Rural America: A Challenge for Medical Education

San Antonio Texas   February 1990

A review of this conference and progress toward goals set by

Robert C. Bowman, M.D., Associate Professor

University of Nebraska Medical Center Department of Family Medicine

Director Rural Health Education and Research

Past Co-Chair NRHA Rural Medical Educators Group

Chair of STFM Group on Rural Health

Where we are in 2004 at  Medicine, Education, and Social Status

Legislative and Health Policy items

The great things of the world are done by naïve people. The skeptics have already figured out that it can't be done.   Henry Kissinger regarding Issac Stern and the preservation of Carnegie Hall

Academic health centers must add a fourth leg of social accountability if they hope to support themselves and the other legs of service, research and education. - Tom Johnson, San Antonio 1990

The first thing that we need to do is define and measure rural.

The next thing is to define underserved.

From Robert Talley February 1990

Rural physicians, rural hospitals, rural health, rural communities, rural education, and rural medical education all share common ground. All are fragile and require great cooperation to survive and thrive. Rural systems of all types represent the best training grounds for a nation that all too soon will realize that there are limited resources. Years ago Tom Bruce noted that any time we allow geography or income or color or lifestyle to wall off any part of a nation, we all suffer. Where there is maldistribution of resources there is poverty, ignorance, and hopelessness. These are the breeding grounds of violence, injustice, abuse, and terrorism. This is not about democracy, or political parties, or religion. It is about people caring for others enough to sacrifice. It is not about sacrificing money or taxes or donating goods, it is about investing in the lives of others, particularly children of all ages. RCB    more at Servanthood

I started several times in several different ways to prepare for a series of encounters 14 years later in 2004. I consistently bogged down due to the overwhelming problems, the multiple dimensions, and lack of sufficient assistance. Seem familiar?

Fortunately I stumbled onto an antique issue of Academic Medicine from 1990. In the past 14 years there has not been such a group gathered with a wide range of rural medical education experience. I find that I can scarcely improve on their fine efforts. Sadly there has been only a slight improvement in reimbursement and a few stellar efforts to document the value of rural medical education principles. Few of their recommendations have been followed…

Rural America: A Challenge for Med Ed, Summary of Recommendations

1. Payment Reform - There must be substantial reform of payment systems favoring rural and primary care  - David Kindig  Federal reimbursement systems glaringly discriminate against rural residents and providers - Fickenscher
2. Rural Leadership development should be a key goal of academic health centers - Sam Cordes, Tom Bruce
3. Interact at all levels of education and medical education from middle school to those out in practice with relevant CME and technical assistance. Tom Bruce
4. Fight the battle against rural myths and the socialization process in academic medical centers   Sam Cordes, Tom Bruce      This disease of assumption has grown to frank ignorance and intolerance in academic centers in 2004.
5. Do not allow any segment of the population, rural, low income, minority, less educated, to become set apart - Tom Bruce. Select for the rural and disadvantaged and work with education at all levels for these folks - Kevin Fickenscher        major declines in this area
6. Choose those most likely to become Family Physicians and rural doctors - several, major declines of 2000 rural background students a year admitted to medical school each year.
7. Liability issues are a key concern, particularly for OB - several, even worse in 2004
8. Rural locations and communities have advantages for the study of systems of health, education, problem solving, etc - several - updated talks by Clint McKinney in 2004 read much the same way with his emphasis on quality care in rural health and how rural has an advantage and should be a leader
9. Adopt a broad perspective that realizes the complexity and interrelatedness of rural health and the economic, social, and cultural context of the community - Fickenscher    Good advice for all areas of the state and nation, particularly in health and education
10. We must reverse the current negative attitude toward primary care - Fickenscher and others in 1990. Much worse in 2004.

