Rural Background, Rural Interest, Rural Workforce

Body Section

Robert C. Bowman, M.D.

for summary see Rural Background Summary  
for final section see Additional Value from Rural Medical Education Programs

see also Medical Schools and the Family Medicine Match

Genesis 41   Pharaoh's Dreams

¹ When two full years had passed, Pharaoh had a dream: He was standing by the Nile, ² when out of the river there came up seven cows, sleek and fat, and they grazed among the reeds. ³ After them, seven other cows, ugly and gaunt, came up out of the Nile and stood beside those on the riverbank. ⁴ And the cows that were ugly and gaunt ate up the seven sleek, fat cows. Then Pharaoh woke up. ⁵ He fell asleep again and had a second dream: Seven heads of grain, healthy and good, were growing on a single stalk. ⁶ After them, seven other heads of grain sprouted-thin and scorched by the east wind. ⁷ The thin heads of grain swallowed up the seven healthy, full heads. Then Pharaoh woke up; it had been a dream.
 

Shortages and maldistributions have always been and will always be. Shortages of physicians in various specialties and location have been a problem for decades. Lack of access to health care is still a major problem in a nation that spends incredible amounts on health care. A few years of government- and business-sponsored managed care efforts threw an appropriate scare in the nation's medical institutions, with a temporary rise in interest in primary care, but since that time there has been open warfare on the American pocketbook. This will continue until the next major recession or panic.

The nation has had 7 years that were sleek and fat for primary care, family medicine, and rural practice. With adequate numbers of primary care physicians the needs of urban, large rural, and rural areas were largely addressed. Shortages continued in isolated rural areas but progress was made with increased graduation rates of family medicine residents to such areas, at least for a time.

During this time significant work on rural background and on models in family medicine education and rural medical education have demonstrated that there is a cure for the rural component of maldistribution. There are indeed efforts that have met the workforce needs of states, not only in numbers but in the kind of training and preparation needed.

Now we have entered a time of famine. This includes the composition of entering medical students and those currently in a long pipeline lasting at least 7 years if not more like 11. A return to 20 or 25% of rural background students admitted to medical schools (similar to Australia) seems unlikely. Awareness of the problem is non-existent. Awareness of solutions, some of which have been around for decades, is at the lowest point ever. Deans more commonly talk about the distribution of specialists than primary care. The remaining cows and wheat are eating each other up.

Medical education, already in decline, continues to sacrifice relevance and the quality of training in pursuit of research dollars and revenues. These are of course guided by severely distorted national health policies that insure increased health costs and declining quality and access. Medical students are being denied access to the kind of training needed by the continuing scourge of liability and the complete lack of continuity in the nation's health care system. It is enough that these insure that faculty are less likely to allow students and residents access to patients, but audits and punitive actions and bureaucracy make matters worse. There are also distorted incentives in medical centers set up by the lure of research dollars and the conversion of academic faculty from teaching practitioners to revenue centers.

In such an environment, it is difficult for rural health to take a proper role. Already hampered by distance from medical centers, and by small numbers in population and health resources, there are few advocates and even fewer researchers. However rural health has the ability to make major contributions in terms of addressing several areas. These include:

1. the quality of care - rural health systems are good models for study

2. the quality of medical education - rural medical education models graduate some of the best physicians in the nation

3. the qualities of medical centers - students interested in rural practice, often from rural backgrounds, have much to give.

Rural background students have drawn interest primarily for their potential as rural physicians. They do fulfill this role, but they have much more to offer. It may indeed take a village to raise a child, but it takes the consistent efforts of a nation to graduate physicians from rural and underserved communities. The loss of 2000 students from any single ethnic category would be considered a tragedy and would evoke a prompt, consistent national effort. Such a loss of professionals from a group most likely to serve rural America is intolerable.

The impact of this decline appears to have been delayed by the long length of the medical education pipeline. It takes 10 or more years for some of the changes in education to begin to impact the numbers of rural background students. Changes in affirmative action occurring in several key states in the late 1990s are only now impacting family medicine graduates of 2002 and 2003, with more impact to be seen. The numbers of graduating rural family physicians appears to be holding at 750 a year. However there appear to be declines in those choosing the smallest towns, the rural and isolated rural categories (Bowman FP Grads 2004). It will take another year or two to confirm this trend. It may be that primary care beyond family medicine can serve urban and larger rural areas, but the needs of isolated rural areas can only be met by well-trained family physicians, most often originating in rural areas.

