Rosenblatt, Roger A. MD, MPH, MFR
Dr. Rosenblatt is professor and vice chair, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington.
Editor's Note: This is a commentary on Chen F, Fordyce M, Andes S, Hart LG. Which medical schools produce rural physicians? A 15-year update. Acad Med. 2010:85;594–598.
Correspondence should be addressed to Dr. Rosenblatt, Box 354696, Department of Family Medicine, University of Washington, Seattle, WA 98196; e-mail: firstname.lastname@example.org.
Persistent shortages of rural physicians have plagued the U.S. health care system for much of the last century. Recent, sharp declines in the number and proportion of U.S. medical students entering primary care have exacerbated this chronic problem because primary care physicians are the foundation of rural health care systems. The article by Chen and colleagues in the current issue of this journal replicates findings of a study 15 years ago by the author of this commentary and his colleagues that demonstrated that a relatively small number of medical schools are responsible for a large share of all of the rural physicians in the country. The lack of progress in the ensuing 15 years is distressing because there is now excellent evidence that targeted rural tracks in medical schools—including selective admissions of students from rural backgrounds and supportive integrated curricula—yield dramatic increases in the number of students choosing rural careers. U.S. medical schools—supported in large part by public funds—have a responsibility to ensure that the specialty choices and practice locations of their graduates meet the needs of the nation at large, as well as the rural and underserved communities in the regions they serve.
Pity the poor medical school. These elite institutions select the best and brightest students from across our nation and train them to become the physicians who sit at the top of the pyramid of our spectacularly skillful health care workforce. Society provides generous support for medical education, with billions of dollars of Medicare educational subsidies flowing to U.S. medical schools and teaching hospitals, and many more billions of federal dollars indirectly supporting these institutions' teaching mission through research funding. Yet despite their obvious success as reflected in the quality and number of applicants clamoring to gain admission to their hallowed halls, and their financial and intellectual clout, medical schools are criticized for failing to meet the health care needs of our diverse and growing society.1
What Is the Social Role of Medical Schools?
Is this criticism justified? The answer to this question depends on what role our 131 American medical schools play in meeting the social and medical needs of the U.S. populace. From an economic perspective, medical schools (and their related teaching hospitals) are multiproduct enterprises, taking care of millions of patients, generating new knowledge, and training health care personnel ranging from physical therapists to lab technicians. Medical student education represents only a small portion of this gigantic enterprise. Yet the revolution in medical education catalyzed by Flexner's historic report a century ago started with the training of the medical student, and this focus remains at the center of the social contract between academic health centers and the American people.2
One notable area where medical education—and by implication the nation's medical schools—have failed is in training an adequate number of physicians to serve rural communities. The issue of the shortage of rural physicians has been in the literature for at least 85 years.3 The problem has in some ways grown more acute as a smaller proportion of U.S. medical graduates enter the primary care specialties—especially family medicine—that constitute the clinical foundation of America's rural health care system.4 This persistent disparity in the geographic distribution of doctors has been attributed to many factors, but one of the most important causes is that most medical schools do not consider providing doctors for underserved populations a central part of their mission.5
As Chen and colleagues6 report in this issue of Academic Medicine, the situation has not changed materially since my colleagues and I7 studied the same problem more than 15 years ago. Chen and colleagues report that 11.4% of physicians who graduated from medical school from 1988 to 1997 were practicing in rural areas in 2005. Our earlier study found that 12.6% of physicians who graduated between 1976 and 1985 were practicing in rural areas when they were located in 1991. Although the methods were slightly different in these two snapshots of the rural physician supply, comparing the two sets of results reveals that the proportion of doctors practicing in rural areas had actually slipped during the 15-year period. And because of the precipitous decline in the proportion of American medical students who entered family medicine from 1997—the apogee for that specialty—to the present, both studies understate the extent of the problem. The shortages of rural physicians in general and family physicians in particular have become more severe in the last 10 years and will continue to fall unless something dramatically changes the current trend.
Can Medical Schools Influence Where Their Graduates Practice?
To what extent are medical schools responsible for the fact that rural areas across the United States have persistent and severe physician shortages year after year? Medical school occupies only one segment of a long educational pipeline. Specialty and practice-location choices of graduates are influenced by many factors, from students' socioeconomic background to the amount of educational debt they accumulate. Perhaps medical schools should be considered an industrial operation similar to an automobile manufacturer: They produce a wide range of models, but don't really have much influence on who buys them or where they are driven.
But the fact that there are large, systematic, and persistent differences in the types of physicians that emerge from medical schools, and in the locations where they choose to practice, suggests that medical schools are not merely passive educational conduits training physicians without influencing their career paths. There are huge differences across medical schools in the propensity of their graduates to seek rural practice, and the relative standings haven't changed much over time. Chen and colleagues demonstrate that DO-granting schools produce more rural physicians, probably because they produce more family physicians than their MD-granting counterparts. But as DO graduates are increasingly subsumed within the dominant medical education culture—and especially as these graduates increasingly seek out specialty residency slots in traditional teaching hospitals—I expect that DOs will make very similar specialty and geographic choices as their MD brethren.
The convenient conclusion for the traditional academic health center is that student preferences and market forces are exerting their invisible and inexorable force on medical students, and that the ultimate choice of practice location cannot be easily affected by medical schools themselves. Convenient, but incorrect. In a series of methodologically impeccable studies across two decades, Howard Rabinowitz and his colleagues8,9 have demonstrated that a variety of medical schools across the country have been able to create rural training tracks that graduate physicians who more often than not end up in rural practice. Given the fact that the absolute number of physicians needed to adequately staff rural areas is relatively small, a targeted commitment on the part of half of the medical schools in the country to such a rural program would address the rural physician shortage.
