My favorite quotes for American health care, especially for rural areas: 1. Americans can always be counted on to do the right thing, ....after they have exhausted all other possibilities. Winston Churchill and 2. There is a very fine line between participatory democracy and decisional paralysis. Bruce Amundson, M.D. 1997

Providing medical care in rural and remote areas can be one of the most fulfilling, exciting, and challenging types of work that a physician could imagine. And despite the inevitable personal and professional challenges faced by their physicians, hundreds of thousands of Canadians across the country have been well-served by these dedicated professionals. -Barer Stoddart 1999

The importance of recruiting and admitting future physicians who have grown up in rural and remote settings now seems clearly established... However... only a fraction of what could be done in this area is currently being done. -Barer Stoddart 1999

A clear message emerging from the extensive research that has looked at what factors influence physicians' decisions about where to practice medicine is that matters affecting the lives of spouses and children are among the most important considerations. -Barer Stoddart 1999

The issue of access to medical services in rural and remote areas is one of the most complex and difficult problems in health care policy, and it should not be approached with the expectation that it will ever be "solved" completely, to the satisfaction of all parties. -Barer Stoddart 1999

While the existing array of strategies is better than doing nothing, it has not prevented the sharpening of rural/remote access as a policy issue. Something different and additional will have to be done in future if rural/remote access is to be improved. -Barer Stoddart 1999

The combination of shifting from a rotating internship requirement to a minimum two-year residency training program for family practice, together with the decisions taken about the overall mix of residency positions, have meant that fewer physicians are now leaving the training pipeline with general/family practice credentials. -Barer Stoddart 1999

It is usually possible to make a very reasonable living even in urban areas that are well-supplied or over-supplied with physicians. The urban alternatives, which most physicians prefer because they offer professional and institutional capacity and support as well as social amenities, are therefore relatively unrestricted. -Barer Stoddart 1999

“Improved geographic distribution of medical services will require a concerted effort to create a broadly based and integrated policy package of reinforcing initiatives." -Barer-Stoddart, 1991

“...We go to the people!... Look out the windows - a whole street of houses. That's where the doctor must go. Into every house, into every city, into every village. From door to door. We take medicine right down to the last individual..." -Dr. Norman Bethune, 1935

The Nazis came for the Jews, and I was not a Jew, so I was silent. Then they came for the editors of the newspapers and the radio commentators, and I was not in mass communications, so I was silent. Then they came for the professors in the universities. I was not a professor, so I did not speak up. Finally, they came for me, and there was no one left to speak. -Dietrich Bonhoeffer 1945

Small rural health systems represent a variety of ever changing environments with two endangered species: hospitals and practitioners. Those who would treat rural communities with the disease of "retentionitis" would do well to learn from experienced healers such as Sir William Osler who said that prescribing external remedies is far less important than understanding the lifestyle and habits of the patient. Robert C. Bowman, M.D. 1997

Have we forgotten the underserved that brought us to creation. Family practice graduates choosing rural locations continue at the same 600 per year. This is no different now than shortly after our re-creation. This has occurred even though we have tripled the numbers of FP graduates. Graduate numbers choosing urban poverty locations are on the decline in recent years. Have we become part of those who exploit rather than those who contribute? Are we increasing the experiences that will lead our graduate to choose underserved locations? Robert C. Bowman, M.D. 2000

Academic Impacts on Family Physicians

Many of us thought the battle for Family Practice was over. We are finding that the battles have just begun. It is a hard road that we have to travel. Family practice has survived creation and vision, it must survive revision and complacency - Robert C. Bowman, M.D. 2000

It is no longer about establishing family medicine as a discipline. The battle is much larger. It is about the kind of health care delivered in the United States and our role in shaping the caregiver that will best serve our patients. This is no easy task because the general awareness of these issues is low. - Robert C. Bowman, M.D. 2000

This is really the only strategy that works if you plan to care for patients at all. Seems simple, but we have missed the point too long. Our patients deserve the best, our learners deserve the best, and family medicine must have the best in order to survive these turbulent times and come out ahead and influential in the decades to come. Robert C. Bowman, M.D. 2000

