Robert C. Bowman, M.D.

Over recent decades we have begun to understand the important role of student characteristics such as rural background and interest in a career in family medicine as major determinants of the decision for rural practice. Beyond this, we understand much less about these students.

Madison did detailed work on the admissions process and highlighted the importance of service orientation and eventual choice of primary care, but studies connecting service orientation to rural practice choice are lacking. Medical schools that are interested in graduating more for underserved areas have been using such characteristics and the choices of primary care and underserved areas have been encouraging.

The relationship between family medicine and rural practice has been highlighted in various articles. Most tend to take the perspective of family medicine being responsible for at least some of the decision for rural practice. Given the studies by Rabinowitz, however, it seems that it is family medicine that is dependent upon students with an interest in returning to rural and underserved practices. Two trends are worth brief mention.

The number of family medicine residents choosing rural practice has been constant over many decades despite major changes in the total number of graduating residents, the increase in minorities and females, and the implementation of rural training models. This is more consistent with the characteristics of the candidates determining the choice of family medicine. It appears that family medicine happens to be the best current method of preparing physicians for such careers. Keeping family medicine accountable for the broad range of skills and preparations needed is becoming more and more difficult in a medical education world increasingly focused on specialism and technical prowess instead of service and real world problem-solving.

The number of rural background students admitted to medical school has fallen from 22% to 16%. There has been no change in the rural-urban distribution of students taking the Medical College Admission Test over the same time period. Fewer rural background students are being admitted. This raises concerns about small colleges and education systems in rural areas. It may not be a surprise that states such as Pennsylvania and Minnesota, with a higher emphasis on education that most states and higher average MCAT scores, have had successful programs to graduate and retain rural physicians. Admissions committees in such states may be able to superselect or choose students that go and stay in rural areas.

Methods

Each year the United States graduates about 16,000 medical students. The Association of American Medical Colleges performs an annual survey of graduating senior students. The following data was extracted from the Association of American Medical Colleges Graduation Questionnaire in 1995 by Michael Schuchert, research associate, as requested by Robert C. Bowman, M.D. This was a comparison of rural-interested senior medical students as compared to their peers.

Results

There were 294 senior medical students in allopathic medical schools that were interested in practicing in towns of less than 2500 as compared to the  13334 responding graduates. This would adjust to 362 out of 15888 total senior medical students if all had responded. An indication of rural interest at this point (M-4 yr) may not mean eventual rural practice nor is the analysis anything more than descriptive, but the comparisons are interesting. 

There were 1000 students interested in locating in towns of less than 10,000, a slightly larger but still definitely rural category. Some would also consider towns of up to 25,000 to be in the large rural category, but this was not one of the categories in the AAMC study. For FP residents locating in this category see Fam Med Residency Programs and the Graduation of Rural Family Physicians.

The 1000 may be a good approximation of the annual output of allopathic medical schools regarding rural physicians of all types. This is likely a major source of the 600 - 700 family practice residents that graduate each year and choose rural practice.

Origin of Rural Interested Students

The spouses of the students interested in rural practice were evenly distributed across population divisions whereas the students themselves tended to come from rural areas. Attempting to convince an urban spouse or finding small town to meet the needs of both a physician and a spouse with a more specialized career may be difficult. The middle category for small city would be difficult to characterize as rural or urban.

Rural interested seniors tended to be white, married, and a bit older and male. Black senior students were as interested in rural practice as their peers, not so in other racial groups. Females were more interested in rural practice as compared to their peers. Public medical schools had a surprisingly narrow advantage compared to private.

Activities and Rotations During Medical School by Year

Perhaps the most important comparison between the groups (all senior students vs rural interested seniors) is in their choices of electives and volunteer work. More did volunteer work at public health clinics and served the underserved outside of rotations (twice as many) than typical medical students. Twice as many rural-interested students took rural experiences, international electives, and military or government experiences at every year of medical school when compared to their peers (see table below). Over 60% of rural-interested students planned to locate their practices in a socioeconomically deprived area as compared with only 11.5% of other medical students.

Recently family medicine has noted research efforts to be competitive with the match etc         helping people research is not out of the question though

Summary:

Immersion in the Underserved

General Comparisons:   Rural-interested students are slightly older and more likely to be married and have kids. More are from rural backgrounds and have rural spouses, but the differences are small. Of the 294, 117 originated from urban locations. If small city (10 - 50,000 pop town) is considered urban, the numbers are equal. This is also consistent with studies showing that half of rural physicians have an urban background. Higher percentages of whites and females are interested as compared to their graduating peers. Lower percentages of hispanics and asians show rural interest, consistent with studies by Bowman and Xu. Higher percentages of those from public medical schools are interested in rural practice consistent with studies by Rosenblatt. Fewer rural students are interested in research, but when interested, they are interested in researching health care delivery or social science. They are no different in impressions of health care access as compared to peers. 

Career Orientation:  Family practice is by far the preferred specialty. Twice as many had decided on this specialty before medical school began (30 vs 15%). This raises the question why we cannot select more rural interested students, as Rabinowitz has so elegantly demonstrated  PSAP in Pennsylvania, Rabinowitz. A significant number decided during medical school, however. Primary care components guided their career choice. Private group practice is also the preference with a significant group (71) interested in state/federal practice. The total number of those interested in state/federal is three times the number of National Health Service Corps students who may have responded. The rural-interested seniors preferred the west and avoided the midwest in eventual state location plans. Rural students expected less future income. There were not major differences in debt, but rural students got somewhat less support from medical school loans and more support from private or other loan sources.

Curriculum Reflections by students:   Rural-interested students thought the overall medical curriculum in basic science, research, and hospital teaching was a bit excessive, and thought clinical skills, geriatrics, preventive, HIV, public health, and primary care issues lacked enough emphasis. Twice as many rural interested were dissatisfied with their medical education as compared to peers. 

Reflections: Service stands out as an important characteristic associated with interest in rural practice. This data is consistent with past studies on rural background and current studies by Rosenblatt and Rabinowitz regarding choice and selection and medical school characterisitics. See Service Orientation

In some ways, rural interested seem to have characteristics of extreme family medicine and primary care residents. Madison noted the importance of service in the admission of candidates likely to choose primary care careers and these rural students certainly demonstrate service ethic. Past studies have noted that those tending to choose family medicine tend to be older and rural interested folks are older and have more family and kids. Rosenblatt demonstrated that medical schools with more research emphasis (NIH funding) had less graduation of rural physicians. These rural students do not demonstrate research interest, but when interested, they were interested in social issues, consistent with their caring and service interests. 

It is interesting to speculate that the needs of the military for physicians may compete with the needs of the underserved in this nation.

One can make a case that the medical curricula is not working well for these students, as twice as many were likely to rate the curriculum as inadequate as traditional medical students.