Strong medicine is needed to solve America’s rural health crisis – STAT

By | July 25, 2019

Growing up in the rural community of Fort Kent, Maine (population just shy of 4,000), I watched my parents struggle to find and keep a primary care physician. When I was young, this town in Aroostook, the state’s northernmost county, had a few die-hard general practitioners and surgeons, but as they retired I witnessed firsthand the toll their departure took on patients and families.

I started dreaming of becoming a family doctor when I was 12. After medical school, I hoped to practice in a community like Fort Kent, but married a city boy from St. Louis who was tentative about rural life and tall snowbanks, and who wouldn’t go any further north than Connecticut.

The health care situation in rural America has gotten worse since my childhood. Rural Americans face serious health disparities because of the shortage of physicians and the resulting lack of access to care. According to the Centers for Disease Control and Prevention, rural residents are generally sicker and poorer than urban residents, and are more likely to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than their urban counterparts. Residents of rural areas who have cancer are diagnosed at later stages of the disease, have less access to clinical trials, worse outcomes, and spend 66% more time traveling to see cancer care providers.

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Since 2010, more than 100 rural hospitals have closed, forcing people to drive extra hours to see a physician or seek medical care. Without the support of an area hospital, it’s difficult to replace independent physicians once they retire.

Seeking help in an emergency is one thing, but how many people will travel long distances for preventive care, or even prenatal and maternal care?

How great is the need for rural physicians? The National Rural Health Association reports a ratio of patients to primary care physicians in rural areas at 39.8 per 100,000, compared to 53.3 per 100,000 in urban areas. Family physicians, who make up only 15% of the physician workforce nationwide, provide 42% of the care in rural areas.

And the problem will only get worse. A Perspective article in this week’s New England Journal of Medicine on the graying of the rural doctor population — more than half of them are now age 50 or older — forecasts that retirement will account for 23% fewer rural doctors by 2030.

Most physicians tend to practice where they trained, and the majority of medical schools and residencies are affiliated with hospitals in urban areas. Rural salaries are also lower, and young physicians often factor loan repayment into decisions about how and where to practice. In its latest survey of medical school graduates, the Association of American Medical Colleges found that among the three-quarters of students in the class of 2018 who needed loans to pay for medical school, the median debt was $ 195,000.

Presidential hopeful Joe Biden, on the campaign trail in northwest Iowa, made improving rural health care a key piece of his strategy for boosting rural America. Speaking at a hospital in Le Mars, Iowa, Biden said his top goals are to keep rural hospitals open and to reduce out-of-pocket expenses paid by rural Americans.

He’s not the first to call for investment into rural health care. Several state and federal programs and proposed legislation also aim to improve it:

  • The National Health Service Corps’ Loan Repayment Program repays the loans of primary care physicians in exchange for working — and earning a competitive salary — in rural, tribal, or urban communities with limited access to care.
  • South Dakota has a recruitment assistance program that offers an incentive payment of $ 231,384 for qualifying physicians or dentists who make a three-year commitment to one of the state’s community clinics, and more than $ 66,000 for qualifying physician assistants, nurse practitioners, or nurse midwives.
  • Alabama, which ranks in the bottom five states for health care, has several innovative programs including scholarships, a rural physician tax credit, and early pipelines to the medical and health professions that target high school students.
  • The federal Rural Physician Workforce Production Act would, if passed, provide funding so rural hospitals could hire more residents. Currently, 99% of graduate medical education funding goes to recipients in urban areas.
  • The bipartisan Training the Next Generation of Primary Care Doctors Act would authorize nearly $ 650 million over five years to train medical residents in low-income, underserved rural and urban neighborhoods. Coincidentally, the bill’s co-sponsor, Senator Susan Collins (R-Me.) is from Aroostook County.

The American Association of Family Physicians found that physicians who practice family medicine, have a rural background, and take part in rotations in rural areas while in medical school are more likely to choose to practice in rural areas. That’s confirmed by a study published in the Journal of Rural Health showing that an eight-week rural rotation was enough to give urban students positive opinions about living and working in rural communities.

Although it may be hard to entice city folks to live in the country, it’s possible if you start early. This is supported by data from the Washington, Alaska, Montana, and Idaho Program (now renamed WWAMI with the addition of Wyoming), that has been doing rural immersion programs for more than 25 years. These clerkships for third-year medical students combine six core components — primary care and family medicine, internal medicine, psychiatry, pediatrics, OB-GYN, and general surgery — in a continuous fashion over nine to 12 months instead of breaking them into traditional six-week “blocks.”

This spring, I returned to Fort Kent as director of the Netter School of Medicine’s inaugural integrated clerkship for third-year medical students. For nine months, four medical students will work in the core components described above at Northern Maine Medical Center in Fort Kent and Northern Light AR Gould Hospital in nearby Presque Isle. (The nearest tertiary-care hospital is almost three hours away in Bangor).

The students work with physicians and nurses as they see patients in the clinic, emergency department, operating room, and labor and delivery center. One of the advantages of working in a rural area is the absence of competition from residents and fellows. This offers ample opportunities for hands-on experiences that are often elusive in teaching hospitals — I’ve heard of third-year medical students finishing traditional obstetrics rotations without participating in a single birth.

Another perk: The students will do all of this in a spectacularly beautiful setting.

Regardless of whether these students decide to live in or practice in rural communities, they will emerge from the program with a new respect for rural hospitals and the joys and challenges of rural medicine.

We need to marshal every resource to solve the looming health care shortage in rural America. Medical schools must create more programs to showcase the variety of options for physicians. Financial incentives must be provided so physicians who want to practice in communities of need can afford to do so. And we need to pass legislation on the federal, state, and local levels to support efforts to provide rural residents with the health care they desperately need.

Traci MarquisEydman, M.D., is a family physician and director of the longitudinal integrated clerkship and rural medicine electives at the Frank H. Netter School of Medicine at Quinnipiac University in North Haven, Conn.

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