David Kindig and Rural Physician Supply

David Kindig has been a national leader in workforce in research efforts and playing a key role in COGME. Those attending the conference noted that he left rural medical education for 8 years, and returned, finding out that little had changed. I will start with his words:

Abstract Policy Priorities for Rural Physician Supply - A number of efforts can be attempted in rural medical education initiatives in recruitment, socialization, curricular reform, and community technical assistance. Further work is needed in identifying strategies that are most appropriate and cost effective in different states and regions that may have different situations and needs. Careful consideration needs to be given to reasons why such ideas have not moved beyond the demonstration stage over the past 20 years (1969 - 1989). It is suggested that without substantial reform of payment systems favoring rural and primary care, educational reform will have marginal effectiveness and remain at the demonstration level. Acad Med 65, Supp 3(1990): S 15 - 17

Well indeed educational reform has had marginal effectiveness and continues to remain at the demonstration level. The marginal improvements in payment systems have not been enough to keep abreast of rural health needs, much less make progress. The few models have been implemented by devoted individuals, with little replication and now a season of crisis brought on be worsening finances, increased regulation, and decreased appreciation.

Economics and Rural Life by Sam Cordes of Nebraska

Sam discussed 7 myths of Rural America.

1. Rural America is shrinking

2. Rural is farming

3. Rural economics is unlike urban

4. Rural economies are isolated

5. Rural people and urban are different

6. Rural people are healthier

7. Rural people are homogeneous

He noted that all were false assumptions and myths. I would add that many if not most have gotten worse given lack of contact with rural areas and media distortions.

Sam links various economic concepts to rural health, noting the importance of jobs, services, etc. However he has one point that I wish to emphasize:  Leadership development. He notes it is a crucial factor with research documenting its true importance (DeWitte, National Governors Association). Second it is one of the factors that can be changed…. Health professionals, including physicians, often have leadership skills that are in short supply in rural areas."

Tom Bruce - My Heartland Hero

I have never really had a chance to spend more than a few minutes with Tom Bruce, but he has been a lifelong mentor. His book, Improving Rural Health, which I first read while in rural practice in the mid 1980s, became a text and career guide for my later rural medical education efforts. His concepts plus the Waco Fellowship largely resulted in the Minifellowship in Rural Family Medicine that I directed 1990 - 1992 at East Tennessee State. I still keep his book handy above my computer screen along with Tim Hendersons OTA report on rural health and Bob Boyer's video regarding Myths and Obstacles to a Career in Rural Health.

In re-reading his prose I now see more than ever what he saw back then, a situation that is much more obvious today as we realize that the high school that you attend often dictates your potential for college and professions. Locked in this high school is income and societal priority. Rural and inner city locations are being locked out of higher education.

In his 1990 presentation Bruce notes

"In the US we seem to be evolving our own variant form of "apartness" in our innermost cities and in much of rural America - not a system set up by government policy and not necessarily based on race but a system of social inequality where some citizens get less than a full share of the American way of life. It is wrong to call this progressive American drift into an underclass system "apartheid," but there are some unfortunate similarities."

Just wrote this for an email to fellow fp faculty:    In a 15 year period 1978 - 1998 we had nearly 2000 fewer rural kids admitted into medical school out of some 17000 a year. In their place are ultra urban kids from "college-style" high schools. These same kids have had far less exposure to FP. Such declines in any minority, would have sent folks screaming, yet there is silence....

Note: no intolerance is intended. Certain ethnic groups tend to originate from urban areas (and return to them).

It certainly looks like rural American kids are being set apart. They still take the MCAT in the same numbers and distribution, but they do not get in to allopathic US schools. Rural states have lower MCAT averages and it appears that many medical schools are more willing to go out of state for matriculants rather than improve education in their states.

Addendum 10/17/2004:

Admissions Ratios, Parent Income, and Choice of Family and General Practice

The above notes the relationship between admissions probability, parent income level of county of birth, and % choosing FP. More at Medicine, Education, and Social Status 

I find it to be an indictment of our country that we import more family physicians than originate in this country. Ross University in the Caribbean is the top single source of US FP Grads in 2003 at over 90, with more to come. International and osteopathic medical schools are the primary source of physicians who serve the nation. A nation that cannot find enough servants to choose Family Medicine as a career is a nation with great problems.

