Plugging the Leaks in the Rural Pipeline
- Rural rotations in residency training
The establishment of a more
rural rotations or a policy that set forth a minimum of time for family
medicine residents to spend in a rural location would have the immediate
impact of more rural workforce, it would have the potential for better
education, and could result in more rural physicians in the future. Those
willing to fund such rotations include rural physicians, rural hospitals,
locums groups, and networks of clinics or hospitals. State and federal
policies favoring these arrangements by funding residencies to work with rural
sites could increase these efforts.
Removal of impediments to the development of rural rotations. One
impediment to examine is the maximum two month continuity restriction. Another
set of restrictions favors training programs in larger settings. The Residency
Review Committee could be much more flexible, given the needs of the nation.
More study of the impact of timing, length, and type of rural experience.
Studies could also examine earlier rural rotations and continuity rural
ambulatory experiences. Program directors often like to wait until later in the
training to send residents to rural areas, but later may not be as good for
recruitment to a rural practice. Large scale studies of earlier experiences and
extended two, three, and four month rural experiences could confirm or deny
additional benefits at the graduate level.
Increased information about rural medical education for students, residents,
and faculty. This would include improved information in the annual
directory regarding the mission statement, required rural months, the presence
or rural tracks, the percentage choosing rural practice after graduation from
the program, and the amount of obstetrical volume at the program. Students
currently have to do extra work to find the type of training that would help
them prepare for rural practice. Efforts to connect this information to existing
resources for students might work best through the current family practice
student interest movement and the annual "Strolling through the Match"
mailing to all students.
Combined residency training programs. Combined programs may meet both
the needs of students and the smallest rural communities.
Students interested in rural practice are often caught in the dilemma of
wanting the breadth of family medicine, yet needing the focus of a specialty
to either feel more competent, to be of more service to specific community
needs, or to obtain privileges. Some might benefit from combinations of family
practice with surgery, obstetrics, anesthesiology, geriatrics, or psychiatry.
Combinations with certain aspects of pediatrics or internal medicine may also
be options.
The most challenging rural situations are counties of less than 10,000
people. There are 33 states with nearly 3 million people that still have a
doctor and a hospital in these small counties. Combined training of current
residents may enhance the skills of some of the 1600 physicians that will
choose practices in these locations, although others might argue that combined
training would merely replace physicians with "combined" skills who
will soon retire. This would help some of the 400 hospitals in these counties
to continue to provide a broad range of services.
Increased tracking and analysis of the practice choices of graduates of
family practice programs, including their service to underserved rural
communities, care for the elderly, and obstetical services. Family
medicine should be the primary and continual source of this information to
assist program directors and others with decision-making at the program, state,
and national levels.
Development of rural programs and rural faculty This involves academic
programs and departments and rural sites both.
Rural Physicians as educators No longer are academic institutions the
primary source of information about academic matters. Rural physicians have
much to offer. They receive top marks for teaching from students and
residents. Previous surveys of rural faculty note that many feel that they
have much to share in the area of rural faculty development, but have no means
to do so. Rural doctors deliver the curriculum in some of the nation’s most
evaluated and best medical school rotations. A rural minifellowship noted that
fellows needed much support from colleagues and consultants to be able to
develop a significant rural program.
Planting the seeds early in the academic "fields" Students and
residents still spend much time in academic centers. Rural infrastructure in
family practice programs and departments could help initiate or develop rural
programs. Infrastructure such as a chair position, division, or department
would support rural student interest groups. Rural faculty and rural
physicians have a definite role in influencing top level medical school
leaders, including not only curricula, but admissions and finance. Research
studies on rural practice, rural medical education would benefit from an
academic coordination and facilitation. The academic and rural communities
have much to gain from a mutual arrangement.
Improvements in obstetric training It is often difficult to make the
arrangements to get enough obstetrical volume for family practice residents.
Little is known about the relationship between training and choice of obstetrics
in the future. Policy decisions are made with little information. For example,
one potential impact of managed Medicaid is a reduction in the obstetical volume
to training programs in several states. The midwestern states have a limited
number of volume obstetric training centers. These centers must be maximally
utilized to be able to train the obstetricians and family physicians that will
provide prenatal care in these states. Another example of a decision made
without much information is the decision by the Residency Review Committee (RRC)
not to require a minimum of 40 deliveries for each family practice resident.
Requiring 40 deliveries might increase resident interest in doing more
obstetrics or it might increase resident anxieties over obstetics. A minimum
could siphon deliveries away from residents really interested in doing
obstetrics. Without initial obstetric experience in medical school and
residency, few will show interest. In any case, the RRC may regret this or any
training decision that results in fewer rural physicians or less obstetrical
access. Some states with significant obstetric access needs may want to act to
increase obstetric training support and add their own requirements. Changes in
obstetrics training should be examined closely.
Graduate medical education dollars to rural hospitals Rural hospitals
often support rural rotations yet receive no GME reward. The expertise to
collect these dollars is in academic centers. More consistent scheduling of the
residents at one or more programs could package the residents into a 1,2, or 3
year schedule at one or more sites, making it more worthwhile to obtain GME
funds. Coalitions of rural hospitals and training programs would bring both
together so that further mutually beneficial interactions could occur.