Economic impact of a rural physician
Also see Locums Programs for Pro and Con
For programs that work, see getting rural doctors to the smallest towns
There is no need to try to establish rural medical education at the graduate level without major efforts to select the right medical students for rural practice (rural background, spouse rural background, more mature, family practice interest, service motivation and record, slightly lower GPA and MCAT scores). Incentive programs might induce some trainees to go into rural communities for a few years, but long term retention is not likely.
Some criticize the National Health Service Corps for the lack of retention, but given the nation's poor emphasis on rural selection, and given that the more costly schools are private, and even less likely to graduate rural physicians, this has been a good program. The good part of the National Health Service Corps is that the graduates did meet the needs of communities in extremely underserviced locations. The graduates also greatly assisted in the development of rural health networks of community health centers. NHSC graduates also stayed in some locations, moved to other rural locations, and when they did leave rural areas, they were far more likely to practice in underserved locations. From the national perspective, this has been a great help.
Programs that work together with small colleges to improve their programs and admit more students into health professions from small colleges are a good investment. Students with the right stuff can also be kept in the state with the right incentives.
It is entirely possible to proceed with program development that is out of the correct order. Why develop graduate programs without having the right students in the pipeline already? Start with the right students and make the changes in anticipation of these students, rather than trying to attract students that have little interest.
It is entirely possible to throw dollars into rural medical education and create rural faculty, administrators, coordinators, and others who do little in and for rural communities. Faculty might rationalize that it takes a lot of paperwork, committee work, etc. to do the job, but that is not what rural communities and constituents want to hear. They want rural doctors.
Optimally the dollars are invested in programs run by devoted individuals who take the time and effort to make a difference. The Minnesota Legislature gave notice to the medical school that it was about to suspend funding. To its credit, the legislature came up with funding that created the Rural Physician Associate Program. The success of the effort was due to Jack Verby, a rural doctor for 20 years. Jack learned the lessons of the medical school bureaucracy, managed to learn about evaluating the quality of education, and spent most of his time on the road visiting communities, physicians, and students.
Programs where faculty try to call or email to make arrangements for training are doomed to failure.
Successful programs can be established at the state level. The Office of Rural Health at Wisconsin stands out as an example of a program that can make a difference. Any doctor interested in the state can go in and find several practices that are suitable within minutes. This is because the staff spend so much time traveling in rural communities and assisting them in their effort. The staff know what is available and keep it updated. It is tough to find staff or faculty that travel and meet rural needs by visiting in person, but it can be done.
Nearly all medical students can get the funding to get through medical school. Students face far too many decisions (spouse, specialty, residency location) to be relied upon to choose a particular rural site or rural sites in general. The right kinds of students (currently in a rural community and married) might be a possibility, but this would take a special program. Some scholarship programs manage to fund themselves with paybacks and penalties, but .....
Increases in class sizes may seem to offer the potential to improve the distribution of physicians, but this is a costly intervention. This "trickle down" theory has been disproved on a number of occasions, but it still persists. Mostly medical schools have used this to increase their funding from state and federal sources. For most specialties, increases in the number of the specialty has resulted in more maldistribution (Ricketts). Family Medicine and Obstetrics have been the sole exceptions. In recent years family medicine may have changed its tone to neutral (Bowman, Rural Graduation). Increases in the numbers of family practice residents have not increased the number choosing rural practice. The lesson here is that a prerequisite for graduating more rural physicians is getting more family physicians, but they need to be the ones that are driven by service rather than job availability.
Declines in class sizes have resulted in fewer family physicians. Studies have shown that students likely to choose family practice and rural locations are those that are selected near the bottom of the admissions priority lists.
Remember that rural family physicians are primarily selected, then retained inside the narrow pipeline of training to rural practice by rural experiences and removing the obstacles along the way.
Perhaps one of the greatest health problems facing the nation today is too many physicians.
State and federal policies have contributed to this by rewarding institutions that professed to care for the underserved.
Family practice has learned to avoid medical school connections because the state and federal dollars can go to medical schools, but are often not seen by family practice training programs who actually do the work.