Recent events have again brought the problem of physician maldistribution to the light of day. The loss of the 2700 J-1 Visa Waiver physicians over the next 2 years represents another challenge. A liability crisis looms on the horizon as yet another derivative of the 911 event. Small towns will soon be losing prenatal access and rural physicians will lose an important source of satisfaction and income. Medicare cuts continue to impact more heavily on rural physicians. Insurance companies have long taken advantage of those in smaller practices and now even an entire state medical association (Tennessee) has found it necessary to take the delays and denials to public attention through court action. The overall impact is as yet unknown, but few expect these events to contribute to rural physician satisfaction and retention. Rural health systems, constantly battling larger systems for market share, will face even more obstacles with the loss of additional services. Shortage area search site: http://bphc.hrsa.gov/databases/newhpsa/newhpsa.cfm
We should expect more rural physicians retire, reduce services, and leave practice
The one shining moment in all of the past events is the continued and expanded support for Community Health Centers. Of course this will only increase the demand for physicians in shortage areas. Another area of hope is that the nation will realize that the true source of terrorism regardless of nation, is hopelessness. This will give attention to the need for collaborative long term preventive efforts to address peoples without hope.
How will we address the continued maldistribution crisis as a nation, as a profession, and as a discipline?
We basically have two approaches that we can choose to "fix" the problem of maldistribution of physicians. One is a crisis-oriented, emergent approach that does little for the long term needs of underserved communities. The other is a long term approach driven by the community needs and leadership and addressing the major facets of community life such as economics, education, leadership, and health care.
In the first approach, leaders alternate between two positions. Sometimes they take both positions at the same time to different audiences.
Attempts to produce enough physicians to force them to trickle down to needy areas have not helped. In some cases they have contributed to spiraling health care costs. Resources invested in temporary solutions can be costly as well. Even though state and federal programs have contributed to rural shortage areas, temporary physicians can be costly. Buchbinder calculated the cost of turnover of any primary care physician at a quarter of a million dollars for each primary care physician lost. Remember that the areas least likely to tolerated extra expenses are the ones that are underserved! Buchbinder research for AHQR
Communities involved in temporary solutions also become dependent on continued streams of new physicians, rather than improving the very conditions that make them unattractive. Temporary physicians are not good for building market share and developing systems and networks. Patients with more resources often bypass temporary measures. One of the key problems for rural areas is retaining market share of all types of services and jobs.
Americans can always be counted on to do the right thing,
....after they have exhausted all other possibilities. Sir Winston Churchill
Delays are an expectation of participatory democracy. Delays are a common choice by our nation regarding complex issues. We have also delayed universal health care, insurance reform, education reform, and other areas. As health care expenditures reach a ceiling, we will be forced to make choices. Crisis decisions are again likely to impact the underserved areas in a negative fashion, again.
Our health care leaders continue to escape accountability because the underserved are an unseen minority. Often it is assumed that they are chronically dependent and a drain on the nation. This is not the case with those who care for such populations daily. We watch patients cycle between poverty and self-support. Often the only difference is a chronic disease, a child’s illness, injustice by the courts or housing authorities, or lack of mental health access. Repeated cycles do lead to frustration, depression, and significant impacts on impressionable children.
There is an even more important reason to take steps now to change our priorities. It also takes a number of years to prepare, select, train, and retain physicians for underserved areas. In particularly deprived areas, preparation needs to begin in middle school or before.
For those who still doubt whether significant authorities have recommended a different approach, note the following:
One of the problems plaguing physician support programs is the question of what would happen if no special programs or funding occurred.
Medical education plays a key role in that our graduates provide economics, leadership, and health care for underserved communities. Medical education also has a history of stimulating major change in high school and college education as evidenced by the Flexner impacts. If we use the admissions process, and special preadmission programs, to choose the students who are likely to become health professionals that are also likely to return to their underserved areas (key point!) then we are actually providing an incredible economic, health care, and leadership boost to such areas. In economics alone rural doctors are worth 1 million bucks per year in economic impact (see OK study below). If we do not admit students who are likely to return (rural background, underrepresented minorities, those from lower socioeconomic groups) then we are choosing
1. To deprive these communities of the very resources that they need to resolve their difficulties, 2. To try to do more expensive and less effective emergent programs.
This does not include their contribution to other economic, social, and leadership areas. It does not include the support of young professionals for others in the same or nearby towns. Granted that not all physicians would locate in such areas because of efforts, but even a small portion has significant impact. The rural needs of the state of Oklahoma have also contributed to changes in selections and training. This combined impact has also long been known to be an effective strategy:
When loan forgiveness programs have been instituted without any other strategies, the results have been dismal. But when they have been combined with other efforts, such as careful selection of candidates who are motivated to work in the areas of need, specially designed teaching experiences, and counseling and placement services, they have been quite successful. Southern Regional Education Board 1983
Programs such as those in West Virginia, Arkansas, and Nebraska may be much less expensive than paying for loans and scholarships and FP residencies, as Oklahoma did. Selecting students with the right characteristics may be most of what is needed, as Rabinowitz demonstrated showing that 1% of Pennsylvania's medical students, selected for rural background and FP interest, now makes up 27% of the rural family physicians in the state. In his program 78% of the reason for rural practice is known at matriculation (rural background and FP interest). Physician Shortage Area Program graduates also stay longer than other studies have noted.
We are beginning to have some evidence that the statewide or community-driven approach works, such as the long term efforts in Arkansas where in only 5 years the doctor patient ratio doubled when compared to other states in the midwest and south with a program of AHEC, selections, FP emphasis, and outreach (Improving Rural Health, Bruce and Norton, 1984). The reason that we still have NHSC and J-1 programs (and Title VII) is that we fail to admit the right students who will choose primary care and underserved areas.
Obviously some areas will need education and economic support in addition to health care resources. The reason that Germany and Japan recovered so well was because their education, economic, and leadership components were still basically in place. Places such as Afghanistan, Bosnia, certain African nations, border areas of the US, Native Reservations, and Appalachia will need more generations of work and more reaching out to middle school and elementary levels, but at the same time working not to distance the future young professional from the communities that he or she will be working in. More of the training will need to be out of the major medical centers for this reason.
Primary care is prevention and long term and continuity and cost savings and access, overuse of primary care has yet to be arranged, measurement is global and more qualitative
Specialism is costly and short term and dramatic and narrow focus and episodic, measurement is specific
The ultimate approach involves retention
See quote by Bruce
Tom Bruce's book Improving Rural Health in 1984 and Rosenblatt and Moscovice's in 1982 had most of the things that we continually rediscover. From Bruce and Norton:
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. Improving Rural Health P 162
Only need a few each year in the most rural state’s medical schools
Only need to hold these
Retention involves change in rural communities as well as medical schools - Pennsylania
Iowa vs more isolated state
For more on this area try http://www.unmc.edu/Community/ruralmeded/fewyoung.htm
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