| Robert C. Bowman, MD, Chairman, STFM Group on Rural Health
The Crisis in Rural Health Health Policy Reforms Favor Rural Each passing day brings new debates regarding health care. Rural practice is no exception. Once largely ignored, rural health is gaining a more prominent position. The rural caucus is the largest caucus in Congress. The Resource Based Relative Value Scale and other reforms have helped rural doctors. Congress is debating increasing the bonus to rural physicians in underserved cares from 10% to 20% and a 30-50% increase in capitated payments for Medicare patients in rural areas. The National Health Service Corps has scholarships and loan repayments available for students and residents interested in rural practice. Federal loans to medical students, once open to all students, have been changed to primary care loans, prioritizing the needs of those who choose primary care. States have followed this lead and over half provide some form of loan repayment for rural service. Reorientation of Medical Training Medical schools and residencies have recognized the need for special training for rural practice by establishing rural training experiences. There are 24 medical schools that require rural experiences and a total of 99 out of 126 that have some rural experience available. Nearly all of the osteopathic schools have rural experiences and 148 out of the 400 FP Residency Programs have rural training (see program listing or database). State and federal agencies are diverting graduate medical education funds from specialty to primary care training. Major reforms could force GME to devote 50-55% of all residency slots to primary care training. The Demand for Rural Physicians is Great The market for primary care physicians is unique. While specialties such as pathology and anesthesia have no openings in entire regions of the nation, primary care demand is skyrocketing. Family practice openings outstrip all other specialties combined by a two to one margin. States, hospitals, and communities compete against each other with special recruitment and retention programs to attract rural physicians. Graduates of family practice programs who choose rural practice almost always make more than the faculty that trained them. Rural Practice Is Rewarding in Other Ways Having a practice where you know your patients is the best experience in all of medicine. Working with the community is a big plus in rural practice. The academic stimulation is great also. Many leaders in family medicine initiated their studies of behavioral medicine, the doctor-patient relationship, addictionology, practice management, and health policy and planning during their rural practices. The outlook for those interested in rural practice has never been brighter. There should be more rural physicians, but barriers remain. The Chinese character for crisis combines the symbols for opportunity and danger. Rural practice similarly has great opportunity and great challenge. Rural medicine is for those who enjoy the challenge of personal and intellectual growth. Rural physicians work closely with patients, staff, and peers. Rural physicians are active in school boards, health departments, and community organizations. Rural practice tests the limits of interpersonal, management, and clinical skills. Every physician has limits regarding time, resources, and knowledge, but rural practice seems to challenge these limits more thoroughly.
Rural docs see the entire spectrum of disease from angina to Zollinger-Ellison. They see patients of all ages and in all stages of disease. Rural practitioners see 20 - 30% more patients a week and rural patients are often sicker as they are less likely to come in for routine illnesses. Because you know the patient, giving just a prescription is often not enough. Social or mental health situations often demand some unique solutions. The end result is a demanding variety of diseases, conditions, and situations. Problem solving skills are tested and quality care involves more than what goes on in the office or hospital. Another reason for the lack of rural doctors lies in the long pipeline to rural practice. Despite much rhetoric, few medical schools or residencies truly prioritize primary care, much less rural practice. Only 47 of 125 have primary care in their mission statements and only 24 require some form of rural experience. As most medical schools turn to their subspecialty and research faculty to improve their financial picture, rural interests can lose out. Most schools have few rural faculty or programs. Students with rural interest are mostly on their own. The loss of primary care and rural interest during medical school is staggering. Many if not most students in past years have begun training with primary care goals, only to bow to other pressures or interests as the years pass. Medical students who do not shape their own careers may find themselves following the subspecialty influences of faculty, facilities, and fellow students. Choosing the Rural Pathway Students who wish to examine rural practice must take a different pathway. This pathway should include primary care and rural training experiences, top-notch medical education, procedural training, and rural faculty advisement. Career choices are not a single decision, but a whole series of decisions made during the seven years of training. One preceptorship, one faculty advisor, or one conference may not be enough. Students interested in rural health must pursue the advisement and experiences that will shape a career in rural health. Rural Experiences Across the Nation The National Health Service Corps Fellowship program is a similar program operating in over 25 states. Students work with patients, rural physicians, Community Health Centers, and community leaders to develop a community-oriented primary care project. In Nebraska, the Fellowship program is called Community Connections because the program connects students to communities as well as the medical center to rural communities and their providers. The Appalachian Preceptorship at East Tennessee State University invites some 20 third and fourth year medical students to participate in two weeks of training before going out for a month into a rural community. Students learn about the impact of culture on health, the doctor-patient relationship, the role of the rural physician in the community, and more. Students may choose to create electives by talking to Family Medicine departments, residency programs, state FP academies, or offices of rural health. Students going to the rural sites are impressed with the devotion of the physicians and staff. This role modeling is often a key component of a good rural experience. Students may also work with rural faculty to do summer primary care research projects such as studies on the recruitment and retention of rural practitioners, the management of a rural family practice, or common occupational illnesses. Create Your Own Interest and Support Group for Rural Students who hope to maintain and develop interest in rural practice can form a rural student interest group. The North Carolina Student Rural Health