Wednesday, January 9, 2013

Fwd: qotd: Joshua Freeman on the shortage of rural family physicians

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Joshua Freeman on the shortage of rural family physicians
Date: Wed, 9 Jan 2013 06:36:12 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

Note:Today's message on the shortage of rural family physicians was
prepared by Joshua Freeman, MD, Professor and Chair of the Department of
Family Medicine at the University of Kansas Medical Center. He also
writes a highly commendable weekly blog on Medicine and Social Justice,
accessible at:

Journal of the American Board of Family Medicine

January-February 2013vol. 26no. 124-27

Retention of Rural Family Physicians After 20–25 Years: Outcomes of a
Comprehensive Medical School Rural Program

By Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W. Markham,
MD and Abbie J. Santana, MSPH

"/The shortage of primary care physicians in rural areas, especially
family physicians, has been a serious problem for decades, with major
implications in access to health care for a substantial proportion of
the US population….Retention is a key component of the rural physician
supply, in part because it has a multifold impact on the rural
workforce; for example, one physician practicing in the same rural area
during a 35-year career has a similar impact as 5 physicians who
practice for an average duration of 7 years…"./

The authors describe the impact of the Physician Shortage Area Program
(PSAP), a special program at the Jefferson Medical College of
Pennsylvania that "…/recruits and selects medical school applicants that
have grown up or lived in a rural area or small town for a substantial
portion of their life after college and who were committed to practicing
family medicine in a similar area" /and provides them with other
experiences during medical school. "/Of the 37 PSAP graduates /[from
1978-86] /who originally entered rural family medicine, 26 (70.3%) were
still practicing family medicine in the same rural area in 2011
(including 5 in adjacent counties). Comparable data for non-PSAP
graduates showed that 24 of 52 (46.2%; P = .02) were in the same rural
area (including 5 in adjacent counties)."/


These are really good results, demonstrating that the PSAP at Jefferson
is effective in training students who not only enter rural practice but
remain in it over time. And, they indicate, "/PSAP outcomes are similar
to those of the 5 other RPs with published outcomes."/


Health Affairs, January 2013, 32(1):102-110

The Redistribution Of Graduate Medical Education Positions In 2005
Failed To Boost Primary Care Or Rural Training

By Candice Chen, Imam Xierali, Katie Piwnica-Worms, and Robert Phillips

ABSTRACT Graduate medical education (GME), the system to train graduates
of medical schools in their chosen specialties, costs the government
nearly $13 billion annually, yet there is little accountability in the
system for addressing critical physician shortages in specific
specialties and geographic areas. Medicare provides the bulk of GME
funds, and the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 redistributed nearly 3,000 residency positions
among the nation/'/s hospitals, largely in an effort to train more
residents in primary care and in rural areas. However, when we analyzed
the outcomes of this recent effort, we found that out of 304 hospitals
receiving additional positions, only 12 were rural, and they received
fewer than 3 percent of all positions redistributed. Although primary
care training had net positive growth after redistribution, the relative
growth of nonprimary care training was twice as large and diverted
would-be primary care physicians to subspecialty training. Thus, the two
legislative and regulatory priorities for the redistribution were not
met. Future legislation should reevaluate the formulas that determine
GME payments and potentially delink them from the hospital prospective
payment system. Furthermore, better health care workforce data and
analysis are needed to link GME payments to health care workforce needs…

/Comment, by Joshua Freeman, MD/

What is wrong with this picture? Taken together, these studies show us
that despite the fact that we know what strategies work to increase the
number of rural family physicians, they are not being truly embraced by
policymakers at either the medical student or resident level. The PSAP
and similar programs are effective, but are far too small. Twenty
percent of Americans live in rural areas, but over the 9 year period
studied in which 37 PSAP graduates entered rural practice, Jefferson
Medical College, which has an enrollment of over 250 students a year,
thus graduated over 2200 students. This is at a school with one of the
nation's most successful programs; at many schools it is much worse. At
the graduate training (residency) level, only 3% of redistributed
positions went to rural training, despite that being a primary intent of
the policy.

The problem is that there are powerful forces whose interests conflict
with these goals. Medical schools and their faculties are often more
interested in replicating themselves by recruiting students with high
grades who will enter medical subspecialties or research than they are
in recruiting students who will meet the most urgent healthcare needs of
our nation. The same motivation affects graduate medical education,
where most training positions are not in primary care, and the vast
majority are in urban centers. In addition, hospitals, which are the
main sponsors of residency training, tend to be more focused on their
own interests than the community's.They therefore prefer residents and
fellows in specialties that can make them more money or lower their
costs rather than those training to be rural primary care providers.

At the medical student level, programs like PSAP need to be dramatically
increased, even if taking more students committed to rural practice
decreases the number admitted who have more "traditional" strengths. At
the residency level, loopholes must be closed so that new residency
positions intended to create more rural primary care doctors are not
instead used for other, more popular or more financially desirable,
specialties. To the extent that medical schools and hospitals can "game"
the system, they will, so policymakers must recognize these tendencies
and explicitly block them.

No comments:

Post a Comment