Facilitating More and Better Rural Docs

This is the page with more links and text, less text at Facilitating Rural Health with Rural Faculty


Assistance to Communities Interested in More Rural Admissions at UNMC


Successful rural medical education must have rural physicians acting as preceptors and former rural docs facilitating the programs, acting as faculty. Rural physicians who have moved into positions on admissions committees, particularly leadership positions, have been very successful in choosing the students who are likely to return to rural communities (Admissions Package). Just as important is having rural coordinators to keep the programs, rotations, experiences, and rural-specific training going (Rural Coordinators).


The best approach to rural medical education is a continuous approach. This approach needs to involve rural communities in a major way (Community Driven Approach). Rural faculty need to stay focused on this approach and look at every level, particularly the beginnings.


The starting point of this approach is rural communities, since research by Rabinowitz demonstrates that 78% of the decision to become a rural physician is rural background and interest in Family Medicine (Physician Shortage Area Program by Rabinowitz). Rural communities, teachers, and physicians help identify students from rural areas who desire to return to rural practice (See local impact). Small college health advisors are particularly helpful in this process (Small Colleges and Advisors). States must support small colleges or else these rural interested students will not be able to choose rural locations for their college experience, where they will meet other potential young professionals. Forcing students to attend larger and more urban universities introduces them to the urban lifestyle and spouses who are urban and more likely to have careers that will lead them away from rural locations.


The key to strong and vibrant rural communities is young professionals. Young professionals are jobs, services, education, and leadership. They also support one another and help recruit new young professionals. Small colleges are the breeding grounds of young professionals. States who kill off small colleges or who force small colleges to give up the preparation of young professionals, are killing small towns (The Continued Centralization of State Educational Resources and the Potential Impact on the Location of Young Professionals).


Medical schools have demonstrated that they can strengthen small colleges, thus increasing the numbers of young professionals with small college origins (Rural Health Opportunities Program).


Medical schools must work with rural schools and colleges to facilitate the advancement of students likely to return to rural and underserved areas. Medical schools who do not facilitate this effort are also killing off small towns. Medical schools who say that they cannot do this have forgotten that the Flexner reforms provided a major stimulus for high school and college education in this nation. Strengthening the quality of the candidates for medical school by improving education and preparation has always been more important than strengthening medical school efforts (Flexner’s Impact on American Medicine). This is similar to the outcomes of a pregnancy. The primary determinant of outcomes is the status of the mother at conception, hear health, nutrition, etc. The characteristics of the student at admission are the key.


As you can see from the above, rural faculty and preceptors have a difficult task.


There is a Federal Role in Admissions that certainly influences who is chosen. Sometimes the

Best and Brightest are not the Best Fit For the State.


From Jordan Cohen's Opening Address to AAMC November 4, 2001

Section on Time to Address Current Realities within Medical Education

"But before we address misperceptions about the distant future of medical practice,
we must address some current realities within medical education itself -- realities that
I fear are also dissuading many promising college students from seriously considering a
career in medicine. The first is the way we select students for admission to the
profession, and the second, and even more important, is the way we acculturate the
students we do admit to become professionals by the time they finish their formal


Admissions choices and socialization are key factors.  


The foundation of rural medical education is admissions (Admissions Package). A secondary role is played by Socialization.   The medical schools graduating the most rural physicians have done so because:

·        They were located in a more rural state and have been encouraged by state rural leaders to meet the needs of the state (Medical Schools and Rural Graduation Rates).

·        They had strong rural faculty and academic leadership  (Leadership Factors in Developing RME)

·        They developed a series of specific programs to facilitate the development of rural physicians reaching out to middle school, college, medical school, and residency (Best Rural Programs). The best programs also support current rural practitioners regarding network and health systems development, in addition to assisting them with workload. Long term preceptorships, residents doing locum tenens, and rural rotations that give more than they take are key elements of this support (Community Friendly Aspects). Newer programs such as rural training tracks and accelerated programs may be able to improve the retention of rural physicians as they prepare graduates more specifically for rural practice.


These Coordination Factors have been known for years, but they continue to be ignored


Successful rural faculty and program directors must balance frequent contact with rural communities and preceptors with a political presence in academic medical centers. It also helps to have experiences in educational program development, evaluation, and research.


