Robert C. Bowman, M.D.
If an admission committee informs itself of "what finally happens" to those it admits, its decisions can contribute to achieving whatever policy its medical school adopts with respect to the mix of physicians it wishes to produce. Acad Med 1994 Oct;69(10):825-31, Medical school admission and generalist physicians: a study of the class of 1985. (148 graduates UNC included, review of AMCAS data only) Madison DL
see also Medical Schools and the Family Medicine Match
Continue on for Summary
Body of Text Continues at Rural Background Body
Third Section is Additional Value from Rural Medical Education Programs
Small towns of less than 10,000 once supplied 4000 of the nation's 16500 matriculating allopathic medical students. This figure now is down to 2000 (AAMC Data on Matriculating Medical Students). See graph of background admissions and rural interest declines More physicians come from areas that are not only urban, but are the most urban parts of the nation. The increasing numbers of females mean fewer locating in rural areas. Studies also demonstrated that those from minority backgrounds were least likely to choose rural practice Rural FP Grads, Bowman FP Grad Studies 2004. Rural background students are like O negative blood. They can care for people in almost any location, urban or rural. The military has long prized family physicians from rural areas and this may be one reason. Rural background students are particularly valuable for the rural and underserved primary care parts of the nation in most need. Other students are hampered by lack of previous contact, inappropriate attitudes, and myths. Rural background students are the ultimate in workforce flexibility. Loss of this alone is a serious problem.
Presentation Regarding Rural Background and MCAT Scores and Education Levels by State
Rural background students represent about 60% of those interested in rural practice as senior medical students. This group is twice as likely to volunteer to assist with public health and care of the indigent at every year of medical school, twice as likely to do international rotations and missions, and twice as likely to do military and rural experiences (Characteristics of Rural Interested Students AAMC GQ 1995). They also expect less income as physicians.
Family physicians distributed best according to the distribution of the US population. Only in the most isolated towns is are there fewer family physicians in comparison, 3.8% FP vs 6.1 % US population in RUCA 10s except 10.1 Bowman FP Grad Studies 2004
Rural background students are the ones most likely to choose the isolated rural areas, the ones remaining in need of physicians. Rural background students interested in family medicine are also the best choice for longer term retention in rural practices. Boulger - also Duluth Plus RPAP Over time even 1% of the medical school graduates of a state can result in 12% of all rural family physicians in a state PSAP - Physician Shortage Area Program Links and Info. Superselection is a method of choosing such physicians. Another way of approaching this is that selecting for rural background reduces the Numbers Needed to Train or NNT, a term coined by Howard Rabinowitz. Declines in interest in primary care and rural practice has made such special selections even more valuable (Rabinowitz, Howard)
Rural Impact to Compare the Effect of Rural Background Admissions and Rural Training
Maldistribution actually has a cure, at least for isolated rural locations. Current medical education models can graduate more physicians who will locate in these isolated rural areas. PSAP and Duluth also have been able to retain physicians in rural areas, a clear benefit for all. Without retention, more are needed to train and the physicians in rural areas are not as effective, or as efficient. Temporary physicians, locums, international physicians, or indeed city boys like me do provide workforce, but they are not as productive and effective when compared to physicians staying longer. The orientation ($225,000 per doc), recruitment ($30-50K), and socialization costs are staggering for health systems barely making it. Widespread application of the lessons learned is missing.
Declines in medical education, a process termed Medical Education Retardation, may make it difficult for many to consider practice in all underserved areas, but particularly for the rural underserved areas that have fewer potential physicians. Full contact medical education can encourage a location in underserved areas (RPAP, Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training). Rural medical education can improve or restore quality medical education. A strong case is made that rural preceptorships represent the best in current medical education Why a Preceptorship Is Best with James, Gjerde,Verby studies
Lack of primary care and rural experiences in medical education is a significant impediment to rural workforce. Primary care is more complex and takes 6 months or more to get over being overwhelmed. Verby Articles Medical schools disperse, diffuse, and discredit primary care training. Successful rural medical education models have included significant increase exposure to the real world of rural primary care, including RPAP, RTT, Duluth, RMED, ARTP, and preceptorships. Specific primary care training tracks and models (Verby studies, Bowman studies, Best Models).
Rural medical education models could also impact the growing number of international medical graduates who come to the US. Such models could increase the choice of primary care and rural practice, they could improve the clinical preparation of those planning health careers in the US, and they could facilitate the process of orientation to US health care, rural living, and rural practice. This could improve healthcare quality in many rural areas, even for the temporary physicians that locate there. (Proposed model at Improving International Graduates).
Long term preceptorships in rural areas and coordinated rural residency experiences can meet the needs of students, residents, communities, rural physicians, rural hospitals, and medical education (CORE Program Nebraska FP Residency). Rather than stealing the resources of health systems constantly on the edge of survival, such rural medical education efforts can supplement workforce and support staff and practitioners.
Medical leadership must coordinate efforts to effectively meet workforce goals by facilitating education in rural communities and colleges by reaching out with career assistance, career fairs, assistance to health career advisors, and encouraging development of health career education contacts or centers in every rural community.
Workforce studies highlight the importance of adequate numbers of family physicians to be able to meet rural needs. Shortages in primary care are likely to impair the flow of physicians to the most isolated locations. Other policies divert physicians most likely to choose rural practice (military vs other scholarship programs) Failure in supply and coordination of workforce is likely to greatly impair the quality of care in rural areas.
Efforts to increase rural background students, improve support packages for those interested in rural practice, and to enhance rural training and experiences could increase physician workforce by recruitment, retention, and productivity. Such an effort would likely increase the quality of care.
This ends the summary section. To continue with the body of text,
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Additional Value from Rural Medical Education Programs
see also Medical Schools and the Family Medicine Match
www.ruralmedicaleducation.org
