Rural Health Leaders Pipeline, 1990–2005: Case Study of a Second-Generation Rural Medical Education Program

ABSTRACT

A pipeline model has been suggested to increase the rural physician supply. This study is an institutional case report used to describe the context, development, and in-house evaluation of the University of Alabama Rural Health Leaders Pipeline, 1990–2005. This program was developed at a University of Alabama School of Medicine branch campus to target rural students at multiple levels, elementary schools through residency, and includes a minority focus. Requirements to enter the medical program include living 8 years in rural Alabama, meeting admission requirements, and affinity for rural lifestyles. Twenty-six percent of 316 high school participants, all 40 students in the minority-focused college program, and 3% of 90 medical program students were African American. The program includes (1) puppet shows in elementary schools depicting different health professions, (2) Rural Health Scholars Program for 11th-grade students, (3) Minority Rural Health Pipeline Program for college students, (4) Rural Medical Scholars Program, a 5-year track of study in rural community health and medicine, and (5) assured admission to family medicine residency. Outcomes studied in this case report included medical school performance, graduation rate, selection of family medicine specialty, and rural practice location. Medical scholars were anticipated to experience academic difficulty, select family medicine specialty, and locate in rural practice more often than peers. Compared to peers, medical scholars showed lower scores on preclinical courses and USMLE steps 1 and 2, reflective of their lower MCAT and GPA scores, but had (1) similar graduation rates (95% vs peers 84%), (2) higher family medicine selection rate (47% vs Huntsville 27% vs Tuscaloosa 12% vs Birmingham 4% [OR compared to Birmingham 22.7, 95% CI 10.5–49.4]), and (3) higher rural practice rate (67% vs peers 14% vs national group 9%) in the first RMSP classes. Based on these important outcomes being better than or equal to the traditional student cohorts, the institution concluded that the Rural Health Leaders Pipeline demonstrates successful use of the rural pipeline model.     

Who goes into family medicine?

A study was designed to identify criteria that could help select applicants to medical school with a lasting commitment to family medicine and to test the application of such criteria to predict career choice. The sample included 43 residents and physicians who chose family medicine when they entered medical school and five residents who decided on family medicine later. From the initial group, 19 remained stable in their choice of family medicine, and 24 switched to another specialty. Medical school folders and telephone interviews were used as data sources. The characteristics of stable family physicians and those who became specialists were identified, and the predictive power of these criteria was tested with 30 graduates selected at random. Based only on their entrance records, 25 of the 30 graduates were correctly identified as future family physicians or specialists. The use of these criteria in the admission process is discussed in terms of increasing the number of students who will become stable family physicians.     

Relationship between US medical school admission policy and graduates entering family practice

Rural areas in the United States continue to lack an adequate supply of primary care doctors, particularly family physicians, despite the oversupply of physicians nationally. Previous studies have provided strong evidence that students from rural backgrounds, as well as those who expressed an interest at the time of medical school admission for a career in family medicine, are significantly more likely to eventually practise family medicine in rural areas than their peers. US medical schools were classified into three groups based on their written selection factors for preferentially admitting students into the graduating class of 1982. Of those schools with selection factors for students from both a rural background and an interest in a future career in family medicine, 23.7% of their graduates entered family medicine training programmes. This compares with 14.5% of graduates from schools with a preference for students from a rural background, and 12.4% from all other schools (P less than 0.001). Coupled with previous data which shows that family physicians from rural areas are more likely to eventually practise in rural areas than their peers, preferentially admitting students from rural backgrounds interested in a career in family medicine could help to solve the problem of the shortage of primary care physicians in rural areas in the US.     

Do students from rural backgrounds engage in rural family practice more than their urban‐raised peers?

