Harold Williamson, Jr., M. D.

Professor & Interim Chair, Family & Community Medicine

University of Missouri School of Medicine

Columbus, MO

As Dave mentioned, we just recently completed a survey of the rural training tracks. Spokane, Washington really was the pioneer for this concept where residents would get their first year of training in an urban area and then their second and third year of training in family medicine in a rural community. Most of the sites reflect what is going on in their state and really present a model of what rural practice is like in that particular state. So as you can imagine, some are very, very frontier, and some, like ours in New York, are not anywhere near so frontierish. The rural training tracks use a variation of local physician groups. Some are private practice groups that have been drawn into the process and do an excellent job of teaching; others are models where the rural physicians actually become full-time faculty members. We try to use area specialists as much as possible so that in most of the situations, the entire second and third year experience, in fact, is done in the rural area or often within 30 miles of the rural practice. And in all cases a rural hospital is used. Funding sources have come from hospitals frequently using their former recruitment budget to support a rural training track. Virtually all of the models have some state funding, get some Medicare funding, and some Title VII funding.

It is interesting that 47% of these rural training tracks are in health profession shortage areas, which we are glad to see and suggest that we are at least attempting to accomplish some of our goals. The average size of the hospitals may be a bit larger than you would have anticipated. The largest was 424; the smallest was 45. The average distance between the practice site, where the resident sees their patient and the rural hospital can be anywhere from being on the campus to being a couple miles away. But some are quite distant. The average number of physicians in the group were two, so these are very small practice sites although some of them were larger. The number of residents trained in each site was 4.5. The difficult experiences for the rural campuses to organize were dermatology and urology. Surgery was one of the easiest, particularly the general surgical experiences. These curriculums tend to have more surgery, more OB, and more procedures such as first assisting and colposcopy. Training, then, is generally evident in the urban programs. There have been 94 graduates overall, so far, as of 1996, and the percentage of people who went into rural practice as their first practice site was 75%.

Well, how do you get one set up? First it truly is a partnership between the local health professionals, medical schools, large medical centers, communities, regional colleges are often included, and local providers. For any of you that run AHEC programs, this is an AHEC model. You will solve problems in ways that you never thought of. Many things will be multidisciplinary. The way you get behavioral science training is frequently unique to each campus and sometimes more patient relevant that you see in our urban programs. You need somebody in charge of medical education. Most of the programs bring the physician in charge of medical education for the site into a central meeting place or something like that on a very regular basis, at least once a month, if not every other week. It is important to have that kind of constant connection. You can get a lot of support from your local public health department for community projects and things; we have found them very supportive. Basically, what you are doing is you are doing education the same as it is done in the urban model but with a rural focus and a rural twist. The quality is the same, the outcomes may be even better. And don’t forget research. That is an important part of what these campuses can do.

I spend most of my time opening and closing the valves that run the pipeline that most of these people have talked about. In the last three or four years, though, I have worked with our state health department, and in doing so, I have discovered that one of the things that we in the ivory tower, as it were, are not very smart about is what happens after we train them, sort of what happens to them after they get to the farm. I have four transparencies I would like to show.

Most of you who are physicians, from rural communities, or advocates of rural communities, I think will understand most of these things. Some of them are counterintuitive; most of them are not, but there are only about three things I think you need to know. This is one of several different kinds of studies on what are the factors that influence a physician’s going into rural practice? To give you a little bit of orienting statistics, by the way, about 12% of U.S. physicians are in rural areas, and about 30% of family physicians are in rural areas. That is why a lot of the focus, for those of you who are wondering, is on family practice. That is the single group that is more likely to go into rural areas. This is one study, not particularly better than any of the others of about a half a dozen or so studies asking residents when they graduate, Why did you pick the community that you did? I picked this study because it shows either common sense statistics or the statistics of common sense--I’m not sure which, but I wanted you to look.

There are four columns here; on the left are the items that were deemed important in choices, and these will not surprise you. In this particular case they found, in a group of Minnesota residents, that choosing partners, location, opportunity for recreation and so forth were the rank order listed, taken from a mean of a 10. Likert Scale. So you line up and say, "How important was this to you on a scale of 1 to 10?"

The second column is a mode, which you probably know is the most common choice and follows along fairly clearly.

