I would start with the following explanation of where we are in medical education. for update see
Status of Rural Health and Rural Medical Education
Previously I discussed how medical leaders favored graduates who were more likely to become researchers. They can priorities high MCAT scores and GPA and select those with research experience. Those interested in rural practice do not have scores as high and are more likely to prioritize service. Rural interested senior medical students specifically did not prefer to do research. WAMI studies note that the more NIH dollars, the less likely that the school has graduates who choose rural areas. Increases in NIH dollars and the increasing business prominence in medical education makes this even more difficult.
Medical education has faced many challenges and has had to make choices. State systems have also made choices that ignore the needs of rural areas. The following reflects the attitudes of top medical experts, many of whom think that rural areas will never be served well. Leaders such as Dr. Cohen note problems with the economy, isolation, and "a paucity of satisfying cultural and civic outlets". This is a narrow viewpoint well suited to short term fixes but not the kind of visionary problem solving thinking that rural communities deserve.
Physicians Can and Will Choose Rural Practice
Why Doctor's Don't Go Where They're Needed
My response:
Poor Rural Economy: Health care is a substantial portion of rural economies and those who block the flow of rural physicians are basically are a major reason for the poor rural economy. Without physicians a town cannot keep jobs or recruit new jobs. Hospital and clinic closures lead to massive outmigration.
Isolation: The medical literature exposes the myth of professional isolation. Leaders are out of touch with today's rural physicians who have the same forms of communication and access to an incredible range of technology and services. That leaders choose to believe journalistic or anecdotal worst case scenarios is a matter for remedial education for these leaders.
Paucity of culture: Rural culture is different. Or better said, the various types of rural cultures are different from urban and from each other. Rural does not mean a lack of culture, it means different cultures. Such statements are inflammatory and it is a measure of the separation of rural and academic communities that no one has challenged Dr. Cohen on this or other statements.
Defects in medical education: Medical students still lack some basic skills and training important for serving rural and underserved populations. It is not a surprise that this comes from medical leaders since the graduating medical students that they teach list cultural competence and exposure to the underserved as sadly lacking in the education provided by medical school (AAMC Graduation Questionnaire 2000).
The Facts:
Medical leaders do not understand rural practitioners, communities, culture, and lifestyle (Why Doctor's Don't Go Where They Are Needed - Cohen Editorial). This is not a matter of discrimination, it is a matter of lack of contact and lack of priority. Medical leaders and those in government need more contact with rural communities, practitioners, and associations. Their information resources do not include such contacts. They do not have the same understanding of the importance of service and they do not understand generalism. A century ago generalism was the dominant mode of operation and many of the strong cautions about specialism set forth by medical education leaders of the time have come to fruition. Osler and Rural Practice Without broad training and contact with rural and underserved communities and significant primary care contact it is very difficult for medical education leaders to stay in contact with the reality of health care in this century.
Rural people do deserve to have well trained physicians who stay in practice, not rookies (that they avoid as they did me for my first rural years) who are there only for a few years. I strongly disagree with Dr. Cohen in his message to the contrary. Medical education is only a start. Osler and others noted it only to be a framework for a lifetime of learning. I learned far more in 4 years of rural practice that I would learn in 10 years of medical education. Well trained physicians have several years of experience that new graduates will never have.
Also rural people need to have doctors that stay in rural practice long term. I was in practice 4 years before people started coming in to me that made up the core of my practice. I have been in Nebraska in practice for 9 years at one clinic and it has taken this long to learn about the really high risk folks and the resources to work with them. Continuity of practice is a matter of 4 - 6 years and the attitude of the practitioner to take care of all who come to see him or her, not a concept taught in a few months. Long term rural doctors anchor rural health systems and help them ride out the ebb and flow of physician supply to a small area trying to balance enough to do care and too many to support.
Admissions is the top priority for those who hope to supply rural physicians to small towns. Rural background people are the ones who choose rural practice. Rabinowitz demonstrated that 78% of the decision for rural practice was rural background and FP interest. Admissions Package
We do not admit enough rural background people to meet rural needs (AAMC study). Therefore we must admit more and get other sources of rural physicians.
Admitting more through feeder programs - There is great variation in the states in terms of educational quality. Not surprisingly these are the same areas in need of physicians and all types of young professionals. Programs to boost local education would be helpful but expensive. Programs to improve the education of rural background students who were gifted in academics and service desire would help. Programs to improve the pre-professional success of small rural colleges have also helped (RHOP Nebraska Rural Health Opportunities Program).
