Problem that may result in fewer rural practitioners

Documentation

Solution or Potential Solution

Spouse factors are widely recognized as key issues and there are more dual professional families where either or both parents are physicians. In the past it was perhaps much easier for the physician to dictate a rural location choice to spouse and family.

Recruiters have long utilized this. Studies in Texas and other states note this. It is difficult to locate dual professional families in rural areas with less variety of professional jobs.

Recruit students who have rural background and interested spouses. Use long term commitments that impact on spouse choice or orientation toward rural. Have rural communities develop lists of spouse jobs available and willingness to "create" job openings within or outside the health job market (education, law, etc.)

The numbers of rural-interested senior medical students is still near an all time low. Declines in rural background student admissions and failure to attract the interest of other students is a major problem.

Fewer rural hospital volunteers, fewer scouting programs, less health career exposure in rural areas, declines in rural education quality

Address science and math education needs in rural elementary through secondary schools. Implement Physician Education and Placement Programs  (Kentucky) type intervention programs. These take naive rural kids and teach them the ropes of getting in to medical school. Take admissions into small colleges that are more likely to have rural background students and, perhaps more importantly, rural spouses.

Emphasis on medical schools on board passage sometimes puts rural programs into question or reduces the numbers of rural background students.

Some of the students from rural backgrounds did not receive the same science background. This when coupled with some schools lack of educational resources for helping such students, can result in fewer rural admission slots.

The PEPP program in Kentucky showed that rural background applications could be kept up with 1/3 going into medical school with interventions at the high school and college level regarding MCAT prep, college courses, etc.

Previous studies noted a trend that the higher the MCAT score, the less potential for rural practice.

Lack of exposure to primary care and rural practice in medical school

Institutions and programs do not implement rural training as much as they could by expressing concerns about quality of education

For concerns about quality see Verby’s work on RPAP grads in MN, higher quality from avg or below students. The students consider rural rotations their best education.

Education of medical school committee members. Identifying the real issues behind wanting not to implement rural rotations or wanting to decrease rural experience time in existing curricula. Perhaps the faculty have forgotten one of the missions of the school. 

Institutions complain about the difficulty of arrangements

Many institutions forget that a key rural value is personal contact. Emails and phone calls are not enough. 

Faculty must visit rural communities and physicians in person to make arrangements. Find rural faculty who will do effective outreach and translate rural needs for institutions. Infrastructure and funding changes, rural faculty hired and supported with coordinators, legislative support

Medical leaders often don’t believe that preceptorships or other forms of rural medical education work to graduate more rural physicians or ones specifically trained for rural practice

There are successful models at all levels of training. Rabinowitz work on PSAP pipeline to rural practice in Pennsylvania, publications from Duluth, Upper Peninsula, WAMI paper on medical schools that graduate rural doctors, East Carolina, Mercer, Dakota studies, Norris studies, AHEC, statewide studies at WAMI and New York

Address at all levels: Premedical education and Admissions, Each yr of med school/Rural student interest, Each year of residency and Recruitment, Retention, Bridge the transitions, Studies to continue to document the benefits

Rural opportunities are often difficult to access.

They are easily pushed aside by aggressive and well-organized urban recruiting techniques.

Programs and institutions that prioritize rural community needs with rural recruitment fairs, dinners, noon talks, preceptors come in from rural practice to teach and supervise residents in residency clinics

Need for specific rural training. More barriers to rural training have been erected recently. BBA cuts have delayed or terminated new rural programs.

Fowkes, Norris, Bowman articles. Recent medicare regulations make it more costly to provide supervision for smaller numbers of residents at smaller programs.

More required rural training. BBA relief, GME finance reforms. Medicare needs to be educated.

Training location is important. Need training in programs where no or less other residency programs train FP residents. 

Bowman articles

More stand alone FP residencies. Family practice programs in smaller locations could graduate more rural physicians, but smaller programs face multiple barriers regarding accreditation.

Need for more ob training

Bowman articles

More ob training

Obstetric and procedural training are difficult to access.

Student, resident, and internet contacts, RRC problems with requiring minimum number of deliveries, most programs have minimum 2 months of ob and 2 months of surgery

More procedural training.

Alliances with private institutions. More fellowships to "recover" from lack of procedural training and train existing physicians

Procedures in Rural Practice

Students have less background in "hands-on" training. This may result in less comfort and confidence in students, more fear in being caught in difficult trauma, OB, or other situations when relatively alone in a rural practice, and so less consider rural practice. Fewer students discover the joy of doing procedures and take up the intellectual and technical challenges specifically rather than broader challenges in the broadest of specialities, rural family practice.

