Robert C. Bowman, M.D.
Shorter more recent version at Centralization and Regionalization
Perspective
Many rural leaders lament the disappearance of the 20 - 44 year old age group from their communities. The energy and leadership of this group contributes much to life in small towns. This group includes business leaders, young professionals, parents, and consumers. Rural organizations and leaders in business continue to devote much time and effort to understand this problem. State government is also interested, but it may have difficulty with this issue. The reason is that the state may have a conflict of interest. State policies do give priority to more central urban government centers. This centralization of resources tends to attract more and more people and resources.
Education, economics, leadership, the lack of similar young professionals, and cutbacks in government and higher education feed into a downward spiral as rural resources and population and services decrease. This means that fewer young people choose to locate in rural areas. The following impressions span time and disciplines and numerous contacts. The theme is that various policies, attitudes, trends, and reactions to stressful situations promote centralization.
It is possible to reverse this process and balance the distribution of resources and investment. First, however, we must become aware of this problem. The bottom line outcome for any program or policy is that the population of rural areas must increase. Another outcome worthy of promotion is the development of regional population centers, distributed evenly throughout the state or region.
International and national economic factors have great influence. When the national economy is going well, rural and underserved areas may begin to catch up. When recession hits, then states and higher education and government tend to cut back and centralize more. Rural areas also are more dependent on a single source of jobs (agriculture, mining, etc.) or only a few sources Periodic economic swings also impact rural communities that often have little diversity to rebound. The lack of educational facilities such as community colleges and technical schools can also make it difficult to adapt to changes in the local job market.
About the Author
My background includes rural practice and academic positions in several states. My career focus has been rural medical education, with a focus on what needs to be done to get the kind of physicians that will go and stay in small rural communities. This focus involves more than just medicine and education. The following are impressions gained from personal and internet interactions in small towns, at small colleges, with health profession advisors, with rural sociologists, and with rural educators and students. I share them with you for your consideration and personal reflection. It all began with rural practice in 1983 in Nowata, Oklahoma, my best education....
The Global Impact, Inch By Inch and Step By Step
During my years of rural practice, I watched the state and federal government reduce services in small towns in multiple areas. These included the welfare office, home extension, and public health. Only recently have we become aware of how federal and state funding has become so imbalanced in rural vs urban distribution.
Sometimes the redistribution has some personal impacts. Cuts in medical education in Oklahoma resulted in closure of the rural-oriented family practice residency where I taught part time. In 1983 this was one of only a few such programs oriented toward rural practice. Other young professionals such as teachers were also concerned about the redistribution of education funds. Our town lost top quality educators to nearby towns who paid more. Police officers often started in our town before moving to urban or state positions. The state did little to level the playing field. The cuts to various programs were small, but cumulative in many areas.
Economic problems in the agriculture and oil fields eventually drove over 2000 people out of my county and me out of rural practice (Over 12000 to 9996 people in 5 years). I recharged the grandparent batteries in Houston, teaching family practice residents at Baylor. My dreams of teaching rural health at Baylor fizzled as funds were cut. The larger urban hospital decided not to share GME funds with the family practice department, not an uncommon problem. Also I was still in depression from the loss of my rural community. There are few bonds that exist in medicine and one of the strongest exists between a doctor and the people that he or she serves as a part of the community. When I left I thought I could teach rural in an urban academic setting. This is nearly impossible. I realized that my rural community was the best rural teaching resource.
Awareness is a Curse
After leaving rural practice, the subject of rural physician retention kept me occupied most of the time. I wondered how I or others like me have stayed longer. Initially I gained some peace of mind when I heard about many others like me that departed from the midwest because of the agricultural problems. At this stage I was much like our current medical leadership, focusing on the economics of the situation and the perceived lack of lifestyle as a reason for not recruiting and retaining rural physicians (Cohen). Why Docs Don't Go This was reinforced as I watched urban Texas recover from the economic devastation of the mid-1980's, leaving rural Texas far behind. State politicians were polite, but committed no funds to assist rural communities with recovery. I remember wondering if rural and disadvantaged folks took a beating with every such economic disaster.I watched as urban hospital networks acquired, abused, and dumped rural hospitals.
Why Do Policies Tend To Centralize?