Rural background is not a cure all. They are small in number compared to urban students, but they are a concentrated source of FP and rural docs. Studies demonstrate there are few other sources of quality physicians for the 6% of our population that live in isolated rural locations. Policies that could add a few in each state would help. These include admissions based on potential for rural practice or selecting according to income guidelines. The best admissions efforts have demonstrated not only recruitment to rural areas, but retention (Duluth, PSAP). This is a process of superselection and Boulger describes it well. Rockford is a prime example of this also. This admissions effort, often using college health advisors, doubles or triples the effectiveness of each rural graduate, a concept Rabinowitz calls numbers needed to train  (NNT). Those staying longer reduce the NNT and also are much more effective and cost efficient, since it takes less for recruitment and orientation. Another source of rural physicians is currently the military. The nation needs certain rural doctors even more than it needs military doctors. Physicians for the armed forces have many sources. Currently the military support packages are most attractive to the very physicians we need  for rural areas, those from small towns from low income families who have families of their own to support. When rural support packages nose out the military programs as the number one source of tuition for osteopathic schools, there will be an additional 10 - 15% national production of rural family physicians, beyond the 750 a year we have now. Those from small towns that are most interested in FP and returning are a critical resource that cannot be wasted.

Bruce goes on to note that paternalism is a cause of this apartness and medical centers are bastions for this quality. Having come from a Balint meeting with first year residents becoming more and more disenchanted with the academic medical center treatment coming from attendings, nurses, and even receptionists, this certainly rang true. This attitude moves out beyond our residents, to our state leaders, our communities, the underserved, and our discipline. Our graduating students note that they have been ridiculed and belittled far too often. The numbers of students who had been publicly belittled or humiliated is sobering. A solid 25% experienced such trauma at least once and 54.3% occasionally with 6.7% frequently. To allow quality young professionals to experience such an environment is unacceptable. A smaller number reported racially or ethnically offensive remarks, but adjustment for the smaller size of minority population reveals a problem at least as significant. Clinical faculty, residents, and nurses were the source of such difficulties.  (AAMC GQ 2003). If medicine continues to ignore others, others will certainly ignore us, even those of us who do listen!

Bruce notes four areas to address:

1. Recruitment

2. Socialization

3. Curricular reform

4. Technical assistance

He lists a table familiar to all of us regarding rural background, spouse rural background, rural lifestyle, schools, health resources, etc.

Recruitment of Rural Background

1. Special college affiliations with those with large numbers of rural students (technique of Nebraska RHOP program, Rockford, others)

2. Middle school health career clubs - Not college, not high school, but middle school (Bruce was way ahead of his time!)

3. Organize a special rural admissions track - he was right!

4. Give special attention to rural minority/disadvantaged

5. More rural scholarships and loans

Socialization Goals

Bruce acknowledges the attrition that occurs in medical education, but lists ways to limit it. He also talks about the PUSH and PULL factors that tend to tug folks toward urban and subspecialization.

1. Sensitize faculty/staff to rural needs, also leadership

2. Appoint the best PC teachers to early student contacts

3. Orient the students to the schools goals

4. Develop early rural preceptorships (why not even before med school)

5. Adopt a buddy and support efforts

6. Provide environmental reminders such as rural recruitment fairs, rural practice exhibits, rural speakers, and weekend rural trips

7. Organize student primary care societies (we are doing better with FP, rural student interest, AMSA, international, and local service efforts with clinics, but only when we admit the right students, the ones with service orientation, the ones that choose primary care 70% of the time according to Madison)

8. Assist students to volunteer efforts

9. Include spouse or other in activities

Again the AAMC GQ of 2003 is relevant. Students were asked to comment on “Physicians who work hard will always be able to build a successful practice.” Although 10.5% strongly agreed and 42.6% agreed, 19.7% had no opinion (or were unsure) and 24.8% disagreed.  It is a sad reflection on the current environment of medicine that those who should be most enthused are already so cynical. Seeing hard working faculty, residents, and physicians who do not get rewarded appropriately is the only way such attitudes can develop. A nation that is currently in great need of leadership in health can ill afford to lose 25% of its graduating physicians to such attitudes at only the halfway point of medical education. Repeating a Graduation Questionnaire at the end of residency would be even more revealing regarding the status of medicine before a career in medicine even begins.

