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COMMENTARY Patching the Rural Workforce Pipeline—Why Don’t We Do More? Jared Garrison-Jakel, MD, MPH 1 1 Santa Rosa Family Medicine Residency, University of California San Francisco, Santa Rosa, California doi: 10.1111/j.1748-0361.2010.00341.x The relative shortage of rural physicians is a persistent feature of American health care. 1 Despite mid-century in- vestment in expanding medical schools and recruiting in- ternational medical graduates, we have failed to fill the workforce gap. 2 Simply increasing the number of physi- cians has proven an inefficient strategy for meeting ru- ral health care needs. 1 The central paradox of provider shortages remains that “The number of people living in designated health professional shortage areas (HPSAs)— and the number of designated HPSAs—has increased at the same time that the ratio of physicians to population has doubled.” 2 Moving into a new era of health care reform, the re- cruitment, training, and retention of rural health care practitioners continues to be a major challenge. 3 In fact, the well-documented access disparities facing America’s 61 million 4 rural citizens are only likely to worsen. With only 3% of recent medical graduates planning to practice in small towns and rural areas, 5 this unfortunate trend seems unlikely to abate without intervention. To ensure the adequate supply of rural physicians, we must explore and utilize those factors predictive of sub- sequent rural practice among prospective medical stu- dents. For example, rural background and intent to prac- tice family medicine have been demonstrated to strongly predict future rural practice. 5 Those with both a rural background and an interest in family medicine on admis- sion to medical school have a 36% likelihood of practicing in a rural region, compared to 29% of those with only a rural background and just 7% of those lacking both characteristics. 6 In fact, in a prominent policy analysis, Geyman and associates stated that “increasing the num- ber of physicians who grew up in rural areas is not only the most effective way to increase the number of rural physicians, but any policy that does not include this may be unsuccessful.” 7 In addition, the influence of the specialist-centered urban medical education and the concurrent depriva- tion of community-based training experiences are impor- tant. We know that those exposed to nonurban clini- cal work during their medical training are 1.7 times as likely to choose rural practice. 8 Yet student physicians routinely lack the structured opportunities to explore ru- ral medicine that are necessary to counterbalance an ed- ucational system, favoring urban and suburban practice. Given these factors, medical schools have been iden- tified as a promising point of intervention. Several such programs are currently implemented in medical schools across the country. A recent review by Rabinowitz and colleagues identified published outcomes from 6 medical school rural-workforce programs. Impressively, investi- gators determined an average of 57% of program grad- uates were practicing in rural areas after completing resi- dency, demonstrating the efficacy of this approach. 5 One example, the Jefferson Medical College’s Physi- cian Shortage Area Program (PSAP) selectively admits students with rural backgrounds and the intent to prac- tice family medicine. 9 Each PSAP student benefits from a faculty advisor and rural clerkships. Program graduates are 3 times more likely than their peers to practice rural medicine (34% of graduates), 4 times as likely to be prac- ticing family medicine (52%), and 8.5 times more likely to be practicing rural family medicine (21%). 9 They now represent 20% of Pennsylvania’s rural family physicians, despite comprising just 1% of state matriculants. 9 Ad- ditionally, 79% of those program graduates who began their career in rural medicine were found to remain in rural practices for more than a decade after graduation. 5 This successful program is implemented at a low cost 9 and while these promising results have been critiqued for self-selection bias, 10 they pave a path forward. If all US allopathic medical schools implemented similar programs serving just 10 students per school per year, for instance, the number of rural physicians produced annually would double. 5 Despite calls to do so, medical schools have been slow to replicate such programs. In their Eighteenth Report, the Council on Graduate Medical Education (COGME) The Journal of Rural Health 27 (2011) 239–240 c 2010 National Rural Health Association 239

Patching the Rural Workforce Pipeline—Why Don't We Do More?

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Page 1: Patching the Rural Workforce Pipeline—Why Don't We Do More?

COMMENTARY

Patching the Rural Workforce Pipeline—Why Don’t We Do More?Jared Garrison-Jakel, MD, MPH1

1 Santa Rosa Family Medicine Residency, University of California San Francisco, Santa Rosa, California

doi: 10.1111/j.1748-0361.2010.00341.x

The relative shortage of rural physicians is a persistentfeature of American health care.1 Despite mid-century in-vestment in expanding medical schools and recruiting in-ternational medical graduates, we have failed to fill theworkforce gap.2 Simply increasing the number of physi-cians has proven an inefficient strategy for meeting ru-ral health care needs.1 The central paradox of providershortages remains that “The number of people living indesignated health professional shortage areas (HPSAs)—and the number of designated HPSAs—has increased atthe same time that the ratio of physicians to populationhas doubled.”2

Moving into a new era of health care reform, the re-cruitment, training, and retention of rural health carepractitioners continues to be a major challenge.3 In fact,the well-documented access disparities facing America’s61 million4 rural citizens are only likely to worsen. Withonly 3% of recent medical graduates planning to practicein small towns and rural areas,5 this unfortunate trendseems unlikely to abate without intervention.