People work better together than alone. This is as true for rural economists, rural special education teachers, or rural physicians. There is a critical mass that allows shared functions. In rural areas, there are often fewer people that have need for a dietician, special ed teacher, etc. Centralizing these functions makes sense so that the professional has less travel and more time to deliver services. The only other option is cross training professionals, such as lab technicians doing x-ray services. In a few cases this can work out with good quality results, but in other cases there are few options other than centralization. Decreasing population also means decreased need for services and those attempting to anticipate future needs may overestimate the loss of population and service need. In some cases the state or county may need to provide extra FTE so that services remain accessible. Another option is part time work to match demand with services. It is a difficult balance, but not one that needs to forget the needs of rural areas entirely.
There is another important consideration. What if conditions improve? This is a most interesting question. The physician to population ratio keeps increasing from rural to urban settings. In shortage areas that solve some of their problems, the demand for services will increase. Physicians who stabilize a system will also build market share. In some cases demand may return faster than FTE can locate in a small system. One of the reasons why we see slow progress regarding rural doc to population ratios is that successful areas draw demand. Also some outcome studies do not take into account the fact that other nearby areas close services. Our measures of workforce, demand, supply, etc. are very inadequate.
Can rural areas take advantage of some areas of growth, can they move as fast as urban? What happens if a shortage area gets enough physicians? This is not an uncommon situation in small systems when one doctor can take a system from too little to actually a bit too many. First the doctors have to adjust to the fact that they are less in demand. This may mean a bit less income and the need to do more marketing and availability See Building a Practice - from Journal of Rural Health article by me in 1995 . The lessons I learned from this research was that small systems have a critical balance between each of the components for efficiency and survival. Smaller systems also were more interdependent for economics and relationships. See by the numbers for economic impacts of rural doctors In the smallest systems, all had to get along or none would survive. This means hospital administrators, doctors, board, nurses, community leaders, etc.
"Physicians occupy an unusual spot in the social structure of rural communities. From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationships to strike a workable balance." Rosenblatt and Moscovice, 1982
Why Few Rural Doctors?
Many argue that the key reason is the poor rural economy. Others note the "paucity of cultural outlets." Over the past decade I began to question the economic and lifestyle arguments. The lifestyle argument was simple to contest. As I traveled to rural communities in different states, I saw a great variety of people, leadership, values, and resources.
Rural areas have different cultures. They don’t lack culture.
See Ultimate Recruitment Experience - from practice search research I did in 1989. Each area has its own recreational and social attributes, rural or urban. Surprisingly some of my best sources in this discovery were urban people who moved to rural locations. They saw the social life that home folks did not appreciate. They also saw some of the problems more clearly than those living in small towns all of their lives, like poor community self-image. For example many rural people regarded kids returning home after college as failures. It became clear that there were kids who really loved rural life while others wanted an escape. One business owner took this bull by the horns by sponsoring a graduation dinner for several graduates, including a Regents Scholar, and a farmers' kid. She placed the farmer's kid at the head of the table. He was the one who was already a volunteeer at the fire dept. He was staying home and would likely spend his life there serving the community. Yet he was the one who was regretting not having all of the academic and award notations by his graduation picture in the paper. The Regents scholar, who would never see town again, also gained a different perspective. My rural practice made me aware of this in the personalities and career plans of various graduates. My research showed that there were programs that selected those who loved rural areas and these programs were successful.
Clearly part of the problem was that we weren’t admitting the right students. Medical schools said they were trying harder, but without results. In the last quarter of the century senior medical student interest in rural practice declined to record lows. The attrition rate was faster than just a decline in rural economies and population. Something had to be going on even before medical school.
Breakthrough: A Program That Reverses Centralization
After many years of struggling with these issues, I began to put the pieces together. A breakthrough came when I was visiting with professors involved with the RHOP program in Nebraska. Programs such as this have been created based on research demonstrating that doctors that go and stay in the smallest towns were from similar size towns (Wigton, Rabinowitz). RHOP admits college freshmen to medical school (6 slots a year out of 120) from two rural state colleges, Chadron and Wayne State. They attend the rural college for 4 years and then move on to the health profession school. One problem with the program is that students run into complications on the way to rural practice. They may fall in love with a subspecialty or an urban spouse, making a rural choice difficult. RHOP seemed to have great promise, but it was only a few students a year, with few actually staying in a small rural pathway. Then I found out that there was more to the program than meets the eye of the academician or politician.