Another concept to consider is how medical school environments impact students. Selection vs Socialization . Keeping students out of this environment is a good plan.


Rural preceptorships are now known to be some of the best medical education in the nation (Why a Preceptorship Is Better). Despite this, few exist. The Flexner Reforms resulted in a disdain of the preceptorship method that remains to this day. During this time, preceptors were not well educated. Now preceptors are some of the best clinicians in the nation. They are also the ones most likely to let students make decisions and do procedures, since they know their patients. Despite this the poor attitude remains.


With each passing year, preceptorships look more attractive as medical education becomes more passive and irrelevant to the needs of patients. Physicians-in-training need to be able to make decisions and do procedures. In this nation it has become difficult for students and residents to get this “hands-on” type of training (Procedures in Rural Practice).


When many of the above efforts become a sustainable partnership with rural and academic communities as equal partners, then this has become a community-driven approach (Community Driven Approach). This is the approach most likely to resolve the maldistribution of physicians in this nation (Fixing Maldistribution). It is also the approach most likely to save federal and state governments billions of dollars spent in futile short term support programs such as National Health Service Corps and scholarship programs. The National Health Service Corps has re-discovered that the key to physicians for underserved areas is physicians from rural and minority and other backgrounds who have a strong motivation to practice in such locations. Unfortunately they are not allowed to do this, since NHSC has no role whatsoever in choosing the medical students that are admitted. It NHSC had such a role in admissions, then NHSC might not need to pay such huge sums to influence doctors to practice in underserved areas for a few years (Perennials vs Annuals).


Rural communities do not need a series of rotating rookie physicians to meet their needs, as has been suggested by some medical leaders (Why Doctor's Don't Go Where They Are Needed). Such physicians will be underutilized as rural people bypass them for doctors that can best meet their needs, even if they have to travel many miles. What rural communities need is physicians who desire to practice in small towns and live there for many years.


Rural physicians who do stay long term are a critical resource for economic support for rural communities (The Role of the Rural Community and Practitioners). Rural physicians are worth 1 million a year in local economic impact (By the numbers: Rural Doctors and Rural Economies). They also anchor recruitment efforts so that the community can attract new physicians and other young professionals.


Rural Communities have a responsibility to

·        Support local education and identify students who are likely to return to small towns as young professionals (The Role of the Rural Community and Practitioner)

·        Support and develop local rural health systems and services, this involves significant training and support (IMPLEMENTING A COMMUNITY BASED APPROACH). Academic centers can and should assist in this area

·        Train health professionals (The Role of the Rural Community and Practitioner)

·        Recruit and retain health professionals (Retain Rural Doctors, Recruiting New Rural Practitioners)

·        Resist consolidation of schools that may destroy the bond between student and small town. This bond may be critical in motivating students to overcome the many obstacles that stand between them and their rural practice (Consolidation and Bonding).


State legislators have a key role to play to keep educational policies progressive and hold medical schools responsible. Some programs are very effective and cost very little (Legislative and Health Policy). State governments must support reasonable reimbursement for rural physicians in areas such as Medicaid and in support of the care of indigent populations. States must help rural physicians with the hassle factors so that they do not grow frustrated with paperwork and overhead costs.


Policies PC RME Workforce


The federal government must do the same with Medicare programs and federal regulations such as EMTALA and HIPAA. Some areas such as Critical Access Hospitals and Rural Health Clinics have been helpful. Reliance on insurance companies to run programs is a questionable policy. If insurance companies do a good job, people think government programs are a good thing and they begin to question why insurance companies are needed. If insurance companies do a poor job, people continue to believe that the government cannot manage something as large and complex as health care. Of course managing government in our nation is far more complex and we continue to trust our government to do so. Perhaps we should trust the government to do more regarding health care.


State and federal governments, as they impact health through various programs, play a key role in helping people to escape poverty, or in trapping them there (Poorer Health in the Process). A few months without access to health care can result in death, financial ruin, or disability.


The nation is ignoring the needs of underserved peoples (Underserved - Overview and Models).



Other related items:

STFM Perinatal Page

Support for family practice educators, Jason and Westberg http://www.uchsc.edu/CIS


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