We need to be very careful when addressing Congress regarding this area. The Title VII studies, although suggestive, do not document that Title VII funds have increased the flow of physicians to rural and underserved areas. The General Accounting Office recommendation still stands when it last stated that there was some effect, but the funds could be targeted better.
Of course at the local level there can be significant impacts FEATURED STORY from CCPH site. WHERE DOES IT HURT, DOC? WHERE THEY CUT OUT THE TRAINING Read the entire story at http://futurehealth.ucsf.edu/pdf_files/PM092002.pdf
More from Title VII advocates at http://www.aamc.org/advocacy/hpnec/
Frankly, with properly done studies including factors such as minority, it is likely that there would be no difference over time, as the numbers of increasing minorities (who are 4 times more likely to choose inner city underserved) would likely outweigh the effects of funding. In my studies of FP Programs who graduate rural physicians, one of the greatest predictors of rural practice was the percent of the residents who were minorities. The higher the per cent of minority residents, the less likely that the program graduated rural physicians. Other factors include rural mission, rural state, rural ambulatory clinics, rural months, ob months, Program Director as rural contact person. An additional study did not show an impact of % of osteopathic residents or the Title VII funding given to the residency program. Title VII funding is not a contributor to the graduation of more rural physicians at the residency level. This does not mean that funding at earlier levels is without impact.
In the first years of family medicine, we graduated 600 a year into rural practice (towns of less than 25000 not adjacent to a metro area). Throughout the 30 + history of family medicine and including recent years, we still graduate about 600 a year into rural practice, despite major increases in the number of residents.
Perhaps you might be able to say that the increasing numbers of minorities and females has impacted this area and decreased rural numbers, but gender does not impact the regression equation and although minority does, the number of minority residents is relatively small and clearly dwarfed by the massive increases in the numbers of FP residents over 30 years.
Rural recruitment is dependent on getting a certain type of student into medical school, the ones interested in family practice and also interested in returning to small towns. Admissions Package It is harder, but not impossible to pick out the urban background candidates that are likely to choose rural practice. Rural and urban background graduates and even spouse rural background students still stay in rural practice the same length. The advantage of rural background selections is 5 or 6 times as many choose rural practice as compared to urban background.
Rural retention is based on other factors such as training factors, procedures, confidence. This area is not fully understood.
Another potential factor, yet to explore, that might predict retention at or before the time of medical school admission, is service or mission orientation. Service Orientation Selections such as at RMED at Rockford in Illinois may add to our knowledge in this area. The current literature has service linked to PC choice, not necessarily rural or inner city. Minorities clearly choose inner city poverty in much greater numbers.
Family medicine's battle is not with Congress and the President, it is with medical school deans and admissions and those in the state. Our allies are state fp and rural organizations. Our target is state legislators and governors. We must not settle for less than full control over at least 10% of the class, if not the whole class.
Our second battle is internal. If we truly want graduates to go to underserved locations, we must target training to these locations, promote the residencies that train residents in and for underserved locations, explain what inner city and rural training is to ourselves and potential recruit students. We must sacrifice dollars to allow faculty to be on admissions committees and rise to control these committees.
As far as I know, Title VII funds have helped support a few rural student and graduate programs, but not many. These dollars are dwarfed by the overwhelming contributions of rural physicians and rural hospitals and people in rural communities.
Title VII funded one rural faculty development program (The ETSU Minifellowship in Rural Family Medicine) that resulted in the top two awards at the National Rural Health Association meeting this year. Our UNMC FP department won program of the year and a rural minifellow, Jim Buechler, won the educator of the year award, but the $300000 for this program from 1990 – 1992 is a drop in the bucket for all of the years of funding of Title VII.
Title VII has never helped increase the numbers of rural months, a more rural state, ob months, rural mission or other factors known to assist in rural graduations.
We in Family Medicine chose infrastructure over impact years ago and have been fortunate to escape retribution so far. Rural and underserved communities have not been so fortunate.
Graduate chart over the years at
http://www.unmc.edu/Community/ruralmeded/model/gradu/gradcht.htmFP grad article and factors chart: http://www.unmc.edu/Community/ruralmeded/model/gradu/rurgrad.htm
As indicated on Table 1, about 29% of family medicine residents in the responding programs chose rural practice settings during the three year period. Twenty programs graduated over 75% of their residents into rural practices and 49 programs graduated over 50% into rural practice. About 165 programs (48%) had some form of rural training. Family practice residents provided 3742 months of medical services to rural communities in 1994 on required rural rotations alone.
The 63 programs with a rural mission graduated an average of 50.9% of graduates into rural practice while those with no rural mission graduated an average of 21.3 % into rural practice. Programs with only 2 months of obstetrical rotations graduated an average of 23.8 % of graduates into rural practice and programs with 5 or more months of obstetrical training graduated 42.1% into rural practice.
NHSC History
http://jama.ama-assn.org/issues/v283n20/ffull/jmn0524-1.html