When I visited Wayne State I talked to a professor who taught microbiology. She mentioned that during the seven years of RHOP, the number of A grades in her Microbiology class had gone from just 2 to 14 well-deserved ones per semester. She noted that the quality of the students, both RHOP and non-RHOP, continued to improve. She attributed this to increased competitiveness between the students. Other science and math professors echoed this viewpoint. Enrollment at both schools had increased at a time when other small colleges were losing ground. This sounded like a fairly good benefit for little cost and the extra efforts of a few faculty, but I began to wonder....
What was it about this insignificant program that made such a difference in the college?
It dawned on me that RHOP was one of the few factors that leveled the playing field. For once, these small colleges had an advantage over the large urban colleges as far as admissions. Because of the program, the students attracted more competitive students, this resulted in improved education at the college. This was a positive feedback loop because as the students got better, more were admitted to further professional training. This is indeed true. Non-RHOP students at Chadron and Wayne are getting in to professional schools in greater rates. This was quite a change from the past. I asked myself how things had been deteriorating for so many years?
Another key fact dawned on me in 2002. Rural high school kids that wanted to go to college in a rural area could now do so and not risk the possibility of giving up a professional career. Their first choice of a location after they left the home could be and often was, a rural choice. When we are trying to study the rural location decisions of medical school and residency graduates, it makes sense to choose students who have chosen to live in rural areas for college for 4 years.
Do State Policies Encourage Centralization of Educational and Other Resources?
Shortly after the Wayne State visit I got a form letter from the President of the University System noting politely that it would be necessary to revise the class offerings at many of the schools so that the system could be more efficient. This would involve closing some classes and consolidating others. This looked like his usual annual letter, but now I realized what was happening to higher education. Given previous experience, these dollars would tend to remain centrally at the larger colleges and the small colleges would suffer disproportionately. Some of the most-specialized, least-attended, and most costly courses were the ones involved in the preparation of professionals.
There was now little doubt that centralization policies were forcing
pre-professional students to attend larger and more urban colleges.
With the current policies students attending the smaller colleges would not get "the right stuff." They could not compete with other students as well. This would result in fewer specialized courses and instructors, less health career encouragement, and potential of failure for those admitted to professional schools.
www.ruralmedicaleducation.org/education.htm
How Can Centralization Result in Fewer Professionals Returning to Rural Areas?
It is not surprising that the medical literature reflects these concepts. The longer the training in urban areas, the lower the probability that graduates will choose rural locations. Spending more time in urban, higher education centers erects barriers to a rural return.
Do Health Advisors and Faculty Play a Role in Centralization?
Students depend on others for their information about health careers. They talk to other students, faculty, and health advisors. Some of these contacts are official during classes or meetings. Some contacts are at the request of the student for special needs or advice. Faculty or advisors also initiate some contacts to encourage, advise, or support students. Advisors sometimes face some difficult challenges. Internet discussions with advisors reflected a "gatekeeper" function.
This means that there may be a tendency to ignore or discourage some students from applying that are borderline candidates. We know from previous research that these are the students that tend to get admitted last. It was easy to identify students with the grades. It was more difficult to identify those who had great gifts in other areas, but average scores. In my own experience, I did not apply to medical school until the college advisor encouraged me. I can see how encouraging "the best and brightest" might displace others with less statistical recognition and perhaps more dedication to medicine as a serving profession.
Some advisors go out of there way to identify students that they feel would make great physicians, but they admit that they have difficulty when these students have borderline grade points or admissions scores. Even before college, students who have health career exposures may have an advantage. Teachers and counselors may have important impacts at the high school level or sooner. Work with rural high schools revealed that many students had little health career exposure. Students reported that counselors were busy with the more challenging kids. The advantage for professional careers has increasingly moved to urban kids or students from professional families. These students are also not as concerned about debt and financial issues. Unfortunately these students are not as likely to return to rural areas. I began to look for other evidence that state policies were a contributor. I did not have to look far.
What About the Effect of School Consolidation?
States have faced major challenges regarding health and education. Nearly all have regarded small school districts as inefficient. School consolidation is seen as a way to improve education and decrease costs, but are there side effects from this "treatment?" I talked to a rural sociologist who works regularly in the health and education fields. He was talking to various rural education groups and they related to him that voluntary (and state-imposed) school consolidations were having an impact on the leadership opportunities for students. When 3 small high schools reduced down to one, that meant 2 less quarterbacks, 2 less class presidents, and similar decreases in leadership positions for other rural students.