INTRODUCTION: In a previous prospective study, students from rural backgrounds were found to be significantly more likely to consider rural practice than their urban-raised peers. The purpose of this study was to determine whether the students with rural backgrounds who participated in the original investigation were more likely than their urban-raised peers to be currently engaged in rural family practice. METHOD: In Canada, family doctors have the greatest opportunity to practise in rural communities. Consequently, rural and urban background students from the original study who entered the discipline of family medicine as a career were identified for practice location follow-up. Participants were categorised as either rural (population less than 10 000) or urban practitioners according to the population of the community in which they practised. The proportion of rural and urban background students engaged in rural or urban practice was analysed using chi-square and relative risk probability. RESULTS: A total of 78 students from the original cohort were found to be practising family medicine; 22 of them had been rurally raised. Seven (32%) of the rural background students were practising in a rural community, compared to 7 (13%) of the 56 urban background students (RR = 2.55; P < 0.05). CONCLUSIONS: Rural background students who went on to complete family medicine residency training were approximately 2.5 times more likely to be engaged in rural practice than their urban-raised peers. Altering medical school admission policy to recruit more rural background applicants should be part of a multi-dimensional approach to increasing the number of rural practitioners.     

Rural Health Research: Rural and Urban Physicians: Does the Content of Their Medicare Practices Differ?

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.     

The effect of federal grants on medical schools' production of primary care physicians.

OBJECTIVES. Title VII of the Health Professions Educational Assistance Act of 1976 was created to encourage the production of primary care physicians. This study explored recent trends in the proportion of US medical school graduates entering primary care in relationship to Title VII funding. METHODS. The American Medical Association Physician Masterfile was used to determine the specialty choice of all students graduating from American medical schools between 1960 and 1985. RESULTS. The proportion of graduates entering primary care rose from 19.7% in 1967 to 31.1% in 1976 and remained stable for the subsequent decade. The increase occurred before implementation of Title VII. Rural, state-owned medical schools with departments of family medicine tend to produce a greater proportion of primary care physicians than urban private schools without family medicine departments. CONCLUSIONS. The values of American medical schools and the reward structure of American medical practice favor the production of specialists over primary care physicians. Although Title VII helped to encourage and sustain the development of primary care educational programs at both the medical student and graduate levels, an increase in the proportion of primary care physicians will require fundamental changes.     

Physician Redistribution: A Worldwide Medical Problem

Verby J (Department of Family Practice and Community Health,University of Minnesota, Medical School, Box8l, Mayo MemorialBuilding, 420 Delaware Street SE, Minneapolis, Minnesota 55455,USA). Physician redistribution: a worldwide medical problem.FamilyPractice 1985; 2: 151–158. The Rural Physician Associate Program may be the only undergraduatemedical education programme in the world that has been ableto successfully redistribute family physicians into geographicallyisolated areas where there are serious shortages of doctors.A number of factors are essential to this success of the scheme:(1) absolute moral and economic support from the people andtheir elected leaders; (2) a willingness of medical school facultyto give academic and clinical support to an ongoing, long-termeffort with undergraduate medical students and practising familyphysicians; (3) the free volunteering by rural practising physiciansto make the commitment to teach the medical students for overnine months and to pay these students up to $5000; (4) the emphasisof the programme to be placed on the importance of using a biopsychosocial-sexualmodel in creative problem solving; audiovisual taping, behaviouralmedicine seminars and family therapy sessions are additionalcurriculum tools in helping students and physicians care forpeople with somatic complaints; (5) the student's spouse andchildren to be included in the professional conditioning experience;there is no legal commitment for the student and family to returnto rural Minnesota after the programme.     

Characteristics of medical students with rural origin: implications for selective admission policies

OBJECTIVES: Selective admission policies of medical schools favoring students of rural origin have been implemented in many countries in hope of increasing rural physicians. This study evaluated the characteristics of medical students from rural origins and their choice of future practice location. METHODS: Personal, familial, and academic information of 1929 graduates of Jichi Medical University (JMU), a Japanese medical school with a special mission to produce rural doctors, was collected on admission and graduation between 1972 and 1997, and follow-up information on workplace addresses were collected in 2000, 2004, and 2006. Jichi Medical University has a unique contract system under which all the graduates have the obligation to work in rural areas in exchange for having their tuition fee during their 6 years of undergraduate medical education waived. RESULTS: Subjects with rural origin were more likely to have parents with lower academic background, improve their academic standing throughout undergraduate medical education, and engage in rural practice than those from urban origins. Positive linear relationships between places of upbringing and workplaces were recognized in various geographic/demographic indicators. CONCLUSIONS: The selective admission policy seems to be a reasonable way of increasing the number of rural physicians without placing an undue burden on medical schools.     