If you want physicians to go to location where they need to do more caring and service than usual, you have to pick students who want to do more service and caring than usual - Robert C. Bowman, M.D. 2001

Service orientation has built Marriott and indeed most other major corporations. Why can't service orientation restucture medical schools, who are supposed to serve the nation? Robert C. Bowman, M.D. 2001

What can you do to encourage the servants that are growing up right now in your own community? Do your part to remind medical schools and all who train health professionals that service is the top priority and the rest will take care of itself. - Robert C. Bowman, M.D. 2001

If you don’t feel comfortable with the basics, you won’t be able to move to the more advanced levels such as problem solving involving the community. Both Osler and Flexner and Medical School Deans at Tufts and other medical schools in past decades have made statements to the effect that the best students should choose rural practice, for they are the ones most capable of handling this kind of challenge - Robert C. Bowman, M.D. 2001

Rural Family Practice is about standing up for values. While addressing a highly motivated group of young scientists Albert Einstein said, "Gentlemen, try not to become men of success. But rather, try to become men of value." From Robert C. Bowman, M.D. 2001

I may be naïve, but I still think that a career in rural family medicine offers the best opportunity for the best doctors to be at their very best and have fun doing it and find those moments where you too will be dear and glorious. Robert Boyer, M.D. reference to Taylor Caldwells book about Luke, the physician in the Bible who wrote Luke and Acts

Built within our traditional medical systems are roadblocks. I find many of these to be irrelevant or myths. I try to spend my time getting by these to deliver the best care that I can. Robert Boyer, MD, Kingman, KS. First AAFP doctor of the year 1993

The appalling cost to both the physician and to the rural community of this mismatch has not been well described. The young physician and his family moves to the town in good faith, making a long-term commitment. Within weeks or months it becomes apparent that the expectations of the doctor, and sometimes the town, are not to be realized. The agonizing decisions then begin whether to sever the relationship... For the rural community the trauma is almost as great: it is easier in most instances to be perennially without a physician than to find one, go through the process of change in adapting to a new one, lose the doctor and start the entire cycle over again. - Tom Bruce in Improving Rural Health

This community study lends support to the belief that the ability of a community to attract physicians is closely related to the ability of that community to confront problems and take necessary actions – Bruce and Norton, Improving Rural Health 1984 p 66

It is a basic consideration that the Rural Medical Development Program could have achieved on or both of the following, recruitment and/or retention in rural communities. It is the considered judgment of the program staff members after several years of work in this field that recruitment represents about 20% … and retention 80%… if all of the communities who had recruited physicians over the past years had been able to keep them, there would be no problem of access to rural medical care today. Bruce and Norton, Improving Rural Health P 162 1984

These efforts have been most helpful: AHEC, expansion of primary care residencies, move of rural preceptorship to earlier position, development of Office of Community Medical Affairs with its host of outreach and bridging activities. Bruce and Norton, Improving Rural Health P 165    Admissions for generalists and rural physicians

The state of Arkansas basically had twice as much gain in the ration of physicians to population from 1975 to 1979 when compared to states throughout the south and midwest and at 18% growth, had the 5th largest growth of any state in the nation. Bruce and Norton, Improving Rural Health P 168 1984

The efforts that continue to be deterrents: inadequate facilities and support systems (transportation), lack of spouse opportunities, lack of education opportunities for children, lack of group practice opportunities and consultations, economic disadvantages of practicing in areas of high poverty and unemployment "or in which the entire business and financial infrastructure fails to thrive." Bruce and Norton, Improving Rural Health P 168 1984     Actually medical education can address many of these, see

