WASHINGTON – Rural family medicine residency programs are doing what they can to attract more primary care physicians to underserved areas and keep them there, but they are faced with an ever-larger task. Rural communities will be the most hard-pressed to meet growing demand for physicians as more Americans gain health insurance and seek a regular medical care provider, said several experts at a forum on Capitol Hill sponsored by the American Academy of Family Physicians.
The majority of the nation’s rural areas are underserved by physicians, and in particular by primary care.
Alicia Ault/Frontline Medical News
Dr. Ted Epperly
The problem is exacerbated by the fact that the number of medical school students choosing primary care residencies still lags far behind those electing to pursue other specialties, said Dr. Ted Epperly, president and chief executive officer of the Family Medicine Residency of Idaho in Boise.
"It all starts with making sure we have a pipeline developed of training broad, well-trained, comprehensivists," said Dr. Epperly. Generalism is the most important attribute needed for primary care, but "what we’ve created is a system of subspecialization, so at a time when we need a complex skill set to be able to handle problems, we’ve micro-detailed our physicians into looking at the left kidney," Dr. Epperly said.
Some 62 million Americans, or 20% of the nation’s population, live in a rural area, said Amy Elizondo, vice president of program services at the National Rural Health Association. Only 9% of the nation’s physicians practice in rural areas, and 77% of the 2,050 rural counties in America are designated as Health Professional Shortage Areas by the Health Resources and Services Administration (HRSA). A shortage area is one in which there is one or fewer primary care physicians per 3,500 people, according to HRSA. The agency estimates that, as of Nov. 14, there were 5,800 total primary care shortage areas in the United States, which can be located in urban or rural areas. It would take an additional 7,500 primary care physicians to end the shortages in all of those areas, said HRSA.
Physician organizations and HRSA, among others, have been trying to figure out how to draw more primary care doctors to those areas. The Affordable Care Act established a grant program for states looking to study their workforce issues, but so far HRSA has not been given any money by Congress to fund any grants. When the State Health Workforce Development Grants were announced in 2010, the Department of Health and Human Services said that almost $6 million would be made available to 26 states.
The ACA also established a National Health Care Workforce Commission, but that, too, has never been funded, although members were appointed in 2010 by the head of the Government Accountability Office. The GAO was given the authority under the health law to appoint the commission’s members.
"Right now we don’t have a unified policy or approach to addressing our workforce," said Dr. Stan Kozakowski, director of medical education at the American Academy of Family Physicians.
Dr. Kozakowski said that another way to boost the numbers of rural physicians was to increase training slots devoted to family medicine and, more specifically, residents trained in delivering medicine in rural areas.
A number of family medicine residency programs have developed a rural training track, which requires residents to spend 1 year in the larger academic medical center, followed by 2 years in the rural area, which may or may not have a hospital. Currently, there are 26 active rural training track programs. All are strapped for funding because fewer than half are eligible to receive traditional graduate medical education funding from the Centers for Medicare and Medicaid Services (CMS), said Dr. Randall Longenecker, professor of family medicine and assistant dean for rural and underserved programsat the Ohio University Heritage College of Osteopathic Medicine in Athens.
But the programs have proven to be effective, said Dr. Longenecker, who is also the executive director of the new nonprofit RTT Collaborative. He cited data showing that, 3 years after graduation, almost half of recent rural training track participants had continued to practice in rural areas and about a third were serving in professional shortage areas.
"The biggest challenge for retention is getting people to live in a rural place," said Dr. Longenecker, adding that, by living and training in the area for 2 years, physicians learn how to live there.
"The longer they stay, the longer they stay," agreed Dr. Epperly. He said that 85% of the physicians trained through the rural sites of the Family Medicine Residency of Idaho end up practicing in those areas. Another key is to help spouses become acclimated, which his program does through group outreach, Dr. Epperly said.