Updated version at
Why We Are Graduating Fewer Rural Physicians
Response to FamilyL discussion 8/19/2002
I. Recruitment
A. Vote early and often - find the right kind of students early (rural or minority origins or both, Service Oriented, lower socioeconomic, lower socioeconomic, FP interest), encourage them constantly
B. Train in underserved locations as much as possible
C. Continuous support by faculty, environment, peers
II. Retention
A. Link transition points together, college to medical school, medical school to residency, residency to fellowship, etc.
B. To meet the special challenges, train specifically for underserved practice, use special tracks, use all 7 years of medical education, use underserved locations, etc.
C. Hands-on training - those in preparation for underserved practice have no time to waste observing, they need to be active in decision-making on patients with active supervision throughout training. This accelerates their development and allows them to move forward expeditiously into the higher level concepts such as practice management, efficient use of limited community resources, community oriented care, community medicine, public health, health policy, etc. A major problem in today's medical education is that they are still trying to master medicine late in residency training. Residents with "higher level" thinking will do better choosing practices, impacting communities, serving populations, developing leadership, etc.
D. Encourage courtships early in training to help graduates find the best "marriage" to an underserved community and practice. Too many choose poorly, or choose communities that do not deserve them and waste this incredibly valuable resource, a physician dedicated to underserved areas.
Dr. Mullen has rightly chastised the Bush Administration for the lack of vision regarding AHEC. Of course the other side is that AHEC dollars have not been as efficiently utilized as they could have been.
Even more damaging has been the near extermination of the Department of Education and subsequent termination of many if not all of the early minority and disadvantaged programs. At a meeting with Little Priest Tribal College last week, I was informed of this. Just after this consortium of higher education folks has gathered and organized, their special funding for preparation for professional training has disappeared.
In the state of Pennsylvania with a tremendous educational network at all levels, you can afford to wait and pick your candidates from small colleges and small towns. This is one of the reasons that Rabinowitz has been able to choose students that now make up 21% of rural family physicians in the state, even though he has only about 1% of the graduates of the state each year. If you are in the Midwest you can choose at the high school level. If you are in more disadvantaged parts of the nation - border, inner city, reservation, or in other countries where poverty and education conspire against you - then you must choose earlier and earlier so that students can do well enough to get to college and do well.
We have spent much time and effort at meetings and on the Health Profession advisor list serve and there is no other solution to the problem of maldistribution other than early encouragement programs.
The drawback is that the earlier that you go and the more involved you get, there are socializing influences that enter. For rural kids that means you may encourage them to urban locations and careers that will not allow them to return. Many in reservations or small towns fear this and this is a barrier also, of course if they do not let go, then they will not have any return to help them with jobs, services, education, and leadership.
That means that anything that impedes the development of young professionals and socializes them away from the communities that need them is a major problem:
1. Medical schools - admission policies, lack of encouraging colleges that could provide them with students, failure to reach out to earlier levels, failure to use AHEC appropriately
2. Presidential administrations - all, for most of the same reasons
3. Or perhaps most importantly, state policies (Centralization of State Resources, declines in minority and small colleges, lack of support for minority and tribal education)
My studies have demonstrated that the factors most related to graduating into rural areas are the same as those graduating underrepresented minorities. Leadership, voting power, experiences, and accountability
1. The leadership of people such as Tom Bruce and others in Arkansas (Arkansas Approach), Waldeman and Hill in Nebraska (Rural Health Opportunities Program), Verby and Boulger and Crouse (formerly) in MN, Roger Tracy and others in Iowa, the North Carolina folks, the Kentucky group, Wolff and Baird and Rosenthal in NY, and people such as Joe Hobbs Hobbs, the folks at Mercer, the black community and faculty at East TN State, the pre-professional programs at UTMB Galveston - FP programs where the program director was the rural contact graduated more rural docs (Fam Med Res Prog and Grad of RFP - Bowman and Penrod), medical schools with a rural director or dean graduated more rural doctors (Bowman unpublished - Medical Schools and Rural Graduation Rates), minority leadership also seems to matter (no data yet on this)
2. The voting population - the higher % rural, the better the rural graduation rate, same for URM and URM minority graduation rate (Bowman unpublished)
3. Curricular experiences - even though these are limited by LCME (FSU, rural experiences, impediments) and ACGME (away limitations), the retardation of todays medical curricula where there is too much observation and not enough doing
4. Accountability - some programs exist because rural and minority legislators stood up and held medical schools accountable, especially where they found good leaders and sometimes even with significant medical school obstruction
More at the following web site about Howard University and ACGME, Susan La Flesche Picotte, the contribution of FM, Centralization and state polices, the Waco FP Program and Public Health Expenditures, Pathman's article, and AMA, AFMO, and AAMC links: http://www.ruralmedicaleducation/underserved.htm
FM and medical school leadership could jump on the bandwagon and make a huge difference, particularly working state to state or regionally. Suffice it to say there are many. I just find it puzzling that over 50% of family physicians are in rural practice, were in rural practice, or have connections to rural areas by birth or marriage or other; yet few FP resources support rural efforts. We also need a coalition between inner city, minority, disadvantaged, and rural.
Barriers To Serving the Underserved
Back to Underserved
Robert C. Bowman, M.D, Co-Chairman
Rural Medical Educators Group of the National Rural Health Association
UNMC Department of Family Medicine Director of Rural Health Ed and Research
983075 Nebraska Medical Center Omaha, NE 68198‑3075
(402) 559‑8873 or fax at ‑8118 Email: [email protected]
http://www.ruralmedicaleducation.org