To ensure the adequate supply of rural physicians, wemust explore and utilize those factors predictive of sub-sequent rural practice among prospective medical stu-dents. For example, rural background and intent to prac-tice family medicine have been demonstrated to stronglypredict future rural practice.5 Those with both a ruralbackground and an interest in family medicine on admis-sion to medical school have a 36% likelihood of practicingin a rural region, compared to 29% of those with onlya rural background and just 7% of those lacking bothcharacteristics.6 In fact, in a prominent policy analysis,Geyman and associates stated that “increasing the num-ber of physicians who grew up in rural areas is not onlythe most effective way to increase the number of ruralphysicians, but any policy that does not include this maybe unsuccessful.”7

In addition, the influence of the specialist-centeredurban medical education and the concurrent depriva-tion of community-based training experiences are impor-

tant. We know that those exposed to nonurban clini-cal work during their medical training are 1.7 times aslikely to choose rural practice.8 Yet student physiciansroutinely lack the structured opportunities to explore ru-ral medicine that are necessary to counterbalance an ed-ucational system, favoring urban and suburban practice.

Given these factors, medical schools have been iden-tified as a promising point of intervention. Several suchprograms are currently implemented in medical schoolsacross the country. A recent review by Rabinowitz andcolleagues identified published outcomes from 6 medicalschool rural-workforce programs. Impressively, investi-gators determined an average of 57% of program grad-uates were practicing in rural areas after completing resi-dency, demonstrating the efficacy of this approach.5

One example, the Jefferson Medical College’s Physi-cian Shortage Area Program (PSAP) selectively admitsstudents with rural backgrounds and the intent to prac-tice family medicine.9 Each PSAP student benefits froma faculty advisor and rural clerkships. Program graduatesare 3 times more likely than their peers to practice ruralmedicine (34% of graduates), 4 times as likely to be prac-ticing family medicine (52%), and 8.5 times more likelyto be practicing rural family medicine (21%).9 They nowrepresent 20% of Pennsylvania’s rural family physicians,despite comprising just 1% of state matriculants.9 Ad-ditionally, 79% of those program graduates who begantheir career in rural medicine were found to remain inrural practices for more than a decade after graduation.5

This successful program is implemented at a low cost9

and while these promising results have been critiqued forself-selection bias,10 they pave a path forward. If all USallopathic medical schools implemented similar programsserving just 10 students per school per year, for instance,the number of rural physicians produced annually woulddouble.5

Despite calls to do so, medical schools have been slowto replicate such programs. In their Eighteenth Report,the Council on Graduate Medical Education (COGME)

The Journal of Rural Health 27 (2011) 239–240 c© 2010 National Rural Health Association 239

Page 2: Patching the Rural Workforce Pipeline—Why Don't We Do More?

Rural Workforce Pipeline Commentary Garrison-Jakel

recommended that training institutions more aggres-sively pursue their social obligation to develop an ade-quate workforce, which they define as “one that is bothsufficient in size and appropriately geographically dis-persed such that most Americans do not experience anaccess problem.”11 The report goes on to advocate thatschools actively encourage graduates to practice in un-derserved areas.

Furthermore, COGME reinforced the need to increasethe admissions of students with rural backgrounds,11

challenging us to expand our conception of diversity toinclude geographic origin. This is consistent with the As-sociation of American Medical Colleges’ assertion that adiverse and sufficient workforce must not only reflectracial heterogeneity, but also the geographic and socioe-conomic diversity of our nation.12 However, continuedresistance prompted yet another COGME statement inMay 2009, regarding the urgent need to realign gradu-ate medical education with national health priorities.13

So why have institutions of medical training provenreluctant? COGME suggests admission policies continueto favor privileged applicants likely to enhance institu-tional reputation among ranking agencies such as USNews & World Report, in which the prestige of exclusiv-ity is valued over the institution’s success in meeting na-tional health care needs.6 Furthermore, concerns aboutadmitting underprivileged rural applicants appear unjus-tified as the medical school performance of these studentshas not significantly differed from their class as a whole,despite lower admission test scores.14 The value placedon the current rankings is, clearly, to the detriment ofthe country’s most vulnerable communities, underscor-ing the need for an outcomes-based ranking system thatis now either absent or poorly visible.

Instead of asking what an applicant will bring to theinstitution, admission committees must turn their gazeoutward and contemplate whom that applicant is likelyto serve in his or her career. Reform must not be delayed.Our rural communities need physicians, and our medicalinstitutions must embrace those policies known to nur-ture a workforce for this significant, neglected quintile ofthe American public.

References

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and rural America. West J Med. 2000;173(5):348-351.

2. Council on Graduate Medical Education. Tenth Report:

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Office; 1998.

3. Gamm LD, Hutchison LL, Dabney BJ, Dorsey AM, eds.

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People 2010, Vol. 1. College Station, Texas: The Texas A&M

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4. Morgan A. A national call to action: CDC’s 2001 Urban

and Rural Health Chartbook. J Rural Health. 2002;18(3):

382-383.

5. Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR.

Medical school programs to increase the rural physician

supply: a systematic review and projected impact of

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10. Ranmuthugala G, Humphreys J, Solarsh B, et al. Where is

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11. Council on Graduate Medical Education. Eighteenth

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13. Robertson RG, Phillips R. Congressional Memo; Available

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240 The Journal of Rural Health 27 (2011) 239–240 c© 2010 National Rural Health Association