The Loss of Rural Background Students in Allopathic Medical Schools

Data collected by the Association of American Medical Colleges includes rural background origin. The AAMC data reveals that rural background students declined from 27% to 16%. Given 16500 total matriculants, this means that the count of rural background students lost each year compared to the early 1980’s is 1815.

AAMC data on matriculants, senior students  AAFP Graduate data

As you can see from the graph, the % of rural family physicians weaves around the declining percentage of rural background students admitted. The data is matched by cohort so that the 1980 matriculants match with 1984 senior students and 1987 FP Graduates.

Further calculations reveal the distribution of rural background students lost. Over 2000 of the students most likely to choose rural practice according to Xu (choice of rural practice by ethnicity), Bowman (Senior student interest in rural practice), and others, are no longer being admitted to allopathic medical schools each academic year.

The totals for each of the ethnic groups is held constant. Totals of students remain as per AAMC data. A ruural-urban distribution is applied to each group with 10 – 15% of the group considered from rural background. Holding the AAMC figures of 27% and 14% constant for rural background for all entering medical students, the distribution of rural and urban for white matriculants was calculated. This revealed a figure of 18% for white medical students with rural background.

Economics and Workforce

Studies by Newhouse and the Rand Corporation noted that increases in total physicians would force physicians to located in ever smaller locations (Newhouse et al Where Have All the Doctors Gone? JAMA 1982; 247:2392-2396). Many have applied his work to overall physician numbers, however, few note the latter half of his paper. In this closing section he notes that smaller locations were most dependent on the supply of family physicians.

It is important to note that Newhouse excluded the smallest rural locations from his analysis. This made it difficult to study such areas. Other studies have examined the supply of recently graduated family physicians (Bowman FP Grads 2004) as well as the importance of rural background selections for medical school admissions (PSAP and sDuluth). These indicate that supply of the isolated rural areas is most dependent upon well-trained family physicians of rural origin. The value of such admissions for isolated rural areas is seen below.

Traditional Medical Education vs Enhanced Medical Education Using RME

Duluth is a 2 year medical school that selects medical students primarily for their potential to become rural family physicians. Rural background is a key characteristic (Boulger – Duluth studies). Duluth students join other University of Minnesota students in Minneapolis for their final two years. Studies show that both groups have graduated about 80 rural family physicians from 1997 - 2003, although the class size of the parent is much larger than that of Duluth (Bowman FP Grads 2004). Here is the distribution of each regarding the type of rural location. Large rural is RUCA 4 – 6, rural is RUCA 7 – 9, and Isolated rural is RUCA 10. The urban focused codes are 1 – 3, 4.1, 7.1, and 10.1.

The Duluth graduates that chose family medicine are much more likely to choose family medicine all three rural categories, particularly the most isolated rural locations by over 3 to 1. Comparisons with the table below reveal the difference in outcomes. US pop distribution is in the final column with 6.1% in isolated rural locations

How Important is Graduation to the Isolated Rural Category?

Consider the distribution of family physicians in the nation who graduated from residency during 1997 to 2003 in the table above.

More widespread implementation of the Duluth model across the nation would be more likely

1.      To improve the numbers of rural background students and

2.      To distribute family physicians to the most rural areas of the nation.

It is important not to discount the role of the Rural Physician Associate Program (RPAP) in preparing such physicians for rural practice. RPAP students spend 9 months with a rural family physician in the third medical school year. Equivalent numbers of Duluth and U of MN students have taken RPAP during this time period. The combination of Duluth selections and environment, coupled with intensive and specific rural medical education, is a powerful weapon to combat one of the most persistent and troubling areas of medical education – maldistribution. In addition some 60 RPAP students have returned to the rural sites of their 9 month experience. The value of such graduates is difficult to calculate in terms of recruitment cost, orientation cost , and acceptance by patients, a key factor in rural practice. Towns that get involved with training may aso be more willing to embrace the final product.

Rural background and admissions may be the foundation of rural medical education, but specific rural training may be the icing on the cake. Again review the impact of specific rural training such as Rural Training Tracks and Accelerated Rural Training Programs as noted above in the table.

Workforce Implications

Also it is important to note the limitations as stated by Newhouse and others. If shortages of family physicians continue to develop, there will be increased competition for family physicians from urban and large rural and rural areas. This will tend to deflect efforts directed at isolated rural areas. This may make it more difficult for communities in the isolated rural areas to recruit and retain even Duluth/RPAP graduates. Click on this to see COGME predictions with decrease in primary care and rural workforce. The predicted loss in numbers for the 18 million people in the isolated rural category alone is staggering.

