Bringing Better Health to Rural America | Education

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Apr 19, 2020

For Vincent Proy, 28, deciding to become a rural family doctor wasn’t a tough call. His father has a family practice in his hometown of Corry, Pa. (population 6,834), and growing up, Proy saw firsthand what the job was like. “I knew I wanted to practice rural family medicine because of all of the interesting challenges that my father faced,” says Proy, who graduated in 2007 from the Physician Shortage Area Program at Jefferson Medical College at Thomas Jefferson University in Philadelphia. 

Facing a continued shortage of primary-care physicians nationwide, and an especially tight supply in rural areas and small towns, medical schools are making an effort to recruit students like Proy to launch long-lasting careers in rural areas. While 1 in 5 U.S. residents lives in a rural area, just 9 percent of doctors practice there, according to a 2002 study. The shortage of primary-care doctors in rural areas isn’t new, but it’s poised to get worse. Fewer than 4 percent of recent medical school graduates say they intend to start their careers in rural areas or small towns. And the number of practicing physicians will shrink as baby boomers retire.

Since the early 1970s—after national recognition of physician shortages in the 1950s and 1960s—medical schools have ramped up efforts to recruit, train, and provide support for new doctors in an effort to encourage them to build their lives and their careers in small towns. Many students who choose to go into rural medicine, like Proy, are from small towns themselves and either decide to go back to their hometowns or move to a community of similar size. “Studies show that one of the biggest predictors of [practicing in] a small town is coming from one,” says David Luoma, chief executive officer of the Upper Peninsula Health Education Corp., a nonprofit created in partnership with Michigan State University that administers the school’s Rural Physician Program. “One of the biggest predictors was the size of your high school graduating class.”

It’s unusual for students from big cities to choose to practice in a rural area. That’s largely because of misconceptions about what making that choice means, experts say. “The culture of most medical schools is that no one in their right mind would want to become a rural family doctor,” says Howard Rabinowitz, director of Jefferson’s Physician Shortage Area Program. “People tell these students, ‘Why would you want to live in a small town? You can’t practice good medicine; you can’t have a personal life; you can’t take care of patients adequately.’ ” But those are “all myths,” Rabinowitz says. Doctors in rural areas “tend to be much happier personally and professionally, [to] have a better life balance,” he says. “Really, it comes down to where people want to live.”

Rural immersion. To give students an idea of what life as a rural family doctor is really like, rural medical education programs send students to small towns for a portion of their time in school. They get hands-on, usually one-on-one experience working with doctors, and they see and develop relationships with patients. During their third year in school, students in Jefferson’s program participate in a six-week course in Latrobe, Pa. (population 8,994). In their fourth year, most students work one-on-one with a doctor in a rural area. At the University of Minnesota Medical School’s Rural Physician Associate Program, third-year students spend nine months working with a primary-care doctor in a small Minnesota community. While seeing patients regularly, the students “also live in the community and understand and step into the role of healthcare professional in a way that they haven’t before,” says Kathleen Brooks, director of Minnesota’s program.

That aspect of the program was a highlight for Austin Krohn, 26, a fourth-year med student at the University of Minnesota. “I really enjoy the relationships that you can build,” he says. He doubts he would have gotten similar training so early in his career if he’d gone to a larger city. “I was able to be first assistant on a lot of surgeries and also get a lot of freedom to do things on my own,” he says.

Of course, participation in a rural medicine program is no guarantee that students will go to a small town and remain there. Research that looked at six medical schools with a combined 1,600 rural program graduates over three decades found that 53 to 64 percent of grads practiced in rural areas, according to a review published in March 2008 in the journal Academic Medicine. Doctors who choose to leave rural areas generally cite the workload, income, and a preference for living in a larger city with access to cultural or educational options that may not be available in a smaller town.

Medical schools typically track grads to determine how successful their programs are in encouraging students to go into rural medicine and stick with it. Jefferson’s data show that 11 to 16 years after starting practice, 68 percent of the Physician Shortage Area Program’s graduates were still practicing family medicine in the same rural area in which they began; an additional 11 percent were practicing family medicine in another rural area. About 75 percent of the graduates of the National Center for Rural Health Professions at the University of Illinois–Rockford College of Medicine are practicing medicine in towns of fewer than 20,000 people, says Matthew Hunsaker, director of the college’s Rural Medical Education Program. The University of Minnesota says that nearly half of the more than 1,200 graduates of its program work in rural communities.

Rural medicine programs seem to be making a difference in small communities, Rabinowitz says. But retention is key. On average, rural doctors stay about seven years in one rural community, so it takes five doctors to equal the work of one who would spend a whole career there.

Physician retention starts with early recruitment, as students consider which medical programs to apply to. For schools, that means having a presence online and identifying and working with feeder colleges and universities that can refer good candidates. Jefferson works with various Pennsylvania and Delaware colleges to help identify potential applicants, and the Upper Peninsula Health Education Corp. uses its website and social media to reach out to students. The University of Minnesota Medical School’s rural program looks for students who have a passion for practicing rural family medicine and primary care, are service oriented, and are from small towns themselves. The hope is that by targeting recruitment to students already interested in rural medicine, the rates of students who start practicing in rural areas—and stay there—will continue to increase.

For Proy, now doing a residency at Ventura County Medical Center in California, a small-town practice is a sure thing. “I’m going to work side by side with my dad at his clinic in Corry,” he says. He is excited about practicing rural family medicine because he will have to dip his hand into various specialties—pediatrics, geriatrics, and cardiology, for example—to care for his patients. “I can’t think of any other specialty or field of medicine where it offers such comprehensive medical care,” Proy says. “It’s really quite varied, and that’s what I love about it.”


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