Recent trends in rural health make it imperative that primary care leaders understand the program characteristics that could result in more rural physicians. Rural health is facing a critical time of change and reorganization.

• Rural practice is in the midst of major changes in ownership and organization.
• Rural hospitals continue to struggle externally with funding agencies and internally with the needs of their own communities.
• Smaller rural communities are finding it more and more difficult to find practitioners and some have stopped looking. Communities still grappling with shortages of physicians will simply cease to exist or lose all potential for local input in the development of health systems.

The following are arguments in favor of increasing rural emphasis in family practice programs:

1. Increase in future rural workforce Studies clearly indicate the need to pursue rural emphasis to better address the nation’s workforce needs in coming years. Rural training could influence more family practice residents to choose rural practice, especially urban, female, and minority residents. Graduate training needs to stay in step with preparation, admission, predoctoral, and statewide efforts to maximize the potential for a rural choice.

2. Increase in current rural workforce Residents and students support rural communities with their services. Longitudinal rural students can provide significant medical services. The rural rotations of family practice and other primary care residents can contribute much support to rural physicians, especially in critical need areas such as after hours call. The community can benefit maximally in situations where residents become the fourth or fifth person sharing call and clinic duties. This can help stabilize a rural health system in need of workforce. The resident benefits from the responsibility, the volume, and the variety of an actual rural practice in such situations.

Suggestions

• Family practice programs or cooperatives of programs that arrange residents into 6 continuous two month rural rotations can greatly assist rural communities in need of workforce.
• More flexibility in accreditation could improve this to 4 rotations a year of 3 months, with even more benefits for the practitioner, the community, and the education of the resident.

3. Retention of rural workforce Currently over 800 faculty in family practice used to be rural physicians. Many rural faculty note frustrations when trying to teach rural after they have left their patients and contacts behind. If the training had moved to them through rural training tracks or regular rural rotations instead of them moving to academic sites, much workforce could still be in rural communities. These would also be experienced workforce with much greater potential for significant community impact, not new recruits that may take years to get established. Accreditation restrictions favoring larger locations for training inhibit family medicine s ability to increase rural physician workforce Even teaching on a part time basis can have workforce impact. Studies note that those who teach, stay in rural practice longer.

Suggestions:

• Screen for practitioners that are interested in more teaching responsibilities or those who might be leaving practice shortly.
• Mobililize training resources such as residents to assist communities and practitioners that have lost a rural physician and need help until one can be found.
• Identify physicians in practice and resident physicians who may need some support to go to a rural community. A part time teaching job may be enough support to recruit or retain someone for rural practice in the challenging first two years. This was how I got into rural practice and made it for the first two years.

4. Increased need to train the right physicians Clearly the nation cannot afford to train excess physicians for the wrong specialties or locations.

• Many schools are considering recommendations to decrease class size to reduce overall physician supply.
• Reductions in medical school class sizes have been shown to reduce the numbers choosing family practice by 12 - 25%, the specialty needed most by small towns (Fahey PJ, Sachs LA, and Bauer LC. Declining class size and the decline in graduates choosing family medicine. Academic Medicine 1992;67:680-4.).
• It would be a good idea to take measures to insure that these reductions do not result in decreased health care access for the elderly, pregnant patients, or the poor in rural areas.
• Programs in states with more than the state mean of 23% of their population in rural areas produce as many rural physicians as states with less rural populations, but it takes half the number of family practice programs for programs in more rural states to do so.

5. Educational value of rural training Studies document the value of rural experiences. The best research in this area involves the Rural Physician Associate Program (RPAP) in Minnesota where clinical students spend 9 months in a rural area. Studies indicate significant differences between students in RPAP and regular students, especially in behavioral, procedural, and practice management areas. Many note similar improvements with preceptorships in mixed rural and urban situations. As with many interventions in education, sometimes it is difficult to tell whether the intervention is the improvement, or whether the current education method is so bad that any change is an improvement.

6. Political value of graduates who choose rural If family medicine is no longer recognized as the specialty that goes where it is needed, federal and state funding could be jeopardized. Although family practice residencies continue to graduate about 600 rural physicians a year, both the numbers and the percentage of rural physicians has been higher in the past. Urban poverty and large urban locations are increasingly the choice of family practice residency grads. (see gradcht)

Family practice residency programs continue to be the hope for small towns across the nation. Further study of these programs and the development of effective interventions at the state and program level may help the nation address the chronic maldistribution of physicians.