Sometimes a cruise ship ignores repeated warnings from those fellow travelers isolated in the high seas, warnings about icebergs. This is a setup for a disaster of Titanic proportions.
I read the Ruralmed postings with great interest. Many of the issues dealt with by our associations and list serves seem to be far less consequential than people writing with passion to get help for patients and communities with real need for access and care and support and encouragement, especially the rural physicians and their communities. One thing I do not see is the work of those behind the scenes in the rural community, the hospitals etc. I hope that these people are working together with you. The legislators may not listen to you, because they may be seeing you and other physicians as whining about more pay, but they cannot deny the real and expressed needs of the people in their areas. Our National Rural Health Association has been a great help in this area. Your medical associations have been very supportive, especially when compared to ours though.
I am not sure that we are ready for change in this country, but yours certainly sounds as if it is getting ready.
Perhaps what all rural peoples need is an approach that will help them deal with their own needs effectively and without constant dependence on national good will or resources.
In my observations and reflections as a former rural practitioner, a medical educator, a researcher, and a service-oriented citizen, I am coming to the conclusion that health, education, economics, jobs, leadership, and other key factors are all interconnected, especially in the smallest and most isolated communities.
Some areas are more important in the process. Small colleges are the feeders for the young professionals that will eventually return to these communities and help stimulate jobs, the economy, leadership, education, etc. Medical schools have always held a key role in shaping education not only at the highest levels, but also down to college and high school. All of this must have a supportive government that understands and facilitates needed change. We still have far to go. One example, only recently have we realized the magnitude of differential of public health support in rural vs urban US locations.
Those in national leadership positions can continue to ignore repeated warnings until disaster strikes, usually from a person or persons who have grown hopeless and have nothing to lose.
The primary weapons against hopelessness (and the violence and chaos that follows) are education, health care, economics, etc. Once these are established then there is a chance for leadership and democracy and community rule.
I am a science fiction fan and the Foundation Series was one of my favorite reads. In the story line, there were two foundations created to keep the known universe from plunging into the 1000 year dark ages predicted by psychohistorian Harry Seldon. One worked on the surface and overtly while another worked behind the scenes. Eventually the Second Foundation led to an approach that merged mankind with the planet.
Right now we have temporary solutions, imports, exports, temporary positions, etc. In the United States we have costly National Health Service Corps programs providing 1300 docs. We have also had a J-1 visa waiver program providing twice as many physicians as the NHSC (2600). Many think that temporary doctors are a help, but it costs $225,000 to recruit, orient, etc a new primary care physician. Changing physicians each 2 or 3 years is costly in terms of health, economics, etc. Many of these are needed first foundation programs, hopefully temporary.
The Second Foundation approach needs to be a community-driven approach. It should arise from rural and underserved communities in admissions and in design, with training as much as possible in underserved communities (as orientation, training, and a source of workforce also), and such a program should be expected to return graduates into underserved communities (where young professionals mean jobs, leadership, economic impact, demand education, etc.).
I have been impressed with how quickly Japan and Germany recovered after WWII and how some areas of the supposedly advance US (indigent peoples, Appalachia, minority areas) resist change. The difference was that the education and economic and health segments in Germany and Japan never had time to collapse and for once these systems were retained. In Appalachia after the civil war some areas went for 30 - 40 years without recovery of education systems and the economics are often owned from outside the community, etc.
In some areas of our nations it will take decades, but that does not mean that we should not start. It just means that we need a more intensive effort earlier in the process. West Virginia has had a Partnership approach for a few years brought on when the state threatened to close one of 3 medical schools and the leading candidate (not meeting state needs) was the elite institution. This Partnership reaches out to middle school and high school, grants free tuition to colleges and health professions training. This is a long and involved and necessary effort. In another 10 years they will have some graduates.
In Nebraska we have had a piece of such a program, the Rural Health Opportunity Program, not as comprehensive, but a longer time period. We have seen these rural background people return to rural practice in good numbers in the state. We converted our entire 16 position per year FP residency into 5 rural training tracks and an accelerated rural training track. All of these positions would sit empty except a former dean pushed rural background admissions and a former rural doc ran the admissions all of this time.
Howard Rabinowitz is perhaps the most noted rural admissions expert. His program, the Physician Shortage Area Program in urban Philadelphia at a private medical school, involves only 1% of the medical students in Pennsylvania but now boasts 21% of the rural family physicians in the state. With each physician involving $2 million in economic impact per year, what a difference the 1% can make.
I do not know the Canadian medical education programs as well but there are elements of such programs in a number of places. Those on the list serve can contribute more than I.
The main consideration is that it is time to get started. A program starting at the middle school next year will begin to graduate physicians for underserved communities in the year 2020.
Please do not consider this a disrespect toward those from other countries or from urban areas who are serving the underserved. In the US, half of our rural doctors come from urban areas and more than 2000 foreign physicians serve in the most underserved areas in our nation where our own graduates will not go. In the long term however, it will take more connections between rural and academic communities, a community-driven approach, to meet the needs more effectively and for the long term.
An article on a similar topic is being prepared for the Journal of Rural Health.
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.unmc.edu/Community/ruralmeded/