A History of Allopathic Rural Medical Education in the United States

History of Public Health

Facilitating More and Better Rural Docs

Flexner’s Impact on American Medicine

Maldistribution Concerns and the Rise of Specialism

Generalism Revived    Generalist Role

Generalism Gets Re-Established in the 1970’s

Early Pioneers and the Decision for Rural Practice   Jack Verby

Sustainability and Recognition

Family Medicine Reproduces in the 1980’s

Recruitment Insights

Newer Generation Medical Schools

Graduate Program   

Preceptorships    Why a Preceptorship Is Better

The Response to Primary Care Shortages: Physician Assistants and Nurse Practitioners

AAMC Rural Meeting 1990

Rural Faculty Development - Minifellowship at ETSU    Minifellowship updates

Rise and Decline of Family Medicine in the 1990’s

Growth of Graduate Rural Training Choices in Graduate Programs

Family Practice Barriers    Accreditation and Demands of Rural Practice

Focus on Retention, Not Just More But Better

Next Generation Programs and Possibly Schools

Osteopathic Consistency

Organizing Rural Medical Educators   Rural Medical Educators Group

Coming full circle in med ed: Why a Preceptorship Is Better

Do you know who Marcus Welby was

A Century of Reform

pastfutu.htm - outline duplicate to review

Other History of Medical Education http://elane.stanford.edu/wilson/Text/22a.html

Before 1900 there was no need for Rural Medical Education. Physicians were trained in cities and migrated or else they did apprenticeships and then set up practice. There was no licensure and no allowance for quality. The distribution of physicians in Tennessee, as it became a more settled area, was according to the distance of a buggy ride for the day.

Mark Twain had some interesting viewpoints in pre-Flexnerian Medicine - see Mark Twain, Honorary Doctor  

The quality concerns of the day mandated changes in modes of training and standards of care. Organized medicine of the day at the state and national level, grew increasingly frustrated. The Carnegie Foundation authorized a study, closely monitored and assisted by the American Medical Association. Abraham Flexner, a high school principal, visited nearly every medical school. Coupled with licensure changes and the power of the media of the day, medical education underwent drastic changes. For more on this see Flexnerian Origins. One of the effects of such changes was elimination of apprentice training and with this, the rise of rural shortage problems. Inner city problems can trace their difficulties back to this as well. Most black medical schools closed and the others faced major challenges as a result of Flexnerian Reforms. The ten year old Johns Hopkins model espoused by Flexner became the dominant model for the next 100 years.

Now or Then - 38 physicians seek rural practice, for a real comparison to how little things have changed compare this to    Why Doctors Don't Go to Rural Practice   Attitudes much change for leaders to be able to lead us to solutions for maldistribution

Maldistribution Concerns and the Rise of Specialism

As early as 1926 Bridger noticed problems in Alabama. In the 1940’s one of the deans at Tufts University noted that those who desired a challenge stayed generalists, and those who wanted an easier path should be specialists. Just a few years later, medical schools completely reversed course toward specialism. Soon those who did rotating internships or those who went quickly into practice were lumped together with physicians who failed to make the grade in surgical and other residencies. Specialism ruled and generalism had few proponents. Some changes in medical schools and medical experiences during World War II and after resulted in some generalists, but the rise of science and research and technology fueled specialism to new heights. Those who researched the popular diseases such as hypertension or lipid disorders began to dominate funding and medical administration.

Soon enough, the public began to miss a physician who was able to relate to individuals and families. Commissions were organized (Willard, Millis) and generalists organized (American Society of Generalists). They faced an uphill battle for acceptance. After mergers and re-organization, the American Academy of Family Physicians was formed. State and federal funding fueled the development of graduate training in Family Medicine. The length of training was debated. Some leaders such as Nicholas Pisacano, supported a two year training period after medical school. Others, concerned about acceptance by the rest of allopathic medicine, managed to push a 3 year curriculum into existence. Eventually this movement developed into an entire family of organizations.  More at http://www.aafp.org/fpr/970100fr/4.html

Allopathic Family Medicine graduated 30% or about 600 of 1800 graduates during this decade into rural practice. The National Health Service Corps, the Hill-Burton construction funding, the Community Health Movement, and Medicare and Medicaid began to establish rural health systems. More doctors were needed. State and federal governments responded with funding for Family Medicine, primary care, and Area Health Education Centers. Medical school class sizes were enlarged in the hopes of attracting more to rural communities. A seriously flawed article was widely utilized to demonstrate that doctors would trickle down to rural communities, if only enough were graduated. Later the authors retracted the article, noting that it excluded the smallest rural communities. It would be some years before it was realized that it takes 2000 patients to sustain a family physician, 5000 for a general internist or pediatrician, and many times this to sustain various specialists.