The rising popularity of procedural workshops, the disappearance of preceptorships, the liability situation, the lack of doctors knowing their patients with less comfort letting trainees do things on patients, the impact of medicaid to move patients away from institutions where training occurs, students overevaluate rotations like rural FP where they get to do things as opposed to training in other settings

Efforts within programs to battle other specialties for supervisory roles for FP residents, FP residents get on "code teams". ACLS, ATLS, PALS, ALSO training. Rural rotations or rotations at sites where preceptors will let students and residents actually do procedures.

Why a Preceptorship Is Better

Many new resident positions are located in larger towns. New programs and program expansions in states and cities with higher ratios of primary care physicians "steal" physicians who might choose family practice residency programs in more needy locations. PA and NP programs also have the same problems with program location and training not suitable for rural graduation of practitioners. Programs created in later years have also tended to graduate fewer rural physicians

Program location is a significant factor in the choice of a practice (Dorner, Denton, WAMI articles). Many states depend on students and residents educated in their states for 80% or more of their rural physicians, especially those in the smallest rural locations.

Restrict growth of programs in areas with adequate supply or beyond. States develop "bridging programs with a rural orientation that "bridge" two or more transitisions from college to medical school to FP residency rural to practice. Use of "accelerated programs" to bridge gap and add rural fellowship (NE). States pay more for FP residents that promise rural and fund with state and community support (OK).

Too high an expectation of rural practice is a problem. Few studies have been done. Studying too soon or incompletely might damage the development of rural training. Studies need to assess not just first practice location, but retention of grads in rural practice.

RTTs and rural fellowships mostly started in mid to late 1990’s. Required rural rotations moved from 84 to 145 in a decade (Bowman articles)

Studies needed that adjust for years of operation and goals of training, not only first practice choice rural outcomes.

Lack of rural experiences in residency training

RRC restricts rural training in size characteristics of sponsoring location and only 2 months per year away from main location for rural and away rotations

Accreditation would need to be relaxed so that residents would have 3 - 6 months at a rural location for FP and primary care residents instead of 2 or fewer. This may also help residents access more procedures, often lacking in urban medical centers. Accreditation and Acceptance Issues

Efforts to retain physicians poor to non-existent at the state and community level

rural physician interviews and rural community studies, personal experience in rural practice

service on committees and working with offices of rural health, locums committees, rural health associations.

Community awareness of local medical problems impacting on physicians such as workload, ER, other doctor availability, family needs, general appreciation

State efforts to improve locums use and decrease their cost

WAMI, New York, Bowman articles

More studies of interventions that address gender and minority barriers. More community work to address the need for more flexibility with call situations, needs of dual professional families, better quality education from rural schools to meet expectation of physicians in those locations. As more females and minorities enter rural practice, they can role model others to follow them.

Lack of natives, minorities, females in underserved rural areas, reservations, migrant communities

Unknown, needs a demo project for verification

Rationale is success of dispersed medical education and the establishment of branch campuses in smaller or rural locations. Success noted in other professions such as nursing, social work, and mental health. Support often lacking. 

Ultimate solution may involve Retention-Priority Medical Education programs where students that are already established in the desired location are selected. These students are then trained as much as possible in their current locations. Basically retention is less of a problem because they never leave the site for training. 

Family medicine has not been proactive regarding current efforts that could be modified to increase rural emphasis

Personal contacts with AAFP, rural faculty contacts, contacts with past presidents and doctors of the year . Near termination of rural committee, termination of rural presentation despite its high ratings and high need a few years ago, low priority of rural medical education efforts, poor coordination of various families of family medicine regarding rural efforts,

Rural staff person with at least 51% rural responsibilities, not other major duties such as legislation or practice managment

Major rural interest effort in fp interest groups across the nation. Support and send speakers to all schools with fp interest groups, especially those who want to set up rural interest sub groups.

AAFP might want to reconsider its decision not to include information about a career in rural health, in its annual mailing , Strolling through the Match, to all medical students.

Program director activities, workshops, regional STFM meetings such as previous ones in the northeast. Efforts to support rural faculty and programs through Title VII, GME, and other funding sources, not just protect the general flow of funds

Efforts to quantify ob volume, procedural emphasis, mission of programs, numbers of rural graduates of programs, through annual studies and surveys of graduates and program directors

Medical education can be a burden to rural doctors, not a blessing in terms of time to teach, costs of food and board for trainees, etc.

Preceptors with RPAP students in Minnesota for 9 - 12 months billed for $40,000 to $70,000 more (Jack Verby)

Longer rotations would minimize the burden and increase the benefit to the physician and rural community. Nearly 10% of students doing longer rotations return to the same town and hit the road running, their orientation already behind them.