Arkansas Approach 

1973 Ad Hoc Rural Committee by Dale Bumpers, Governor

  1. AHEC
  2. Train Physician Extenders
  3. Increase U Ark capability for more FP docs and WATS telephone access to U Ark consultants
  4. Develop Emergency Medical Services
  5. Improve Arkansas Health Dept a)district health offices b) more nurses, sanitarians, health educators to shortage areas c) ambulatory centers in shortage areas d) more dental care and transportation e) telephone access
  6. Expand Title XIX for medical assistance to needy, drugs, family planning, home health, clinic services, nursing homes for those less than 21

Governor worked with state-wide coalition and key legislative groups to provide special funds for this and charged the medical school to pay attention and set up an action-oriented program for medical school intervention.

"The ramifications of this innocuous-sounding plan were, in fact, to be profound. The classical function of a medical school have been to teach the scientific basis for disease and to educate new physicians in effective ways to treat those who are ill. Promoting specific medical career specialties and a geographic (rural) practice site for graduates, plus defining the particular educational support systems which would be needed to achieve these goals- all these were significant changes from this classical tradition. Moreover, when the mission was broadened still further to train not only the physicians but also the rural towns in which doctors were to located, a major departure had emerged from the comfortable medical school role of the previous hundred years.

Next - Reliable information - doctors, origins, mobility, turnover, locations

Then Understanding Rural Communities

New programs launched in 1974

  1. Commitment to become involved at all levels, dean, faculty, media, meetings, student news and groups, public
  2. Medical admissions committee charged to "review small town/rural applicants with special interest" - managed to maintain 25% of class despite increases in total admissions and urbanization of state
  3. Family Medicine Department and Faculty with early contact with students, especially in first 2 years of medical school
  4. Clinical electives expanded and more offered at regional centers
  5. Statewide Rural Preceptorship revised and moved to summer before clinical rotations
  6. AHEC regional centers for senior student teaching
  7. Increased primary care training positions, especially family medicine
  8. Office of Rural Medical Affairs
  9. Office of Research - social sciences and rural
  10. Office of Community Medical Affairs, bridge between training and placement, experienced director
  11. Ambulatory center, small modules for teaching like rural on urban campus
  12. Model rural practice center
  13. Evening rural discussion group monthly for 5 years
  14. Liaison with government
  15. Rural Practice Loan and Scholarship program increased from 6 to 20 per year and increased to towns of up to 8000 pop

The new American Board of Family Practice, at its July 1973 meeting, decided not to approve the Arkansas plan to amalgamate the senior year of medical school into the residency program. Improving Rural Health, p 109    The integration of medical school with residency training was an attempt to keep primary care physicians going into rural areas. Family medicine training added 1 or 2 years to the time that trainees spend in more urban areas and its adoption decreased the number of physicians choosing rural areas, at least in these first few years (Verby noted similar problems in Minnesota with the transition to more formalized family medicine training).  Verby Articles

When legislators became aware of some of these issues (support of FP faculty and plans) and the unhappiness of the new residents (FP), they blamed the clinical chiefs of the established medical school departments." They designed a bill to limit administrative positions to 4 years upon approval of meeting state needs and expected changes in curriculum. This caught the attention of the legislators even though it was not passed. Improving Rural Health, p 109

It is a basic consideration that the Rural Medical Development Program could have achieved on or both of the following, recruitment and/or retention in rural communities. It is the considered judgment of the program staff members after several years of work in this field that recruitment represents about 20% … and retention 80%… if all of the communities who had recruited physicians over the past years had been able to keep them, there would be no problem of access to rural medical care today. P 162

These efforts have been most helpful: AHEC, expansion of primary care residencies, move of rural preceptorship to earlier position, development of Office of Community Medical Affairs with its host of outreach and bridging activities. P 165

Outcomes and Recommendations

The state of Arkansas basically had twice as much gain in the ration of physicians to population from 1975 to 1979 when compared to states throughout the south and midwest and at 18% growth, had the 5th largest growth of any state in the nation. States with comparable efforts had tremendous population growth (marked with #), significant primary care efforts (marked with *), or both.    From P 168

State Number of Office-Based PC MDs/DOs PC Ratio to Population Percent change
  1975 1979 1975 1979  
Arkansas 729 906 34 40 18 *
Georgia 1690 1980 34 36 6
Iowa 1365 1633 48 56 17 *
Louisiana 1253 1436 33 34 3
Michigan 5296 6271 58 68 17 # *
Minnesota 1873 2179 48 53 10 *
Mississippi 723 861 31 34 10
Missouri 2518 2965 53 60 13 *
Oklahoma 1306 1652 48 55 15 *
Tennessee 1405 1695 34 37 9

A June 1983 report by US Dept of Health and Human Services on Diffusion and the Changing Geographic Distribution of Primary Care Physicians noted that Arkansas had the 4th largest increase in PC docs in the nation at 22% and a higher ratio of office-based pc docs when compared to the entire southern US. At the starting point, Arkansas had the most depleted supply of physicians in the nation p 164

The efforts that continue to be deterrents: inadequate facilities and support systems (transportation), lack of spouse opportunities, lack of education opportunities for children, lack of group practice opportunities and consultations, economic disadvantages of practicing in areas of high poverty and unemployment "or in which the entire business and financial infrastructure fails to thrive." P 168

To those medical schools who are planning to improve their efforts in rural development it is suggested that a broad-brush approach be used in which faculty, students, and administrative officials equally are expected to participate in planning and implementing the program. There must be a serious and visible commitment from the medical school to make a contribution to rural medicine and to support the existing rural practitioners.

To those legislative groups: finance properly the regional educational centers, sponsor incentive programs for rural hospitals, clinics, and professionals which have been carefully coordinated with the educational ventures and look at better ways to support rather than undercut rural medical care

To professional societies: address professional isolation, CME, the need for support groups and consultations

To rural communities: do not rely on outside efforts, work with the leadership of your town to analyze problems and carry out a logical plan to remedy the problems and work to develop new leaders to carry on.  p 168 - 169