“One of the major problems of rural health is the chronic shortage of health care practitioners in rural, remote and northern areas,” said Dr. Raymond Pong, founder of the Centre for Rural and Northern Health Research in Canada.
In Canada, 31.4 percent of the population lives in predominantly rural regions. And, according to Amy Elizondo, vice president of program services at the National Rural Health Association (NRHA), “Roughly 62 million people choose to live in rural America.”
Despite almost a quarter of the American population living in rural areas, only about 10 percent of doctors practice in these areas. This maldistribution of health care providers in both Canada and the United States is a pressing issue that contributes to health inequality.
Given that remote areas tend to be underserved, several strategies have been examined to rectify the deficit of rural doctors.
“So far, the most effective and lasting strategy seems to be the rural education strategy: training health care providers in rural areas, in smaller towns, exposing them to smaller environments, as well as recruiting trainees from rural areas,” said Pong.
While strategies offering incentives to those willing to work in rural or remote areas are effective to an extent, Pong stated that this leads to a ‘revolving door’ effect with poor retention of health care providers.
A recent publication in Biomed Central Medical Education described the success of an initiative designed at the University of Calgary’s Cumming School of Medicine which introduced students to rural settings during the pre-clerkship years.
In the study, students had the opportunity to take one of their pre-clerkship courses in a rural community. Some of the learning was done via video conferencing and podcasting, while clinical skills and focus groups were led by generalist preceptors at rural sites.
The study demonstrated that there was no difference in academic performance between students in rural and urban settings. In addition, the students described their rural learning experiences as positive, with one student saying, “The preceptors were very enthusiastic and had interesting stories about when things go right, when things go wrong, how you work around the system, and interacting with physicians in the larger centers.”
Successful initiatives have also been implemented to expose medical students to rural communities during the clerkship years. Indeed, the initiative described in the study was part of the longitudinal integrated clerkship at the Cumming School of Medicine.
In this program, students live and complete clerkship requirements in a rural community. Interest in this clerkship model has been high and Dr. Doug Myhre, associate dean of rural medicine and first author on the publication, said they have roughly twice as many applicants as available spots each year.
Myhre and his colleagues have also been tracking the results of the longitudinal integrated clerkship at Cumming. Shortages of rural physicians are a problem in Alberta, the province where the study was conducted, as approximately 20 percent of the population lives in rural communities but only 14 percent of physicians practice in these settings.
“Some communities have now completely reversed their physician shortages and have waiting lists of doctors,” said Myhre.
Myhre stated that 76 percent of students who complete the longitudinal integrated clerkship go into family medicine, in contrast to 32 percent in a matched cohort of students in the rotation-based model.
Again, there was no difference in academic performance between the two groups. Of the students who went into family medicine from the longitudinal integrated clerkship, about 85 percent went into rural practice.
As the integrated clerkship was only introduced in 2008, there is not yet any data from this program indicating if physicians remained in rural practice in the long term.
There have been long-term studies on rural medicine retention of resident physicians, conducted on graduates of the Northeastern Ontario Family Medicine Program.
The Family Medicine Tracking Study was initiated in 1999 and included entry, exit and follow-up surveys of graduates of the Northeastern Ontario Family Medicine Program.
Northern Ontario is a vast landmass with a relatively small and dispersed population. Most of the region has been designated by the Ministry of Health as ‘underserved’ by general practitioners.
While 63 percent of people in the program had grown up in communities with populations under 100,000, 88 percent of respondents practiced in communities of that size after graduation from the program.
Though only a third of entrants had grown up in northeastern Ontario, two thirds stayed there to practice. This suggests that postgraduate training in this rural setting may have influenced the practice location decisions of these physicians.
There are roughly 37 rural-track training programs in the United States, according to Elizondo.
While most rural medicine initiatives aim to recruit family doctors, there is also a need for specialists in rural communities.
The Northern Ontario School of Medicine offers a Northeastern Ontario Postgraduate Specialty program. This program is unique as it examines postgraduate specialty training rather than family medicine training in rural settings.
Pong and his colleagues at the Centre for Rural and Northern Health Research tracked the practice locations of program graduates from its inception in 2000 until 2006. They found that there is a strong positive association between participation in the program and practicing specialty medicine in northeastern Ontario.
Furthermore, those who spent more time in northeastern Ontario were more likely to practice there than those who had shorter rotations.
“In terms of rural medicine as a whole, what you’re getting is an experience that allows you to see a more holistic view of the patient,” said Myhre. He added that learners in rural settings develop better skills with respect to taking a histories and physicals, perform more procedures, and rely less on technology and specialist consultation.
While Dr. Myhre and his colleagues were concerned that students learning in rural areas might feel isolated, the study demonstrated that these students formed tighter bonds with their small groups and took more responsibility for each other’s learning.
One study participant said, “…it was isolating in a sense that we were away from the 180 students that are here at Calgary, but then it was a lot more connected as well because our small group got along really well, so we got to know each other a lot better and we did a lot more things together than we did here in Calgary with everyone else.”
Pong added that the nature of collaboration is different in a rural setting and members of different professions work more closely together than in cities where patients are typically referred.
“Rural training helps you establish a rural network so that you work with not only other physicians but also other professionals in other disciplines,” said Pong.
The problem of maldistribution of doctors is complex, but several initiatives influenced by a growing body of research have shown success in terms of meeting the needs of underserved populations. Additionally, the clinical skill level, dedication and enthusiasm of many rural preceptors tends to impress those with little rural experience.
“You need to push the envelope and you need to have a very long horizon of at least 10 years to see your efforts come to fruition,” said Myhre.
Writer-in-Training
Faculty of Medicine of Memorial University of Newfoundland
Kelly Aminian is a first year medical student at Memorial University of Newfoundland. She holds a BSc in neuroscience from Carleton University and an MSc in clinical neuroscience from King’s College London. Her hobbies include playing harp and travelling.