Targeted Med School Programs Could Alleviate Rural Physician Shortage

U.S. medical schools could significantly increase the number of rural physicians by establishing programs that encourage physicians to practice in rural areas, according to a report (9-page PDF; About PDFs) in the March issue of Academic Medicine.

The study, conducted by researchers in the department of family and community medicine at the Jefferson Medical College, Thomas Jefferson University in Philadelphia, found that the nation's medical schools could more than double the number of physicians choosing rural practice annually by creating rural physician programs that would turn out as few as 10 students per class.

"Initiating new programs in every medical school would be expected to result in 1,139 rural physicians yearly, more than twice the number produced if there were no such programs," says the study. "During the next decade, this is projected to result in 6,260 additional rural physicians."

Howard Rabinowitz, M.D., of Philadelphia, one of the authors of the study, says training an additional 10 students in each class each year for rural practice may seem like an insignificant number, but even small numbers in multiple schools would "put physicians into literally thousands of communities that don't have any physicians."

The study identifies six U.S. medical schools with comprehensive training programs for rural physicians and uses them as models other U.S. medical schools can emulate. During the past three decades, more than 50 percent of graduates from these six programs have become rural physicians, compared with the 3 percent of current students overall who say they plan to go into rural practice and the 9 percent of physicians who currently are practicing in rural areas.

Physicians from these six schools also stay and practice in rural areas longer than physicians trained in other schools. "Although we did not quantitatively include retention outcomes in our model, retention has a critical and multiplicative impact on the rural physician supply," says the study. "For example, having one rural physician who stays his or her entire career (i.e., 35 years) is equivalent to having five consecutive rural physicians who each stay for seven years (assuming a community is successful in continually recruiting successive new physicians immediately after the departure of the previous ones)."

In the past few years, medical schools have been expanding their class sizes in response to a projected physician shortage. If a portion of the 30 percent expansion in class size the study recommends were used to initiate rural physician programs, this could produce 12,920 rural physicians during the next decade, more than 2.5 times the estimated current output, according to the study.

About 20 percent of the nation's population lives in a rural area; however, only 9 percent of physicians practice in these areas, according to the study. In fact, the study says, more than 20 million of the 60 million people in rural areas live in federally designated health professional shortage areas.

"This rural physician shortage has existed for more than 80 years, despite the fact that, in general, people living in rural areas have a greater need for medical care, being older, sicker and poorer than their nonrural peers," the report says.

In addition, the rural physician workforce is likely to decline even further in the future, says the report, "with only 3 percent of recent medical students planning to practice in small towns and rural areas."

According to the report, rural physician shortages are driven, in large part, by the decreasing number of residents who are entering family medicine. Family physicians are more likely to practice in rural areas because of the nature and scope of their practices, making the links between family medicine and rural practices critical, says Rabinowitz. About half of physicians in rural areas are family physicians.

"I live in Philadelphia, and if 10 orthopedists, for whatever reason, decided to leave Philadelphia, it becomes a headline in the newspaper," says Rabinowitz. However, "there is not one person who would not get a hip replacement done, because there are so many orthopedists in large cities. On the other hand, if you lose one or two primary care physicians in a rural area, it has a huge impact on people getting health care."

Most medical schools are aware of the shortages of rural physicians, but they are not always clear on how to solve the problem, although data exist on how schools can successfully address the dilemma. At the same time, there is an inherent "disconnect" between the "needs of the population" and the multiple missions of medical schools, says Rabinowitz. "They have lots of missions, and rural health care is only one of them."

Nevertheless, there are indications that a few medical schools are initiating programs to address rural issues as they expand class size. "Some schools are asking how they should expand," says Rabinowitz.

Meanwhile, the AAFP's Robert Graham Center in Washington released a policy paper last year that says medical school expansion represents an opportunity to meet rural health care needs.

"If medical schools all over the country are considering expanding their class size, why shouldn't they do it in a very purposeful way and commit part of that expansion to rural education and practicing in a rural area?" asks Robert Phillips, M.D., director of the Graham Center.

According to the Graham Center paper, "Medical school expansion provides an opportunity to reconsider how the physician workforce can be aligned with national and local needs. Expansion without consideration of physician distribution will likely perpetuate the concentration of physicians in urban areas and near major medical centers. Policies aimed at selecting students most likely to practice in rural areas could assist in securing an adequate supply of well-trained rural physicians."