The following programs have all been supported or incented by legislatures working with medical schools.
KEEPING HOME-GROWN PHYSICIANS AT HOME Many students have attended state colleges and state medical schools and are looking for or are told that they need a different experience. Since residency program location influences the location of practice, many state tax dollars are lost to other state. Oklahoma pays students who choose FP programs in their state a $5000 bonus and an extra $1000 a month. When they choose a community, they can receive further funding. This program keeps good quality candidates at home. Missouri recognizes outstanding high school students and sets up special programs to retain them in the state. Early admission programs accomplish the same in Nebraska, Pennsylvania, and other states.
PREPARATION FOR MEDICAL CAREERS Some states are blessed with excellent education to rural areas. Others lack such quality. The numbers of rural background students steadily dip each year. Education and orientation to college is part of this. Experience and interest in health careers is another. Kentucky's Physician Education and Placement Program began in 1971 to identify high school students from underserved areas who had an interest in health careers. Counselors gave advice on admissions and courses and testing. Students attended seminars and received a higher priority score for admission to medical school. Graduates of the program do as well as other students and choose primary care at a rate far above the national average. Only about 1 in 3 make it to medical school, but the students are more likely to go back to the underserved counties from which they came.
The East Tennessee State University Rural High School Health Career Fair brings rural high school students from underserved areas to the campus of ETSU to examine different health careers. They spend time with students and faculty in Medicine, Nursing, and Allied Health. They see interesting demonstrations (such as heart and lung anatomy) and attend presentations by the many health disciplines. They discuss obstacles to their choice of a rural health profession. Students and faculty discuss ways to bypass these obstacles, including scholarships, special counseling and academic preparation courses, preferential admissions, early admissions, and loan repayments. The Washington (state) Academy of FP has physicians that work with all high schools and colleges on medical careers. Some county chapters have science or math awards for outstanding students. Chadron State in Nebraska attracts over 200 students from 3 states to their high school career fair. Some schools bring their entire class. The Chadron fair improves health career orientation, gets students to visit college campuses, and attracts students to small college campuses so that students don't feel that they have to go to the big urban schools to get ahead.
ADMISSIONS TO MEDICAL SCHOOL is a critical area. The national average for rural physician production by medical schools is 6% of their output. The current best in this area is East Carolina with 15.9 % rural output (WAMI report). ECU has had four FP's on the admissions committee for years. Wright State has six. The WAMI system (Seattle) uses rural physicians on this committee. Private schools, often receiving just as much state support, have dismal records of producing rural physicians (2 -3 %). Perhaps the best indication of appropriate admissions is the family practice match. Marshall, Mercer, and others exceed 40%. As medical schools prepare for specific rural community-based training, the admission of primary care and rural preference students becomes even more critical. Legislative incentives at the national level have created these and some osteopathic programs that have done a good job of meeting the nation's needs.
SPECIAL RURAL ADMISSIONS PROGRAMS can multiply the effect of rural medical education programs. The Physician Shortage Area Program in Jefferson began in 1972. It has chosen up to 15 students each year based on their rural background, their interest in rural practice, and their plans for a family practice career. Over 22 years this program with 1% of the medical students in the state has graduated 12% of the rural physicians of Pennsylvania. Nebraska's Rural Health Opportunities Program accepts 3 freshman college students each from Chadron and Wayne State Colleges into the medical school. After three years and appropriate courses and grades, they enter medical school. These students come from towns of 300 to 2000 population from the most rural areas of the state. Chadron itself is a town of less than a thousand. The program has had a significant impact on the college, its educational quality, and the location of students. No longer do students need to go to urban colleges to do well enough to get into professional school. The cost is low but the benefit is high. Pressures from legislators can go far in this area.
SHAPING THE MEDICAL SCHOOL ENVIRONMENT Those with rural interest must be identified and encouraged. In some medical schools they may need to be isolated from other students or faculty. Rural Student Interest Groups may be helpful in this area. These groups identify students with family practice or rural interest as early as possible. These students meet with each other, with rural faculty, and with rural preceptors in the first two years for information and support for rural experiences, for realistic and practical information on rural practice, for consideration of special rural training experiences, and for career counseling. The rural students themselves are a major resource. They can develop programs to meet their own needs. The Rural Health Career Fair at ETSU is such a program. The Rural Student Interest Group began this annual fair for high school students from underserved areas of the state. After all, if they know they are choosing rural, they will need physicians graduating behind them to be rural colleagues in the future. They have a big stake in the future of medical education for rural practice. This is a more difficult task for legislative programs, but legislators can put pressure to force funding based on actual outcomes (rural graduates). Then it becomes easier for medical schools to comply with state needs.
SPECIAL RURAL TRAINING PROGRAMS allow students to fully appreciate rural practice and the role of the rural physician. Nebraska sends all of its 120 third year students into a two month rural family practice clerkship. It also gives them three weeks of rural training at the end of the first year of medical school. Every health profession school at UNMC sends its students on required rural experiences. The Appalachian Preceptorship instructs 12 students each year in the basics of rural practice, the role of the physician, and the effect of an individual's beliefs and culture on health delivery. Students then spend 4 weeks in a rural community, armed with the curiosity that will allow them to probe the practice, the community, and the physician. All familiy practice residents in Nebraska attend the Combined Outstate Rural Experience, a required 2 month rotation. Rural practice cannot be taught from a book or in a lecture. It is dynamic and must be seen and examined in person. The Nebraska program is unique because only a few sites are selected and used consistently over a 3 year period. When compared with randomly arranged rural rotations, this allows more benefit to the rural physicians, the rural hospital, and the community. Little state funding is needed in states with existing preceptorships, incentives may be needed to get current rural doctors to accept students when they have not done so. This could be done through Medicaid programming.
