Robert Graham Center Forum

Support for Rural Training Programs Key to Continued Health Care Access for Many Americans

January 29, 2014 03:22 pm Nancy Kuehl Washington –

As headlines about primary care physician shortages in rural areas of the United States proliferate, the need to forcefully address these shortages becomes increasingly important at the federal level. The Robert Graham Center on Policy Studies in Family Medicine and Primary Care recently held a forum at the U.S. Capitol Visitor Center for policymakers and other interested parties on just this subject.

Former AAFP President Ted Epperly, M.D., talks with a student about rural training track programs in the Pacific Northwest during a forum presented by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in Washington.

According to panelist Amy Elizando, M.P.H., vice president of program services for the National Rural Health Association in Washington, 62 million Americans rely on rural health care professionals. Rural patients have to deal with extreme distances to reach a physician, as well as with other challenging geographical and weather considerations. "'Rural Americans are older, poorer and sicker than their urban counterparts. … Rural areas have higher rates of poverty, chronic disease, uninsured and underinsured, and millions of rural Americans have limited access to a primary care provider,'" said Elizando, quoting a 2011 HHS report.

"When you are talking about rural docs, you are talking about family physicians," said former AAFP President Ted Epperly, M.D., of Boise, Idaho, another of the panelists. In the United States, he noted, "We have a lot of people taking care of body parts but no comprehensive care."

Epperly pointed to a number of strategies needed to grow the U.S. rural physician workforce, including a focus on the kindergarten-to-12th-grade pipeline. Students who would make good primary care physicians need to be identified and encouraged early, particularly those in rural areas. In addition, students need shadowing and mentoring opportunities, loan repayment programs, and recruitment efforts that are aimed at retaining them in primary care, said Epperly.

Story highlights
  • A recent Capitol Hill forum on rural health care highlighted the shortages of primary care physicians and other health professionals in rural areas for policymakers and other interested parties.
  • Currently, 62 million Americans rely on rural health care professionals, but the number of physicians available in these areas is not increasing rapidly enough to keep pace with the need.
  • Forum panelists pointed to the success of the Rural Training Track Program and stressed the need for continued support of this program.

"Our system is organized to produce physicians in an academic medical center, but we need physicians trained in communities so they care about the health care needs of that community," said Tim Putnam, president and CEO of the Margaret Mary Health System in Batesville, Ind., who provided backup to the panelists.

In particular, Epperly and the other panelists pointed to the Rural Training Track (RTT)( educational movement as a way of successfully incorporating and keeping family physicians in rural areas.

The RTT model combines one year of medical training in an urban setting with two years of training in a rural setting, according to panelist Randall Longenecker, M.D., executive director of The RTT Collaborative and assistant dean of rural and underserved programs and professor of family medicine at the Ohio University Heritage College of Osteopathic Medicine in Athens. Longenecker pointed to the success of RTT programs, noting that more than 70 percent of graduates from these residency programs choose to practice in rural areas.

However, Longenecker added, RTT funding is threatened. Funding from Medicare and Medicaid for graduate medical education (GME) in RTTs has depended on state and intermediary funding, he noted. To remain viable, most RTTs rely on state subsidies; area health education centers; local hospital, clinic and community support; patient care revenues; and grant funding.

The funding issue for RTTs is vital, agreed Putnam. Currently, programs don't always know how the funding piece will work out, he said. Clarification on policies is essential to ensure trainees can be guaranteed that their residency program will be there throughout their training.

Longenecker pointed out that the number of RTTs has declined during the past 10 years from a high of 35. Currently, there are 26 RTTs, with another six in the planning stages, but they are up against serious funding challenges. "Only three new RTTs have developed based upon traditional CMS funding; three others have closed, in large part because of funding difficulties," said Longenecker.

To boost support for the RTT model, a number of organizations -- the National Rural Health Association; the National Organization of State Offices of Rural Health; the Rural Assistance Center; and the Washington, Wyoming, Alaska, Montana, Idaho Rural Health Research Center -- have partnered to create the RTT Technical Assistance Program.

According to Elizando, the program is "a consortium of organizations and individuals committed to sustaining RTTs as a strategy in rural medical education." The three-year demonstration program, which is sponsored by a grant from the Health Resources and Services Administration's Office of Rural Health Policy, is designed to

  • sustain current RTT programs,
  • help develop new RTT programs,
  • increase the number of students who match to RTTs, and
  • create a masterfile of data on RTT program characteristics and outcomes.

RTTs are a way forward, said Longenecker, because they embed medical trainees in the community, resulting in physicians and other health care professionals who are uniquely adapted and relevant to the needs of their communities. RTTs are interprofessional out of necessity and are easily accountable to funders and other accrediting bodies because of their small size and simplicity.

According to Stan Kozakowski, M.D., director of the AAFP Division of Medical Education, when it comes to increasing the primary care workforce, it really matters where and how physicians train. He pointed out to the legislators in the audience that the National Healthcare Workforce Commission still needs to be funded, and GME slots have to be expanded -- but in a way that creates accountability. In addition, said Kozakowski, payment reform is vital to making any efforts to create a rural medical workforce work.

Because of the amount of work that still needs to be done to ensure the overall success of RTTs in providing for the needs of the rural population, "the biggest thing new RTT programs will need is courage," said Longenecker.

"We need to have people with fire in their bellies," Epperly added, referring to the need for physician and administrative champions in RTT programs. "We must reinvest in generalization in this country. America suffers because of the level of specialization" the nation currently experiences, he added. "We need to broadly train primary care physicians in rural areas, and then let them narrow their focus based on the needs of their community."

Additional Resources
Journal of Graduate Medical Education: "Rural Primary Care Physician Workforce Expansion: An Opportunity for Bipartisan Legislation"(
(December 2013)

Rural Residency Training for Family Medicine Physicians: Graduate Early-Career Outcomes(
(January 2012)

Training Physicians for Rural Practice: Capitalizing on Local Expertise to Strengthen Rural Primary Care(
(January 2011)