Why We Are Graduating Fewer Rural Physicians

Robert C. Bowman, M.D.    

Just the Facts

Admissions committees in allopathic medical schools in the United States are admitting 1800 fewer rural background students each year when compared to 1983 when 25% of medical students came from towns of less than 10000. This is a reduction of over 37 %. The urban, female, underrepresented minority, and Asian background students admitted increasingly over the same time period are far less likely to choose and stay in rural practice. The white male rural background group that is most likely to choose rural practice, has had a 55% reduction. During the years from 1978 to 1998 the number of senior allopathic medical students interested in rural practice decreased from 12% to 6.4% or from 1800 to only 1000 a year. This has obvious impacts upon choice of family medicine and rural practice. See chart at Changing Rural Background for details

Changes in Admissions in Allopathic Medical Schools

Updates at Five Periods of Health Policy and Physician Career Choice, especially regarding the most important health policy impacts.

Family physicians have consistently greater choice of rural and underserved locations. Logistic Regressions: Location The last 7 years of graduates (1997 - 2003) have distributed well in comparison to the US population:

However examining the data year by year reveals steady declines in the numbers of family practice and general practice physicians choosing large rural, rural, and isolated rural practices. This includes graduates of all types of US medical schools, private and public, allopathic and osteopathic schools. It includes males and females. Gender and Rural Practice The numbers of family physicians from international medical schools has doubled, but this doubling, involving an additional 320 FP graduates compared to 4 years ago, has only resulted in a total nationwide increase of 11 doctors for isolated rural areas in 2003. Going Caribbean Increases in the numbers graduating from osteopathic private schools have not resulted in more family physicians and general practice physicians, and there have been no increases in the numbers choosing rural practice. Even steady family physician and rural performers such as Mercer and South Dakota have begun to fail primary missions.

Many of the successful interventions in medical education face reductions, closures, and termination. Rural training tracks have had great success in graduating rural family physicians, some have over 90% rural graduation rates with over 40% entering isolated rural locations.  Compared to just 3 years ago, over 30% of RTT programs may be closed. The accelerated family medicine training programs that combine medical school and family medicine residency also have been terminated. Accelerated Family Medicine Training Programs These programs graduated 2 - 4 times as many family medicine residents to rural communities as compared to the usual family practice programs. Some of the accelerated programs graduated 20 - 30% to isolated rural locations, 5 - 7 times the usual graduation rate. States and medical schools have cut funding for preceptorships and medical school programs involving rural medical education in several states. A former governor cut funding for a rural training track that graduated 60% into the isolated rural locations that dominate the landscape in South Dakota.

The geographic distribution of students taking the Medical College Admission Test (MCAT) has not changed from 1991 to 1999. States with the highest percentages of rural population tend to have the lowest average MCAT scores. The median score for every state except the bottom 5 states, would be sufficient to insure graduation. Efforts to screen students using test scores, grades, admissions data, and other predictors can predict 90% of students who might have academic difficulty. However 80 % of this "suspected failure" group of students will still graduate from medical schools (Alabama studies). No physician would base medical decisions on a medical test with only a 20% specificity. Rural Background and Rural Interest PowerPoint Presentation

Multistate comparisons of MCAT and GPA scores suggest that MCAT scores of 8, total MCAT of 25, and GPA of at least 3.0 give a reasonable chance of obtaining a medical license and more than enough to insure success in residency training. Average MCAT scores at most schools are above 10 with 3.7 or above for GPA and over 30 for the total MCAT (resentations at CMEA meeting Omaha, March 2004). Students from more diverse backgrounds and those who face obstacles such as educational preparation and income are increasingly denied entry into the nation's medical schools with small towns the ones most likely to suffer as a result.

Medical schools as yet are unaware of the declining numbers of rural background students admitted, or the impact of such decisions. The data is tracked yearly, but comparisons over longer periods have rarely, if ever, been made. However medical schools have made admissions decisions and loosened state residency requirements to admit more from other states. Often this has been done to admit more from underrepresented minorities and also more that are considered likely to consider careers in research. This is not helping efforts to graduate more to family medicine and rural practice. Schools with a higher percentage of students born in the same state tend to graduate more family physicians (Bowman FP Grad Studies 2004).

Rural background students with interest in Family Medicine at matriculation will choose rural practice 30% if the time. Of all such students, 50% will choose Family Medicine (Duluth, Rural Background). Those that choose family medicine choose the most rural of locations, isolated rural practices, at a rate 3 - 8 times as often as traditional family medicine residency graduates (Bowman FP Grad Studies 2004).

