The National Rural Health Association (NRHA) held its 30th annual Rural Health Policy Institute here Feb. 5-7 to focus on the growing health care divide between America's urban and rural communities. It's no secret that rural America is facing a serious physician shortage at a time when, according to NRHA statistics,(www.ruralhealthweb.org) populations in rural communities are older, sicker and poorer than at any time in recent history.
During a presentation on rural workforce shortages at the Rural Health Disparities Summit, family physician Michael Kennedy, M.D., tells the audience that medical students want to go back and serve in communities like those they grew up in. "They also need to pay off their loans … and they want to practice medicine, not paperwork," he added.
Family physicians are on the front lines. According to an AAFP position paper titled "Keeping Physicians in Rural Practice," family physicians comprise 15 percent of the U.S. outpatient workforce but handle 23 percent of those outpatient visits overall -- and a whopping 42 percent of those in rural areas.
For that reason and more, the AAFP partnered with the NRHA to host, on the final day of the policy institute, the Rural Health Disparities Summit. It was a morning filled with speakers versed on topics critical to the future health and well-being of rural America.
During this final event, Julie Wood, M.D., AAFP senior vice president for health of the public and interprofessional activities, hosted a panel discussion on workforce shortages and their impact on rural health.
Recruiting Rural Physicians
As part of that panel, two family physicians working in very different rural environments -- one in Alaska, the other in Kansas -- spoke about the challenges of recruiting family physicians to their communities.
- The AAFP recently partnered with the National Rural Health Association (NRHA) to host the Rural Health Disparities Summit in Washington, D.C.
- The summit, scheduled on the third day of the NRHA's 30th annual Rural Health Policy Institute, featured speakers well-versed on issues related to health care in rural America.
- Two family physicians, AAFP President John Cullen, M.D., of Valdez, Alaska, and Michael Kennedy, M.D., of Wichita, Kan., tackled the topics of how to recruit rural physicians and utilize telemedicine.
They agreed that giving students an up-close and personal view of the joys of rural practice is the best approach.
"That's how you recruit residents, by having them in your clinic, because it's a really important way to get them excited about what we do," said AAFP President John Cullen, M.D., of Valdez, Alaska.
"I use all of my medical education every single day. Rural family medicine is an absolute challenge, and it requires you to use all of your faculties," he added.
Cullen's practice in his frontier town of 4,000 has just recently grown to include five family physicians who provide all the outpatient, inpatient and emergency physician care for this population.
Except for the two founders of the practice, all the physicians, Cullen included, first visited Valdez as residents.
"I was my senior partner's resident, and that tradition has continued. We've never been able to recruit anybody who didn't come through that process. You have to grow your own if you're going to do this," said Cullen.
And it helps to have an older physician there as an anchor, because without that anchor, it's very hard to start things up, he added. "If you have older physicians in your community, make sure they stay. Do everything you can to keep them," advised Cullen.
Michael Kennedy, M.D., associate dean for rural health education at the University of Kansas School of Medicine-Wichita, tells a similar tale, but with a twist.
He started out in a rural practice in Burlington, Kan., population 2,500, and for nine years practiced full-spectrum family medicine alongside two FP colleagues. "We built our practice and did some amazing things. We had students come out with us on a frequent basis, and that led to a love of teaching," said Kennedy.
Kennedy left private practice to return to his medical school and make an impact, or, as he put it, "to take this rural family doc and get in front of as many medical students as I possibly could. So that's what I do now for a living, and it is extraordinary."
Kennedy noted that Kansas has some major workforce challenges. Thirty-four counties in the state have two physicians or fewer, a situation he called "unsustainable, long term."
His job, simply put, is to get students out to the rural areas for hands-on experience.
"I go around and talk with the docs in this region and I've heard some incredible stories," along with disheartening ones about practices that have been recruiting for a new physician for 10 years and come up short, said Kennedy.
But what does get results is hosting medical students in the community. "It's magical because students fall in love with the place," said Kennedy. That hosting has become all the more important as rural hospitals facing financial crisis cut budgets -- including housing allowances for visiting medical students.
During the recent Rural Health Disparities Summit, broadcast journalist Ted Koppel serves as moderator for a panel discussion on chronic disease challenges in rural America. At one point, Kopple said to panel members, "As I listened to all of the speakers who've been up here today, I realize there is a limited supply of funding, and it is not equitably distributed; diseases come in conflict with one another. How do we deal with that?"
The physician shortage in Kansas is set to worsen because 254 rural Kansas physicians are age 55 or older. "In the next 10 years, we'll need close to 300 new doctors," said Kennedy.
In response, his medical school has deviated from the standard pipeline program to something called rural medicine training.
"We have a rural track with 'destination rural,' but we have cars on the train that represent various programs, and the students can safely get on, test it out and get off -- or they can ride the whole train. About two-thirds of the students on this rural track are students who are dedicated to rural," said Kennedy.
And, ever the teacher, Kennedy brought five of those students with him to D.C.
The use of telemedicine has become mainstream in remote areas such as Valdez. For instance, when Cullen first diagnosed a patient's malaria, he wanted confirmation.
"I just took a picture of the microscope through my iPhone and sent it off to an infectious disease specialist. She agreed it was malaria. This is the kind of stuff you do as a physician in a rural community," said Cullen.
"Telemedicine works really well when you have providers in the community who are able to access specialists in a metropolitan area. I have tried to talk people through the emergency procedures in other communities, and I can tell you that it's really hard."
AAFP Launches Rural Health Tool
At the close of a panel discussion during the Rural Health Disparities Summit -- recently hosted in Washington, D.C., by the AAFP and the National Rural Health Association (NHRA) as part of the NHRA's Annual Rural Health Policy Institute -- the AAFP introduced a new tool called the Rural Health Explorer.(www.healthlandscape.org)
The tool, developed by HealthLandscape for the AAFP, focuses on health outcomes and access to care in rural America. It includes, among other things, a rural population health mapper and a health care workforce mapper.
"The AAFP is excited to announce this, and we hope you can use this in your advocacy moving forward," said Shawn Martin, AAFP senior vice president for advocacy, practice advancement and policy. "We'll certainly use it in ours."
Ideally, Cullen would like to have telemedicine access to any subspecialist he needs -- straight from his office with his patient right there.
But telemedicine alone won't cut it. "I do worry a lot when people think of telemedicine as the solution without trained providers in those communities. You have to have people there who are interactive," he added.
Telemedicine can provide huge cost savings to patients. Subspecialists, said Cullen, often don't realize the financial hit patients take when they make that extra appointment.
"It costs my patients at least $1,000 every time they see a subspecialist, and most of the time, they don't need to seem them at all. If you look at subspecialties like endocrinology and pulmonology, that consult is more of a reassurance that we haven't missed anything, said Cullen.
And when a patient in Valdez is diagnosed with cancer, even chemotherapy is available right there in the community.
"I have a really good relationship with oncologists in Alaska, so we actually do provide chemotherapy, because when people have complications from that treatment, it happens here, not at the infusion center in the city," said Cullen.
With this kind of technology, "there is no reason why we have to accept a lower level of care in rural communities."
And, Cullen added, the same telemedicine capabilities that work for rural Americans also have potential in big cities such as Los Angeles -- where terrible traffic, more than geographic distance, can keep patients from accessing their physicians.
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