-405, July 1989.
Other FP research efforts support this, but really few done with the rural perspective. Dorner FH, Burr RM, Tucker SL. The geographic relationships between physicians residency sites and the locations of their first practices. Academic Medicine 1991;66:540-4.
There is a fairly convincing theory that residents fill local spots in the town of their graduate training, and then fill nearby locations.
I think that this is true of family medicine residents, but not those who are interested in rural practice and just happen to pick family medicine training.
Program factors - Research also supports rural mission, more rural months of training, procedural training, summarized in
Geyman, John; Norris, Tom; and Hart, L. Gary. (eds.). Textbook of Rural Medicine. New York: McGraw-Hill, 2001. pages 369 - 375 or try out
My contribution at http://www.unmc.edu/Community/ruralmeded/model/gradu/rurgrad.htm
Also more at http://www.nrharural.org/dc/issuepapers/ipaper13.html the section on Graduate Training by Deb Phillips:
Graduate training can positively enhance recruitment to rural communities and impact retention by training the physicians for the realities of practice through rural selectives, rural training tracks and rural emphasis (Brazeau, 1990; Foley, 1994; Mangus, 1993; Connor, 1994; Rosenthal, 1998; Fryer, 1997; Bowman, 1998; WONCA, 1995). Rural selective sites mostly have not been reimbursed for graduate medical training and the funding for primary care programs with a rural initiative has been inadequate and unsecured.
The current effort to roll back support of graduate medical education (GME) will hinder the newly developing rural medical schools and rural residencies. GME funding linking reimbursement to inpatient hospital volume specifically hinders the expansion of primarily outpatient setting residencies, such as family medicine residencies (Saver, 1998). The relatively small number of family physicians educated has contributed to the shortage of rural physicians (Council on Graduate Medical Education [COGME], 1998). As the nation works within the constraints of the Balanced Budget Act of 1997, any freeze on GME
spending must ensure reallocation to address these issues.
If I wanted to convince someone to locate graduate programs in Northwest Pennsylvania, there would be several arguments:
1. more rural docs for the area by graduation and location
2. more rural workforce for the area by delivery of rural health services by program, faculty, moonlighting
3. more retention of local rural docs in area by support of moonlighting, teaching opportunities
4. economic arguments of rural docs using 1 million in impact per rural doc per year
5. access arguments per Alex Christ and Title VII work
Integrated rural training programs involving medical school and residency
Why?
In Nebraska, the selection of rural background, mature candidates allows the Accelerated program to graduate docs that go to the smallest towns in the same numbers as the RTT programs despite 7 years of training in an urban area (Omaha). In these grads, their clear rural interest, their moonlighting, their cohort support of each other, and their inability to do what they have been trained to do except in rural locations forces them rural.
These candidates used to go to Lincoln and Wichita before to get this kind of training. Lincoln had incredible rural retention rates that we now have stolen, since we got the people they used to get. Now they get a mix of some of these folks and others from out of state.
All of this is based on Jeff Hill's selections at UNMC and several rural feeders for students from college and high school.
Other readings
Fryer GE, Stine C, Krugman RD, Miyoshi TJ. Geographic benefit from decentralized medical
education: student and preceptor practice patterns. Journal of Rural Health 1994:10:193-198.
Fryer, GE, Stine, C, Vojir, C, & Miller, M. (1997). Predictors and profiles of rural versus
urban family practice. Family Medicine, 29(2), 115-118.
Gray JD, Steeves LC and Blackburn JW (1994). The Dalhousie University experience of
training residents in many small communities. Acad Med 69(10): 847-51.
Foley, AE. (1994). A Strategy to increase the number of urban family practice resident
physicians who enter rural practice. The Journal of Rural Health, 10(2), 119-121.
Hobbs J (1999) Increasing recruitment contacts between generalist residents at the Medical
College of Georgia and rural and underserved communities. Acad Med, 1999 Jan
Lin G, Rosenthal TC, Horwitz M. Primary physicians practice location choice: an analysis of
factors in New York State. New York Rural Health Research Center, State University of
New York, Buffalo NY. July 1994.
Saver, BG, Bowman, R, Crittenden, RA, Maudlin, RK, & Hart, LG. (1998). Barriers to
residency training of physicians in rural areas. Rural Health Research Center, University of
Washington School of Medicine, Department of Family Medicine. Barriers to Graduate Medical Education http://www.unmc.edu/Community/ruralmeded/model/gradu/barriers_to_graduate.htm
West PA, Norris TE, Gore EJ, Baldwin LM, Hart LG. The geographic and temporal patters
of residency-trained family physicians: University of Washington Family Practice Residency
Network. WAMI Rural Health Research Center, Seattle, Washington. February 1995.
McLennan County FP Residency Impacts - contributions of FP programs to underserved areas in terms of savings of public health costs