Selections and Going Rural

Dr. Durel's posting, with permission 6/27 11 am

May I please add another view to the discussion of attracting physicians to rural medicine? A recent post: ...The cultural challenges are too great" deserves more discussion.

Years ago, some of us in a public health setting, discussed the problem of inadequate health care in rural Appalachia. It was clear that a substantial part of the problem was that few well-educated people want to raise their own families in such a setting. Included among the cultural challenges may be poor schools, social isolation, a lack of the usual denominational churches, scouting, and such for families. As we noted, why, after having
"escaped" such poverty (financial and cultural) through our education, would we want to put our own families there? Indeed, many of our parents worked very hard to get their families to areas with better "opportunities."

If we are serious about providing health care in under-served areas, then it seems to me that we must address these cultural challenges. I don't have answers for this, but do believe that answers begin by being honest about the problems. While more providers raised in rural environments than in suburbs and cities may be willing to serve in rural (or inner-city) America, it is likely the few will stay if staying presents real hardship for their
families.

Do the foreign-born docs stay in U.S. rural settings because these are much better than those of their homeland? Do American-born docs choose, as do most of us, to raise families where the cultural challenges are less great?

If this factor does address a fundamental problem, then perhaps part of the answer is found in encouraging short-term service in under-served areas (rather than in giving preference to premeds from under-served areas). The military has models for such situations; for example, families stay put when the service member is posted (usually for a short time) to an area not conducive to family life. Perhaps the time has come to put the Public Health Service in under-served areas.

May we have a discussion? (I apologize for the lengthy message.)

Lynn A. Durel, Ph.D.
Associate Professor     Psychology
University of Miami

Posted on the Health Prof site by RCB 6/26 3 PM:

Kansas had a golden opportunity a few years back to take Wesley foundation money and work to encourage the right kids to go to medical school. Instead the money was diverted to preventive health and then to medical school use and as far as I can tell, there has been very little impact. In fact it is hard to find out what ever happened to the money.

Kansas FP programs, included rural oriented ones, suffer from lack of interest and I attended the farewell for the Topeka FP program a few weeks ago. Over half of this program's last graduating class was going into rural areas, similar to previous classes. Now this source of rural Kansas docs is gone also. Others in the state found out too late and no one stepped forward in state or medical leadership to help them. This happened to the residency where I had my first teaching job in Bartlesville OK in 1988.

Kansas has 40+ counties with less than 10,000 people at least one doc and a hospital. It is second only to Texas with 60 such small health systems. These are the most challenging areas to recruit and retain physicians. Kansas must learn to grow its own doctors. Kansas, like Nebraska, will rarely be able to keep a foreign-born physician or an urban born one for that matter. The cultural challenges are too great. Now if we had rural foreign-born physicians, we might have a chance, but this is rarely the case. Adjusting to US culture, and to a specific rural culture is a tremendous challenge.

In the Nebraska section, one of our small rural colleges, Peru State, is on the chopping block. The issue so far is urban vs rural and whether to cut one a lot, or many small amounts. Of course the fact that this school graduates many young leaders for the southeast corner of the state that help support jobs, services, and the economy is not a current issue.

For multiple viewpoints of the J-1 Visa issue from the AAFP Rural list serve (obtained and posted by permission), go to my web site at http://www.unmc.edu/Community/ruralmeded/RMEPost/j1_visa.htm  Oh, and by the way, foreign physicians are in competition with your students in many ways already, with more likely to appear.

Also have added student questions about rural lifestyle and rural practice and rural doc comments at
http://www.unmc.edu/Community/ruralmeded/model/medsch/student_dreams.htm  and at
http://www.unmc.edu/Community/ruralmeded/RMEPost/internal_med_vs_fp.htm

Robert C. Bowman, M.D.

Restoring Rural America by restoring Young Professionals to small towns
 

Health prof posting by Dr. Lechner, by permission

Some of you may be familiar with the character Dr. Neil MacNeill in the novel "Christy" by Catherine Marshall, in the CBS drama series (circa 1994) based on that book, and in several recent feature-length movies that also are based on the book. The doctor really existed; "Christy" is a fact-based work with the names changed. The character Christy Huddleston was based on Leonore Whitaker, the author's mother.

"Christy" is set in the Great Smokies circa 1910. MacNeill grew up in the mountains and was befriended as a teenager by a group of vacationing physicians whom he served as a hunting guide. They saw the poverty and lack of medical care in that community, and decided to finance MacNeill's education in the belief that he would return home to practice, which he did.

Lynn Durel is right that physicians may not want to go to a disadvantaged area, practice there for most of their careers, and raise their families there. That they were foreign-born and that socioeconomic conditions are better in rural USA than in their nation of origin may not change this. Physicians are more likely to serve an underserved area if it is their home and they have emotional, family, ethnic and cultural ties to it. The character Neil MacNeill loved his mountain cove, loved its people, and devoted his career to them. That much is true to life. In the movie I saw last night, MacNeill ended up marrying the teacher, Christy. That part didn't turn out that way in real life; she really married the preacher.

