Robert C. Bowman, M.D.

The Group on Rural Health and the Group on Admissions have shared a common chair and common efforts. There are also similarities shared with groups involved in low income and underrepresented populations with plans to expand mutual activities. There are also significant linkages with Australia. Australian family medicine physicians have visited the US. Australia and United States STFM physicians serve together on the Rural and Remote Health board which recently managed Medline approval. The list serve shared with the NRHA Rural Medical Educators group has grown to 450 participants. Activities continue at STFM and National Rural Health Association annual meetings. Web activities include rankings of medical schools and residency programs graduating the most rural physicians. http://www.unmc.edu/Community/ruralmeded/ranking_rural.htm.

New studies note that the age of a physician at graduation from medical school is a key characteristic related to rural practice location. About 2 % of younger medical students choose rural family medicine, increasing to 4.9 % for allopathic graduates who are older at graduation from medical school (29 - 31 years). The impact of age is similar for family physicians (10 % to 18 %) and psychiatrists who double from 3 to 6 % with older age at graduation. Older medical student admissions have declined in recent years. Admissions of older students "revives" in times of decreasing applicant pool. Older graduates and those born in rural areas are the heart of the family medicine contributions of allopathic schools created after the birth of FP, osteopathic schools, and Caribbean schools. Students born in the same state as their allopathic public medical school also make important contributions to family medicine choice (20 % higher).

Birth origins increasingly are linked to choice of career and location. Those with lower socioeconomic origins (rural, older, less urban, underrepresented minority) are less likely to be admitted but when admitted are the most likely to distribute where needed  The only thing that has impacted the most urban groups involving 67 % of allopathic medical students has been health policy.

Birth Origins and FP Choice 

Admissions and choice of family medicine appear to be related strongly to one another through socioeconomic measures. Those of lower income origins are the least likely to gain admission and the most likely to choose family medicine. Students born in other countries are the fastest growing group of students, now occupying 16 % of allopathic medical school positions nationwide. Most have been raised in counties of over 1 million people. These core urban counties are the birth origin of half of allopathic students. Those born or raised in such counties are the least likely students to choose family medicine, rural practice, rural family medicine, office-based primary care in poverty locations, and psychiatry. Those most likely to choose family medicine and rural practice and other distributional careers continue to decline in number and percentage. These include those born in metro areas of the US in counties of less than 1 million, those born in rural areas, older students, and allopathic public medical school students born in the same state as their medical school.

Black students and rural students now share the lowest ratios of admission in the US in allopathic schools with half the rate of admission (250 medical students per 100000 college age students age 18 - 24 in the US) as compared to all medical students (493). The process of admissions with a focus on scores and academics (at college, MCAT, and USMLE1) may be a primary limitation of physician distribution, second only to primary care health policy and closely related to the intensity and specificity of training for underserved areas.

Admissions Ratios and US Medical Students

Medical schools with greater numbers of the most urban, the youngest, and foreign born allopathic students were impacted by supportive national primary care health policy a decade ago for a brief time period involving the classes graduating 1995 - 1999, but have resumed their resistance to the needs of the nation as in previous decades. The only other period of great primary care support quadrupled the numbers choosing primary care, family medicine, internal medicine, and office-based primary care in poverty locations, coincident with the creation and escalation years of Medicare and Medicaid (1965 - 1978).

When the nation had increased numbers of medical students choosing family medicine, residency programs diversified to serve a great range of underserved needs, from inner city to remote rural areas via rural training track and accelerated programs. These programs graduated 50 - 90 % into rural locations for the past 7 years and together contributed some 150 extremely well trained and mature rural family physicians. Accelerated programs graduates choose primary care critical need areas 80 % of the time -  1) rural areas, 2) urban poverty locations, and 3) faculty positions. This study involved 150 accelerated graduates from 11 programs. Accelerated programs have been terminated and rural training track programs compromised.