Hope: Students From the Underserved, For the Underserved

To those medical schools who are planning to improve their efforts in rural development it is suggested that a broad-brush approach be used in which faculty, students, and administrative officials equally are expected to participate in planning and implementing the program. There must be a serious and visible commitment from the medical school to make a contribution to rural medicine and to support the existing rural practitioners. To those legislative groups: finance properly the regional educational centers, sponsor incentive programs for rural hospitals, clinics, and professionals which have been carefully coordinated with the educational ventures and look at better ways to support rather than undercut rural medical care. To professional societies: address professional isolation, CME, the need for support groups and consultations. To rural communities: do not rely on outside efforts, work with the leadership of your town to analyze problems and carry out a logical plan to remedy the problems and work to develop new leaders to carry on. Bruce and Norton, Improving Rural Health P 168 – 169 1984

One concern of may American health planners in 1984 is how to utilize some of the extenders who have been produced in great numbers, and how to phase back their educational programs now that an adequate supply of physicians is at hand. Bruce and Norton, Improving Rural Health 1984 p 69

The new American Board of Family Practice, at its July 1973 meeting, decided not to approve the Arkansas plan to amalgamate the senior year of medical school into the residency program. Bruce and Norton, Improving Rural Health, p 109 1984

When legislators became aware of some of these issues (support of FP faculty and plans) and the unhappiness of the new residents (FP), they blamed the clinical chiefs of the established medical school departments." They designed a bill to limit administrative positions to 4 years upon approval of meeting state needs and expected changes in curriculum. This caught the attention of the legislators even though it was not passed. Bruce and Norton, Improving Rural Health, p 109

I tell you the old-fashioned doctor who used to cure you of all illnesses has quite disappeared. Now there are only specialists and they all advertise in the papers. F. Dostoyevsky The Brothers Karamazov 1880 from Joseph Merrill M.D.

It is not sufficient to classify the population as rural simply on the basis of having a combination of total population and population density which is less than a specified threshold the regional context of the population in question is equally important. -Ehrensaft and Beeman

The small town needs the best and not the worst doctor procurable, for the country doctor has only himself to rely on. He cannot in every pinch hail specialist and nurse. -Dr. Abraham Flexner 1910 "Advancement of Teaching Medical Education in the United States and Canada"

“On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best trained physician that can be induced to go there." -Dr. Abraham Flexner 1910 "Advancement of Teaching Medical Education in the United States and Canada"

Medical education is not just a program for building knowledge and skills in its recipients... it is also an experience which creates attitudes and expectations. Abraham Flexner 1914

“The site of postgraduate training appears to be one of the important factors in the selection of practice locations." -Gray JD; Steeves LC; Blackburn JW The Dalhousie University experience of training residents in many small communities. Acad Med (United States), Oct 1994, 69(10)

Carl Hammerschlag was asked by a Native American patient if he could dance. He shuffled his feet a bit and the patient said, “That’s good.” Realizing that there was some purpose to the patient’s request, Carl asked him if he would dance as well. The patient adjusted his oxygen cannula and danced vigorously right there on his bed. Carl paused for a moment, then asked the patient if he could teach him to dance like that. The healer said, “I can teach you my steps, but you must hear your own music.” Carl Hammerschlag 1999

In one year the student develops surprising professional maturity. In the classroom of real life he has learned tha sound medical practice is born of sound medical theory. He has seen how rural family practice can bend or break a man but how it rarely bores him. He has witnessed the challenging clinical mix of the mundane and the monstrous. And he returns to academia a wiser, more confident, more searching student. JK Heid 1979

RPAP (MN) builds bridges of good will between the University and rural doctors. Many physicians recall the days when the hapless and hopeless referring LMD was dismissed with scorn at the professor's grand rounds. Times have changed! Monthly University visits have done much to dispel the doubts. When men of professional stature… come out to the rural hospital, make rounds, break bread, and discuss common problems with the local medical staff, new bonds of understanding grow quickly between small town and gown." JK Heid 1979

Does RPAP (MN) motivate the student to later return to the rural area as a fully training doctor? This, of course, is the ultimate test of the success of the program… (stats presented) … In our case, our first RPAP student returned to join us in practice (as have 60 of 900 so far - ed note). And it may signal the wave of the future to note that this young physician, an honor student, chose primary care rather than academic medicine or research. RPAP could just become the best doctor recruitment program that the rural areas have known. JK Heid 1979