Editor’s Note: Unfortunately, the concept of overproduction continued. Medical school leaders to this day have yet to realize that it takes special individuals and special programs to graduate doctors into underserved communities. Much of their focus is on the poor rural economy as the reason, despite several studies documenting successful ways to graduate doctors to remedy the maldistribution problem.

Realizing that rural areas needed help in the 1970’s, some programs adopted rural rotations into the training process. Family Medicine residencies were largely in urban academic centers. Shortages in rural areas were recognized. Little was known about the decision for rural practice, but what was known was applied in a few programs such as the Rural Physician Associate Program and the Duluth Medical School in Minnesota and the Physician Shortage Area Program in Pennsylvania. The University of Washington system known as WAMI also began to organize a decentralized approach to training. Other states such as Arkansas and North Carolina utilized Area Health Education Funding and state funds to deal with maldistribution. Tom Bruce put together perhaps one of the first texts on RME, Improving Rural Health.

Rural communities and academic communities were being drawn together, but often by the efforts of one man. These pioneers included Jack Verby of RPAP and Howard Rabinowitz of PSAP. Some admissions efforts began to include rural physicians or community members. By and large, however, most medical schools phased out primary care and rural preceptorships. They began to focus on the more intellectual applicants, using grade point average and Medical College Admission Test scores. Some faculty members realized that rural shortages began with medical school admissions, and new programs were developed.

Kentucky funded a pre-admission program called the Physician Education and Placement Program. Other universities reached out into rural and minority areas with programs such as Bio-Prep, working deep into even the elementary level so that some would be able to do well enough to get into college and then into medical school so that they could return to underserved communities.

Tom Bruce - Improving Rural Health, one of the first texts on Rural Medical Education

Tom Johnson - Presentations, AAMC, Rural Conference in San Antonio, Mentorship

Don Madison - Decisions to Admissions

Cooper - The Decision for Rural Practice

Sustainability and Recognition

Rural medical education programs have long suffered from sustainability and recognition. Because programs take many years, even decades to show results, they are difficult to sustain. It usually takes a devoted faculty member working over many years in the same location against multiple obstacles. Few programs survive to the point of publishable data. Also those who are good at visiting rural communities and role modeling and running programs are often too busy to publish. Often new programs have begun without the benefit of a publication or faculty colleague to consult. RME programs face difficult tasks regarding publication. RME involves a small part of generalism, too small to publish in the generalist publications. The rural publications are often not as recognized.

RTT model introduced, Blondell article notes some rural programs and little use of AHEC in graduate education, rise of community based programs, recognition of the need in rural health systems of call systems with at least 4 to share the load for best retention, best support of a hospital

2 year schools – Upper Peninsula and Duluth

Newer Medical Schools – Quillen Act and others

Growth of family medicine residency programs and including programs entirely in rural areas for all three years.

More formalized preceptorships were set up. A program of mention is the Combined Outstate Residency Experience Program or CORE program in Nebraska. This was the creation of Mike Sitorius, Jim Stageman, and Don Larsen. It involves the UNMC, Lincoln, and Offatt AFB programs and did involve Creighton at one time. The program gives a bit more back to rural physicians and the rural communities than most rural rotations. The residents spend two months in their second or third year at an underserved site in Nebraska. Typically this is a site with 3 other practitioners (44 such counties in Nebraska). Residents "become" a fourth provider and share call and duties. UNMC arranges with the communities to provide a resident every two months for up to three years. In return the hospital pays for stipend, lodging, and travel. The rural docs supervise and keep the revenue generated. Residents benefit from the experience, practitioners get the support and encouragement, and the community often gets a valuable lesson as to how to recruit more effectively. Only two sites have not managed to recruit a physician during their time as a CORE site. One site had physicians working over 80 hours a week and the other site experienced strife between various practices (it eventually attracted a CORE participating resident). Numerous sites managed to keep going with residents long enough to get another practitioner. The residents have helped the site kept the local market share at home - a key issue for rural communities who lose a practitioner. Sites short of physicians were ideal for training because the residents got to see a good volume. The CORE program had more to offer than the typical haphazard arrangement of a month here and there, mostly arranged by residents.

Primary care shortages continued to plague the nation. Current training programs were not able to meet the needs. The federal government borrowed military ideas and supported mid-level practitioners. Physician Assistants and Nurse Practitioner programs grew in number. Midwife programs had more formalized training and acceptance. Programs with decentralized training an missions to serve the underserved accomplished their goals. Unfortunately there were many who did not embrace these goals. Federal funding also specified masters and above type graduate programs, the ones least likely to graduate practitioners into rural areas. Some programs began on target for their mission, but lost their mission and ended up serving academic roles. This was ironic because it was the failure of allopathic academic medicine to address the needs of the nation that resulted in the need for PA and NP programs.  Many rural communities were slow to accept PA and NP grads. Some programs met local needs and graduates have spilled out into surrounding states. Many graduates are absorbed into the specialist markets in medicine, especially some of the higher paying medical specialties.