Successful programs such as the Physician Shortage Area Program that have made substantial health and economic impacts on the State of Pennsylvania (and many other programs throughout the world) are still not supported by state funding. Changes in accreditation may also impact rural experiences in residency programs. Many residents and program directors are facing the reality of falling numbers of continuity patients and potential delayed graduation. Rural experiences take residents out of their "continuity" clinic and make it difficult to process the required numbers of patients. The termination of rural experiences is a likely result of these pressures. This will likely result in loss of a "true" continuity experience, although brief, in the effort to have a paperwork continuity experience. Rural faculty continue to "multitask" with rural activities a minor part of their total workload. Rural program directors face increasing difficulty with recruitment and convincing program sponsors of the importance of their programs.

Rural physician, family physician, office-based primary care physicians in poverty locations, and rural family physician numbers continue to decline in an alarming fashion, a likely impact of the collapse of primary care health policy in the nation. The previous short years of "good" primary care health policy were enough to demonstrate that the nation could produce sufficient rural family physicians and office-based primary care physicians in poverty locations, with nearly 900 of each needed each year. This was enough to make some gains on shortage needs, but the nation was not willing to sustain this effort. The numbers for 2004 and beyond look like the nation will be graduating about half of this amount or less each year in each category.

Rural physicians face increasing difficulties with overhead costs due to liability and regulation and Medicare and Medicaid cuts and slow recovery from recession. Just like their poor patients they are finding increases in one area balanced by decreases or increased costs in other areas. Some have decided not to replace fellow providers when they leave or retire just to improve finances even though this will mean longer hours and more call.

Robert C. Bowman, M.D.
3/1/05
rbowman@unmc.edu

From previous status reports:

See table   The pipeline to rural practice is a long one, extending across several years and several locations. The following are estimates of the impact of rural programs on the medical education process. Although the total impact is small and only a few models exist at each level, the contribution of FP is significant. See guidelines for developing rural med ed.  See also centralization in state education policies

At the medical school level there are...

A few admissions programs to facilitate those with rural background impacting on perhaps 1% of 17000 entering students:

Only 47 schools with a mission statement mentioning pc. In the past few years, more have added this to the mission, but with little priority in primary care.

Some medical schools have damaged fp depts by giving them little or no money or too many responsibilities for the funding they are given.

Health Career Fairs – only a few, by AHECS, East TN St Med School, various colleges Chadron State in NE, Oregon. Medical schools feel little responsibility to underserved rural areas. The focus is still on finding intellectuals rather than the right students.

Combined preparation/admissions programs - PEPP, KY (1981), RHOP, NE (1989), BS MD Gannon Hahnemann JMedEd 63 1 Jan 7-10 more chose fp, some include obligations too. Others exist, but again for academic reasons rather than rural underserved. Hazard KY may be a shining star for the future with all college, med school, and residency at one rural location.

Special admissions - Jefferson, PA Physician Shortage Area Program, Rabinowitz, prefer rural and fp, improved production, Fresno HCOP disadvantaged from rural to med school

Admissions and PC curricula – Duluth/RPAP, Upper Peninsula, WAMI(1971) jmeded 62 Oct 810-17, Illinois J Med Ed 48 4 april p323-331, 

Scholarships - NHSC, Ohio 70s, New England late 70s (MA) 6mon per yr support, most rural states have some sort of funding here

Purchase training in another state for obligation to underserved - NY State contract program, Wyoming, WAMI, Maine, Rhode Island

Orientation program - Ohio State

A few obligation programs to finance students with service commitments to the underserved impacting on fewer than 5%? state and fed scholarships NHSC - 200, uniformed services - ? Alabama NHSC recipients Scutchfield, J Comm Hlth 8 4 summer 240-247

A Few Interest groups - Some rural topics given to fp, amsa, ama, snma interest groups. More success with community service, international service

Special curricula for rural - 113/141 med and osteopathic with rural experience available but only 24 required rural, Over the years the rural experiences have decreased in length from 8 - 12 wks to 4 - 6 wks or have been terminated. The length may be important. Studies show that schools with over 6 weeks of family practice clerkship have 19% of their students choose FP (11% is average). Does over 6 weeks of rural impact in a similar way? NE has an 8 wk required for all 120 students. Phil COM4 in 3rd and 12 wk in 4th, Penn State 30-50% of the 388 med students enroll in 1st 2nd or 4th yr and Johns Hopkins 3-10 students a year in this, AHECs, SEACOM FL Melnick rural, minority, geriatrics, U New England COM rural Maine, Wisconsin 80% rural sites Beasley JFP 17 5 nov 877-882, U of Alabama past?, Kirksville,

Extramural - AMSA's HPDP, other PHS programs, and the Appalachian Preceptorship touch just 3% of students. With many turned away and program terminated. NHSC SEARCH in 20 states with up to 40 student per year in these programs in some states. Appalachian Student Health Coalition Vanderbilt/Meharry, Appalachian Student Health Project AMSA 1971.