But the third column, which is not included in most research of this type, or at least not published, is the range. The reason I want to point that out to you is that, although the range is a little bit narrow up at the top with sort of the choices that had the highest average, if you look down at things like salary, near the bottom for example, where physicians said, "Well, the salary was not all that important," the range is 3-10, which means for some people it was not important, but for some person it was one of the most important things. And indeed if you look down that whole column on the range on the right, each one of them has somebody who thought it was the most important thing. So in this congregation of rural health experts, we frequently say "Once you’ve seen one rural community, you’ve seen one rural community," I think it is important to know that once you have seen one interested candidate for your position, you have probably seen one interested candidate, and they are not all going to have the same kinds of factors influencing their choice.

The second issue is retention, and that issue is much less well studied. This is from a study of physicians in Eastern Kentucky about retention, and a question of a hypothetical case was posed to them about a young physician coming into practice, and they said, "In five years from now, what are the kinds of things that are going to determine whether this person will still be here or not?," and this was their assessment of an open-ended group of questions asked by physicians. This is somewhat theoretical. This is what physicians thought would keep people in the rural community. It is not terribly different than what you would expect, I think.

The sociocultural integration, actually a geographer’s term, which means "I like my community; it fit well with me and my spouse." The medical care context is the partners, the support that the hospital might give you over five years.

Economic stability really relates to "How much money can I make, and what is the community like?" And this one, by the way, had 6 comments as opposed to 16-30 in the first category. So these are apparently now less popular reasons anyway.

And then the geographic situation, "How geographically friendly was the area?" Those things probably don’t surprise you, but remember, those are our theories; those are what physicians thought might matter.

The next is from a study by Don Pathman, who is in this room, and this study takes the issue of satisfaction and retention one step further, and I think if I heard Don right at the last meeting, they have an ongoing study, which will even help us understand things a little better. This slide relates to the physician satisfaction. The things that rural physicians were satisfied with were their relationships with patients, the clinical autonomy they have, the fact that they had medically-needing patients, meaning "I was trained to take care of people who really needed my help. I want to be able to do that," and then small-town life. Those were things, which, in general, were satisfying.

The things that were not satisfying tend to be the flip side: access to urban amenities, for example, and time spent away from practice. Notice that the kinds of things that we worry about--professional isolation-- are, in fact, the flip side of some of the things that the physicians find very satisfying like autonomy and relationships with patients, needy patients, and so forth.

When Pathman and colleagues then correlated those satisfaction items with retention, how long people stayed, and this was much less of a theoretical question than the last study I showed you, they really found two items which they could identify, which were more important than the other ones that were issues of satisfaction with physicians who stayed a long time, not necessarily physicians who left but those who stayed a long time: the community, that is, my fit with the community, how good do I feel about being here, and opportunity for professional goals, which were some of those things I showed in the last slide; earnings, I have down there with a space and in smaller print because it was barely statistically significant and much less important than some of the other ones. Notice things that did not show up on here that the dissatisfaction with workload and hours.

My take home from this is that although all of us are very concerned about changing reimbursement patterns and so forth to make life better for rural physicians, I expect that at least for the next generation or two of physicians, we will still be needing to rely on well-trained people who are willing to work hard and put their heart and soul in a community to be successful. From the community standpoint, it is clear that whatever study you look at, the fit of the physician and his or her family with the community is probably one of the most important things that attract people to a community and keep them there. And I think there is a lot of hope for many of us that are interested in rural areas.

One final comment about what the crystal ball looks like for the future. Many of you know, I think, that there is a controversial but broadening belief that the United States is experiencing and will experience into the next decade a glut of physicians. That is already certainly true in some geographic areas. It may be affecting specialty selection to some extent, moving more towards primary care physicians although that is less clear. And it may have the effect, in fact, of making it easier for rural communities to recruit and retain physicians. I think that remains to be seen. I have never been to Italy, but I have talked to at least three people who have gone to Italy and have their cab driver be a physician. So at least in Italy somebody would rather stay in Rome and drive a cab than practice in their rural under served area. I don’t think that will be the case in the United States, but I do think the kind of programs that we have talked about here and the kind of programs that your communities can come up with are likely to have better success in the next decade than we have had in the last several.