Curricular Reform

1. Include rural tidbits as clinical "tasters"

2. Modify physical diagnosis to include health risk

3. Develop a PC clinical track

4. Emphasize ambulatory sites

5. Training in community/population relevant problem-solving

6. Options for rural research

7. Organize a bevy of rural elective program options

8. Expand graduate programs with a visible and recognized connection to rural health

9. Develop joint programs in primary care with full range of other health, social, etc folks

There have been few that have approached this in a comprehensive and consistent fashion, a very few, and some very successful few that have met and exceeded goals for the nation's health.

Technical assistance

He notes that small towns and rural health systems are fragile. Often the docs and hospital are not appreciated. His life has demonstrated that medical schools can greatly help in good times and bad. By decentralizing the location of residency programs, Arkansas has also improved the distribution of health resources and population.

1. Provide consultation regarding clinical facilities

2. Assistance with leadership training

3. Help with Recruitment Retention

4. Combine students, residents, and docs in community health and development works with consultants

5. Help develop innovative and alternative solutions for difficult problem areas

6. More relevant, efficient CME

7. Mobilize support from private agencies, foundations, to solve problems

I would add that none of these are helpful, or appreciated, unless they are approached with a collaborative attitude.

David Kindig addressed policy priorities for Rural Physician Supply

His Abstract: A number of efforts can be attempted in rural medical education initiatives in recruitment, socialization, curricular reform, and community technical assistance. Further work is needed in identifying strategies that are most appropriate and cost effective in different states and regions that may have different situations and needs. Careful consideration needs to be give to reasons why such ideas have not moved beyond the demonstration stage over the past 20 years; it is suggested that without substantial  reform of payment systems favoring rural and primary care, educational reform ill have marginal effectiveness and remain at the demonstration level. Acad. Med 65, Supplement 3 (1990): S15 – S17.

Kindig's comment highlighted in bold above is perhaps the key take-home point from this effort!

Kindig  begins by noting his background as an activist to work to establish community training and assist the National Health Service Corps. "I mentioned these events to make clear my early convictions that educational initiatives are critical in preparing physicians and other health practitioners with the desire and skills for careers in underserved areas. If students have not been exposed in a positive way to rural practice settings early in their medical education, the chance of their making such career choices greatly diminishes."

Students need frequent and regular and significant reminders that they can make a difference in the lives of others. Medical school has become a series of exams to pass and months to spend. It should be constantly connected to patients, to communities, and to people in need. Studies clearly note that those interested in rural practice and care of the underserved are also more likely to participate in service, volunteerism, rural rotations, international electives, and service efforts such as AMSA HPDP and NHSC SEARCH.

Kindig re-entered the fray in 1975 after noting that the concept of maldistribution had left the public policy table in favor of "diffusion" of extra doctors into rural areas. Studies by Newhouse and the Rand Corporation were used to gain expansions in medical schools. Of course these studies noted that Family Medicine was a special category in that the supply of family physicians was critical for small towns. Lack of attention to this area indeed brought about the disastrous failure that Kindig  anticipated for rural communities. He noted that the closure of rural hospitals finally brought about interest in the problem of maldistribution.

Kindig noted the successful efforts of WAMI and the Jefferson (Rabinowitz) Physician Shortage Area program. He cited an early work by Douglas Campos-Outcalt on the impact of preceptorships. It seems interesting that the same efforts are still about all that we seem to hear, with some updating of the original works, but no change, no widespread replication, and no application of the principles.

