Wednesday, August 24, 2011

Rural Health Care - who's out there?

20% of Americans or approximately 60 million people live in rural America. Those who live in rural communities are older, poorer and have more chronic diseases than the typical city dweller. The problem: few doctors choose to practice in rural America. And the doctors who are out there are getting older themselves and are close to retirement.

Medical schools, with few exceptions, are located in urban areas. What, you may ask, about medical students who we recruit from rural areas? Are they more likely to go back?

Take a typical 18-year old female raised on a farm in Nebraska. She goes to college in a city, stays for medical school in a city and then marries an aerospace engineer. Is she likely to go back to her home town? Hmm... probably not. On a positive note, studies do report that those from rural areas are more likely to return there... but not enough of them do.

Who are the doctors out in rural areas now? They are mostly family doctors. Family physicians are the only specialty that's evenly distributed across all settings - inner city, large rural and frontier, isolated rural. Other specialties (as seen in the graph below) cluster themselves in cities, where they can actually sustain a practice. BUT, we've had fewer people entering family medicine over the 10 years (exception of this year) and, as such, the rural doctor pipeline is drying up.

Figure: Physicians per 100,000 people

To ensure the health of rural Americans, we need to have more doctors practicing in rural areas. From studies, we know the type of doctors who are likely to end up in rural areas:
  • doctors in family medicine (not pediatricians or general internal medicine doctors... and definitely not sub-specialists)
  • doctors with rural origins
  • doctors who are married when they graduate medical school
  • male doctors (not being sexist - this is a statistically proven fact)
  • doctors who have rural experiences during medical school and/or residency
So what do we need to do? We need to support more residency and medical school experiences in rural communities. Possibilities include rural elective opportunities, expanding rural residency training programs or rural training tracks.

We also need to talk about rural medicine as an exciting opportunity! In rural settings, family doctors get to do everything - from deliveries to surgeries to colonoscopies... a family doctor gets to call all the shots (unless the patient's condition is really serious). A family doctor gets to practice his or her full scope of training.

Doctors, especially family physicians, are needed now in rural areas! Otherwise, in a generation's time, we may not have rural communities and rural America!


  1. Good blog.

    FM choice does work. But voluntary choice does not work as too few choose FM and too few are found in rural locations. The solution is specific workforce - not generic designs.

    Also rural communities exist reasonably well with or without a lot of things - which allows rural people to concentrate on areas most important in life.

  2. University of Illinois @ Chicago has a Rural Med program at their Rockford campus. I'm an M3 in this program. You should take a peek at it.

  3. RPAP, RMED, PSAP, WAMI (now WWAMI) and other four letter words depend upon the family medicine component for rural results. So do other sources.

    Family medicine began with 30% rural in the first years. Since 1980 with about 3000 annual graduates, family medicine has kept over 600 per class year or over 20% in rural practice. This is possible when a source of family practice stays over 90% in family practice for a career.

    The physician assistants that are found in family practice have had even greater rural distribution (30%), but this FP proportion has shrunk from over 40% in the 1980s to less than 25% found in FP and less than 20% entering FP in more recent years. Rural, primary care, and underserved contributions all melt away when grads depart FP.

    Only the NP grads that stay in family practice contribute consistently to health access. Only 12 - 14% of total NP grads are rural direct care practitioners based on 17.5% of direct care nurse practitioners found in rural locations (AANP 2010). About 30% of NP grads are not active as direct care clinicians. The family nurse practitioner that remains in family practice appears to have at least a 25% rural location rate, but retention in family practice requires dedication in NP. Such a graduate must maintain family practice against US health policy that acts year after year to drive flexible sources (NP, PA, IM) away from the careers and locations and populations in most need.

    Again and again family practice is the SMART health access solution, but only when the workforce stays in family practice - as in over 90% of family medicine residency graduates - distribution consistent by design.

  4. You are right. I agree with you. Young medical students must come forward to provide treatments to people in rural places. That way, they do real service.

  5. This is a really helpful blog. You have some great ideas. Private Hospitals