Excellent location in San Antonio. Much needed boost for Rural Medical Education. Much networking and rural faculty development. Unfortunate debate on unifying primary care distracted meeting. Excellent summary publication in Academic Medicine.

Local efforts were successful in Minnesota with Jack Verby. Periodic meetings and visits informed preceptors. Preceptors attracted by specialists that Jack brought out, when they would come. More important was the fact that RPAP was actually doing faculty development on the students that took RPAP. After doing their 9 months, they knew the curricula. When they located in their rural site for practice, they were ready for students, especially if they located in the same site that they did as a third year student (some 60 of 800 did locate at the same site).

Another formalized faculty development program was the Minifellowship in Rural Family Medicine program at East Tennessee State University directed by Robert Bowman. Minifellowship update  This was supported by a three year faculty development grant at $100,000 per year. Participants had a stipend and support from their director or chair. Some participants already had rural programs going. Some used the program to develop them, while others started their programs from scratch. Graduates of this program included the RTT directors at Hazard and Greeley, although Joe Ferguson was well along in his program and was more of an instructor. Others attending were Barb Doty, one of the key program developers in Alaska, Jim Buechler, the director of the Rural Center in Terre Haute, IN, Judy Monroe, a key rural person in Indiana and a co-director of her residency program, and Paul James (active in agromedicine and family medicine education). Tom Rosenthal was a consultant for the minifellowship. The minifellowship was more of a group support and information sharing vehicle than a typical ivory tower creation. Surveys of rural faculty across the nation confirmed that they would rather contribute their expertise rather than just be recipients. The final year of the minifellowship extended this concept with 5 regular minifellows attending sessions at family practice and rural conferences, but other rural faculty attending, contributing ideas, and presenting their curricula or program. The use of the conferences allowed the program to access more rural experts inexpensively as well as utilizing the rural resources of the conference. Funding for the program ended in 1993 and advertisements of positions without funding did not attract applicants. The concept of the minifellowship was replicated in the STFM Rural Med Ed Preconference Workshop in New Orleans and later in various rural medical education conferences.

Rural-oriented Local Site Development at The Case for Involvement in Rural Communities

Rise and Decline of Family Medicine in the 1990’s

This decade was perhaps the most turbulent of all. Managed care increased the attraction of primary care, but did little to attract the right candidates. Despite major increases in the number choosing family medicine residencies, programs continued to graduate 600 a year into rural practice. See Graduate FP chart - The total FP graduates rises over the years but rural grads stay the same. Perhaps the real reason is that admissions is the constant. When the right candidates are admitted, they choose rural, regardless of what happens in training. Without enough students chosen for rural and service oriented characteristics, all rural-oriented programs suffered. Also students in a panic over conditions perhaps sought more established programs. Recent efforts have focused on informing students about rural opportunities. For more see  RURAL TRAINING IN FAMILY MEDICINE or Why Choose a Small Rural Training Program. The best rural presentations and presentor is at the following: Dr. Robert Boyer in streaming video. His presentations received unprecedented high marks at the AAFP Student-Resident Meeting for years.

The Spokane program and Bob Maudlin piloted the RTT effort, with a second generation following in a few years at SUNY Buffalo, Nebraska, Greeley CO, and Hazard KY.  The second generation faced more stringent criteria. These programs were a way that urban and academic programs could make a difference by branching out training to rural areas for the last two years. Conversion of residency slots in Nebraska diverted the training from 95% urban in Omaha, to 90% rural. Research on rural graduate programs demonstrates that rural locations can graduate more rural physicians (Bowman and Penrod). 

Choices in Graduate Programs

In practicality however, the true contribution of RTTs is likely more focused rural training and preparation for practice. Despite the addition of rural programs at the graduate and post-graduate level, fewer family practice graduates became rural physicians than a decade ago. Declines in rural interest in medical students as well as the environment of rural practice continue to be problem areas.

One-two rural residency tracks in family practice: are they getting the job done? [see comments] (Rosenthal TC; Fam Med, 1998 Feb)

Using rural training tracks to encourage rural practice careers and enhance training in family medicine. (Damos JR; Acad Med, 1998 May)

The American Academy of Family Physicians has had an interesting track record regarding rural medicine. The academy has often done much in past few years to encourage interest in rural practice. In more recent years, the academy seems to have focused efforts in other areas. Key leaders seem to have bought in to the "it's the poor rural economy" argument as the reason for maldistribution. See Why Doctors Don't Go . Most AAFP Presidents and doctors of the year have been rural, but some have been frustrated by the inability to get rural health as a priority. This is difficult to understand since over 30% of family physicians are rural and nearly 50 % have some contact with rural or a key interest in this area. At times the AAFP donated brochures and assisted with the distribution of materials and surveys. AAFP also set up a rural speaker's bureau. STFM also helped, but had little funding and many other priorities.

