Is There a Doctor in the Town?

(Editor’s note: This story is part of a special report for The John A. Hartford Foundation.)

Before enrolling in medical school at Michigan State University (MSU), Carter Anderson worked as a paramedic for six years. For the first time, he saw what health care is like in much of rural America.

“Some people there never saw doctors, and we’d be their only contact for medical care,” he said. “We could really make a difference in people’s lives. I wanted to incorporate that into my work as a doctor.”

Now in his fourth year in MSU’s Leadership in Rural Medicine Program, Anderson plans to practice medicine in Traverse City (population 15,500) and serve the wider surrounding rural areas of northern Michigan.

The U.S. has a critical need for young physicians like Anderson who want to work in rural communities. Despite concerted efforts to increase the rural workforce, the long-standing shortage of physicians and other medical personnel is expected to worsen as the population ages and physicians retire.

There is a physician shortage across the nation, but it “is exacerbated in rural areas,” said Dr. Janis Orlowski, a physician and chief health care officer for the Association of American Medical Colleges.

Orlowski experienced the shortage firsthand, when her parents moved from the Chicago suburbs to rural Wisconsin. They were unable to find a primary care doctor who took new patients. “We looked in a 40-mile range,” she said. Her parents ended up driving four hours to Chicago to see their former physician.

Twenty percent of Americans live in rural areas, but only 10 percent of physicians practice there, according to the National Rural Health Association. At the same time, 18 percent of those in rural communities are 65 or older, compared to 12 percent in urban areas.

Those on Medicare are much less likely to have prescription drug coverage than their urban counterparts. They are also poorer by more than $9,200 a year per capita.

“When you look at rural populations, they are older, they tend to be less well-insured, they have more chronic illnesses and less access to utilization of preventive services,” said Dr. Byron Crouse, with the University of Wisconsin’s school of medicine in Madison. “The physician workforce also tends to be older.”

These disparities have serious consequences. Over the last 40 years, the gap in life expectancy between rural and urban populations has grown, with rural residents living increasingly shorter lives. According to a 2013 study, “… [cardiovascular disease], respiratory diseases, lung and colorectal cancers, diabetes, and kidney diseases are becoming increasingly important determinants of excess mortality in rural areas and among the rural poor.”

Improving access to health care is one factor that could help close the gap, the researchers noted.

In addition to demographics, some say the Trump administration’s immigration policies and proposed budget cuts may worsen the shortage. According to research published on the Health Affairs blog, the 2017 executive order restricting visas from six predominantly Muslim countries could have a significant impact on rural medicine.

Physicians trained in Iran, Libya, Somalia, Sudan, Syria and Yemen (Venezuela and North Korea were later added) provide 14 million appointments in the U.S. annually, including 2.3 million in rural and other underserved areas. (The visa restrictions were challenged in court and the Supreme Court will hear arguments on April 25.)

In addition, an AAMC analysis of the administration’s FY 2019 budget request found that a $48 billion cut in graduate medical education payments that support new physician training would exacerbate the shortage, especially in small rural hospitals.

Although doctor shortages in rural areas persist, medical schools and the federal government have developed successful programs aimed at recruiting young doctors to such underserved areas. The challenge now, say experts, is to expand what works.

Among the proven strategies is the National Health Service Corps (NHSC), which helps physicians and medical students with student loan debt relief in exchange for service in underserved areas. Some 10,200 NHSC doctors are now at work, many of them in rural areas, with another 1,400 in training. Most stay and practice in underserved communities.

In 2017, NHSC gave nearly $282 million in scholarships and medical training loan repayment to students and clinicians (doctors, nurses, dentists, physician assistants and nurse midwives), who are willing to practice primary care in underserved areas, including in rural communities.

In its recent budget agreement, Congress modestly increased funding for the program to $310 million annually. Yet NHSC had to turn down thousands of qualified applicants.

MSU’s Leadership in Rural Medicine program recruits medical students such as Anderson who will plant roots in rural communities. “We’re really looking for people who plan to practice long-term,” said Dr. Andrea Wendling, who directs the program. “We have really good outcomes.”

The program annually admits 24 students who have been accepted into MSU’s medical school. It targets students who either come from rural areas or who have had significant experience there. Studies have found that students with rural roots are more willing to practice in rural communities.

Another critical component is placing these students in rural medical settings rather than trying to convince them to relocate after medical school.

“If you train at an urban tertiary-care center, you learn how to practice medicine in that setting,” said Wendling. “If you’re then placed in a 25-bed critical care center you don’t even know how to practice. You’re used to calling cardiology and the team will come down and you have a lot of support.”

In contrast, at a small rural hospital, a doctor has to stabilize patients, perform triage and know when to transport patients safely. “It’s a different type of skill set,” Wendling said.

For Anderson, this has meant two years of full immersion in rural Michigan, including going to family practice clinics and a 63-bed hospital.

“It’s pretty teeny, but I’ve gotten some amazing hands-on training,” he said. “Falling in love with these communities is an incredible opportunity. And it’s been great to see how much the doctors and the hospitals are excited to have students there. They bend over backwards to make us feel welcome and part of the team.”

One study found that over 30 years, Leadership in Rural Medicine graduates were more likely to practice primary care in a rural high-needs area than were their MSU medical school counterparts who trained on the main campuses. “Our most exciting finding was that 27 percent were actively practicing in the [rural] Upper Peninsula,” said Wendling.

Another successful program is University of Wisconsin’s Wisconsin Academy of Rural Medicine (WARM). Like MSU’s program, WARM recruits students from rural communities “who are comfortable with a breadth of activities” rather than a narrow specialty, said Crouse, who directs the program.

Medical students begin their training in Madison and then move to one of three centers to learn how to practice in a rural area.

Since 2007, 45 WARM students have graduated and set up practice, more than half of them in rural Wisconsin. “And 38 percent of our graduates are in their home community, which is probably twice what I would have predicted,” Crouse said.

Similar programs are in many other states. Yet given the small number of graduates, it will take much more to meet the need.

“It would take money and personnel resources such as faculty in rural communities,” Wendling reflects. Experts say more institutions need to set up community-based training and to foster admissions policies and programs to attract students from rural areas, who often do not think medical school is even a possibility for them.

Crouse added: “We need to be mindful and vigilant, whether as an academic member of the community or as a consumer. I’d want to hold our institutions accountable for meeting the needs of our community, our state and our nation. We know what works.”

By The John A. Hartford Foundation

The John A. Hartford Foundation is a private, nonpartisan, national philanthropy dedicated to improving the care of older adults. The leader in the field of aging and health, the Foundation has three priority areas: creating age-friendly health systems, supporting family caregivers, and improving serious illness and end-of-life care.