“You can take the boy out of the country... but once the boy becomes a doctor, how do you get him back there?" - JK Heid 1979

The basic science of medical education is money…Heat is to water as money is to curricular change - John Hickner, M.D. 1993

Non-metropolitan areas in Canada are often simply referred to as rural Canada, without enough attention paid to their inner differences it is clear that non-metropolitan Canada is anything but homogeneous. More research is needed to bring out this diversity so that social policies can be better tailored to the needs of non-metropolitan Canadian populations. -Howatson-Leo and Earl 1995

“New Math n=n+1 : Whatever the number of doctors defined as needed for a rural community, to make it sustainable it must be increased by 1 to allow for cross coverage, locum relief, administrative load and teaching." -Peter Hutten-Czapski 1997

“Quantum Theory of rural practice: If rural decay causes you to loose the surgeon, the results include further erosion of health services in the community." -Ian Park and Peter Hutten-Czapski 1998

“Teaching hospitals are run by doctors who have chosen a small area of medicine in which, with the aid of expensive technology, they have become expert. How can doctors be expected to feel competent or wish to practice in country areas hundreds of kilometers away from such technology." -Kamien 1984

“The country preceptor has to show the student the satisfaction and fun of rural practice and how it is possible to practice high quality but cost effective medicine without... a CT scanner." -Kamien 1984

Successful training programs include "teaching staff who work every day with physicians with patients in little towns and rural settings and hold rural physicians in high regard and honestly support students when interested in rural medicine." -Lampert 1991

I think it is difficult for young physicians who have not worked in a rural setting, and some older doctors who have (But have only seen one way of doing it), to understand that it is not "Family" or "Practice" but rather the effective integration of the two. There are many models for creating protected time for personal and family space in any setting, especially rural, and the only physicians who make it long-term in any setting are those who either ignore/neglect family or practice, or those who find incredible fulfillment by learning to integrate their lives. -- Randy Longenecker ³A Reflective Practitioner in a Rural Setting² 2001

Building a community-responsive rural practice is endless work, a job that inevitably becomes as frustrating as it is rewarding. It requires a large tolerance for uncertainty and willingness to risk. One must deal effectively and tactfully with a variety of constituencies, any one of which can enhance or threaten the success of the venture. These include community people - supporters and opponents - local physicians, government officials, a hospital, one or more funding sources, a new staff and, of course, patients and their families. Not everyone is enthusiastic for the new practice or empathetic with its leaders- who are at all times expected to maintain their own idealism, energy, and optimism. New rural health centers are fragile entities, both economically and politically. When they finally succeed in becoming established it is usually because their people-leaders, staff, board members-were as stubbornly determined as they were resourceful. Donald L. Madison, 1980

“In medicine and health, put the emphasis on the rural areas." -Mao Tse Tung

“When someone is in the dean's office keeps hammering away on something it is amazing how some of the most resistant faculty suddenly take for granted that it is going to change." -Mayer 1990

“I'm not a magician, I'm just an old country doctor." Dr Leonard H. McCoy - "The Deadly Years" Star Trek Episode 41. Dec 8 1967

The best places to learn are not always the most convenient places to teach - Helen McIlvain, FP faculty, researcher, educator, counselor, friend 2001

In sparsely populated Canada the 14 largest cities are home to 14 of our 16 medical schools. Is it any wonder that recruiting and retaining physicians for rural/remote areas is a chronic national, as well as provincial, problem? -McKendry 1999

Given the growing population, the increase in physician workload and the longer working hours, the changing attitude of physicians, the increasing number of women practising medicine, the number of closed practices and the growing number of communities looking for physicians, the current supply of physicians... is not sufficient -McKendry 1999

With the current level of migration of... physicians, the aging of the current physician workforce, the decrease in the number of new graduates... the current relative under supply will become more severe in the future if nothing is done to influence the factors that determine the overall size of the active physician pool. -McKendry 1999

