Among the many forms of disparity in access to health care, the imbalance between rural and urban/suburban areas in terms of physician and other healthcare provider workforce is one of the most obstinate. The problem has been well-documented and been discussed by myself and others on a number of blog posts (e.g., Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 31, 2001, Training rural family doctors, November 5, 2010). While the latest data from the Census Bureau show that the percentage of Americans living in rural areas has dropped from the 20% I have often cited to 16% in the 2010 census (as reported by Hope Yen for the Associated Press in Rural US disappearing? Population share hits low), 16% is not yet “disappeared”. In addition, the percent of doctors working in these areas (which I have previously cited at 9%) is almost certainly lower as well, given both retirements of older doctors and the low level of interest in entering even primary care (requisite for rural practice), not to mention rural practice itself, among graduating medical students and residents.
The problem of lack of availability of health care in many rural areas is further complicated by the aging of the rural population, which is associated with increased need for health care. There are wider reasons to fear the loss of rural doctors. Rural medical practices not only enhance health directly, they provide income and economic development for a community (jobs), and may indeed be one of the key determinants (along with schools) of why some rural communities will survive while others slowly disappear. We need strategies to increase the number of students matriculating in medical schools who are interested in rural practice, and strategies for encouraging and supporting them to enter family medicine (which is the main medical field that works in rural areas, although there are also roles for other primary care doctors such as general internists and general pediatricians, and some specialists, particularly general surgeons).
This is why the fact that the University of Kansas Medical School (KUSoM) is opening a 4-year medical school campus in the small central Kansas city of Salina is big news, not only in the state (as in reports from the Kansas Health Institute [KHI]) but nationally (as demonstrated by front-page coverage in the New York Times and on NPR). Like many state medical schools, KUSoM has long had a regional campus, in Wichita, where a portion of medical students have done their third and fourth (“clinical”) years of training. That campus will be expanded to have 8 new first-year students this year, and 28 beginning next year, who will spend 4 years in Wichita. But the bigger news is in Salina, a north-central Kansas city of just under 50,000 whose previous opportunity for fame as the place where Bobby McGee “slipped away” in Kris Kristoffersen’s song itself slipped away when Janice Joplin, in the most widely-known version, sang it incorrectly as “Salinas” (well, she was from Texas and lived in California!) [OK. I HAVE IT ON GOOD AUTHORITY THAT I AM WRONG AND IT WAS ALWAYS SALINAS. OH WELL, IT WOULD HAVE BEEN A GOOD STORY.]. Eight students per year will spend their entire 4 years in Salina, making it the smallest city to have a 4-year campus and making the “New Salina med school campus unique in US” according to Dave Ranney of the KHI. Or almost unique; Indiana University School of Medicine has done something similar, expanding a first-two-years campus in Terre Haute to 4 years. The KUSoM Wichita campus has done a good job of producing primary care doctors who practice in rural Kansas compared to most places, but Wichita is the largest city in Kansas, not in itself at all rural.
A.G. Sulzberger notes in his piece, “Small town doctors made in a small Kansas town” (NY Times, July 23, 2011) that “when one visitor from the Liaison Committee on Medical Education, an accrediting body whose approval was considered a major hurdle, [s/he]remarked with surprise that the area was not just cornfields.” Of course not! Kansas is the Wheat State! That aside, Salina, on the banks of the Saline River in the Smoky Hills, does sit in the middle of an agricultural region. Indeed, it is the home of the Land Institute, a wonderful organization dedicated to developing a perennial prairie grass that will produce an economically-usable grain, that I take every opportunity to direct people to.
The perspective of New Yorkers aside, Salina is not really a small town. A 4-year curriculum equivalent to that in KC or Wichita would be impossible in too small a town because the community must have at least the “core” specialists of internal medicine, pediatrics, surgery, obstetrics-gynecology, and psychiatry as well as family medicine. Salina is a prosperous town with a large enough medical community to support all the “core” clerkships that medical students need to take in their 3rd year, as well as faculty to lead the small groups for Problem-Based Learning (PBL) sessions, and to support the basic biomedical science education. All of the materials for the modular curriculum for the first two years of medical school is available on-line, and the fact that all lectures are podcast means that Salina students will have the option of emulating many Kansas City-based students and not attend them all. But if they do, they will be directly tied in via high-quality, high-resolution interactive TV, and will even be able to ask questions of the KC-based lecturer just as if they were in the room.
The CEO of Salina Regional Medical Center, Micheal Terry, is quoted by Sulzberger as saying “When they go off to the ritz and the glitz and pick up a spouse from the big city, it’s always hard to get them back to small-town America.” Even if you think that the ritz and glitz of Kansas City and Wichita do not make them New York or Paris (but you should visit these cities before judging), it is not just “how you gonna keep ‘em down on the farm after they seen Paree”. Medical students are usually in their 20s, at the age where they often meet their spouses, and they meet them where they live. If that is in Kansas City or Wichita, it is more likely that the spouse will be from that area and unwilling to move to a rural area, or have a job that precludes them from doing so. If the Salina program is successful, it could be a model for decentralizing even more of the KUSoM curriculum to other Kansas cities, and of course for other states.
But how will we know if it is successful? In the very short term, we will see how the students and their teachers assess the experience, as well as student performance on exams. In the relatively short term (4 years), we will see whether they mostly enter primary care programs, and some years after that, whether the indeed enter rural practice. We don’t know, of course, whether, even if they do, it will actually increase the number of students entering rural practice, because some already do. Since the students were admitted first and then those who wanted to go to a rural site chose Salina, there is at least a possibility that 8 students who would have entered rural primary care practice anyway are matriculating in Salina, and we just took 8 additional suburban students in Kansas City who will not. We hope this is not the case, and look forward to expanding the program.
In any case, it will be extremely important if it demonstrates that medical education can be decentralized and effectively taught in smaller communities, and that it can be done with high quality and in a setting that does not demand relocation to major metropolitan areas. With this new setting, we have to make sure that our admission process favors students who are most likely to become rural primary care physicians. If we do that well, we may really have something here!
Small towns have been training physicians well in more than core rotations for decades in the MN RPAP - Rural Physician Associates Program. The RPAP graduates chaff when returned to academic settings where learning is too passive and too limited.
The U of MN took decades to figure out how valuable RPAP was and granted increasing credit for core curricula based in small towns.
James, Gjerde, and others have demonstrated at least equal training. Verby with RPAP expanded medical education evaluation in ways important for primary care in all settings.
What small towns cannot do is provide medical students the academic rotations that lead to prestigious fellowships.
What 4 years of small town practice did for me was to prepare me thoroughly for 24 subsequent years of delivering, teaching, and researching basic health access.
Robert C. Bowman, M.D.
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