Why Doctors Do Go To Small Towns

This was a response to Why Doctors Don't Go They claim that the poor rural economy is to blame and they cannot do anything. Clearly they are misinformed and continue to lead the nation poorly in this area.  Physicians Can and Will Choose Rural Practice

Fixing Maldistribution

For years medical education has lamented the maldistribution of physicians. This, of course, has not stopped the leaders of medical education from approaching government coffers with promises to cure this dread disease. Many of these "cures" have had to do with graduating more doctors. As in medicine, every treatment has consequences. The extra dose of doctors for the country will cost us in side effects for generations. All of these "treatments" had no basis in science, despite a century of scientifically driven medical schools. It is hard to explain why doctors do go to small towns when most studies focus on the problems of rural practice. This type of focus does not attract students and residents to areas where they are needed. Since this is the focus and bias of many leaders, it is no wonder that misconceptions continue and students perceive that there are significant obstacles that disappear upon close examination.

On the other hand, some academicians have worked quietly to research the reasons why doctors do choose rural practice. Often they have worked alone and with little support from their own institution, their state, or other sources. Other rural medical educators have taken this information and created innovative programs that actually do graduate doctors that go and stay in rural practice. 

Incidentally, these programs also graduate more family physicians and primary care physicians and more physicians that are interested in service. According to the AAMC, rural-interested students are also less interested in monetary rewards. All of these are important goals for this nation and have been for over a century.  

Why these programs are still models that are not widely replicated is a mystery in medical education.

Clearly doctors do go where they are needed:

1. When the doctor wants to go to a rural location (and usually knew this before medical school)

2. When the family wants to go to a rural location

3. When medical students and residents see rural practice in a favorable light 

    (and get accurate comparisons of the advantages of rural training)

4. When potential doctors are prepared for the rigors of rural practice

5. When doctors are chosen and trained for personal responsibility and personal management skills

6. When doctors choose the right community

7. When the incentives favor doctors going and staying in rural communities

See getting rural doctors to the smallest towns       More Rural Doctors 

Rockford Rural Health Needs Challenge Doctors 

Medical Schools and Rural Graduation Rates - New Research 2002

Selecting Doctors To Go - Those wishing to get doctors to small towns will select medical students based on a documented desire to go to rural areas. Those who select must be willing to accept some academic risk, some potential for accepting students that will need assistance, in order to admit the right ones. Recent studies by Rabinowitz demonstrate that 80% of getting the right doctors is selection. See PSAP in Pennsylvania, Rabinowitz.

Families That Go - You can actually select candidates who have established roots in rural areas. Data on the family can be used in admissions decisions. The rural spouse is often more important than the trainee in this area. Also, admission programs can reach out into rural areas. This can act to reverse centralization in state education policies so that small colleges can admit as well as the larger urban ones. Some medical schools train rural-interested health professionals together and have found that some rural-rural marriages result, greatly increasing the probability of a rural location. 

Favorable approach - In today's large urban academic centers it is difficult to get a proper orientation to primary care, much less family medicine or rural practice. Because of these issues, it is necessary to ttrain in rural locations with rural practitioners who love their work. This impact needs to be soon enough to make a difference. Some medical schools actually have medical students spend time with rural doctors before medical school classes begin. When in larger centers, efforts need to concentrate on reducing the negative socialization factors so that students are open to rural and primary care possibilities (curriculum and experiences), move medical education to small branch campuses or add major rural group support to existing urban sites (tele-education potential)    

When doctors are prepared - Recruitment and retention are separate items. Selecting for rural interest and rural background select for recruitment. Training involves retention. This means getting the kind of decision making, picking or training for maturity, developing personal skills, etc. Often we are hung up on jumping through the hoops of the accreditation bodies. Of course we need approved programs, but rural programs should focus on what prepares doctors for the rigors of rural practice primarily.

Policy Center One-Pager on Impact of RTT    - more at AAFP Policy Center   

Family Med Residency Prog and the Grad of Rural Family Physicians      Research published in Family Medicine regarding rural months, ob months, program directors, procedures, etc.

Links to Family Practice Residency Sites with Rural Training

Chosen and trained for personal responsibility and personal management skills - We need the best doctors to be rural doctors. We need those oriented to service, not to self. We need them to have leadership experience and decision-making skills. They need to train in programs that allow residents to make decisions on patients. The seven years of medical education should concentrate on these areas. Rural physicians also need personal management skills such as learning to say no, delegation, prioritization, etc. Those who do not have or develop these skills will not stay long enough to impact on the long term care of the community.

Choosing the Right Community - The correct role of training institutions is to connect training to practice. Not only is training important, but marriages between trainees and their rural communities are important. Early contact with communities is helpful in shaping the training of the trainee and program. Academic rural faculty can arrange visits, fairs, noon conferences, rural physician staffing, rotations, interest groups, and act as rural advisors.  Academic centers can support rural faculty who work with rural communities to evaluate, maintain, and improve their health services, integrate care with larger systems, and work with practitioners effectively. Without healthy rural health systems, there are no needs for practitioners. Why train students and residents to go rural if their communities don't have the health system, relationships, and facilities put together? Again this leads to physician turnover. We need rural physicians to stay decades, not a few years.

Retention involves versatility on the part of both resident and community. Both have to adjust to one another for a long lasting marriage. Rural communities can ill afford a regular stream of short term doctors. They cannot afford this economically as each change costs them in market share and loss of patient revenues. They cannot afford the high cost of orientation and start up, estimated at well over $250,000 per loss of doctor by AHQR.

Incentives to go and stay - Income is not a top priority, but debt load can be a problem. Rural physicians must be able to care for their families, their rural patients, and those they work with. Low reimbursement rates are a problem that needs constant attention. Most need assistance with debt repayment, technical assistance, and other areas. Some need support to make the multiple adjustments to the challenges of rural practice. Innovative programs are working to establish some retention efforts at the local level, involving community members who also plan to stay and really care. (See Partnerships - Hilda Heady)

Appeal for a Collaborative, Continuous Approach

The problem will not be solved by government programs alone. It takes a team work between rural communities, governments, and academic centers so that graduates can go and stay in rural communities. Responsible medical and academic leaders would facilitate the adaptation of models and relationships that would accommodate the training of more future rural physicians. This should be done regardless of training cost or incentives, because it is the right thing to do socially and scientifically. It should also be facilitated by the state and federal governments because it is the right thing to do from the health, economics, and education perspectives.

Physicians Can and Will Choose Rural Practice

Community Driven Approach

Osler and Rural Practice

I love rural practice because

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