School consolidations also impacts the type of students that become "the best and brightest" and are therefore eligible for professional schools. Studies show that smaller schools do seem to distribute educational resources more appropriately. This benefits the disadvantaged and, to some degree, restricts the affluent. Larger schools and districts benefit affluent students on the whole moderately, but they compound the negative effects of poverty on the educational achievement of poor students. These results apply whether the school is in an urban or rural place. In other words, smaller schools and districts currently penalize their own "best and brightest" which diminish their chances of professional school. Students from larger schools in larger towns are more likely to be admitted. For more information see The Ultimate Education Reform: Make Schools Smaller
The process of consolidation to increase school size increases the potential for affluent students and increasingly impair the chances of those who were in poverty. Continual increases in the size of schools, coupled with the retraction of affirmative action programs, may insure that primarily the affluent students from the largest school districts will do well enough to enter professional school. Since we already know that those higher on the socioeconomic scale are least likely to choose generalist careers and underserved areas for practice, this would mean fewer and fewer rural professionals. Even the rural students would be affected by school consolidation. Rural students facing consolidation are often forced to attend more distant schooling and have fewer connections to their rural community and with less appreciation of community interactions. Rural students attending larger, more distant schools would have less opportunities for extra-curricular activities and leadership experiences. The statistics regarding the declining interest in rural practice were beginning to make sense.
Why do rural kids return to small towns? Perhaps it is the experience of the bond
with the town that these kids seek. If we destroy this bond with consolidation,
what will draw them home again?
There are also reasons not to consolidate based on outcomes. Smaller school districts, although more costly, have better high school graduation rates! In a more and more competitive global workforce environment our nation should prioritize this first key step more and more.
I then began to ask myself if we depended on rural areas for future leaders for our towns, states, and nation. Many of our greatest political leaders have come from rural backgrounds. In the American Academy of Family Physicians (AAFP), almost all of the AAFP presidents and Doctors of the Year have been rural doctors and most came originally from rural communities. What was there about this rural influence that made such a difference? I reflected on other rural people that I have met, from physicians to babysitters to hair dressers. National leaders who were raised in rural areas also came to mind. Rural people seemed to me to have a better work ethic and dependability. This might be the fact that they come from a lower socioeconomic group where they had to earn their way or it might be a rural factor. When talking with some rural science teachers I had new appreciation for the way their schools were resisting school consolidation at great local cost. They wanted to preserve these opportunities for their students. It certainly looks like state policies are diminishing the quality and quantity of leaders for small towns, the state, and the nation. Rural areas are increasingly denied the very assets that they develop!
Compounding the Injury: The Importance of Other Young Professionals in Small Towns
My best friends in rural practice were other young professionals: the teachers, ministers, and business people in various community and church groups. Without these folks I would have been far less likely to go and stay in rural practice. The departure of key friends in this area also heralded my own rural departure a year later. The town became less desirable to us as young professionals when we faced such losses. With fewer young professionals choosing rural areas, small towns become less and less desirable to others with similar backgrounds. The economic impacts of such domino losses in terms of jobs and services is enormous. As I sit here typing this update, I am looking at a map of the US noting the Landscape of High Growth Companies. The rural areas of the midwest and south have the lowest growth rates. This map is virtually the same as those mapping the US by the age of the population.
Young professions of all types bring jobs, economic impact, a variety of services making the community more desirable, education impact, leadership, and more. Breeding Young Professionals and Healthier Rural Communities
Why Is There Variability in Admissions Selection for Rural Background and Interest?
It is interesting that this article is near the end, but medical school admission procedures have not been discussed. Most medical education experts start with the admissions process, but others feel that starting with medical school is too late, particularly if the desired outcome is doctors that go and stay in rural practice. Studies show that schools with a rural mission graduate more rural physicians, but few schools or programs have a rural mission. Medical Schools and Rural Graduation Rates Schools with a rural mission usually include rural physicians and others from rural communities on admission committees. Some medical schools work with college advisors, but there is little education of college level advisors or admission committee members to help them identify and encourage those most likely to go into rural practice.
Admission committee members are often aware that students play a game in order to increase their chances of getting admitted. Students will mention that they are interested in rural practice, primary care, or family practice. Some also include altruistic goals such as serving the underserved. Unfortunately few, if any, admissions teams spend the time to truly examine such interests and previous indicators of such interests. Even a casual question about student recreation needs might turn up a number of interests that were not compatible with the rural practice. These alone are not a concern, but if the students has not even though of how they will keep up their interest in a rural location, it means that the rural thoughts are more of a whim than a life choice. By gauging the student's response, the committee member could better identify students with true rural interest. As mentioned previously, students from rural colleges are a better risk in many instances because they have already made one rural location choice.