Art Kaufman then addressed a broad spectrum of issues in

Rurally Based Education: Confronting Societal Forces Underlying Ill Health

He noted the major causes of death and the need for population-based and societal approaches to be able to address these causes. He made the case for extending the boundaries of the university outside and vice versa.

Bridging efforts recommended

1. Faculty development with relevant topics

2. Rurally-based clinical research

3. Faculty outreach to clinicians, in support of students, involving consultations in a number of areas

He noted the importance of working with residents on community-based issues since they were vehicles to teach students, communities, and fellow physicians.

Indeed I experienced the New Mexico interdisciplinary program that he helped develop. I was greatly encouraged by community providers who were skeptics regarding this program. Over a year or two they were the greatest supporters, noting how the program had increased interactions between a variety of disciplines across the community and hospital. It appears that medical education can stimulate needed interaction and improvement in health care in a number of ways.

Robert Talley - ahead of his time

Dr. Talley recently retired as dean in South Dakota, but he stirred up the pot at the 1990 conference. He suggested a merger of primary care. He felt this would best meet the needs of underserved areas. After years of, well, resentment, at how the conference got distracted from rural health, I now realize that his was not Dr. Talley's fault. In fact he may well be right about a central primary care source of funding, accreditation, and graduate medical education. Without such a source, we will never meet access or health goals. Primary care remains dependent on the medical centers and hospitals that will never understand them and have never supported them. Separate funding changes this dependency into independence and innovation. Primary care physicians that are not family physicians will never be able to gain respect or support from their internal medicine and pediatrics leadership until they are separate.

Talley suggested that residents be allowed 6 months of training in rural areas, far beyond the 0, 1, or 2 months segments that we still have. Sadly the major opponents to his suggestions were family medicine leaders.

He noted that designation as an "experimental program" was not particularly helpful and could be restrictive to the development of models that may better serve rural areas. Given the challenges in replicating various efforts, Dr. Talley was a prophet. The following vehicles of rural medical education have certainly fallen prey to delays in implementation, hassles, and accreditation conflicts:

1. Rural Training Tracks and even long-standing residency programs in rural areas. 

2. Programs with documented outcomes success in education and location such as the Nebraska Accelerated Rural (and Inner City) Training Program

3. The dispersed education model of Florida State

4. Difficulties with RPAP replication

Talley notes that "Obstetrics is necessary in rural areas, if only to screen all pregnant women, (for high risk and referral).

His recommendations

1. Develop a consensus definition of rural

2. Develop a definition of underserved

3. Educate rural communities regarding medical education and supervision

4. RRCs should not only allow but support rural rotations of up to six months

5. RRC should not make a number of residencies at a site a factor in approval

6. RRC should judge the quality of the product, the resident, and not the process

7. Residents should be able to be taught by any competent physician

8. All resources and departments of the medical school should be involved in solutions to rural health problems

9. New opportunities for funding should be explored, Veterans, IHS and underserved.

10 COGME recommendations for increased funding for primary care residencies should be a top priority of AAMC

There is little progress regarding these areas.

He also suggested that primary care graduates must leave the medical center and practice for a minimum of 2 years before being allowed to return to subspecialize. He made an extra year of training for obstetrics the only exception, since the need was so great.

Again he was far ahead of his time and in a position to influence many, yet he was largely ignored.

Neal Vanselow then reviewed some data that I have long committed to memory

Bob Wigton did studies on origin and locations of medical students in Nebraska and this is his chart regarding the origin and location:

This was a study in 1977 with 95% response rate of medical students and house offices at UNMC. At this time a slim rural majority held sway in Nebraska population with a few less from rural areas in medical school. Seems like little change in attitude exists compared to today. The primary care graduates from this study were traced and 33% chose rural initially. During 12 years 50% did time in rural areas. At the end of the study, 33% were still in rural practice. There was an equilibrium between flow of primary care physicians to and from rural areas in a state with 50:50 rural:urban population.

