Rural Medical Scholars

The issue of healthcare on this island intimidates me so thoroughly that (as you have probably noticed) I largely avoid it.

But recently I started thinking about what I could contribute to the debate and it occurred to me that if I approached reporting on the subject the way you would eating a bicycle — one small(ish) piece at a time — it might just be do-able.

So I picked out a piece of the crisis on which to focus: the shortage of family physicians in rural areas.

And I found someone to discuss it with: Dr. William Curry, associate dean for rural programs and primary care at the University of Alabama School of Medicine in Birmingham.

And here I should explain something before you get lost: The University of Alabama (UA) and the University of Alabama at Birmingham (UAB), along with the University of Alabama in Huntsville (UAH), make up the University of Alabama System. Each university is an autonomous institution and together they count 70,000 students.

The UAB School of Medicine has its central campus in Birmingham, but has regional campuses in Huntsville, Tuscaloosa and Montgomery. The Tuscaloosa campus is located on the campus of The University of Alabama in Tuscaloosa and is part of the College of Community Health Sciences (which Dr. Curry used to head).

Got that?

I contacted the UAB Medical school after reading about its Rural Medical Scholars Program — one of a number of such programs in the United States — in a US News & World Report article by Joseph P. Williams. The program, which was established in 1996, has a mission:

…to produce physicians for rural Alabama who are leaders in developing healthy communities.

The Tuscaloosa campus was the first to have an RMSP program, but about 10 years ago, UAB Medical School established a similar program — the Rural Medicine Program — with the College of Sciences and Mathematics at  Auburn University (located in Auburn, Alabama),

Between the two programs, there are 22 spaces each year for potential rural doctors.

UAB public relations manager Bob Shepard put me in touch with Dr. Curry who, he said, “is our primary coordinator of the various efforts to boost access to care in underserved areas such as rural communities.”

I spoke to Dr. Curry by phone on Monday.

 

Recruits

He started by telling me something about Alabama:

We’re a very rural state with the exception of we have several metropolitan centers — Birmingham, Huntsville, Mobile, primarily — that are relatively large, but then most of the rest of the state is rural, rural and small town. And that’s where we have a problem with having enough physicians, especially, of course, primary care physicians…

This figure from the Association of America Medical Colleges (AAMA) “2017 State Physician Workforce Data Report” illustrates the problem: it shows active primary care physicians per 100,000 population by degree type. Alabama, you will note, is well below the median level of 90.8:

I asked if doctors in Alabama, like doctors here in Nova Scotia, tend to gravitate toward urban centers and medical specializations and he agreed, but then dug a little deeper:

Why are people more interested in urban areas? Well, of course, that’s lifestyle usually…Part of that is the reason to try to select rural students. There’s good research out of North Carolina and Pennsylvania…that…shows someone from a rural background is four times as likely to end up in rural practice as someone from a non-rural community.

Curry characterizes the medical school’s rural education programs as a “pipeline” for rural family physicians. The first step, he says, is to:

…identify students from rural backgrounds who at least believe they have an interest in having a career in rural medicine…There are some programs that reach back as far as high school and then there are some that connect with people toward the end of college or at the end of college…

[The] medical school admissions process is a very important part. Recruiting students to apply, helping them to be qualified, having medical school admissions criteria that take into account that these students may need a little more academic help but they’re going to help meet the mission of our medical school when they go out into practice.

More about that “academic help” in a moment. First I want to tell you what Curry had to say about that other siren call — the one luring medical students away from family medicine and into specialized fields:

Why do people want to select specialties? Well…some of that is money driven, I don’t know how much variation there is in the Canadian system, but there’s a lot here — two or three times as much, it wouldn’t be unusual, compared to what a physician makes. If you’re a cardiologist, you might make two or three times that, it all depends on circumstances, but it can certainly be a lot more. And even though the training takes a little bit longer, still, in a lifetime, you make a good deal more money.

And sometimes the lifestyle is much better — a specialist…can control their hours and their workload and that sort of thing more easily than a family physician, very often, who’s just trying to meet the needs of their community…

So, we’re trying to find ways to address that. It helps for students to get some background and mentoring about how to select a community, how to select a practice to go to. They often wind up with someone who’s maybe a Rural Scholar who’s now in practice, [who] connects with the program says, “I’m looking for a partner,” so you wind up with a practice of two, three or four of those graduates in the same place. Or other classmates that are connected, so there is a network, official and unofficial, that builds around that.

Curry then raised an aspect of Alabama’s physician shortage problem that is somewhat different than hours:

[T]he other thing that gets involved is the economics of rural communities. Here, some of them are doing pretty well but a lot of them are very challenged economically and…so that’s a barrier…that, obviously, may create a problem with having a practice that brings in enough patients with good insurance that can help pay the bills, to manage the overhead, to make the practice sustainable. That may be a little more unpredictable than the Canadian system.

We can’t solve those from the medical school, but we try to at least make students informed and prepared when they get out of here.

 

Catch-up time

To qualify for the Rural Medical Scholars Program, students must be Alabama residents with a minimum 3.3 GPA and an MCAT score of 495 or higher. Students accepted into the program — either at the end of their junior year or during their senior year of college — are provisionally accepted into the UAB School of Medicine. Then, says Curry:

They get…what’s called a pre-matriculation year — matriculation just meaning enrollment to medical school — so a pre-enrollment year that’s on the Tuscaloosa campus, which is the main campus of the University of Alabama, and there they get a science course, maybe an English composition course, an epidemiology [course], they do some work that makes them eligible, if they want to, for a masters degree in…[the] community health field…But they at least get some additional knowledge and academic skills to get them better prepared for medical school.

