By Osman Sanyer, MD
Throughout my career as a family doc, it has remained a constant challenge to train and recruit family medicine residents to practice in rural areas, and to retain family physicians in these rural practices. Work force demographic studies suggest that these challenges will continue to increase for years to come. Concerns include the aging of the current family physician workforce, the greater numbers of women becoming family physicians (a significantly greater percentage of rural family physicians are men), and the longer work hours required of rural family medicine doctors.
Programs such as targeting rural applicants to medical school in the recruiting process, rural longitudinal experiences in the clinical years of medical school, rural tracks in family medicine residencies, and state based or National Health Service Corps loan repayment programs have had some success in addressing rural physician staffing needs. However, these programs have not been able to produce the numbers of rural physicians that will be needed in the future (or at present).
In June of this year, I had the opportunity to attend the annual conference of the Rural Doctors Association of Queensland. The conference was held in Caloundra, Australia, in a spectacular setting on the Sunshine Coast. I had arranged to attend the conference in part because I was interested in learning more about the practice challenges for physicians in remote parts of Queensland (which is roughly twice the size of Texas, with most of the population centers collected near the coast) and in part to connect with a former colleague from the Department of Family and Preventive Medicine here at the University of Utah who has spent the past ten years developing a training program and expanding role for Physicians Assistants in Queensland.
The conference also happened to be the graduation ceremony for the Rural Generalist Pathway fellows. The Pathway is a training program for General Doctors (essentially equivalent to our Family Physicians) that sends doctors in training to work with groups of general doctors in inner and outer regional centers for the last two years of their generalist training (the residency is three years total) as well as an extra fellowship year for added specialty training. The specialty areas include: anesthesia, emergency medicine, indigenous health, internal medicine, mental health, obstetrics, pediatrics and surgery. Nearly 90% of the fellows choose programs in anesthesia, emergency medicine or obstetrics. After completing the fellowship, the graduates then join a group of General Doctors that has a need for added clinical support in the area in which the fellow trained. These General Doctors practice general (family) medicine as well as providing the added service in which they trained for their region.
The growth of the program has been spectacular. In 2006, ten interns entered the program during the first year. By 2016, four hundred and twenty seven interns had started the training program in the preceding ten years. The number for Fellows working rurally grew from five in 2008 to one hundred and thirty three in 2016.
In talking to the conference attendants, including practicing doctors, residents and fellows, there seemed to be several factors that are contributing to the success of the program:
- The rural General Doctors work about ten hours a week more than their urban counterparts. However, their compensation is near double the earnings of the urban General Doctors.
- During the last two years of residency, as well as the fellowship year, the residents and fellows are paid essentially the same income as the practicing doctors with whom they are training.
- The residents and fellows observed that the relationships that they developed with colleagues and a community while training are key factors in their decisions to continue as rural doctors.
- The added specialty training offered by the fellowship year is perceived as making their future practice opportunities more interesting and more challenging.
I think it would be fascinating to explore what it would take to develop a similar training model, and to offer a similar proportional increase in compensation, as a means of training and retaining family physicians here in the United States. Given the proven economic benefit to a rural community that has been shown to come with the presence of a family physician, this enhanced rural training model seems to be one worthy of exploration.
Osman Sanyer, MD is an Associate Professor (Clinical) for the Department of Family & Preventive Medicine in the University of Utah School of Medicine.