The combination of rural background plus family practice interest plus enhanced primary care/rural training can greatly improve the recruitment and retention of rural physicians. Rural Background

With efforts directed at rural background and family practice interest alone a small percentage of medical students in a state, as little as 1% can result in 12 % of the rural family physicians in a state (Rabinowitz). With enhanced training this number could be double or triple (). Consistent efforts applied in a statewide fashion over the preprofessional, admissions, medical education, and family practice residency years can greatly enhance rural workforce, recruitment, and retention. Rural Medical Education Works

The rural forms of physician maldistribution involving primary care can be cured.

The principles involved in such successful efforts are also being applied to inner city underserved populations and could be applied to improve access to primary care in reservations, border locations, and other rural locations where minority populations remain underserved. The same principles of selection and training could also be utilized in dental and mental health, which are even more difficult problems for rural areas of the nation. Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training

Some regard the poor rural economy as the primary reason that small towns do not have physicians (Cohen - Why Doctor's Don't Go Where They Are Needed). Others note that rural physicians contribute $1 million in economic impact each year (Minnesota, Oklahoma, By the numbers). Health care in rural areas is 15% or more of the economy, with higher percentages in the most rural towns (Doeksen). In other words, medical schools that do not admit physicians who will go and stay in rural practice are a key reason for the poor rural economy. Rural physicians also support other young professionals, provide leadership, and promote education. Small towns losing physicians will not be able to recruit new jobs or businesses and will likely lose additional jobs.

Any medical school can graduate physicians for large rural areas. It takes some effort, but any medical school can also graduate physicians to rural and isolated rural areas also. Successful medical schools include all medical school types including allopathic, osteopathic, and international. They include public medical schools but private schools in the most urban areas have been successful.

The graduation of adequate primary care and family practice physicians can address the needs of urban, large rural, and rural populations. However the isolated rural areas that involve 6% of the population will not receive adequate physician services without admissions of rural background students. Temporary physicians are only a stay of execution for small rural health systems and have limited productivity, access, and acceptance.

After a few years of decreased numbers of family physicians and primary care physicians at the same time as decreasing rural background admissions, the nation can expect widespread shortages of physicians in isolated rural areas, rural areas, and even some large rural areas. Such access problems would involve the 6.1% in isolated rural areas plus an additional 6.9% in rural areas for a total of 13% of the US population at risk or 36 million people. Such decreases may be intensified by decreased admissions of those from lower income families, those with service orientation, those who are older, and those who are married. These are all more likely to choose rural family practice.

In times of increasing physician shortage those with more resources involved in recruitment efforts will attract more physicians. States such as North Carolina and Wisconsin as well as large health corporations will tend to weather periods of shortage better than most. Other states have growth rates that will bring physician resources to their states. Most other states will compete ineffectively for a much smaller number of rural, primary care, and family physicians. The impact on health care costs, access, and mental health alone will be devastating. Comparison of current recruitment efforts in North Carolina compared to surrounding states In this graphic states such as Tennessee and South Carolina contribute family medicine graduates to other states while North Carolina recruits new FP docs from almost every other state.

Shortages of rural physicians will impact certain populations to a greater degree. The frail elderly and disabled populations will have worse health care outcomes. Studies note worsening outcomes for those who need immediate access to emergency services, such as those who present with heart attacks or strokes.

Medical education has no idea how much it has to lose by not admitting the students that are most interested in rural practice. These rural background and interest (RBI) students make significant contributions before, during, and after medical school. Comparisons with their peers reveal that RBI are 5 times more likely to be interested in serving in underserved areas. They are 1.3 to 2 times more likely to volunteer, do public health screening, go overseas for international experiences or missions, and do military electives at every year of medical school. They are also more likely to show interest in what the nation needs regarding workforce, including electives and experiences in community health, public health, and geriatrics. Characteristics of Rural Interested Students

Failed health policy involving medical education in the United States has far reaching impacts on other nations. The United States imports half of current family medicine residents. These represent leadership, education, jobs, access, tax dollars, and significant investment on the part of other nations, some of which can ill afford to lose such valuable contributors. Health and education are the primary means of restoration. No war against terrorism will succeed without improvements in health and education sufficient to restore hope to parents, their children, and especially teens growing up and forming their concept of their role in the world community.  Restoration of Communities, Nations, People: Role of Rural Family Docs

Careers in health and education represent significant investment of time and great sacrifices on the part of individuals and their families. If individuals feel that the effort is not worthwhile, if they feel that only the rich or the powerful can access higher education and leadership, if they feel that they are mistreated in the process, and if they feel that their efforts will not be rewarded, they will not make such efforts. In the United States a career as a physician is increasingly restricted to those with higher income, those with professional parents, and those who can access certain types of high schools and colleges. Medical students still face significant abuses and far too often they feel that their extra efforts will not be rewarded (AAMC GQ 2003). It is likely that many of the students needed most by medicine are choosing other careers.

Best Works on Site

Physician Workforce Studies

www.ruralmedicaleducation.org