Now with years of study, much more is known about methods to improve the production and retention of rural physicians. This work is a response to an inquiry by a rural physician. The physician states, "I have maybe a rhetorical question or two -- Do we not already know how to recruit and retain rural physicians? Is not the issue finding the money and interest to employ those strategies? If so, what are the objectives of the conference?"

The arguments for rural are more than recruitment and retention. The main problem is the whole process of medical education. It is interesting that many medical schools have realized that to meet national goals regarding the graduation of physicians with more diverse backgrounds, schools have targeted students at earlier and earlier ages, well into high school and earlier. In some sense these are easier for urban-based medical schools because many minorities are located nearby. It is more difficult for Native American populations that are often at a distance from the medical center. For rural populations, often just as diverse and different, few programs exist to facilitate the types of advancements and career orientation necessary to consider medical careers.

Over the 7 years of medical education, students continue to fall away from family practice and rural interest. The initial high numbers may be partially influenced by the student's need to tell admissions folks that they want to be a small town fp to get in. Even if the attrition rate slowed and more stayed with rural fp, there would be only a minimal dent in addressing the shortfall in rural docs (AAMC Kassenbaum). These statistics are confirmed in Kentucky where the medical schools admit every candidate with a reasonable chance of completing school, but cannot find enough rural background and rural interested candidates (Rick Blondell at U of Louisville). Given that med school class sizes are not going to increase and could decrease (with likely a decrease in fp and rural numbers (Bauer), we must be more efficient at producing rural physicians. The fact that other practitioners profess and promote primary care only adds to the problem. These include IM, Peds, and OB (over 90 % urban bound). Studies do show more non-FPs going rural, but not to the communities in need. Reimbursement issues continue to influence NP and PA grads to urban subspecialty careers. Additionally NP and PA grads suffer from past rural successes and there are fewer openings in rural communities than ever before (NE and other Offices of Rural Health).

Programs in medicine and other health professions (PA and NP) have demonstrated increased rural production with continuous rural health professions training. These include Mercer, Michigan’s Upper Peninsula program, and the combined Minnesota rural track programs (Duluth plus RPAP). The process begins with admissions.

At nearly all medical schools, committee members fail to discern true rural preference from a temporary profession of interest. This comes from pressures to get in at any cost as well as failure in admission committee selection and training.

Medical schools also have a global failure in orientation and training students to be comfortable with primary care. Even students with an interest in primary care need 6 months just to be comfortable with the uncertainty and variety of challenges of primary care (RPAP data). Most schools have far less than this level and training in ambulatory settings in admittedly distorted environments (urban and academic).

In graduate education we don't have a true ambulatory model, much less rural. Even family medicine graduate training is less than 25% in clinics, despite the fact that 90% of actual family and rural practice is ambulatory. Many fp residencies have only 3 half days a week of continuity practice, leaving over 70% of resident's time over the three years at the whim of hospitals, specialists, and their own free choice regarding time.

Rural just doesn’t rate much at academic centers. The presences of a rural mission was the top factor in multivariate analysis of what produces rural graduates at fp programs (Bowman 1998). With the lack of a rural mission goes the lack of rural infrastructure. Norman Kahn of AAFP stated that the existence of an FP Department explains 58% of the variance of primary care production. The lack of rural divisions or a designated rural person is a similar problem at medical schools and residencies. Nationwide rural faculty surveys reveal only about 20 family practice faculty even half time in rural with most people having only small percentages. How can you advise students, do rural student interest groups, rural faculty development for full and volunteer faculty, and keep a presence much less hope to dominate admissions, curriculum, managed care contracting, etc?

Rural emphasis would produce rural curricula, cooperative efforts with rural physicians and communities, and other efforts to improve rural health in coming years.

Finally, the academic model is entrenched in urban locations. Faculty are far too comfortable in many centers. Arrangements for rural experiences must be made in person, not over the phone. Recruitment Fairs to bring communities in for recruitment efforts are worthless compared to getting residents and faculty out into rural communities to see what is involved in rural practice and life in small towns.

Proposal for More Complete Medical Education:

Students must complete a 6-8 week community project in an underserved (preferably rural and not a town they have lived in before) preferably addressing a health need of the population. This project and their evaluation becomes part of the admissions process. Students demonstrating responsibility, pursuit of knowledge, communication skills, and service motivation would be given preference in the admissions process. The added benefit of this approach is that students would be more likely to have better communication skills, more people interest, more maturity, etc. Some of the gifted intellectual students would be admitted to special tracks. This would be a reversal from the current situation with a few underserved tracks with the majority intellectually- selected.