Joseph H. Lechner, Ph.D.

Professor of Chemistry

Mount Vernon Nazarene College

800 Martinsburg Road

Mount Vernon, OH 43050-9500

[740] 397-9000 extension 3211

Mount Vernon Nazarene University after August 1, 2002

Originally posted on Health Prof list serve 6/27 5 PM

I would encourage you to examine current thinking regarding American health care for rural areas. The postings reflect the thoughts of many in this nation. Some are assumptions that need to be examined. The source of such assumptions includes many top officials. In his support letter for the National Health Service Corps, Jordan Cohen noted the following in Academic Medicine in 1998:

Please note that Dr. Cohen has since embraced improve admissions and collaborative care. He may have even had some time to visit some rural sites or examine his past work and may have changed his mind in some of these areas. If not he may want to do some visits. What he has written has been passed on by previous leaders and associations. A fresh examination may result in other beliefs.

I would like to highlight three common assumptions in this one paragraph.

1. Life long physician relationship - First of all, never try to wean people from the notion of having a life-long physician. The country does almost everything wrong to discourage a lasting doctor-patient relationship and it is very wrong. Eventually you will need a doctor for more than a cold or sore throat or infection, and a long term doctor can be a trusted friend and advocate. If you doubt this, then you have likely not had such a relationship or the medical school that selected and graduated such a physician did not do a good job. The best physicians have usually had significant or traumatic life experiences that have caused them to examine what really makes a good physician and have endeavored to become that kind of doctor.

My four years in Nowata OK did much more training to make me a better physician. My life experiences have also improved my quality of care. This training continues with my patients and colleagues and family even today. Next there is a feeling that temporary physicians are OK for underserved peoples. This is a rationalization that really represents discrimination in a not so subtle form. Why should underserved peoples have less experienced physicians? My entire career has taught me that underserved people need the best trained physicians who are able to do complex problem solving in more than the medical arena. Getting to know patients takes time learning about them, their families, the community, the social resources of the community, oh and yes, it is important to be able to practice medicine well.

Next, a minor point about our military physicians. It is very likely, although not proven by any study, that the military competes with the same pool of physicians that do rural and underserved primary care. If we were not taking so many into the military FP programs, we would likely have more rural and underserved docs. Again the controlling variable is willingness to serve and to some degree, need for financing.

Finally, please do not accept my word for more than face value. My perspective is a bit unique. Many of my ideas are untried. You and others in your area may have more experience and more practical knowledge. I value multiple perspectives as we attempt to answer complex questions. More than a few times I have made bad assumptions and have even spread them.

BOB, THANKS FOR THE RESPONSE, YES, DO POST MY COMMENT TO THE RURAL MED LIST

SERVE. I LOOK FORWARD TO A DISCUSSION. I WILL CHECK YOUR SITE.

Some background. At the time (late 70s) I became sensitized to the issue, I

had just moved to Kingsport, TN and was teaching at East Tenn. State

University (undergraduates). Their med. school was fairly new then. The

area outside, especially to the west, of the Tri-Cities area

(Kingsport-Johnson City-Bristol) is extremely poor and "under-served"--which

is why the med. school is there. Execs of coal mining companies commuted

long distances to work while they and their families lived in Kingsport

(with excellent public schools because Eastman Kodak chemists and engineers

work there). Indeed (if I remember correctly) the county adjacent to

Kingsport includes the town of Spring Hill. This town gained notoriety years

ago because it is apparently a center for a snake-handling religion and the

school system refused to use textbooks approved by the state system, deeming

them too liberal.

Accustomed to thinking of "rural" in terms of the mid-West, I was shocked. I

remember thinking to myself that no graduate of ETSU med. school would

willingly settle in that county. And, it was very unlikely that people

living there would be able to become docs or nurse practitioners because

their educational system was so poor and it seemed that most had no

expectation of any college education. (I taught some classes in Western

Kingsport nearer to the rural areas; many students were very poorly prepared

for the simplest college classes.)

That situation was such an eye-opener that now I am rather distrusting when

people talk about students from under-served areas who "deserve" to go to

med. school because they want to and because they might return to the

under-served area. Frankly, I think that a good many advisors on the

HLTHPROF listserv see themselves as advocates for these students AND NOT FOR

SOCIETY AS A WHOLE WHICH NEEDS WELL PREPARED DOCS. I teach many premed

undergraduates from a broad range of high school situations. They tend to

think they are smart enough and well educated enough to go to med school.

(Grade inflation is so bad here that they do well in the easy courses they

seek out and "only" have trouble with math and science! They can't

understand why they do poorly on the MCAT.)