Programs integrating rural in the first two years -, Duluth, PCC SouMedJourn 75 9 sept 1110-1117, East Carolina, WAMI J med ed 63 5 may 347-355, Kellogg sites - (ETSU, el paso, WV, others).

Programs involving the last two years Upper Peninsula, RPAP, RMED, and last two year tracks impact on less than 2% of the 16000 students

Preclinical and clinical rural both - Nebraska, many Duluth students choose RPAP in MN

Rural Sites - many areas have clinical rural sites, Upper Peninsula Michigan, Dartmouth JMedEd 50(12 pt 2) dec 44-48, ETSU, FL am j pub hlth 61 6 june 1196-1207, several osteopathic sites

Unspecified rural curriculum – U Missiouri Kansas City, Mercer

General programs FP track - Utah Jmeded 57 8 august 609-614, Human Values Morehouse JMED ED 57 feb 121-123 , CUP Arizona underserved Public Health Reports 95 1 janfeb 26-28 spencer outcalt, FP pathway U Cal Davis, Primary Care Track PCC in New Mexico

10 accelerated programs which smooth the bumps in the primary care trail by bypassing the match. They could be rural, but only one uses it as such (Nebraska). The rest use it to improve FP match in academic programs.

Short term rural training - Minimodule Bontrager Ohio State

Major declines in rural interest over the years of medical school and residency. The environment is rotten for rural as med schools are urban, tertiary, hospital, subspecialty (increasing), research-oriented (as NIH dollars increase match in fp decreases), and increasingly hands-off with high tech and decreasing student responsibility for patients.

Strategies - WAMI rosenblatt pub hlth rep 95 1 janfeb 12-15, Arkansas Saltzman 1980 J ark med soc 77 2 july 93-97, ETSU continuous, NE continuous, AL Scutchfield pub hlth rep 95 1 janfeb 16-18, RPAP, AHECs, Graduate, fp, or other state councils, SUNY Buffalo

At the residency level...Table giving info on numbers of different types of rural graduate training

FP produces only 600 or so rural doctors out of the 2400 graduating each year. Increases in FP residents have not increased this number.

Rural program information - interested students have few sources of information about rural programs and no information about who actually produces rural doctors until this year. The listing of rural programs in family practice residencies can help there. This listing needs to be updated by the program director survey each year.

Rural orientation of residency - 119/400 fp programs say rural in the AAFP directory. Having a listing as "rural" is statistically not related to the production of rural practitioners. 100/400 report some rural experience either mandatory or elective. Few mandate rural experience. Most seem to avoid requiring rural rotations as this is feared to drive away some candidates in order to make sure positions filled, improvements in the match may help some, but programs will need to focus on their own unique mission as all FP programs cannot train all types of fp residents. Various residents are interested in rural, urban, behavioral, community, procedural, faculty, fellowships, other.

Accreditation limitations - FP faces major limitations regarding rural training due to size, continuity, subspecialty, and hospital requirements.

Faculty limitations - Most family practice faculty who do rural programs and research can contribute only a few hours to rural programs due to multiple other commitments. Faculty at community-based residencies may be particularly hard pressed to obtain the support to be able to emphasize rural.

Rotation lists outside of local residency training - AMSA/Public Health Services lists resident experiences, Monroe LA, Anchorage AK and other IHS sites

Balanced Budget Effects – major disincentive to new rural training programs as several years before rural hospitals see any funds from GME dollars, paperwork a big headache in places with no history of such, flak from Medicare intermediaries, potential trouble getting programs in small enough areas for Secretary of HHS to declare rural, yet large enough for FP accreditation.

