Med schools seek right fit for rural practice

Family physician Frank Swisher, DO, is up every day at 4:30 a.m. to see patients at the nearby hospital before heading to his office.

He works an average of 80 hours a week at his solo practice in Jane Lew, W.Va., a rural town with a population of less than 500. Many patients drive more than an hour to see him, and he's always on call.

But Dr. Swisher loves his community and his patients, and he says there are many rewards to being a small-town doctor.

"You get to know the patients better," he said. "I know their families, where they work and the kind of work they do. I'll see grandkids, parents and grandparents."

Small-town doctors throughout the U.S. say they are drawn to rural practice for the sense of community and personal connections with patients. Yet physician shortages have been a persistent problem in rural America for decades.

Medical schools nationwide are trying to tackle the problem. In the past decade, many have developed programs aimed at steering physicians toward rural practice.

"Medical schools all around the country have developed rural-track programs," said Randy Longenecker, MD, clinical professor of family medicine and assistant dean for Rural Medical Education at Ohio State University College of Medicine.

There's no national count of such programs, and the types of programs vary widely from one school to the next, he said.

Alan Morgan

Some schools focus on identifying students from rural backgrounds through the admissions process or as early as high school, while some seek to give students a breadth of experience in rural medicine during medical school. Other schools are opening campuses in small towns and cities to immerse students in rural settings.

Nationwide, there are an average of 104.5 primary care physicians per 100,000 residents in urban areas, compared with 65 primary care physicians per 100,000 residents in rural areas. Rural physician shortages are expected to worsen as older doctors retire and health care coverage expands under the health system reform law.

"There are just going to be incredible needs everywhere," said Jim Nemitz, PhD, vice president for administration and external relations at West Virginia School of Osteopathic Medicine in Lewisburg.

Five million rural residents live in counties with fewer than 33 primary care physicians per 100,000 residents, and about 27% of rural primary care physicians are older than 55, says a July report by UnitedHealth's Center for Health Reform and Modernization.

Meanwhile, rural residents are more likely to be considered in poor health and have conditions such as cardiovascular disease, hypertension and diabetes. And the health system reform law is expected to expand insurance coverage to 5.4 million currently uninsured rural residents.

"There are 62 million rural Americans, and only about 10% of physicians today practice in rural areas," said Alan Morgan, CEO of the National Rural Health Assn. "Throw on top of that the Affordable Care Act -- the numbers are going in the wrong direction."

The value of experience

Two examples of new efforts to train rural physicians are the rural-track program at Rocky Vista University College of Osteopathic Medicine in Parker, Colo., and the University of Kansas School of Medicine's four-year campus in Salina.

Rocky Vista will graduate its first class in May 2012, including the first 12 participants in its honors rural program. Admission is competitive, and those accepted work an extra 20 to 25 hours per semester in a rural medical practice during their first two years of medical school. Students also work in rural emergency departments and receive extra training in aspects of rural medicine, such as how to treat altitude sickness and how to aid in search-and-rescue operations, said Bruce Dubin, DO, the college's dean and chief academic officer.

During their third and fourth years, rural-track students alternate between training in rural medical clinics and larger urban centers.

Rural doctors must be prepared to fill multiple roles, including being the local obstetrician, psychiatrist and emergency dentist. "The rural physician is often the jack-of-all-trades in these small towns," Dr. Dubin said.

Salina, a city of about 50,000 people in the center of Kansas, is away from major urban areas and has a vibrant medical community, said William Cathcart-Rake, MD, an oncologist and campus director.

The campus's first eight students will begin classes there this fall. They will take basic science, be assigned a rural physician mentor, and do their third- and fourth-year clinical training in Salina or surrounding communities, he said.

"We want students who are attracted to life outside a major metropolitan area, who like wide open spaces," Dr. Cathcart-Rake said.

Offering students hands-on experience in rural communities prepares them for the realities of rural practice, Dr. Longenecker said.

"The more months students spend in rural areas, either in medical school or residency, the more likely they are to go into rural practice," he said. "We're creatures of habit, and the context in which we are trained seems to be more important or as important as how we are trained."

Barriers to attracting students

A major obstacle to attracting more physicians to rural practice is that medical schools historically have drawn the best and brightest students from affluent urban communities, where they have access to top-notch schools, Morgan said. Many medical schools also have a strong focus on specialty care, while primary care is the focus in rural communities.

"The current system really favors, rewards and encourages students to go into specialties and go into cities," Dr. Longenecker said. "To change that system is really difficult."

More medical students need to be drawn from rural communities. "We know what works -- it's attracting students with a rural background and an intent to practice in rural areas," Morgan said. "It's not rocket science. We're just not doing that."

The University of Minnesota Medical School has had a rural-track program at its Duluth campus since 1972. Since then, the campus has graduated 1,636 physicians. About 46% of graduates have gone into family medicine, and 44% practice in communities with populations smaller than 20,000, said Jim Boulger, PhD, professor and director of the school's family medicine preceptorship program.

Coming from a rural background is an important factor in the admissions process. "Then we look at service commitment and what people have done with their lives -- more than just GPAs and MCAT scores," Boulger said.

Adam Amos is a fourth-year medical student at Indiana University School of Medicine's new campus in Terre Haute, Ind. He grew up in a rural community outside Greencastle, Ind. Amos said he chose to go to medical school at Terre Haute to be close to family and because of the specialized rural training offered there.

Unlike IU School of Medicine's other satellite campuses, students on that track must come from rural communities and spend all four years in Terre Haute, said Randy Stevens, MD, the campus's clinical clerkship coordinator. They begin spending time with a rural physician within the first month of their first year and are assigned a rural patient to follow throughout medical school.

"I think of rural medicine as an exciting challenge where creativity and ingenuity play a large role in getting patients the care they need," Amos said. "Whether it's working through the strong sense of self-sufficiency and pride that patients often have in the rural setting or getting patients needed resources that simply aren't available, it takes a knowledge beyond just the medical to really help your patients."

Some negative aspects of rural practice are the isolation and perception of lower pay, said Nemitz, of West Virginia School of Osteopathic Medicine. It also can be a problem for unmarried physicians, because their social options are limited by the fact that they are prohibited by ethics guidelines from dating their patients. But the advantages far outweigh the disadvantages, he said.

"There are incredible rewards," Nemitz said. "You can be a leader in your community. One person can make a difference in thousands of people's lives. You can't put a price on that and the way that makes you feel."