Alternative Models to “Growing Your Own”

Short of such an approach, the nation will need to continue to use substitutes for rural workforce. This is a concern because such substitutes have the potential of creating problems with quality and also may not have the desired impact on access.

Temporary physicians - Shortages of rural doctors tend to increase the demand. This will, in turn, increase the cost of temporary assistance. Other changes will result:

1. More loss of continuity primary care physicians to provide higher paying temporary assistance.

2. Increased cost of recruitment and retention and physician workforce for rural hospitals.

3. Increased likelihood of fewer physicians and less willingness on the part of physicians to stand call and do inpatient work.

4. Hospital closures and declines in physician access for more communities.

Family medicine residents are a key source of temporary assistance, but international graduates often have limitations on licensure during residency, military regulations will not allow their graduates to moonlight (despite the great training this has been), and work hours limitations will make this area much more of a challenge. The care provided by such physicians is more expensive and lacks a long-term focus. There may also be quality issues with the care provided, particularly follow-up care.

Hospitalist plus Emergency Physician model - In more severe physician shortages in parts of rural Canada, overwhelmed physicians have cut back on call coverage for hospitals and emergency rooms. This has forced some hospitals to embrace a new hybrid model of hospitalists and locums. This again is a much more expensive mode of care that is likely to overwhelm even the temporary fix of critical access hospital designation. “Orphaned” patients, those without a regular physician, suffer in such situations. Retention becomes a more and more difficult process in situations where all must work together for the most fragile rural health systems to survive (Bowman JRH, Building a Practice).

International Medical Graduates - Current models of care for the underserved have limitations, in rural areas of the United States. Increasingly the US is importing physicians to care for underserved populations. This brings in elements of communication, cultural competency, practice efficiency, retention, and continuity. These are all additional problems for underserved rural areas, the locations that need to be most efficient in resource management. The problems are not limited to international medical graduates. National Health Service Corps Scholars are often reluctant to go to many of the most isolated rural locations.

Quality Issues

The supply of well-trained rural family physicians may be the most important factor regarding quality of care in rural areas. With increase in this supply, there is better choice of physicians.

Limitations in the supply of family physicians, the supply of physicians most likely to choose isolated rural areas, limitations in preparation for rural practice, and increased problems with temporary physicians might be concern enough. Given the nature of rural practice where patients are older, in poorer health, and face more obstacles regarding access, the quality issues are enormous.

Studies Regarding Rural Background, Rural Interest, and Education

The following is a review of various studies regarding rural background and rural interested students. Again this is not a result of fewer attempting to gain entrance into medical school, since the distribution of those taking the MCAT has not changed.

Declines in admissions of rural background students are likely the result of several factors:

a.       declines in rural education, especially secondary education and college

b.      declines in admissions of students from lower income levels

c.       the lack of consistent health care career orientation in rural K-12 education and also in colleges with more rural origin students

d.      various pressures exerted on admissions committees (legal, research emphasis, accreditation, prestige, board scores, pass rates, increasing student debt)

e.       lack of application of a consistent evaluation tool or “score” that would balance the influence of the current GPA-MCAT-college prestige trilogy

f.        poor targeting of national and state resources much later in the pipeline to rural practice. Current efforts involve the clinical years of medical school, residency, and beyond. Better efforts would be directed to the early years of medical school and efforts in colleges, high schools, and middle schools graduating rural students as well as those who advise them.

The end result is a lack of “polish” similar to underrepresented minority candidates

Perhaps the largest obstacle facing rural workforce is the poor recognition of this problem on the part of medical education.

Declines in rural admissions appear to be related to decline in rural interest at the senior year and also declines in rural choice of practice of family medicine residency graduates.

