Improving Health and Health Care in Rural America
January W. Payne

 

The nation's small towns need more physicians, and medical schools aim to fill the gap

For Vincent Proy, 28, deciding to become a rural family doctor wasn't a tough call. His father has a family practice in his hometown of Corry, Pa. (population 6,834), and growing up, Proy saw firsthand what the job was like. "I knew I wanted to practice rural family medicine because of all of the interesting challenges that my father faced," says Proy, who graduated in 2007 from the Physician Shortage Area Program at Jefferson Medical College at Thomas Jefferson University in Philadelphia.

Facing a continued shortage of primary-care physicians nationwide, and an especially tight supply in rural areas and small towns, medical schools are making an effort to recruit students like Proy to launch long-lasting careers in rural areas. Although 1 in 5 U.S. residents lives in a rural area, just 9 percent of doctors practice there, according to a 2002 study. The shortage of primary-care doctors in rural areas isn't new, but it's poised to get worse. Fewer than 4 percent of recent medical school graduates say they intend to start their careers in rural areas or small towns. And the number of practicing physicians will shrink as baby boomers retire.

Many students who choose to go into rural medicine, like Proy, are from small towns themselves and either decide to go back to their hometowns or move to a community of similar size. "Studies show that one of the biggest predictors of [practicing in] a small town is coming from one," says David Luoma, chief executive officer of the Upper Peninsula Health Education Corp., a nonprofit created in partnership with Michigan State University that administers the school's Rural Physician Program. "One of the biggest predictors was the size of your high school graduating class."

It's unusual for students from big cities to choose to practice in a rural area. That's largely because of misconceptions about what making that choice means, experts say. "The culture of most medical schools is that no one in their right mind would want to become a rural family doctor," says Howard Rabinowitz, director of Jefferson's Physician Shortage Area Program. "People tell these students, 'Why would you want to live in a small town? You can't practice good medicine; you can't have a personal life; you can't take care of patients adequately.' " But those are "all myths," Rabinowitz says. Doctors in rural areas "tend to be much happier personally and professionally, [to] have a better life balance," he says. "Really, it comes down to where people want to live."

Rural immersion. To give students an idea of what life as a rural family doctor is really like, rural medical education programs send students to small towns for a portion of their time in school. During their third year, students in Jefferson's program participate in a six-week course in Latrobe, Pa. (population 8,994). In their fourth year, most students work one-on-one with a doctor in a rural area. At the University of Minnesota Medical School's Rural Physician Associate Program, third-year students spend nine months working with a primary-care doctor in a small Minnesota community.

Of course, participation in a rural medicine program is no guarantee that students will go to a small town and remain there. Research that looked at six medical schools with a combined 1,600 rural program graduates over three decades found that 53 to 64 percent of grads practiced in rural areas, according to a review published in March 2008 in the journal Academic Medicine. Doctors who choose to leave rural areas generally cite the workload, income, and a preference for living in a larger city with access to cultural or educational options that may not be available in a smaller town.

Medical schools typically track grads to determine how successful their programs are in encouraging students to go into rural medicine and stick with it. About 75 percent of graduates of the National Center for Rural Health Professions at the University of Illinois -- Rockford College of Medicine are practicing medicine in towns of fewer than 20,000 people, says Matthew Hunsaker, director of the college's Rural Medical Education Program. The University of Minnesota says that nearly half of the more than 1,200 graduates of its program work in rural communities. Rural medicine programs seem to be making a difference in small communities, Rabinowitz says. But retention is key. On average, rural doctors stay about seven years in one rural community, so it takes five doctors to equal the work of one who would spend a whole career there.

Physician retention starts with early recruitment, as students consider which medical programs to apply to. For schools, that means having a presence online and identifying and working with feeder colleges and universities that can refer good candidates. The hope is that by targeting recruitment to students already interested in rural medicine, the rates of students who start practicing in rural areas -- and stay there -- will continue to increase.

For Proy, a small-town practice is a sure thing. "I'm going to work side by side with my dad at his clinic in Corry," he says. He is excited about practicing rural family medicine because he will have to dip his hand into various specialties -- pediatrics, geriatrics, and cardiology, for example -- to care for his patients. "I can't think of any other specialty or field of medicine where it offers such comprehensive medical care," Proy says.

Tip. Many students who go into rural medicine are from small towns. Some choose to return to their hometowns to practice.

Smart Choices

Because of physician shortages, new graduates specializing in infectious diseases or hematology-oncology are sometimes offered the same salary as doctors with more experience. The median annual pay for hematology-oncology grads is $350,000.

Insider Tip

Between 2005 and 2008, the specialty with the greatest salary boost was pulmonary medicine: Median pay rose from $180,000 in 2005 to $249,531 in 2008. The median salary offered to dermatologists was $270,000 in 2008, up more than 37 percent from the $197,000 offered in 2005. But not all specialties saw increases. The median salary for gastroenterologists fell by 1.5 percent over the same period.

Getting In

Build a Base. Medical school applicants should have a strong background in math and science, especially biology, general chemistry, organic chemistry, and physics. Being a doctor also requires good people skills, and a liberal arts background is important, too, including courses in humanities and social sciences. Extracurricular activities like volunteering at a local hospital or medical clinic can also help your application stand out, according to the the Association of American Medical Colleges. About 90 percent of medical school applicants apply during their junior year of college and start medical school right after college. Others take time off after graduation or go through an early admissions or accelerated program while they are still undergraduate students.

Reality Check

The number of female applicants to medical schools reached its peak in 2007 -- 08, with a total of 20,735 applicants that year. For 2009 -- 10, 20,252 women applied to medical school, slightly down from the 20,360 who applied the year before -- About 3.2 percent of all male college grads applied to medical school in 2008 -- 09, compared with about 2.2 percent of female college grads. The disparity becomes more apparent when you consider that more than 57 percent of all bachelor of arts and bachelor of science degrees were awarded to women in 2008 -- 09, according to the AAMC -- For the 2009 -- 2010 school year, median in-state tuition at medical school (public) was $22,800; for out-of-state students, it was $42,210. Median resident tuition at private medical schools was $42,000; nonresident tuition was $42,472 -- Students typically apply to about 13 schools apiece. Medical schools received 562,694 applications from 42,269 applicants for the 2009 -- 10 entering class.

 

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