Can the formula discovered by places such as Jefferson Medical College be replicated? In actual fact, any medical school can increase its output of rural physicians by adopting two interventions. The first is an admissions process that affirmatively encourages acceptance of qualified students from rural backgrounds with rural and primary care interests. The second is a longitudinal curriculum that helps to protect this cohort from the siren song of the dominant medical ethos, by providing them with appropriate role models and satisfying intellectual experiences that reinforce their early predilections.10 In many ways, the process is analogous to ensuring that an adequate number of underrepresented minorities become physicians: targeted admissions processes; creation of a self-reinforcing social group; mentorship; and appropriate curricula.11 Just as a large number of medical schools have committed themselves to increasing racial, social, and ethnic diversity, so could they also embrace a similar goal of admitting a cohort of rural students with a high likelihood of returning to practice in places similar to those where they were raised.
What Should We Expect of Medical Schools?
In our earlier research, we distinguished between public and private medical schools, but this is a false dichotomy. The stark fact is that all MD-granting U.S. medical schools are more public than private, simply by dint of the flow of state and federal funds that sustain the clinical and research activities that subsidize medical student teaching.12 It seems entirely reasonable for the nation to expect in turn that medical schools will pay meaningful attention to producing a mix of graduates that mirrors the public needs.
The persistent shortage of rural physicians is a reflection of the fact that the dominant medical school culture is urban, technologically intensive, and specialty-dominant. Rural physician shortages are in large part due to the systematic bias against primary care that is built into the culture, organization, and reward structures on which our medical care system is built. The growing social and economic disparities across the medical specialties distort our medical care system in much the same way that subprime mortgages contributed to the distortions in the banking industry that plunged the United States into its current economic morass.
Not every medical school needs to undertake the training of future rural physicians. One of the strengths of our system of medical training is the diversity of programs across medical schools. However, given the implicit social contract between academic health centers and the broader public, all of our medical schools have an obligation to acknowledge and identify their responsibility to the society at large.
I would suggest two concrete ways in which our medical schools could make a substantial contribution to improving not only rural health care but also health care for the general public, without undermining the other missions they cherish. First and most important, medical schools should embrace primary care and support public policies that strengthen the allure and stability of primary care disciplines. Nothing has a more pernicious impact on the quality, cost, and availability of health care in this country than the paucity of primary care providers, a situation that complicates fundamental organizational reform, access to care, and the practice of efficient, evidence-based medicine.13 The federal government can help catalyze this sea change by altering the incentives—for example, by increasing primary care educational funding through Title VII and tying Medicare medical educational funds to measurable changes in the workforce composition at both the medical school and postgraduate training levels. But at their core, medical schools need to look outside their own cloistered walls to the needs of the larger public on whose largesse they depend, and for whom they ultimately exist.
Second, a smaller number of medical schools—particularly those situated in medical service areas that include substantial rural populations—can use the three decades of experience accumulated at other medical schools to create effective rural tracks. Getting involved in this effort will stimulate medical schools to reach out to the communities they serve, both by improving math and science education in rural school systems and by supporting the rural medical practices that will be staffed by their own graduates. If these schools are appropriately rewarded by a reallocation of Medicare educational subsidies and appropriate Title VII funds, these new programs should be both affordable and effective.
The time has come to make rural physician shortages in the United States a historical curiosity rather than a persistent reflection of our inability to serve this important segment of our population.
1 Schroeder SA. Training an appropriate mix of physicians to meet the nation's needs. Acad Med. 1993;68:118–122.
2 Cooke M, Irby DM, Sullivan W, et al. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355:1339–1344.
3 Pusey WA. Medical education and medical service. JAMA. 1925;84:281–285.
4 Colwill JM, Cultice JM. The future supply of family physicians: Implications for rural America. Health Aff (Millwood). 2003;22:190–198.
5 Ludmerer KM. Time to Heal: American Medical Education From the Turn of the Century to the Managed Care Era. New York, NY: Oxford University Press; 1999.
6 Chen F, Fordyce M, Andes S, Hart LG. Which medical schools produce rural physicians? A 15-year update. Acad Med. 2010:85;594–598.
7 Rosenblatt RA, Whitcomb ME, Cullen TJ, et al. Which medical schools produce rural physicians? JAMA. 1992;268:1559–1565.
8 Rabinowitz HK, Diamond JJ, Markham FW, et al. Medical school programs to increase the rural physician supply: A systematic review and projected impact of widespread replication. Acad Med. 2008;83:235–243.
9 Rabinowitz HK, Diamond JJ, Markham FW, et al. A program to increase the number of family physicians in rural and underserved areas: Impact after 22 years. JAMA. 1999;281:255–260.
10 Brooks RG, Walsh M, Mardon RE, et al. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: A review of the literature. Acad Med. 2002;77:790–798.
11 Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood). 2002;21:90–102.
12 Reinhardt UE. Academic medicine's financial accountability and responsibility. JAMA. 2000;284:1136–1138.
13 Sandy LG, Bodenheimer T, Parlson LG, Starfield B. The political economy of U.S. primary care. Health Aff (Millwood). 2009;28:1136–1145.