One of the greatest challenges facing those who craft health policy is to ensure that people who live in rural America have access to medical care. Although physician workforce analysts differ in their views on whether there are too many or too few physicians in the country as a whole, virtually all agree that the number of physicians practicing in rural communities is inadequate. And there are very legitimate reasons for believing that the number of such physicians will decrease in the years ahead despite the fact that the size of the physician workforce overall will continue to grow.
Over 30 years ago, the U.S. Congress, recognizing that relatively few physicians wished to practice in rural communities after completing their residencies, established the National Health Services Corps (NHSC). That program, which provides financial aid to medical students in return for their commitment to practice in underserved communities after completing their residencies, has been the core of the federal government’s effort to meet the health care needs of rural residents. Over the years, other government programs have been established to complement the NHSC. For example, a number of states now have programs that obligate medical students to serve in rural communities when they complete their training in return for financial assistance. Also, Congress has established a program that releases certain international medical graduates training in this country from the obligation to return to their own countries if they agree to practice for a period of time in a rural community.
While these programs and others are critically important, they cannot on their own provide the number of physicians required to meet the medical care needs of rural America. Unless the number of medical school graduates interested in practicing in rural communities increases, it is inevitable that the situation will grow more serious with each passing year.
One of the key reasons why the supply of physicians for rural America is unlikely to increase in the future is the extraordinary decline in the number of U.S. medical school graduates choosing careers in family medicine. This is a critical issue because physicians trained in family medicine make up the majority of the physicians who decide to practice in rural communities. It follows, therefore, that as the number of graduates choosing careers in family medicine declines, the number of new physicians entering practice in rural communities will decline also. And this will be the case regardless of any increase that may occur in the total number of physicians entering practice each year as a result of greater medical school enrollments.
But even if the number of graduates choosing family medicine as a career would unexpectedly rise, there are a number of factors that make it unlikely that new family physicians will establish practices in rural communities or, if they do so, will remain there throughout their careers. For example, rural communities are often unable to provide career opportunities for physicians’ spouses, and they are generally viewed as having poor schools. As a result, family considerations often dissuade young physicians who are inclined to establish rural practices from doing so. It is also known that physicians practicing in those communities often leave after a few years because they feel isolated professionally, they worry about finding themselves in medical situations they are unable to manage, and they are unable to take time away from their practices to pursue continuing medical education opportunities.
Despite these realities, medical schools must continue to make efforts to interest their students in careers as rural practitioners. And they must also try to enroll students for whom the advantages of being rural doctors outweigh the problems and who thus will make long-term commitments to rural care. Because the challenge is so great, schools that have not established programs for this purpose should consider doing so. To help shape the thinking of the deans and faculties of those schools about what they might do, there is much that can be learned from the experiences of schools that have had successful programs in place for some time.
This issue of the journal offers information about four such programs. Lang et al. describe the program conducted for the past two decades by the Department of Family Medicine at East Tennessee State University. Rabinowitz et al. report the results achieved by the Physician Shortage Area Program of Jefferson Medical College. Smucny et al. describe the results of the Rural Medical Education Program of SUNY Upstate Medical University. And Pacheco et al. describe the impact that the University of New Mexico Family Medicine Residency Program has had on the rural physician workforce in that state.
In considering how appropriate it might be for other schools to emulate these programs, it should be noted that the programs vary greatly in design and that the schools that sponsor them are not all located in predominantly rural states. Indeed, one (Jefferson Medical College) is located in a major East Coast city— hardly the heartland of rural America. It is also important to know that additional schools have conducted similar programs, and that others have used a variety of strategies for interesting their students in rural medicine careers. Shapiro and Longenecker describe one such approach that was carried out by the Rural Health Scholars program at The Ohio State University College of Medicine.
But even if every medical school develops an approach for exposing their students to the challenges and rewards of practicing in rural America, the need for physicians in rural communities will not be met unless the number of medical school graduates opting for careers as generalist physicians can also be increased. I noted above the decline in students’ interest in training in family medicine. But it is also important to realize that the number of internal medicine residents pursuing careers as general internists has also declined markedly in recent years.1 So in a very real sense, the challenge of meeting the need of rural America for physicians is linked inextricably to the challenge of increasing the interest of students and residents in careers in generalist medicine.
To my mind, increasing the supply of generalist physicians is one of the greatest challenges facing U.S. medicine. If those who project a large shortage of physicians in this country are even close to being on target and current trends in specialty choice by graduating medical students remain unchanged, this country will face a major dilemma in the not too distant future. Who will give the kind of comprehensive medical care now being provided by generalist physicians? We need to recognize that the situation currently facing persons living in rural America may well portend what the future holds for many Americans living in metropolitan communities. It isn’t far-fetched to project that the scenarios suggested a few years ago by Schroeder2 will become reality: Those who can afford it will pay out of pocket to be enrolled in a boutique practice in which a generalist physician manages their medical care needs. And those who cannot afford to pay, or who are unable to gain access to such a practice, will have to obtain care in emergency rooms or from nonphysician practitioners of one kind or another. If that situation becomes reality, the very meaning of the practice of medicine and its link to the medical profession will be forever changed.
Michael E. Whitcomb, MD