Joshua Freeman on the shortage of rural family physicians

Retention of Rural Family Physicians After 20–25 Years: Outcomes of a Comprehensive Medical School Rural Program

By Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W. Markham, MD and Abbie J. Santana, MSPH
Journal of the American Board of Family Medicine, January-February 2013 vol. 26 no. 124-27

“The shortage of primary care physicians in rural areas, especially family physicians, has been a serious problem for decades, with major implications in access to health care for a substantial proportion of the US population….Retention is a key component of the rural physician supply, in part because it has a multifold impact on the rural workforce; for example, one physician practicing in the same rural area during a 35-year career has a similar impact as 5 physicians who practice for an average duration of 7 years…”.

The authors describe the impact of the Physician Shortage Area Program (PSAP), a special program at the Jefferson Medical College of Pennsylvania that “…recruits and selects medical school applicants that have grown up or lived in a rural area or small town for a substantial portion of their life after college and who were committed to practicing family medicine in a similar area” and provides them with other experiences during medical school. “Of the 37 PSAP graduates [from 1978-86] who originally entered rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 (including 5 in adjacent counties). Comparable data for non-PSAP graduates showed that 24 of 52 (46.2%; P = .02) were in the same rural area (including 5 in adjacent counties).”

These are really good results, demonstrating that the PSAP at Jefferson is effective in training students who not only enter rural practice but remain in it over time. And, they indicate, “PSAP outcomes are similar to those of the 5 other RPs with published outcomes.”


The Redistribution Of Graduate Medical Education Positions In 2005 Failed To Boost Primary Care Or Rural Training

By Candice Chen, Imam Xierali, Katie Piwnica-Worms, and Robert Phillips
Health Affairs, January 2013, 32(1):102-110

ABSTRACT Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation’s hospitals, largely in an effort to train more residents in primary care and in rural areas. However, when we analyzed the outcomes of this recent effort, we found that out of 304 hospitals receiving additional positions, only 12 were rural, and they received fewer than 3 percent of all positions redistributed. Although primary care training had net positive growth after redistribution, the relative growth of nonprimary care training was twice as large and diverted would-be primary care physicians to subspecialty training. Thus, the two legislative and regulatory priorities for the redistribution were not met. Future legislation should reevaluate the formulas that determine GME payments and potentially delink them from the hospital prospective payment system. Furthermore, better health care workforce data and analysis are needed to link GME payments to health care workforce needs…

Note:  Today’s message on the shortage of rural family physicians was prepared by Joshua Freeman, MD, Professor and Chair of the Department of Family Medicine at the University of Kansas Medical Center. He also writes a highly commendable weekly blog on Medicine and Social Justice, accessible at:


By Joshua Freeman, MD

What is wrong with this picture? Taken together, these studies show us that despite the fact that we know what strategies work to increase the number of rural family physicians, they are not being truly embraced by policymakers at either the medical student or resident level. The PSAP and similar programs are effective, but are far too small. Twenty percent of Americans live in rural areas, but over the 9 year period studied in which 37 PSAP graduates entered rural practice, Jefferson Medical College, which has an enrollment of over 250 students a year, thus graduated over 2200 students. This is at a school with one of the nation’s most successful programs; at many schools it is much worse. At the graduate training (residency) level, only 3% of redistributed positions went to rural training, despite that being a primary intent of the policy.

The problem is that there are powerful forces whose interests conflict with these goals. Medical schools and their faculties are often more interested in replicating themselves by recruiting students with high grades who will enter medical subspecialties or research than they are in recruiting students who will meet the most urgent healthcare needs of our nation. The same motivation affects graduate medical education, where most training positions are not in primary care, and the vast majority are in urban centers. In addition, hospitals, which are the main sponsors of residency training, tend to be more focused on their own interests than the community’s. They therefore prefer residents and fellows in specialties that can make them more money or lower their costs rather than those training to be rural primary care providers.

At the medical student level, programs like PSAP need to be dramatically increased, even if taking more students committed to rural practice decreases the number admitted who have more “traditional” strengths. At the residency level, loopholes must be closed so that new residency positions intended to create more rural primary care doctors are not instead used for other, more popular or more financially desirable, specialties. To the extent that medical schools and hospitals can “game” the system, they will, so policymakers must recognize these tendencies and explicitly block them.