Rural Medicine Programs Aim to Reverse Physician Shortage in Outlying Regions

William Bell, M.D., did not have what one would call a typical medical school experience.

As a first-year medical student at the University of Washington School of Medicine, Dr. Bell did not sit through anatomy lectures alongside his peers in Seattle. Instead, he spent that year with practicing physicians in Alaska, often flying to small villages to treat local patients.

Dr. Bell’s stint in the “land of the midnight sun” made such an impression on him that he decided to return during his fourth year of medical school and again after completing residency in the early 1980s. He has been practicing family medicine in Homer, Alaska, ever since and does not plan to leave anytime soon.

“I didn’t come into it blind,” Dr. Bell said. “I had the chance to experience Alaska during my years of training so I had a good feeling about what I was coming into.”

Initiatives such as the University of Washington’s five-state Washington Wyoming Alaska Montana Idaho (WWAMI) medical education program give students the opportunity to study medicine in rural settings with the hope that they will be encouraged to practice in smaller locales. The curricula range from single elective courses to clerkship experiences in rural towns lasting nearly a year.

Addressing the Shortage

Many rural medical practices across the country have been grappling with a shortage of doctors for quite some time, and rural medicine programs have provided a much-needed boost to these regions.

“As I talk to hospital administrators and physician leaders in New York State, almost all of them can name two or three specialties for which they are having trouble filling positions,” said James Greenwald, M.D., associate professor at SUNY Upstate Medical University’s department of family medicine and director of its rural medicine program.

Most rural family doctors also say that their towns would greatly benefit from having an additional primary care physician, according to Dr. Greenwald.

The situation is no different on the opposite side of the country, as University of Washington School of Medicine’s John Coombs, M.D., vice dean for regional affairs, rural health and graduate medical education, can attest.

Thirty-seven percent of the combined population living in the states of Washington, Wyoming, Alaska, Montana and Idaho is in non-metropolitan areas, according to Dr. Coombs. A University of Washington survey found that 42 percent of primary care practices in those five states and 18 percent of medical surgical practices are actively recruiting new physicians.

As in most other areas of the country, doctors in those five states are unevenly distributed, with significantly fewer physicians serving rural communities.

In rural Illinois, there are almost 40 open positions for physicians, according to Matthew Hunsaker, M.D., director of rural medical education at the National Center for Rural Health Professions, part of the University of Illinois College of Medicine at Rockford.

The medical school has a comprehensive rural medical education program that runs through all four years of training.

“It’s tough to think of 61 million people as an underserved population, but the fact is that outside of urban areas the vast majority of the United States is rural,” Dr. Hunsaker said.

“If we don’t look at recruiting and training more people for rural practice, we will leave large areas of the country without coverage.”

With such long-term concerns in mind, rural medicine program officials have attempted to recruit students who reside in rural areas or who express the desire to practice in a rural location after completing their residencies. Studies have shown that students who come from rural and underserved communities are more likely to return to their hometowns to practice.

Dr. Greenwald’s institution sponsors a series of high school and college visits to inform students from rural areas about the school’s rural medical education opportunities. The program’s representatives will visit approximately 10 colleges this year, he said.

Rural Pledge

The Illinois rural medicine program requires participants to pledge to return to a rural part of the state upon completion of their residencies. In addition, applicants are screened for what Dr. Hunsaker calls their “rurality,” or the likelihood that they will return to rural America.

The University of Washington’s WWAMI program, which promotes the sharing of facilities and personnel from the states’ universities and communities, also targets the educational pipeline to get rural students into medical school.

One of its K-12 initiatives, U-DOC High School Outreach, is a four- to six-week summer enrich-ment program that aims to attract the interest of high school students from medically underserved areas to a career in the medical profession.

Besides getting students from rural communities to attend medical school, the University of Washington also tries to encourage its current students to enter a rural practice setting. Washington students can do a variety of things, such as spending the summer in a rural clinic working with a preceptor, doing community-based research in rural areas or taking part in a six-month program that includes medical activities in rural settings.

Encouraging Data

Outcome data suggest that many of these programs are successful in creating a coterie of rural practitioners. More than 70 percent of Illinois’ rural medicine program graduates are practicing primary care in rural Illinois, and 26 percent of SUNY’s rural program graduates end up practicing in rural settings, according to school officials.

In addition, the University of Washington is one of the few medical schools in the country in which more than 20 percent of graduating seniors end up practicing in rural or medically underserved communities.

But even if students who participate in rural medicine programs decide not to “go rural,” the experiences they acquire provide them with invaluable skills, according to Dr. Greenwald.

“We find that our rural medicine students acquire a lot more confidence and a more holistic overview of the specialties to which they are exposed,” he said. “Their communication skills tend to be better when compared to their classmates’ by various measures.”

Rural medicine students are forced to be more independent than their peers who study at university hospitals and count on the constant supervision of residents, fellows and faculty, he added.

“The decentralization of the medical school experience is a real strength of rural education programs,” said Dr. Greenwald. “It is great to work with super-specialists in medical school, but for that basic education in primary care and some of the specialties to take place, it is much better to be in a place where you’re not falling over fellows, residents and interns.”

A Country Kind of Guy

Mark Barreto, a fourth-year medical student at SUNY Upstate, has had just that kind of decentralized experience in Oneonta, N.Y.

“I have been fortunate to get one-on-one teaching directly from attending physicians and patients,” he said. Barreto says that the idea of practicing in a rural setting always appealed to him.

“I always considered myself a country kind of guy,” he said. “I like the whole idea of a small town where you can just walk down the street and people know who you are and you also know who they are.”

During the time he has spent in Oneonta, Barreto established close relationships with local physicians and many of his patients.

“In rural settings, doctors get to know each other really well, so that most family physicians know the specialists to whom they refer patients,” he said. “Specialists are more than just names doctors write down on a pad.”

Because smaller communities allow for greater continuity of care, patients also become more than just names and diagnoses, something that Barreto deeply appreciates and wishes to have in his future medical practice.

“I just talked to one of the physicians here, and he invited me to join him in practice in four years after I’m done with my residency,” Barreto said. “There’s a very strong possibility that I will return to where I am now.”

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