For slides on State to State Education and MCAT scores see

Presentation Regarding Rural Background and MCAT Scores and Education Levels by State

Interventions in Rural Workforce

What could be done:

A.     Increasing the numbers of rural background students

B.     Leveling the playing field between military incentives and rural underserved incentives

C.     Adopting Rural Medical Education Models for increased and more efficient rural workforce

Increasing the numbers of rural background students by changes in admissions of rural background students and outreach to high schools and colleges - Calculations of restoration of rural background students to those admitted. Students from various types of communities vary in their interest in rural practice. Those from the largest cities are the least likely to choose rural practice at only .0069. Some 15% of students from the smallest rural towns are interested in practice in towns of less than 10,000. Increases of students from current levels of rural background students to 20% or 25% by increasing class size only for such students, would increase the graduation of rural family physicians by 100 or 180. They would be joined by an additional 300 – 400 students who go to rural practice but do not note interest in rural practice as seniors. In some states only a few rural doctors a year going to the smallest towns makes a significant difference in workforce, rural economics, and other factors. The following note the contributions at various levels of rural background students. The 2003 figure is the distribution based on 1995 data and a 13.4 % rural background number. This is followed by 20% rural background, then a restoration to the 25% figure from two decades ago.

Improvements in rural background admissions could increase the potential that the nation could have more physicians in the most rural locations. This would require an additional 500 students in total admissions, with admitted with rural background, with loss of 400 from the most urban areas. These students would contribute to workforce beginning in the clinical years. As these students entered FP training, particularly in rural training tracks and where FP programs are in rural areas, additional workforce is provided.

Again without continued graduation of enough primary care and family physicians, the numbers choosing isolated rural practices would suffer in the competition for a limited supply.

In the past, rural medical education efforts have managed to continue to graduate steady numbers into rural practice, but without extra efforts directed at admissions, these efforts will fall short of national needs.

Rural Background, Quality, and Those Interested in Rural Practice

Some face the difficult task of mastering the basic academics required to become a physician. Others who become physicians may never master the responsibilities required of physicians. It is better to take a chance on the former rather than deal with the consequences of the latter. Robert C. Bowman, M.D.

Admissions Evaluations - Students from rural backgrounds represent a wide variety of characteristics. A common problem for rural anything is that rural is so diverse, in location, in lifestyle, in culture, in tradition, etc. Many assume a difference in rural living as compared to urban, but comparisons note more similarities than differences (Cordes, Fluharty). For the purposes of admissions, rural background students can be well-prepared or not. They may be truly interested in returning to smaller towns or they may be using higher education to escape rural life. Those evaluating rural students for admission face even more challenges. Often rural students come from a different set of high schools and colleges, requiring a breadth of knowledge that may take time and effort from admissions committees.  Rural students can have a tendency to lack confidence. Some face the challenge of adjusting to urban areas, interviews, and a faster mode of operation. The ability to convey who you are and demonstrate your confidence and ability to handle most anything is important to admissions representatives.

Rural Workforce and Rural Background - About half of rural physicians come from rural backgrounds. Declines in rural background students raise questions about a key source of rural physician workforce. At least 2000 fewer rural background students are entering the medical pipeline each year compared to a decade ago. Changes in rural schools, small colleges, and admissions to medical school must be understood.

Rural Background and Income Levels - Those from lower income levels are finding it harder to gain admission to a prestigious college. Pell grants that once covered 40% of college expenses now only cover 15% (R Beck).  Rural background students are much more like underrepresented minority students who can find family assistance only 6% of the time compared to the usual medical student who gains 20%. Income levels, service orientation, and rural background have all been related to choice of rural practice (Owen). Older students also have been a mainstay of both rural and family practice. This group may also be decreasing as medical schools go with more and more competitive applicants.

Rural Background and Rural Interest - Students who are interested in rural practice are mostly rural background students. Additional urban background students develop rural interest over time, but it is doubtful that they will do so without a rural experience. Selection of urban background students without previous rural experience has been a chronic problem in the National Health Service Corps. Over recent decades, students have had less and less rural experiences. 

Impressions of Rural Living - Faculty, deans, and medical leaders once made statements such as “Only the best of our graduates should go into rural practice” (Flexner, Dean at Tufts 1947 per David Doane, M.D.). Now medical leaders note that rural communities have trouble attracting physicians because they have “a paucity of satisfying cultural and civic outlets (Cohen – Why Doctors Don’t Always Go Where They’re Needed, Academic Medicine December 1998). Other medical leaders are wondering whether the need for specialists in rural areas is greater than the need for primary care physicians.

The environment of medical education is a real concern. Students hear occasional disparaging remarks about “wasting their lives in family medicine.” Students who experience rural practice and family medicine often have a difficult time processing what they have seen and heard. They see a more complete picture of the life of a physician as compared to the hospital attending models that dominate their clinical education. It is not hard to infer that the hassles are not worth it. Proper orientation may help students understand that hassles are increasingly a part of the lives of all physicians. Finally attitudes toward rural life and rural practice are not improving as experienced by urban students throughout education and training and through the media. Rural experiences may be the only way to reverse poor attitudes, myths, and assumptions regarding rural situations. It is also getting to be more difficult to pull deans, faculty, and medical educators out to visit rural communities. Such contact is essential to understanding small towns, rural practice, and preparation for careers in rural health (Hobbs, Invisible Faculty, in Family Medicine).