Factors related to the choice of family medicine: a reassessment and literature review

BACKGROUND: Recent decreases in the number of students entering family medicine has prompted reconsideration of what is known about the factors affecting specialty choice. METHODS: Thirty-six articles on family medicine specialty choice published since 1993 were reviewed and rated for quality. RESULTS: Rural background related positively and parents' socioeconomic status relates negatively to choice of family medicine. Career intentions at entry to medical school predict specialty choice. Students who believe primary care is important, have low income expectations, and do not plan a research career are more likely to choose family medicine. The school characteristic related to choice of family medicine is public ownership. Large programs to increase numbers entering primary care seem effective. Required family medicine time in clinical years is related to higher numbers selecting family medicine. Faculty role models serve both as positive and negative influences. Students rejecting family medicine are concerned about prestige, low income, and breadth of knowledge required. Students planning on a career in a disadvantaged or rural area are more likely to enter family medicine. CONCLUSIONS: Multiple factors are consistently shown to be related to the choice of the specialty of family medicine.     

A COMPARISON OF MEDICAL STUDENT EXPERIENCES IN RURAL SPECIALTY AND METROPOLITAN TEACHING HOSPITAL PRACTICE

ABSTRACT: One factor in solving the rural medical workforce shortage is to foster student interest by greater exposure to rural medicine. However, many medical school teachers are concerned that this may cause students to be disadvantaged by missing core lectures, tutorials and ward rounds in the setting of the high quality of teaching hospital medicine. This paper compares the rural specialty experience of 28 fifth-year volunteers with 28 'pairs' who remained in the city teaching hospitals. Rural students saw double the number of medical conditions, assisted in or performed six times as many procedures, and all but three students were sure that they had a better educational experience than their city counterparts. This is a strong academic argument for greater medical student exposure to rural specialty practice.     

Rural Medical School Applicants: Do Their Academic Credentials and Admission Decisions Differ From Those of Nonrural Applicants?

CONTEXT AND PURPOSE: Medical schools located in states with sizable rural areas are concerned about preparing physicians for practice in these areas; this is of particular concern for medical schools that are part of a state-owned university with a responsibility to educate physicians for rural areas. Because individuals from rural areas are most likely to return to practice medicine in rural areas at the conclusion of their training, it is important to recruit these individuals to medical schools to educate them for rural practice. METHODS: This study examines 7 years of admission data for students who applied and were accepted to the University of Missouri-Columbia School of Medicine, which has as a specific mandate to prepare physicians for rural practice. FINDINGS: The study indicates that rural applicants are more likely to be admitted to the medical school, and based on admissions criteria they are at least as academically qualified as nonrural applicants. CONCLUSIONS: The study demonstrates that a medical school can maintain competitive admission criteria while at the same time accepting those students more likely to enter rural practice. This is valuable information that medical schools with a similar mission to prepare physicians for rural practice might consider in their admissions decision-making process.     

Rural-urban differences in primary care physicians' practice patterns, characteristics, and incomes

CONTEXT: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. PURPOSE: To examine rural-urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians. METHODS: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics. FINDINGS: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: -$14,569, -$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts. CONCLUSIONS: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.     

Family Medicine Spokane Rural Training Track: 24 years of rural-based graduate medical education

Twenty percent of the US population lives in rural communities, but only about 9% of the nation's physicians practice in those communities. There is little doubt that the more highly specialized physicians are, the less likely they are to practice or settle in rural areas. There is clearly a population threshold below which it is not feasible for specialist (in contrast to generalist) physicians to pursue the specialty in which they have trained. Much of rural America falls below that threshold. This leaves large geographic areas of America to the primary care physician. The proportional supply of family physicians to specialists increases as urbanization decreases. Family physicians are the largest single source of physicians in rural areas. Family medicine residency programs based in rural locations provide a critical mechanism for addressing rural primary care needs. Graduates from rural residency programs are three times more likely to practice in rural areas than urban residency program graduates. There are two primary goals of training residents in rural areas: producing more physicians who will practice in rural areas and producing physicians who are better prepared for the personal and professional demands of rural practice. Rural Training Tracks, where the first year of residency is completed in an urban setting and the second and third years at a rural site (1-2 model), initially proposed by Family Medicine Spokane in 1985, have been highly successful in placing and maintaining more than 70% of their graduates in rural communities. Similar and modifications of the "Spokane RTT model" have been established around the country. Now, more than 24 years of educational experience has been accumulated and can be applied to further development of these successful family medicine residency programs.     