Financial incentives in residency - OK salaries were boosted with fp choice, extra incentive with community match, mixed results as with any program that forces early choices

Completely rural residencies - complete listing in program list

Rural Training Track programs have grown to 9 program locations and now over 40 but each RTT is small. RTTs may only impact on 50 60 residents per year. Rural Grad rate is 75%. Spokane RTT was the first, others in NE, KY, SD, NY, IN Some of these are on probation. New types arising with only one resident at a site (Buffalo).

Few non-FP rural programs exist - Dartmouth - rural peds Hanover NH, Nebraska's Primary Care Track includes FP and IM. Rural general surgery a great need.

Legislative actions by states - Required rural rotations - TX, CO

Prepractice seminars GA J med assoc of GA 70 9 sept 641-644, IA, SC, TN, NE, others

Phys Recruitment conf GA J med assoc of GA 70 9 sept 641-644 for communities

Former Montana FP program – it used to be 2 month rural rotation, about 25% of over 200 have come to practice in Montana, now there is a full time residency with a 36 month program. We’ll see if it does as well in meeting state needs.

At the rural community level...

Few communities and few hospitals have the personnel or organization to effectively recruit. Most efforts are intermittent and haphazard. Few communities work with family practice residency programs, the most likely source of candidates.

Many or most rural communities blame outside policies or entities for their problems instead of focusing on what they can do with local resources utilizing a process of resource inventory, needs assessments, and working together on common goals.

Many rural docs are screaming for help as colleagues leave or retire. Desperation makes for some poor decisions by physicians and communities.

Obstetrics in rural communities is caught between the demand of obstetrics with its tough call and situations, aging rural doctors, declining numbers, loss of general surgeons who often did C-Sections as a backup for other docs in town, and lack of resources or trained staff at facilities.

Legislatures and congress are looking to blame someone else for health care problems. They are not always listening to rural interests. They often go for the quick fix or working with special interests rather than working for the long term with definite goals seems to be the rule. Quick fix suggestions are abundant regarding licensure requirements, locum tenens programs, liability, service obligations to the very smallest of rural towns, and other issues have the potential for damaging rural health. As they may get match physician/community needs poorly or influence current rural physicians to leave or do locum tenens instead of continuous primary care.

Activist organizations may do much to attract attention to some real problems, but they can potentially decrease student interest in rural careers. They can also contribute to the sense of powerlessness that pervades many rural communities. Policies that focus on most needy areas may actually decrease the total rural physician pool as physicians may leave sooner

Retention programs, policies, and research are virtually unknown.

Few State Centers for Rural Health, Rural Research at Georgia Southern, Hazard KY

Offices of rural health new and at mercy of health depts (good and bad)

Cluster consolidations, NHSC reductions, Offices of Rural Health reductions, AHECS reduced, limited research in pc, rural, nothing regarding study of rural medical education

With the last century of subspecialty scientific emphasis, things are bad enough, but new distractions are on the horizon. The emphasis on preparing generalists dominates the headlings. Retraining subspecialists is a hot new item. The basis for this emphasis is a "trickle down" effect. If we just train enogh generalists, we will force doctors where we need them. The need now is the same as it was in 1920 or 1930 or 1960 or today. We need practitioners to serve the underserved.

Never was there a greater need for rural faculty to be able to truly influence medical education yet there are only a few hundred faculty doing rural programs on mostly a part time basis. What does family medicine need to be able to address rural health and the production of rural practitioners at the state level?

There needs to be research and programs that concentrate on what it will take to produce rural physicians. The major lacking ingredient for this is faculty to do the rural research and the rural programs. Studies have shown that the length of an FP clerkship is related to the family practice match. The proportion of a medical school faculty who are in FP is also related to the match. The strength of primary care and rural within the medical school is a key part of successful rural programs.

First for the 1990s assumptions - most faculty in primary care who are interested in rural have at least 30% clinical work and 30% teaching of students and residents, the rural work will be done part time by full and part time FP faculty. The mission and the resources and the interest are just not high enough now.

