One Pagers | Jul 01, 2000
Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD
Accredited family practice rural training tracks place their graduates in rural settings at very high rates: 76% overall and 88% among programs implemented in the last ten years. Favorable, immediate results could be expected from their continuation and expansion, permitted by adjustments in the Balanced Budget Act of 1997.
In the early 1960s, concern mounted that a physician shortage was developing. Five comprehensive commission reports published from 1959-1970 recommended that the supply of physicians be expanded. Assisted by public funding, 40 additional medical schools were begun and enrollment more than doubled nationally over a period of just 20 years. Now, after years of steadily increasing this country’s supply of doctors, there is growing consensus that it exceeds need.
Even with this possible surplus of physicians, their maldistribution with respect to both practice specialty and location continues to hinder access to primary medical care for millions of Americans. There is broad agreement that geographically, rural (non-MSA) regions are the most disadvantaged. In 1997, 787 of the 859 counties that were Federally classified health personnel shortage areas (HPSAs) were nonmetropolitan. Another 641 rural counties had been partially designated HPSAs. Historically, the residents of remote, sparsely settled communities have relied on family physicians for their health care. In many rural settings family practice is the only generalist specialty that practice is economically viable.
A variety of programs have been implemented to address this inequity in access to care. Previous research suggests that residents whose training occurs in rural areas and emphasizes services necessary for rural practice, are likely to establish practice in rural communities. Among the 474 family medicine residency programs in this country, 29 have established separately accredited rural training tracks. Information about the practice location of graduates from these rural tracks was collected in September of 1999, by questionnaire. Data were not attained for 7 programs (1 closed, 4 new and yet to graduate residents, and 2 non-responses to the questionnaire). Remarkably, every graduate (all 40) of half (11 of 22) of the reporting programs had established practice in a non-MSA county. Overall, 76.0% (136 of 179) of the graduated residents were serving rural communities. Benefit usually accrued to the state in which the training occurred; of the 136 rural practice sites, 95 were located in the state of residency training.
The effect of the substantial success of the separately accredited rural training track components of family medicine residency programs has been limited by several variables. First, they are small. The largest graduates just 6 to 8 residents annually. Most are new; only 3 had graduated more than 5 classes. The tracks are few in number. This is of particular concern since 1 has closed and another will terminate at the end of this year. However, new starts demonstrated immediate effectiveness; among programs implemented within the past 10 years, 88% (94 of 107) of graduates provided care in a non-MSA county.
This performance for rural placement should be viewed in the context of what has otherwise occurred. Nationally, among all non-Federal allopathic family physicians actively providing patient care in 1997, 21.0% practiced in non-MSA counties. For the other 2 primary care specialties; general internal medicine and pediatrics, the proportions were 8.0% and 7.4% in rural practice respectively.
The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP.
Published in American Family Physician, Jul 1, 2000. Am Fam Physician. 2000;62:22. This series is coordinated by Sumi Sexton, MD, AFP Associate Medical Editor.