Other factors may contribute to perceptions of students and residents. Those advocating for more funding and better training may tend to use examples that do not paint a rosy picture. Posters at hospitals and magazines such as Medical Economics sell advertising by using the worst case examples. This also becomes a part of the environment of medical education. Competition for declining numbers of primary care interested students may also be fostering dysfunctional relationships between primary care specialties and among those in the same specialty.

Additional Value from Rural-Interested Students

Rural-interested senior medical students are twice as likely to volunteer, to do public health screening, and to do rural, international, and military experiences at all levels of medical education. They tend to be older with families and are more likely to choose family medicine. (Bowman AAMC GQ, Rural interested vs all students).

Rural background students and those interested in rural practice contribute greatly during training. They often provide leadership for classmates, family practice interest groups, and community service groups. At each year of medical school they are twice as likely to volunteer locally and do public health screening as compared to their cohorts. They take more rural, international, and military experiences, again at a level twice that of their cohorts at all years of medical school. They are also more likely to be older, white, and married. They are not as satisfied with current medical education in a number of ways compared to cohorts including lack of primary care, public health, health promotion, and community health areas. (Bowman, Studies of Rural Interested Senior Medical Students, from AAMC GQ data in 1995).

Students who have overcome obstacles often have many of the qualities of personality and character that we most need in medicine, or in any profession. Those from underserved communities are also most likely to return to such areas to practice. Bowman, Character, Color, Admissions, and Physicians

Solution #2 Reduce Differentials Between Military and Underserved Scholarship Programs

The National Health Service Corps is in the process of converting funds almost entirely to loan repayment. Last year I would have been happy with this scenario, until I began to talk to students in various allopathic and osteopathic schools. Much of this thinking is based on past problems with location and retention of the National Health Service Corps. There are two key limitations for NHSC:

a.       NHSC cannot choose the physicians that are admitted to medical school.

b.      NHSC has needs in two different types of sites, with the differing potential for retention and productivity and acceptance

Current NHSC physicians are 3 times much more likely to be underrepresented minority physicians (AAMC GQ data). It is likely that nearly all are from urban areas.

Military family physicians are more likely to be white, male, osteopathic, and a bit older, with families. These are all characteristics of rural family physicians also. In some studies these are the ones who go and stay in rural areas. Military funding is the largest single source of osteopathic tuition.

It is possible that a significant subgroup of the 200 military family practice graduates each year might choose a rural pathway, if given a similar support package.

Even though NHSC has a need to be efficient with funds, it may be that the real problem is lack of enough funding. Better funding might allow the physicians most likely to choose rural family practice to do so. This might add 50 – 80 more rural family physicians a year to the nation’s rural workforce.

The combination of special rural admissions, excellent rural training in medical school and residency in tracks, and support packages similar to those in the military might greatly increase the numbers and improve quality of care in rural areas, or at least prevent future quality problems.

Beyond efficiency is understanding the decision-making process of various types of medical students, particularly those few who might make excellent rural family physicians.

The picture for rural areas with concentrations of underserved minorities is looking more bleak. The nation used to graduate dozens of Native American Family Physicians. This number is now in single digits. Declines in Hispanic FP doctors are also noted (Bowman FP Grads 2004)

Changes in minority distribution in FP Graduates 

The rural distribution of the above graduates is also a concern. Although natives are small in number, almost half of native FPs choose rural practice. Black and Hispanic fp graduates choose rural about 8 – 10%. In 2002 the following numbers of minority FP Graduates located in rural and isolated rural areas of the nation (RUCA 7 and above not urban focused):  12 black, 11 hispanic, and 7 native family physicians. This compares to 209 white FP graduates choosing rural and isolated rural areas.

A coordinated effort could identify other areas where the nation is making it difficult to obtain much-needed rural workforce.

Continue on with this

Additional Value from Rural Medical Education Programs

see also Medical Schools and the Family Medicine Match

Charts and graphs at

Changing Rural Background

Family Medicine Physician Distribution

Rural Choices by Medical School Origin

Rural Impact

Physician Workforce Studies

www.ruralmedicaleducation.org