By Thomas D. Rowley
at http://www.nal.usda.gov/ric/richs/RHNSum01.pdf
Other works by author:
Understanding Rural America http://www.soc.iastate.edu/sapp/soc130.nrc01.html
Rural vs Urban http://www.terrain.org/articles/10/ruraldilemma.htm
Workers in the Rural South http://www.ers.usda.gov/publications/rdp/rdpoct99/rdpoct99e.pdf
Land Use http://www.rural.org/publications/Rowley01-01.pdf
Key items in a Family (Doctor) Affair
It’s difficult to overstate the importance to rural areas of family physicians. You might even say they’re the backbone of rural healthcare. How so? According to the American Academy of Family Physicians, family doctors provide more than 90 percent of the primary medical care in rural communities. That family docs provide the lion’s share of rural care is due largely to their propensity to locate in rural areas, which is due largely to the fact that family physicians serve much smaller populations than do other specialists. The average family physician serves 2,000 people; the average neurosurgeon serves 100,000.
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The Roots of Decline
Ominous though they are, the declines in family physicians and in physicians locating in rural areas are merely symptoms. The underlying causes—the obstacles to family practice and to rural practice—are many.
While the family doc occupies a special—albeit perhaps nostalgic—place in our hearts, family practice is no longer the specialty of choice. Doctors Pugno, McPherson, Schmittling, and Kahn write in Family Medicine that "…interest in family practice and, in fact, in all primary care specialties, has declined. Market factors, lifestyle choices by medical students, escalating educational debt, and the general turbulence of the health care environment all contribute to this trend." On average, family physicians make less money than other specialists, they tend to work longer hours, their work is less high-tech and less flashy, and they tend to bear the brunt of pressure and criticism associated with managed care. In addition, as Pugno and his co-authors point out, many students see family practice as more complex, and therefore more demanding, than other specialties. At the same time, others see family medicine as too easy, and therefore less glamorous. Finally, federal funds tend to promote research and specialization at the expense of primary and family practice within medical schools.
Finally, and speaking of training, 29 of the 474 family medicine residency programs in the nation have established separately accredited rural training tracks. These training tracks place residents in rural areas where they can not only learn medicine, but also learn what it’s like to practice medicine in a rural area. The idea behind the program is that doctors are more likely to practice where they train. And according to a 1999 survey of the programs by the AAFP, the idea works. Overall, 76 percent of the graduated residents went on to serve in rural communities.
A Question of Will
Dr. Robert Bowman is a fan of rural training tracks, but thinks the nation and its medical schools could do more…a lot more. Bowman, himself a family physician, is director of Rural Health Education and Research in the Department of Family Medicine at the University of Nebraska Medical Center—the National Rural Health Association’s 2001 Outstanding Rural Health Program. You might say that he is a man with a mission: namely, to increase the number of family doctors practicing in rural America. To do that, he says, will require changing medical education in this country, beginning with admitting the "right" students to medical school.
According to Bowman, the right student—that is, the student most likely to become a rural family practitioner—may not have the highest MCAT scores, but more than makes up for it with a desire to serve and a concern for rural areas—usually stemming from a rural background.
"We waste tremendous resources on primary care by not picking the right students. These include Title VII, NHSC, and several sources of federal dollars, state dollars spent on family practice programs, etc. If even a small portion of [these resources] was devoted to better admissions, then we would have far more efficiency in meeting national goals for the underserved."
Once the right students are admitted, the focus shifts to providing more, better, and earlier rural training opportunities—all of which increases the likelihood that the students will choose to practice in rural areas. The battle, however, is decidedly uphill. Most medical schools, according to Bowman, "don’t get it." The few "that do it right, do so because a senator or someone else got fed up and made them change. It’s a question of political will."
To further the mission, Bowman and others have formed a Rural Medical Educators group within the National Rural Health Association. The group’s purpose: add here. He also maintains a website (http://www.unmc.edu/Community/ruralmeded/index.htm) that has a wealth of material on increasing the number of rural physicians.
On the question of will, Dr. Rosenblatt concurs. "We can do it, but we just have to do it."
Note by RCB - The match rate is not related to rural graduation rate. Increases in the numbers going into FP have not increased the number going into rural practice. see The total FP graduates rises over the years.
Other overview works:
Rural America 100 yrs ago http://www.ers.usda.gov/publications/ruralamerica/sep2000/sep2000c.pdf