Rural Graduate Medical Education: Challenges and Solutions

While there is almost universal acceptance of the need for more graduate medical education (GME) opportunities (ie. residencies) in primary care and in rural settings, formidable barriers face those wishing to establish new programs. A new article in Health Affairs describes the failure of federal initiatives to create more of these programs.

The study looked at trends in residency positions from 1998 to 2008 – a period which captures a baseline period and any changes after the implementation of a major federal government initiative related to GME, the 2003 Medicare Prescription Drug, Improvement, and Modernization Act. One of the objectives of this Act was to increase GME in primary and rural care but the authors conclude that this objective was not met. For example, across the entire country, “only twelve rural hospitals received new GME positions, for a total of eighty-three positions.” The authors argue that “…prioritization language is insufficient to redirect the GME system. Stronger safeguards are needed even to maintain current levels of primary care training, and larger reforms are needed to move the GME system to address the priority physician workforce needs of the nation.”

Here in Arizona, there is a GME Working Group which is focused on increasing primary care and rural residency opportunities for physicians. It is expected this will be an issue which our state legislators will be looking at in the near future. There is also some good news in that the Yuma Regional Medical Center will be accepting its first class of six medical residents into its new residency program this summer. While this is good news, that organization has been trying to establish a residency program since 2005. Another organization in the state which is also trying to establish a rural residency program is searching for a residency director.

The Arizona Center for Rural Health, through support from the Arizona Area Health Education Center (AzAHEC), is conducting health workforce analyses for the state, which has verified the need for various health professionals in rural parts of the state. In addition, we are also involved in the recruitment and retention of physicians and other health professionals to rural communities in Arizona through the Arizona Rural Recruitment & Retention Program (Arizona 3RNet). Our Center has also invited national rural physician recruitment expert Dr. Dave Schmitz to Arizona next week to talk about approaches he and his colleague Dr. Ed Baker have developed in Idaho with the intent to explore how they might be used in our state. Dr. Schmitz will also be speaking at a Recruitment and Retention Forum in Phoenix on January 15th, hosted by the Arizona Department of Health Services and co-sponsored by our Center.

It appears evident that addressing the current and future rural primary care workforce shortage will require creativity and a multi-tiered approach. In the same issue of Health Affairs, there is another article which suggests that the current primary care physician shortage could be improved by further use of information technology, interdisciplinary teams and better use of allied health professionals. Related to this last point, the study authors suggest that, “…the use of non-physician professionals to deal with more routine problems and the decreased need to respond to urgent requests for care that comes with shared practice can increase the attractiveness of primary care careers for new physicians…”

What do you think are the best approaches to enhance primary care, especially in rural and other underserved areas? Will we be ready for the surge in demand for services that is expected to come with the implementation of the Affordable Care Act?

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