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Rural Matters

Andrea L. Wendling, MD

(Fam Med 2016;48(8):593-5.)

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

—Martin Luther King, Jr.

 

Health care inequality is arguably one of the most disturbing, pervasive, and persistent social injustices in the United States. In America, life expectancy differs based on gender, race, education, income, and geography.1,2 Mortality rates increase with increasing levels of rurality3 and poverty,1,3 leaving rural poor and rural minorities particularly vulnerable. Frustratingly, as a country, we have allowed the life expectancy gap between our resource-rich and our resource-poor communities and individuals to widen over the past 2 decades.1-4

The rural physician shortage was first documented in the literature over 90 years ago,5 soon after publication of Flexner’s original report,6 which called for a centralization of medical education to academic centers. Many benefits were a result of this reform, but an unintended consequence was the significant and persistent maldistribution of physicians away from rural America. And the injustice is that although we understand and could affect many of the factors that impact the rural physician disparity, we have not moved quickly enough to improve it. A widening life-
expectancy gap is a profound consequence. Those rural lives matter.

The physician maldistribution is not the only disparity affecting rural America, and admittedly it is hard to solve problems complicated by multi-generational poverty and inopportunity. The physician maldistribution falls squarely in the realm of medical education, however, and, as family medicine educators, that is where we can most effectively advocate. So, for rural medical education, what matters?

Admissions matter. Students from rural backgrounds are significantly more likely to practice in rural areas,7-9 yet are consistently underrepresented in medical schools.10,11 Similar to other disadvantaged and underrepresented populations, this is often an issue of longstanding educational and socioeconomic challenges for these rural students. Reforming admission policies to provide more holistic review of applications and less dependence on standardized test scores has been shown to result in higher acceptance of students from many disadvantaged backgrounds,12-16 yet resistance to admission reform remains—ironically often supported by the argument that admission policies should be equal for all. Regardless of race, color, ethnicity, or gender, training a workforce that is motivated to practice in areas that have been historically underserved is necessary to ensure a just health care system for all, and consistently it has been shown that students who originate from underserved communities are more likely to return as physicians. As primary care educators, we need to continuously remind our medical schools of their responsibility to society. Our admissions committees need to determine which students are truly and passionately going to serve vulnerable populations and then ensure these students have a place in every medical school. Debt reduction needs to be a focus to attract disadvantaged applicants, as these students are more likely to practice in underserved communities. And if each matriculating class does not mirror the communities and populations a medical school is intended to serve, we should demand an explanation for why.

Place matters. Students trained in rural and underserved areas are more likely to practice in these communities.9,17-20 Physicians trained in high-resource areas—where specialty consults happen quickly, technology is readily available, and generalists are rare—are competent within tertiary care systems but are often uncomfortable when presented with a hospital or a community that lacks access to similar resources. In order to educate physicians comfortable with practicing in remote or underserved regions, we need to support training opportunities within these communities. As we expand medical education, the United States needs to be more strategic than it has been in the past. We need to consciously develop and fund programs in rural and other underserved communities, for generalists of all specialties. We need to acknowledge that today’s rural physicians are often part of two-career couples, who require different social and professional support than previous generations may have needed. And telemedicine, specialty outreach, and a broad definition of community need to be incorporated into the education of all physicians, in order to better support those choosing rural practice. The injustice is that once recognized, any educational model that perpetuates disparity should no longer be acceptable. We have recognized that a specialty-driven, tertiary-care focused, urban model of medical education has perpetuated some of our current disparities. It is now time to improve upon this model.

