Programs to Cultivate Rural Family Physicians Yield Big Successes

Alabama and Missouri health officials don't focus much on recruiting family physicians to the rural areas in their states. Instead, they grow them locally.

The greenhouse in each state is a rural medical scholars program that reaches out to undergraduates, proceeds through medical school and ends with completion of residency training.

Both programs have yielded impressive results.

The Alabama Rural Health Scholars Program began in 1993 at the University of Alabama School of Medicine, Tuscaloosa, and has been expanded this year to include Auburn University, Auburn, Ala. The program works with high-school students, and thus far, 364 young people have been part of the program. In addition, the universities have accepted 111 medical students from among those students.

In 2006, the first class of scholars in the program completed residency. The yield: Of the four classes that have completed the program to date, 60 percent chose to enter primary care, and of that percentage, 40 percent chose family medicine. Fifty percent entered rural practice in Alabama.

By comparison, only 6 percent overall of University of Alabama School of Medicine graduates choose family medicine, and only 3 percent of recent medical school graduates nationwide have opted for rural practice, according to John Wheat, M.D., director of Rural Health Programs at the University of Alabama's College of Community Health Sciences.

A similar program offered by the University of Missouri -- the Bryant Scholars Pre-Admissions Program -- admits qualified college sophomores to the University of Missouri-Columbia, known as MU, School of Medicine. The Bryant Scholars program, which is a part of MU's rural track program, has graduated 27 students through undergraduate preparation and medical school. Early data indicate 70 percent of these Bryant scholars chose primary care, and 38 percent opted for family medicine or pediatrics, according to Kevin Kane, M.D., M.S.P.H., associate professor of family and community medicine at MU and faculty advisor for the Bryant Scholars program. Data are not yet available that indicate what percentage of the scholars entered rural practice.

However, Kane noted that of the 120 participants in Missouri's Third Year Rural Clerkship Experience, 66 percent entered a primary care residency and 37 percent chose family medicine. Comparatively, only 53 percent of participants on a nonrural track entered a primary care specialty and only 14 percent chose family medicine.

The secret, say academic officials, is each program's focus on a student's potential, current abilities, interests and background. Test scores rank second in admissions decisions.

That's because research shows that test scores don't predict the success of a medical student or the quality of the graduating physician, according to Wheat. His review of the Alabama Rural Medical Scholars program showed that its students graduate on time and choose primary care; several become chief residents and most take on leadership roles in their communities.

"We place the highest value on the rural background for admission to medical school," said Wheat, adding that the school largely discounts students' Medical College Admission Test, or MCAT scores. "Studies show that MCAT results don't predict how good a doctor someone will be," he noted.

Kane agreed. "We are getting students who are already interested in rural medicine and helping them learn the joys and challenges of having a rural practice," he said. "Preliminary data show that we're making a difference."

Both Alabama and Missouri identify and cultivate young people who hail from a rural background and have an interest in medicine or health care. And although it's not the deciding element of the admissions process, Alabama rural scholars are required to have scored 24 or better on the MCAT.

Missouri's Bryant Scholars are selected from sophomores who graduated from rural high schools in Missouri, scored 30 or more on the ACT or 1,300 or above on the SAT college admissions tests, and have high academic achievement through high school and their freshman year in college. Because they are pre-admitted to MU's School of Medicine, Bryant Scholars do not take the MCAT.

Recognizing that rural communities often look on their family physicians as community leaders, both the Missouri and Alabama programs provide experiences that expose students to the clinical, social, economic and cultural fabric of smaller towns.

The Alabama initiative sows the seeds of interest in family medicine with a three-pronged program. The first prong -- the Rural Health Scholars Program -- introduces 11th-grade students to the University of Alabama through a five-week summer session that includes college courses for academic credit, visits to rural health facilities and meetings with medical school admissions staff.

The second prong -- Alabama's Minority Rural Health Pipeline Program -- works with students from underrepresented communities by offering summer classes that augment their undergraduate courses and prepare them for the MCAT.

Students can enter the third prong -- Alabama's Rural Medical Scholars Program -- in their senior year of college. A five-year, combined medical and master of public health degree program, the Alabama Rural Medical Scholars program accepts 10 students each year at its Birmingham and Auburn campuses. Participants begin their master's degree work as seniors by taking courses in rural community health, epidemiology, health care administration and environmental health. As medical students, they also visit rural family medicine preceptors and the Alabama AFP, as well as travel to Washington, D.C., to learn about federal advocacy. Their second two years of medical school include two-month rotations in rural Alabama, where they complete a project that introduces them to a community's health needs, socioeconomic conditions and cultural norms.

Similarly, Missouri's program introduces young people to medical school as undergraduates through the Bryant Scholars program. During their sophomore through senior years, scholars attend weekend seminars that introduce them to life in medical school, professionalism, leadership development, and -- with medical school faculty facilitating -- clinical experiences, such as conducting a physical examination and practicing procedural skills. Students also take part in problem-based learning sessions, which simulate the primary learning method they will encounter in the first two years of MU’s medical school.

Between their first and second years in medical school, Bryant scholars work with a rural community preceptor for six to eight weeks. In their third year, they spend six months on the Third Year Rural Clerkship Experience, during which they receive clinical training in one of six rural Missouri communities. During their fourth year, students are encouraged to go back to these same communities for elective rotations.

Rural medical scholars programs such as those at the University of Alabama and University of Missouri are a win-win proposition for both aspiring physicians and the rural communities they serve, said FP Clifton Garris, M.D., who opened a practice in Sylacauga, Ala., after completing his family medicine residency and an OB/Gyn fellowship seven months ago.

"I wouldn't be here if it weren't for the program," Garris said of the Alabama Rural Medical Scholars Program. "A lot of people from cities will go to a rural area for a short period of time, and then they're gone. But this program gets applicants from rural Alabama into medical school, and they are most likely to go back home to practice medicine."

Moreover, through requirements such as the second-year community project, the program prepares students for the real world. "It gives you an opportunity to get into the community and see what the problems are in rural Alabama," he noted.

Garris and his partner care for 1,200 people in Sylacauga, which has a small hospital where they see medical patients, deliver babies and complete numerous procedures. Without this two-physician practice, Sylacauga residents would have to travel as much as an hour away for care, said Garris.

The success of the programs has caught the eye of other states. Mississippi looked at the Alabama program when it developed its own high-school program, and it is working toward a medical scholars initiative patterned after its neighbor's program, said Wheat. Louisiana officials have invited Wheat to discuss establishing a similar program there.

Alabama AFP EVP Holley Midgley, C.A.E., isn't surprised. Programs such as those in Alabama and Missouri "could be duplicated anywhere," he said. "I don't know of a state that doesn't need more family physicians and more rural family physicians."

Kane noted that although 61 million Americans live in rural communities, only 9 percent of physicians practice in rural settings.