Hope: Students From the Underserved, For the Underserved
Urban background students - Selecting those with service characteristics (CV, background, experiences, personal statement), older students, and from those from lower socioeconomic backgrounds would likely increase those interested in rural practice. Service Orientation Rural experiences before and early in medical school would likely boost this number. Rural interested medical students serve more underserved people during medical school and are likely to do so afterward (AAMC GQ 1995).Rural Interested Students
Admissions barriers - Rural background people do not have polished applications, similar to minorities and those from schools that are in poorer areas of the country (Admissions committee members and health professions list serve). Feeder programs can help this situation. State programs and Area Health Education Centers often reach out to middle schools and high schools and colleges, but they cannot sustain this effort as there is no money for these programs over the long term. Title VII dollars expended on feeder programs or early or longer rural medical school experiences can be effective. Title VII Concerns Later in medical education there is less impact.
My research demonstrates that more rural months during FP training means more graduates to rural locations Fam Med Res Prog and Grad of RFP. Family Medicine restricts such training by accreditation policy on size of program and the number of months that residents can be away. This means that residency training cannot filter down to the smallest and most needy locations even though the Spokane RTT model was very successful doing this. FP also restricts individual residents to only 2 months away from the main residency location. If Family Medicine was forced to choose between restrictions on time in rural areas, I hope that they would choose the underserved locations and extend training to 4 or 6 months. Individual states and programs could buck this guideline and Family Medicine would then have to decide whether it truly embraced training for underserved areas or not. Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training
The continuity argument that Family Medicine gives as an excuse for not allowing more adaptation of training to the needs of rural and underserved communities is bogus. The constant changing of insurance and medicaid contracts makes continuity near impossible for anyone, except in contained populations like rural practices. Family Medicine claims that it needs continuity practice for its residents but it bows to hospital rotations that constantly interrupt the clinics and few if any residents have even a single solid month of ambulatory practice. OB residents doing 4 months of FP clinic do more ambulatory care than some family practice residents get in 20 months of FP training.
NHSC has done a better job each year in selecting scholarship recipients who will be more likely to go and stay in underserved areas, but they cannot fully apply their knowledge because medical school admissions is in the hands of medical schools. NHSC could take over admissions of its scholarship recipients and then medical schools could have the honor of training them, or they could choose to ignore the needs of the underserved formally instead of informally.
Without NHSC, J-1 Visas, and other expensive programs, medical schools would be forced to address the nation's needs for physicians for underserved communities. Just the mention of restrictions on National Institutes of Health funding or Graduate Medical Education funding because medical schools fail to pay attention to the needs of underserved communities would scramble them into action, mostly defensive, but potentially positive action.
Title VII dollars to graduate medical education programs do not graduate more rural physicians (Bowman logistic regression, 1995 data). This does not mean that support for Family Medicine is bad, rather that is should be targeted to underserved areas. Title VII dollars are valuable, but better spent early in the lives of students, rather than later. Feeder programs, service learning programs, early rural experiences, and long term rural experiences can help rural communities with health improvement and much needed workforce, during medical education and after graduation. This targeting is consistent with GAO recommendations in recent years.
Community-Driven Medical Education - Another possibly less expensive approach to restoring physicians to rural areas is followed by several states who reach out to rural and underserved communities. UTMB Galveston has a feeder program that has kept up minority applications despite the loss of affirmative action. Several medical schools have adopted special rural track admissions or medical school locations in more rural areas. These have resulted in more rural doctors. The PSAP program in Pennsylvania run by Rabinowitz has only had 1 % of the medical students coming out of the state's medical schools, but 21% of the rural family physicians in the state are PSAP graduates and this has increased every year since the program began in 1971.Community Driven Approach
The prime example of a less expensive, high potential, program to meet needs is in West Virginia. Their Partnerships model is a program to support students from middle school to high school to college and health professions school (Partnership). All of these efforts are tuition free and reach out to students who have a strong desire to serve and improve their situation. They will have no crippling debt to overcome, but my prediction is that their devotion to underserved areas will be much greater and longer than the indentured graduates we have had. Even during their training, students and residents in such programs will provided needed workforce, community health projects, and retention support for communities in need. These students are also more likely to return to rural communities and help restore the young professionals needed to support and enhance rural economies, jobs, services, market share, and leadership. The RHOP program Rural Health Opportunities Program in Nebraska reaches out to admit rural high school students to health professions schools. They attend one of two small rural colleges then do professional training. The program restores small college admissions and academics, improves communication between the college advisors and admissions, and is also likely to help restore young professionals to rural areas.
This is the type of long term approach that
More on Community Driven Approach
