Minnesota programs serve as model for recruiting primary care, rural doctors

The need for primary care doctors and rural physicians is growing while the number of these health practitioners is shrinking. But Minnesota has found a way to counter that trend. 

A recent study from The Council on Graduate Medical Education found that fewer than 20 percent of all U.S. medical students choose primary care specialties, a number that has been steadily declining in the past 20 years. USA Today reported that since 1997, there has been a 53.7 percent decrease in medical school graduates who choose residency in family medicine. The low compensation, the long hours and the administrative work may all be reasons why fewer medical students choose to go into primary care, while even fewer choose to do so in rural areas.

Minnesota recognized the need for primary care and rural physicians years ago, and in the late 1960s two programs--the Rural Physician Associate Program (RPAP) and the medical school at the University of Minnesota-Duluth--were created within the university system to address the issue. In fact, the success of these two programs is the reason why UMD graduates more rural physicians than any other school in the country.

An April 2010 paper, published in the journal "Academic Medicine," detailed the outcomes of the programs. Professors from the University of Minnesota-Twin Cities and UMD found that of those who participated in both UMD and RPAP, 86 percent chose general primary care and 77 percent chose family medicine. This is substantially higher than the national trend of only 20 percent choosing primary care specialties. Additionally, the study found that 54 percent of those participating in both programs chose rural practice, and participation in either program recruited 34 percent to rural areas. Again, these are substantially higher numbers than the national average of 4 percent. Over the lifetime of RPAP, 64 percent of participants still practice in a rural setting.

But the exact opposite is happening around the country. The American Academy of Family Physicians predicts there will be a 40,000 family medicine practitioner shortage in the U.S. by 2020.

What's causing the sharp decline?

First, there's the compensation issue. A study by the Medical Group Management Association found that between 2005 and 2008 the median starting salary for primary care physicians has increased 7.4 percent to $150,000 compared to a 25 percent increase, or a $275,000 starting salary, for all other specialties during the same period.

Then there's the workload. Every day, primary care physicians spend a substantial amount of time on urgent but uncompensated tasks such as answering telephone calls and emails, refilling prescriptions, reviewing lab results, and consulting with other physicians, according to study in the New England Journal of Medicine.

The study looked at a five-physician practice in Philadelphia and found that each physician had an average of 18 patient visits per day, 24 phone calls, 17 emails, and 12 prescription refills to manage, as well as 20 lab reports, 11 diagnostic imaging reports, and 14 reports from consultants to review. All this work added up to an average work week of 50 to 60 hours, and by the end of the year, nearly three weeks was spent on administrative constraints dealing with third-party payers.

Equally concerning as the lack of primary physicians is the overall lack of physicians of all specialties in rural areas. According to a recent US News and World Report article, although one in five U.S residents live in rural areas, only 9 percent of physicians practice there. The same article also states that fewer than 4 percent of recent medical school graduates intend to practice in rural areas.

So what is Minnesota doing right?

The UMD medical school bases its admissions procedures on predictors of specialty choice and practice site, meaning they emphasize rural origin and interest in family medicine at the time of admission. Once admitted, students participate in the Family Medicine Preceptorship Program in their first year. The program places each student with a practicing family physician and the students meet with their preceptors 10 times during the year. Sessions vary across days and times to expose students to a variety of activities. In the second year of medical school, students live with a rural preceptor for three days to gain exposure to the physician's everyday work responsibilities and lifestyle.

RPAP is designed for third year medical students, who spend nine months in a rural community under the mentorship of a primary care preceptor and experience the full scope of primary care and rural living. RPAP is open to students from both the Twin Cities and Duluth medical school.

When RPAP was established, it was the first program of its kind in the country. Up to that point placement in rural settings were only six to eight weeks long. Dr. Keith Stelter participated in RPAP at UMD in 1987 and is now on the RPAP faculty.

Stelter grew up in a town of 700 and was interested in the program when he began medical school. He wanted the opportunity to train in a smaller town, and through RPAP, he did a residency in Blue Earth County.  He found that working in a rural area gave him the opportunity to follow his patients over several months and build experience in other fields. For example, Stelter would help the visiting cardiologist understand the background of the patient while he himself learned about cardiology.

When Stelter was in his fourth year of medical school, he did his residency in Minneapolis. While there, he would change hospitals every four to six weeks and found it frustrating that he seldom got to follow up with patients or learn how their procedures and illnesses turned out.

Twenty-three years after participating in RPAP, Stelter still maintains a relationship with his preceptor and his experience is not unique. Life-long relationships are common for RPAP students and their preceptors who function as teacher, mentor and friend.

However, UMD and RPAP don't address the relatively low compensation for doctors who choose primary care or a rural practice.

That problem is helped through the Rural Physician Loan Forgiveness Program at the Minnesota Department of Health's Office of Rural Health and Primary Care, which works to preserve access to rural and underserved areas through the administration of loan forgiveness for health care providers who go to rural and underserved areas.

The loan forgiveness program currently has 151 participants, counting 19 rural physicians, 25 pharmacists, 36 nurses, 23 midlevel practitioners, 38 Nurse/Allied healthcare faculty and 10 dentists. Starting in July, another 32 participants will join the program. One of them is Dr. Christa Waymire, a family physician in Glencoe. When she graduated from medical school, she, like most other recent graduates, left school with a huge student loan.

Waymire's father worked in Glencoe as an emergency room doctor, and having had the opportunity to spend some of her residency at the same hospital, she knew she wanted to work in a rural area. Participation in the program requires Waymire to stay in Glencoe for the next four years, and she is happy to do so. In fact, she intends to stay there for the rest of her practice; something she thinks would have been much harder to do without the money from the loan forgiveness program.

"I think this is one of the few good programs in place to recruit graduates into primary care," Waymire said. "I feel very lucky and very blessed to be participating in the loan forgiveness program."

A 2007 evaluation of the program found that as many as 86 percent of physicians and 93 percent of nurses stayed at their sponsoring facility after their service obligation.

Despite the loan forgiveness program's success, it faces huge budget cuts after 2011 when the $1.295 million state budget will be cut by almost a third. Waymire believes cutting the program will hurt rural placement. "Anything that decreases income will have horrendous effects on primary care and medicine in general," she said.

The recently passed federal health care reform puts the onus on primary, i.e. preventive, care, but there is a shortage of such physicians, especially in rural areas. Minnesota's programs serve as a model to grow and solidify medical students' interests in primary care and rural practice, emphasizing opportunities to hone skills, build relationships and experience the daily routine under a mentor. The loan forgiveness program makes these options financially feasible.

As the demand for primary care and rural doctors increases, the pool of those available shrinks. Minnesota should strive to preserve these successful programs, and other states should take note-the Minnesota model to recruit primary care doctors and rural physicians is working.

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