Vanselow noted the success of Duluth with over 50% family physicians and over 30% in rural areas when selecting for rural background and family medicine interest and working before, during, and after medical school.

His abstract:  While there is good evidence that decisions regarding practice site are influenced by experience in medical school and residency, medical education constitutes only one of a complex set of factors that have made it difficult to recruit physicians to rural America. A solution to the rural health crisis will require not only changes in student selection, curriculum, and training location, but also strengthening of the rural economy, improved reimbursement to rural hospitals and primary care physicians, and increased sensitivity by leaders of the medical profession to the needs of rural areas and rural practitioners. Acad Med 65 Suppl (1990) S27-31

Eugene Mayer gave the history of the AHEC movement

He described the premier North Carolina efforts in a number of areas. His graph of physician location to NC rural areas as compared to 2000 rural counties was most impressive as NC had twice the rate of increase from 1972 - 1988.

The Impact of Recruitment Investment by 2 states

From my studies of recent FP grads, I can tell you that NC continues to do well. All states medical schools, and residencies donate to meet NC needs. This is the result of a superb and mature statewide multilevel effort. Visits to Virginia also revealed that those faculty most interested in outreach had been taught the value of such efforts by even short times working with this AHEC system.

The universe of this study is all FP graduates 1997-2003 with contact in NC

1 = Birth state of NC for all grads         2.=Medical school in NC for all FP grads

3 = FP residency in NC                        4 = Choose NC locations for practice

Kevin Fickenscher provided a Symposium Summary and Recommendation for Action

In his abstract he calls for a task force to begin active dialog. Sadly the nation continues to wait upon consistent national efforts. It is not coming from organized medicine, organized medical education, or even from those who work with rural communities. We have few rural faculty and they are getting fewer in number and in time that they can afford to give for such efforts.

Fickenscher -We must support initiatives which identify and support the disadvantaged and rural student. In the same manner that we have responsibility for maintaining the education of the physician through continuing education, we have a responsibility for supporting the future physician through proactive educational support.

More from Dr. Fickenscher in summaries at the beginning.

What have we accomplished in 14 or perhaps 30 years (compare to conference findings at beginning)

1. Payment Reform - There must be substantial reform of payment systems favoring rural and primary care  - David Kindig  Federal reimbursement systems glaringly discriminate against rural residents and providers - Fickenscher

Some limited improvements in financing have arrived, particularly for rural hospitals (Critical Access). CHC and FQHC expansions have improved physician finance, but not in a way that improves medical practice in rural areas.

Massive increases in overhead, particularly liability costs continue to drive physicians out of practice. Electronic medical records and other technical improvements continue to be too costly and not well-targeted to rural practice. Costs are tied to that of urban hospitals and specialists who can more easily afford such technology.

Salaries in rural primary care are fixed by urban fee scales instead of rising with the great demand and the variety of skills and challenges. RBRVS has made some improvements, but none of the major criteria help physicians in rural and underserved areas where patient encounters are often more complex and patients are in worse health. The bulk of the care delivered by rural physicians continues at a great discount. Even bonus and incentive programs are utilized more by those who game the system instead of the rural physicians that the programs were designed for.

Controversy still exists regarding international physicians, the National Health Service Corps, and other methods of providing temporary physicians to rural areas. Efforts to "Grow Your Own" have been limited, especially compared to health professions with shorter pipelines. Lack of implementation of even basic rural medical education principles is a real problem.

2. Rural Leadership development should be a key goal of academic health centers - Sam Cordes, Tom Bruce

Rural leadership development, particularly for health care, continues in decline. Links with business, industry, and community groups, stimulated by partnerships with professional schools, could do much to improve this area.

