printThe points of this column are briefly stated:
• If you want to know which medical school applicants will become country doctors, ask them three questions.
• Medical school programs aiming to select and train students for rural careers are effective.
• Rural docs and hospitals may be much more influential than they realize, particularly if they join with other primary care interest groups.
Currently, allopathic schools, i.e., those that grant M.D. degrees, are increasing in size and number. With notable exceptions they have generally disavowed any responsibility for their graduates' career choices — for their choice of specialty or location.
There is a lot of information on who is likely to become a country family doc scattered through the journal Academic Medicine over the last 40 years, but the April 2012 issue, with its papers and bibliographies, can get you started on the subject in a couple of evenings.
In this article, Howard Rabinowitz, who has spent a professional lifetime on rural medical education, followed up graduates of Jefferson Medical College 30 years after graduation to see who was in rural practice.
He analyzed his results on the basis of what was known at the time of admission, examining three self-reported factors. These are the three questions that a medical school could ask if it wanted to pick students who would take up a career in rural America.
1. Did the candidate grow up in a rural community?
2. Did s/he plan to practice in a rural community?
3. Did s/he plan a career in family medicine?
Each positive added 15 percent to the probability of a rural career. All three positives got you 45 percent. Twelve percent of the graduates with no positives on admission are now in rural practice; impressive, especially for a private medical school. Obviously there is a lot more to the story but these questions will do for now. The point is that all that data was available to the admissions committee.
Council of State Governments Map shows the counties that are underserved — in red or yellow for counties that are partially underserved. Long-term follow-up of the graduates of the rural programs of Jefferson, the University of Illinois at Rockford and the University of Minnesota, Duluth, suggest that about half of the graduates of dedicated medical school rural programs wind up in long-term rural practice.
That sounds pretty impressive to those of us accustomed to figures below 10 percent of graduates in rural practice for many medical schools.
When I was a brand new assistant dean going through my first accreditation review 35 years ago I asked Dr. Gus Swanson, who was in charge of the review for the Liaison Committee on Medical Education, "Why is it so hard to get schools to do what everyone knows they should do?"
He replied, "You have to understand, for practically all schools, medical students are a byproduct. The school's main product is either referral care or research."
Case in point: The University of Kentucky in 2011 had an overall state appropriation of $310 million dollars for everything from English to engineering to medicine. The budget of its academic medical enterprise was over $870 million. It is interesting to ponder, who is the most powerful person on campus? Realize that a sizable proportion of that medical business is referred from rural areas. The numbers are different but the pattern is similar in many schools across the country.
Case in point: Some years ago Duke University decided to abolish its Family Medicine residency or department, I can't remember which, and it doesn't matter. In response, the family docs around the state steered their elective referrals to other academic medical centers. Within a week the decision was reversed.
Obviously not all state universities with medical schools run under the sort of financial structure I cited, but many medical schools are big referral businesses. It is not unreasonable for those responsible for the care of rural, and for that matter, other disadvantaged people, to hold the schools responsible for the results of their offerings.
Outcome expectations should be negotiated and made explicit up to a decade in advance. This would have the additional advantage of moving the very substantial lobbying influence of the medical school toward support for primary care.
Note that I said "results." You should be monitoring the percentages of graduates practicing what is needed, where they are needed, by your school. Realize that rural people in need of primary care and other specialties have much in common with inner city minorities. Rural and inner city people should join forces and link interests.
Don't underestimate the difficulty of the transition. Our allopathic schools have played leading roles in shaping our anonymous, fragmented, overspecialized health care situation. Many schools are doing very well thereby.
The underlying question is whether those schools will be able to adapt to patient-centered, rather than organ-centered care, and to prepare doctors to work in it. Maybe you can help them.
Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine. This article first appeared in the Spring issue of Rural Monitor.