In Family Medicine this month of October on page 640 you will see a nice review of the factors that distinguish med student's career interests. Bibliographies 5 - 7 document that students begin medical school with pre-established beliefs. Madison did a similar study using service motivation at UNC. My study using AAMC data noted only 362 of 16000 allopathic senior medical students were interested in a practice in a town of less than 10,000. These students were also twice as likely to know their final rural practice career decision before matriculation. Until these numbers improve, the downstream medical school and residency program investment is wasted. In graduate allopathic FP we still have only about 700 fp residents graduating into rural practice each year (towns of less than 25,000 not adjacent to urban areas). This has been almost constant for 30 years. To change the rural numbers, you have to impact the beginning point.
Family medicine is more a means to an end that students dream about, especially for those with a dream for rural and underserved practices. FP depends on the 700 rural directed and 200 urban inner city directed folks to make up a significant 30% of those choosing FP. If FP loses its stature as the best way to prepare for underserved areas, some other specialty would get these students.
When we admit more students to medical school with service motivation (madison) and interest in long term relationships with patients, ability to provide continuity of care, variety of patients encountered, variety of patient care problems, meeting the needs of the underserved, and involvement in community health related activities (Haq et al), then we will get more interested in primary care and family medicine. Rabinowitz has perhaps the best stats noting that 70% of the decision for rural practice was rural background and interest in family medicine at matriculation. Rabinowitz also has great retention numbers in his PSAP program grads, something that no other retention study has shown. Pathman has the best studies on retention and there is no difference in retention for rural background of physician or spouse. It is my feeling that Rabinowitz, in the state with the largest rural population in the nation and one of the best educational systems in the nation, and working with the small colleges in the region, has one of the largest numbers of well-qualified rural potentials anywhere.
When we admit more with intellectual qualities for a variety of reason such as more MD PhD candidates, or more out of state or province students (declining to 70% in some states that have had over 90% in state students), then we are decreasing the numbers with other qualities such as the above.
By doing rural programs at medical school, you might influence some to hold on to a dream that otherwise would be socialized out of them. You might also convince a few to be interested in rural practice, but your best bang for the buck regarding rural choice is admissions and the best way to influence admissions is to look at where the students you need come from, especially small rural colleges. You might also look at socioeconomics, since Toronto has been admitting more and more from families with better socioeconomics. TORONTO STAR EDITORIAL, Apr. 9, 2001 A study of first-year medical students at the University of Western Ontario shows that the average income of the students' parents is 50 per cent higher than three years ago. Students whose parents earn less than $60,000 are down from 36 per cent to 15 per cent.
http://www.unmc.edu/Community/ruralmeded/admissions_package.htm
Once you impact admissions, then you can reinforce with a year one experience, student groups, and year 3 and 4 influences. Canada should actually go for a 6 year entire rural FP school from admissions and throughout the training. Our closest are the RPAP in MN and our accelerated programs. For descriptions of these and their dependency on admissions, see http://www.unmc.edu/Community/ruralmeded/model/gradu/nerurprg.htm and click on the first link or two.
Quality of Rural Preceptorships
Doing the later stuff without the earlier will only lead to bad match rates, frustration, broken promises, and poor access.
Also if you pick the ones with the right stuff, you will not need to work so hard on the student groups, volunteer organizations, rural experiences, etc. These students will demand them and will work to see that they get done, that is because they are the right ones. It is in their nature.
I will be happy to discuss this with you in Montreal at the rural med ed portion of the Canadian FP meeting November 9th. I will be speaking about this and similar topics.
Robert C. Bowman, M.D., Co-Chairman
Rural Medical Educators Group of the National Rural Health Association
UNMC Department of Family Medicine Director of Rural Health Education and Research
983075 Nebraska Medical Center
Omaha, NE 68198?3075
(402) 559?8873 or fax at ?8118
Email: rbowman@unmc.edu
http://www.ruralmedicaleducation.org or
http://www.unmc.edu/Community/ruralmeded/
Recent list serve postings in rural medical education at
http://www.unmc.edu/Community/ruralmeded/member/rme_recent_list_serve_postings.htm