AAFP delegated rural duties to persons who often were isolated and very busy in Washington or buried in other positions such as practice management for all of family medicine. Efforts to lobby for a specific rural staff coordinator at AAFP failed (resolution permanently tabled), but the leadership did establish an AAFP staff person in this area. Unfortunately this person's skills were in information technology. AAFP did put together some excellent brochures and a rural video, but despite urgings and meetings, no rural student interest packet or broad distribution has made these materials available. Another new person has taken over part time with other duties in publications and a nursing background. AAFP supports some FP CME at NRHA meetings, but in reality, very little has been done for rural health and almost nothing was done for rural medical education. Family Practice Management has had some excellent materials for rural practitioners. 

Just a few years ago the academy terminated the rural presentation at the student-resident meeting, even though it was one of the best attended. The rural group lobbied to have a rural page added to "Strolling through the Match". This was not added, but the decision was made to again have a rural presentation and this continued.

Again this year, in 2002, there will be no rural career orientation type presentation, no reason was given other than competition. Of course 12 our of 14 years is not bad.

At times AAFP has worked with the National Rural Health Association and other organizations. At other times AAFP leaders have failed to assist rural faculty and programs. In one instance, a key leader opposed the creation of perhaps the best rural program in the nation, one that has placed 60% of graduates in the smallest towns.Program directors have been slow to recognize rural program directors and help inform students and AAFP about their programs or ways to access them, a failure that fueled the growth of the specific rural medical education effort.

The families of family medicine have to balance political situations, but decisions seem to constantly penalize rural programming. Attitudes against a 4th year of graduate training almost terminated an important program in Nebraska (Accelerated Rural Training Program). The American Board of FP moratorium on creation of new accelerated programs has impeded replication of a successful model, the accelerated rural training program. This model may even lead to further support of family medicine medical schools, as specific primary care training has several advantages. This would take family medicine out of the constant threat of dependence on the match. See Nebraska Programs

Family medicine has also not worked with osteopathic medicine well. The combination of osteopathic medical school and allopathic rural residency training in family medicine is a particularly potent combination for preparing rural practitioners. Osteopathic medicine could work more closely in this area as well. More osteopathic graduates have chosen FP residencies, but those with more osteopathic graduates have not resulted in more rural locations for graduates, neither has Title VII dollars contributed to rural graduation rates.  See Bowman - Additional Rural Research on FP Programs

Family medicine was offered the opportunity to work with rural medical educators. The Division of Education at AAFP has great resources. AAFP failed to respond to Rural Medical Educators and we chose another sponsor.

AAFP student and resident staff and leaders have continued to be responsive to rural medical educators, but many other academy areas have not. The Rural Medical Education presentation at the AAFP Student Resident meeting has continued to draw a large number of very satisfied residents and students.

The AAFP is under new management. It is also realizing that it needs some changes. Hopefully it will work more cooperatively with those involved in rural medical education.

Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians. (Rosenblatt RA; J Am Board Fam Pract, 1996 Jan-Feb)

Medical education and physicians' career choices: are we taking credit beyond our due? [see comments] (Pathman DE; Acad Med, 1996 Sep)

Research Along the Pipeline to Rural Practice

Medical Schools and Rural Graduation Rates - New Research 2002

Accreditation Barriers at LCME, ACGME  

Newer Rural Medical Education Models

Mercer

WAMI

Nebraska

Kentucky

Accelerated Programs

Rural Primary Care Schools

Other nations

Lack of response

Efficient training

No dependence on match

Obviously the above has omitted osteopathic physicians. Osteopaths continue to make up only 5% of physicians yet over 15% of rural physicians. The emphasis in service-oriented admissions and primary care training has succeeded in meeting the needs of the nation much better than allopathic medicine. Osteopathic schools face the same distorted national incentives that tend to distract them from these goals. Graduate training has also been a problem area, although in recent years there is a move to a more formalized curriculum over 3 years. 

For years the only national group involved in rural medical education was the STFM Group on Rural Health. Established by Tom Norris and Rick Blondell, the baton was passed to Robert Bowman, Jeff Stearns, and Deb Phillips. The group organized various STFM Rural Theme days and surveys of rural faculty, programs, and curricula. A national survey was published in Family Medicine (Bowman and Penrod).  

Group Workshop in New Orleans

Rural Medical Educators Group of the National Rural Health Association

Rural Graduate Medical Education ConferenceGrowing Your Own Future - May 2001 at NRHA

Meeting in KC May 14 2002 RME Conference

Physician Workforce Studies

www.ruralmedicaleducation.org