3. Interact at all levels of education and medical education from middle school to those out in practice with relevant CME and technical assistance. Tom Bruce

Some efforts extend to high schools, but rarely beyond to impact education and preparation. Rural education is in sad decline. Rarely do rural communities have anyone to help rural kids compete with urban kids regarding health careers, particularly medicine. Those who do learn the ropes are usually teenagers, who take their knowledge with them to college when they graduate. Establishing a contact or central point for health career orientation and guidance is a critical need for all rural and inner city locations.

5. CME remains largely irrelevant and inefficient.

6. Fight the battle against rural myths and the socialization process in academic medical centers   Sam Cordes, Tom Bruce     

This disease of assumption has grown to frank ignorance and intolerance in academic centers in 2004. Rural myths and the socialization process continue, with little progress despite the continued growth and diversification of rural communities, the replacement of a wide variety of general practice physicians with a more quality crop of rural family physicians, and diffusion of information and other technologies to rural areas.

7. Do not allow any segment of the population, rural, low income, minority, less educated, to become set apart - Tom Bruce. Select for the rural and disadvantaged and work with education at all levels for these folks - Kevin Fickenscher       

Rural areas are increasingly set apart with education a growing barrier for rural and all low income kids. Property tax-based education, declines in Pell Grant funding, and continued improvements for finance for those with more income (education tax cuts) and those who can afford better schools and school districts mean worsening class separation, less restoration, and more hopelessness.

6. Choose those most likely to become Family Physicians and rural doctors - several, major declines of 2000 rural background students a year admitted to medical school each year.

Selections for rural practice exist at a very few locations. Fortunately some survived and have also published extensively in these areas, documenting the value and the important outcomes of practice location in the smallest areas. Duluth graduates choosing FP (50% of the time) also choose the isolated rural areas (14.4% of FP grads) three times more than University of Minnesota colleagues choosing FP (4%) and also all recent family medicine graduates (3%). They also stay in such locations longer than other rural physicians. Getting rural physicians to the smallest towns and keeping them there is the top priority of rural medical education. Sadly Duluth is being forced to combine with U of MN medical school. Hopefully this will not impact their admissions and outcomes.

7. Liability issues are a key concern, particularly for OB - same in 1990, even worse in 2004

Rural doctors are losing a key source of finance and satisfaction. Some are leaving. Rural programs have lost faculty. Prenatal access is clearly declining with the potential for increased problems. Students and residents, already facing the obstacle of few deliveries, will be unlikely to consider FP, OB, and rural given these circumstances.

8. Rural areas still have advantages for education, problem solving, etc. Clint McKinney took his expertise as a rural family physician and chair of AAFP rural committee to work with rural hospitals on quality measures. He feels strongly that rural approaches have great advantages and should help lead national health care quality efforts. Folks at the Rural School and Community Trust are doing the same for rural K-12 education, with impacts on even urban schools. Previous works have outlined rural advantages:

Rural Community Characteristics Contributing to Success: Advantage Rural

uAwareness of issues   +++             uMotivation from within    +++

uSmaller geographic area ++++       uAdaptability ++

uSocial cohesion +++                        uAbility to discuss, cooperate ++

uIdentifiable leaders +++                 uPrior success

9. Adopt a broad perspective that realizes the complexity and interrelatedness of rural health and the economic, social, and cultural context of the community - Fickenscher    Good advice for all areas of the state and nation, particularly in health and education

Forced into survival mode, many of the key areas regarding rural health and rural medical education are in retreat and disarray. Few on the state, medical school, or national level have the ability, time, or resources to adopt a broad perspective. Even between primary care disciplines and among them, there is conflict and destructive competition.

10. We must reverse the current negative attitude toward primary care - Fickenscher and others in 1990. Much worse in 2004. 

Great words, great minds, not bad leadership positioning, yet no progress…

With all that has happened, one might think that Rural America is still a great challenge for Medical Education, however, Rural America is the best opportunity for progress that Medical Education has.

Admissions Summary

RME: the Best Kept Secrets in Med Ed

Rural Training in Family Medicine

www.ruralmedicaleducation.org