Next for the hard choices - one person may attempt all rural duties. This is impossible. Junior faculty can try, but do not know the program or institution. Program directors or chairs have been most successful, but rural duties can force them to neglect other areas. The best choice is several faculty of various experiences working together. A review of successful rural faculty and the types of job descriptions reveals the following areas of emphasis:

Positions at Medical Schools

assistant/associate dean position

rural task force, interdisciplinary, AHEC and family practice and rural grants, need to train pc faculty for dean and chancellor positions - few if any in searches

the shining example is a few new branch medical school

campuses that may offer some help in rural medical education

admissions

Actually need several members (as in ECU), a chairman who is willing to work hard and long hours to evaluate and maintain a course toward rural and primary care selection, members who are also devoted to admissions with big chunks of time to really screen candidates and interview them, rural docs or rural people as admission members, rural-interested students could be on admissions, great need to educate admissions directors and staff, educate recruiting staff, admissions to run any bypass programs such as those facilitating rural state college candidates

Address deficiencies of current system - GPA, MCAT, science base - why not people base or look for more likely rural fp personalities, pick out the more mature. An interview-based system takes lots of time. May desire a longer time to evaluate prior to considering for admission to measure suitability and likelihood for primary care

curriculum committee development

Early PC integrated, gets role for fp docs and faculty to reverse trend toward urban, sub speciality, and facility.

Rural experiences required in significant chunks (takes 9 months to become comfortable with pc - RPAP) Consolidate and coordinate core clinical rotations of FP, IM, Peds, Surgery, in medium to large rural locations so that rural interested can spend chunks of time in the same location. Longitudinal programs like RPAP and Nebraska's Extended Preceptorship

Keep a balance between the academic pressures of accreditation/board exam demands and the mission for primary care and rural and underservice.

Implement programs that have enough resources, faculty support, and good evaluation. Never be too hasty but keep moving forward.

 

Positions at Family Practice Departments

rural predoc

Coordinate rotations, develop local curricula, train preceptors, recruit preceptors, develop perks for preceptors, sponsors fp and rural student interest groups

advise students

About rural opportunities, electives, rural residencies, rtt, rural fellowships, rural faculty at other programs, co-sponsors rural and fp student interest groups also CMDS and AMSA

Visitation program

Most if not all department faculty should participate in rural programs in the above and visit rural preceptors and sites to understand the needs of rural towns and practitioners, reduce the town-gown, develop the local curricula (improve rural rotations), and support rural physicians. Part of the duties in this area is to take residents and their spouses out to towns to check out the possibilities. Another duty is to set up recruitment events. See Invisible Faculty by Joe Hobbs in Family Medicine.

 

Rural faculty development

Can use the resources of a state or university, at least one community-based program does fp faculty development for the state. Community-based programs may have more motivation for rural faculty development Preceptor education project may help - for ideas on getting faculty to meetings or rural fac d come to session at 3

Positions which could be university, community-based, or volunteer rural practitioner-faculty

rural residency rotations

Coordinate rotations, train preceptors, recruit preceptors, develop perks for preceptors, develop local curricula - apply rural curricula at the local level, work one on one with preceptor, visit and practice in the community or hospital a few days, have preceptor in to teach and learn

rural fellowships/rural training tracks

Develop program and be a true program director with all qualifications and duties including recruitment, curriculum development, finances, advisement, problem solving, clinic services, etc.

work with other faculty who teach procedures, supervise rotations, or precept

advise residents

Keep up with resident preparation and progress, push to moonlight, do procedural electives, act as a PHS advisor, push practice management, use experience as a former rural docs or rural program director, connect with state opportunities, prepare some for teaching students and residents after graduation

research/data keeping for residency/FP/State

can be done by university FP, community-based FP, or state FP academy, legislative activity, contacts with rural communities, work with state rural associations and primary care organizations

pc research in rural areas - on networks, resources

Central leadership and coordination - faculty alone will not be enough, they will need support and direction, Must hold medical leadership accountable for not implementing the programs than have proven records of graduating more rural physicians!!!!!!

More cooperation and opportunity sharing between the Office of Rural Health Policy, FP groups, NRHA, AAMC, state offices of rural health

Broader representation and exchange of information between academics, government, community leaders, and rural health providers

 

Bibliographic Listing of Rural Health Professions Educational Strategies MSU Victor Cocowitch MPH, Kevin Fickenscher MD, Carol Keefe Ph.D, Cynthia Weber MS