One of the myths about rural family medicine is that country physicians don’t have a desirable lifestyle. Nothing could be further from the truth, says John R. Bowling, DO, the assistant dean for rural medical education at the University of North Texas Health Science Center Texas College of Osteopathic Medicine (UNTHSC/TCOM) in Fort Worth.
“Family physicians in rural Texas and all over rural America can do well financially and have time for their families and outside interests,” Dr. Bowling says. “Unlike rural family physicians, those in urban areas are less likely to see hospital patients. And they are less likely to do obstetrics, they do fewer procedures, and they typically don’t do testing in their offices.
“Urban family physicians basically have outpatient office practices and use the evaluation and management codes in billing, while rural family physicians do a lot and bill for a variety of services.”
Dr. Bowling and other educators who oversee rural medicine programs are attempting to dispel misconceptions while recruiting those most likely to practice in small country towns. These programs aim to reverse a brain drain: Future physicians who grow up in rural locales are less likely to return if they attend college and medical school and pursue graduate medical education in urban areas.
Rural areas contain 20% of the U.S. population but only 9% of the physicians, according to the National Rural Health Association (NRHA). To alleviate the growing shortage of primary care physicians in rural America, approximately five osteopathic medical schools, including UNTHSC/TCOM and the Des Moines (Iowa) University College of Osteopathic Medicine (DMU-COM), and 30 allopathic medical schools have rural medicine tracks, states a policy brief issued by the NRHA in September.
But that publication neglects to mention several osteopathic medical schools that integrate rural primary care into their overall missions, including two consistently ranked among the top 10 medical schools in rural medicine by U.S. News and World Report: the University of Pikeville-Kentucky College of Osteopathic Medicine (UP-KYCOM) and the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg.
Educators at rural-focused schools have adopted a multipronged strategy for encouraging students to pursue rural family medicine: Recruit the right enrollees, immerse them in positive rural clinical experiences, and help them find loan-repayment opportunities and rural graduate medical education spots.
“If you take students from rural Appalachia and train them in rural Appalachia, they are more likely to stay—that’s been our model since our school’s founding,” says AOA Trustee Boyd R. Buser, DO, UP-KYCOM’s dean and vice president for health affairs. That paradigm applies to other regions of the country as well.
Identifying best recruits
The rural scholars program at UNTHSC/TCOM, a state school, recognizes that students who grow up and attend college in rural Texas are more likely to eventually practice medicine in rural Texas. Consequently, Dr. Bowling has developed relationships with smaller colleges and universities in the state, which tend to draw students from rural high schools.
“I prefer not to take students from large urban-based schools,” says Dr. Bowling, who reviews applications from prospective students who indicate interest in the rural scholars program. Even those from rural backgrounds can easily become infatuated with the night life, cultural attractions, conveniences and perceived career advantages of city living, he notes.
For a number of reasons, rural-raised premedical students may be less competitive academically than those from more populous locales. Individuals from small country towns are more likely to be first-generation college students who may not have the depth of exposure to the physical and biological sciences beginning in high school that students from metropolitan areas have. Often economically disadvantaged, more apt to marry when they’re younger and start college later in life, rural premeds frequently juggle jobs and family responsibilities in addition to coursework.
“We look at a student’s whole portfolio when deciding whom to accept into our program,” Dr. Bowling says. “It’s not just about academics.” Many factors are considered, such as an individual’s understanding of rural health care needs and passion to practice osteopathic family medicine.
Beyond students with rural roots, Dr. Bowling sometimes recommends for acceptance applicants with other strong ties to rural America, such as having fond memories of spending summers on a relative’s farm or ranch or having a spouse who grew up in a small town.
But rural medical schools and programs also consider candidates who want to sever their city roots and who have genuine interest in rural practice.
WVSOM’s Robert Foster, DO, has developed a number of interview questions to identify candidates who would make enthusiastic country doctors.
“What do you like to do for fun?” is one of the most telling, according to Dr. Foster, an associate dean. Candidates who enjoy hiking, fishing and canoeing are more likely to take to rural life than those who love golf, tennis and dining out.
“How do you visualize yourself in 10 years?” is another key question. “We want to get a sense of who these candidates are and what they want to do beyond medicine,” Dr. Foster explains. “You can’t live in a rural community and do only doctoring. You have to be a well-rounded person to communicate with everybody in town.”
Dr. Foster also likes to ask prospective students about their community service experience. He looks for personal commitment to specific causes.
“Many medical school applicants have done various community service projects just to get school credit or listings for their curriculum vitae,” Dr. Foster says. “I’m looking to see if they have a passion for something, whether it be hospice care or helping victims of domestic violence. I’m looking for students who have served their community because it sang to their hearts.” Such individuals are more likely to relish the extensive community involvement expected of rural doctors, he says.
In addition, interviewees who seem snooty or pretentious rather than down-to-earth are weeded out as being a poor fit for rural practice, Dr. Foster says.
Before they can be accepted into UNTHSC/TCOM’s rural scholars program, Dr. Bowling requires candidates to shadow one of the rural Texas physicians who serve the school as clinical preceptors.
Dr. Bowling explains during the interview process that rural scholars spend their entire third year away from Fort Worth, moving from one rural clinical site to another. “I tell candidates that if you have a spouse or a significant other for whom this is going to be a problem, you need to resolve this now, not in your third year,” he says.
If a candidate volunteers that he or she is married, interviewers can discuss related issues. One hurdle to rural practice today is the prevalence of dual-profession couples. Physicians may be reluctant to settle in a small town if their spouses can’t find employment there.
Priming the pump
Schools that emphasize rural medicine provide students with early clinical experiences and exposure to the types of injuries and illnesses common in rural areas.
