Medical education has become paranoid in such areas as liability and federal audits. This may have implications regarding the quality of training and the potential contribution of medical education to workforce, particularly in underserved areas.
Current studies also note that the teaching of medical students is primarily a burden, up to an extra hour a day. However such studies focus on easily obtained measures, and do not capture the full impact of medical education in rural areas.
It is important to recognize that there are many ways to influence workforce. These include numbers of physicians, types of physicians, the amount and training of various assistants and other factors. It is possible to influence workforce in a number of ways beyond the numbers of patients seen.
Rural Physician Associate Program
Jack Verby, the first director of the RPAP program noted that rural practices billed for $40000 – 70000 more a year when they had and RPAP student as compared to years without as student. This does not mean illegal billing. It does mean that students assist with a variety of activities that make the physician’s efforts more efficient (challenging patients, needing to be two places at once). Studies in Australia noted that students doing 4 months become contributors to local workforce. Some note contributions in less time. Most US studies focus on the extra time involved in precepting. This has led to the need to pay preceptors. With longer term preceptorships, there is no need to pay preceptors because students and residents become valued additions.
Combined Outstate Rural Experience
Most rural experiences in residencies are limited to 1 month. Often they are electives more suitable for checking out a practice location than education or contribution to local workforce. In Nebraska most of the family medicine residency programs coordinate rural experiences in a few locations. Choice of those areas in need of workforce best meets the needs of the community, the resident, the program, the practitioner, and the rural hospital. Hospitals pay stipends and residents become as much like practicing physicians as possible. Supervision is always available. Scheduling 6 residents at a single site back-to-back also allows clinics to add personnel that can help process patients and also facilitate the educational mission.
The Need for Community and Preceptor-Friendly Rural Medical Education
Current preceptorship experiences at the student and resident level rarely contribute to workforce and cost millions to communities who can ill afford such expenditures, even though they are most supportive. Longer term and coordinated rural education can be effective for education and rural practice. Pay for preceptors may be a flawed approach. Most states have long worked with a variety of preceptors without the need for such support. Any pay is taxable, reducing any added value immediately. Studies of community-based education for students reveals education quality the same or better than that in academic settings.
Switching from poorly coordinated short term experiences could reduce the cost of education, improve workforce, and improve the quality of education.
Accelerated Family Medicine Training Programs
Accelerated Rural Training Program
Most accelerated family medicine programs involve 3 years of medical school and 3 years of residency. Nebraska adapted the model to graduate physicians for the underserved areas in most need in the state. Initially the model involved 3 years of medical school, 3 years of a family medicine residency, and then a 1 year fellowship involving procedures. This was superb preparation for the isolated rural sites that comprise half of the counties in the state. This model was also adapted to an inner city community health center location for specific care of others facing access problems.
Just as in the case of the Duluth/RPAP model, the Nebraska Accelerated Rural Training program graduated more to the isolated rural locations in the state. ARTP graduates also had specific training in skills that were in need in their locations, developed a working relationship with consultants during training, and provided significant workforce to a number of rural hospitals throughout Nebraska and Iowa. Stageman, Bowman, Harrison, Accelerated Rural Training Programs, Journal of the Board of Family Practice
Finally medical education can provide a great stimulus for education in K-12 and colleges. The Rural Health Opportunities Program in Nebraska admits students from small towns directly into a special medical school track. Students attend two small state colleges at either end of the state located in rural areas. After 4 years students begin medical school in Omaha. The output of this program is small in total numbers, but big in impact for education. Chadron and Wayne State have experienced great improvements in numbers, in the quality of academics, and in finances since RHOP began. The program cost is small and the benefit is high. Also students that desire to live in rural areas can do so much longer, giving some immunity against urban living and the specialized urban spouses that can prohibit a return to rural areas.
Changes in the Origin of Family Medicine Residents
Due to declining interest in family medicine in US medical schools, most FP residents come from international locations. The following data on FP residency graduates notes changes from the medical school graduates of 1994 – 2000. Since that time the trend toward international graduates has continued if not accelerated. Currently the largest single source of allopathic family medicine residents is Ross University in Grenada. Other medical schools near to the US have increased their output.
Some such as Ross do an excellent job of graduating rural family physicians. Ross in 2009 is the largest single source of US primary care and the reason is 115 family physicians out of 469 graduates. A major reason is that the Ross graduates have additional incentives to choose family medicine programs to get back into US GME training. Any method to graduate more family physicians is critically important for rural workforce, underserved workforce, care of the elderly, care of the poor and near poor, CHC care, whole county primary care shortage areas and other locations where family physicians are 2 to 4 times more likely to be found.
Allopathic public medical schools continue to be the mainstay of rural physician workforce (not shown in graphic), but declining to only half of the total contribution. Previously this was as much as 75%. Changes will give increasing importance to osteopathic schools as well as international schools near to the United States and those more distant. Characteristics of the new osteopathic schools and osteopathic admission policies might also determine whether osteopathic graduates continue to choose family medicine and rural practice. Although osteopathic medical schools have higher family practice and rural graduation rates, it remains to be seen whether the newer private schools located in the most urban high growth areas of the nation will contribute.
Note: In this graphic the rural numbers for osteopathic and international graduates are decreased due to information delays to the AMA Masterfile. This decreases numbers and also tends to catch the FP graduate at their zip code of residency. The 2000 figure above also suffers from the same malady.
It makes sense to re-examine our current choices for better quality, access, economics, and education in rural areas of the United States.
More studies are needed, but we may need to reconsider health policy regarding scholarships and funding of various types of medical schools.
Separate funding and accreditation for those meeting the primary care workforce needs of the nation also needs serious consideration. The nation should reward those meeting national workforce goals instead of neglect and punishment.
Finally, unless we change the reimbursement structure to encompass the challenges inherent in the delivery of comprehensive care in rural areas, we are unlikely to have quality care in such areas.
The nation needs a separate funding mechanism for primary care services that involve a number of areas of prime importance to the nation. These include universal access, national security preparedness, military reserves, liability protection, retirement security, the quality of medical education.
According to Kindig, Talley and others at the Rural Health Conference of AAMC in San Antonio in 1990, until we address these areas, rural medical education will continue to be too small, too few, and too hidden, just like the rural background candidates that we need, the quiet, dedicated and efficient rural doctors that we have, and the fragile rural health systems areas that are most in jeopardy.
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