It appears that previous efforts to manage physician resources have suffered from a lack of longitudinal planning and specific planning horizons when planners recheck original assumptions against the current changing environment, and continually modify their plans based on new information. -McKendry 1999

Past efforts to manage physician supply have also suffered from the tendency to be selective in implementing planning recommendations: for example, reducing undergraduate enrolment but not always instituting other complementary measures (such as different payment plans and different delivery models). -McKendry 1999

Even with low population growth, ...[there will be a] significant increase in population to physician ratio, if nothing is done to influence the factors that affect physician supply. Based on these assumptions, it will take an increase of at least 20% in new graduates plus an increase in IMGs entering postgraduate training to compensate. -McKendry 1999

Presently the uneven distribution of physicians and the lack of availability of some physician services is more problematic than an overall lack of physicians. However, the under supply also aggravates the maldistribution of services. What was once a rural problem is also becoming an urban problem. -McKendry 1999

Given the interaction and interdependence between climate, human activity and biosphere, it is clear that no single variable is sufficient to define the North. -McNiven 1999

“The average physician should shun politics, as he would drinking and speculation" -Osler

“[There is] a trend towards a progressive deterioration in health as one moves from that area bordering urban centres into the very remote hinterland" -Pampalon, 1991

The residency is a period of unbelievable professional growth and development, and with good fortune, may even be accompanied by comparable logarithmic personal enlargement. The resident should make a knowing and informed commitment to be a physician: to take care of patients with compassion, justice, honor, dignity, scholarship, and devotion Solomon Papper M.D, Doing Right 1983

There are almost as many definitions of "rural' as there are researchers as it appears in most studies, the concept is either implicit or not consistently defined. -Pong 1999

As my sainted grandmother, Dr Mary, used to say, "There are two kinds of people. Those that do the work and those that take the credit. Bill, try to be among the first group. For one thing, there's a lot less competition to belong." Bill Rodney, M.D. 1999

The interdependence of actions in the several sectors of health service has become increasingly recognized as necessary for rural improvements. Programs for facility construction, manpower expansion, economic support, and quality promotion are all obviously intertwined. These actions, in turn, are all interdependent with general social changes in agriculture, employment, transportation, education, social security, and other spheres. Reaching goals in any one of these sectors usually depends on parallel actions in several of the others Milton I. Roemer, Rural Health Care, C.V. Mosby Co. St. Louis, 1976

Rural communities are particularly vulnerable to the uncertainty this situation (delegating defense against disease to complex health care systems) can cause becaue their health care systems are fragile, often controlled by people whose roots and orientations are alien to the community. Yet, paradoxically, it is in rural areas, where greater proportions of the poor and elderly populations live, that health care services are most needed. Rosenblatt and Moscovice 1982 Rural Health Care. John Wiley and Sons, New York, 1982

Communities do not have the luxury of remaining ignorant about the intricacies of medical practice. Unless they understand the tribulations and rewards of country practice, they will be unable to attract and retain people with the spectrum of skills that rural areas require. Rosenblatt and Moscovice 1982 Rural Health Care. John Wiley and Sons, New York, 1982

Physicians occupy an unusual spot in the social structure of rural communities. From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationships to strike a workable balance. Rosenblatt and Moscovice, 1982

I would go for the biggest bang and one focus per year. Therefore I suggest Admissions. If we get more rural origin students in the pipeline we will get more rural docs and less burnout therefore more retention….. If your intent is to breed cocker spaniels you don't start by buying poodles. Tom Rosenthal, M.D., Editor of the Journal of Rural Health 2001

…major changes in the distribution of physician services will not come about until policies that are designed to redistribute medical services recognize that a major locus of the problem is in general differences between communities and not solely in the attitudes, motives, values, and other personal characteristics of individual physicians. William A. Rushing, 1975

The Real Frontier lies in the stimulation of the Creative mind of Man. - Mari Sandoz 1896-1966