Illinois RMED: a comprehensive program to improve the supply of rural family physicians

BACKGROUND: Rural areas of the United States are perennially medically underserved, and the state of Illinois is no exception. A recent survey showed that 75 of Illinois' 84 rural counties are primary care physician shortage areas. In response to this chronic physician shortage, the Illinois Rural Medical Education (RMED) Program was developed by the University of Illinois College of Medicine at Rockford. The RMED program is a comprehensive, multifaceted program that combines recruitment, admissions, curriculum, support, and evaluation components and is longitudinal across all 4 years of the medical school experience. The admissions process seeks to select students who possess traits indicative of success in eventual rural family practice. These traits are fostered and developed by the 4-year rural curriculum, which emphasizes family medicine, community-oriented primary care, the physician functioning in the context of community, relevant aspects of the "hidden" curriculum, and service learning. After 6 years, RMED has graduated 39 physicians; 69% have gone into family practice, and a total of 82% have selected primary care residencies.     

A Comparison of Diabetes Care in Rural and Urban Medical Clinics in Alabama

This study sought to determine the differences in the level of diabetes care of patients in a rural family practice clinic and an urban internal medicine clinic in Alabama. Medical records of patients with diabetes were reviewed and management practices were compared to current American Diabetes Association (ADA) standards of care. The rural practice had fewer patients at goal A1c, goal LDL, and goal blood pressure. Rural patients were also less likely to receive screening and preventative services such as lipid profiles, eye examinations, microalbumin screening, aspirin therapy, and vaccinations than urban patients. Although, adherence to the ADA standards of care was lower with rural patients, the results suggest that there exists significant opportunity to improve the delivery of diabetes care services to both patient populations.     

Rural–Urban Differences in Primary Care Physicians' Practice Patterns, Characteristics, and Incomes

ABSTRACT:  Context: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. Purpose: To examine rural–urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians. Methods: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics. Findings: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: −$14,569, −$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts. Conclusions: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.     

Fixing family medicine residency training

The number of US medical students entering family medicine continues to decline. Despite the increased presence of family physicians on medical school faculty and increased exposure to family medicine during training, students still cite lack of respect and excessive knowledge base to master as reasons for not choosing our specialty. Specific changes must be made to family medicine residency training to make it more attractive to students and more compatible with the realities of practice today. These changes include eliminating maternity care as a requirement, lengthening training to 4 years, and reducing the number of residency slots available. These changes will ensure that graduating family physicians will be better prepared for practice, better qualified to obtain privileges in the hospital and clinic, and more respected by their colleagues and the public.     

The Rural Physician Workforce in Florida: A Survey of US- and Foreign-Born Primary Care Physicians

CONTEXT: To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed. PURPOSE: This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida. METHODS: Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians. FINDINGS: Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians. CONCLUSIONS: Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.     

Family Medicine Education and Rural Health: A Response to Present and Future Needs

The importance of family medicine in providing rural health services has been established for quite some time. The need to train physicians who select the specialty of family medicine is critical at a time when medical student interest in the primary care specialties appears to be diminishing. Renewed efforts by educational institutions and incentives at the state and federal levels will be necessary to assist in the alleviation of shortages of rural physicians. The educational program at the University of Minnesota, Duluth, School of Medicine has achieved a great deal of success in training rural family physicians. A coordinated program effort, featuring the efforts of more than 200 family physicians during the past 15 years, has led to 52.5 percent of all graduates selecting family practice and more than 41 percent choosing practice sites with a population fewer than 20,000. Elements of the program at Duluth could serve as a model for other schools desiring to increase the number of students entering family medicine and rural practice.