“Our students have early exposure to primary care practices, and the curriculum in the first two years is dominated by primary care doctors,” Dr. Buser says. First- and second-year students at UP-KYCOM spend considerable time with family physicians around Pikeville.
On campus, the family medicine department has the most influence. “Family medicine and primary care are portrayed as important through a role-modeling perspective,” Dr. Buser says.
Because the rural track at DMU-COM is interdisciplinary, osteopathic medical students take classes alongside physician assistant and nursing practice students. “We’re doing interdisciplinary rural medicine so they understand one another’s capabilities,” says David Plundo, DO, the college’s associate dean for clinical affairs. “Rural family physicians have to rely on PAs and NPs.”
Students in DMU-COM’s rural program receive instruction in dealing with agricultural emergencies. “Last year, we brought in a grain bin and lowered some students into it,” Dr. Plundo says. “Other students had to rescue them. Then we talked about the issues involved in resuscitating people caught in this situation.”
At WVSOM, students are taken on extended field trips to observe and speak with miners, loggers and laborers on natural gas fields to learn about the hazards of these occupations. “The students get to talk to people about their health and about their insurance,” Dr. Foster says. “You can’t just teach rural medicine in a classroom.”
In UNTHSC/TCOM’s rural scholars program, first- and second-year students receive instruction that supplements the regular curriculum. When studying the respiratory system, for example, the students would work on a separate case in which the standardized patient they interview and examine has a condition more common in rural regions.
“It might be lobar pneumonia that developed after chronic exposure to bacteria in an agricultural environment,” Dr. Bowling says. “I always try to twist the case in a way that makes students think about what can occur in a rural setting.”
The rural scholars also learn to perform more procedures than other students do. For example, they are taught how to insert central lines and chest tubes and perform colonoscopies on a simulator.
“I bring in rural family physicians who do these procedures, so students understand that this is what they will do when they’re in practice,” Dr. Bowling says.
During their third year, UNTHSC/TCOM’s rural-track students serve rotations at various small to medium-sized community hospitals in rural Texas.
“They are one-on-one with the physician, so they get more hands-on experience,” Dr. Bowling says. “During the surgery rotation, they don’t have to stand behind fourth-year students and residents. They are at the surgery table with the attending. Usually they first-assist on anywhere from 120 to 150 procedures.”
Because Lewisburg is a mountain town with fewer than 4,000 people, WVSOM students experience rural living while on campus in their first and second years. “Although the town has cultural attractions and restaurants, unlike some small West Virginia communities, we don’t have a shopping mall,” Dr. Foster says.
In their third year, students at WVSOM serve most of their rotations in one of six rural communities in or near West Virginia. By staying in one place, students get to know the townspeople, which is a key aspect of being a country doctor.
But during their fourth year, WVSOM students are expected to serve some rotations at hospitals outside of West Virginia. “It’s not good to train in one place because then you’re just seeing one style of practicing,” Dr. Foster explains. “So we want our students to get out there.” This way, students acquire greater breadth of knowledge and develop more awareness of when and where to refer seriously ill patients, he says.
WVSOM also encourages third- and fourth-year students to serve international rotations in Third World countries. “If students get the experience of caring for people who are really in need, this helps them grow spiritually and emotionally and it reinforces their desire to serve the underserved in rural America,” Dr. Foster says.
WVSOM, UNTHSC/TCOM and other rural-focused DO schools have forged relationships with rural family medicine residencies in the regions they serve. But some residency programs are better than others, notes Dr. Bowling, who has developed a set of standards for rural family medicine residencies that has been approved by the American College of Osteopathic Family Physicians and the AOA. These standards require rural GME programs to train residents in a wide range of procedures.
Since medical students from rural areas often have fewer financial assets to begin with, their student loan debts can be especially crushing. To lure physicians to rural locales, many states and hospitals will provide loan-repayment assistance in return for a commitment to practice for a certain number of years.
“We help our students find places where they can get loan forgiveness,” Dr. Foster says. “We try to keep them in West Virginia, and we’ve been fairly successful at that.”
Up-front tuition assistance is available at some rural-focused DO schools. DMU-COM, for instance, offers full-ride scholarships to six students a year in its rural medicine track.
At UP-KYCOM, students who agree to enter primary care can take advantage of a tuition-reduction scholarship that is financed through a state tax on coal mining. “There is a service obligation,” Dr. Buser says. “For every year a student takes this scholarship, he or she has to practice in Kentucky for a year in a primary care specialty.”
The amount of the scholarship is equal to the difference in tuition rates between UP-KYCOM, a private school, and the average of the in-state tuition rates of Kentucky’s two public medical schools. “What it does is level the playing field for us,” Dr. Buser explains.
Once a year, WVSOM hosts Rural Practice Day, during which family physicians throughout West Virginia come to the campus to speak with students. “The doctors talk about the joyful lives they lead and how they manage their practices,” Dr. Foster says.
Rural family physicians become close to the families they care for, he notes. They frequently are high school team physicians, county medical examiners and public health officials. Community leaders, they often serve on the governing boards of local banks, libraries and schools.
“Since they don’t have to deal with traffic congestion and other challenges of urban living, rural doctors have a high quality of life,” Dr. Foster says.
Because of the Internet, rural doctors today are less likely to feel isolated than in the past, he notes. They can buy anything online and communicate with anyone anywhere. The main drawbacks are limited store hours and longer drives to airports, movie theaters and good restaurants. But the benefits of rural practice outweigh the disadvantages, as far as Dr. Foster is concerned.
“As we emphasize to students,” he says, “the intrinsic rewards of rural medicine can’t be surpassed.”