Students would have an integrated first two years including basic sciences and population-based primary care. Students would take 4-6 weeks of a community or research project after the M-1 year. Students would start their clinical year with 3-12 months of rural/underserved preceptorship. Those taking 9-12 months would include all with state or federal obligations, those planning to obtain loan repayments, and those with rural or faculty interest. One option from this is have the third year start with 2 months rural, then other clinical months, then opt into a special rural track with a rural location during the entire 4th year (similar to accelerated programs) getting credit for a year of residency but requiring three more years or a total of 4 graduate years and 3 medical school years.

Graduate needs to start with rural in the first year, but few do. Many required rural rotations are in the third year, too late to impact on careers. Since there is less continuity practice in the first year, it also makes sense to do 2-4 months of rural then. Residents also get to do more in rural locations. If residents did the first year in rural locations, they could also do more as second or third years back in urban locations due to their experience and confidence. They would also have a better understanding of family practice.

Two other options could also impact on the numbers choosing rural. One is a social intervention, the other is a political one.

Spouse factors

The intervention is to move medical schools as much as possible out of large urban areas (Upper Peninsula, WWAMI). M-1s or even college students are 90% unmarried and spend 11 years (4 college, 4 med, 3 graduate) in urban areas before considering rural practice and by this time over 80% are married. Their spouse is therefore most likely to be urban. We know that the data show that older students and those from small and public universities choose fp and rural more often. Rural interest wanes as marriage rates rise. Smaller medical school classes trained in rural areas could reverse this situation. Clinical, especially clinical with rural months could also work fine in this model. Those who would question the quality of rural clinical education would find RPAP to be among the best documented and highest quality medical education experiences ever.

Mandates

States may take matters into their own hands and require primary care service in underserved areas for 3-4 years before being able to specialize. As difficult as this seems, the priorities become clearer. Students not interested in primary care would have longer to sacrifice and would be less likely to choose health professions. The curricula would have to prepare for primary care. Eventually specialists would have been generalists first, with a presumed better understanding of this role. The workforce would also be more flexible as specialists with previous primary care experience could shift back.

Demand Side

I am actually concerned that recruitment and retention of rural physicians will worsen, given the difficulties regarding maintaining a critical mass to share call and other duties.

Factors likely to increase demand for Rural Doctors

Continued declines in graduates with rural interest

Larger rural leeching patients from smaller rural

Earlier retirement rates for new generation of FP docs (speculation)

Factors that will decrease demand for Rural Doctors

Increasing PA and NP grads

Increasing availability of specialists in rural areas

Rural vs urban economic demand

By the numbers, economics of rural practice

Other potential influences on retention include some potential for loss of rural physicians as fewer own their practices.

Physicians, association leaders and others note side problems which many have equated as the lack of economy in rural areas, etc. Rural folks do have problems with tax base, jobs, etc., but I think the problem is more than economic.

I view the problem more as a lack of organization of health care at the rural community level. The WAMI rural hospital study IMPLEMENTING A COMMUNITY BASED APPROACH demonstrated that communities would support services that even consultants didn't think possible. Even the smallest communities have managed to collect half a million or more for various health projects.

Organization and leadership at the local community level is not the best. Communities continue to prioritize the hospital when "less" (ambulatory plus short term holding) could be more. Hospital dollars are often wasted when ambulatory dollars could increase services and market share. Studies also show that a 10% increase in local market share in rural hospitals is better on the hospital balance sheet than a 30 % increase in medicare and medicaid reimbursement. A primary example of organization problems is the recruitment process.

Many small towns are awful at recruiting. They attend fairs without practitioners, they don't go to visit recruits, they fail to follow up, their offers are not realistic, they fail to accommodate females and spouses, they fail to identify candidates that are likely to stay long term (have connections), and they are becoming increasingly dependent on "outsiders" for recruitment. This may generate contacts, but not result in someone signing a contract. There is a way for them to improve and the best learning is interactive. The best info comes from potential recruits, such as family practice residents looking for a site. Seeing what residents are and what they want then allows communities to recruit successfully. Faculty can facilitate these efforts.

Having docs who stay a long time (rural background, fp interest, rural lifestyle preference) has helped stabilize many rural health systems, and having more long term stayers would be a major improvement. Picking for rural background, rural lifestyle preference, and fp interest can improve the selection of these folks ( Program Brings Family Physicians to Small Town America Rabinowitz, UNMC RHOP Rural Health Opportunities Program, WAMI).

The down side of the lack of organization is that time is running out for the smaller rural communities. They will likely be absorbed if they do not organize well because corporate and organized medicine is numbers.

Admissions Committee Efforts