THE "HANDS-ON" APPROACH Students who plan rural health careers need to experience the responsibility of patient care first hand. They should manage patients in the clinics and at the hospital. Students should aggressively pursue competence in decision-making as well as competence in procedures. The learning curve is maximized when students get to actually practice medicine with appropriate and available supervision. Students should choose residency programs that will facilitate these rural goals. Students and residents at Veterans or county facilities often have this chance to practice. Faculty should assure supervision and the opportunity to actually do the procedures. Faculty must also make a commitment to "hands on" by learning and teaching procedures in patients or in seminars. Training in suturing, EKG interpretation, casting, and splinting are very popular with students. All Nebraska family practice faculty go out to rural sites to visit with the physician-preceptors as well as the residents. One of the resident's advisory sessions occurs at this time. This visit reinforces the mission and vision of the institution and department. This is a good area to ask about when legislators make visits to primary care training programs.
FELLOWSHIPS IN RURAL MEDICINE Fellowships can emphasize the rural difference. Fellows concentrate in areas that will facilitate their chosen careers. Rural fellows often concentrate on procedures, obstetrics, and rural practice management. They may have an idea of the type of practice that they desire, or they may need to examine several types of rural practices. Other fellows choose experiences leading toward a career as a rural faculty member or rural health administrator. The presence of fellows at the university tells students that rural medicine is rewarding and challenging. Students in this environment learn to respect rural practice and practitioners. Fellows add to the critical mass necessary to establish and maintain quality rural medical education and can support rural satellites and procedural training of residents and students. Fellows can also provide locum tenens in exchange for valuable practice and practice management training. The state of Tennessee created one of these programs at ETSU and drew a rural faculty there to run the program and also stole several good rural practitioners from other states. The Fellows also provided extra FTEs in the VA hospital, the GME programs, the clinic, and a rural site.
RURAL FACULTY DEVELOPMENT After the closure of the ETSU Minifellowship in Rural Medicine, formal rural medical education was discontinued. A few temp programs exist along the lines of preparing preceptors. There is a need to for rural faculty to understand the many facets of rural medical education. They need to know about rural health policy and rural curriculum so that they can return to their own programs and best advise rural-interested students and residents. Such training continues with the Society of Teachers of Family Medicine Group on Rural Health. Special group sessions have continued in the tradition of the minifellowship. Rural Medical Fellows can take a special curriculum offered through the group.
Faculty who visit rural physicians and communities can be a great help in social support, occasional coverage, specific training in procedures, and as a consultant to rural practices. They can help identify community health problems and refer communities or physicians to sources of assistance. Faculty can facilitate the grouping up of solo physicians to aid in teaching, recruitment, and retention. Common methods of assisting rural communities or hospitals in distress are community needs assessments, strategic planning, and training for hospital boards.
SUPPORT FOR GRADUATES WHO CHOOSE RURAL The most critical area in the planning of a comprehensive rural health program is support for graduates. Investments at all other levels can be lost if the state does not have excellent recruitment and information programs. Loan repayments can begin prior to graduation to funnel candidates into a rural decision. Care should be taken to inform and screen rural interested residents so that there is a high likelihood of retention as well.
State support includes reimbursement policies for Medicaid and other insurance and support for rural practice modes such as Rural Health Clinics and Community Health Centers. Rural networks are important. States vary in liability climate. States with high liability costs may discourage the full range of practice that rural physicians can desire. States also vary in the support for rural-friendly legislation and programs. This support can impact on state policies, state programs, or academic departments.
States want to be sure that their tax dollars are used wisely. The best rural producing programs may end up losing graduates to other states if the state does not attend to some of these important areas. Rural practice incentives such as loan repayments can be very important. The state of Tennessee has an innovative loan repayment program that repays $50,000 for 30 months of service in rural Tennessee. Another $25,000 is included for practice start-up expenses. Solo physicians receive $5000 locum tenens coverage each year. Technical assistance is available to new physicians. Tennessee has recruited 71 doctors in the last two years and will recruit another 13 this year. Many other states have loan repayments, community match programs and other incentives.
Geographic differentials in Medicaid and insurance programs need to be eliminated or modified to better support rural physicians. Medicaid eligibility and reimbursement policies regarding obstetrics can support or discriminate against rural physicians. The state also determines the complexity of the program.
Rural physicians often receive guarantees of $120,000 a year or more with other practice assistance and free rent. Some have received signing bonuses of up to $40,000. Procedurally trained physicians may receive even higher offers. Antitrust "Safe Harbor" rulings by the courts may interfere with the rapid acceleration of rural physician salaries and benefits, but the incentives for finding and keeping a rural physician are limitless in variation and amount. Many hospitals may want to combine of private practice and 8 - 12 hours a week in the ER to support and attract new physicians as well as improve the community's attitude toward the hospital. Critical access programs may also impact on the comfort level of new physicians.