Unfortunately, a lot of our rural students when they graduate high school are not well prepared for college and so their college experience may not be as successful as it would be otherwise. And so they will not make it into regular admission to medical school but they’re fully capable of doing it, they just, they need some catch-up time.

During this year they will also have an opportunity to “shadow” a rural family physician, an aspect of the program Curry says is “essential.”

You need to see a good role model so that…you’ll be satisfied that, “This is something I can do,” that it’s achievable, it’s rewarding and it’s sustainable, you know…You need to see it done well. So they will do that in that pre-matriculation year, pre-enrollment year, they’ll have opportunity to do some of that and be strongly encouraged and facilitated to do that.

If, following this pre-matriculation year, they are able to do well enough on the medical school entrance exam, their provisional acceptance “translates into full acceptance” into medical school.

All students, whether in the RMSP or the RMP, spend their first two years on the main campus of the medical school in Birmingham where, says Curry, they’re in a class with everybody else — a class numbering 186 (compared to 112 in the Dalhousie class that will graduate in 2022.)

So, those two groups will spend their first two years of medical school in Birmingham, taking the same curriculum as everybody else but with some contact from the people who run those programs just to try to keep connected. And then at the end of the two years they’re ready then for their clinical two years of medical school…

The RMSP students do those two years in Tuscaloosa while the RMP students spend two years in Huntsville, because there is no medical school campus in Auburn. Says Curry:

[T]hey have experiences that are oriented toward primary care, that emphasize family medicine, but there’s no obligation for them to do that. Then, the Huntsville program now has a bridge program between the fourth year of medical school and the first year of residency or internship in family medicine that is very attractive to some students who choose to do that. And that’s been successful, it’s just a couple of years old.

But the point is that, at the end of their medical school, they’re free to do whatever they want to try to match into.

Curry says there’s always some “leakage” along the way in the pipeline, as:

…people decide rural life is not really for them or primary care is not or they have a spouse or someone who has a job that doesn’t fit, isn’t compatible with that. So, all kinds of things can get in the way even of the best intentions, but the idea is to keep people connected to that commitment and interest in underserved populations, especially rural populations, and being a primary care physician.

In fact, Curry says that 18-20 of the participants graduate each year and about 80% of them wind up in primary care, and about 60% end up in family medicine. That, he says, is several times higher than the national average or the UAB School of Medicine average.

It’s much higher than the percentage of Dalhousie students — 20.4% — who listed family medicine as their first choice in 2018. In fact, it’s higher than the percentage in any medical school in Canada last year:

Curry says about the same percentage of graduates — 60% — are practicing in rural Alabama and “remain their over time.”

That US News & World Report story that sparked my interest in the program reports that of the 220 students enrolled in the RSMP since 1996, “190 moved on to medical school and 71 became primary care doctors practicing in Alabama. Few have dropped out.” (The statistics don’t include the students who’ve graduated from the RMP at Auburn.)

And this 2018 commencement message by medical school Dean Selwyn M. Vickers notes that they had just graduated 177 new physicians, a third of whom intended to spend their residencies in Alabama and 42% of whom (about 75) intended to specialize in primary care.

 

Economics

The two programs discussed in this article don’t have any scholarship money of their own, says Curry, but they are connected to programs that do:

[T}here are several other sources. One is, we have what’s called Primary Care Scholars, that’s an internally funded program of the Medical School, with several scholarships per campus and about half of those positions are filled out by rural scholars.

Then we have a state scholarship program that’s funded by the State of Alabama and again, that’s for rural primary care practice and a large number of the people who claim those scholarships are Rural Scholars out of these two programs. That program has a lot of requirements and if someone doesn’t fulfill the requirement of practicing for several years in a rural area there’s a big default payment that’s due, but these students, they don’t default, they get out into practice and stay there when they take that scholarship.

This brought us back to the issue of money again, and Curry raised the specter of debt:

Medical student debt, I think, is similar in Canada to what it is in the US…and that can be another factor in someone saying, “I need a higher-paid specialty to work in so that I can pay my debt off more quickly and it’s not as burdensome.”

The research around that, as to whether that really drives a career decision is a little hard to pin down. So, you get people arguing that, “Oh, we don’t have proof that that matters,” but if you just talk to students, they’ll tell you it matters [laughs]…

[S]it down and talk to some students thinking about their career, they’ll tell you, “Yeah, if you can take some or all of my debt away, that makes it easier for me to be a family physician in a small town. Which is what I really want to do if I can.”

On the flip side, though, is the economic benefit a physician brings to a rural community:

You know, here we say it’s about $1.1 million per year that that physician will generate for that community. If that physician has obstetrical skills, then that goes up to about one and a half or one point six million dollars. So that’s the economic impact per year on that community.

The point is, if you put a physician out there, there’s a lot of economic value to that community — and of course there’s a tremendous amount of health value for the health and safety of the community. So, economically if you’re just trying to say, how do we justify the expense of something like that? It certainly has an economic impact on the community as well as all the rest.

Curry says the main expense of the rural medicine programs is staff time:

It’s not like you can just do it all by email and expect it to happen, it has to have some face-to-face time for the recruiting, for the admissions process, for mentoring people, for supporting [them] through the whole course.

The program hasn’t been “as easy” as they would have liked, he says, but it has certainly enjoyed “some success.”

 

Featured image courtesy of the Alabama Rural Health Association.

 

 

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