The rural response is that health care is a substantial portion of rural economies and those who block the flow of rural physicians are basically are a major reason for the poor rural economy. The medical literature exposes the myth of professional isolation. That leaders choose to believe journalistic or anecdotal worst case scenarios is a matter for remedial education for these leaders. Finally rural culture is different. Or better said, the various types of rural cultures are different from urban and from each other. Rural does not mean a lack of culture, it means different cultures. It is not a surprise that this comes from medical leaders since those they teach, graduating medical students,  list the pursuit of cultural competence as sadly lacking in medical school (AAMC GQ 2000). - RCB

Medicine's social contract entails the granting of many privileges to the profession in return for its willingness to be accountable for serving societal needs. But, on occasion, medicine is held accountable for solving a societal problem that is not totally within its power to resolve. A case in point is expecting the medical profession, in particular its academic component, to solve the dilemma of doctors' not choosing to practice in some areas where they are needed.

As we all know, many Americans living in rural and inner-city areas do, indeed, have limited or no access to physicians' services. The complaint that doctors don't choose to practice in these locations is valid. What is invalid is the expectation that the mere existence of a need for physicians' services will suffice to offset the many disincentives faced by physicians who might otherwise respond to that need. There are many factors beyond a given community's need for doctors that individual physicians must weigh in deciding whether to set up practice there.

For openers, the individual's specialty is a major consideration; the greatest need in most underserved communities is for primary care physicians, not neurosurgeons. So, for practical purposes, the first step in addressing the need is to enlarge the pool of generalists, who then might be persuaded to fill the gap. On this one, academic medicine clearly has been responsive; since 1992, the number of medical school graduates planning to practice as generalist physicians has increased almost threefold.

But simply increasing the supply of generalist physicians will not, as some policymakers glibly assume, solve the problem. A major issue is the economics of medical practice in many underserved communities. Leaving aside the not-inconsequential matter of medical student indebtedness (the mean for 1998 graduates with debt is $85,619), a physician considering practicing in a medically underserved area must ask whether it is economically feasible to do so. Typically, communities that need physicians are populated by many people who lack insurance or who are otherwise unable to pay for their medical care. Consequently, many physicians who might otherwise choose to serve such communities are dissuaded from doing so out of concern about being able to support themselves and their families.

Finally, even if economic considerations can be met, the social and cultural characteristics of most medically underserved areas present daunting obstacles to many physicians who might contemplate practicing there. In inner-city settings, these obstacles include concerns about personal safety, working in impoverished surroundings, and dealing with a host of intractable social problems inextricably entwined with the provision of medical care. In rural settings, professional isolation, lack of employment opportunities for one's spouse, limited educational options for one's children, and a paucity of satisfying cultural and civic outlets naturally enter the calculation when young physicians weigh their practice options.

Policymakers and lawmakers representing the underserved seem to be unwilling to accept as legitimate these and other reasons that dissuade many young doctors from settling permanently in needy communities. As a consequence, their efforts to correct the geographic maldistribution of physicians have been notoriously ineffective. I believe it is time for us to cease beating our public-policy heads against a wall. We need to de-emphasize the necessity for permanent physician settlers in areas unattractive to most physicians. I believe, along with many others, that we can solve the geographic maldistribution problem by placing fully trained U.S. graduates in underserved areas for substantial, albeit limited, periods of time. The model for doing so is already at hand in the National Health Service Corps. We need to greatly expand the NHSC, or initiate a similar program, to enable many more U.S. medical school graduates, after completion of post-MD training, to spend two or three years in public service, perhaps in return for substantial educational loan forgiveness.

The NHSC has just celebrated its 25th anniversary, and is examining how it can be most effective in the future. The AAMC has stepped up its own advocacy on behalf of an expanded NHSC, and I think everyone in academic medicine would do well to vigorously support such an expansion. Substantial public education will be required, however, to wean many people from the notion that the only way to access quality medical care is to have a lifelong relationship with a single physician. Having a series of two- or three-year relationships with fully trained physicians is far better than nothing. As is so often the case, the quest for perfection can be the enemy of the possible.

For a paragraph by paragraph critique

For a response of why doctors do go to small towns

Rabinowitz identified background and preference for family practice and small towns as 80% of the reason that his selected candidates go into rural practice.

The importance of local rural schools and colleges

Medical Schools and Rural Graduation Rates

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