Wheeler County, Oregon boasts a fairly unusual distinction: It has more square miles (1,717) than residents (1,354). But it is like many rural regions in its struggle to provide residents with medical care.
“There’s no doctor in the county. No psychiatrist. No dentist,” says Joy Anderson, who runs a community health center in the county seat of Fossil. Twice a month, a doctor travels to the center for half a day. But in situations like a serious emergency, complicated labor, or a need for chemotherapy, “patients have to travel 70 miles to see a physician at the nearest hospital and often even farther,” Anderson notes.
Across the country, physician shortages have left a growing number of communities like Wheeler County desperate for care. Of the more than 7,200 federally designated health professional shortage areas, 3 out of 5 are in rural regions. And while 20% of the U.S. population lives in rural communities, only 11% of physicians practice in such areas.
The lack of physicians is deeply worrisome. That’s in part because rural residents are more likely to die from health issues like cardiovascular disease, unintentional injury, and chronic lung disease than city-dwellers. Rural residents also tend to be diagnosed with cancer at later stages and have worse outcomes.
“Patients have to travel 70 miles to see a physician at the nearest hospital and often even farther.”
What’s more, the situation likely will worsen. As many rural physicians near retirement, nearly a quarter fewer may be practicing by 2030. Equally troubling, medical school matriculants from rural areas — who are most likely to practice in such regions — declined 28% between 2002 and 2017, reports a 2019 study led by Scott Shipman, MD, AAMC director of primary care initiatives and clinical innovations. And that decline came at a time when the overall number of matriculants increased by 30%. In addition, in 2016 and 2017, students from rural backgrounds made up just 4.3% of the incoming medical student body.
Encouraging young doctors to take up rural practice is challenging for several reasons. Rural areas offer fewer opportunities for working spouses, and schools in rural communities may have fewer resources. Young doctors also may worry that they will earn less, which is a serious concern for those with major student debt. In addition, subtle messages sometimes dissuade students from rural medicine. “The culture that most medical students train in values specialization and diminishes the intellectual challenge or importance of family medicine and rural practice,” says Randall Longenecker, MD, assistant dean for rural and underserved programs at Ohio University Heritage College of Osteopathic Medicine.
To counter all these forces, a growing number of medical schools — more than 40 by the latest count — have created rural training tracks. Using extensive outreach and significant supports, these programs strive to attract students likely to take up rural practice and then carefully prepare them for success.
Medical students who grow up in small communities far from urban centers are much more likely to return to them to practice, research shows. So, many medical schools aim to identify potential candidates from rural communities and encourage them to take up medicine.
“As part of our effort, we go out to community colleges and four-year colleges in rural parts of the state to connect with students who already have an interest in the health care professions,” says Debbie Melton, director of undergraduate medical education at Oregon Health & Science University (OHSU) School of Medicine. “We provide guidance on navigating through the medical school application process and information on financial aid resources. Probably just as important, we help them see that going into medicine is a do-able and realistic goal for them.”
Several years ago, OHSU invited college students from around the state for an open house that included presentations about medical career paths and a tour of the Portland medical campus. The program proved so popular that it’s now offered three times a year. In addition, OSHU representatives attend high school career days in rural areas to attract students who might never have considered medicine.
Other medical schools are using similar strategies. For example, the Scholars in Rural Health program at the University of Kansas School of Medicine identifies and encourages promising undergraduate students from rural parts of the state, inviting them to apply in the second semester of their sophomore year. Qualified candidates are guaranteed admission contingent on successfully completing college.
“We’re turning to rural and underserved communities to help us identify good candidates, and then we support them through medical school, and finally link them to one of 31 residency programs.”
Paul Gorman, MD
School of Medicine at Oregon Health & Science University
And in an ambitious new effort, OHSU and the University of California, Davis, School of Medicine have joined forces to create COMPADRE — California Oregon Medical Partnership to Address Disparities in Rural Education and Health — to place more physicians in rural and underserved communities.
“We’re turning to rural and underserved communities to help us identify good candidates, and then we support them through medical school, and finally link them to one of 31 residency programs we’re partnering with that will allow them to continue their work in rural and other underserved communities,” explains Paul Gorman, MD, assistant dean of rural medical education at OHSU. That’s particularly important because more than half of residents nationwide end up practicing in the state where they trained.
Explaining the inspiration behind the program, Gorman describes visiting a small town in Oregon and seeing a framed newspaper article about a local student getting into medical school. “That’s the kind of student we want to support with the COMPADRE program. Who knows better than local communities who those candidates are likely to be?”
Boots on the ground
The hallmark of nearly all rural training programs is the opportunity to pursue clerkships in rural communities. These rotations provide hands-on experience, including the scope of practice required of a primary care physician in a community where there may be no OB/GYN or general surgeon, for example.
