Sunday, December 15, 2013

Guest Post: To solve rural health shortages, train more family physicians

- Robert C. Bowman, MD

Training more family physicians is the obvious solution for all of the practice locations with low physician concentrations. Across 30 states behind in graduate medical education positions, across 40,000 zip codes with lower concentrations of physicians, across 2900 counties lower in physician concentrations, and especially for rural locations in need of workforce, family physicians are the multiple times solution.

It is a matter of mathematics. As concentrations of physicians decline due to health, economics, income, and other designs, the proportion of family physicians increases. Family medicine stays relatively constant at 30 per 100,000 while other specialties follow the pattern of higher concentrations found where other specialties are more concentrated. For rural workforce or for workforce where it is needed, family medicine is a 3 times greater solution.

Comparing the 2013 version of the American Medical Association Masterfile to the 2005 version, family physicians have increased to 28% of rural physician workforce and overall numbers are steady. Internists represent 13% of rural physicians and falling. Pediatricians are 6% of rural physicians. General surgery and obstetrics-gynecology each contribute 5%, and general orthopedics 3%, but all are declining. Rural areas have very specific workforce needs for generalists and general types of specialists: fields that are poorly addressed by current training designs.

Physicians coded by county concentrations yield the same proportions of physician specialty contribution for counties with lowest concentrations or less than 150 physicians per 100,000 (27% from family medicine, 13% from internal medicine, etc.). These 2438 urban and rural counties represent 28% of the American population most left behind. Typical training designs do not work well for counties lower to lowest in physician concentrations. Will the current recommendations to train more physicians actually result in care being provided where unmet demand is greatest?

To address physician shortages, the Council on Graduate Medical Education has recommended more trainees in internal medicine, in geriatrics, in psychiatry, and in general surgery. The evidence suggests that training more residents in internal medicine or general surgery will not resolve the major problem of few graduates remaining in general internal medicine or general surgery.

In rural America, it is most commonly the family physician who provides critically needed services in internal medicine, geriatrics, pediatrics, inpatient care, women’s health, emergency care, and mental health. In 1000 counties with the greatest rural workforce challenges, about 8% of the family medicine workforce serves this 8% of the U.S. population - the half of the rural population that is most disadvantaged in key areas such as health status, health access, education, income, employment, and insurance coverage.

The solution that can best increase the number of family physicians, add value to the care given, and increase family physicians where they are most needed is also common sense. All years of preparation, all training years, and all practice years must be specific to community-engaged family practice. Family physicians should guide middle school and high school children and patients and local family practice interest group students into a future of family medicine. Recent Graham Center Policy One-Pagers in AFP have demonstrated that comprehensive medical school rural programs targeting family medicine and support for in-state family medicine residencies produce family physicians where they are most needed.

We must not lose sight of family medicine's unique contribution to rural health care. We must also not lose sight of workforce solutions arising from rural areas that can benefit most Americans who remain in need of basic health care.


Dr. Bowman is a North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and a long term chair of the STFM Group on Rural Health. He maintains the World of Rural Medical Education and Physician Workforce Studies web sites and blogs at Basic Health Access.