Training matters. In rural and other underserved areas, comprehensiveness is vital. Rural hospitals and small communities look to family physicians to deliver the majority of care; the current trend to reduce comprehensiveness in family medicine education is ominous for rural practice. The percentage of US family physicians providing maternity care has declined significantly, yet rural hospitals still depend on family physicians to provide obstetric services, including surgical obstetrics.21 Many rural family physicians will staff emergency departments without specialty backup, will provide geriatric care for a community, and will be called to resuscitate and care for newborns. In most rural counties in America, they will also provide the majority of mental health services.22 These skills are no longer typical for family physicians in all practice settings, yet all residency programs serve communities in which they may be necessary. Comprehensiveness as a tenet of the discipline of family medicine is important, and morphing the specialty to fit the model of the majority will only worsen health care disparities. Upon graduation, family physicians should be prepared to practice in any community. In order to accomplish this, we need to value and preserve the model of comprehensiveness, even within those communities where its usefulness is hard to recognize.

And finally, as Evans et al eloquently pointed out in this issue’s lead article,23 once students interested in rural practice are identified, medical educators need to honor that passion by leading them toward training opportunities that truly will support and foster a rural career. Students should be able to trust that family medicine residencies will prepare them to meet the health care needs of their future communities. Without exception. Our residency programs, especially those identifying as rural, should cultivate a generation of physicians that practice to the fullest scope of their potential. And our medical schools and society should no longer tolerate the injustice of leaving any population behind.

Correspondence: Address correspondence to Dr Wendling, University of Michigan, Department of Family Medcine, 1113 Summerhill Way, Charlevoix, MI 49720. 231-547-2533. Fax: 231-582-5338. wendli14@msu.edu.

 

References

 
 

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  2. Olshansky SJ, Antonucci T, Berkman L, et al. Differences in life expectancy due to race and educational differences are widening, and many may not catch up. Health Aff (Millwood) 2012;31(8):1803-13.
  3. Singh GK, Siahpush M. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health 2014;91(2):272-92.
  4. Singh GK, Siahpush M. Widening rural-urban disparities in life expectancy, US, 1969-2009. Am J Prev Med 2014;46(2):e19-29.
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  6. Flexner A. Medical education in the US and Canada: Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston: Carnegie Foundation for the Advancement of Teaching, 1910.
  7. Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA 2001;286(9):1041-8.
  8. Rabinowitz HK, Diamond JJ, Markham FW, Santana AJ. The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later. Acad Med 2012;87(4):493-7.
  9. Phillips R, Doodoo M, Pettersen S, et al. Specialty and geographic distribution of the physician workforce: what influences medical student & resident choices? Washington, DC: The Robert Graham Center, March 2, 2009.
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  15. Witzburg RA, Sondheimer HM. Holistic review—shaping the medical profession one applicant at a time. N Engl J Med 2013;368(17):1565-7.
  16. Drees B, Nairn R, Nivet M, Danek J, Glazer G, Bankston K, Urban Universities for Health. Holistic admissions in the health professions. Findings from a national survey. September, 2014. http://urbanuniversitiesforhealth.org/media/documents/holisticadmissionsinthehealthprofessions.pdf. Accessed July 18, 2016.
  17. Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health 2009;9(2):1060.
  18. Balance D, Kornegay D, Evans P. Factors that influence physicians to practice in rural locations: a review and commentary. J Rural Health 2009;25(3):276-81.
  19. Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. Acad Med 2008;83(3):235-43.
  20. Chen F, Fordyce M, Andes S, Hart LG. Which medical schools produce rural physicians? A 15-year update. Acad Med 2010;85(4):594-8.
  21. Kozhimannil KB, Casey MM, Hung P, Han X, Prasad S, Moscovice IS. The rural obstetric workforce in US hospitals: challenges and opportunities. J Rural Health 2015;31(4):365-72.
  22. Xierali IM, Tong ST, Petterson SM, Puffer JC, Phillips RL, Bazemore AW. Family physicians are essential for mental health care delivery. J Am Board Fam Med 2013;26(2):114-5.
  23. Evans DV, Patterson DG, Andrilla HA, Schmitz D, Longenecker R. Do residencies that aim to produce rural family physicians offer relevant training? Fam Med 2016;48(8):596-602.

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