Coalition in North Carolina has chapters at Chapel Hill, Duke, and East Carolina. NC students work with rural communities to deliver primary care at monthly clinics under the supervision of local practitioners or faculty. Students also assist with health fairs. The Rural Student Interest Group at East Tennessee State University organizes an annual career fair for rural high school students. Family practice student interest groups, American Medical Student Association groups, Christian Medical and Dental Society chapters, and Student National Medical Association groups also sponsor rural activities. Students interested in rural practice are twice as likely to volunteer their services locally or internationally (AAMC data 1995). Students interested in rural practice also have a vested interest in starting early to attract practitioners who will join them as partners or colleagues in rural practice. What Will Prepare You for Rural Practice The preparation for rural practice involves "hands-on" training. Students need to take responsibility for patient care. They need faculty and residents who will invest the time to assess them, allow them to work within their expertise, supervise them when they need help, and give them feedback to allow them to move beyond their current limitations. Residents need to direct the care of critical patients, trauma victims, and cardiac emergencies. They need to be competent in many areas such as obstetrics, cardiac testing, endoscopy, colposcopy, and other services needed in rural areas. Rural practice is demanding and the preparation involves the full seven years. Selecting a Residency Program That Prepares for Rural Practice The first major step to rural practice is a rural-oriented family practice residency. These can be identified by discussions with faculty or by using the Rural Database developed by the STFM Group on Rural Health. The annual meeting of the family practice students and residents in Kansas City each August is an excellent opportunity to examine rural programs and talk to rural faculty. Family Practice is the preparation of choice for rural practice. Currently few internal medicine or pediatric programs emphasize rural practice and it is more difficult to share call when physicians cannot cover all of the patients who might call or come in. Larger rural areas do have internists or pediatricians, but there is little shortage in these areas. Internal medicine is broadening its focus and pediatrics is extending age limits and OB-Gyn is now doing some rotations in family practice clinics, but family medicine is still the best choice. Students should verify a rural-oriented program by talking with faculty and residents. They should ask for details about the curricula, the rural sites, the faculty, and whether the program actually produces practicing rural physicians. Programs with a proven track record are a good choice. Research demonstrates that programs with the following characteristics graduate more rural physicians: 1. Programs with required rural training, either rural rotations or ambulatory clinics 2. Programs with a mission for rural health 3. Programs in more rural states 4. Programs with more months of obstetrics (4 or more) 5. Programs where the program director is the primary rural contact person A rural faculty advisor can be a major help for those planning a rural career. These faculty have often been rural physicians and work on rural programs or research. They know other faculty and programs across the nation who can meet the needs of students interested in rural health. The STFM Group on Rural Health has a listing of potential rural faculty advisors. The Choice of a Practice Match Well to Do Well in Practice Students face many personal challenges when considering rural practice. Medical education takes its toll in time from family and debt. Those considering rural practice need to know about time for family, income, jobs for spouses, and debt repayment. No location, urban or rural, meets all needs. The search for a practice is a courtship that ends up in a marriage with a practice and a community that best fits these needs. Rural practices are no better or worse than urban. While some specialized surgical studies show poorer care in rural hospitals, others show slightly better care in studies of routine surgical procedures, adverse events, and liability suits. Rural areas do not lack culture or recreational opportunities. The opportunities are different and a matter of personal preference. The Rural Search Is More Complicated The information about rural communities and practices is less available. In studies of family practice senior residents, residents invest just a few days to search for a location and a practice. After spending half a lifetime to train, such a minimal investment in the search process does not make sense, especially when the search process is such a growth experience, offering time for residents to learn about themselves and their families. Residents and their spouses should begin to gather information about practices during the early years using the phone, state contacts, rural faculty, and other sources. Residents can plan rotations and moonlighting that give them a chance to visit rural communities. During those visits, residents should gather information to insure that the community can support the physician with the income, call coverage, facilities, and community resources needed. Three or four visits or an on-site elective can be very helpful in examining a location. Residents who have made more detailed searches of rural communities feel that the existence of an active recruitment and retention committee is important. Rural communities should never ever stop looking for physicians. Physicians can and should choose sites with a future, not those who are most desperate. Residents who begin a search late can do locum tenens work or a rural or procedural fellowship year and use the time to examine more rural practice opportunities. A Uniquely Rewarding Experience Those who wish to face the challenges of working with people rather than diseases should choose rural practice. Rural physicians develop a tremendous bond with their communities. They become an integral part of it. They belong there. The rewarding part of rural practice is often not seen until a physician leaves and then endures the resultant depression as they suffer the loss of their unique bond with the community. It is hard to replace this kind of appreciation, despite the challenge. Physicians at the end of their careers often consider the years of rural practice to be the ones when they felt most like a physician. For further information on any program mentioned here, or for information on rural programs in family practice residencies, rural training tracks, programs, faculty, or to receive the Rural Family Doctor Newsletter, contact:
Dr. Bowman works with communities, students, residents, staff, and rural faculty to establish rural high school career days, rural student interest groups, rural and community-oriented rotations, rural fellowships, and rural faculty development. |
Last modified: May 10, 2002