I suspect that premeds all over the country tell non-faculty advisors that

they are well prepared for med school and such advisors believe them. (Well,

they tell us faculty too, but we know about their performance in the

classroom.) Some advisors seem to discount the value of the standard test

scores (SAT and MCAT) and emphasize GPA and "desire." I think these advisors

are primarily dealing with minority, inner-city students.

So, the bottom line, I would make distinctions about undergraduate students

from under-served areas. Those from the rural mid-West are likely to be

better educated on average than those from inner-cities and, say, very poor

rural areas of the South (simply because I know these somewhat). And the

Mid-Westerners are likely to come from a culture that values academic

achievement. Those I teach tend to be from schools, homes, communities, that

do not value real academic achievement. (Please understand that I do not

denigrate their characters; their daily lives may be so difficult that

academic achievement is not really possible. We have many high schools here

in Florida and the Miami area that produce mostly illiterate grads.)

Indeed, years ago I had a premed student here from the mid-West. She had

come here on a basketball scholarship and really struggled to play ball and

do premed. Although her academic record and test scores were a little less

than competitive, she had very strong support from the docs in her town in

the Mid-West. I was pleased to support her application and was thrilled when

she got into med. school. My bet is that she will return to practice

medicine in her home town. I think these are the students you are talking

about.

I want to learn more about the cultural challenges you speak of and more

about the area you want to attract docs to. What do you do to get docs to

your area? And, what about rural areas in, say, the Mississippi Delta and

Appalachia? Does it make sense to have a program sort of like the Peace

Corps where the docs (and nurses and others in health care) would serve for

a couple of years to work off part of their loans?

I try to interest students in the military (Public Health Service, Indian

Health Service) as a way to get an MD without taking on astronomical debt.

(We have a student who will be going to a Boston area med. school this Fall

who will be borrowing $60 just for the first year! She probably already has

debt from her undergrad. education.) But most are not interested in these

programs and are willing to take on the debt if they can get into any med.

school, even the expensive ones. Even if she is interested in practicing in

an under-served area, she will need to seek a position and a specialty that

will pay enough to get the loans paid off--probably not under-served general

practice. Such a dilemma.

I could go on (you have guessed this). This is all a worry to me. I hope you

will post to the HlthProf listserv some of the strategies you use to get

docs to under-served areas. I will be listening. Thanks for listening.

lynn durel

--

Lynn A. Durel, Ph.D.

Associate Professor

Psychology

University of Miami

Wow Really enjoyed your messages

I also spent time at ETSU from 1989 - 1992 and my only hands on med school admissions experience was one year there. We did have some students with difficulty with grammar and writing, but they managed to do well in med school and excel in residency. You also know about the examples where the rural schools would close because it was so cold and they could not afford the extra heating bills. Mountain city managed to redo economics, jobs, and health, but schools still got less than $2000 per student per year and changing school supers each 2 or 3 years was the "solution". The distrust in authority is thick and makes it most difficult to organize anything.

Hazard is doing pretty well with their osteopathic school, hopefully they will pick kids that take advantage of their opportunity.

Pennsylvania - In regard to variability across the nation, clearly the secondary education systems make a huge difference. Rabinowitz with the PSAP program in Pennsylvania benefits from one of the best state ed systems in the nation and one of the largest rural populations. He is able to work with the 5 small college advisors to really fine tune the kids that will be likely to return. His PSAP program with only 1% of medical students in the state now boasts 21% of the rural docs in the state, with incredible retention rates. This to me speaks of super selection. Studies show that 78% of rural decision is rural background plus FP interest. Retention studies in all other situations in many other states show no difference rural and urban background or spouse background (Pathman) The fact that Rabinowitz gets rural choice (recruitment) plus retention again suggests super selection.

Kentucky - On the other hand, Rick Blondell in Louisville does feel that they do all they can to pick any and all rural kids that will survive academically, of course many of these do not have the same desire to return that Rabinowitz has. As a result, KY needs feeders reaching out into middle school. ETSU was much like this, so was NC.

In Nebraska we are in the middle and late high school interventions seem to work. This seems true in the Midwest. Another factor is the degree of rurality, which makes Nebraska, Kansas and Texas, with lots of really small rural health systems challenging. If we have better large towns more spread throughout the state like Iowa, it would be much better for locating a variety of services in small towns. Arkansas actually did decentralize medical education and residency training and the health care segment was more widely spread in 7 regions. I think this has really helped the entire state distribute better in a number of areas. As we face another series of cutbacks, the reverse is likely to happen.

In Nigeria, they will need to start at 10 and 11 years old in order to get the right kids prepared by age 17 to take their big determining exam. At this age it is difficult to choose those who want to return, much easier in college or high school.

Interestingly the ETSU and eastern folks did not seem to appreciate my midwestern videos and examples. Different types of rural I guess.

Bob Bowman