There is controversy about admission procedures. Those with the highest grade points and Medical College Admission Test (MCAT) scores may not be as interested in rural practice (Harris). In some states, rural education may not be good enough to prepare students for the rigors of college and professional school. MCAT scores do vary by state, almost by educational expenditures and the rural nature of the state. The south tends to score lowest (among all students taking the MCAT), followed by the midwest, with the north and east higher. According to my interpretation and review of MCAT scores nationwide, more students in the south score in the 8 range, the number considered a minimum without increase risk of academic problems. This means that states such as Kentucky may struggle to get students with rural backgrounds that can do well enough on the MCAT to justify the "risk" of admission, especially if the two or more state schools compete for the same students. Pennsylvania, on the other hand, may have many more students from rural communities because the state has a much larger rural population and a higher standard of education. This may have allowed Rabinowitz in his Physician Shortage Area Program (PSAP) to choose those with a much higher degree of rural and family practice interest. He strongly believes that selection is everything and subsequent training is less important. The PSAP program, involving 1% of the medical student population of the 5 medical schools in the state, has provided 21% of Pennsylvania’s rural family physicians (Rabinowitz).
It is possible that rural students are desperately trying to catch up to their urban peers in college. Studies in Kansas City did compare urban and rural students and by graduation, there were no significant differences. Students in Minnesota's Rural Physician Associate Program (RPAP) See Duluth Plus RPAP are mostly from rural areas and start out lower on MCAT and GPA, but equal or exceed non-RPAP students multiple areas at graduation. The top student in one Illinois medical school started with MCATs in the 6.7 range and ended at the top of the class Rockford Rural Health Needs Challenge Doctors. It may be that rural background students need a different MCAT scale for admission. Certainly feeder schools at the high school and college levels have been successful in selection and preparation. More studies need to be done in this area.Community Driven Approach
For most schools the risk of admitting those with more likelihood of choosing rural practice may be too high. Students who did not make it would cause problems for the school because the state's cost of training would be wasted. The admissions committee would have to suffer the stigma of having admitted failing students, even if they truly attempted to admit those most needed by the state. Students likely to be on probation would need some counseling and some real teaching. They would take (horrors!) much faculty time and effort. Schools that required boards to be passed for continuation would have students taking the test over and over. The school would suffer lowered national board score averages and a higher licensure failure rate. Admitting more rural-likely students would damage the school "image" and increase the potential for increased surveillance by accrediting bodies which would be more costly, etc.
Finally there is evidence that the best and brightest may not be the best. A recent article about Florida family physicians noted that those with the higher board scores were sued more often. Higher scores may not correllate with being a better physician. Perhaps those with higher scores relate to things rather than people.
State Recommendations
Medical School Recommendations
National Recommendations
Side Effects of Selecting for Family Medicine
Medicine, Education, and Social Status
Admissions Ratios and US Medical Students
Priorities For More Rural Docs
http://www.zwire.com/site/news.cfm?BRD=1994&dept_id=227937&newsid=7114112&PAG=461&rfi=9
Reduction in the Northeast Texas Consortium operating budget, $350,000: The Northeast Texas Consortium (NETnet) is a high-speed wireless data network designed for distance learning that links 15 higher-education institutions in 50 rural Northeast Texas counties. It is a collaborative effort that also includes rural hospitals, public school systems, the Texas Department of Health and regional public health districts. NETnet's headquarters, the Center for Educational Technology, is located on The University of Texas Health Center at Tyler campus. NETnet has been supported by state dollars over the last four years, and will continue to focus its efforts to develop new revenue streams to finance its continued success.
Closing of the Mineola Medical and Surgical Clinic, $180,000: The decision to close this clinic was certainly the most difficult to make. The Mineola clinic has struggled financially over the past few years. UT Health Center assumed clinical responsibility for it in April 2002 in an effort to bolster support for it. Despite great effort on the part of the health center and the Mineola clinic physicians and staff, the clinic was not able to stabilize financially. In light of the governor's requested budget reduction, a decision was made to close this clinic effective April 1, 2003. This will affect seven staff members who will be given the opportunity to apply for posted vacant positions at the health center.