University of South Dakota (USD) Sanford School of Medicine medical student Kristin Inman, who grew up in Pierre (population 13,980), did a rotation last year in the tinier town of Winner (population 2,852) thanks to the school’s Frontier and Rural Medicine program (FARM). The experience was even more gratifying than she expected.
“Because the community is so small, I was able to work closely with the same attending physician all year, which was the best learning experience really anyone could have,” she says. “Everyone on the team got to know me, to identify my strengths and weaknesses and encourage me.”
Some leaders in the field, in fact, are convinced that rural rotations should be part of every medical school curriculum — as they now are at OHSU and a number of other medical colleges. A required rural rotation would introduce all medical students to a career path that some may never have considered, advocates argue.
Hadley Pope, MD, who graduated from the University of New Mexico (UNM) School of Medicine’s Rural and Underserved Populations (RUUP) program last year, grew up in Albuquerque and attended a leading Midwestern liberal arts college. “I didn’t really have any particular interest in a rural practice until I got to the University of New Mexico,” she says. In her first year, though, she was selected to join RUUP, where she learned more about the opportunities of global family practice. “You get to do everything — work in the ER, deliver babies, work in the clinic and in the hospital.”
During her rotations in the program, Pope worked with the Indian Health Service (IHS) and rural communities around the state, where she began to think seriously about a rural practice. Now a resident at the University of Arizona College of Medicine – Tucson Family Medicine Residency Program at South Campus, she hopes to serve as a physician with the IHS.
Fostering a sense of community
Given that some students are hesitant about pursuing rural medicine, many programs work hard to foster a sense of community among their rural track students.
For example, medical students in UNM’s RUUP program form their own learning community to support and encourage one another. They also get to participate in special seminars on various underserved populations and the roles of different specialties working with those groups.
At Ohio University Heritage College’s Urban and Rural Scholars Pathways (RUSP) program, students in the rural track attend monthly meetings, called Clinical Jazz, where they can ask the group to brainstorm solutions to problems that could arise in a rural practice.
“In a small community [there’s] a continuity of care and a kind of gratification that’s very hard to find in any other kind of practice."
Susan Anderson, MD
USD Sanford School of Medicine
The University of Colorado School of Medicine’s rural track cultivates a sense of community even before medical school begins. Incoming students are invited to participate in a weeklong interdisciplinary rural immersion experience during the summer before classes start. What’s more, mutual support is maintained long after medical students have left the program. “We keep in touch with all our graduates, some of whom have gone on to become rural preceptors for our program,” explains Mark Deutchman, MD, director of the rural track program.
Signs of success
The growing number of rural training track programs alone won’t solve the crisis in rural health care, experts say. For example, additional government funding for rural residencies is essential, notes Shipman. Still, there are signs that the programs are making a real difference.
For example, 2 out of 3 graduates of the Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School have gone on to practice in that state, and 40% of them practice in rural locations. Of the 127 doctors who have graduated from the University of Colorado Medical School’s rural track since it began in 2005, 35% are practicing in communities that are considered rural or frontier.
Of the 70 students entering the class that will graduate in 2023 from the USD Sanford School of Medicine this year, 54 graduated from high schools in the state, including many students from small rural communities. Many applied to USD in part because of FARM, which allows medical students to do rotations in 1 of 7 rural communities in the state.
Perhaps more importantly, participating in a rural track training program is a life-changing experience for many students.
“In a small community, you get to know patients in the context of their community and their families,” says Susan Anderson, MD, dean of rural medicine at the USD Sanford School of Medicine. “You take care of the whole family and in some cases multiple generations of families. Birth, death, trauma, you see your patients through it all. There’s a continuity of care and a kind of gratification that’s very hard to find in any other kind of practice.”
Indeed, in the rural areas they serve, many doctors do more for the health of the community than simply practice medicine. “One of our graduates developed a program that gets people who are abusing opioids into treatment promptly, as soon as they are first seen,” Deutchman explains. Other alumni are working on projects like promoting firearm safety and improving health screenings. “One of the many rewards of rural medicine is that that you can make a difference not only to individuals, but to the community.”
It’s not surprising, perhaps, that a recent study in South Dakota found that the rate of burnout is significantly lower among family practice physicians in rural settings than among urban practitioners.
Medical students intuitively sense that, says Longenecker. “They see what life is like for too many family physicians in an urban setting, who may have a very limited scope of practice and possibly less continuity of care with patients. By participating in a rural track program, they discover an alternative pathway, an opportunity to practice medicine in a very different way — a way that may ultimately offer them more access to the rewards and joys of practicing medicine.”