Abstract: The author has directed rural programs over the last 15 years, encountering various difficulties with institutional commitment, program development and survival, resource challenges, having a critical mass of faculty with similar interests, lack of a rural "team" and the need for an organizational rural focus. The article examines each area.
Introduction: The nation needs 8000 more rural physicians. Family physicians are by far the most likely to choose rural locations. These will not come by convincing current physicians or even family physicians to go rural. Those hoping to train more rural physicians point to the need for a coordinated and comprehensive approach. The most important steps involve admissions of students that will choose rural practice. Unfortunately those interested in Family Medicine and rural health are locked in a survival mode:
1. Survival of family medicine programs and positions
2. Support for faculty and departments
3. Title VII support for primary care
4. Challenges to rural health systems
As a result some never think about rural initiatives and programs, some see the need but are frustrated, others respond poorly, and a few respond well. The author has directed or participated at each of these levels.
It is a time of great challenge to family medicine. Health care crises continue to give opportunities to those who are prepared. The basic financing of medical education is being shaken with changes in reimbursement, graduate medical education, research, and other areas. If family medicine fails to respond, other entities can and will surely make the most of these same opportunities.
Family medicine organizations strain to deal with internal priorities. Rural physicians and rural practice were the roots of the discipline. Now groups within family medicine complain that residency programs do not prepare residents for rural practice. Program directors disagree as 85% of them feel they are doing this (AAFP Survey, Murray). National committees advising programs on the future of FM curricula proposals consider excluding obstetrics, except for those interested in rural practice (Future curriculum recs). Curriculum committees struggle to deal with changes in the availability of training resources, expansions in medical knowledge, and advances in technology. In an era of difficulties with the match, programs must decide whether to widen their nets or concentrate in certain areas. These decisions all affect the residency's ability to train for rural practice.
Rural programs can be a major asset to FM programs. Rural programs can help with recruiting faculty and residents. They can help programs train residents more effectively. Rural programs can improve the funding base and broaden the political support for family medicine training.
Departments and residencies with the commitment, the faculty, and the resources can prepare physicians for rural practice. Rural program directors can make the difference in this effort. This article is for those who plan to accept a position as a rural program director and those who will assist them.
Lack of Institutional Commitment Programs must have devoted faculty and supportive resources. The mandate must be stated, understood, and applied. Medical schools who hire subspecialist-oriented chairmen or establish other residencies which are not committed 100 % to producing primary care physicians do not have this commitment. Examinations of actions are louder than words. Institutional mission is best illustrated in the choice of deans, chairmen, faculty, and priority of training programs. Those with a true commitment will, when facing tough financial times, prioritize primary care programs.
There should be no or few other major agendas for the institution. A small institution should have a single focus. Larger ones may have one or two with others that are closely related. Primary care does not have the luxury of established funding. Institutions pursuing the biomedical research mission (billions in National Institute of Health) or the exorbitancies of subspecialist reimbursement may face difficulty pursuing primary care or rural health (Which Medical Schools Produce Rural Physicians? Rosenblatt).
At the recent STFM Annual meeting, one major research medical school made a "conversion" to family medicine, but the institutional mission and responsibility for primary care was to remain solely with the newly created department of family medicine. Why waste scarce resources where the commitment is not there? On the other hand primary care research can go hand in hand with primary care education and service.
Perhaps the most important consideration is the approach. This is the application of mission and resources. The Community Driven Approach should guide efforts to resolve maldistribution. Partnership models are worth exploring for mutual benefit.
New programs need funding commitments for several years, usually at least as long as it will take trainees at the intervention to graduate plus two or three years for a sufficient group to study. It takes at least this time to develop the staff, faculty, networking, and political support for survival. Rural programs often do not start up as large grants or divisions. They begin small and work up. Each project feeds into the next. Many sources of funding are possible, but it takes time and faculty resources to evaluate and pursue the best ones. Medical schools should be ready to support such proposals. Constant communication with the foundations, legislatures, and the federal government is a priority. The time to ask for extra funding is when the programs are strong and growing, not when they are threatened with extinction. External funding sources continue to abound in rural health. Traditional FM sources adopt a more rural focus. The time from final definition of the request for proposal to the deadline grows shorter each year. Keeping abreast of the ideas and decision makers is important. The best approach is regular contact with a group and continual education of faculty throughout the institution.
Faculty must be experienced in rural health. They must be committed and enthusiastic. Rural physicians can make ideal faculty, but they must first conquer the ghosts of their own rural practice weaknesses. They must also face up to the loss of many of their strengths. It is hard to teach rural medicine without being in a rural community. If rural physicians do not experience some sense of loss or depression when leaving practice, one could question their value as a rural faculty.
Facilitating More and Better Rural Docs
There must be enough faculty. A few should be full time to provide an undivided focus. A key failing of rural programs is faculty who get pinched between patient care, teaching duties, and rural programs. Physicians will and should always choose people needs over administrative ones. Careful time management and negotiation skills can help faculty to accomplish multiple tasks and goals.
Faculty must work as a team. Many rural practitioners "did it all". Their staff, their patients, and their style of practice favored independence. Success in as an academic faculty involves individual work as well. Rural programs are often not established. They compete with other entities for funding and support. Successful rural programs involve team work. Rural faculty must identify allies and friends within the departments, medical school, and state. They must meet together to plan and support one another. They must work for the long term and not be discouraged by lack of early success. Networking and travel expenses are necessary to get faculty together and keep them in contact with rural locations and other rural faculty. A common focus for meetings is faculty development and program development.
Rural Faculty Development: Facilitating Town Plus Gown
Rural faculty must have access to the latest information on rural and family practice programs in order to best pursue teaching resources, funding, and other necessary elements for the rural programs.
Leadership Many rural programs are the vision of one person. Various mechanisms force this vision on the rest of the faculty. If the person is dynamic enough and supported enough, the programs will survive. A drawback can be the loss of that person or support. If that person has not prepared for this day, the entire development will be compromised.
Others approach rural programs as a team. This can be difficult when rural is so broad and faculty come from many backgrounds. Leadership Factors in Developing RME
With either method it is necessary for information and resources to be assimilated into a vision that is do-able for the institution. This will involve change, political struggle, tact, diplomacy, and a willingness to invoke the institutional mandate when necessary. Those who wish to change institutions must understand the rules better than those who run the institution. Planning allows for quick reactions in times of change or crisis. It is important in these times to understand the long term plan and know what intervention can shape this change. For instance legislatures in many state in the past 20 years have demanded that medical schools be held accountable for their graduates failure to meet the needs of the state. Those who have planned well, have secured funding and programs to better meet these needs.
Personal limitations and obstacles to overcome include time management, organization, understanding various perspectives (state view, local, national view), understanding departmental politics, the state mission, the unstated mission, etc.