Rural Physicians & Rural Communities

Originally Presented to the LEAD Program

Education - Top-notch education in many rural communities has given countless students from rural Nebraska a chance to excel. Nebraska rural communities support UNMC, UNL, Creighton, and other health professions students with over a million dollars worth of support a year. Nebraska may well lead the nation in this area.

Involvement and Cooperation - A health system or hospital that divorces itself from the community cannot survive. Administrators, physicians and other health professionals, hospital board members, and community leaders must work to stay involved & work together.

Leadership - One of the weakest links in the rural health system is the lack of training of hospital board members. One hospital Board President did not even know the annual revenues of the hospital.

Economics - A rural family physician is worth $380,000 in annual local economic impact and 18 jobs. The rural hospital employs up to 25% of the local workforce and millions of dollars to the local economy. Not just getting a doctor, but finding one that matches the community and working to keep that doctor:

"The appalling cost to both the physician and to the rural community of this mismatch has not been well described. The young physician and his family moves to the town in good faith, making a long-term commitment. Within weeks or months it becomes apparent that the expectations of the doctor, and sometimes the town, are not to be realized. The agonizing decisions then begin whether to sever the relationship... For the rural community the trauma is almost as great: it is easier in most instances to be perenially without a physician than to find one, go through the process of change in adapting to a new one, lose the doctor and start the entire cycle over again." - Tom Bruce in Improving Rural Health

Understanding the Role of the Rural Physician - "Physicians occupy and unusual spot in the social structure of rural communities From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationship to strike a workable balance." Rosenblatt and Moscovice, 1982, in Rural Health Care

The state and its institutions must have an institutional mandate for primary care and rural. Despite much effort there is much to do. Only one town in the state has enough Fps (Omaha).

Health professions training must be specific for rural.

The preparation for rural practice (producing a rural doctor) starts in the "village", it continues in every year of training, and it extends out into practice. Nebraska has the most continuous and comprehensive rural medical education programs in the nation.

Nebraska is nearly last (49th of 50) in state expenditures per capita for public health. Not only do we lack basic needs in this area, we do not even know how little we know. The health department is dependent on outside sources for most of its funds.

Investments at the national level

A 30% increase in reimbursement to hospitals for medicare and medicaid would not improve the situation as well as a 10% increase in the local market share for rural hospitals. The average rural hospital market share is 40% (50% for physicians). Keeping rural people in the rural health system is the key to doing well. Communities should not look to the state or federal government to "save" them. One of the real contributions of rural people is their willingness to tackle problems and situations with few resources. This expertise is needed in many areas.

The investments of time and energy regarding rural health systems, recruitment and retention, and rural medical education must be continual. The town, the state, or institutions should never expect immediate results. It takes eleven years of higher education to train a physician and another ten years to evaluate the impact of changes in the training of physicians. We will never "know" how to do it, we will always be doing what we hope is our best, guided by keen minds, willing hands, and the best information possible.

Robert C. Bowman, M.D., Director of Rural Health Education and Research