We began to realize very recently that we have been doing something which ……may be destined to failure. As far as physicians, we have had limited success… What can we do that maintains that person there? … what can you do to change the pattern of isolation, low status, and lack of consultation that occurs in most of the places we are talking about? We feel tat the present time, that without changing those three things, one will not retain a physician, or any other health professional, beyond that 5 or 7 year limit when most of the statistics say they leave. Particularly the young ones. Robert Shannon, M.D. National Health Service Corps: Overview and New Directions. Report of Regional Workshops on Health Manpower Distribution, National Health Council, New York, 1975

George Bernard Shaw's Doctor's Dilemma" around the last turn of the century "Make up your mind how many doctors the community needs to keep it well. Do not register more or less than this number, let registration constitute the doctor as a civil servant with a dignified wage paid out of public funds". Submitted by "John Frey, MD" 1898

“For 25 years, rural obstetrics and surgery have existed almost as an anathema to specialist colleges, defying rules, regulations, designations and restrictive teaching programs based on the flimsiest or (non-existent) evidence." -Dr. John Shepherd in Maximising the Use of Clinical Skills in Rural Practice

Will we be like many of our physician leaders who are focusing on dollars and control and position or will we continue to embrace patient care advocacy and teaching values to learners. I think what we can all agree upon is that reflection, re-evaluation and change is necessary. Barbara Starfield, as well as many other knowledgeable leaders, has documented that primary care is not delivering on its promise. Our founders are crying out for a new paradigm. Doctors McWhinney, Carmichael, White, those at Keystone (AAFP retreat), et al. are proposing and airing their ideas. To me, they are not attempting to write in stone, but are raising the bar on future negotiations for a change process. We must consider their words. Times are changing, there are many warning signs, and the public is growing restless. In my opinion, the concepts presented by these leaders can be a beginning point for a new and necessary revolution in family medicine philosophy. Lead and the warriors will follow. Lawrence Silverberg

I am not sure if call is intended to have educational value. Although it sometimes does, call is more about the responsibilities of patient care. Its teaching value is in preparing learners for the demands that may be placed...am wondering more and more if we are losing something. " Dan Sontheimer 2001

In its meeting in June last year the AMA added two principles to its Code of Ethics. One of those, Principle IX, says "A Physician Shall Support Access to Medical Care for All People." It will be interesting to see how widely known and accepted that change becomes and what practical implication it has for policy, lobbying, and outcomes in real terms. It might be interesting for those of us who support the idea to challenge the AMA to "walk the walk" in addition to "talking the talk." Stuart Sprague, M.D. 2001

Change is always more troublesome than sitting still. Change is most easily accomplished at the medical school-college interface or in the first two years of medical school. Innovation at this level will never have much effect on the educational program, because the majority of a doctor's education comes after that period of time. Any significant change will have to affect the clinical years of medical school, internship, residency, and postgraduate education. Eugene A. Stead, Jr., M.D. 1982

“...the rural population is a vulnerable one because of occupational risks, for example, of fishing and farming. We also know that seniors, single mothers and their children, and others who lack mobility are vulnerable, too often because of the dual impact of poverty and isolation. A search through publications reveals little research has been undertaken..." -Toward Development of a NRHS 1999

Both the ideal and the reality of rural community are hard to define. -Troughton 1999

The reality of what presently constitutes "rural" in many developed countries, most notably in North America, needs to be critically examined and redefined to meet the requirements and challenges of the twenty-first century. -Troughton 1999

Medical schools in West Virginia, Arkansas, the Dakotas, and others are asking for more information in implementing the RPAP (MN) model. The massive transition in clinical undergraduate, graduate, and postgraduate medical education as proposed here would help to cut medical education costs and upgrade medical care and education throughout the state. It will produce a more humanistic physician with a broader knowledge base and steeped in primary care and family medicine experience, as recommended by the New York State Commission on GME and the AAMC. The hostile polarization of people towards hospitals and physicians will be reduced, eventually helping to alleviate the current malpractice crisis and producing more of the right physicians for the right place. Verby, et al 1989